In the old fable about the blind men and the elephant, each blind man touches only a part of the elephant: the one who touches the tail believes an elephant is like a rope, the one who touches the side believes an elephant is like a wall, the one who touches the tusk believes an elephant is like a sword, and so on. The moral of the fable is that by sharing perspectives, they achieve a more complete picture of the elephant than they could individually. That moral was on display at a panel discussion, “Re-Imagining Healthcare in Pennsylvania: The Next Five Years and Beyond,” sponsored by the Central Susquehanna Citizens Coalition (CSCC), which took place on Thursday, May 7th at the Union County Government Center in Lewisburg, with about 30 citizens in attendance. In this case, the healthcare system itself was the elephant in the room.

Allison Clark, who directs ACTION Health, and Jill Fecker, who works for A Community Clinic in Sunbury, offered two different front line reports on the current healthcare system. Clark sees a number of large issues that need collective and concerted attention. For example, few people know about the huge rise in diabetes rates in the Susquehanna Valley. Chronic diseases like diabetes and other systemic health issues require education, prevention, and collaboration, not simply treatment. At A Community Clinic (which is listed under “A” on page 1 of the Greater Susquehanna phone book), Jill Fecker sees another side of healthcare. A Community Clinic has seen over 3,300 patients since it was started (originally through ACTION Health, though it is now a completely separate organization). A Community Clinic sees only patients who have no health insurance of any kind. They have been unable to find a dentist to keep their dental clinic open, and they continue to rely on volunteers and a few committed healthcare providers to do what they do. As with many service models, run on grants and donations, they have seen a large increase in the need for services in this economic downturn while also seeing a decrease in donations.

Andrew Sandusky, who works for the Pennsylvania Academy of Family Physicians (PAFP), and Chuck Pennachio, who directs Healthcare for All Pennsylvania, looked at the bigger picture, offering systemic views of the healthcare system within the context of Pennsylvania politics. Sandusky began with a plain explanation of what he does. “My title is Vice President of Governmental Affairs. That means I’m a lobbyist.” He lobbies the state legislature on behalf of family physicians. He explained why primary care physicians are necessary and in short supply. Simply put, doctors can make a lot more money if they go into a specialty such as surgery. If we magically provided healthcare to all, we wouldn’t have enough primary care doctors to provide service to everybody. Sandusky believes insurance companies can be part of the solution and said that he didn’t want to pick on them. He is promoting a concept called “Patient-Centered Medical Home,” which would mean that everybody would have a primary care doctor with whom he or she had a continuing relationship: no more fifteen minutes with a random doctor, as happens in some cases in the current system. Many of us take things for granted because we have a primary care physician—things as simple as reminder calls about upcoming appointments.

In the question and answer period, somebody asked about the state’s incentive program to get doctors to serve in areas that are in need of doctors. Sandusky noted two problems: the program is poorly funded, and many needy areas don’t qualify under the federal guidelines because they are relatively close to areas that are well off and do have doctors.

Chuck Pennachio had a different take on healthcare in Pennsylvania, saying that he did want to pick on the insurance companies. Insurance companies have administrative costs of 18%, and they impose indirectly another 17% onto others. Private insurance companies’ total administrative costs are therefore about 35%, compared to Medicare’s costs of about 3.5% (or in that range. The difference between these two numbers implies a potential savings of close to 30%.)

Pennachio’s organization’s proposal goes by the name “Civilized Healthcare for All,” since nearly all other leading countries (27 of the wealthiest 28) provide some kind of healthcare for everybody. Because the U.S. system evolved through employer-provided healthcare after World War II, we’ve never moved to a unified health insurance system. Pennachio cited findings that more than one million Pennsylvanians do not have healthcare insurance and that 74% of Pennsylvanians who do not have health insurance work full time. He also noted that many full time workers do not get insurance through their employer. The employer provided system of health insurance is fragmented and broken, which implies a need for and potential public support for a new kind of system. Pennachio believes Pennsylvania could be ready to act, especially if a commissioned study shows what he thinks it will show: that the “Civilized Healthcare for All” proposal could deliver comprehensive health coverage for about the same money now currently spent. Most businesses, for example, would save money over what they currently spend by paying a 10% “business health and wellness fee,” and they could get out of the business of providing healthcare coverage.

Approaching the healthcare elephant from another direction, Bucknell economist Amy Wolaver looked at the lessons from the Massachusetts experiment with healthcare for all. She began with some revealing slides about American healthcare economics. Charts (from sources such as the Kaiser Family Foundation and the Commonwealth Fund) show just how much the U.S. spends on healthcare already (significantly more than any other country) and how our overall results on a variety of measures (longevity, infant mortality, etc.) are poor relative to other countries’. While this general point is well-publicized, it is not widely known that the U.S. public subsidy for healthcare is actually larger than any other country’s. We just aren’t aware of the subsidy because it primarily takes the form of a tax exemption for employer-provided healthcare benefits. In effect, the people with the best healthcare packages get the biggest public subsidy, which is a pretty good way to guarantee poor results overall, since the people who need healthcare coverage the most don’t get much of anything. Wolaver pointed out a few key lessons from Massachusetts: a “bare bones” approach to healthcare isn’t terribly effective. Underfunding has been a chronic problem in Massachusetts, and that problem gets worse in a recession. There’s also a problem with a stratified system if healthy people have an incentive to stay out of the insurance programs that are seen as being just for sick people. If only the sick people are in those programs, the costs go up and up, the premiums go up and up, and more and more healthy (and even sort of healthy) people opt out. The cycle feeds on itself and the whole thing collapses because the program is no longer spreading the risk and no one can afford the premiums.

So, what’s the answer? Should we collectively work on the problems of chronic diseases? Yes, of course, we could do more to create healthier people and also better manage chronic care. Extend health insurance coverage and affordable access to healthcare to the uninsured? We seem to have moved in the other direction in the last decade, which has made the problem worse. Build up our fragmented and fragile system of primary care? Yes, the family doctor system continues to be the foundation of our system. Restructure the health insurance system in ways that move us away from employer-provided health insurance? It seems employers are moving that way already. Rethink the way we use public dollars in healthcare? It looks like this recession will force us to do that. We may even need to rethink the long-standing tax exemption for employer healthcare benefits.

Some members of the audience shared their own impressions of healthcare in the question and answer period. For those who find themselves in the “donut hole” of Medicare prescription coverage, that is the most pressing problem. Others were outraged by pharmaceutical companies’ advertising and promotions (and their CEO pay). (Most found it hard to accept Wolaver’s claim that the biggest cost drivers are elsewhere, in major heart surgeries and in end of life care, for example. Most also seemed not to know about a new law that has dramatically restricted gifts to doctors from drug companies.)

Wal-Mart received some praise and some blame for its role in healthcare. Jill Fecker talked about how Wal-Mart’s $4 plan for prescription drugs has been very helpful to patients with no insurance; Chuck Pennachio noted that Wal-Mart is an employer that encourages its workers to file for public subsidies and does not provide healthcare coverage for most of its workers.

In the end there seemed to be some agreement that healthcare in Pennsylvania and nationally is an issue that we will be talking about for years to come. We don’t fully understand this healthcare elephant, but we can see some of its problems. Jill Fecker had perhaps the most poignant statement of the night on the theme of re-imaging health care for five years and beyond: “five years from now,” she said, “I hope there is no need for A Community Clinic because that would mean everyone would have at least some kind of healthcare coverage.” At the end of the discussion, it was clear that is a possible future, but only if there is political commitment on all sides to create a better system for all.

Note: CSCC (www.csccnow.com) is an all-volunteer, grassroots organization centered in Union County. CSCC’s members have voted “Health Care for All” one of its political priorities at both the state and federal levels. It has not endorsed a specific plan.