What do we want in a health care system?
It’s a question Dr. Donald Berwick asked an audience of 5,000-plus people at the Institute for Health Care Improvement’s National Forum in Orlando, Fla. on Tuesday.
Such an easy question. I can quickly rattle off answers: I want health care for my family. I want to be able to see a doctor when I’m ill. I want to be made healthy.
Stop. Berwick asks again. What do you really want? I want to be healthy.
This time think about it. Step back. Inhale. Think. Exhale. What do you really, really want?
Berwick explains how hard it is to skate ski and how he only hits perfection a few times out of every hundred kicks. Yet it’s those moments he pursues. That’s what he really, really wants.
How does a cross-country kick fit into the health care reform debate? Berwick almost had surgery to replace his knee – something that would have prevented him from ever cross-country skiing again. But another doctor found an alternative to surgery. Perfect. Berwick wanted bliss, the richness of the human experience. One more moment on a mountain.
That notion is far removed from the politics of health care reform. The debate in Washington is about the role of government or insurance. It’s not about capturing bliss.
“Health care has no intrinsic value at all. None, Health does. Joy does. Peace does,” says Berwick. “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”
But our current system is not designed to empty hospital beds. Our reward system – dare I say, the very foundation of free enterprise – works best when hospital beds are full, CT scanners are humming and doctor visits are available on demand. That’s even true in government and the Indian Health Service because the appropriations process does not pay for those patients not requiring treatment. Yet that very idea, a paradox, is what could lower health care costs for all.
Berwick said it’s our version of the Tragedy of the Commons. The 1968 article in Science by Garrett Hardin described a pasture open to all that works reasonably well until “a day of reckoning, that is, the day when the long-desired goal of social stability becomes a reality. At this point, the inherent logic of the commons remorselessly generates tragedy.” The commons no longer works because each of us seeks the best deal for them.
“Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off,” Berwick said. “So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?”
Let’s make being a chump a good thing. The fact is the spirit of cooperation is already driving down medical costs in places as diverse as Anchorage with the Southcentral Foundation and Alaska Native Medical Center to Cedar Rapids, Iowa. Indeed, the great thing about the Indian Health System is a head start in this regard. There is a long history of consultation – doctors and government officials working together with tribal leaders – for common solutions (and with little money). The Indian Health Service invented a prevention bundle – a series of tests – that look at many aspects of a patient’s life that helps identity and then treat problems ranging from spousal abuse to depression.
“I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong,” Berwick said. “It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.”
Forget health care reform. Let’s shoot for what we really, really want. But if we seek bliss, that means we must get folks working together.
Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. www.marktrahant.com
On its surface, Grants doesn’t look like the Gateway to the Nuclear West. Its shuttered buildings, dilapidated store fronts, and overgrown vacant lots are what’s left of the promised prosperity from the last uranium boom. To really understand Grants’ and the region’s past and potential future, you’ve got to go below the surface.
From the 1950’s until the mid-80’s Grants was the epicenter of the uranium mining industry in America. The uranium that was used in the atomic bomb that was dropped on Nagasaki came from here. Later, the Grants area also gave us the uranium that ushered in the era of “too cheap to meter” nuclear power. This is a town that was built on the 1950’s utopian dream of a George Jetson-like personal hovercraft powered by atomic reactors and endless nearly-free nuclear generated electricity that would turn the high desert into a Garden of Eden. But when the uranium market tanked in the mid-1980’s the fickle uranium mining companies packed up and left, leaving the local population jobless, broke and sitting on hundreds of piles of radioactive and toxic waste.Uranium mining is rarely talked about in the media, yet it is indispensible to the nuclear fuel chain. Read More ...
A generation ago Indian Country wasn’t included in the conversation about health care reform. When Congress enacted Medicaid and Medicare it pretended that the Indian Health Service didn’t exist. It was as if it had never occurred to the government, that it, too, ran a major health care delivery system.
Say what you like about health care reform, the fact is that Indian Country is included in a big way this time around. If either the House or the Senate bill becomes law, there will be a significant boost in resources for the Indian Health system.
The largest single line item is the reauthorization of the Indian Health Care Improvement Act, included in H.R. 3962, the Affordable Health Care for America Act. The Congressional Budget Office “scores” the cost at $100 million through 2014 and $200 million over a decade. Most of that cost is attributed to the “expansion of payments under Medicare.” This is important because American Indians and Alaskan Natives have the highest percentage of any population over 65 not currently enrolled in Medicare programs.Read More ...
If the American Farm Bureau Federation has its way, the issue of whether herbicide spraying over water requires a Clean Water Act permit will be heard by the Supreme Court. A coalition of agricultural groups led by the Federation has petitioned the nation’s highest court to reverse an appellate court decision which found that such spraying requires an NPDES clean water permit. NPDES permits are required when pollution is delivered to a water body from a point source. What constitutes a point source for Clean Water Act purposes has been a major US legal issue for well over a decade with several previous cases reaching the Supreme Court.
The battle over pesticides and their regulation has been a constant of US environmental politics since Rachel Carson’s landmark Silent Spring was published in 1962. In the West the conflict heated up in the 1970s when a group of women from Alsea, Oregon documented what they believed was an association between spontaneous abortion rates and herbicide spraying in the industrial forests near their homes. Erik Jansson was working on pesticide issues for Friends of the Earth at the time. He publicized the plight of the Alsea women and helped create a national campaign to restrict aerial herbicide spraying.
The warning from Alsea and Friends of the Earth exploded across the West where an army of back-to-the-land hippies had recently arrived in search of a life free from industrial threats. Here in Northwest California health workers at Native American clinics also took note.
They’re calling it a “uranium renaissance.” Wyoming is prepping itself for what is slated to be another boom in uranium mining for the fourth time in 60 years.
Wyoming and the Rocky Mountain West are all too familiar with energy boom and bust cycles. Just ask all the people who lost jobs in the oil bust of the '80s, or in Wyoming’s Cold War-fueled uranium boom and subsequent bust of the ‘50s.
Nuclear power accounts for about 20 percent of the power generated by the United States. But this figure is likely to increase - with the green movement, coal-fired power plants aren't as popular as they used to be. Across the United States, 21 new nuclear power plants have been proposed. Worldwide, there are 53 nuclear power plants being built right now, with many, many more in the works. Even Nevada, who held strong to the “we don’t have a nuclear plant so we we’re not taking your nuclear waste,” argument against the Yucca Mountain storage facility, is considering going nuclear. Overall, the World Nuclear Association estimates a 78 percent increase in uranium demand over the next 20 years.
This is where Wyoming comes in.Read More ...
“When I saw the night sky for the first time in the Mojave National Preserve I felt like a layer of film had been peeled away from my eyes,” says David Lamfrom, the Barstow based field coordinator for the National Parks Conservation Association.
“I want the kids who live in the high desert to realize how rare and precious it is.”
Lamfrom and his partner Rana Knighten are on a mission to share their love of nature and the Mojave National Preserve with underserved students from California’s High Desert. They’ve created the innovative Tortoises through the Lens Program, which takes diverse youth and teaches them conservation ethics through nature photography and field study. The students take field trips, do volunteer work and go to lectures to learn about the ecology and life history of the threatened desert tortoise. The planning, photographs and writing they do throughout the course of the year culminate in a published book about Desert Tortoise Conservation and an exhibit of the students’ photography at the Kelso Depot Visitor’s Center in the Mojave National Preserve.
Lamfrom knows the challenges of engaging today’s youth in nature.
“Many children who grow up in highly urbanized and underserved communities - and I’m speaking from personal experience - live in a world of buildings and streets and noise. When they come to wild places they are scared because it’s so foreign to them.”Read More ...
Bryce Andrews of the Clark Fork River Coalition, reports from a Superfund Meeting at the Opportunity, Mont., Community Center
I drove in just before 7 pm, down a little spur road that headed west a few miles after Warm Springs. Ahead of me the Anaconda Stack, lit up by amber lights around its base, slipped in and out of view behind willows. Glimpsed from the corner of my eye, the faint-glowing stack looked like a plume of smoke. It towered over roadside yard-lights like the stalk of a mushroom cloud.
It’s no accident that driving to Opportunity feels setting a course for heart of something huge and awful: The area around that blithely named one-horse town is closing in on a century of use as our regional trash can.
Read More ...
I pondered featuring this reader photo a couple weeks ago, but ended up with a different choice. Today, though, the sparkling vermilion of these aspen leaves, now blanketing forest floors across the West, brought me a bright remembrance of Colorado's autumn moments, which I wanted to share with you.
Across most of the West it's starting to feel like winter. I don't mind holding on to fall a little bit longer, though.
Depending on who you listen too, sweeping water-related legislation recently enacted in California is either a solution to the states water conflicts, a recipe for increased conflict and the domination of corporate water brokers, or a partial step forward that will succeed or fail depending on future legislative and administrative actions.
Here’s how Lester Snow, director of the California Department of Water Resources, described the package of bills and the $11.14 billion water bond needed to fund them:
“This package represents a new approach for California---total water resource management, including conservation, water recycling, habitat restoration, water storage and many other water management actions….. This package represents a significant shift in water management that will serve as a platform to address 21st century water needs.”
Others – including the California Water Impact Network (C-WIN) – believe that the legislation and bond package is a step backward for California Water Management. They believe the legislation could ultimately make it possible for powerful Southern California agricultural and development interests to grab more of Northern California’s water by building new reservoirs in the north and a large new canal to by-pass the Sacramento-San Joaquin Delta. Here’s an excerpt from a C-WIN letter to legislators about the package of bills which has now passed into law:
“C-WIN firmly believes that California has enough water to meet all its needs. California does not have enough water to continue wasteful and unreasonable uses that harm public trust resources and compromise our state’s agricultural, economic, and environmental future. There is no real surplus water anywhere in northern California to fill a Peripheral Canal, even if it is built.” (emphasis is from the original)
C-WIN’s concerns that the legislation will facilitate renewed efforts to divert more Northern California water south have been echoed in the Klamath River Basin where the Hoopa Tribe and others battled for years to restore some of the water previously diverted South in order to restore the Trinity River, the Klamath’s largest tributary. Part of the funds for removal of four Klamath River dams is included in the $11.14 billion bond package which will go to voters in 2010. However, some Klamath watchers fear that construction of new dams and reservoirs and the Peripheral Canal will result in renewed efforts by powerful agricultural and development interests to divert Klamath River water south.
The package of bills contains a call for a 20% reduction in urban water use but contains no similar goals for agriculture. Agriculture currently consumes 80% of California’s water supply and numerous studies indicate that substantial water savings are possible in the agricultural sector. Irrigation interests, however, have resisted meaningful water conservation. By controlling more water these farm corporations will be in a stronger position to earn income as water brokers. It is the potential for substantial water savings in the agricultural sector which leads C-WIN and others to suggest that new dams, storage reservoirs and canals are not needed.
One of the most respected voices in California Water – Dr. Peter Gleick of the Pacific Institute – has taken a different view of the water legislation:
“What will be the ultimate outcome? Are we going to be better off with this bill than with no bill? Will California legislators now say they are done dealing with water, and refuse to tackle the unaddressed, partially addressed, or badly addressed issues? If so, then this package isn't going to be nearly enough. But if instead legislators and other water interests treat it as a beginning, not an end, and work to build and improve on the good pieces, it could be a major step forward. We'll have to wait and see how it changes our actual water problems.”
Doctor Gleick identifies four major California water “problems” which the legislation has not addressed including:
1. Insufficient monitoring of water use – especially groundwater use;
2. Lack of adequate political will and funding to enforce existing water rights – including ending the epidemic of illegal water use;
3. Lack of a requirement that the state’s largest water user – agriculture – implement water conservation, and
4. Lack of user fees for water users which would incentivized conservation and provide stable funding for maintaining and improving California’s water infrastructure.
Gleick believes these four issues must also be addressed if the new legislation is to prove out as “a major step forward.”
As generally happens when there is major legislation affecting the environment, the environmental community split over whether to support or oppose the legislation. And, as is usually the case, the split was generally along the grassroots-national divide. In spite of the fact that they are members of the Restore the Delta coalition which opposed the legislation, the Natural Resources Defense Council supported the legislation as did the Environmental Defense Fund and The Nature Conservancy. Opposing the legislation were a host of local and regional organizations ranging from the California Sportsfishing Protection Alliance and Clean Water Action to the Stockton Chamber of Commerce.
Largely absent from the legislative debate over the future of California water were the state’s 108 federally recognized Indian tribes. Many of these tribes have potential reserved water rights which, if they were asserted, could be a significant wildcard in California water politics. Federal tribes could also begin pumping and selling groundwater supplies which are already being over-exploited without fear of interference from state or local governments.
While powerful agricultural interests were helping draft water legislation behind closed doors, however, tribal and other Native leaders were listening to speeches and attending luncheons as part of a “Tribal Water Summit” hosted by the California Department of Water Resources. Individuals who attended report that nothing of significance took place during the Summit. For now at least, the tribal water wildcard is not being played in California.