#1 - Vermont Woman Special Series: Green Mountain Care Board Profiles

 Anya Rader Wallack and Healthcare Reform: Guiding One Big Elephant!

by Roberta Nubile


Green Mountain Care Board Chair Anya Rader Wallack, Ph.D. has laid a strong foundation for the nation's first single-payer healthcare system.

Wallack To Step Down — Her Own Words:

"In late March, 2013, I announced with great sadness that I will be stepping down as Chair of the Green Mountain Care Board in September. By then I will have spent almost three years commuting between Rhode Island and Vermont to do this job. I had hoped I could lure my husband and son to Vermont, but that has not happened. They love where they are, and as a family we need to spend more time together.

I remain deeply committed to Vermont's reform plan and process, and hope there are ways I can continue to assist after September without taxing my family quite so much. We have done some great work over the past couple years and we have a great team in place to continue the progress at full speed."

– Anya Rader Wallack

Vermont healthcare reform reminds me of the fable of the elephant and the blind men; comprehending the whole is tough. To do so, we need time to educate ourselves; attend or view the many public meetings; read hundreds of newspaper articles, blogs and reader responses; and pore over the state of Vermont's websites. Most of us cannot do that.

We learn what we can through bits and pieces we pick up from passing conversations with friends who have encountered the elephant, or read snapshots in the news.

I am a nurse. The piece of the elephant I see is the quality of health care delivered to patients: It is often rushed, and often dependent on medication and quick fixes, rather than long-term lifestyle teaching, or investing the time to sit and really listen to each patient's true needs.

Primary care physicians try to meet their patient's needs in ten minute slots; specialists don't always have streamlined processes to receive or transmit information about whatever aspect of the client illness they have attended.

Time Magazine's recent in-depth study on the rising cost of health care ("Bitter Pill," Feb. 20, 2013) shows the itemized bills of the insured, uninsured and the underinsured, charged for everything from two Tylenol to an MRI. The part of the elephant the healthcare consumer encounters can bring a lifetime of debt, bankruptcy or unrelieved poverty as a result of even one catastrophic hospital bill from delayed care or emergency treatment or chronic illness.

Small business owners see another piece of the beast—and one that will manifest itself in January 2014, when a federally mandated exchange takes effect. Then, business owners must make thoughtful and informed decisions about whether to drop their current employee health coverage and instead encourage employees to purchase individual and family insurance (see sidebar).

And middle-income families rightly ask how they can afford insurance premiums and out- of-pocket medical costs if they are in an income bracket ineligible for federal assistance? Affordable care for whom, they ask the elephant?
Meanwhile, hospital CEOs may be concerned about new constraints on hospital budgets that just came down the pike from the Green Mountain Care Board, the people in charge of the state's reform of "the elephant." How do those changes affect their businesses?

History of Healthcare Reform in Vermont

Dr. Dynosaur (a Medicaid program), providing access to insurance for income-eligible children and pregnant women, was created and signed into law by Gov. Madeleine Kunin.

Dr. Dynosaur expanded during Gov. Howard Dean's administration, and Vermont Health Access Plan (VHAP)--an income-eligible health insurance for adults over 18 to cover those not eligible for Medicaid--was signed into law

Under Gov. Jim Douglas's administration, with work from key players including Vt. House Speaker Gaye Symington, U.S. Rep. Peter Welch, and Vt. Senator Jim Leddy, several health reform laws were signed into law. Included are Catamount Healthcare, an insurance program for those not eligible for Medicaid or VHAP; Blueprint for Health, a health management initiative focused on chronic care; and Choices for Care, a Medicaid-funded, long-term care program to pay for care of older Vermonters and people with physical disabilities. The laws all focused on expanding access to coverage, reducing heath care costs, and improving quality and performance of the healthcare system. Under the Douglas administration, the underinsured rate went from 9.8 to 7.6 percent, and Vermont garnered the number one spot as healthiest U.S state. It has won this ranking annually since.

May 2011
Gov. Peter Shumlin signed Act 48, legislation to create a single-payer system in Vermont. Act 48 created a Health Benefit Exchange (a requirement of the federal Affordable Care Act signed into law by President Obama on March 2010). The law assigned the Green Mountain Care Board responsibility for controlling the rate of growth in healthcare costs and for improving the health of Vermonters, and laid out a broad outline of a single-payer system in Vermont.

October 2011
Green Mountain Care Board convened to begin the process of carrying out federal mandates, while at the same time crafting a single-payer system in Vermont to deliver affordable, quality healthcare to all Vermonters.

Enter the Eagle Eyes

The leaders in the Vermont healthcare reform effort are charged with looking at the whole elephant.

The Green Mountain Care Board first convened in October 2011, and is comprised of Anya Rader Wallack, board chair; doctors Karen Hein and Allan Ramsay; business owner Al Gobeille; and Con Hogan, former secretary of the Agency of Human Services.

This group is entrusted with no less than overseeing the overhaul of Vermont's healthcare system and developing an improved healthcare delivery system, while adhering to President Obama's specific mandates for healthcare reform. The task is enormous, the challenges many. This elephant in our room is of mammoth proportions.

But with a history of trailblazing in other social and environmental fronts, and a more than 20-year history of healthcare reform, Vermont is uniquely poised to successfully move to a single-payer system and universal care; it would be the first U.S. state to do so.

A year and a half into GMCB's life, with a target date of 2017 for implementation, the board is now moving from data collection to data analysis and projection. It has listened to and read public commentary (an ongoing process), been advised by technical committees consisting of doctors and hospital CEOs, and reflected on research and reports prepared by hundreds of Vermont state employees and outside consultants.

While voices of dissent against a single-payer system exist, and valid fears and questions are expressed in the press and among readers, Vermont polls largely show support for the work of board. GMCB works under the premise that Vermont's present healthcare system is unsustainable and unaffordable for too many stakeholders. We can do better in improving the health of Vermonters.

Wallack in Charge

I met with Dr. Any Rader Wallack to learn more about her and the tasks ahead of the Green Mountain Board. Wallack has a welcoming way, and moves easily from intimidatingly smart to approachably genial.

She intersperses academic jargon with slang like "stuff" and "sucks," punctuated now and then with an infectious laugh.A skillful MC at GMCB's public meetings, she moves the agenda, reflects on comments, and ensures that all voices are heard.

Wallack, born in Calais and raised in Central Vermont, attended UVM for political science and received a Ph.D. in social policy from Brandeis University. She has worked for more than 20 years in healthcare reform, first with Howard Dean and then with Hilary Clinton.

I asked her if she could recall any childhood influences that may have shaped her.

"Not in healthcare reform specifically," she answered. "I grew up in a family with a strong awareness of public policy and politics. We read the paper every day, and my parents were involved in a lot of political issues. My mother worked in early childhood education and as a school librarian, and my father spent many years as a career counselor for Vietnam veterans, then as a city clerk in Burlington. He went to work for his college friend Bernie Sanders when he was mayor, and then in Congress.

"I got into healthcare reform specifically because I was working with Howard Dean, and got assigned, without a whole lot of experience in the policy area, to be responsible for that chunk of his agenda. It quickly became a big part of his agenda. That was when Bill Clinton got elected, and he had his whole health reform plan. I just kept going deeper into it, and said, 'I guess I will become an expert.' Before that I was a generalist."


The Green Mountain Care Board's task, overseeing the state's
healthcare reform, is enormous, the challenges many.
This elephant in our room is of mammoth proportions.
 ~ the author


Balancing a Life

Clearly Wallack has empathy for those of us who are not experts on the whole system, its fixtures and gears and jargon. I told her I had spent a few hours poring over articles and websites, and became overwhelmed and glassy-eyed over the sheer amount of information and the monumental task of it all. How did she not burn out?

She laughed. "Who said I wasn't burnt out?"

"But how do you take care of yourself?

"I hang out with my dog. That's the best medicine," she answered. "I snowshoe, run, lift weights. Exercise is my main method for taking care of myself. It is an intense job. There is always too much work, and I have piles of stuff in my house I would like to read someday. And stuff I should read immediately. And they all keep growing."

She said she found she could sustain the job, but the bigger stress came from being away from her family. Her husband and 12-year-old son live in Rhode Island. She and they have taken turns sharing the commute, she explained. "The first nine months I was here, they stayed there, and I would commute. Then last year, my son came up, and went to school here, and my husband commuted. And now they are both back in Rhode Island, and I commute."

Does she ever not think about HCR?


So it's more than a full-time job. "I'd like to work just 40 hours. That would be nice," she smiled.

Wallack's Purpose

Wallack works in GMCB's office on the third floor of Montpelier's City Center at 89 Main Street. What motivates her most, she told me, is that everyone is agreed the state has a big problem that needs fixing. The status quo for our healthcare system is unsustainable: "Find me someone who will disagree with that, and I'll give you 100 bucks."

But interestingly, what fascinates her are the problems' technicalities and complications--the very things that glazes most people's eyeballs. She said, "Part of the value that I can bring is to conceptualize how all the components fit together.

That kind of technical and organizational stuff is what I like to do, and is my strength.

"And third, I just work with some great people. Everybody here is really committed. There is a good attitude in the office; people are fun, with a great sense of humor, and have good coping skills."

Wallack said that, like everything complex, the healthcare issue involves politics, business and money, but it is also a highly personal and touchy issue, since it affects people's health and well-being.

"Often times, you think you are making progress, but it's two steps forward, one step back," she said. "The thing that undermines our work more than anything is the lack of trust across all the parties that have to cooperate in order to change the system for the better.

"Sometimes you can find those magic moments where the trust is there, and you say, 'yeah, let's do this,' and other times you run up against people being suspicious and turfy, and not open and honest. Those are the frustrating moments when you think, okay, everyone has just gone back into their own corner, and they're protecting their own turf, and not giving up stuff in order to achieve the greater good."

What does she think about those critics who have called GMCB "elitist" because it is comprised of technical insiders?

"Everyone who is on this board is here because they care deeply about this issue," she said, "and everybody who is here tries really hard to stay connected, to stay in touch with the ground.

We have tried to incorporate in our work—and it's hard to do this—lots of avenues for public input. It's a huge challenge, because just explaining this so people can digest it and give us good feedback [is hard.] Your average person on the street is not surfing the web to find us, and comment on hospital budgets on their lunch hour."

What is The Exchange?

According to Emily Yahr, Outreach and Education manager for the Department of Vt. Health Access, the exchange will be "a website where Vermonters will compare health insurance options, enroll in a health plan, and secure financial assistance to help pay for healthcare." Under the federal Affordable Care Act of 2012, each state must implement its exchange by January 2014. The only state with a successful exchange already in place is Massachusetts.

All plans in the exchange must carry "essential health benefits." No pre-existing medical conditions can be denied (also referred to as "guaranteed issue"). Premiums will limit insurance price variations. In other words, the plans will all carry identical benefits, but be offered in four comparable tiers ranging from bronze to platinum, with differing out-of-pocket expenses. Federal support may help pay for premiums, and lifetime and annual limits are eliminated. Plans must include coverage for children up to age 26, while preventive care, including breast cancer and colorectal screenings will be covered at no cost to the patient.

By providing a one-stop shopping site, much like online price comparison sites for airline tickets, the exchange is expected to increase competitive pricing, as well as honesty and transparency among private insurers that will be part of the exchange.
Vermont's exchange will list private and public insurers side by side, so that Vermonters can tell what plans they are eligible for, or can receive assistance for, based on household income and family size. By 2017, Vermont intends to have a single-payer plan in place. The details of this plan will be worked out over the next four years. Vermont will then apply for a federal waiver to end the exchange.

The exchange will be available to the public by October of 2013, and by January of 2014 its plans can be purchased. A federal "individual mandate" holds that an individual must purchase health insurance, or pay a yearly penalty at tax time.
Medicare will not change. Federal assistance under the Affordable Care Act, already generous in Vermont, will increase to cover more people. Low- and middle-income families will be eligible for tax credits to help lower premiums and out-of-pocket costs. Small businesses may realize the biggest impact, and will be faced with making educated decisions on whether or not to continue to carry employee plans.

In 2017, Vermont's exchange will go away, and the as yet undefined single-payer universal healthcare system that the GMCB is developing will provide healthcare to all Vermont residents.
Trained specialists called "navigators" and call centers will be available by October 2013 to help individuals choose the best options for them.

Public Input

Wallack said the board was working on getting more input that isn't just off-the-cuff visceral, but thoughtful; already it had gotten good ideas. Each board member finds ways to stay rooted, whether it is staying in touch with small business people and the public they service, volunteering at a free medical clinic, or just reaching out to people who have different perspectives critical of the board's work. Board members bring that feedback into their board discussions.
"They say, 'well, so-and-so said this,' and at times that may be uncomfortable for board members to do that," she noted, "but clearly it is an important role they play. We are going to hold town meetings in various parts of the state, and hopefully people will show up. Our public meetings are televised, much to my horror. I flip through the channels and stumble across us having a meeting and think, God, I look tired."

How have the turnouts been for the public meetings?

Wallack said that so far public turnouts have varied, depending on the topic. They have public meetings at their conference room in Montpelier every Thursday, and get a full room, 20 to 30 people, most of the time.

"We have had public forums for specific topics. We had one in Chittenden for business people to talk with us about how we do insurance rates, and I thought, we are only going to have three people, because who wants to come in the middle of the day to talk about insurance rate-making? And we had a full room, 50-ish. Great, great input.

"We had one for hospital budgets last year on interactive TV, where people could go to sites around the state. That format didn't work so well. We are still testing these things out."

She said her proudest accomplishment for 2012 was putting GMCB's regulations all into one place. It has begun to connect the system's separate pieces in a coherent way. "That's not a job that is done," she said, "but we made tremendous progress in terms of educating ourselves, and educating the folks who pay attention to our work. We have come a long way. We are almost a year and a half into our work, and we seem to have broad credibility.

"Yeah, there are those that call us elitist and all-powerful, but in general the feedback we get is, 'You guys are doing good, hard work, we understand it, and we will give you more time to make this a success.'"

"To me, maintaining our credibility, and being able to make this idea operational and functional and successful is something, because we could have found ourselves a year and a half out, and have everyone shouting at us, and people saying, 'You suck, and let's repeal this.'"


We have tried to incorporate in our work—and it's hard to do this—
lots of avenues for public input.
~Anya Rader Wallack,
Chair of the Green Mountain Care Board


The Elephant Ahead

Clearly the legislature and Gov. Shumlin have not been displeased, for the most part. So what will 2013 hold for GMCB?
"A lot of work around something that sounds really boring, but is incredibly important and is really the foundation for everything we do. It is getting our house in order around the data we use to drive our analysis, and to feed our decision-making, and then to track the impact of our decisions."

Ah, which means?

She gave as an example the latest version of the state's expenditure analysis and the need for accurate spending forecasts. She said the board has work underway "to really improve how we do forecasting of expenditures into the future. And that's a really important baseline to have when we implement things like payment reform."

Wallack anticipates the new method will enable the board to evaluate its decisions, asking, "Did we change anything? What did we expect to happen without that? And what happened with it? And can we have a credible methodology for saying we changed the world, or we didn't, and be honest and transparent so people can understand how we are doing that? So that kind of data foundation is a huge front on which we are working."

She calls their regulatory processes "a tool to both constrain the rate of growth and healthcare costs, and to influence where the money is going--not just saying we will only let so much money go into hospitals, but also trying to create some incentives for good investments, good changes—so hospitals are less focused on filling beds, and more focused on keeping populations healthy."

Another area of focus is the health insurance rate review process. Again Wallack was looking for logical connections between data and the healthcare system's pieces. She said, "Up until now, there has been a real disconnect between a lot of the other health policy realms, and what happened to the rate review process. We've just kind of let the rates go. We are trying to hook that car onto the train, and make sure there is coherence."

She uses a graphic to show how she sees regulation making Vermont more "smart and deliberate about what we are doing and, in our regulatory processes, using that information. I have this slide, which I love to use."


Getting back to what keeps her going every day, Wallack said the most important thing Vermonters need to know is that Green Mountain Care Board is working hard to support positive changes in Vermont's healthcare system. "We have a legitimate reason for thinking we can constrain cost growth. If you look at the innovation plan, we talk about creating the best healthcare system in the country in Vermont, and I really think we can do that.

"That's our goal: to create the best healthcare system, so we can cover everybody, and afford it. And number two, while it's uncomfortable for people, nobody benefits from us just sitting back, and throwing up our hands, and saying this is too complicated, too hard, creates too many enemies, ruffles too many feathers. Everyone benefits from us moving forward with this agenda. But they may have to give us some control, or get out of their comfort zone."

Where is Prevention?

I told Wallack that whenever I read about preventive care as defined by insurance companies, I see breast cancer screening, vaccinations, colorectal exams. But for me, preventive medicine includes exercise and nutrition. When and where are these ever going to be addressed in healthcare reform?

She answered that setting up expectations and incentives—for example, within the new Accountable Care Organization (See Vermont Woman, Winter 2013)—will drive providers away from more medicalized treatments to what really keeps a population healthy. She said the state's current expenditure analysis focuses on traditional medical expenditures "because that's what you track through the data sources we have used historically. It's mostly based on claims, and that's where the measures like breast screening are found."

Right now, Vermont cannot easily track from any really good data source whether Vermonters eat right or exercise. She said, "We need to figure out some financial or business model that drives people to do that. We want CEOs or CFOs to say 'I don't care if people are using hospital services, because I have an incentive to do all sorts of things to keep them out of the hospital.' Right now, the model is exactly the opposite."

Learn More and Get Involved

General info about the progress of Green Mountain Care to date: http://hcr.vermont.gov/

About the exchange: http://healthconnect.vermont.gov/

To set up a presentation to a group on the exchange, contact http://vthealthconnect@state.vt.us

About the GMC Board: http://gmcboard.vermont.gov/

Written public comment: http://gmcboard.vermont.gov/public_comment

Public meeting times, dates and agendas: http://gmcboard.vermont.gov/meetings

Past meetings can be viewed at: http://www.orcamedia.net

Roberta Nubile, an R.N., lives and works in Shelburne. Look for her series on the GMCB members and their perspectives on healthcare reform in upcoming issues of Vermont Woman.

Special Series: Vermont Health Care Reform

1. Vermont Healthcare Reform: Guiding One Big Elephant! by Roberta Nubile , April/May 2013

2. Con Hogan – Seasoned Elder of Green Mountain Care Board by Roberta Nubile, June/July/August 2013

3. GMCB’s Al Gobeille: The Voice of Business in “Health Connect” by Roberta Nubile, September/October 2013

More articles in this series will be forthcoming in the Nov/Dec 2013 and Feb/Mar 2014 of Vermont Woman