Health Care Reform Grows from Grass Roots

Photo by Graham Ramsay David Blumenthal

Envision the mother who postpones treatment for her baby’s skin infection, or the diabetic who loses his foot because he delayed care for a festering sore, or the middle-aged woman who puts off a visit to the doctor to examine a lump in her breast.

All of these patients have something in common. They are emblematic of a failing health care system that leaves 46 million people without health insurance protection. We doctors have all seen these people in the routine practice of medicine. They live each day in fear of facing a catastrophic illness that they can’t afford or get treatment for. The problem isn’t new. But for the first time that I can recall, the prospect of being uninsured is a condition that is seeping into middle- and moderate-income families.

The Unhealthy System
This gap in access to care is just one symptom of the problem with health care in America today. The others may be more subtle to detect, but are just as threatening: Americans get the health care they need only half the time; the cost of health insurance is consuming an ever increasing portion of American wages and disposable income; despite the high price of health care, purchasers do not get sufficient value; and many chronic conditions are exacerbated by personal behaviors and by missed opportunities for medical professionals to prevent these behaviors.

Despite the pressing and escalating nature of these problems, the federal government shows no evidence of asserting decisive leadership to address them. Perhaps some day this will change. In the meantime, Americans must look elsewhere for inspiration and action.

Recognizing this, the Harvard Interfaculty Program for Health Systems Improvement (PHSI) concluded, based on an 18-month series of forums held around the country, that states and communities are not only engaged in building reform, but offer the greatest promise for rectifying our proliferating health care problems.

That’s the message of our new report, A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up. We found that despite a dysfunctional and chaotic health care system, a lot of innovation is occurring within states and localities, from large efforts in Massachusetts and Maine to smaller ones in Asheville, N.C., and Milwaukee, Wis. We saw unique ways to improve the management of chronic diseases and deliver health care services to the mentally ill, to curb rising health costs, and to widen access to care.

Promoting a bottom-up approach is a very American style of reform. Welfare reform and other major attempts at effecting major policy change in the United States have often originated in trial-and-error experiences at the local and state levels. Our plan, developed by a diverse group of stakeholders, sets out a blueprint for what government, medical providers, consumers, businesses, insurers, and others can do to stimulate innovative local efforts to achieve critical health care goals within 20 years. These goals include expanding access, reducing medical errors, making health care more affordable, and promoting efforts to attack serious public health problems. This effort in no way precludes national reform. But in the absence of that effort, the federal government can help states and localities seize opportunities to develop and cultivate replicable models for addressing their health care problems.

Small Beacons
Harvard is well positioned to facilitate these efforts. It can create a setting in which localities can share lessons learned, use its research capacity to evaluate what makes a program successful or not, and be a convener of important stakeholders to promote local experiments and to encourage governments to evaluate and learn from these efforts.

In medicine, we constantly try to move new knowledge into practice. The Program for Health Systems Improvement is hoping to achieve the same result. The PHSI has begun an inventory, now up on our website (www.phsi.harvard.edu), that offers stakeholders a glimpse of what is occurring in localities around the country and what makes for successful local reform. The program will also foster efforts to educate governors, legislators, mayors, and others about these “bright lights” while promoting attempts to build a national consensus for reform.

Though we remain convinced that local reform is critical to achieving an improved health care delivery system, local communities cannot solve all the problems. The federal government has a vital role to play in addressing what ails the American health care system. But after 35 years of depending on national solutions, we agree that realistic health care reform must start and be nourished at the grass roots, like so many other movements that have transformed our nation.

—David Blumenthal is director of the Harvard Interfaculty Program for Health Systems Improvement and the Samuel O. Thier professor of medicine and professor of health care policy at HMS and Massachusetts General Hospital.

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