Healthiest State Blog

WHF Recognized at Challenges in Caregiving Conference

Janelle Guthrie, Director of Communications for the Attorney General

Caring for her ailing father helped Janelle Guthrie understand the importance of supporting caregivers. It also brought Ms. Guthrie, the Director of Communications for the Attorney General's office, to the annual Challenges in Caregiving Conference, where she gave a moving speech in praise of caregivers.

Ms. Guthrie's speech struck a personal note when she described her own experiences with caregiving. "My father passed away in 2009," Ms. Guthrie said, emotion swelling in her voice. "My mom stepped up as a caregiver just like all of you, and she'd never been a nurse, she never had any experience doing all of that, and throughout the time that my dad was sick, we did many things to try to help her through that." Ms. Guthrie spoke of how the experience left a special place in her heart for caregivers, who often have no choice but to help a loved one in need.

She highlighted several of the WHF's ongoing projects to support caregivers, including:

• A deck of cards designed to inspire mutual healing between care partners.
• The Alzheimer's Cafe program, a network of cafes where care partners can bond in a social setting.
• Early stage memory loss programs, a partnership with the Greenwood Seniors Center to help care partners express themselves through improv theater, self-reflective and guided journaling, somatic yoga, free drawing, and film screenings.
• The Arts and Dementia Care Coalition, a way to share resources between those who work to provide arts-based programming in the field of dementia care.
• Music and the Brain, an upcoming forum on brain health in collaboration with Songwriting Works Educational Foundation. The forum brings together experts on neurology, music, and myth to explore their relationship to brain health. Check out our event page for more information about the upcoming event in Port Townsend, WA on June 18.

Ms. Guthrie went on to detail the productive relationship between the WHF and the Attorney General's office, built on the Attorney General's history of supporting vulnerable adults and seniors. That support extends not only to the sick, but to caregivers as well. "Caregivers are the invisible heroes in this work. They face some of life's most difficult moments with unparalleled grace and dignity," Ms. Guthrie said. "Caregivers, the people who give so much of themselves, deserve to get something in return."

Center For People's Health

Change. For the past 20 years – the Washington Health Foundation has been calling for it, working toward it and innovating to drive it. Change is at the very core of our organization’s DNA. Today…..we are changing. Not our mission. That will always be to improve health for the people of Washington. The change lies in how we plan to reach that lofty goal.

We are reorganizing our work around a bold new concept that we are calling the “Center for People’s Health.” This ‘Center’ will allow us to continue to serve as a connector of various entities toward better health while focusing more attention on individuals and families, and helping them connect with the disparate parts of a fragmented health system.  The Center for People’s Health is the backbone the Foundation’s ten-year strategic platform for pursuing its vision of making Washington the Healthiest State in the Nation. Our core beliefs and our core values will not change and we will continue to stand shoulder to shoulder with the people of Washington to fight for better health. But that fight comes at a cost and the Washington Health Foundation will require additional resources to pursue this strategy.

We will be unveiling the details of our Center For People’s Health when we announce its Grand Opening in the spring of 2013. More information on this exciting new program is coming soon!

Governor's Health Bowl Week 6

Personal Responsibility- Opportunities and Challenges for a Healthier America
by: Greg Vigdor, Washington Health Foundation President & CEO 

The 2012 presidential election is only a few weeks away and it seems like Barack Obama and Mitt Romney can’t agree on much of anything. Lots of arguing, lots of finger pointing…..but not much common ground. Funny thing is – one of the only things they do agree on, they’re wrong about!

Both candidates have revealed by action that, despite the rhetoric, they are in pretty much the same space with regard to how to deliver and finance medical care.  That is, through the current American health care delivery system, rather than some major change to it. Haven’t we tried that long enough? Isn’t it time we look for new ways to fix our broken system? 

For example – one of the health issues that has popped up in the Campaign is the reference by Governor Romney to the now infamous "47%”.  Specifically, the suggestion, spoken by the candidate but usually unspoken yet believed by many leaders on both the right and left, that nearly half of all Americans are unwilling to take "personal responsibility" for themselves. Right or wrong, that idea is worth taking a look at – particularly if we want to move toward real change in the health system.

As explained many times in our Healthiest State blogs, emails, letters to the editor, and other communications over the past decade, this 47 percent thing is a pretty big deal if it’s true.  This is because the "social determinants of health"- which detail how it is that we can produce health for ourselves, our families and our communities- largely depend on people taking action to improve their health.  More than half of these social determinants relate to our individuality, outpacing such significant community based determinants such as education, housing, and the like.  Even more striking is that individual action dwarfs the potential of medical care to produce health. The numbers clearly bear that out; while consuming over 97% of our health resources, medical care contributes no more than eight-to-ten percent to the creation of health.   

So, it is a fundamental starting point for our Healthiest State Campaign that we must engage people to take responsibility and action to improve health.  Much of our multi-million dollar financial investment in the Healthiest State Campaign related to helping people do this over the past 8 years. Even with limited organizational resources, we were incredibly successful in doing so.   

From this extensive work, I would observe that it is relatively easy to get people to take action to improve their health, if presented with the right frame and opportunities. It is critical to speak to peoples’ aspirations and hopes more than their fears.  Through practical and meaningful ways to get engaged, and even better if imbued with fun, competition or other natural motivators.  And even more powerful when we can reach out and listen to them as individuals and develop customized solutions for them, rather than canned answers from insensitive bureaucratic systems.  For example, what our Personal Health Advocates do to help people figure out how to pick and use their health coverage - including how to help clients accept personal responsibility for some facets of their health.

Yet, doing this work on a grander scale remains a challenge, largely because of the way the call for "personal responsibility" plays out practically in our society.  First, health care organizations, political parties, government bureaucrats, and others who benefit from the status quo make it hard for organizations like ours, or untold millions of people, to pursue their dreams for health and their willingness to take greater responsibility for health.  It just isn't in their interests to help people do this, so they point their huge resources at other things- the things that benefit their bottom line. Shame on them.

To counter this ‘resistance to change’, we need to find some change juice in the public, or a more transcendent national belief in the better angels of our nature.  Yet, the opportunity to do so also gets caught up in the loud philosophical divide of thought leaders on the left and right over social issues in our Nation.  They may share a belief in the end result of better health behaviors by people, but filter it through their ideological purity.

On the left, the usual refrain is that we must create health by collective action.  On the right, by greater personal action.  Our belief - supported we think by the vast majority of regular people who consider this question- is that you can only achieve this by building not just action but responsibility for doing both.  We must both promote personal responsiblity AND build greater collective responsiblity.  It is NOT one or the other.   

On the left, there is usually lip service to the role of the individual and need for personal action and responsibility but an overwhelming focus on how the collective will create better health FOR people.   One basis for this is their sympathy for the plight of many of those in need of better health behaviors- the poor and needy- who don't have the resources, time or circumstances to take greater responsibility.  So, they say, we must find ways to help them.  And, it would seem to us, we should.    

But for many on the left, it seems like it is far more about a philosophy that relies on state paternalism.  That is, a belief that it is the government's job to force better behavior on behalf of the whole. For example, the Affordable Care Act provides major new resources to pursue health through a Prevention Fund (something that we argued strongly for during the health reform debate).  But, the bureaucracy of the federal government's use of these funds largely misses the connection to apply this to the opportunity of personal action.  The vast majority of the millions of dollars in new money is being directed at government efforts to take collective action through "policy change" toward healthier habits, rather than more directly trying to change behavior at the individual level.  Their argument is that the policy environment will set the tone for healthier living and better personal behaviors, deploying health improvement by making the healthy choice the easier choice for people.

It is not an argument without merit- and a major part of our Healthiest State Campaign over the past 8 years has aimed to implement this ideal in Washington state.  For example, by requiring the inclusion of tobacco cessation drugs in the state medicaid program. That allowed  addicted smokers access to the necessary tools to help them stop.  Or making healthy options available in vending machines. Another example would be requiring informed consent by parents before they choose to not immunize their children.  These types of strategies are supported by evidence that suggests they can succeed as part of a broader effort to build greater personal health action on the part of people.  But they will not work alone- witness a recent study that points out how people who live next to a new park actually use it for physical activity less than others. Or, think of whether you reach for the chocolate cake or the fruit bowl at parties. 

We also need to be exceptionally careful when trying to create personal health through the arm of government.  How far can this go?   Should the state compel healthy choices by outright bans on certain products (tobacco, ingredients in food, etc.), requirements to take certain acts (use seat belts, bicycle helmets, etc.), or tax penalites (e.g., cigarette taxes)? More accurately, since many of these already exist, where is the line that justifies the government to do so in some cases or ways versus others?

We have taken the view that individual health decisions through government action should be an approach of last resort. It should only be pursued in those instances where there is a compelling need, and when the case has been made strong enough that a clear consensus of people exists to support the proposed government action. Not just majority rule, but 70% or more of people in agreement.  It just doesn't seem like the unfettered growth of the public health police fits with who we are as a Nation, outside of intervening in true public health emergencies like a pandemic flu.

The debate on this now has a new twist with the primacy of health insurance and coverage as the means to manage the financial insecurities of our health needs.   That is, if we all share in the cost of bad individual behaviors through how we finance our health care, then doesn't this now justify even greater intrusion into behaviors that push costs on to the whole?  That the Supreme Court has upheld the ability to require all to buy insurance fuels the fear among some that this Act is opening the door to a far more intrusive role by the state into our personal behaviors than ever before. Perhaps it is an unfounded fear; perhaps not.

Those in public health tend to support the world view that it is their collective actions that should be supported into the future, rather than direct people strategies.  Some of this certainly means putting financial resources into their agencies and work, but it also seems that it is the result of the odd view that service to the individual is already being managed by the health care system.  I kid you not- I have heard this stated as an agreed upon truth at public health conferences.   Odd, because while the medical care system surely deals regularly with personal health issues, it is notoriously bad at helping people manage their heatlh behaviors.  Its strength is intervening in times of illness or injury, but it has shown little ability to manage people's health over time. In particular,  how to help people adapt to the life changing circumstances that negatively affect their health.  You know, the things that really challenge our ability to be healthy. If the medical care system does intervene in such circumstances, it usually does so with a short attention span focused on clinical issues and not the person's larger life transition. It also gravitates toward canned products forced on people, rather than customized personal level solutions that can activate personal responsibility and action.  If you have been following our work, this is why we believe the bigger transformation needed in the health care delivery system is our notion of a Health HoME. A Health HoME is designed to empower people so that the system responds to them, not the other way around.  

Now, this all might sound like a diatribe against the left and its formulations about how to improve health. But the commentary really stems from the reality that throughout most of our Campaign, "democrats" and therefore the left have largely been in charge of health policy. That gives us a lot more real examples to comment on and be critical of - certainly in our state and at the national level through the passage of the Affordable Care Act.   

But don't misinterpret me to believe that the "right" has some stronger position with respect to this issue of personal responsibility and engaging individuals.  While they are more likely to invoke the words "personal responsibility", as we heard from Governor Romney, there is little in the way of meaningful policy suggestions as to how to create this for people.  It seems a talking point more to criticize the left than a policy principle for hammering out a plan to really help people build on their personal responsibility for health in modern America.  Or worse, as was suggested in the video, a reason to just ignore their needs because they can't be helped. 

When pressed on the policy translation of personal responsibility, the right usually goes to other talking points, such as the need for "choice", as if this magically creates responsibility.  Missing the fact that limitless choice frequently overwhelms people who are trying to take responsibility- and what can be more confusing than the health and health care system already?   There is also the common theme of money in the conservative toolkit. The idea is that finances can somehow drive personal responsibility through financial incentives or penalties. But this is almost always framed around how they might pay for health coverage or medical care, not how they might pursue actual health improvement.

Well, we do think there are some things that can be done to stimulate personal responsibility, despite the lack of inclination of those on the left and the right to actually do so. Financial incentives can be part of the overall toolkit.  So can setting the context for individual action in ways that make it easier for people to activate this concept of personal responsibility.  But what we need is broader and multiple levels of practical supportive approaches that allow personal responsibility to activate, thrive and carry the day for health improvement.  Joined by a broader belief that building health through people is the heart and soul of the agenda for action.  It is the very approach that our Healthiest State in the Nation vision was built around.

We were told that these notions were crazy when we began our Campaign-  by ideologues on the left and the right and many within the health care system vested in protecting the status quo.  But our work in the Campaign has shown us that it isn't crazy.  Rather, that it can work!  Just one piece of evidence is the Governor's Health Bowl.  Through the unwavering engagement and support of the people of Washington – the Health Bowl has generated more that 25 million miles of health during the past eight years. It is truly a staggering number! In addition - it is living proof that one can use the aspiration of health, along with fun opportunities to do this with others, as a way to build personal responsibility.  

Has it made us the Healthiest State in the Nation?  No. Will it get us there by itself as a strategy?  No.  But it is clear that it is an example of how one can engage many people in healthier behaviors that they are responsible for initiating. Even while we also search for practical ways to support collective actions to improve health.  And then blending these and other practical approaches into an effective overall strategy for making a difference in health- rather than fighting over ideology or using divisions to advance political, financial or other self interests.

More thinking like this might indeed be the way forward to address what stands as the largest stumbling block in building a wave of health improvement in this country through individuals and their actions. That should be something we can all agree on no matter who gets elected.

 

Governor's Health Bowl Week 5

Avoiding Addictions

By: Greg Vigdor, Washington Health Foundation President & CEO

Addiction. It is a frightening word and with good reason. Most of us know someone who has battled (or continues to battle) an addiction and we often witness firsthand the toll it takes it takes on them and their family.

Addictions are one of the greatest threats to our health, both individually and collectively. They are also a driving force behind some of our most adverse health consequences. For example, smoking is one of the leading causes of death through its association to cancer, heart disease and stroke. And then there’s alcohol and drug abuse – each with its own myriad of poor outcomes, from failing livers to motor vehicle deaths to accidental overdoses and more. It’s hard to overstate the extent to which addictions can affect our lives. Here at the Washington Health Foundation – we fully realize that addictions create a major barrier to our vision of making Washington the Healthiest State in the Nation.  

This is why "Avoiding Addictions" is one of the six key action areas of our Healthiest State Campaign.   It is not just that smoking, excessive drinking and drug abuse is bad for us in terms of health outcomes; for many people, the addiction is one that carries psychological or physiological qualities that form habits that cannot be easily broken. Many find themselves powerless to stop their behavior, and the impact on their lives and others spins out of control.  

So, the best thing to do, as our action area suggests, is to avoid the addiction altogether. We understand that is often easier said than done, but there are strategies we can use to help battle this ever-growing problem. Whether it’s through health education, disincentives, policy, or by engaging potential users to take control of their own lives through our suite of Health HoME tools  – there are things that can and should be done to help people avoid dangerous addictions. These strategies can be successful, if they are applied correctly. Rarely are addiction strategies easy to implement and often they can be controversial. Witness the war on drugs, and the serious social question of whether incarcerating huge numbers of people for marijuana possession is the right way to limit drug use in American society.

However - the larger issue seems to be that so many people are already addicted.  Do we just focus on those who are not yet addicted, or try to intervene (from a health standpoint) on behalf of those who are already under the spell of these behaviors? Recent history would indicate that we often choose to intervene for many addictions that are already rampant in our society. Tobacco cessation is one of the major health strategies of the past forty years. Similarly, alcohol and drug abuse programs are all around us. 

One of the important attributes that we believe is necessary for a program to be ‘successful’, is to make sure it addresses the unique and often individual qualities that make the behavior "addictive" to so many. The truth is - not everyone is affected by tobacco, alcohol, or drugs in the same way. I vividly remember my mom quit smoking many years ago. It didn’t seem to have a huge effect on her, so I have concluded she was not ‘addicted.’ Meanwhile, I have many friends who have been unable to quit smoking. They often find themselves "jonesing" for nicotine and needing a cigarette so bad that they just couldn't stop.

Advances are being made, technologically and in terms of health policies across the nation.  For example, drugs are now available that are able to intervene and help ease a smoker’s cravings. One of our major Healthiest State efforts was to get employers, insurers and the state government (through its Medicaid program) to include easy access to these drugs as part of their cessation programs. The reason is simple – these types of interventions can and do make a difference. Especially for those people who would otherwise struggle to find success when they attempt to quit smoking.

So we need to figure out how to treat those already addicted, while trying to stem the tide of new people who might find themselves susceptible to addiction. How well we do this moving forward will be one of the critical issues for our personal health and the health of those around us.

But, perhaps even more challenging is to understand the breadth of health risks, and which should fit under the tent of addiction.  An online search of potential addictions is a wide array of common vulnerabilities in our society- gambling, sex, sugar, food, love, desire, prescription drugs, illegal drugs, and smoking, just to name a few. Are we compelled to determine who is actually addicted to any of these things, or is it better to allow social mores to dictate which of these indulgences should be branded with the addictive label and which should not? Think of when a famous person is caught with their pants down, and then ends up being treated for sex addiction.  How many of us scoff at the notion that their behavior can be excused in the world of public opinion by this alleged addiction?

Perhaps it is totally accurate that this is what is going on.  And perhaps many of our other questionable behaviors are explained by real addiction.  After all, psychological dependence is part of addiction, and our new age is all about trying to influence our behaviors through billions of dollars in marketing.  Buy products. Behave in certain ways.  Vote for certain people and support specific causes.  Would it be any shock that the net impact of these multiple stimuli has left us in great danger of succumbing to things that tickle our marketing fancies and are beyond our control to stop without some trauma to ourselves?

Maybe.  And maybe it is just that we need to take greater personal responsibility for our decisions and our bad behaviors…..at least some of them.  

Most likely, we need to do both - take greater responsibility and know when we are under the spell of something so we can seek help to break that spell.  Our health improvement strategies need to recognize the importance of both of these factors. It is particularly important if we are to somehow improve our health as individuals, and not just continue to invest trillions of dollars in treating the consequences of our bad behaviors through the medical care system (or think that we can merely legislate bad behavior until it goes away).  Not easy stuff to figure out. But it is a key front in the ongoing battle to build and cultivate real health in American society. Maybe we should get addicted to THAT!

 

Governor's Health Bowl Week 4

Investing in Prevention

By: Greg Vigdor/WHF President & CEO

"An apple a day keeps the doctor away".  "An ounce of prevention equals a pound of cure". You probably know where I’m going with this. If trite sayings and old wives’ tales were how we made our decisions on directing investments in our health care system, there is little doubt that we would be doing something differently - investing in prevention, for one.

Sadly - that is not now the case.  The health care system has developed through the prism of science and clinical expertise aimed primarily at treating illness or injury; things such as cancer, broken bones, heart attacks, kidney failure, and the ravages of infectious diseases. To its credit, the health care world has made incredible progress in figuring out how to better treat or even cure the devastation of these diseases and injuries over the past 50 years. It has also figured out better and less invasive ways to diagnose these health care problems. We are surely fortunate to enjoy the benefits of these advances.

However, this success comes at a price. It has cost a tremendous amount of money to achieve this progress.  Once a small fraction of the American economy, health care rose to account for eight percent of the gross domestic product in the 1970s. This was a statistic that many found troubling. Some even suggested that we needed to put a lid on this cost growth before it pushed out other critical elements of the American economy. Others maintained that health care was an economic sector to be desired in this Nation - and that additional money should be invested in it. 

Whether by design or by the inability to control health care cost pressures, what is certain is that the societal investment in health care has grown dramatically over the years since. In most years, we saw double digit increases in our investment.  Over time, the investment in health care moved from large to massive, with health care now making up nearly 17 percent of our economy. Most experts believe it will grow to more than 20 percent within the next five years - even with health care reform. 

While it remains the case that health care is a "good" thing for many people, the tremendous cost of it has become a national crisis. We know this by listening to the frustration of the people that pay the bills (such as businesses and governments), and also from regular people who are paying more and more of these bills out of their own pockets. Polling shows that people see the cost of service as the compelling problem of health care, far more so than access or quality concerns. It has been this way for more than a decade, probably much longer. 

The numbers bear out the public concern with health care costs; there are trillions of dollars at play. For those who see our Nation now competing in a global economy, the numbers are even more troubling. We spend double on health care per person than most other industrialized nations and 1/3 more than the second highest spending country on the world list (Norway).  All while the health care system clamors for even more, activating this call with enormous political campaign contributions to make sure that policy makers continue the flow of money to this sector. 

With so much white noise surrounding this issue, it is hard to focus attention on the need to invest more in prevention, even if it makes practical economic sense to do so.  How can we put more money into this aspect of health and health care when we have this overwhelming cost problem to tackle?

Well, if only we actually were tackling the health care cost problem; we certainly need to do that. But how? One way might be to substitute our investment in medical care for larger investments in those social determinants of health that offer more promise to actually improve our health.  That is, things like education, housing, greater individual responsibility for health and the like. These are a handful of the social determinants that contribute well over half of what can be done to produce health in this Nation.  While medical care contributes no more than 8-10% toward creating health, we currently invest more than 97% of our vast health care resources to it. So, we should constrain how much we spend on medical care and move it to other more valuable health investments - such as K-12 education.

The call for more investment in prevention should also address how the medical care system spends its 97%.  A small but important chunk of that 97% goes toward medical services that are preventive in nature.  These services include medications, screening tests, counseling and other health care interventions that have proven to be worthwhile.  The list of the recommended services is developed and published by the United States Preventive Services Task Force, based on their ‘best evidence’ review. Our own Healthiest State Report Card provides a composite listing of some of these services so that we can judge how well we do in these areas when compared to different states.  Despite the science, the list, the benefits, and the reality that most are very low cost interventions, there is far more money to be had for treating the diseases or illnesses once they occur than these proven clinical preventive services. 

Why is this?  Well, for one, there is no constituency to say “enough” on the part of those who are receiving dollars from the current investment patterns in health care in this Nation.  These folks may be marginally okay with putting more into prevention if it is coming out of someone else's pocket but not their own.  And part of what they consider their own is the view that they will require more money in the future, not just what they are currently earning.

One would think that budgeters in the government and private sectors would be fast to make the argument that more prevention would be a good thing in terms of distributing costs and benefits in this society.  Trouble is that most prevention investments will save money over much longer time periods than most governments and businesses can conceptualize (or are willing to tolerate), so prevention is treated as an additional short term cost rather than what it should be; a long term investment that will translate into lower costs far into the future. 

Prevention also suffers from ignorance as to what it entails and how much better we need to be at it.  Witness a comment from a health care executive about this at a conference a couple of years ago.  When asked by a news reporter about investing more in prevention, this insider commented that "we just don't know what to do to invest in prevention", citing conflicting newspaper stories about different diets and the like.  Apparently, this executive was unaware of the work of the U.S Clinical Preventive Health Services Task Force. This health care leader created the impression that the industry would do more prevention if only those on the inside knew what to do.  Well, they do.

In this state, and probably in others, many are also willing to be ignorant of the realities of how poorly we are doing in providing clinical preventive services to our people.  Our Healthiest State Report Cards have shown that our state lags behind most others in delivering clinical preventive services.  We have shared this data-based observation time and time again with health care executives, government health leaders and others.  Yet, it has been almost universally ignored, as it conflicts with the preferred story line that casts Washington state as a national leader in delivering health care services.  Hard to imagine how that can be the case when we rank 32^nd in receipt of clinical preventive health services!

Those are just a few of the obstacles as we look to change our health care investment patterns toward prevention.  So, there is much to do in helping to drive that change. And making sure that change happens is one of the keys to making us the Healthiest State in the Nation (or the Healthiest Nation in the World!). There remains little doubt that it must be done. To get it done, we will need to convince those who are vested in the status quo to take a broader and less self-interested look at the question of prevention. Daunting – yes, but we will continue the fight to make sure this issue is heard - heard above all the prevailing health care cost chatter. That’s because when it comes to prevention - “silence is not golden!” 

"An apple a day keeps the doctor away".  "An ounce of prevention equals a pound of cure". You probably know where I’m going with this. If trite sayings and old wives’ tales were how we made our decisions on directing investments in our health care system, there is little doubt that we would be doing something differently - investing in prevention, for one.

Sadly - that is not now the case.  The health care system has developed through the prism of science and clinical expertise aimed primarily at treating illness or injury; things such as cancer, broken bones, heart attacks, kidney failure, and the ravages of infectious diseases. To its credit, the health care world has made incredible progress in figuring out how to better treat or even cure the devastation of these diseases and injuries over the past 50 years. It has also figured out better and less invasive ways to diagnose these health care problems. We are surely fortunate to enjoy the benefits of these advances.

However, this success comes at a price. It has cost a tremendous amount of money to achieve this progress.  Once a small fraction of the American economy, health care rose to account for eight percent of the gross domestic product in the 1970s. This was a statistic that many found troubling. Some even suggested that we needed to put a lid on this cost growth before it pushed out other critical elements of the American economy. Others maintained that health care was an economic sector to be desired in this Nation - and that additional money should be invested in it.  

Whether by design or by the inability to control health care cost pressures, what is certain is that the societal investment in health care has grown dramatically over the years since. In most years, we saw double digit increases in our investment.  Over time, the investment in health care moved from large to massive, with health care now making up nearly 17 percent of our economy. Most experts believe it will grow to more than 20 percent within the next five years - even with health care reform.  

While it remains the case that health care is a "good" thing for many people, the tremendous cost of it has become a national crisis. We know this by listening to the frustration of the people that pay the bills (such as businesses and governments), and also from regular people who are paying more and more of these bills out of their own pockets. Polling shows that people see the cost of service as the compelling problem of health care, far more so than access or quality concerns. It has been this way for more than a decade, probably much longer.  

The numbers bear out the public concern with health care costs; there are trillions of dollars at play. For those who see our Nation now competing in a global economy, the numbers are even more troubling. We spend double on health care per person than most other industrialized nations and 1/3 more than the second highest spending country on the world list (Norway).  All while the health care system clamors for even more, activating this call with enormous political campaign contributions to make sure that policy makers continue the flow of money to this sector.  

With so much white noise surrounding this issue, it is hard to focus attention on the need to invest more in prevention, even if it makes practical economic sense to do so.  How can we put more money into this aspect of health and health care when we have this overwhelming cost problem to tackle?

Well, if only we actually were tackling the health care cost problem; we certainly need to do that. But how? One way might be to substitute our investment in medical care for larger investments in those social determinants of health that offer more promise to actually improve our health.  That is, things like education, housing, greater individual responsibility for health and the like. These are a handful of the social determinants that contribute well over half of what can be done to produce health in this Nation.  While medical care contributes no more than 8-10% toward creating health, we currently invest more than 97% of our vast health care resources to it. So, we should constrain how much we spend on medical care and move it to other more valuable health investments - such as K-12 education.

The call for more investment in prevention should also address how the medical care system spends its 97%.  A small but important chunk of that 97% goes toward medical services that are preventive in nature.  These services include medications, screening tests, counseling and other health care interventions that have proven to be worthwhile.  The list of the recommended services is developed and published by the United States Preventive Services Task Force, based on their ‘best evidence’ review. Our own Healthiest State Report Card provides a composite listing of some of these services so that we can judge how well we do in these areas when compared to different states.  Despite the science, the list, the benefits, and the reality that most are very low cost interventions, there is far more money to be had for treating the diseases or illnesses once they occur than these proven clinical preventive services.  

Why is this?  Well, for one, there is no constituency to say “enough” on the part of those who are receiving dollars from the current investment patterns in health care in this Nation.  These folks may be marginally okay with putting more into prevention if it is coming out of someone else's pocket but not their own.  And part of what they consider their own is the view that they will require more money in the future, not just what they are currently earning.

One would think that budgeters in the government and private sectors would be fast to make the argument that more prevention would be a good thing in terms of distributing costs and benefits in this society.  Trouble is that most prevention investments will save money over much longer time periods than most governments and businesses can conceptualize (or are willing to tolerate), so prevention is treated as an additional short term cost rather than what it should be; a long term investment that will translate into lower costs far into the future.  

Prevention also suffers from ignorance as to what it entails and how much better we need to be at it.  Witness a comment from a health care executive about this at a conference a couple of years ago.  When asked by a news reporter about investing more in prevention, this insider commented that "we just don't know what to do to invest in prevention", citing conflicting newspaper stories about different diets and the like.  Apparently, this executive was unaware of the work of the U.S Clinical Preventive Health Services Task Force. This health care leader created the impression that the industry would do more prevention if only those on the inside knew what to do.  Well, they do.

In this state, and probably in others, many are also willing to be ignorant of the realities of how poorly we are doing in providing clinical preventive services to our people.  Our Healthiest State Report Cards have shown that our state lags behind most others in delivering clinical preventive services.  We have shared this data-based observation time and time again with health care executives, government health leaders and others.  Yet, it has been almost universally ignored, as it conflicts with the preferred story line that casts Washington state as a national leader in delivering health care services.  Hard to imagine how that can be the case when we rank 32nd in receipt of clinical preventive health services!

Those are just a few of the obstacles as we look to change our health care investment patterns toward prevention.  So, there is much to do in helping to drive that change. And making sure that change happens is one of the keys to making us the Healthiest State in the Nation (or the Healthiest Nation in the World!). There remains little doubt that it must be done. To get it done, we will need to convince those who are vested in the status quo to take a broader and less self-interested look at the question of prevention. Daunting – yes, but we will continue the fight to make sure this issue is heard - heard above all the prevailing health care cost chatter. That’s because when it comes to prevention - “silence is not golden!” 

Governor's Health Bowl Week 3

Increasing Value in Health Services
By: Greg Vigdor/WHF President & CEO 

"Transforming Health Care".  If we had $1,000 for every time a health provider, insurer, politician or government bureaucrat claimed that they were ‘Transforming Health Care’ - our national health cost crisis would be solved! Everyone and I mean everyone in the health care system makes that claim.

And that might be a good thing, because we are in desperate need of a transformation. In terms of value for dollars invested, our health care system is perhaps the most inefficient industry in world history. Strong words – yes. But it’s pretty hard to argue.

Other nations struggle to keep health care under control too, but we have taken that struggle to a whole new level. The last time the World Health Organization (WHO) ranked health systems across the globe, the U.S. finished 37^th! That, despite spending far more per person than any other nation and more than twice that of most industrialized nations. Health care leaders in Washington state try to distinguish our state's performance from this national debacle by insisting we are an exception. Problem is – these leaders use selective Medicare hospital data to make their claim;  more inclusive data relating to other services and populations shows Washington state is like most states that deliver poor value in health care. 

But isn't it a good sign that these health care providers are firmly committed to "transformation"?  Of course, but knowing that they are sipping the transformation ‘kool-aid’ isn’t enough to convince us that major change is around the corner. The Washington Health Foundation was a national pioneer in calling for "transformation." We have been talking about this issue since 2001, and we believe we are a pretty good judge of what it takes to actually "transform" the system.   

What we asserted back then was that the health care system was completely out of whack. It was fragmented, ineffective, inefficient and exceptionally costly to all affected. We believed then, and continue to believe now, that the system should organize around the people it serves, rather than force people to organize around its failed structures and operational paradigms. We put together an aggressive "Transforming Health Care" program to pursue what this real change might look like and how we might get there, primarily by talking to real people about the problems they were experiencing. Ultimately, this effort led to our Healthiest State in the Nation Campaign and our attempt to show that a Health HoME can (and will!) empower people to take more control over their health and be the basis for a real solution to what ails us. 

Providers, insurers and government were among those engaged in our Campaign. But most were only interested in the fun, healthy living initiatives that we offered. They showed less interest in the deeper systemic changes we were talking about; changes that might really transform the system for people who need care and ultimately pay the bills for it. So, why has the tune of those in the system changed now?  

A good bet is that national health reform legislation has gotten them to wake up and smell the coffee that big change is coming with or without them. Those that believe reform is necessary are jumping at the opportunity to transform themselves. Those that don't are still feeling that they have to jump into the mix or they will fall behind their competitors.  Also not to be overlooked is the reality that much of health care reform legislation is a multi-billion dollar bribe by governments to get those in the system on board.  From money to develop electronic medical records (in what other industry has the government had to invest in the use of computers to improve their operations?), to incentive payments for accepting new provider payment models, to new funds for medical homes, accountable organizations or some other alphabet soup of allegedly new health care structures.  Maybe one of the grant requirements to get at this money is to simply say you are transformingsomething. 

If we are truly in the midst of real and big change, than the motivation it took to get here is immaterial. Whether transformation is the result of strongly held social beliefs, financial incentives or some combination – it wouldn’t matter. The important thing is that we are ‘transforming health.’

Unfortunately, I remain skeptical of how much real "transformation" those in the system, political or institutional, really want.  Much of the transformation actions in health reform legislation are pilot programs and tests of payment approaches that have already been tested over the past 20 years. Rather than just taking what we know about these to scale to clearly set a course of transformation, the government is doling out incentive money in the hope that these will eventually translate to a big change. Worse – it’s happening without any accountability that this ‘change’ will actually happen. More on this another time.  

Let's stick to the question of what insurers and providers are doing to transform. Even as they speak to transformation, and accept bags of incentive money to do health reform pilot programs, or even invest their own resources in "transformational" change initiatives, it seems clear that these are secondary strategies. Instead, what I see as the primary strategy is to become as "big" as they can through merging, acquiring, partnering and otherwise expanding. Controlling more market territory, growing their production span to more activities, and otherwise trying to become the biggest, baddest kid on the health care block.  

If behavior rather than words is the judge of intent, it seems that the real transformation at play is to become as big as one can be in order to make sure that one can resist change rather than create it. It is not that hard to imagine a future where our choices are even more limited and controlled than they are today by the creation of a health care delivery system where only a handful of players remain. This is a distinct possibility despite the government’s belief that the transformation we are in is creating a thriving health delivery marketplace for us.  

A recent study about health care costs communicates how out of touch those within the system are when it comes to health care delivery problems. In outlining the list of factors contributing to our cost crisis, no one points a finger at the notion that there are already just a handful of sellers within this marketplace.  And seemingly fewer into the future. This is particularly troubling in the insurance industry where government regulations already make fresh competition difficult due to onerous reserve requirements and other regulatory barriers to entry. Meanwhile, the health care reform legislation purports to transform health care by investing even more money in these large entities, and then relying on competition among them, through government driven programs such as health care exchanges, to create public good.

I guess that would qualify as a transformation. More power to them if it works. Look – I’m not saying that the solution needs to be one that relies on creating a free market for health care services. But selectively ignoring the reality of how the system works, or providing some lip service to this fundamental problem, won't transform the system either. Nor will just allowing health care providers and insurers to declare that they are transforming the system while they are mostly aggregating markets and the means of production.

We believe that transformation calls for vision and belief in something more than market power, government-based smart design or voluntary action by the health care industry to changle on its own. And we continue to believe that the best bet in achieving transformation is to make the health care system more about people than itself.  A great example of that can be seen in transformative innovations like our own Health HoME project. Our suite of Health HoME tools and resources enable people to take greater control of their health. And that is a great first step in truly transforming health. Another important step is to continue to develop and refine relationship support that helps people navigate the complexity and confusion of the health care system. We are doing that though our Personal Health Advocate Service. We also need a health care payment and delivery system that effectively and efficiently meets the needs of people, and doesn’t pigeon hole them into the canned solutions that institutions and bureaucracies prefer.  

Are we crazy? Perhaps.  But the Institute of Medicine recently came out with a report that supports our line of thinking.  What they said was that the limited set of changes now being adopted within institutions will fail to meet the challenges and complexities of the health care problem.  We agree.  And have some ideas about how to do this.  Join us.

Protecting Against Injury & Disease

By: Greg Vigdor
Washington Health Foundation President & CEO

Looking to improve your own health? Or maybe you’re hoping to improve the health of your family or your community. One of the keys to building better health is learning how to protect ourselves from Injury and Disease. Now let's be clear- there is nothing absolute about this protection.  Despite all efforts, a meteor may indeed fall on your head.  Or, anyone of us may find that some rare form of cancer or infectious disease has pulled our name at random and we will be dealing with a most unwelcome challenge.

But there are things that can be done to create "protections" for us.  Some of the greatest health advances of all time have been discoveries made in the face of horrible infectious “diseases” like yellow fever, smallpox and the plague. We learned that cleaning up water systems, eliminating large numbers of mosquitos or otherwise devising defenses from germs can save hundreds of thousands of lives.  Some of the most important health work on this planet NOW remains trying to make sure that we can apply this knowledge across the entire globe, not just in those countries with the money or peace to apply it.

We also know that there are things that can be done to protect us from "injuries".  What's more, as we have conquered many infectious diseases in this nation by our public health interventions, the threat to our health from injuries has become more significant.  As have our efforts to do something to win this fight.  

For example, motor vehicle accidents have become a leading health indicator over the last generation, both in terms of deaths and non-fatal injuries. In many states, it is one of the leading causes of accidental injuries and death.  And we have intervened as a society to try and make car travel safer, even as the danger has become more evident, through speed limits, mandatory engineering of roads and cars, and the now legal insistence that we wear seat belts.  Washington state is a national leader in encouraging people to wear seat belts (as we have noted in our Report Cards), and the advance in getting people to do this has been a combination of laws, health education over time as to why one should want to, and financial penalties for failing to do so.  The approach is to make it unacceptable or inadvisable at the societal level to not wear a seat belt, but ultimately something that registers with us as individuals to actually take the healthy action.

That is critical- because when you really dig into the prevention strategies for injuries and disease, they are things that ultimately require us as people to take action.  We have found that most people do want to be healthy.  So this shouldn't be that hard, right?  But it is – perhaps because so many of us are wired to resist change.  Or, on the flip side, some of us are wired to take more risks.  And perhaps for some of us the issue is that part of our unique identity as Americans is to assert our independence.  In particular, to be highly suspicious when the government insists that we do something, even if it might be good for us.  Laws and scare tactics will not be sufficient to break down this barrier. If anything, they reinforce the reaction that it is big brother telling us what we have to do!

The seat belt experience in this Nation shows us that we can make progress in preventing injuries, but that it takes a lot of money and time to reach our goal.  So, as we move to a health age where protecting requires personal action, how can we speed up or improve the process for getting people to accept healthier behaviors as we identify them?   

Consider the example of prescription and over the counter drug abuse and misuse.  You might be surprised to learn that prescription drug abuse became the leading cause of unintentional death from injuries in this state in 2008 – supplanting motor vehicle deaths. This issue has emerged nationally as a major health issue as well. While some in public health were a bit slow on the draw in realizing this shift was occurring, efforts are now growing to do something about it.  Many of these responses are important as part of a solution - laws enforcing the protections against using or dispensing these drugs, "scare" public education campaigns showing the horror of what can happen when they are abused, and even practical methods of helping to get the supply of unused medications out of circulation (such as drug disposal programs). 

But it will take more. It will take engaging those that are affected by the danger to understand it and change their behavior. We need to know, from their point of view, why it is that they do what they do…. and what might help convince them to change.  It may sound pollyannish, but the reality is that personally engaging and convincing us to change behavior is a critical part of the 21st century model for accelerating the adoption of healthy behaviors by people. Unfortunately, many still believe that the model remains the traditional legal enforcement and scare message approach.  Others believe it might be even more effective with some financial penalties thrown in for good measure, because money is supposedly everything to us Americans.  

We, on the other hand, perceive most contemporary health challenges as complex issues requiring multiple levels of responses.  Especially if we are hoping for faster resolutions. So we have been exploring issues with this in mind, and especially incorporating our notions of people-based health solutions as the part of the equation we can explore.   

One relevant example of this approach was our recent effort to determine how to promote better health for young adults on college campuses. Working with the Washington State Attorney General's Office, we embarked on a project to learn from college students by listening to them about their health issues. We then took what we learned and helped the students customize their own Health HoME to put them on the road toward a healthier lifestyle. One fast discovery was that prescription drug abuse and misuse was one of the big issues at play, and much of our project honed in on this issue as a priority matter. 

We quickly learned that one of the core lessons to be learned through this project was that those students who abused prescription drugs did so for a variety of reasons.  Not simply for recreation as some might think, but also to help enhance study habits and a host of other reasons.  Perhaps our most important finding was that for many the drugs were a response to the pressures they were facing - to make the world a better place, to compete with their classmates for the very few jobs that seemed available, or to pay for the ever growing cost of their college education.  Changing health behavior then requires a very different approach if this underlying stress is at the heart of the issue.

What we also learned is that the messenger in this work really does matter. Students were clear that it was not helpful when governments or adults (other than parents) told them what they couldn’t or shouldn't do.  Nor were students swayed by the words and warnings of media celebrities. We found the biggest influences were most often student peers. These were the people who could relate to their circumstances and were walking in their shoes.

We began to explore some of the possible ways to promote health based on this knowledge, including initiating a campus led network of health activists.  We ran out of resources to take these solutions to scale, but remain hopeful we can rekindle interest in this project.  But for now, we think this first phase of our College Health Program illustrates well the point of this article - that we must truly work to engage people from their circumstances if we are to speed up the process of getting people to take action to minimize risks from injury and disease.  Just telling us we can't or shouldn't is often not enough.  

At some point, we hope this approach will be accepted as an advance, equivalent to the germ discoveries so many years ago. Those discoveries allowed us to tackle major infectious diseases across the globe. In the same way - we would be well served to use today’s discoveries to find better ways to drive real health behavior change. And not fall into the old formula of using only legal enforcement and scare tactics.  If we can reach beyond that in Washington state, we will be well on our way to becoming the Healthiest State in the Nation. 

 

2012 Governor's Health Bowl - Week 1

Promoting Community Health
by: Greg Vigdor, WHF President & CEO

Here we are at the start of the 8^th annual Governor’s Health Bowl. Since 2004 – this signature event of the Healthiest State Campaign has generated more than 25 million miles of health. It is truly an incredible accomplishment! 

Much of the focus during the Health Bowl is on things that tend to promote personal responsibility such as physical activity, eating better, getting more sleep and so on. And while promoting personal responsibility is critical to our vision of making Washington the Healthiest State in the Nation, it is important to recognize that collective action is an equally critical piece to the health puzzle. You can see it in the laws relating to our health passed by Congress or the state legislature, which can have a powerful effect our health. Another example might be what some employers may do in terms of practices like health benefits, sick time, or creating an environment that some workers find overly stressful. Or even what our local public health departments might do to protect the public's health – from restaurant inspections to handling a contagious disease outbreak.

But this affect on our health extends far beyond these “personal” and "collective" sectors.  More importantly, so may the solutions to what really ails us. 

Working together might have gotten a bad rap in some quarters – largely because some believe this can only happen under the spell of the government.  It actually is a commonplace reality of our lives and can be a real boon to our health. Many of us belong to clubs, social groups, places of worship, extended networks of people who share the same interests, and all sorts of other formal and informal gatherings. We do relate regularly to other people, and should.  And, the real phenomena of the last decade is not that we do this less, but that we now do much of it through texting, messaging, social media and the internet. Working through how best to relate to others in this new way may hold the key to discovering how to really improve health across our communities. 

Examining a health question like this goes far beyond the usual framing of our health problem, which tends to get pigeonholed into ‘not enough access to insurance or health care services’.  And this is why "Promoting Community Health" is such an important action area for our Campaign. While health coverage is an important issue and one that we are working to improve (through our Personal Health Advocate Service at 855-WA-Health/855-924-3258), maximizing personal and group relationships may hold more potential for really improving our actual health.  And, while there may be great division on  "health insurance for all", or at least the means for doing so there may be far greater agreement that we can and should promote our community's health by working together.  

The good news is that there is a movement across the nation to Promote Community Health, and it is one that should have a broad basis of support from liberals, conservatives and independents.  It is called the Healthy Communities movement and dates back to the early 1990s.  Coinciding with our birth as an organization, we have been a big part of building and nurturing this both in Washington state and also across the Nation.

At a basic level, Healthy Communities tries to promote health at the local level by growing leadership; thus building relationships and practices that can provide enduring action to the major health issues we face as people and communities.  The movement has been governed not by top down requirements but by the articulation of some broad patterns that speak to the values and behaviors that will create real, cooperative action.  The Healthy Communities has a prescription for health known as the "Seven Patterns of a Healthy Community.”  

A really important part of this movement is that Healthy Communities is not something to be imposed from above, but something to be home grown; a true grassroots effort.  For example, government may frequently be involved in Healthy Communities projects, but usually would not be the sole driving force in the project’s development.

Healthy Communities is a movement that has meandered across the social landscape in a very uncoordinated way over the past 20 years. No one has been in control of the movement, yet it continues to flow forward. A couple of years ago, some of us who were involved in the genesis of the movement came together and agreed that it was still progressing with numerous projects all across the Nation that fit neatly under its definitional tent.  Our own Healthiest State Campaign is an excellent example of a grassroots, statewide endeavor that is clearly not defined nor directed by government.  

We pledged to try to take some steps to catalyze the movement so that it can further contribute to the health of the Nation. Many new projects have come on line and the future for Healthy Communities remains promising.

Despite the successes, the Healthy Communities movement is also under assault; to a large extent through friendly fire. One example of this is the government embracing the movement and, in turn, making Healthy Communities its work.  The government is able to do this in a pronounced way through the hundreds of millions of dollars in new financial resources that come from health reform legislation. It’s not always a great fit though as the government tends to control and dictate projects rather than softly leading them. I am not an opponent of government, but recognize that "partnering" and "softly leading" are not its strengths.

Also shooting some bullets is the commercial world of health care, which is now at least embracing the term. It is hard not to hear ads on television or radio where health insurers or providers are extolling their intent to contribute to a healthy community.  Many of these companies don't have much of an idea of what a healthy community really means and these ads seem more like a campaign designed to market products and services than to fuel the growth of the Healthy Communities movement. Nice that they believe in the term, but it seems like for many of them it is intended to suggest that their interests are altruistic rather than financial. 

Foundations are also getting into the act by using their money for Healthy Communities projects. Many of the wealthier organizations are fueled by dollars from not-for-profit health care entities converting to for profit status. Legally – they were required to put millions of dollars into Foundations to gain this new status. That's not a problem.  But many of them also draw their staff and strategic direction from the medical care or public health worlds, and frequently they just carry forward the limited view of Healthy Communities from this experience.  Projects rather than people. Drummed up incremental action measures for short-term grants and reports, rather than long-term commitments to relationships and patterns of leadership at the community level.  

Meanwhile, many of the local, poorly funded, and most resource challenged Healthy Communities folks struggle to move forward, even if their work is where the potential for real change resides. We understand because we count ourselves among them. Can we survive the attention from government and multi-million dollar health care system players who want to own the space but not necessarily the full vision and patterns of Healthy Communities?  Time will tell. 

My guess is that to be an enduring movement, Healthy Communities must pass through many phases. Some will be more dangerous than others. And the ability to weather these storms is the challenge of any successful movement. So don't lose hope. If some government, insurers, hospitals, and foundations don't really believe in the true tenets and aims of the Healthy Communities movement, then their attention will soon fade to other things or labels – even if they control most of the economic and other resources to support the work.  And if those of us who really believe in the movement and approach can stay the course, even while we might be starved for attention or resources, the potential of the movement to truly transform the health of the Nation can and will be realized.

My advice is to just keep at it, for as long as you can.  That is our mantra and intent.  Even as we have had to constrict what we are doing due to funding shortfalls, we remain steadfast to making a difference and keeping our unique brand of health improvement alive in the state of Washington.  So should you.

 

Washington's Changing Workforce

Last week, Governor Gregoire issued Executive Order 12-02 which reinforces our state's commitment to developing and supporting a diverse, inclusive and high performance workforce. While the Order ought to be celebrated, it misses on at least one key point in it's assessment of diversity:

The changing nature of work - from a centralized, top down model to a self-organized, distributed network - has as much to do with people's challenge in accessing government services than the traditionally acknowledged barriers of ethnocultural diversity.

So long as government and civil services continue to reflect the structures of the past (e.g. resources getting pushed out from the top down instead of pulled out of the system as needed by users), they will fail to satisfy the high performance vision for Washington's workforce. 

As the Washington Health Foundation has been learning in its interactions with independent workers (through a grant from the Attorney General's Office to leverage our Personal Health Advocacy service), there is a significant gap emerging between the value people want from the systems they interact with (whether those be corporate, governmental, health care, etc) and what they are actually able to obtain. Government action therefore should be minding that gap while at the same time addressing other root causes that hold back our personal and collective productivity.

 

A Closer Look At The Affordable Care Act

 

By: Greg Vigdor/WHF President & CEO

It occurred to me that I should share some observations about the impact of the Supreme Court ruling on the Affordable Care Act.  After all, we have been engaged in health policy and advocacy as a big part of our Foundation’s change model for much of the past 20 years.  And - we were a very active voice for health reform in the state and nation.  In fact, we spoke out regularly on the need for comprehensive reform well before just about anyone else in our state from the late 1990s until health reform became “popular” in 2009.  Including our own statewide leadership efforts to explore the values of Washingtonians - and give them voice - regarding the future of health care in 2003.

As a reminder to all, we actively supported national health reform and this legislation in its early form, and developed a full position paper on its many facets.  Providing access to coverage and care for all was part of our policy position. Partly for moral reasons under our view of the world, based on our day to day understanding of the consequences of people in need being left out of the coverage and care system.  But also because the fundamental unfairness of who was in and out of the system made fixing the broken health system virtually impossible without first doing this.  That the individual mandate and medicaid expansions can go forward today remains something that we support, given that this was the only option really presented for achieving universality of inclusion.  So, we should feel good about today’s ruling.

Our discomfort with the ruling relates to our fundamental disagreement with what else happened - or more accurately didn’t happen - in the reform Act.  That is, the Administration chose to move forward by leaving the “system” essentially as it has been, with all of its many defects.  Especially those that relate to how people interact with the system.  While the Administration and other advocates now speak regularly to things in the Act that might “transform health care”, these ideas are slow moving, incremental tests of ideas that have, in most cases, already been tried.  Some of them would work- but need the leadership act of moving them forward aggressively, not with the permission of insurers and providers and government bureaucrats first, who are all more inclined to take care of their own needs than those of people and patients.  

The legal logic of the ruling supports our take on all of this.  That is, the argument that the federal government could impose a mandate under the interstate commerce provisions of the Commerce Clause was not accepted.  So, presumably there is not enough in the Act that is regulating the commerce of the health care system.  Rather, it is the taxing power of the federal government that constitutionally justifies the Act.  That is largely what is going on with this law so far.  Yes, many uninsured will be covered.  But realize that some number of them are folks for whom health insurance is not something that they feel they need and for whom actuarial tables would say cost very little.  Now, they will be required to buy and will soon find out that the rating approach within the law will have younger healthier people subsidizing even more the rates for older and sicker people.

Again, we support the universality of inclusion.  But just creating this shift in cost is only perpetuating one of the principal defects that has plagued the health care system for the past 50 years.  It is one of the fundamental reasons why health care costs have continued to escalate beyond all reason, leaving many with a deep sense that the system is fundamentally “unfair”.  The incredibly growing share of our economy now going to health care also makes it hard to invest in other things that we know have  a far greater impact on creating “health” than just continuing to invest in an ever-growing medical care system.  This we know well from our innovative work through the Healthiest State in the Nation Campaign.  And, yes, while there were some useful advances around a “health” reform agenda in the Affordable Care Act, many that we actively supported, these provisions of the Act also depend far too much on “government” being the entity that will change our health behaviors, rather than ourselves or our communities.

All to say that what we have done and are doing to fundamentally change the health system so that it works for people is of only greater importance now that we know the Affordable Care Act is moving forward to full implementation.  The true empowering notion of Health HoMEs for all, the value of our Personal Health Advocates to help people customize their own solutions to their health needs, and our newly-inspired dream to create a full and functioning “Center for People’s Health” within the Washington Health Foundation are our building blocks to attain health change that fundamentally works for people and America.  

Thanks for all you are doing to achieve these things- they may ultimately prove to be of far more value to changing the health system for the better than government, provider and insurer efforts to manage incremental change.  And there is no doubt that the immediate help we are providing to many across our state is of vital value to their health now, while health reformers, lawyers and judges figure out what else they can do to fix a broken health system beyond income transfers.  Keep the Faith.