We are living in truly interesting times. The 21st century promises monumental changes in health care, education, communication, and science in general. The technology currently available has provided the tools whereby educated consumers can make critical decisions regarding their own health care and health care providers can call up databases (such as Epocrates ®) to provide up to date information on pharmaceutical agents. Yet despite these promising developments, the status of health care in the U.S. is not good.

     Health care costs have once again begun to escalate faster than other segments of the economy, and the number of uninsured is now 43.6 million Americans. In June, 2002, the Secretary of the Department of Health and Human Services (HHS) met with leaders from the National Academies and challenged them to propose bold ideas that might change conventional thinking about the most serious problems facing the health care system today. The Institute of Medicine (IOM) reported: “The American health care system is confronting a crisis…Tens of thousands die from medical errors each year, and many more are injured. Quality problems, including underuse of beneficial services and overuse of medically unnecessary procedures, are widespread. And disturbing racial and ethnic disparities in access to and use of services call into question our fundamental values of equality and justice for all. The health care delivery system is incapable of meeting the present, let alone the future needs of the American public.” (emphasis added).

     A new development in the area of health care reform is emerging from the Wye River Group on Healthcare (WRGH), which held a National Summit Meeting on Health Care in Washington at the prestigious University Club on September 23, 2003. I had the honor of representing APA at this event, along with Russ Newman (who graciously invited me to join him). The Summit Meeting was the culmination of a project initiated in July 2002, titled “Communities Shaping a Vision for America’s 21st Century Health and Healthcare.”

     Quoting from sections of the WRGH report, “This project is fairly unusual in its effort to understand how health care stakeholders and consumers view the values and principles underlying our health care system…. WRGH held a series of Healthcare Leadership Roundtables in 10 diverse communities around the country. During these roundtable discussions, community health care leaders were asked fundamental questions, such as whether there is, or should be, a social contract for health care in this country….”

      In each community, WRGH assembled a diverse cross-section of public and private stakeholders with detailed knowledge of health and health care. They included physician leaders, hospital and health system executives, community and public health officials, pharmaceutical and pharmacy representatives, business leaders, consumer representatives, and government officials. WRGH also worked to ensure that important constituencies such as the elderly, the uninsured, minorities, and people with chronic illnesses were well represented….”

     “After roundtable discussions were held in all 10 communities and the advisory boards wrapped up their work, WRGH hosted a retreat July 9-11, 2003, at the Aspen Institute Wye River Conference Center in Maryland…. To announce the “shared vision” that arose from this project, WRGH organized a national summit designed to showcase the findings of the 10-city tour and launch a national dialogue on health care among the American public, policymakers and health care stakeholders…”

     “Community health care leaders identified Americans’ expectations as a key area that needs to be addressed in a national conversation on health care. There is a general consensus among health care leaders that the public’s expectations are often out of line with the reality of what the health care system is able to deliver. There is also recognition that the health care system itself has helped foster these unrealistic expectations, in part by not providing adequate information about the true costs and availability of services…”

     “According to community health care leaders, most Americans expect high-quality care, on demand, and at little or no cost. Americans don’t want to make trade-offs and we don’t want to hear about limits. Because of financial constraints on the health care system, this kind of access to inexpensive services may become increasingly unrealistic. Americans need to revisit the discussion about health care as a social contract and also may need to make tough choices about access and availability of health care services...”

     “There is a need to address the expectations that we have of our health care system by increasing Americans’ sense of collective responsibility about their health and health care. Instead of focusing only on whether we, as individuals, have access to high-quality, affordable health care, we need to begin thinking about health care as a collective resource. The choices we make about our health and our use of the health care system have an impact beyond our own quality of life and our own pocketbook; they affect whether there will be more or less resources available for others. We need to start seeing the connections in how our personal decisions affect other people and how we are affected by the choices that others make…”

     “Americans need to have the information to be empowered to make good choices that will benefit their own health, and they need to be aware of the finite availability of some health care resources. This will require a shift in the way many of us think about our health. Empowering consumers, and giving them the necessary support and access to appropriate health care services will help them to make good health care choices about their health. It could also improve quality of life and reduce unnecessary costs for the health care system…”

     It is important to stress the ongoing involvement of the APA in this process. Dr. Sarah Brennen from NM, Sally Cameron from NC, Dr. Dee Yates from TX, Dr. Criss Lott from MS, and Russ Newman all participated in community roundtables. Russ has been attending other related meetings since January, working to insure that the messages that were being created at the community level were finding their way into the national materials. Also Dr. Nan Klein helped draft a case study of community action in Utah related to passing a mental health parity law in the state which is included in the final report.

     Although there are many different aspects to the proposal (of which I have cited only a few), its central thrust seems to be aimed at transforming the role of consumers. The speakers quite appropriately zeroed-in on the facts that seven of the top health risk factors are behavioral (tobacco use, alcohol abuse, poor diet, injuries, suicide, violence and unsafe sex), and that seven of the nine leading causes of death have significant behavioral components. They viewed controlling these “life-style” factors as critical in reducing health care costs. However, the proposed solution was to “make costs more transparent to consumers.” What does that mean? My understanding is that people who engage in unhealthy behaviors would pay more for health care. I was a panelist, so at two of my three turns “at bat” I acknowledged that incentives (such as the prospect of lower health care costs) can influence behavior, but pointed out that all behavior, including unhealthy behavior, is motivated. I further suggested that changing motivated behavior may require more than changing the financial incentives for engaging in that behavior. I was able to draw on my clinical experience in helping clients quit smoking, moderate or quit drinking, and lose weight, to highlight the difficulties many have in controlling these unhealthy behaviors. The audience seemed to understand and appreciate this perspective.

     It should be noted that among the supporting organizations for the WRGH was the White House Council of Economic Advisors. Further, there were several Bush administration officials in attendance, including Rex Cowdry and Mark Showalter from the Council of Economic Advisors, and FDA commissioner Mark McClellan, who keynoted the meeting. All of this suggests that the project might have the ear of the White House. In addition, the project has attracted bipartisan interest, as Senator Leiberman’s staff was present and Senator Wyden was the featured speaker at a "kickoff" press conference. Furthermore, the current phase of the project is attempting to get messages placed and questions raised with as many of the existing presidential hopefuls as possible.

     There are many coalitions and processes similar to this one, but this one seems to have more potential than most. To Quote Russ Newman: “Although this project could come up dry given the overwhelming challenges we face in health care today, it seemed to us in the Practice Directorate to be among the more promising projects we've seen. This effort to stimulate grassroots dialogue and community involvement could very well prove to be the missing pieces for successful healthcare reform."

     As always, I welcome your thoughts on this column. You can most easily contact me via email: (new address): levant@uakron.edu.

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Ronald F. Levant, Ed.D., A.B.P.P., is a candidate for APA President. He is in his second term as Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member at large of the APA Board of Directors (1995-97), and APA Recording Secretary (1998-2000). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

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