We’ll never sort out the hot mess that health care has become in Vermont and in the U.S. until we agree on the fundamental question of whether health care is a definable right or just a lucrative business.

Our persistent ambivalence only extends its cost and complexity with second-class outcomes. With a total domestic cost of $3.8 trillion — 17.7 percent of gross domestic product / $11,600 per American — and worse health outcomes than those of our peers abroad, we can no longer evade the question. Reduced to its simplest terms, today the health of Vermonters must compete with the privilege of those who make billions out of misfortune.

My knowledge about the health care industry dates from 2002-2006 when I was recruited to chair the recently consolidated Fletcher Allen Hospital, just as its former president Bill Boettcher was indicted for lying to regulators about the hospital’s expansion and began serving a 2-year jail sentence. My cram course in the health care industry left me full of questions about its future.

The arcane lexicon of health care doesn’t help. Know what “denial management,” “capitated payments,” “open-source wellness” or “OneCare,” mean? Join the crowd.

To begin with, do 620,000 people living in such a small state need 14 hospitals? Arguably not. Adding five to the 11 hyperlocal federally qualified health centers we currently have would more cost-efficiently serve Vermonters’ health needs —a key focus of Sen. Bernie Sanders. Our two tertiary-care hospitals, University of Vermont Medical Center and Dartmouth, and perhaps six regional critical-access hospitals collaborating — rather than competing — on allocated specialty care and procedures would enhance quality while lowering system costs.

It might also help alleviate the severe shortage of health care professionals. From nurses to nurse practitioners, physician assistants, primary care doctors and specialists, hospitals are struggling to find staff. The well-documented lack of primary care doctors turns the system on its head from a cost-efficiency perspective.

Contrary to conventional market-demand algorithms, the doctors most in demand were at the bottom of the pay scale while the few marquee surgeons earned more than the CEO. Why? Because compensation was based on billing potential rather than need or systemic — read preventive — value. It’s encouraging that UVM is currently reviewing its compensation philosophy.

At UVM, this personnel shortage is leading to long delays in patient scheduling. Patients seeking orthopedic, spinal or pain treatment can wait months for an appointment. I was initially told it would be four to six months before I could get a hip replacement. Many prospective patients now resort to the growing number of for-profit specialty clinics popping up around Chittenden County or travel to Dartmouth where these procedures are more accessible.

Gov. Phil Scott, celebrated nationally for his management of COVID-19 in Vermont, remains curiously silent on the broader issue of health care strategy.

Is it not the governor’s task to lead or assign responsibility?

Who will be the driver and champion of a vision for improving health care access, affordability and outcomes and deploying OneCare if not Gov. Scott, his Agency of Human Services secretary Mike Smith, the Green Mountain Care Board, or John Brumsted, CEO of Vermont’s largest health care delivery system?

Without OneCare becoming a reality across our network of health care delivery systems, our Medicare waiver will not work nor will we ever be able to manage the consumer cost escalations for those who can afford access.

This disturbing lack of vision, leadership, policy formation, and accountability in health care strategy is at the root of the problem.

Under Scott, with the appointment of Sen. Kevin Mullin (R-Rutland) as chair, the focus of the Green Mountain Care Board tilted from visionary goal-setting by experienced health care professionals to more bottom-line cost-control overseen by financial experts. The 50-member care board’s advisory committee, of which I was a member, shrank to less than half of that, many of whom are now stakeholders in the current system.

Although Vermont has partnered with the federal government and bought into the concept of OneCare, it still faces stiff headwinds — not because it’s a faulty concept but because it lacks government leadership.

OneCare’s core tenet is philosophical. To quote Ben Franklin, “An ounce of prevention is worth a pound of cure.”

Move the $6 billion spent each year in Vermont in transactional costs upstream into prevention and “population health.” But OneCare is misunderstood by many in the health care and legislative communities. Often confused with single-payer and multi-payer systems, it works with either, although the latter is clearly becoming the norm.

As one hospital administrator put it, and I paraphrase:

We’re dependent on a steady stream of broken people for our survival. We repair and bill transactionally. The sum of those transactions keeps our doors open. If we were simply given our annual budget against an accountable and measurable commitment to invest in prevention, education and maintaining population health, we would save money and see fewer sick Vermonters.

True leaders don’t try to satisfy everyone. They take political risks. They pioneer. If pleasing everyone, positive polling, and re-election are leadership’s goals, we’ll never see change.

Scott has vastly outperformed his peers in COVID crisis-management. He must now understand health care itself as the crisis and lead.

Bill Schubart grew up in Lamoille County, and now lives in Hinesburg.

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