A confidential contest to see who will assume one of the most powerful seats in Vermont’s healthcare landscape is now taking shape.
When Green Mountain Care Board chair Owen Foster announced in July that he would be stepping down, it kicked off the formal process to find his replacement.
Vermont law stipulates that a nine-person nominating committee — composed of senators, representatives and healthcare experts appointed by the governor and legislative leaders — submit a list of qualified applicants to the governor. Then the governor picks their preferred candidate, who is subject to approval by the Senate, much like the judicial appointment process.
The process is confidential, but that does not mean it escapes public scrutiny, especially as the board’s role has seen a “seismic shift” under Foster’s tenure, as one observer put it. And the soil is fertile for change under new leadership: At the end of September a healthcare watchdog group gave a broad overview for how the Green Mountain Care Board can expand the metrics and processes it uses to set hospital budgets and insurance premium increases.
Gov. Phil Scott is advocating for ways to “reform (Vermont’s) regulatory system away from the legacy architecture” of single payer, as a representative for his campaign wrote to VTDigger earlier this month. The care board is the main regulatory body that still exists in the wake of the single-payer effort.
The board’s role in Vermont’s healthcare system has evolved since its 2011 creation as part of a push for single-payer. Now, the board’s chief responsibilities include approving hospital budgets and health insurance premium increases for plans sold on Vermont’s Affordable Care Act marketplace. Under Foster, the board has taken that authority seriously, slashing the revenue hospitals are allowed to collect from commercial insurers year after year in an effort to force lower prices for insurers and their patients.
The stakes are high for consumers, with the cost of premiums for individual marketplace plans compounding to increase 74.6% between 2021-2025, according to the office of the Health Care Advocate. The care board has tried to curtail that drastically, approving increases between 1% and 6% for those individual and small group plans for 2027, even as the rest of the nation sees median increases of 15%.
Foster described the chair as wearing two hats. In one, the chair has equal voting power to any of the other four board members. But wearing the other, the chair has the unique authority to direct the care board office and staff of nearly 30. The chair sets the care board’s policy priorities, the research its analysts do, its legislative stance, and relationships with other agencies, the governor’s administration and the federal delegation.
“By being able to task the office with what work to take on, you can decide what problems get understood and they get addressed,” Foster, who remains as the care board’s interim chair until his replacement is selected, told VTDigger in an interview.
Foster will leave Vermont’s hospitals in a different place from where he found them when he joined the board in 2022. After a tenure defined by an effort to shrink hospital budgets and move care to lower-cost settings, Foster ended by supporting less aggressive budget cuts for the state’s largest hospital, University of Vermont Medical Center.
“I hope that the next chair continues that trajectory,” said Chris Pearson, who now leads the healthcare advocacy group VT Healthcare 911. He previously sat on the care board nominating committee.
Pearson described the change in the healthcare landscape from one where “spending at hospitals had really ballooned and our premiums were top in the nation,” to one where hospitals, insurers and regulators alike are working towards a shared goal of keeping costs low.
“Frankly, now we are centering Vermonters and the affordability question in the process, which had been missing for a long time,” he said. “I think our state owes (Foster) tremendous gratitude for being willing to tackle just a massive industry.”
But the decision on how the next chair might continue, complement or counteract Foster’s legacy is entirely up to the governor. It’s not the selection committee’s job to prioritize any specific philosophy on regulating, Pearson said. It’s really just a vetting body to send the governor qualified candidates.
“In some ways it’s dull. I didn’t get to inject my politics into the process,” Pearson said.
To Sen. Ginny Lyons, D-Chittenden Southeast, who chairs the Senate’s healthcare committee and also previously sat on the selection committee, an apolitical approach is the point.
The committee should look for someone with “the capacity to understand and distinguish what really needs to happen without taking one’s prejudice or bias into that decision making,” she said.
Still, she said, it’s important to listen to the ways a candidate articulates ideas for how the board may be improved and which parts of the healthcare system need better regulation.
Specifically, she is curious to see how the new chair will approach costs embedded in the healthcare system beyond the board’s regulatory scope — things such as primary care or self-employed and employer-sponsored insurance plans.
In a written statement to VTDigger, Scott’s press secretary Amanda Wheeler said that the governor has encouraged the nominating committee to seek qualified candidates, including those with “a proven ability to improve organizational performance.”
“As Vermont works to improve access, increase affordable choices, and reduce costs, the next Chair of the Green Mountain Care Board will play a critical role in helping build a healthcare system that is more affordable, transparent and accountable to the people it serves,” Wheeler wrote.
Foster advised the new chair to look broadly at the healthcare system.
“The Green Mountain Care Board’s biggest lever, by far, is hospital budgets,” he said. “But it’s not unlimited.”
Now the areas with the biggest potential to reduce costs lie in sectors the board has no authority over, according to Foster. Savings need to come from the ongoing work of redesigning the hospital system, addressing pharmaceutical costs or regulating other insurance plans, he said.
“As a state we need to get together and determine what the affordability goals actually are and define them and say what they are, and then come up with a plan as a state as to where to get there,” Foster said.
