Molly Joel Coye : Running the State’s Health Services Just as the Budget Crisis Sinks In

It’s an awkward time to be California’s top public-health official: Six million Californians have no health insurance, health-care costs are well above the national average and the state has been facing an unprecedented budget crisis.

Dr. Molly Joel Coye became director of the Department of Health Services in June. Now she must preside over $30.1 million in cuts, the elimination of 564 jobs and the weakening of programs ranging from birth-defects monitoring to the MediCal insurance program for the poor.

Cuts don’t come easily to Coye, widely perceived as a pragmatic sort of liberal. An expert in environmental and occupational health, she became well known as New Jersey’s health commissioner for her innovative attempts to guarantee access to health care for the uninsured.

Raised in Wisconsin, Coye got her bachelor’s degree in political science from UC Berkeley, studied in Taiwan and got a master’s in Asian studies from Stanford. She actively opposed the Vietnam War, then, in the early 1970s, switched fields to become a doctor. Coye earned a medical degree and a masters in public health from Johns Hopkins University, worked during medical school for the Oil, Chemical and Atomic Workers Union, then became chief of the occupational health clinic at San Francisco General Hospital.

As New Jersey’s health commissioner, Coye is credited, among other things, with a pioneering program to get comprehensive health care to low-income mothers and infants and with shoring up a system of surcharges on patient bills to cover uncompensated hospital care.

Now 44, Coye is no apologist for the manifest failings of the country’s health system. She is strikingly critical. In conversation, ideas for change emerge in multilayered, architectural sentences that pile up with compelling force.

Coye lives in San Francisco with her husband, Dr. Mark Smith, vice president of the Kaiser Family Foundation, and their 3-year-old son. They are happy to be back in California, she said, in part “because the future history of the United States will be written here.

“We will be the test case of whether our society will see diversity as a wealth and a benefit rather than a social problem,” she mused recently. “I’m optimistic. But then again, I’ve been accused of being a Pollyanna.”

Question: You come from a background in public health, a field often peopled by Democrats who believe health care should be delivered to all people on demand. Yet you’ve worked for two Republican governors in times of budget cutting. How does it feel to hold the ax?

Answer: It’s always painful to cut budgets. . . . But I think that Gov. Wilson really believes in prevention, not as something that should pay off in two or three years, but as a long-term strategy for society. And that is one of the principles of public health. . . . As a Republican governor, he raised taxes in order to avoid program cuts in many, many areas. . . . There is an eagerness to take advantage of the atmosphere of crisis that surrounds a budget problem like this in order to make really profound changes in the way programs are organized. And after working in public health for 15 years, I have a stored-up agenda of the kind of changes that I would like to see made.

Q: What is that agenda?

A: One of the most important things is to begin to turn away from the multiplicity of categorical programs that we currently have. A single family on one block of downtown L.A. could have a case manager for HIV infection, a case manager for a pregnant woman, a case manager for a child with a learning disability. . . . Each of these programs has separate lines of funding, separate paperwork, separate contracts. And it adds up to a chaotic and very difficult way to manage a health-care system.

Many people have pointed out that the term “system” is laughable, that we don’t have a health-care system. What we have is many well-intended pieces that don’t add up to very good care for an awful lot of people. It’s quite true if you get very sick, you are liable to get very good care. Obviously, this is not as true if you are poor or uninsured. But compared to the kind of care you can get if you have a chronic disease, like diabetes, in an emergency you get better care. That doesn’t make a lot of sense. . . . So the issue is not to stop paying for urgent care and invest in prevention. It is to try to invest in prevention and slowly bring down the demand for those urgent care or critical-care needs.

Q: What would you have in place of that multiplicity of programs?

A: First of all, we hope that we will have a strong network of comprehensive primary care. In every community there should be a capacity to provide the personal prevention care, such as mammograms and nutrition education, and the personal primary care, such as taking care of diabetics, a kid with asthma, the kind of chronic diseases that can become very serious if they’re not treated. In order to develop that network, we need to work directly with the providers, which means the private physicians, the hospital-based clinics, the community-based clinics, to maximize what already is there and to develop comprehensive systems so that we have the capacity to meet that need. . . .

So instead of their having to cope with 10 or 15 different programs and different contracts and different billing systems and different eligibility systems, to try to streamline that as much as possible into what would look like a single health-care system. That doesn’t mean there isn’t choice for people. They should be able to choose where they want to get their care. . . .

Most of that initially does not take money. What it takes is breaking down bureaucratically established programs, both at the state level and, over time, at the county level.

Q: Do you support some form of universal health coverage?

A: It should be clear to anyone who has worked in medicine or public health for the last several decades in this country that a tremendous share of our problem stems from the basic fact that large numbers of people don’t have access to the care they need. . . .

There are two key strategies for being able to pay for this. The first strategy is to make sure we’re spending the money we spend now in the public sector wisely. We have many areas in which the lack of coordinated care, or managed care, means that individuals are bounced from provider to provider, get multiple prescriptions of drugs, multiple diagnoses. In other areas, because there is a lack of providers, there is nobody to work on the patient’s behalf to try and get them hooked up with the provider that they need. . . . We are not convinced that managed care is going to, in the short run, bring down the cost, particularly on a per patient basis. But we know that it vastly improves the quality and quantity and services that people get. In the long run, the benefit is in reducing hospitalization, because people are getting primary care. . . .

The second strategy, and the far more important one in the long run, is to actually make sure that people who don’t have insurance can get the care they need. And that’s going to take new money.

Q: What could be done to control health-care costs, since it seems unlikely that employers would support an employment-based insurance system without some assurance that costs would be reined in?

A: I could not support any proposal for increasing access to care that did not have a strong cost-containment element in it. When we look at the level of health status that we achieve for the amount of dollars we spend, it would be unconscionable to continue pouring money into this system without some cost constraints and some reorganization of the system. . . . Right now, the health-care system, to employers and much of the public, is a large, impenetrable black box which no one can make heads or tails of. It’s not surprising that many people are reluctant to continue pouring more money into this. If we can make the system user-friendly, productive, efficient and something which people enjoy participating in, then their willingness to put more money into it may increase.

Q: MediCal rates in California are widely perceived as well below the cost of providing care. As a result, many private physicians and hospitals won’t treat MediCal patients. What does the Administration plan to do about this problem?

A: Obviously, rate increases are very difficult during a period of budget constraint. But if we look honestly at the history of the last 15 years around the country, very few states have done much to really make Medicaid rates competitive with the private sector. . . . Most of the real success in increasing the amount of reimbursement that physicians or nurses or hospitals get has come through changing the system, usually in the direction of managed care. Let me give the example of San Mateo County, where, in their MediCal program, physicians are getting much more reimbursement per patient because they agree to take care of the patient all year long and the patient agrees to see that provider all year long. They choose the provider they want and, by doing good primary care, they prevent hospital utilization. Therefore, there are more resources available with which to pay the physician who’s providing primary care. So, it really is more likely that we will be able to increase per-patient reimbursement to a physician by improving the organization of care than by increasing fee-for-service rates.

Q: Is there a basic level of services to which everyone should be entitled?

A: There’s no single right answer. But at a minimum, it should include the clinical preventive services that the U.S. Public Health Service has recommended. That includes things such as mammograms, screening for drug and alcohol use and treatment of that, cholesterol testing. It also should include basic primary care for everyone, both well-patient care and sick care on an outpatient basis. It should have strong utilization controls to make sure that people don’t get unnecessary medical treatment, but it should then reimburse for inpatient care.

Q: How does your department intend to address the shift in the AIDS epidemic into less affluent, less educated, often minority populations?

A: First of all, it is critical that within the next couple of years we make sure that treatment is available to anyone who is a drug addict and is willing to come into treatment. We have to recognize that this is an addiction just like cigarette smoking, in that it often takes five, eight or 10 tries before people really manage to kick the habit. That kind of treatment capacity is currently being developed . . . for example, (by) redirecting some of the moneys in the correctional system for alternative sentencing--so that people who would have gone to jail can get treatment instead and you use the money that it would have cost to put them in jail to provide the treatment. . . . Secondly, we have got to increase education in the primary school and junior high years particularly--before kids become sexually active, before they begin experimenting with drugs. They need to understand what AIDS is and how it is acquired. That is a very, very important responsibility of our educational system.

Q: How do you get prevention messages to immigrant and minority communities?

A: . . . If the tobacco industry can manage to sell millions of cigarettes to immigrants, and if the alcohol industry can manage to get them to buy lots and lots of beer and wine, we certainly should be able to use the same media of communication in order to get across these important public-health messages.

Q: In New Jersey, you are credited with having initiated innovative programs for getting pregnant women into prenatal care. Do you intend to do similar things here?

A: . . . The most exciting thing in the near-short range is going to be the governor’s initiative to try and extend prenatal care for working-poor women. In the long run, my goal would be that any woman who suspects she’s pregnant can come in for a pregnancy test and for prenatal care with complete confidence that she will receive that care, whether or not she can pay for it. . . . It may take us a while to set that up. Gov. Wilson has already taken a big step toward it, . . . but it will take us a while.

Q: How did your personal politics and early interests in medicine--worker health and safety issues--bring you to where you are today?

A: There’s no question that it is a pattern that looks strange to people if you start out in Chinese history and work through occupational health to spending most of your time on access to care--which is really the issue that I want to spend most of my time on. . . . What I learned from working in occupational health and environmental health is the power of communities and local organizations developing solutions, and the likelihood that a lot of the time they are entirely correct about what is needed in their situation, and that if they are listened to, a tremendous amount of energy and creativity is liberated.