Tackling Health from the Inside: A Conversation with Former Vermont Governor Peter Shumlin
By A. Taylor Thomas
“I actually got into [public service] by mistake.” Struggling with dyslexia before it was recognized as a learning disability, Peter Shumlin never thought he would be the bold political leader he is today. Motivated by his personal learning struggles, Shumlin realized he wanted to change students’ lives. After graduating from Wesleyan in 1979, he returned home to Putney, Vermont to help his parents run a program that provides international educational experiences for high school students. During this time, Shumlin learned the Federal Bureau of Prisons wanted to put a maximum-security prison at the site of Windham College, a small college that shut its doors in 1978 after going bankrupt when enrollment dropped (it was after the Vietnam war, so draft avoidance ended). Though the selectmen, the executive arm of Putney’s town government, had approved the project, the community was outraged at the prospect of a penitentiary disrupting their small-town way of life.
As a champion for students, Shumlin hoped to preserve the educational roots of his town and helped convince the Federal Bureau to abide by a town vote. Shumlin and others knocked on doors for support, and the town beat the vote 90–10 in an overwhelming victory. Following the triumph, the community rallied behind Shumlin and successfully petitioned for him to serve on the select board. Shumlin vowed to find a better alternative for the former site of Windham College, and ultimately attracted Landmark College, the first higher-learning institution to innovate college-level courses for students with dyslexia.
So began his long tenure in public service, serving in the Vermont House of Representatives and Senate, and ultimately as the 81st Governor of Vermont from 2011–2017. Known for his bold policies, Peter Shumlin made the Green Mountain State the first to enact universal pre-kindergarten education. He also passed mandatory GMO-labeling and turned Vermont into a leader in renewable energy. Because of his leadership in climate change, President Obama invited Shumlin to speak about his state’s renewable energy plans at the Paris Climate Summit in 2015. Also known for being a pioneer in healthcare, Peter Shumlin first spoke with the Voices in Leadership series in September of 2017 about his attempt to implement a single-payer state-run healthcare system in Vermont.
The Voices in Leadership series was happy to welcome back Peter Shumlin on Wednesday, September 25, 2019 to continue the conversation about the United States’ most pressing healthcare issues and the insight he acquired while attempting to tackle these problems from the inside. He was interviewed by Dr. Benjamin Sommers, Professor of Health Policy and Economics in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.
Opioid Crisis: Unearthing an Epidemic
A series of reports came out in the 1990s concluding physicians underestimate patient pain, with many cancer and elderly patients living out their final years in tremendous, unnecessary suffering. Increasing concern over the undertreatment of pain led to its introduction as the fifth vital sign and new guidelines encouraging physicians to prioritize pain management. At this same time, Purdue Pharma developed the opiate OxyContin and started aggressively marketing it to doctors as a long-lasting, less addictive opiate. Opiate prescriptions soared, as did addiction. Over 80% of opioid addictions today started with prescription misuse, and opioids contributed to 47,600 deaths in 2017 alone. To date, the opioid epidemic is one of the worst public health crises in U.S. history, and U.S. life expectancy has decreased two years in a row for the first time because of it.
As Governor, Peter Shumlin unknowingly stepped into a raging opioid crisis that had been brewing for years without public notice. When Peter Shumlin took office in 2011, the growing opioid epidemic had yet to surface. Since Shumlin’s dyslexia precluded him from sitting at his desk reviewing briefings and reports, he spent most of his days out of the office speaking with constituents about pressing issues. He got under the hood of cars to speak with mechanics, went to prisons to speak with incarcerated people, and knocked on doors with law enforcement. It was through these candid conversations that he discovered the magnitude of the opioid epidemic in Vermont. He shared:
“I constantly had folks coming up to me…‘I want tell you about my son. I want to tell you about my daughter. I want to tell you about my grandkids that we now have because of what’s happening to one of our relatives.’ You just couldn’t make it up.”
In 2014, he dedicated his entire State of the State address to the opioid crisis, despite concerns that it would bring negative attention to the state. Governor Shumlin opined: “My job as governor is to protect our quality of life. And this is the one thing that could drown us.” At the time Shumlin made his State of the State speech address, someone in the U.S. was dying of opiate overdose every 22 minutes. Today, this rate has sped up to every 13 minutes. Enraged by these harrowing statistics, Shumlin set off to change the criminal justice system so addiction could be treated as a disease and not a criminal offense. Governor Shumlin signed bills and executive orders to increase the number of treatment centers and improve access to naloxone, an opioid antidote. “We did everything everyone else was doing,” Shumlin admits, “but here’s the one thing we didn’t do: solve the problem.”
To Shumlin, the solution is simple: we need to change prescription practices and stop “[passing] pills out like candy.” People in the United States use almost 80% of the world’s opioids, although the U.S. only makes up 5% of the global population. And 80% of the U.S.’ opioid addictions arise from prescription misuse. To him, it’s clear that “This is a problem created by big pharma that profits big pharma to this day.” He scoffed at the Sackler Settlement, pointing to the futility of past agreements. For instance, in 2007, Purdue plead guilty for misbranding OxyContin and paid a US$640 million fine, but had made over US$1 billion in OxyContin sales in that year alone. Today, it costs the government US$18,000–22,000 per person to treat opioid addiction. The money from the Sackler Settlement will go towards these people’s drugs for constipation (a side effect of opiates) and naloxone, whose prices have increased as much as 600% in recent years. Shumlin argued that the Federal Drug Administration (FDA) needs to re-examine the safety and efficacy of opiates, to change prescription practices and address this crisis at its source.
Healthcare Reform and Economics
During his tenure as Governor of Vermont, Peter Shumlin unsuccessfully attempted to pass Green Mountain Care, which would have been the first state-run universal healthcare program in the country. Governor Shumlin spoke candidly about the insights he gained into our dysfunctional healthcare payment and delivery system, explaining how in a healthcare economy that values quantity over quality, providers are rewarded for the number of patients they see, rather than their patients’ outcomes. Shumlin argued that in order to fix the ineffective payment system, the United States must simultaneously fix its healthcare delivery system, a change which must be provider-driven. Under current fee-for-service models, providers focus on volume and do not have the time to adequately address the individual behaviors or structural factors that affect their patients’ health. By switching to a payment system that values quality over quantity, like capitated or value-based care, only then, Shumlin argues, will we see providers take a greater interest in disease prevention and see a reduction in treatment utilization and cost.
In reflecting on healthcare reform’s obstacles, Shumlin concluded that the biggest challenge is “the way we talk about it”. He spoke frankly about needing to talk about healthcare in terms of economics, to depoliticize the topic and win approval of physicians and patients alike. At current reimbursement rates, primary care providers are seeing more patients each day and making less money than they were 30 years ago. Burdened with an average of $200,000 in medical school debt and intensive low wage residency training, low reimbursement is one of many reasons young physicians are opting for higher-paying specialties or leave medicine altogether, contributing to the shortage of primary care doctors. Shumlin argues that a shift toward capitation, salaried, or value-based payment models would reward primary care providers financially for outcomes, while allowing them the flexibility to spend more time with complex patients.
He applied a similar economic approach to the single-payer debate. Regarding the rhetoric around single-payer healthcare, Shumlin pointed out that people “scare easily” when they hear taxes will increase:
“I always say Trump got one thing right. The American people were frustrated with incomes that hadn’t changed in 10, 20 years…What he gets wrong is blaming it on… all this other stuff. It’s all about the fact that we’re spending money on health care.”
Employers funnel much of American’s well-deserved wage increases directly into health benefits to keep up with the rising cost of care. But U.S. employees do not see how much their employers pay for health insurance — they only see stagnant wages and increasing insurance premiums. According to Shumlin, the average health insurance in Vermont for a family of four costs US$22,000, that’s almost 40% of Vermont’s average household income of US$57,513. And this is projected to grow to US$47,000 in the next three years, what would be a whopping 80% of Vermonter’s current annual income. Under a single-payer system, the government would have the negotiating power to decrease costs and curb healthcare spending. While there would be an increase in taxes to cover universal healthcare, the tax increase, it is argued, would be less than the current amount employers would be spending on health benefits. The implication is these large sums that employers are spending on health benefits would be redirected into employees’ wages.
Controlling health spending is vital, as the cost of healthcare will only continue to grow. Our environmental, food, housing, transportation, and drug policies increase our risk of physical injury, chronic disease development and exacerbation, infectious disease outbreak and opioid abuse. These issues, Shumlin warns, will all land on the provider’s doorstep. In fact, as in the case of the opioid crisis, they already have.
Be a Temp
Acknowledging that future generations will be facing daunting tasks, Schumlin concluded with one final piece of advice: “be a temp”.
Speaking candidly about the demands of public office, Shumlin urged those looking for glamor or power to look elsewhere. “It isn’t all that much…you work all the time.” Shumlin emphasized the stress the work places on relationships and the difficulty balancing public and family life. But for those motivated to make change, there is nothing better. He implored the room of aspiring public health leaders to be temps, however, instead of career public servants.
In reflecting on his public leadership, Shumlin’s proudest accomplishment was that he was a temp. As a small business owner and real estate partner, Shumlin took a pay cut when he became governor of Vermont. He wasn’t concerned about keeping his job as governor, he was concerned about making change. Being a temp enabled Shumlin to pursue a bold policy agenda and trigger substantial progress in the Green Mountain State.
“In politics, it is easier to say no than it is to say yes. It is easier to prevent change than it is to affect it. Don’t try to be a full-time employee because then you will be focused on re-election. Be a temp… because then you will make real change. You won’t be concerned about what the polls say…you’ll get the job done.”
Story written by A. Taylor Thomas, who is currently taking a year off between her 3rd and 4th years of medical school to pursue a Master of Public Health in Health Management at the Harvard T.H. Chan School of Public Health. She is interested in the intersection of clinical care, health policy, and health management
Story edited by Sherine Andreine Powerful, MPH, a second-year Doctor of Public Health student at the Harvard T.H. Chan School of Public Health. A Diasporic Jamaican, she received her Bachelor’s degree in Latin American and International Studies from Yale University and holds a Master of Public Health degree in Population and Family Health, with a concentration in Global Health, from the Columbia University Mailman School of Public Health. Her interests, centered around the English-speaking Caribbean, include feminist global health and development leadership; gender and sexual health, equity, and justice; and resilience and anticolonial sustainable development in the context of climate change.