Dear Governor: Scott Armstrong

“Dear Governor: About The State of Reform” is a collection of voices from across the health care spectrum, from four states: WA, OR, ID, and AK.  The book will be published in October.  Excerpts will appear here.

Dear Governor,

There’s no doubt that the Supreme Court’s landmark ruling to uphold most of the provisions of the Affordable Care Act was a key milestone in the evolution of health reform in this country.  But as important as the decision was, it was really just one single step in a process that started long before the Affordable Care Act passed and will continue for a long time to come.

What tended to get lost in all the speculation leading up the Court’s decision, and the focus on the political implications afterward, was an important truth about how health care really works.

There’s no doubt that federal policy plays a vital role in creating the framework for a health system that can provide affordable, high-quality care to all Americans. That’s why the decision to uphold the individual mandate mattered: it kept in place the federal structure for expanding health care coverage when the mandate goes into effect in 2014.

But what happens in Washington State is just as important as what goes on in Washington D.C.  For example, decisions that are made at the state level about how to implement provisions of the Affordable Care Act will go a long way toward determining whether citizens in this state who can’t afford the care they need today get access to affordable, high-quality coverage in the future.

And ultimately, the decisions that affect our health the most are the ones we make every day when we consult with our doctor, or when we choose what to eat and how much to exercise. What really determines the quality and cost of medicine is the access people have to care, the procedures they choose, and how they manage their chronic conditions.

These are some of the challenges that local health care providers around the country are focused on today.

Washington State in particular has been a great laboratory for new ideas about how to make health care work better for local communities. For example, organizations such as Group Health, Virginia Mason, The Everett Clinic, and Providence Health Care of Spokane are leading efforts to build integrated systems that deliver better health and more affordable care. And the Puget Sound Health Alliance is providing information, so that people can make smart decisions about how they spend their health care dollars.

We don’t have all the answers yet, but we’ve learned some important lessons. We know that lifelong health starts with a strong relationship between patients and primary care doctors. Treatment must take into account standards based on up-to-date medical research. Technology should connect patients and clinicians to each other and the information they need. And people must be actively involved in their own health, in the doctor’s office and beyond.

We also know that how we pay for health care is hugely important. The traditional approach in this country—payment for each procedure—leads to a system that emphasizes treatment over prevention. Health care works best when doctors are paid to help people choose treatment that is best for them rather than the hospital or clinic’s bottom line.

As we apply these lessons at Group Health, we’ve reduced emergency room visits by 29 percent and lowered the rate of some expensive elective  procedures by 25 percent. Helping people manage their chronic conditions improves their quality of life and saves nearly $600 per patient each year.

These are great examples of how coordinated health care systems help people live healthier lives and control costs at the same time.

But for all the progress that Group Health and other organizations in the state are making toward care delivery improvements that lead to better care that costs less, the fact remains that health care coverage is still too expensive for far too many people in Washington State.

This is where the state policymakers can make a difference, particularly as they make decisions about key elements of the Washington Health Benefits Exchange.

The starting point for a successful Exchange is to make sure that as many people enroll as possible. This means it is critical that policymakers make it is easy for people to participate.

It’s also important that people have access to transparent information about quality so they can make smart decisions about their care based on a clear understanding of value, and that there are provisions that ensure continuity of coverage as people move between Medicaid and the Exchange. The Puget Sound Health Alliance is a valuable model for how this can work.

There is another area where Washington State can influence the direction and pace of reform in local communities: through payment systems and health plan benefits within the care health programs that it controls.

Because Washington offers medical plans to state employees and pays for Medicaid coverage for eligible residents, it is one of the biggest purchasers of medical services in the state. By designing payments structures and health plan benefits to support efficient, high-value care, the state can nudge local health care providers toward innovations that have been proven to provide better outcomes at lower costs.

As policymakers begin to design the Washington Health Benefits Exchange, there are important opportunities to include similar requirements for health plans that choose to participate.

The truth is that it is going to take a long time and a lot of hard work to fix this country’s broken health care system. As we move forward, the pressure to innovate and improve will increase and the rapid pace of change will continue.

The good news is that there is a lot we can do right here in Washington State to make a difference through local innovations that improve quality and lower costs.


Scott Armstrong