I hope that the health insurance exchanges required by the new federal health reform law will work as well. These virtual market places open for business in 2014. Until then there will be much speculation, pro and con. The promise is that individuals and small businesses will gain access to better health insurance. We do know a fair amount about how they will be constructed. We can only guess how individual consumers will react.

The hope is that insurance exchanges will offer more reasonably priced premiums that vary less year to year. Individuals and small employers will have a choice among health plans on a more level playing field.

Near full participation in these markets is necessary for the exchanges to work. Participation will be “encouraged” through an array of federal subsidies and penalties, that may or may not be strong enough.

But it is a mistake to focus only on the law and the expected regulations. The benefits from this health reform will not come mostly from the government’s action but from the decisions of those using the exchanges. In other words, this reform is less about stop and go lights and more about an intersection with stop signs that requires people to make a choice of when and where to go.

So what choices might people make? Thanks to talks with friends in the insurance business, I think we will see a significant emphasis on plans with stronger primary care networks. This is good as it is generally agreed that Americans would be healthier, and our care less expense, if we used more primary preventative care and less specialty care. Why may this happen?

The exchange rules are intended to make the exchanges fairer for consumers and patients but also to encourage competition to improve the quality and cost of health care. If an insurer offers a product in the exchange, it will no longer be able to adjust the premium based on the health of the insured. (Employers will need to be able to financially incent healthy behaviors by varying the employees’ share of the premium so as to encourage the focus on wellness.)

More than before, insurers will have a business interest in attracting more healthy subscribers than their competitors. In the past, health plans were particularly interested in advertising access to a wide array of specialists and large medical centers. They were also able to charge substantially higher insurance premiums to those more likely to need care, typically much more expensive specialty care. That will not longer be as easy to do.

The insurance exchanges will change what it takes for an insurer and their affiliated provider networks to succeed. Those who offer the most convenient access to primary care physicians, nurse practitioners and physician assistants will attract healthier customers with less of an interest in access to specialty care that they don’t expect to use.

This will create a greater demand for already scarce primary care practitioners, driving up their salaries compared to specialists. It will increase their influence on health care and health policy. It will increase the proportion of students choosing this career path. This is good news for those local and regional networks that have already developed local access to robust primary care services. It will create even greater demands on schools of medicine and nursing to educate the right workforce.

It is yet unclear whether the incentives and penalties in the health reform law are strong enough to make the health exchanges work. If they do, you can expect that primary care will no longer be American medicine’s stepchild. Ever the optimist, I can even hear medical faculty start to say to bright young medical students, “why would you ever want to be a specialist?”

The long sought fundamental change in American healthcare may very well come not from the heavy hand of government but the natural self-interest of the market place.

Make no mistake, whether or not you call it “reform,” health care must and will change in some very basic ways. We, and our country, can’t afford not to change. I have yet to meet a healthcare leader who disagrees with this, although I am sure there is someone somewhere. We all know this, regardless of where we stand in the endless political posturing.

The reality is that the Reform Bill and its implementation will and should be scrutinized and, hopefully, improved. This will happen in hundreds of ways over the next decade or so, with or without new faces elected to Congress.

The key question is will we, in our political clumsiness, throw “the baby out with the bathwater?” Will Congress really “repeal reform” and:

• Take away insurance from tens of millions of hard working Americans?
• Allow health insurers to deny children health insurance because of pre-existing conditions?
• Take away from small businesses tax credits covering up to 50% of employee premiums?
• Allow insurers to put a “lifetime cap” on how much insured healthcare you can receive?

Maybe Congress will. But I doubt it. As a practical matter, it is hard to see how the main threads of health reform can be removed without the whole thing unraveling. Having said that, I’d be the last person to ever try to predict what Congress will or won’t do. Or even less, can I figure out what a worried and divided American public really wants? Pick almost any position and you can probably find a poll that will support it.

So what do I think? I believe rural communities need a Congress that further encourages both public and private sectors to:

• Assure that we have reasonable access to care in local rural communities.
• Stop wasting money on unnecessary procedures with payments driven by the amount of care provided, not the quality of that care.
• Stop unjustifiable differences in what Medicare pays for care in one region versus another.
• Incent providers to keep patients healthy and coordinate their overall care.

With all apologies to the Alcoholic Anonymous Serenity Prayer, my hope is that “Congress finds the serenity to accept the things they shouldn’t change, the courage to change the things they should, and the wisdom to know the difference.”

I studied with George Bugbee, (the American Hospital Association’s first non-physician executive director) to become a hospital administrator just a few years after the creation of Medicare and Medicaid in 1965. Assuring universal coverage for the rest of America was widely believed to be right around the corner. It has been a long corner.

It took us the greater part of twenty years to work through challenges caused but not anticipated when the Medicare Prospective Payment System began in 1983. It will take at least that long for all of us to digest this new change. From a rural perspective, here are some of the priority areas that will need our attention:Protecting access to local care is a high priority as we address the systemic changes this legislation will incentivize. Equally a threat to access is the soon to explode retirement of baby boomers, leading to worsening of the current mal-distribution of healthcare professionals.

Given the history of rural health voices being underrepresented on the current Medicare Payment Advisory Commission, an even more powerful Medicare Commission is potentially threatening to rural equity and will require even greater vigilance.

Health reform’s first installment was the American Recovery and Reinvestment Act and its focus on health information technology. Unfortunately, it appears that many decisions to date, by Congress and the Administration, are leading to an increase in the rural-urban digital divide.

The greatest limitation to this legislation is that it is about “healthcare” much more than about “health” reform. Americans are breaking the healthcare bank due to too much smoking, drinking and eating, and too little exercise, education and jobs. We must expand our efforts to help individuals and communities become healthier–to reduce the need for health care.

I have come to recognize “they grow their own vegetables” as  “rural as Lake Wobegone” myth. For my friends who never stray off of Fox News to National Public Radio, Lake Wobegone is Garrison Keillor’s fictional hometown where “all the women are strong, all the men are good looking, and all the children are above average.”  Not anywhere I’ve seen.

The opposite of an overly idealized version of rural America is the equally extreme view of “rural as backwater.” Unfortunately I hear a lot more of these myths than the possibly less harmful Wobegone variety.

A good example is the myth that Wisconsin patients don’t much like the care they receive in rural community hospitals. The data supports just the opposite view. The most recent results for a national survey of patient experience of care can be found on Wisconsin Hospital Association web site. In Wisconsin, 69 percent of rural patients surveyed ranked their hospital high, 4 per cent above the score for ALL hospitals nationally. The same web site shows that both rural and urban hospitals individually score above and below state averages on a variety of other quality measures.

Another false claim that I still hear too often is that rural hospitals are just “Band-aid stations.” Nothing could be further from the truth. Rural hospitals are the backbone of health care delivery in rural communities, and providers of a broad range of services including: emergency services, comprehensive primary and selected in-patient services, in-patient surgery and day surgery, out-patient and diagnostic services, long term care services and an ever more active role in health promotion.

The source of some attitudes that one part of a state can hold about another often can’t be pinpointed but I don’t believe they arise from bad intentions. I believe it is more about differences in perspectives that come from knowing a place as home versus passing through. And its not just about urban misunderstanding rural. The myths can and do go in both directions. To hear some talk, there is a convention of liberals on every Madison street corner.

The bottom line is that when you have seen one rural community, you have seen one rural community and need to be careful about making general statements. There is probably as much diversity among rural communities and health care providers as there is between rural and urban.

But what does the data tell us? It tells me that there are challenges that we need to face in our rural communities. On average, rural Americans are older, poorer, have less education and fewer jobs. All of these conditions contribute to poorer health and drive the need for local health care. We do know that rural providers have been historically underpaid for the work they do. We do know that urban-focused academic centers can do much more than they have to date to prepare the next generation of providers for rural health care. The list goes on.

The data and my own experience tells me that rural health in Wisconsin is dominated by hard working, skilled professionals, who continuously go above and beyond the call of duty. I know that we in rural health are realistic about both our strengths and about the challenges we face. I believe we invented “doing more with less.” We know our job is to preserve what we have, while continuing to improve and celebrate the hard work and success that defines rural health.

The President spoke to the country in the shadow of the irony of the Massachusetts election. The irony isn’t what happened to the seat long held by Ted Kennedy but that the one state that has, and to all accounts appreciates, universal health care might block the rest of the country from gaining something similar.

The President took a share of the responsibility for a process that has been too partisan and pork laden for most of us. He challenged both Democrats and Republicans to stop making every day and every issue about the next election. For my part, it is clear that America does not like watching sausage being made. This doesn’t make us all vegetarians but he spoke for most of us when he said the people want fewer sound bites and more of the job getting done.

The President strongly believes in the ethical imperative of reform as well as believing it is a fundamental building block of having a strong economy and sustained job creation. Contrary to the pundits, it didn’t sound to me like he was backing away from health reform. He is not quitting.

The bill needs to be seen as only a really important first step on long over due changes for our country. This is not a criticism of Congress but a statement of reality when a country goes about trying to fundamentally improve a huge part of itself, like its healthcare system.

It will take years for healthcare providers, insurers and local communities to adapt to a complex array of new expectations, incentives and resources. In particular, those of us who care about rural health need to be nimble to address the risk of ideas developed in urban communities and frequently not tested in rural ones.

The health reform bill leaves significant challenges for future legislation and regulation and all of us to do outside of government.

No amount of “healthcare reform” can fix our own behaviors. We must work to reduce the amount of care our system needs to deliver. We must get serious about doing what we can to get and stay healthy. We need to do this as individuals, workplaces and communities.

The current system penalizes Wisconsin for the work it has already accomplished in being one of the states that stands out with high quality and relatively low costs.

Wisconsin Congressman Ron Kind was instrumental in getting into the House Bill language that requires a study about how Medicare should create incentives for value of care rather than volume of care. The study will be done by the country’s highest medical authority, the Institute of Medicine; and its recommendations will be implemented unless Congress can take action to block the changes.

Most disappointing is that Congress did not make a simple change that would have saved money and reduce headaches for rural communities. Current Medicare law limits  the number of patients the typical rural hospital can see (those paid as a “Critical Access Hospital”) to a 25 bed cap. We proposed changing that to a 20 bed average to allow for seasonal spikes in the number of patients like during a flu epidemic. Maybe this will be changed in the final Bill but currently this problem remains.

Many people have praised the new Medicare Commission as a way to modernize Medicare without “good” ideas getting bogged down in Congress. But it has key Members of Congress, in both the Senate and the House that have stood up for rural health. It is unlikely that there will be a rural perspective invited into a small Commission. The Federal law that requires proportional rural representation on the current Commission, which is only advisory, has never been implemented.

Don’t underestimate the importance of unintended consequences. It took the country the greater part of 20 years to work through problems caused but not anticipated when the way Medicare pays hospitals was fundamentally changed in 1983. It will take at least that long for all of us to digest this much change.

On a typical day, they are working to protect their patients and community from the effect of not one storm but a plague of once in a generation storms. You see or hear about these events every day but you may not know how they pile up on your local hospital or clinic. Think of the uncertainty on the ground around federal healthcare reform, of state budget shortfalls, of physician and healthcare workforce shortages, the effects of the global recession, and of course, H1N1.  Each one of the five is a big challenge. All five at one time would cause any of us to do more than lose sleep.

Let me be clear, I am not whining on behalf of friends and colleagues who work in the front lines of health care; just the opposite– I stand in amazement at their calmness.

H1N1 brought sick patients into facilities with unvaccinated staff at a high risk of getting it and passing it on. Due to distribution problems of limited H1N1 vaccine, one nurse described the feeling like being sent into a war without weapons. Other supplies like needles and facemasks are abundant in some communities and chronically short in others. By chance, some staff got a seasonal flu shot early, while others won’t be able to get one this year.

The recession has caused the need for charity care to go through the roof. At the same time, the ability to provide charity care has fallen through the floor. Pay freezes, or even cuts, and layoffs have been necessary. The stress felt has risen.

Unemployment is at all time highs. But even in the recession, there are many shortages of health care professionals in rural communities. And hospitals and clinics are already scrambling as they work to prepare for even bigger shortages. Healthcare workers are mostly baby boomers. These healthcare workers are beginning to retire out of health care and increasingly, with age, into becoming patients themselves.

Hospitals, clinics, nursing homes and other providers are facing deep cuts in state payments that are already inadequate for Medicaid enrollees. In Wisconsin, the rightly praised growth of “BadgerCare” to expand access to insurance has brought the downside of providers being more vulnerable to further Medicaid under payment.

And then there is national health care reform. Part of me wants Congress to get it right, but another part just wants them to tell me the new rules so we can get on with it. In any event, fundamental change to a sixth of our country’s economy will require years of additional legislation and regulation. In the meantime, those of us who care about rural health need to be nimble to address the risk of ideas developed in urban communities and not tested in rural ones.

On second thought, just for prevention sake, a hug might not hurt.

The President made it clear he stands on common ground for our country by “building on what works.” A new government run plan that undermines the private sector now seems less likely. A major shift of patients into a plan paying Medicaid and Medicare type rates would harm rural patients’ access to local health care. Reform affecting rural communities must and can be built on quality outcomes and efficiency while delivering care locally. As the President concluded, I “believe we can replace acrimony with civility, and gridlock with progress.”

Martians may land here tomorrow. Congress may start listening to the larger number of us who don’t shout for a living. So yes, trying to help patients and families deal with tough end of life questions can be twisted into something sinister. But when each of our time comes, most of us don’t want end of life heroics. We want to be treated with respect, to be embraced and to die free of pain.

“The practice of advance-care directives is widespread and accepted. It includes living wills with explicit instructions about what should be done for individuals in final illnesses, and what should not be done. It allows people to make ethical, legal, moral choices about treatments, prolonging life, and when additional treatment should not be pursued.” (AARP website)

“The questions are critical, even if some people find them difficult to contemplate. Should a feeding tube be installed when the patient can no longer be nourished by mouth? Should a ventilator be attached when breathing independently becomes difficult? If the patient has severe dementia, should antibiotics be used if pneumonia develops? Should cardiopulmonary resuscitation be attempted if the heart stops beating?” (The New York Times, 8/17/09)

The National Institute on Aging offers a comprehensive 68-page booklet produced under President George Bush’s Administration. End-of-Life: Helping With Comfort and Care provides “an overview of issues commonly facing people caring for someone nearing the end of life. It can help you to work with health care providers to complement their medical and care giving efforts.” Individual free copies can be obtained through the institute’s web site, www.nia.nih.gov, or by calling 800-222-2225.

While such resources are extremely helpful, I suspect most of us would also appreciate our physician or practitioner’s guidance regarding our end of life options. And in America, we tend to get what we pay for.

In the meantime, I hope the Government’s end of life booklet won’t be silenced as well. Most of us understand the wisdom in Ecclesiastes: “For everything there is a season, a time for every activity under heaven. A time to be born and a time to die. A time to plant and a time to harvest.…”