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The national Affordable Care Act is complex, historic, yet controversial legislation to move health insurance toward a regulated public utility, fund experiments to give providers incentive to shift away from fee-for-service to payment arrangements that reward efficiency, and finance universal coverage that can potentially limit the growth in Medicare and Medicaid.
But, two realities are often overlooked.
First, the polarized politics and huge financial stakes have prevented legislators from adequately addressing the core problem—unaffordable costs.
Second, excessive focus on legislation has misled many into thinking that the hard work of health care reform must occur in Congress or the Statehouse. The reality is that it must be done by local, non-partisan, collaborative multi-sector coalitions.
However, local leaders often feel powerless to influence systems as complex as those for health and health care. They correctly understand that lowering health care costs requires a possibly painful reallocation of resources to innovative prevention and more efficient treatment methods. But, they feel incorrectly that they lack the tools and leverage to act locally.
The following examples help explain what locally driven health reform looks like and illustrate the challenge of scaling up to an entire community or region.
In Evansville, before 2000, school representatives and community partners hired technical and strategic-planning assistance to develop a full-service community school. Five schools initially received a 21st Century Community Learning Center grant.
Test scores and attendance are going up, families are becoming more engaged, and discipline referrals are going down. The district has received more than $30 million in federal grants. In 2004, the Evansville School Corp. adopted this model to ensure that this healthy school environment would become embedded into the school culture.
In 2006, after a motivated Bloomington community member shared her excitement about the new national Safe Routes to School movement, the Bloomington Planning Department created the Monroe County Safe Routes to School Task Force. Task force members include government and school officials, health professionals, parents, interested community citizens, the city engineering departments, the county highway department, the city and county planning departments, Bloomington Hospital and local police officers.
The results of the program are impressive in terms of infrastructure improvements, such as sidewalks and bus stop relocations that make it easier to choose walking; the number of schools promoting walking and bicycling; parent-student participation levels; increases in walking and bicycling; and sustainable funding.
At Boston Children’s Hospital, the Community Asthma Initiative buys $150 vacuum cleaners and dust-mite-proof bedding for the homes of its patients; provides case-managed home visits and environmental assessments; and, if needed, legal action against neglectful landlords.
According to Children’s, average asthma hospital cost per child in the initiative is about $2,600, while saving $3,900 in unnecessary hospitalization costs over two years and reducing emergency room visits 62 percent and hospitalizations 82 percent.
Despite this success, it has been difficult to expand across the community, since the program could hurt the hospital’s bottom line. This is one great example of an institution that is doing the right thing, but others won’t follow unless given the resources to do so. And, they won’t have those resources unless the community organizes with providers to figure out how to finance and implement this cost-reducing innovation.
Key takeaways from a recent conference sponsored by Better Healthcare for Indiana include:
• The most critical success factor for health reform in Indiana is courageous local leadership to navigate changes to reduce both future demand for care and the supply of care services that crowds out job growth in other sectors of the Indiana economy;
• A balanced portfolio of locally driven initiatives that address cost, quality and community health concurrently is necessary to offset the inadequacies of market incentives and government regulation; and
• Indiana—with its exceptionally strong hospitals and leading health information exchange infrastructure, understanding of health determinants, entrepreneurial mind-set, and a base of a few successful multisector coalitions (that need to be invested in for reaching scale and impact)—can be a leader for the nation in locally driven, non-legislative health reform.
The task of reforming health and health care from the bottom up is doable, but requires inclusive coalitions that are courageously led, entrepreneurial, data-driven, transparent and action-oriented.
Indiana has the unique opportunity to build on its strengths and generate the investment capital to strengthen existing public-private coalitions and create new ones. A cautious, wait-and-see attitude is counterproductive; the time to act is now.•
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Zwirn is executive director of Better Healthcare for Indiana, a non-partisan not-for-profit created in 2008 to promote formation of inclusive local and regional health improvement councils across Indiana.
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