THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Daily Kos Health Care Series
I run jail-based drug treatment programs for a rural Hispanic County. One day in 1998, John, a staff member, came charging into my office waving a GPRA manual in my face.
At that time, GPRA was the new set of assessment tools required by the feds to measure the impact of all programs. The GPRA tool we used measured improvement in substance-abuse related behaviors.
"I was doing an assessment on a big guy named Jesus!" John shouted. "He had a crucifix tattooed on his bicep. He was in for aggravated battery. I was supposed to ask him, 'Have you had unprotected anal intercourse more than one hundred times this month?'"
"Are you trying to get me killed?!"
If you want to know why the feds demanded that John ask inmates about their sexual habits, and why the OMB's failure to report the results is endangering health care reform today, you will have to read my diary.
The question, which was introduced in the days of Clinton in response to the Government Performance and Results Act of 1993 , was lovingly dubbed "the butt sex question" by my staff. It enabled SAMHSA (Substance Abuse and Mental Health Services Administration) to determine whether certain interventions introduced into urban areas reduced high risk sexual behavior among recently immigrated Southeastern Asian male prostitutes. After several discussions with my grant manager, I was informed that SAMHSA recognized the question to be culturally inappropriate in my community, and was allowing me to omit it.
"We definitely don't want your staff to bring up butt sex again with Jesus," said my contact at SAMHSA.
The GPRA evaluation tools used and enforced by SAMHSA were developed by SAMHSA staff with expertise in substance abuse and mental health programming. SAMHSA regularly solicited and incorporated grantee input into their tools, which were not created with a specific result in mind.
The GPRA evolved over several years into an excellent tool to measure public health outcomes produced by a wide variety of programs and interventions. That may be why the Office of Management and Budget (OMB), charged with the responsibility of furthering the executive agenda, replaced GPRA under Bush, substituting their own subjective and poorly designed measurement tool. PART (Program Assessment Rating Tool), was not created by experts in health care, did not evaluate public health outcomes, and was used to measure the success of projects as diverse as education and highway construction. Eric Bothwell, DDS, MPH, MA, PhD, ABCDEFG, a career Public Health Officer with the Indian Health Services, concluded in a white paper that the OMB had instituted PART to further the president's political agenda. Not surprisingly, PART was used to eliminate 141 programs designed to increase health care access.
This is incredibly important. In an interview with George Stephanopolis about health care, then President-Elect Obama stated:
And we're going to have to make some tough choices. Now what I've done is indicated to my team that we've got to eliminate programs that don't work.
It is essential that we select evaluation tools that measure the actual health outcomes produced.
Just for the sake of illustration, allow me to introduce you to a highly successful program, one that could have provided a foundation for health care reform (upon which we might have built our Single Payer House), had not Bush killed it using the PART. HRSA (Health Resource Services Administration) awarded Healthy Communities Access Program (HCAP) grants in 260 communities in 45 states across the US from 2000 to 2006. In every case, the award was made to a broad-based community coalition to develop a system to implement local health care reform.
- Improved the effectiveness, efficiency and coordination of services for uninsured and underinsured
- Provided better-quality health for those individuals and
- Provided individuals with health care at a lower cost.
HRSA commissioned an independent evaluation of the project through the National Opinion Research Center (NORC) at the University of Chicago. The NORC study found that HCAP lowered costs, improved care and strengthened the community fabric through increased collaboration in culturally and geographically diverse locations throughout the US. HCAP grantees were better able to respond to Hurricanes Katrina and Rita.
The NORC report was never made available to the public or to members of Congress. Instead, we received the following analysis courtesy of a PART evaluation:
Programs receiving this rating are not using your tax dollars effectively. Ineffective programs have been unable to achieve results due to a lack of clarity regarding the program's purpose or goals, poor management, or some other significant weakness.
It is unclear that all Federal funds expand access to health care. Funds can be used for wide variety of activities and the program cannot ensure that the most useful activities are funded. The impact of many of the activities has not been established; it is likely the program subsidizes some activities that are ultimately of limited use.
The program is duplicative of other Federal, State, local, and private efforts. Several Federal programs seek to address the problems the uninsured. Several private programs have addressed the development of health delivery systems.
The program does not have historical data demonstrating progress towards achievement of goals. While an independent evaluation is underway of sufficient scope and quality to determine if the program is effective and achieving results, there has been no independent evaluation to date. (Italics mine.)
As we debate health care reform issues let us remember, any payment mechanism we create will be more effective if communities can come together to build local infrastructure to meet their unique challenges and serve their highest risk populations. Maybe it's time to ask President Obama to reinstate the GPRA, release the NORC report, and revive the Healthy Communities Access Program.