Several gems designed to strengthen communities’ ability to define local systems of care are buried deep within the bowels of HCR. These provisions encourage community coalitions composed of health care providers, patients and other stakeholders to design innovative strategies for meeting their own unique health care needs. Instead of trying to impose a boilerplate solution to what has become a chaotic patchwork of local capacities and vulnerabilities, the community health coalition approach encourages creative, bottom-up solutions to our nation’s pressing problems. And it builds communities’ political power to advocate for future reform.

I’d like to present you with a treasure map.

This push was born out of an unusual alliance: career federal bureaucrats who hunkered down in agency basements to wait out the Bush administration, former federal bureaucrats who left their jobs because they could not wait out the Bush administration, local government officials and community leaders began meeting
in the middle of the last decade to discuss “outcome driven health care.” They realized that the profit driven fee-for-service system employed by insurance corporations was creating massive disparities in access to services. They began looking for ways to compensate providers for producing healthy customers rather than billing for specific but often duplicative units of service.

To provide an example in common English, they wanted to find ways to pay providers to produce healthy birth weights in babies rather than paying for multiple amniocentesis analyses. They wanted to pay providers more for producing desired individual health outcomes in highest risk underserved populations.

Several ingenious provisions in the HCR bill empower communities to accomplish this task. The first, which was championed ironically enough by Senator Charles Grassley (R-IA), requires non-profit hospitals to collaborate with community coalitions to define (and fund) “community benefit” (i.e., charity care).

There is a great deal of money, lobbying power and opacity tied up in non-profit hospitals. Many non-profit hospital chains are attached at the hip to for-profit conjoined twin insurance companies. All kinds of dubious money transfers occur. For example, the non-profit hospital may order multiple unneccesary expensive tests which are paid for (with public money) by the for-profit insurance company. The patient gets no better but the state grows increasingly poorer. Hospital buying groups, which are often operated by Hospital Associations, create opacities in exchanges occurring (with public funds) between hospitals and medical equipment vendors. Until recently, in many communities, hospitals were able to absorb funding from local government at the expense of primary and preventive care. And nobody could follow the money trail.

A brief anecdote: several years back when a nearby non-profit hospital was sold to a for-profit chain, I hired a reporter to look into the financial transaction for a low budget newsletter. The reporter discovered that the non-profit hospital had stashed over $70 million in an offshore account in the Cayman Islands. We never did find out where that money came from or why it was stashed offshore. But we did forward the information to the Attorney General.

Meanwhile, back to coalitions…In what must have been a rare bi-partisan collaboration, the Obama administration borrowed language from Chuck Grassley for inclusion in HCR that requires non-profit hospitals to work with community coalitions to develop data-based needs assessments. Needs are prioritized to define “charity care.” Hospitals can no longer use dubious calculations of unpaid care (such as the proverbial $50 aspirin) to write off as “charity.” Rather, they must contribute to community programs supporting prioritized needs. This gives communities an unprecedented ability to fill gaps in service and both design and implement care coordination.

Another provision (introduced by Patty Murray, D-WA, passed but not yet funded through an appropriation) includes funding for local governments and community coalitions to develop outcome-based care coordination models. This funding stream empowers communities to develop their own solutions to the health care crisis based upon local strengths and local vulnerabilities. One community may choose to address high incidence of childhood asthma in a particular zipcode. Another may develop a seamless system of care to prevent and treat substance abuse. Many communities are choosing to train community health workers, laypersons who know the underserved population, to help the underserved to access care.

There are many extraordinary gaps and weaknesses in America’s health care infrastructure that remain invisible to most of our citizens. These gaps and weaknesses could prevent nationalized health care from ever being effectively implemented. Systemic failures would be attributed to government-run health care, rather than the many invisible disparities and weaknesses created by our corporate, profit-driven system.

The most notable gaps include Health Information Technology (many providers still rely on paper records and no two neighboring HIT systems resemble or communicate with one another). Other notable gaps include behavioral health (jails serve as “treatment facilities” thanks to Ronald Reagan), dentists, primary care physicians and nurses, affordable housing and public transportation. Any one of these deficits could bring a Single Payer system to its knees. Together, they seem nearly insurmountable.

The beauty of coalition-driven health care is that it draws multiple stakeholders into the solution, insuring that as many people as possible understand the gaps communities face along with the impact those gaps have on the service delivery network. In our community, coalition efforts to establish and implement outcome measurements for behavioral health treatment made us aware of the terrible impact of homelessness on our service delivery system. Prior to our experiment, the community at large did not realize homelessness was a major local issue. Because we did not see homeless people under bridges or on the street, we assumed they weren’t there.

When analyzing failed referrals, we realized that 70% of our very high rate of failed referrals involved people who were couch-hopping between members of their extended family. Agency A would refer a client to Agency B. Several days might pass before Agency B followed up. By that time, the contact information was no longer correct and the individual could not be reached. Eventually, the two agencies would begin to argue, each blaming the other for inability to track down the individual. The newspaper would pick up on the argument. The public believed that agencies in our community were too busy battling over turf to provide services.

We used this information to engage battling agencies to address issues of homelessness. We have not yet solved the problem, but we have made the public aware locally that because HUD does not allow certain kinds of past felony convictions in public housing, and because of a lack of behavioral health services, we are circulating the mentally ill and developmentally disabled population between jail and the emergency room, our only sources of “supportive housing” and health care for that population.

There are many forces (such as the private prison industry and the alcohol industry) who have a stake in obscurring this truth. And for the most part, they have been succeeding.

As our recession deepens and the Obama administration responds by cutting budgets, it is important that we help the public to become more aware of the complex specific policies behind the failure of our health care system. We will not build public support for real solutions until we enlist the public in the effort.

This is why community coalitions are critical to meaningful change. Please help establish one in your community. For more information, you can visit Communities Joined in Action.