Healthcare, Education, Housing, Two outta three ain't bad...

Vermont’s most intractable financial challenges are healthcare, education, and housing. Costs for all three have skyrocketed in the last two decades.

According to an analysis by Rees Partners , LLC, based on?National Academy for State Health Policy ?data, Vermont could save as much as $350M annually by simply managing operating budgets to established Medicare reimbursements, as some 70% of comparable academic medical centers do, and doing so profitably or on a break even basis. This simply means controlling non-clinical management and administrative expenses in a way that enables the hospital to break even annually on the amount Medicare reimburses for the procedures they perform.

On the education front, a school construction task force was created in 2023, mandated by?Act 72 , to envision a new, more-affordable network of Vermont schools,?one that would look at alternatives to spending the projected $300M annually over the next 20 years on deferred maintenance and updating outdated school facilities.

Housing is a simple issue of supply and demand, and demand vastly outpaces supply.?Meanwhile, cost increases have outpaced the national average. ?A house and land I bought in 1976 for $42,000 -- but no longer own -- just sold for over $800,000.

But let’s focus on healthcare and education, where solutions that are projected to save some $650M are at least on the horizon.

BTW, can we also set our sights on leaders who lead rather than simply repeat the term “affordability” without addressing its underlying causes? Is it too much to ask for leaders to address what drives unaffordability?

Over my long lifetime, we Vermonters have been obsessed with local control, even though it flies in the face of our regional economies, landscapes, and weather patterns.

Meanwhile, populations in three of our rural counties diminished between 2010 and 2022, while Chittenden County led growth at 8% in the same time. ?Vermont’s overall population grew by just 17 people in 2022 and 354 people in 2023 to 647,464. ?We’re smaller than many urban suburbs.

Given our HO-gauge status among states, it’s only practical to begin to think statewide, especially for critical infrastructure like healthcare and education. In spite of the fierce media and public relations blowback ginned up by hospitals in response to the recent?Oliver Wyman Report to the Green Mountain Care Board ?and to Vermonters, the report laid out a clear and credible path to sustainability, better access, affordability, and quality -- all captured in the definition of “population health.”

If we accept Vermont as it is rather than how we would like it to be, we can see a path that keeps appropriate services in our communities while concentrating larger facilities in our regional centers.

Instead of “healthcare” and “education” think “acuity” and “age.” Acuity is how sick you are. Age is how old you are. Now apply those to a hypothetical line beginning in our small towns continuing to regional centers, then to urban centers and finally to the greater world.

The concept of universal home visits, primary-care clinics with trauma-informed counseling, solo and small practices, parent-child centers, disability, aging and chronic care support groups, mental health first aid, all belong in our small communities as they are appropriate to the scale of each.

Local home visitors would check in periodically on rural folks to see how they’re doing and to assess their physical and mental well-being. They might be specially trained home-health workers, volunteers, mail carriers, fire, or policing staff.

Growing up in Morrisville, Drs. Goddard, Calcagni, and Pease all had small practices. They knew their patients personally. They knew who could afford to pay and who needed free care.

Morrisville was the hub of Lamoille County and so had a small four-story wood-frame hospital with one of Vermont’s first elevators. It was there, at age six, that I had my appendix and tonsils removed. The following year I had a broken arm set after a skiing accident in Mr. Farr’s gravel pit behind our house. But later when I was diagnosed with a slipped upper femoral epiphysis, which I couldn’t pronounce, I was sent to the Bishop DeGoesbriand Hospital -- now the “One Prospect” campus of UVM Medical Center (UVMMC) -- to have a metal pin inserted in my hip. This tiered model based on acuity and complexity can and must work again today, sustaining both our communities and our urban tertiary care hospitals.

Those seeking care will be able to do so in their community at the primary-care level. If a diagnosis shows higher acuity or requires more sophisticated treatment than can be handled locally, it’s escalated to a more sophisticated regional critical-access hospital, or, in extremis, to a tertiary-care hospital such as Burlington, Dartmouth, Albany or Boston. State boundaries are irrelevant; proximity, acuity, and complexity are what matter.

As the Wyman report, conventional wisdom, and experience all indicate, each community health center or hospital trying to be all things to all patients contravenes the basic metric for healthcare quality. The facility that routinely does the largest number of specific procedures is understood to do them better than the facility that does them only on an as-needed basis. It’s also less expensive and yields better outcomes when a high acuity-patient needing sophisticated care is transported by ambulance to a regional center that routinely does these procedures rather than maintaining the technology and specialty staff at all our healthcare facilities just so they can say “we do it all.”

As to schooling, I believe the key metric is age. Parents rightfully want their youngest near home. “Public education” should begin at six months after an initial period of “family bonding leave” to allow for the critical bonding of a newborn with their parents or parent. All the levels we now call crèche, nursery school, kindergarten, pre-school, childcare, and primary grades would be in our community schools close to home.

In such a system, professional early educators with specialized pediatric knowledge and family-support services would replace “daycare workers.” Early educators are also trained to identify early?adverse childhood experiences ?(ACEs) and, if needed, enlist?trauma-informed therapists ?to work with children and families to address and remediate problems that, if undetected and unaddressed, can accelerate into special ed, criminal justice involvement, and often corrections in later life.?The economic impact of untreated ACEs in Vermont alone is determined to be over a $1B a year (slide 10).

Middle school, junior high, and high schools would be regional where greater resources and economies of scale would apply to larger classrooms. The early school "science teacher" would be replaced by anatomy, physics, chemistry, and biology teachers. Bus rides would be longer, but in time our system of school-bussing and our rural transit system must be integrated to, again, provide economies of scale. Why couldn’t the rural shopper going to Rutland ride on the same bus as the teenager going to school? We must begin to think more broadly and less locally.

As to college and post-graduate studies, the farther away from home the better. This is the time when the child becomes the adult and our job as parents is to raise independent, resilient, resourceful young adults, not dependents cautious about exploring a larger world.

If we can get out of our outdated local control mindset, while still applying local value where it lies and understand ourselves and our small communities as part of larger systems that don’t recognize our historical boundaries, we can make social and economic progress.

Using acuity and age as our determinants, we can base diagnosis, prevention, primary care and early education in our communities where they belong and then escalate each consistent with acuity, procedural complexity, and age.

This will go far toward solving two of our three persistent small-state problems.

Two outta three ain’t so bad….

Link

?

?