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The small scale of Vermont\u2019s population and economy, as well as its aging population, are part of why the state sees such high costs to health care, said UVM political science professor Alex Garlick, in light of the publication of his new book. Photo courtesy of Alex Garlick<\/p>\n
In his new book on the role of lobbying in shaping health care policy, University of Vermont political science professor Alex Garlick opens with a scene from his days on Capitol Hill.\u00a0<\/p>\n
Garlick worked as a congressional staffer for Rep. Joe Kennedy III, D-Mass., during the intense debates over the 2017 Republican effort to \u201crepeal and replace\u201d the Affordable Care Act, early in President Donald Trump\u2019s first term, and he describes the scene just after the failed repeal vote \u2014 by a single thumbs-down vote from late Arizona Sen. John McCain \u2014 when he saw then-House Minority Leader Nancy Pelosi, D-Calif., kick off her shoes and leap for joy on the Capitol lawn.<\/p>\n
Eight years later, the publication of \u201cPre-Existing Conditions: How Lobbying Makes American Health Care More Expensive\u201d comes as Congress is engaged in another battle royale with the same law at its core. Senate Democrats \u2014 including Vermont Sens. Peter Welch, a Democrat, and Bernie Sanders, an independent \u2014\u00a0 are pushing for the continuation of expanded tax credits<\/a> for Affordable Care Act marketplace plans in exchange for their votes on a continuing funding resolution that would end the federal government shutdown, now in its third week.<\/p>\n That the continuation of an existing tax credit program for purchasing private insurance is what Democrats are demanding speaks volumes about the influence that industry lobbying has in curbing big health care cost reforms, Garlick said.\u00a0<\/p>\n \u201cI think one of the ways you really see the power of the industry is what kind of reform ideas that people will talk about,\u201d he said in an interview on Oct. 10.<\/p>\n Specifically, he said, the tax credits make health insurance more affordable, not the health care itself. As Garlick sees it, the Affordable Care Act, by providing subsidies for the purchase of private insurance, is a more conservative approach to universal health care.\u00a0<\/p>\n The cost of health care \u2014\u00a0to an insurer \u2014 ultimately is an issue of supply and demand, Garlick explained. The most effective way to contain costs of care itself is to address those issues systemically.\u00a0<\/p>\n Structural Power in Vermont\u00a0<\/p>\n In Vermont, the most salient variable in this supply and demand equation is the scale, Garlick said. Namely, the state has a small population, a small economy, one main hospital network and one main in-state insurer.\u00a0<\/p>\n \u201cThere\u2019s not big competition there, there\u2019s not really any forces trying to push costs downward,\u201d he said.<\/p>\n In \u201cPre-Existing Conditions,\u201d Garlick develops the idea of \u201cstructural power,\u201d explaining the outsized influence large players in a state economy can have on policy. In Vermont, Garlick sees UVM Health Network wielding this kind of structural power, he elaborated in an interview: For instance, in 2024, when the Green Mountain Care Board, a key state health care regulator, set a lower budget than what UVM had proposed<\/a>, the hospital cut services.<\/p>\n \u201cIt probably reminded the care board that they can\u2019t go too far and too fast. They need to tread carefully about how to rein costs in,\u201d Garlick said.<\/p>\n He believes that having a powerful regulator like the Green Mountain Care Board is an important step toward curbing health care costs. \u201cThat said,\u201d Garlick added, \u201climiting marginal growth year over year doesn\u2019t make care more affordable. You can\u2019t put the toothpaste back in the tube of how costs have gotten high in the first place.\u201d\u00a0<\/p>\n How, then, to actually reduce health care costs?\u00a0 \u201cOne way to push back on the structural power of institutions like the UVM Health network is to not rely on them so much,\u201d Garlick said.\u00a0<\/p>\n \u201cThe legislature could be more proactive about trying to increase the supply of hospitals that exist.\u201d<\/p>\n Garlick also pointed to the $50 billion allocated in the budget reconciliation law Congress passed this summer for \u201crural health transformation<\/a>.\u201d He expects Vermont to be well positioned to receive funding through the program. The state is already working on its application for the fund<\/a>.<\/p>\n Expanding the number of clinics and hospitals, he says, is just one potential way to add more leeway in that supply-demand equation.\u00a0<\/p>\n The state would also be well served by thinking more holistically about how the rural health funds can support the health care system, Garlick said. For example, expanding housing options for hospital workers as a key way to ultimately invest in the long-term economic health of the state\u2019s health care system.\u00a0<\/p>\n \u201cWhen it comes to zoning and housing supply, Vermont is coming from a pretty restrictive place. It is difficult to build and difficult for people to find housing,\u201d Garlick said. \u201cWhen it comes to medical and hospital employees, their inability to find housing is making it difficult for (hospitals) to attract and retain staff.\u201d<\/p>\n It can lead locally trained doctors and nurses to look outside the state for employment and the hospitals to pay high wages for traveling nurses, he added.<\/p>\n Informational Bottlenecks\u00a0<\/p>\n In \u201cPre-Existing Conditions,\u201d Garlick also describes another type of leverage that industry can hold via its control of information. In health policy, especially, equal access to information is particularly challenging, he writes. Often people need medical training to really grasp what is medically necessary, privacy concerns keep many details and statistics protected, and a third-party insurance company can obscure the true cost of services.\u00a0\u00a0<\/p>\n Vermont has relatively open access to information through the Green Mountain Care Board. Annually, the board collects financial data from hospitals and insurers, which it makes public.\u00a0<\/p>\n Still, the citizen state Legislature\u2019s capacity to digest that information and act on these complex issues during the short legislative session is itself a type of informational bottleneck, Garlick says.\u00a0<\/p>\n \u201cWhen (lawmakers) lack information, when they lack capacity, that builds a dependence on lobbyists and on the industry to help them make the decisions,\u201d Garlick said. \u201cWhen you\u2019re depending on information from the industry. It\u2019s hard to expect the industry to issue the recommendations that are going to reduce their own revenues.\u201d\u00a0<\/p>\n In his book, Garlick calculates that the state legislatures with the highest presence of lobbyists end up spending the least amount of attention on health care in the agenda and see more expensive health care costs.<\/p>\n Each individual lobbyist in a state ends up costing people roughly $7 per capita in additional health care costs, his research suggests.\u00a0<\/p>\n The constraints on setting policy in Vermont, though, are often as much about process constraints, Garlick said. \u201cBecause the legislative session is not very long, we have these impasses that develop,\u201d he said. \u201cThere are capacity issues of \u2018Can we even do this ourselves?\u2019\u201d<\/p>\n Counterintuitively, perhaps, the fact that the cost of health care in Vermont, and in the country, has gotten so unwieldy has made him more optimistic that it will bring a desire for broader systemic change.\u00a0<\/p>\n