Steve Duncan sometimes feels a bit isolated from the mainstream of medicine. His nearest colleagues are rarely less than 40 or 50 miles away. But Duncan has definite opinions about how to improve U.S. health care. ”I`d like to see services for everybody regardless of ability to pay,” Duncan said. ”I don`t think it`s a privilege. It`s a right. And I don`t think I`d change my mind if I were an M.D.”
Duncan is a physician`s assistant with 33 years of medical background, much of it earned in hard places: in the Navy during the Vietnam War, in a state prison facility and in the two small towns in Washington state where he is the only health officer: Northport on the east side of the Columbia River just south of the Canadian border, and Orient, 61 miles away.
Many of his patients lack the wherewithal to travel 50 miles down the road to the clinic at Colville, says Duncan, whose jeans and cowboy boots fit right in with those of his patients.
”There are people who need to come in here and ask questions and not have to pay a fortune,” said Duncan, who works for NEW Health Programs, a federally funded rural health-care program.
The national debate over health-care reform is very much alive in rural Washington state, and answers are just as elusive as they are in the cities.
In Colville, a town of 4,300, people who wrestle with the financial realities higher up the health-care chain doubt that Duncan`s wish will ever be possible, although they agree that reform of the health-delivery system is desirable and probably inevitable.
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Health-care costs have been rising 12 percent annually, a pace at which they would double in six years. As costs have climbed, it has become increasingly difficult for many, particularly those with no health insurance, to get needed care.
Gerald Wimer, chief operating officer of the Northeast Washington Medical Group clinic in Colville, one of the region`s major health facilities, believes this volatile combination soon will force rationing of medical services. ”We`re going to have to face that fact,” he said.
The result will be hard choices, Wimer believes, particularly when very expensive care or procedures are involved. He poses one such hypothetical situation: ”Are we going to help an 81-year-old leukemia victim or an 8-year- old boy who needs a bone-marrow transplant?”
A few blocks away, Janet Thomas, a community-service officer for the regional office of the Washington state Department of Social and Health Services, says that as much as she`d like to see broad health-care coverage,
”the people who advocate socialized medicine aren`t going to be willing to pay 40 to 50 percent taxes.”
At the same time, though, Thomas has had personal experience with what might be considered care rationing and didn`t much like it when a physician initially didn`t want to operate on her 80-year-old father`s prostate cancer. ”I don`t like that part of it, the idea that you`re too old to be valuable,” she said.
As they wrestle with questions that resonate at both personal and policy levels, the people of Stevens, Ferry and Pend Oreille counties, three of the state`s poorest, try to cope.
Duncan gives the best advice he can to patients who can`t afford the antibiotics they need. Thomas` DSHS office dispenses aid to the indigent while trying to see that no one takes advantage of the system.
Mary Sellecky, administrator of the Northeast Tri-County Health District, the public health agency for the three counties, dispatches RV-borne traveling clinics to far-flung towns to preach the gospel of preventive health care.
Wimer works with Gloria Cooper, chief executive officer of Mount Carmel Hospital, just across the parking lot, to coordinate equipment purchases and staffing hours to avoid duplication.
As a result, though under stress, the health-care system in the three counties, tucked up in the northeastern corner of the state just below the Canadian border, is regarded as one of the best in rural Washington.
Dr. Edmund Gray, a 1953 graduate of the University of Washington medical school and a Colville native, is widely credited with having laid the groundwork for this success.
He was instrumental in organizing the town`s six doctors as a clinical group in 1979 and has been active in community, political and professional affairs and in pursuing new approaches to the rapidly changing requirements of rural health care.
But in the long run, warns clinic founder Gray, just coping won`t be enough; ever-rising costs are going to force big changes in the way the nation dispenses health care, a decision he says is ”far too important to leave in the hands of only the providers.”
His solution is to seek consensus on health-care goals at the community level. But even with a relatively small population-the clinic serves a population of about 25,000, and 47,000 live in the three counties-it is a challenge not easily mastered.