These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated.

This article first appeared January 29, 2019 on Kaiser Health News.

By Sandra G. Boodman

After seven years of a vigorous fight, Jim Hart worried he was running out of options.

Diagnosed with prostate cancer at age 60, Hart had undergone virtually every treatment — surgery, radiation and hormones — to eradicate it. But a blood test showed that his level of prostate-specific antigen, which should have been undetectable, kept rising ominously. And doctors couldn't determine where the residual cancer was lurking.

"I didn't like the sound of that," said Hart, a retired international oil specialist for the federal government. "I wanted it gone," he added, especially after learning that he had inherited the BRCA2 gene, making him vulnerable to other cancers.

So when Andrew Joel, Hart’s longtime urologist at Virginia Hospital Center in Arlington, mentioned the hospital's membership in the Mayo Clinic Care Network and suggested consulting specialists at the Rochester, Minn., hospital for a second opinion, Hart enthusiastically agreed.

A Mayo immunologist told Joel about a new PET scan, not then available in the Washington area, that can detect tiny cancer hot spots. Hart flew to Mayo for the scan, which found cancer cells in one lymph node in his pelvis. He underwent chemotherapy at Virginia Hospital Center and five weeks of radiation at the Mayo Clinic. Since September 2016, there has been no detectable cancer.

"This collaboration was sort of a magic process," Hart said. "I feel very fortunate."

'Benefit By Association'

Hart's experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.

For prospective patients, it can be hard to assess what these relationships actually mean — and whether they matter.

Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.

"Brand names don't always signify the highest quality of care," she said. "And hospitals are really complicated places."

Affiliation agreements are "essentially benefit by association," said Gerard Anderson, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. "In some cases it's purely branding and in other cases it's a deep association."

A key question is "how often does the community hospital interact with the flagship hospital? If it's once a week, that's one thing. If it's almost never, that's another,” Anderson said.

Feeling 'Plugged In'

To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston's MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors.

In return, large hospitals receive new sources of patients for clinical trials and for the highly specialized services that distinguish these "destination medicine" sites. Affiliations also boost their name recognition — all without having to establish a physical presence.

In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children's Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children's Hospital in 2016.

New York's Memorial Sloan Kettering Cancer Center has embraced a hybrid strategy. It operates a ring of facilities surrounding Manhattan and has forged alliances with three partners in Connecticut, Pennsylvania and Florida.

"Every one of these models is different," said Ben Umansky, managing director for research at the Advisory Board, a Washington-based consulting firm.

Local hospitals, he said, particularly those operating "in the shadows of giants," may be better able to retain patients "by getting a name brand on their door. … There is a sense that they are plugged in." (Virginia Hospital Center, for example, competes with Hopkins, MedStar Washington Hospital Center, which has an alliance with the Cleveland Clinic, and the Northern Virginia-based Inova system.)

Doctors can obtain speedy second opinions for their patients and streamline visits for those with complex or unusual medical needs, processes that can be daunting and difficult without connections.

Dr. Michael Kupferman, senior vice president of the MD Anderson Cancer Network, said it seeks to "elevate the quality of cancer care" by forming partnerships with "high-quality [hospitals] to keep patients at home and provide the imprimatur of MD Anderson."

Virginia Hospital Center's association with Mayo is "not just a branding affiliation, it's a deep clinical affiliation," said Dr. Jeffrey DiLisi, senior vice president and chief medical officer at the Arlington facility.

Despite extensive marketing, many patients seem unaware of the linkage. "We still think a lot about 'How do we communicate this?'" DiLisi said.

Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years.

Acceptance is preceded by site visits and vetting of the community hospitals' staff and operations. Strict guidelines control use of the flagship name.

"It is not the Mayo Clinic," said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. "It is a Mayo clinic affiliate."

Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.

For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.

"In theory, it can be very helpful," Binder said of such alliances. "The problem is that theory and reality don't always come together in healthcare."

Case in point: Hopkins' All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins' chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.

"For me and my family, I always look at the data," Binder said. "Nothing else matters if you're not taken care of in a hospital, or you have the best surgeon in the world and die from an infection."

Cancer During Pregnancy

Bryan Mills, chief executive of Community Health Network, was unhappy with his oncology service. Specialists at the Indianapolis-area hospitals he headed were competing against each other and patients were being ill-served. So Mills cold-called MD Anderson and, in 2012, Community joined its network.

"We needed something we could rally around," Mills said.

"This is really not about a competitive advantage to me, but about providing optimal care," said Mills, whose network competes with three other systems including one run by the University of Indiana, which operates a National Cancer Institute-designated center.

"One hundred percent of the work we do is audited by MD Anderson," Mills said. "We can get second opinions almost instantly."

Mills said he believes that the affiliation, which is prominently displayed on Community’s website, has attracted patients. In 2012, he said, Community treated about 2,000 cancer patients. In 2018, the number was 5,000.

Among them is Kamaljit "Kelly" Kaur. Shortly before Christmas 2015 the Greenwood, Ind., licensed practical nurse was diagnosed with inflammatory breast cancer, a rare and aggressive form of the disease usually discovered at an advanced stage. At the time, Kaur was 35 and five months pregnant with her third child.

Kaur said that her Indiana doctors conferred with MD Anderson oncologists and used "their guidelines to treat me. I felt comforted by that, like it was the right choice for me." Her biggest concern, she said, was the health of her baby.

During the final months of her pregnancy, Kaur received weekly chemotherapy. Her son was born healthy and at full term in February 2016. She then underwent a bilateral mastectomy, followed by more chemo and radiation. Kaur said she has been cancer-free since January 2017, when she finished treatment. The collaboration, she said, "helped me get through this."

Kaur's Indiana oncologist, Dr. Anuj Agarwala, said he thought the MD Anderson involvement was helpful, because it reassured Kaur and him by concurring with his recommendations. He said he presented his treatment plan to specialists in Houston and "they didn't change anything."

Overall, he said, "it really doesn't affect what I do very much. We are following national guidelines and not giving off-the-wall treatment."

Initially, Agarwala said, some Community oncologists bristled at having their charts audited by Houston specialists, a resistance, he said, that has diminished.

The affiliation has strengthened safety measures involving the administration of chemotherapy and has made the informed consent process more rigorous, Agarwala said, to the benefit of patients. "Overall it has been a valuable relationship."

"The population I work with don't have the resources to get care outside of their hometown," he added, "and feel more confident with the input of a world-class institution."

So did Dr. James Ouellette, a cancer surgeon with Premier Health in Dayton, Ohio, which joined the MD Anderson network in 2016.

In November 2018, Ouellette removed a huge and rare malignant tumor from Joanne Dotson’s abdomen during a four-hour surgery. The solitary fibrous tumor was in a dicey location: It had grown so large it was displacing Dotson’s liver and compressing her vena cava, a major vein that carries blood to the heart.

Dotson, 70, said she had never heard of MD Anderson until her doctors mentioned it.

The affiliation, she said, did not affect her choice of hospital or surgeon, in whom she had confidence.

"I wasn't even worried," she said. "His hands are God's hands," she said, referring to Ouellette.

Her surgeon felt differently.

"While I was very glad Mrs. Dotson wasn't worried, I was, with a big surgery like that," Ouellette said. Before the operation, Ouellette said he conferred with an MD Anderson surgeon, radiation oncologist and medical oncologist about how best to treat the grapefruit-size growth. As a result of those discussions, Ouellette said, he altered the initial treatment plan.

Getting A Vibe

Virginia Hospital Center officials say that only a handful of the approximately 170 patients, the vast majority with cancer diagnoses, who annually receive second opinions from Mayo wind up getting treatment there. Most of those who do, DiLisi said, received care unavailable at his hospital.

"The patients [that affiliates] send us are more complex patients," said Mayo's Hayes. "We have a broad and deep bench of specialists."

Even so, it's often doctors who suggest a second opinion, not patients who request one. Joel said he mentions the option to those urology patients from whom he gets "a vibe" that they might be interested.

DiLisi said that the affiliation can save patients time and money.

"We get them as good a second opinion as they would get at Hopkins," DiLisi said, without incurring the costs and additional testing involved. "And they don't have to drive to Baltimore."

Many hospitals conduct nightly wealth screenings using software that culls public data such as property records, contributions to political campaigns and other charities to gauge which patients are most likely to be the source of large donations.

This article first appeared January 28, 2019, on Kaiser Health News.

By Phil Galewitz, Kaiser Health News                                      

Nonprofit hospitals across the United States are seeking donations from the people who rely on them most: their patients.

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

Those who seem promising targets for fundraising may receive a visit from a hospital executive in their rooms, as well as extra amenities like a bathrobe or a nicer waiting area for their families.

Some hospitals train doctors and nurses to identify patients who have expressed gratitude for their care, and then put the patients in touch with staff fundraisers.

These various tactics, part of a strategy known as "grateful patient programs," make some people uncomfortable. "Wealth screenings strike me as unseemly but not illegal or unethical," said Arthur Caplan, a bioethicist at the New York University School of Medicine.

Mark Rothstein, a bioethics professor at the University of Louisville, said, "Getting physicians involved in philanthropy is something fraught with danger." He added that it could make patients worry that their care might be affected by whether they made a donation.

Despite such concerns, these practices are becoming commonplace, particularly among the largest nonprofit hospitals. A 2016 survey of 108 hospitals found that 68 had grateful patient programs, according to the Advisory Board, a consulting firm.

"In the last 10 years we’ve seen a pretty dramatic uptick in strategic attention in the formation of these programs," said Nicholas Cericola, a senior consultant with the firm.

Large hospitals that say they screen patients' wealth include those run by MedStar Health in Columbia, Md.; the Johns Hopkins Hospital in Baltimore; Cedars-Sinai in Los Angeles; and NYU Langone Medical Center in New York.

Donations from patients and their families supplement income streams from private and public insurance programs as well as money raised through traditional methods like charity golf tournaments, dinners or gala balls.

"It's a way to get money to the hospital's bottom line like nothing else they are doing," said Bill Tedesco, chief executive officer of DonorSearch, a Maryland company that supplies hospitals with software that helps them conduct wealth screenings.

'Get-To-Know-You Opportunity'
 

Patients and their families were responsible for two-thirds of the $34 million donated to the Sharp HealthCare hospital system in San Diego last year, said Bill Littlejohn, chief executive officer of the system's fundraising foundation.

Wealth screening and the participation of the hospital's doctors are crucial, Littlejohn said. Sharp screens up to 400 patients each night, he said, and adds about 10 to 20 to its database of potential donors.

When he approaches wealthy patients in the hospital, they are unlikely to know that they were selected with the aid of the wealth screening, according to Littlejohn.

"I'm not asking them for money, but I tell them we appreciate them choosing Sharp and hope they have a wonderful experience," he said. "I use this as a get-to-know-you opportunity and let them know Sharp is a nonprofit and philanthropic-supported institution."

Littlejohn estimates that doctors prompted 20% of patient donations through conversations with their own patients. The practice has helped Sharp triple its annual fundraising totals from a decade ago, he said.

Nationwide, donations to hospitals exceeded $10.4 billion in 2017, up from $6 billion in 2004, according to the Association for Healthcare Philanthropy.

"Grateful patients have always been there, but we did not always do as good a job of inviting them to be part of our missions as we are now doing," Alice Ayres, the trade group's chief executive officer, said. She attributed the increased fundraising to grateful patients programs as well as to a shift away from event-driven efforts, a focus on larger gifts and overall economic growth in the United States.

Change In Privacy Law Facilitates Fundraising
 

A 2013 change in federal health privacy law made it easier for hospitals to target their patients for donations. It enabled hospital records departments to share with staff fundraisers some personal details of patients, including their health insurance status, the department treating them, the name of their physician and the outcome of their care.

When patients are admitted, they typically sign a raft of papers that include permission for the hospital to use this information for fundraising. While the 2013 law required hospitals to inform patients that they could decline to be solicited by fundraisers, few patients are aware of this, said Deven McGraw, a former deputy director of health information privacy at the federal Department of Health and Human Services. And, she said, few appear to realize that their wealth may be assessed for fundraising.

Many hospitals send solicitation letters to all of their insured patients, including those with little desire — or ability — to make donations.

St. Clair Hospital in Pittsburgh treated Marcy Grupp in its emergency room for three hours in May for a painful kidney stone, providing a computerized tomography scan, among other tests. Medicare paid the bill.

A month later, the hospital sent Grupp, a retired television engineer, a letter asking for a donation to honor a doctor or other caregiver. "We encourage you to please consider honoring their efforts with a 'gift of gratitude,' by making a donation to St. Clair Hospital," the letter said.

Grupp, 66, said she wasn't rich, and was disturbed by the letter.

"I kind of resent it," she said. "I don't think they need the money." The hospital last year reported nearly $48 million in net income and paid its chief executive officer $1 million.

"I thought the care I got was good and the doctors I had were good, but I don't see why I need to pay in addition to what I've already paid," Grupp said. St. Clair executives declined to comment.

Lech, 58, said the letter had left the impression that her doctor would directly benefit from the donation, which was not the case. "I did not like the implication that doctors would get rewarded when they really aren't," she said.

Morgan Herman, vice president of philanthropy at New England Baptist, acknowledged that the hospital solicited former patients but said that did not affect patient care. "There is no connection," she said.

Unease Among Doctors
 

Many doctors are uneasy about being asked to help raise money from their patients, studies show.

"It makes doctors very uncomfortable for a lot of reasons — No. 1 is that the doctor is there to see the patient for a problem they have and not to ask the patient for money," said Dr. Rosalyn Stewart, an internist at Johns Hopkins who has researched physician attitudes at Hopkins toward the practice.

She said she worried that if a wealthy patient made a large donation, doctors would feel obligated to treat them differently, perhaps by returning their calls more quickly.

"I feel like the risk is we are setting up a two-tiered healthcare system — one for wealthy patients and one for everyone else," Stewart said.

While wealth screenings have been used for decades for fundraising by universities and other nonprofits, ethicists said they raised different concerns for hospitals.

"Needing healthcare is different than choosing to go to college or going to the opera," said Nancy Berlinger, a bioethicist with the Hastings Center, a think tank in Garrison, N.Y. "When you are sick, you need a trusting relationship to be formed and focused on your health. There is a vulnerability there that is not present in other nonprofits."

Dr. Frederick Finelli, a surgeon and the vice president of medical affairs at MedStar Health's Montgomery Medical Center in Maryland, said that while he used to feel uncertain about fundraising, he now saw it as part of the healing process.

"When someone says 'Thanks' to me, it feels incomplete for me to just tell them, 'No problem' or 'I was just doing my job,'" he said. "Talking to patients about philanthropic or volunteer needs is good for patients."

Some patients say they are happy that they were asked for money.

For example, Martin Faga, 77, was treated at Inova Fairfax Hospital in Virginia last year for serious heart problems. A retired president of Mitre, a large nonprofit federal contactor, Faga repeatedly praised his bedside nurses for their care, he said.

When one of those nurses sent an email about this to Mary Myers, a hospital fundraiser, she visited Faga's room to chat about the role of philanthropy and arranged to meet him at his home a few weeks later, Myers said.

Faga wasn't initially interested in making a large donation, he said, because he didn't believe that the nonprofit health system — the largest in Northern Virginia, with five hospitals and $3 billion in annual revenue in 2016 — needed the money. But he said he had changed his mind after Myers told him that such donations were essential for staff training and buying equipment, and has donated $200,000 to the hospital.

"I would still have been in the small-donation category of a couple hundred dollars if not for Mary and the educational process," he said.

The White House this week launched an investigation into surprise medical bills after President Trump met with patients who'd been charged outrageous fees for out-of-network healthcare services.

This article first appeared January 23, 2019 on Kaiser Health News.

By Emmarie Huetteman

President Donald Trump on Wednesday instructed administration officials to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in healthcare.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump tasked his health secretary, Alex Azar, and labor secretary, Alex Acosta, with working on a solution, several attendees said.

"The pricing is hurting patients, and we've stopped a lot of it, but we're going to stop all of it," Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with "the biggest teeth you can find."

"Reading the tea leaves, I think there's big change coming," Silverstein said.

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or not covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said each of 10 invited guests — among them patients as well as doctors with their own stories of unexpected bills — was given an opportunity to talk, though Trump did not stay to hear all of their stories during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose family's experience with a $17,850 bill for a simple urine test was detailed in a KHN-NPR “Bill of the Month” feature last year.

Davis' daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it. Experts said such tests rarely cost more than $200, not nearly what the lab charged Moreno and her insurance company. But fearing damage to his daughter's credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general's office, alleging "price gouging of staggering proportions."

Davis said White House officials made it clear that price transparency is a "high priority" for Trump, and while they did not see eye to eye on every subject, he said he was struck by their sincerity.

"These people seemed earnest in wanting to do something constructive to fix this," Davis said.

Dr. Martin Makary, a surgeon and health policy expert at Johns Hopkins University who has written about transparency in healthcare and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

"This is how most of America lives, and [Americans are] getting hammered," he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation's health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar and Acosta said efforts to control costs in healthcare were yielding positive results, discussing in particular the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans "want to see what we’re doing, like today we lowered prescription drug prices, first time in 50 years," according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said "growth in relative drug prices has slowed since January 2017," not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs; patents have expired on brand-name drugs; and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C. Drugmakers are also wary of increasing their prices in the midst of growing political pressure.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with healthcare, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a "sweeping" investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

KHN correspondents Shefali Luthra and Jay Hancock contributed to this report.

The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming healthcare follow the same trajectory?

This article first appeared January 22, 2019 on Kaiser Health News.

By Elisabeth Rosenthal

Last week, California’s new governor, Gavin Newsom, promised to pursue a smörgåsbord of changes to his state's healthcare system: state negotiation of drug prices, a requirement that every Californian have health insurance, more assistance to help middle-class Californians afford it and healthcare for undocumented immigrants up to age 26.

The proposals fell short of the sweeping government-run single-payer plan Newsom had supported during his campaign — a system in which the state government would pay all the bills and effectively control the rates paid for services. (Many California politicians before him had flirted with such an idea, before backing off when it was estimated that it could cost $400 billion a year.) But in firing off this opening salvo, Newsom has challenged the notion that states can't meaningfully tackle healthcare on their own. And he's not alone.

A day later, Gov. Jay Inslee of Washington proposed that his state offer a public plan, with rates tied to those of Medicare, to compete with private offerings.

New Mexico is considering a plan that would allow any resident to buy in to the state's Medicaid program. And this month, Mayor Bill de Blasio of New York announced a plan to expand healthcare access to uninsured, low-income residents of the city, including undocumented immigrants.

For over a decade, we've been waiting for Washington to solve our healthcare woes, with endless political wrangling and mixed results. Around 70 percent of Americans have said that healthcare is "in a state of crisis" or has "major problems." Now, with Washington in total dysfunction, state and local politicians are taking up the baton.

The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming healthcare follow the same trajectory?

States have always cared about healthcare costs, but mostly insofar as they related to Medicaid, since that comes from state budgets. "The interesting new frontier is how states can use state power to change the health care system," said Joshua Sharfstein, a vice dean at Johns Hopkins Bloomberg School of Public Health and a former secretary of the Maryland Department of Health and Mental Hygiene. He added that the new proposals "open the conversation about using the power of the state to leverage lower prices in healthcare generally."

Already states have proved to be a good crucible for experimentation. Massachusetts introduced "Romneycare," a system credited as the model for the Affordable Care Act, in 2006. It now has the lowest uninsured rate in the nation, under 4 percent. Maryland has successfully regulated hospital prices based on an "all payer" system.

It remains to be seen how far the West Coast governors can take their proposals. Businesses — pharmaceutical companies, hospitals, doctors' groups — are likely to fight every step of the way to protect their financial interests. These are powerful constituents, with lobbyists and cash to throw around.

The California Hospital Association came out in full support of Newsom's proposals to expand insurance (after all, this would be good for hospitals' bottom lines). It offered a slightly less enthusiastic endorsement for the drug negotiation program (which is less certain to help their budgets), calling it a "welcome" development. It's notable that his proposals didn’t directly take on hospital pricing, even though many of the state's medical centers are notoriously expensive.

Giving the state power to negotiate drug prices for the more than 13 million patients either covered by Medicaid or employed by the state is likely to yield better prices for some. But pharma is an agile adversary and may well respond by charging those with private insurance more. The governor's plan will eventually allow some employers to join in the negotiating bloc. But how that might happen remains unclear.

The proposal by Washington Gov. Inslee to tie payment under the public option plans to Medicare's rates drew "deep concern" from the Washington State Medical Association, which called those rates "artificially low, arbitrary and subject to the political whims of Washington, D.C."

On the bright side, if Newsom or Inslee succeeds in making healthcare more affordable and accessible for all with a new model, it will probably be replicated one by one in other states. That's why I'm hopeful.

In 2004, the Canadian Broadcasting Corp. conducted an exhaustive nationwide poll to select the greatest Canadian of all time. The top-10 list included Wayne Gretzky, Alexander Graham Bell and Pierre Trudeau. No. 1 is someone most Americans have never heard of: Tommy Douglas.

Douglas, a Baptist minister and left-wing politician, was premier of Saskatchewan from 1944 to 1961. Considered the father of Canada's health system, he arduously built up the components of universal healthcare in that province, even in the face of an infamous 23-day doctors' strike.

In 1962, the province implemented a single-payer program of universal, publicly funded health insurance. Within a decade, all of Canada had adopted it.

The United States will presumably, sooner or later, find a model for healthcare that suits its values and its needs. But 2019 may be a time to look to the states for ideas rather than to the nation's capital. Whichever state official pioneers such a system will certainly be regarded as a great American.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN's coverage in California is supported in part by Blue Shield of California Foundation.