Here's a pitch for the next reality survival show: Raise the cost of healthcare to extremes, make providers pay enormous medical malpractice rates and under-reimburse them for their Medicaid and Medicare patients, allow medical facilities to compete by duplicating services while operating financially in the black, use healthcare dollars to balance the budget, let politicians vote down healthcare programs at their will.
Then see who wins.
TV execs would shake their heads. "It's already been done," they'd say. Indeed.
In Washington state, 650,000 people (about one out of every 10) do not have health insurance. Nationally, the number of uninsured people is around 45 million. On average, Medicare and Medicaid reimburse healthcare providers at less than 60 percent of the cost of care, forcing providers to be more selective about whom they treat. The operating margin for most of Washington's hospitals is miniscule. Costly emergency room visits have increased because they're the only way many uninsured people know how to obtain medical attention. Pharmaceutical companies are pushing doctors to prescribe an increasing number of pills at an increasing price, just as many physicians find themselves practicing defensive medicine and rummaging through red tape to avoid the career-ending disasters of the tort system.
Our nation's healthcare system, in other words, is complicated and catastrophic -- and it can't survive this way much longer. Yet there is some good news: Our leaders finally agree, at least, on that much.
On Oct. 28, a panel of Washington state healthcare experts, including insurance commissioner Mike Kreidler; the Secretary of the Department of Health, Mary Selecky; and the Board of Health's executive director, Don Sloma, declared unanimously that "Washington's healthcare system is in crisis." Each of them promised to take steps to resolve cost and coverage issues.
Field of Dreams -- More than 300 "fans" showed up at the Seattle Seahawks Stadium and Exhibition Center on Oct. 27-28, but they weren't there to watch Shaun Alexander. Healthcare providers, business leaders, consumer advocates and politicians all showed up to root for a better healthcare system at the first annual Washington Health Summit. It may be surprising, but the summit marks the only time in the state's history that healthcare leaders from all 44 counties in Washington state -- from every branch of healthcare -- have come together to discuss the system.
"I [expect] to hear leaders from the political, medical and business communities meet together and have an open discussion about how we're going to provide quality healthcare to all Washingtonians, not just some," said Mark Johnson, a family physician, just before the meetings started. "Assuring fairness and equity -- that's the problem right now. We've got people with no insurance and who can't get any medical care."
Johnson, in his final year of residency, works at the 45th Street Clinic in north Seattle, a federally qualifying health clinic for the under-served. Johnson sees patients with little or no insurance. He says that stereotypes about the underinsured and the uninsured aren't accurate.
"One of my patients is a 24-year-old student at UW," Johnson says. "He just doesn't have insurance because when he turned 23, he had to get off his parents' insurance. He came in, and I ended up diagnosing him with multiple sclerosis. What my clinic can do is have a pharmacist spend time getting medicine donated. If he would have to pay for his own medicine, it would be something like $3,000 a month." Johnson says his patient's M.S., without treatment, could put him in a nursing home by the age of 40.
After the summit at Seahawks Stadium, Johnson was headed to Los Angeles, where he would attend a nationwide conference for family physicians. He says that being politically involved in healthcare policy is intrinsically linked with being a good healthcare provider. The 45th Street Clinic, and many like it in Washington, has dwindling resources.
Johnson isn't the only one concerned about the imbalance of decreasing resources and increasing patient needs. The Washington Health Foundation (WHF), which organized the summit, is a nonprofit that works to reform Washington's healthcare system by encouraging collaboration among providers, policy leaders and community members. The organization has worked diligently to involve the state's healthcare consumers and workers with its policymakers.
"We have the right type of people here," said Greg Vigdor, president and CEO of WHF, scanning the gathering. Vigdor founded WHF in 1993 in the hope of transforming Washington's healthcare system. "We have someone here from every county in the state," he says. "That doesn't even happen in the state legislature."
For the past year and a half, WHF has traveled to each of Washington state's counties, holding meetings for members of the healthcare community, providing a forum for people to discuss the system's problems as well as what values they'd like to encourage in healthcare policy. Next, WHF organized last week's forum. From there, Vigdor said, it will be up to participants to begin changing the system.
"Our only bias is that something big needs to happen," said Vigdor. "Can we accept that health is a major social problem? You need policy, you need politics, and third, you need the public. We set up the WHF to work on the public part. People need to accept it and care about it, or it will never be solved."
Grass-Tops Movement -- In front of hundreds of summit participants appeared a panel of Washington state healthcare experts, from different and often opposing, sides of the system. Steve Leahy, president of the Greater Seattle Chamber of Commerce, sat near Robby Stern, special assistant to the president of the Washington State Labor Council; Deana Knutsen, chair of the board of directors for Washington Citizen Action (a grassroots advocacy organization) sat close to Mike Kreidler, Washington's insurance commissioner. They were there to speak candidly while brainstorming about the healthcare system.
For many, listening to leaders take responsibility and assure action was an invitation to expect more.
"I am going to go back to my Chamber of Commerce and start asking, 'What are you doing about [the healthcare crisis] and what can we do together?" said Susan Eastman, a representative from the American Academy of Nurse Practitioners. Eastman works at the Reardan Health Clinic in Reardan, Wash. She, along with many healthcare providers at the summit, said she wanted her community to understand that solving the healthcare crisis will involve activism on many fronts. Vigdor, president of WHF, agrees.
"The usual social change is through conventional and narrow models," explained Vigdor. "You take a bill to Olympia, politicize it and get people to support it. You get your 50 votes and that's how it happens. A lot of my career was based on that, and some good things happened, but few of those were long-term changes. The system is built to make sure nothing changes too much -- there are all these checks and balances. So the question [is], 'What do you do when there is a need for a dramatic change?'"
That question has sparked revolutions the world over, but for WHF, it signifies something more constructive: It means dialogue, it means helping people to network with others, and it means putting pressure on politicians to do their jobs.
After two days of panel discussions and dialogues, summit participants worked on drafting a resolution indicating a commitment to changing the healthcare system; it lists a set of shared values for what the healthcare system should look like. (See "The Nine Commandments," page 17.) Gov. Gary Locke was the first to sign the resolution.
"Good healthcare cannot be a privilege for the few," said Locke in a speech to participants. "We need a national solution, but our state must also feature personal, governmental, social and business responsibilities. No sector can sit this out. We must work together. We need fairness. We need bold solutions."
Gubernatorial candidates Ron Sims and Phil Talmadge also came to sign the resolution.
"We can't wait for the federal government to [fix the healthcare system]," said Sims. "The federal government can't do it; they don't have the money to do it."
"Healthcare is the reason I decided to run for governor -- 65,000 to 70,000 people are going to lose [insurance] because of the last legislative session," added Talmadge. "We've got to get the state's own house in order."
For those who have spent years pounding away at healthcare, trying to introduce positive changes, the summit may have seemed like a group hug of sorts -- comforting, yes, but what comes next?
Vigdor would say his group's approach is slow-building, so that whatever solutions emerge are lasting. "Some of the work is grassroots," he said, "and some of it is grass-tops -- like this summit." Vigdor said that the value of gathering leaders together cannot be easily quantified. "These are the people who have innate knowledge, sales people who can galvanize back home. It's not just coming up with ideas from experts, but [it's finding] the message that sticks."
Vigdor, like many social change theorists, believes in evolution, not revolution. He sees an organic transformation of our healthcare system. It will change because it has to, but it won't happen immediately and it probably won't happen soon. That may leave some frustrated, but in the meantime, the frontline healthcare workers will continue to innovate, helping people along the way. Perhaps in that range of efforts, solutions will emerge.
"I think the next step for all of us [is] to describe concrete ways in which to provide equal access and fairness," said Johnson, the Seattle family physician. "We need to talk about how we're going to achieve that goal."
"Why are you here?" Vigdor asked the summit participants. "What history are you trying to build? We have to do more over the long term to see if we have the energy, the will and the collective wisdom to move forward. In one way or another, we need to come together... to say we are willing to work on this issue into the future and solve the problems for the people of Washington. What we're building on is a really, really long beginning."