Copyright © 2001 The Seattle Times Company
Editorials & Opinion: Thursday, March 22, 2001
Guest columnist

Health care's death dance

By Kathleen O'Connor
Special to The Seattle Times

I had lunch in January with a very nice man whose manufacturing company employs 100 people. His health-care costs increased 30 percent a year for the past two years. He is getting another 30-percent increase this year even though his employees have had no major medical claims.

Health costs in the Department of Social and Health Services (DSHS) have grown from 23 percent to over 40 percent of its budget in 12 years. Now blood is on the floor for the department's proposed cuts: $6.3 million for some nursing home programs; eliminate CHORE services for $3.8 million; eliminate voluntary CHORE services - $3.28 million; cut $3.72 million from Adult Day Health; reduce residential beds in secure crisis residential centers for children by 50 percent for $5.1 million; eliminate children crisis residential centers for $6.6 million; downsize in-patient mental-health services, for $12 million.

I will stop here. This represents less than one page of the five-page total of a proposed $350 million in cuts. Unlike a business, DSHS can't raise its rates to cover its costs.

One rainy day, when I worked at the University of Washington's Institute on Aging, a woman called who had two young children. She was a full-time mother and caregiver for her live-in parents-in-law, one of whom had Alzheimer's disease. She called us that rainy February afternoon because, she said, if she didn't find some help, she was afraid she was going to hurt someone because she was exhausted from unrelenting caregiver demands.

Senior Services of King County alone stands to lose $350,000 for the 300 elderly in its adult day-health programs. What happens when these doors close? Who stays home from work to care for mom? Do the caregivers send parents or spouses to nursing homes? If the family can't afford a nursing home, then the state pays for it. There is no savings in this. We are cannibalizing ourselves.

Why is this happening? Declining revenues, earmarked spending from an initiative process that is totally unaccountable for balancing a budget, and fear. No one wants to say the obvious: You can't have a balanced budget without balanced income and spending. But no one is saying anything meaningful about initiatives, other than whining. Leadership is about changing minds, not reading polls, but I gather we have forgotten that.

Dennis Braddock, secretary of the Department of Health and Human Services, says flat out there is no way these cuts can be made without causing further problems.

Let's take mental-health services. In-patient care at Western State and Eastern State hospitals for the chronically mentally ill is about $360 a day per patient. The state plans to pay about $170 a day for care in the community. Where? Nursing homes cost about $110 per day and are desperately understaffed. They don't specialize in mental illness. Group homes? No one wants them in their neighborhood. They won't be ready in time to meet these immediate needs anyway.

How will these patients even find housing? How do they find a doctor? Who is going to manage their medications? How are they going to manage their money? How can the state even keep track of them?

State health costs are only going to increase, Braddock says, unless we get a prescription-drug program for Medicare soon. Low-income elderly with large prescription-drug costs are already "spending down" their assets to become eligible for Medicaid, which covers drugs. This adds to state health-care costs. In the industry, this is called a "death spiral." And, we're in it.

You would think we would get the message.

Since World War II, health care has been a business-to-business enterprise - employers buy it and insurers sell it. Employers hire predominantly healthy people, which insurers like. Government programs were created to care for the sick and the poor, which means the sick and the poor are covered by tax dollars.

Because health care is a business-to-business enterprise, not a community enterprise, we have never asked what a healthy community should be. In fact, as Anita Boser of the Employers' Health Purchasing Co-op says, we have never asked what problem we are trying to solve other than controlling costs. Now, we must. Our rate, regulation and body-part approach to health care has failed us big time. Our only solutions are rate and program cuts. They no longer work.

If I were Czarina of Health Care, I would first create a FEMA for families to help mitigate these cuts or use some reserves to put them off for a year. Then I would get communities - neighborhood by neighborhood - to brain-storm what they need for themselves and their families, like businesses use in strategic planning. We have never done this. We have always assumed only existing structures and revenues.

Then, we could take what we found at the community level to the county level and compare notes - sort of like a constitutional convention with elected freeholders - and finally move up to the state level. We would have people from the schools, the police, store owners, Rotarians, Kiwanis, artists, faith communities, employers, health-care professionals - public and private - but no associations with agendas.

Washington is in a unique position to do this, given the gravity of the proposed cuts, the tradition of innovative community leadership and the regional federal headquarters that could help with necessary waivers. Once we have identified what we need, we can decide who can do what part of the job and the sources of revenue, existing or new, that would be necessary to make this work.

We already know about how much it costs. Best of all, we would have a system that people own because they helped design it. Even better, it would have accountability and responsibility because everyone would know their role and could work toward a common goal rather than pointing fingers. Who's going to pay for this? Foundations and federal grants.

Some communities are actually already doing this - Lake Chelan Community Hospital and CHOICE Regional Health Network based in Olympia.

"If you don't know where you're going, you could end up in the wrong place," someone once said. We are at that wrong place. We must decide where we should be going and find a way to get there.

We can do it. It just takes political will. So let's have a FEMA for families right now to stave off the worst, then make a commitment and timeline to craft a new path to health rather than lingering in the inevitable death dance we're in.

Kathleen O'Connor is a Seattle-based health-care-industry analyst, consultant and publisher of The O'ConnorReport.

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