MONTPELIER — If you’d told Otter Creek Brewing founder Lawrence Miller two decades ago that he would someday play a key role in Vermont’s effort to transition to a single-payer health care system, Miller would probably have wondered if you had consumed a little too much of his beer.
But that’s exactly where Miller’s eventful career path has taken him. It was last week that Gov. Peter Shumlin appointed the former Addison County resident his senior advisor and Chief of Health Care Reform. Miller will be transitioning into the job during the coming weeks after having spent the past three years as secretary of the Vermont Agency of Commerce and Community Development (ACCD).
During a wide ranging interview with the Addison Independent at his new Montpelier office on Monday, Miller discussed his new job, his expectations for health care reform and his appraisal of his time spent as the commerce secretary.
Miller admitted he wasn’t shocked when Shumlin asked him to take on the new health care job. Miller had been immersed in health care issues during his three-plus years heading up the ACCD, as rising insurance premiums continue to be a major cost of doing business in the Green Mountain State. In January, Shumlin asked Miller to assist with the roll-out of Vermont Health Connect — the state’s new health care exchange. One of the main tasks was troubleshooting the Health Connect website, which got off to a rocky start in October and which some Vermonters found very difficult to negotiate to sign up for medical insurance.
As a cabinet-level appointee, Miller had already been advising the governor on a variety of issues — including health care.
“For the past couple of years, I’ve been working with the rest of the health care reform team on the bigger policy questions of health care reform — mainly bringing the perspective of small businesses and our constituents to the conversation,” Miller said. “The conversation was about what the financing impacts might be, what the policy outcomes for small businesses might look like — particularly policy outcomes for entrepreneurs and people joining small businesses.”
Miller has shared Shumlin’s belief that the business community could benefit by shedding health care responsibilities for employees. Currently, he said, many small businesses are unable to help subsidize health insurance for their workers, while larger enterprises are providing family plans that relieve a spouse’s company from extending such a benefit.
“If we can somehow de-couple health insurance from employment, I think that’s pretty powerful, because I know a lot of people who have not started a new business or not joined a business because they were worried about benefits,” Miller said. It’s this prospect of doing health care differently, with a potentially better outcome, that has given Miller a good comfort level with his new job description.
And Miller likened Vermont’s first steps toward health care reform to the growth of a nascent business.
“This is the classic entrepreneurial thing,” Miller said. “The Vermont Health Connect division didn’t exist; it was stood up as a project, and all of a sudden it’s an operating company with normal business start-up challenges.”
Those challenges are varied, and Miller understands he will be the administration’s lead official in keeping track of what he called “all of the moving parts” of the reform effort. It’s a responsibility he takes very seriously.
“When you talk about health care reform, you’re talking about more than $5 billion — 20 percent of the state’s economy,” Miller said. “There is a lot of risk to be managed.”
If everything proceeds smoothly, the plan is for a single-payer health care system to be its own functioning part of state government by 2017-2018, according to Miller.
“My job is to work myself out of a job as quickly as possible, with the least disruption to Vermonters as possible,” Miller said.
SAY WHAT HE THINKS
He believes his experience as an entrepreneur will help him in his new role. And he promised not to mince words when advising the administration about potential pitfalls in the transition to a single-payer system.
“One of the things I bring to it is the commitment to get to where we need to get, but with an understanding of the context of managing the risks of that transition,” Miller said. “I’m also comfortable enough with my colleagues and with the governor to say what I think, and to do so in plain English. I’m not shy about recognizing what the risks are and communicating them.”
He promised to recommend against pursuing a single-payer system, if that’s what the evidence leads him to conclude.
“(The governor) has been completely clear that we’ve got to see cost containment able to work, because we cannot put the state on the hook for the runaway costs that we’ve traditionally seen with health care,” Miller said. “We’ve got to have a financing mechanism that’s a positive for the economy of this state, and not negative. And these are clear triggers that the Green Mountain Care Board has to evaluate before we go forward. I’m going to be completely straightforward with the governor about our prospects for being successful with those triggers.”
He believes that Shumlin “will not tolerate” a system that does harm to Vermonters’ well-being.
“I have confidence in the group of people working on this, that we’ve got the right people on he team to establish a path that will get us there with the risks appropriately managed,” Miller said. “But in the end, if we don’t feel that we can, we’ve also got the leadership that will acknowledge that.”
There is no “Plan B” on the table if the quest toward a single-payer system is abandoned, Miller noted.
“If we don’t see the conditions that we believe will result in a high likelihood of success, we will simply continue to refine the system we have now,” he said. “But certainly, going back to the status quo would not be acceptable. We have to do the cost-containment work. We have to improve health care outcomes, particularly for our most vulnerable population. We have to address the cost-shift.”
But early signs for single-payer have been encouraging, according to Miller, who pointed to a program designed to promote sustainable health care delivery called Vermont Blueprint for Health.
“We’re getting cost-containment results from Blueprint for Health and from the establishment of the Green Mountain Care Board,” Miller said. “Now we need to go into the next level of detailed business planning. We’ve got good macro-economic analysis of what the impact of a shift to single-payer would look like. But when you get down to, ‘What is the benefits package going to look like? What is the out-of-pocket structure going to look like? And how are we going to pay for it?’, these are things that have a lot of inter-dependencies and need some real micro-simulation to understand.”
The system, Miller said, should be designed in a manner that sets reasonable co-pay rates for preventative care, while not rewarding behavior that leads to chronic diseases that cost more to manage.
“The objective needs to remain the best possible health outcomes for people at a reasonable cost,” said Miller, who added he is not surprised that a financing plan for a single-payer system is still pending.
“There’s another layer of questions that need to be answered before we know what that total financing cost is going to look like,” he said, “and we want the ability to test the different ways it could be raised against the assumed structure, so that it works seamlessly.”
PAYING FOR SINGLE-PAYER
It’s clear at this point that a single-payer system would have to be bankrolled through a number of revenue sources, according to Miller. The intent is for any health care taxes to supplant what Vermonters are currently paying in health care premiums in the private marketplace.
“For a stable tax policy, you cannot rely on just one sliver of the economy to deliver a stable revenue base for anything,” said Miller. “This is why the state has diverse revenue sources. You can’t just rely on an income tax for everything; you can’t just rely on a payroll tax for everything. I think we’re going to find ourselves with a blend of revenue sources, some significant and some small.”
He stressed the revenue menu will have to recognize Vermont’s fiscal realities of being a small state bordered by other states that have not chosen to embark on extensive health care reform.
“Knowing what I know, I am confident we can design a system that is positive for businesses and something that they can compare to their other operations and have Vermont look attractive,” Miller said. “I recognize that the transition period is the hardest part of that. I am gratified that while we have been going through a period of uncertainty on this particular issue, we have still delivered the fourth lowest unemployment rate in the country and talked to a lot of new businesses in the past couple of years.”
Vermont will hire consultants to put a single-payer plan through economic modeling, according to Miller. And along with economic modeling, Miller and his colleagues will listen to people — a lot of them.
“I think one of the things that I do well is listen to people who are a lot smarter than I am,” he said. “It’s not like I come into this job with the idea that I am going to take over health policy. I am here to facilitate other really good people doing their work and to help arrive at the trade-offs that necessarily need to be made when you go through this much change, and to do so with an eye toward a ‘balance of interests.’”
Stakeholders, he noted, include the business community, medical providers, schools, municipalities and, of course, individual consumers.
“Ultimately, I believe that businesses’ interests are best served by having great, motivated employees who don’t have to worry about where their health care is coming from and don’t have to worry about whether or not their loved ones can get taken care of properly, so they can focus on the work that they do,” Miller said.
Miller said Vermonters should not construe his appointment as a “swing to the business side” in the health care debate, but interpret it as the debate having gotten to a point where it is ready to have a person at the helm who can balance the interests of the various constituencies and then make clear and objective recommendations to the governor.
It’s a process that he hopes is not overshadowed by politics.
“If I didn’t think this was steeped in a genuine effort (to improve health care), I would not be doing this work,” Miller said.
Nor does Miller see his latest assignment as a stepping stone for his own advancement in state government.
“I don’t think I will ever run for any office,” Miller said. “I feel like in doing this role for a few years, I am continuing my life’s work. I feel very positive about what I’m doing. But I’m not a lifer.”
ECONOMIC DEVELOPMENT
Miller is proud of the leadership he was able to give ACCD during his tenure. The agency’s outreach to businesses during a down economy have paid tangible dividends, he believes.
“The first period of time when I was out, it was always talking to people who were in distress, questioning whether they were going to have to lay more people off,” Miller recalled. “They had been through significant layoffs and cutbacks. There were businesses that closed. Unemployment was about 7 percent …  But now, when I’m out talking to people, it’s mostly about how they’re working with growth and new opportunities. We’re back to the regular business cycle.”
Businesses are now hiring and trying to entice more prospective employees into the job market, Miller added.
“It’s a tremendously different conversation,” he said.
Miller is also proud of the way his agency assisted stores, companies and industries that were devastated by Tropical Storm Irene in August of 2011.
“We had to refocus the entire agency’s purpose and work, for an extended period of time, on immediate crisis management,” Miller said. “That was a big deal. It was a big piece of work that we didn’t expect and I’m really proud of how the folks I work with responded to that.”
The ACCD also modernized its workspace and streamlined its operations during Miller’s watch.
“We saw Commerce work much more closely with Agriculture, the Department of Public Service and the Agency of Natural Resources,” he said.
Two Addison County lawmakers leading the health care reform effort in the Statehouse said they are pleased with Miller’s recent appointment.
“I think Lawrence will bring good leadership to the team; I think it is important for the governor to have someone close to him who is overseeing the various aspects of health care reform,” said Rep. Mike Fisher, D-Lincoln, who is chairman of the House Health Care Committee. “I also think Lawrence brings a new set of skills — development and implementation skills from the business community, and I think that’s a welcome addition.”
Sen. Claire Ayer, D-Addison, is chairwoman of the Senate Health and Welfare Committee. Like Fisher, she believes Miller will bring a business voice to the health care debate and provide another capable person to share what has been a larger workload than she said anyone anticipated.
Miller is anxious to roll up his sleeves and get started.
“This (assignment) was not on the path I thought I was traveling,” he said. “You can always say ‘no’ (to a job offer), but sometimes when you say ‘yes,’ it makes life more interesting.”
Reporter John Flowers is at [email protected].