BY: KATHLEEN O'CONNOR
Ms. O'Connor is founder and CEO, CodeBlueNow!, Seattle.
A New Coalition of Groups Is Working Quietly to Reform U.S. Health Care
The climate is different today, and it's not just global warming. It's health care reform. A number of significant changes have occurred since the 1990s. More employers are involved. More groups are focusing on inequities in the system. Cost is the driving issue, not access. And more groups are working on beginning a dialogue focused on key values and core principles rather than on specific solutions.
"There are three critical issues now. More employers are engaged," observes Peter Harbage, who served in the White House during the Clinton administration's health care reform effort and is now with the Washington, DC-based New America Foundation. "Last time, the employers were involved early on, but then they left. Now we have heads of major corporations like Safeway supporting health reform. Second, cost increases are really affecting more and more people and finally hitting the middle class. And, finally, we now have major states taking a lead in finding solutions, such as Massachusetts, California, and Michigan. You did not have a confluence of these events in the early '90s." Harbage adds that "state reform efforts now focus on the commercial markets, not just Medicaid reform, as in the 90s."
Providence Health & Services, a four-state hospital and health system based in Seattle, would add "justice" to the equation. "We started struggling three years ago with the fact that we have hundreds of acts of charity every day, in terms of covering people without insurance," says Chuck Hawley, Providence's vice president for public affairs. "We believe we need to do more than that — that we need to address the very systemic issue of justice. We need to get to the underlying causes of [the need for] those acts of charity."
Hawley notes that providers can get caught up in the daily fights on the latest budget cuts, advocating enhanced reimbursement, and other issues. "We stepped back and realized that our mission should call us back to our values — which we need in order to talk about justice and core elements of reform."
Providence's leaders looked at the existing reform proposals and began to assess how various proposals were in line with their mission. They then developed a comprehensive set of reform elements to be used in conversations with community leaders and state officials. "We have no illusion that we will be in the Rose Garden for the signing of legislation this year," Hawley observes, "but we wanted our values to be part of the reform conversation."
CodeBlueNow! is a Seattle-based national grassroots advocacy and action group committed to transforming the health care system. Our group believes that this focus on values and principles is a critical difference between current reform efforts and those of the '90s. Health care reform has largely been ideologically driven. Advocates of health savings accounts lob verbal hand grenades at single-payer advocates, who lob back at them — or vice versa. Health care reform has been held hostage by these extremes or by partisan politics. These stalemates and disputes tripped up whatever forward movement might have been possible. But this gridlock is beginning to break up.
Contributing to this breakup is the number of groups that now believe in dialogue and consensus building. We are finding each other and engaging the public to seek consensus. Today, as more groups are engaged and as employers become more involved, a "tipping point" can be reached by truly engaging the public.
To date, the public has been held at arm's length in health care policy debates. The Clintons holed up in Jackson Hole and wondered why the public did not support their ideas.* Lack of public engagement, we believe, is another key reason so little public traction existed for health care reform. CodeBlueNow! intends to change this by partnering with like-minded organizations and their members.
*The basics of the Clinton administration's reform plan were designed by a small group of experts who met in early 1993 in the resort town of Jackson Hole, WY.
Giving the Public a Voice
CodeBlueNow! emerged in 2003 as the result of our deep frustration with the dead-end health care reform debate. We put our money where our mouth was and posted a $10,000 cash prize in a contest we called "Build an American Health Care System." A colleague posted a $5,000 second prize.
Nine independent judges pored over the 109 applications and selected 10 finalists. Ultimately, on October 24, 2003, three winners were chosen. CodeBlueNow!, which was founded the next day, is based on the significant areas of consensus that emerged spontaneously from those 10 very different proposals. On that day, within four hours, a group of 30 strangers reached agreement on the core values and core elements in our Declaration for the Health of America .
We are now using an online survey tool — the Fast Forum Opinionnaire — to test some of these ideas with as broad a range of individuals and groups as possible. We want to partner with more clearly nonpartisan groups to expand our reach and to create a groundswell of support for some core elements that, we believe, thousands, if not millions, of people will support. That is Step One.
In Step Two, we will explore ways we can finance and manage a new system and identify changes we need to make in the delivery system. Some ideas from the contest can help jump-start that discussion. We offer them not as the only models, but rather as a beginning point from which we can start designing a new system.
The challenge facing all of us is the inertia of cynicism. The public is very cynical today, but that very cynicism masks a hunger for hope and meaning. That cynicism protects the fear of hope, because that hope has been bashed so many times. Given what has been learned from the CodeBlueNow! contest, we know that individuals, families, providers, and employers have more in common than most "reformers" believe. By working with numerous groups, by using the Fast Forum Opinionnaire, and by reporting back on our findings, we have a real opportunity to find and demonstrate common ground so that our people can have trust and hope again. We believe the American public is at its best when it uses American ingenuity to problem-solve together.
The critical difference between now and the health care reform effort of the '90s is this search for common ground before presenting solutions. The strength of all "fellow travelers" joining arms to create a groundswell will force our leaders to act. We must remember that it has been people of courage, faith, vision, and determination that throughout history have ensured our rights as Americans, no matter the color of our skin or our gender.
Opportunities and Challenges
Although health care is a top public issue, the public has no clear vision of what that system could look like. Therefore, public support for reform is extremely fragile. If we continue the traditional potshots about assorted plans, we could lose public support for reform. If there is a barrage of negative messages, the public will throw up its hands and walk away. And we will lose again. The key now is to focus on high-level core values and steer away from specifics while we build consensus.
The many groups starting with values are exciting and represent a refreshing new direction. As members of these diverse groups — CodeBlueNow!, the Business Roundtable, CHA, National Coalition on Health Care, Providence Health & Services, Silicon Valley Leadership Group, Group Health Cooperative, and many others — we must find as many areas of common ground as we possibly can. It is possible. In Oregon, thanks to the leadership of the Northwest Health Foundation, 12 disparate and normally not collaborating groups came together and agreed on key common principles and some joint legislative priorities, thereby reframing the health care reform message (see www.oregonhealthreform.org).
Our collective power can create a values-based vision that clarifies those values the American public holds most dear. This can't and won't happen overnight, but if we can work together and find enough areas of common ground to demonstrate our shared values, we have the very real chance to succeed.
Change is possible, but if we move too fast before we have a broad base of support, we could fail. We must create a public movement. But it will be neither overnight nor simple.
Large Social Change Happens
We need to think of health care as we think of civil rights. We are as segregated in our health care coverage as we were in civil rights and women's rights. Our benefits have systemic divisions — state regulated benefits vs. ERISA-regulated benefits.* Our benefits are discriminatory in that they are based on where we work, age, gender, health status, and income. They are, simply put, inequitable. They have nothing to do with our intrinsic value or the contributions we make to our society and our economy. Those who contribute should be covered. And we must ensure care for our frail and vulnerable. That is what good societies do.
*The Employee Retirement and Income Security Act of 1974 sets standards for privately funded pension and health plans.
My father was a naval aviator. We moved every year or two. When I lived in California, I could go to school and talk with anyone. When we lived in Chincoteague, VA, in the mid-1950s, the white schools were not accredited, so a white pupil had no chance to go to college. The black schools had no libraries. In Virginia (as throughout the South), I could not talk with a black person unless he or she was a maid, clerk, or bus driver.
Next we moved to Arlington, VA. My junior high school was the first in Virginia to be integrated. My school newspaper editor and I were asked to write an article for the Washington Post about it. My parents did not want me to write the article because they feared the Ku Klux Klan would burn a cross in our front yard. I wrote it anyway. No burning cross appeared.
When I graduated from college in the mid-1960s, I found two columns in classified ads. One said, "Help Wanted: Men"; the other said, "Help Wanted: Women." All the jobs I wanted were listed under "Help Wanted: Men." What talent we wasted as a nation by making these distinctions of race and gender.
As a nation, we gradually decided that equity must not be based on color or gender. Are we 100 percent there? No. But great strides have been made. Our next battle for equity must be for health care benefits. Our health care, like our nation, won't be a blueprint of some other society's solution. To the extent that like-minded groups are committed to equity and fairness; believe that the people are smart enough to build a system that works for all and covers us all; are starting first with core values and key principles all can support — to that extent the real possibility exists for creating a sustained health care reform groundswell that cannot be ignored.
"We have not reached a tipping point yet," observes Robert Brook, MD, vice president of RAND Corporation, Santa Monica, CA, and professor at the University of California at Los Angeles's Center for Health Sciences. "At RAND, we were convinced in the mid-'70s, during a Republican administration, that we would have everyone covered by 1984 . . . And look where we are four decades later. It's worse in terms of costs, quality, and access. I am convinced we won't have real change without more robust grassroots information and education for people. The understanding of the need for reform must permeate all of society, not just policy professionals. Educating and engaging the public will create that tipping point."
And that is our collective challenge.
Declaration for the Health of America
American health care system reform has been stalled for decades because solutions have been put first. At CodeBlueNow!, we understand that starting with solutions creates partisan divide — but when the dialogue is about outcomes, we can all find common ground.
We believe
Our health care system should support the health of all our people and the communities in which we live.
Principles
We believe the health care system should:
- Make our health the center of the system and build programs and services to promote our health
- Assure we all have the authority, resources and responsibility to make health care decisions about our own physical and mental well-being
- Give us the tools and information to make these decisions
Core Values
We believe the health care system ought to:
- Guarantee a core set of health care services
- Focus first on prevention and health promotion
- Assure access to all licensed health care professionals
- Be accountable to the people and their communities for quality, access and cost
- Improve care by constantly researching and adjusting health care practices
- Reduce the employers' role in health insurance
- Decrease administrative costs and waste
- Address ways in which poverty, the environment and behavior affect health
— CodeBlueNow!