Funding Our Healthcare System: An Old Model Reimagined with John Silver
The Public Utility Model
John Silver joins Beth to discuss the Public Utility Model, a plan to shift the healthcare insurance structure, bringing needed healthcare to everyone. A central council led by nurses – which would also include physicians and other allied healthcare professionals – would work to provide a better and stronger foundation for preventative healthcare for the people of the US, not just disease care. John talks about his look back through history to find a model that could work as a way to fund healthcare, and found that the public utility companies were managed locally and with great success. Healthcare spending is like a runaway train and is not sustainable. John’s ideas about a new twist with an old concept is worth listening to, as it just may be the way to reimagine the administration of healthcare funding.
They discuss John’s Declaration of Independence for Nurses and why John felt it was critical to put it together. They also talk about John’s program, Nurses Transforming Healthcare, and why it’s critical for nurses in this country to come together as a force to bring impactful change to policies of all sorts.
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About John
Dr. Silver started in healthcare in 1974, and became a Respiratory Therapist in 1978. After receiving his nursing degree, he worked extensively in critical care, including medical and surgical ICU’s, trauma units, burn units, and neurological ICU’s. He spent the last decade of practice in the emergency room. Dr. Silver writes and speaks about political issues in nursing and healthcare. He has presented both nationally and internationally on health policy, the restructuring of healthcare systems, and the role of nursing in that process. He has also spoken to a variety of nurse practitioner groups on political tactics for prescriptive authority and independent practice. In 2004, he led Spectrum’s international on-line chat prior to the election. He also studies nursing leadership and has a particular interest in the political fracturing of nursing. Dr. Silver started at NOVA Southeastern in 2005 as an adjunct professor and became an Associate professor full time in 2010. He teaches a variety of courses including health assessment, the second medical-surgical nursing class, as well as problem solving and the trends in nursing class taught in the last term. He has also taught ethics, health policy, and the introductory class in the Master’s program. Currently, Dr. Silver is a Program Chair in an ADN program of nursing.
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Intro:
Welcome to Don't Eat Your Young, a nursing podcast with your host, Beth Quaas. Before we get started, we have a few quick notes. Don't Eat Your young is a listener-supported podcast. To learn more about becoming a member and the perks available to you for becoming a patreon yourself, visit patreon.com/donteatyouryoung. You can learn more about the show, share your story to join Beth as a guest, or connect with our wonderful community in our Facebook group. You can find all those links and more at donteatyouryoung.com. Now, on with the show.
Beth Quaas:
Hello. Welcome to Don't Eat Your Young. I'm your host Beth Quaas. Today on the show we have John Silver. He's been an RN for several decades. He's gone from an associate degree in nursing to a PhD in comparative studies. John is dedicated to improving healthcare systems and empowering nurses to lead the charge. Welcome, John. It's so nice to have you today.
John Silver:
It's a real pleasure to be here, Beth. Thank you.
Beth Quaas:
Tell us a little bit about yourself and your nursing career.
John Silver:
Well, I'm old, so it's a long story. But I started in healthcare in 1974, bunch of little jobs, working my way up, respiratory therapist, '78, and then '84 as a nurse. It was pretty much minding my own business. I was working agency, ICU nights, not really involved in politics or anything. Then in the end of late '90s, I decided, it's my career I should probably go back and get a bachelor's. I started looking at schools, I went to Florida Atlantic University, met all kinds of nurses coming back for their bachelors. And they were all complaining of the same thing they'd been complaining about 20 years ago when I got into healthcare and I started thinking, "Why can't we solve our own problems as professional? It's very troubling."
As I went into my master's, I decided it was politics. So I did kind a political MSN. They let me go up and do some work with George Mason's University's Health Policy Institute in D. C. I did two internships at Congress, came down, I worked with a rep in Florida for a while. I kind of thought it was an image problem, so I did a master's thesis on proactive media utilization. After the masters, I'd started publicly speaking about healthcare and nursing. So the choice was, do I do the NP route, which probably would've been smarter and more financially rewarding, or do I do the PhD route?
So I decided I wanted to step out of healthcare completely and look back at healthcare from my PhDs in comparative studies. It allowed me to use a lot of disciplines to look back at healthcare, historically, structurally, everything. I started working on two threads, which is, how can we fix this problem with nursing where we get back in control of our practice to me? Then how do we fix this healthcare system? Because it was pretty obvious, even by that time, this thing was a mess. I call it the disease care system because that's what it is.
Beth Quaas:
That's right.
John Silver:
So I started working those two threads, which I found out eventually merged into thing, because if we're not empowered as a profession, how do we advocate for the healthcare system design we need to take care of our patients and also protect ourselves? So I started looking at health system design, went to Argentina, studied their system, gave a talk to a design conference in Berlin, talked to nurses, doctors, and people on the street about their system. Went back two years later in Cardiff Wales to the first TTI convention where I met nurses from all over Europe. So one of my first goals when I started looking at this problem was to set up what are the goals of a healthcare system. I mean, if you don't know where you're trying to go, how do you know what to do to get there?
Beth Quaas:
And how can you evaluate what you're doing?
John Silver:
Right. You know, and how would you ever know if you were successful, for example?
Beth Quaas:
Right.
John Silver:
So I started following that thread of writing the goals. So once I had the goals, I put all the system designs I could find around the world on the table, and it turned out none of them at all seven goals, and turned out our system didn't make any of the goals.
Beth Quaas:
Wow.
John Silver:
So then I started rethinking healthcare and that led me to the development of this public utility model.
Beth Quaas:
Which was fascinating to me. Talk a little bit about that public utility model.
John Silver:
When I found myself with no systems that made all the goals I could advocate for, I actually went back and explored US history. And I was looking for something that happened where something was emerging or had emerged that was, we didn't want to call it a right, but it was too important socially and structurally to call it just a commodity. And I found the electrical issue in the '20s. So I studied back through the history of that. Going back to the naturally monopoly stuff in England, I know this is all boring. And I looked at what FDR had done with the creation of this public utility and the public utility was really, if you think about it, water, transportation, electricity, these are all things that are vital to the success of the country, that everybody should have a right to have access to. And yet we don't want to just fund it publicly with tax money.
So healthcare had a lot of the same issues as the electrical issue in the '20s where bad distribution of resources, multiple LLCs sucking out of it, charge whatever they felt, running into some neighborhoods, but not others, abandoning the rural communities. So there were a lot of similarities to it. So I put the public utility model on the table and I found out if I change two two of the variables, how it's financed and how it's administered, this public utility model takes the innovation of healthcare right down to the street level in every community. So it's really going to unleash, for example, NP innovation in what I think is the specialty of nursing, which is how to deliver health services.
So if we can unleash that power and it's something we have that hardly any place in the world has but us, is this layer of providers who are still mission focused by their profession of nursing, but also incredibly innovative in how they reach out. And this all goes back to our history too, the Lillian Wall vision of nursing, for example. So it's the thread that connects our core, our moral center as a profession, and then allows it, which it can't do now in this innovation and in this system, to just explode into communities.
Beth Quaas:
As I read your work, my mind was racing on, oh my gosh, this makes so much sense. Look at the things we can do. We can get out in the communities. And like you said, instead of the disease system, we can go out and do preventative healthcare. That's what we do. Public health nursing. Let's blow that up. Let's get out into the communities. I was amazed.
John Silver:
You know, I know public health has been doing this in public health employees, nurses, but the question I asked public health people is okay, you've been doing these community assessments for what, 40/50 years? We have not met one goal from healthy people 2000. So how successful is your process, which is used as primarily the medical model of assessment of a community. I want to go in and use nursing models like Gene Watson's community assessment for caring, tying in Calista Roy's adaptation because communities adapt. I don't want to know what their resilience is. I want to know how they've adapted to this bad health or the contributors to bad health in their communities, and then figure out how we can work together to improve that. I think that makes more sense.
Beth Quaas:
Absolutely. What you said, resilience, let's get rid of resilience. Let's not have people get to a point where they have to be, let's keep them healthy, get them healthy, and work forward from there.
John Silver:
Yeah.
Beth Quaas:
I love that you said that because resilience means that you've gotten somewhere you don't want to be.
John Silver:
Yeah. And you can just withstand it. Right? And then the other advantage of this model is you've got these NPs and regular RNs. I mean, it's not like it all has to be peace. In these communities, collecting realtime data on living conditions, on [inaudible 00:09:03] plants or pollutions in the water, whatever the issue is that's contributing. In other words, a social determent of health, and being able to relay that information back to your partner in managing these regional zones, public health, EMS, the government, and start addressing these social, and also, I mean, there are limits to what a healthcare system can do, but also bringing attention and focus to the economic problems that cause disease, it broadens the scope of what a health system should be, which is both prevention, monitoring, and treatment.
Beth Quaas:
Imagine the smaller size of hospitals that we would need if we had less patients in them because they're a healthier population.
John Silver:
And that should be our goal. Right?
Beth Quaas:
Yeah.
John Silver:
I mean, it's naive to think that there are never going to be any healthcare problems. There's so many things we don't understand that happen just sporadically through people's lives. We can't predict any of this. You can't, which is why insurance to me is just idiocy. You know, there's no predictability. Healthcare is not a free market issue. There's no predictability whatsoever in healthcare.
Beth Quaas:
Correct.
John Silver:
So why are we treating it like there is?
Beth Quaas:
When I read your stuff on insurance and why we're paying and what it's doing for us, again, my mind started racing. That is exactly right. Why are we doing it that way? Why are we ensuring unpredictability? Tell me why. Tell me more about the insurance companies.
John Silver:
You know, if you go back to the '30s, and '40s, they were very isolated health insurance things. Most of those were union based. And then, of course, the upper echelon didn't have to worry too much about it, but medicine was kind of exploding at that time. A lot of new technologies were coming out, the Eisenhower built or helped build the Truman hospital system across the country. So there was a lot of progress being made. The problem was doctors didn't want to take chickens as payments anymore. So they wanted money. And especially as the specialists evolved in the '60s with the ICUs and all that stuff, they found out that you can pretty much charge what you want. Nobody really knows how much it costs to do a surgery. So that door just got opened up, but they had to have people be able to pay it. So that required its insurance system to recompense the medical teams and the hospitals.
Beth Quaas:
Yeah. We've been talking about transparency for years. If I'm a patient and I'm going to have surgery, I can't go in and get a quote on what it's going to cost. No one seems to be able to tell me what it would cost. So how can I comparison shop then if no one can give me an answer?
John Silver:
Yeah. And then all this stuff about price transparency anyway. I mean, that may be great if you're having an elective surgery on your shoulder that you could price around, but really that's not the way it works.
Beth Quaas:
Right.
John Silver:
Usually you're tied into a doctor, a surgeon, an orthopedic that's been treating you now recommends the surgery. You typically go where he has privileges or she has privileges. So you can get that service done. The other type of healthcare is your acutely ill. So you're vomiting, you got diarrhea, your head's hurting, your blood pressure's way up. You're not sitting there going through calling hospitals to say, hey, if I come into your emergency room, how much is this going to cost me?
Beth Quaas:
Right.
John Silver:
Or if you call 911, they're not going to sit there and say, well, it costs $1,200 if I take you to this hospital, but only 300... I mean, none of that stuff goes-
Beth Quaas:
Well, and truly in insurance policy, it might as well be Greek to me because trying to read and understand, and I work in healthcare. So I understand a lot of the jargon, but for most people, how do you even understand what your insurance is going to cover?
John Silver:
Yeah, so I think the big breakthrough is, I told you I started having the recent healthcare. And if you stop thinking of healthcare as 428 million individual billable interactions with providers, and you think of healthcare as services are delivered to a community that could also operate under a general budget, but not have to be individually paid for and build for. And so, in other words, for example, open heart surgery would be a service that's available to the community for people that need it. But I know how much it cost for open heart surgery. I have an idea how many we do a year. I can budget for that. So that was kind of the revolution I think in allowing this public utility model to develop as a solution.
Beth Quaas:
And where would that budget come from?
John Silver:
Healthcare to me, everybody has skin in the game. So healthcare is a national defense issue. We saw that after 9/11, when something like 60, 65% of the applicants for the military force were denied because of healthcare reasons, obesity, hypertension, all these problems we have. It's also a great concern to states. We live in a federal system. So you have to respect state rights in this. It's a critical issue for states. It's a critical issue for businesses because look how much money is lost in productivity because of healthcare and chronic conditions in this country. It's also a responsibility of individuals. So I think the best solution since I don't believe in single payer and the reason I don't is because of an old quote, I'm afraid, which is, "he who pays the Fiddler calls the tune." So right now we're in a situation where insurance companies are able to deny services.
Do we want the government being able to deny services? And do we want the government collecting our healthcare data? And I say no to both of those. So this is kind of again, that middle of the road solution. So all of us have given the game, all of us pay. How you would pay would be you maybe get a utility bill once a month and it's gas and electricity and water and healthcare. And you're paying 50 bucks a month and you never have to worry about it. You're completely covered no matter what you need. So if businesses pay, if cities pay, if towns pay, if counties and states pay, if the federal government pays, they're going to pay a lot less than they're paying now.
Most states the healthcare budgets around 20% of their budget. If we could drop that to 10%, that's a huge savings for the state. I actually stopped my doctorate for two years to go to [inaudible 00:16:04] MBIC so I could understand this macro finance world. If you do this model and implement this model, what I showed so far was about a 42% drop in healthcare costs in the country.
Beth Quaas:
Wow.
John Silver:
I mean, that's pretty significant.
Beth Quaas:
That's very substantial.
John Silver:
And yet it still accomplishes the large task of Medicare for all. And then everybody gets covered, but it's not my tax money paying for it. It's all of us together as a collector.
Beth Quaas:
That's incredible. And I know you talk some about who would sit on the board, if you want to call it, who would be the overseer of that? And you have listed all kinds of different professions in there and areas of expertise.
John Silver:
So the idea to me is to have a central council in New York. Their basic function is to interact with NIH and CDC and NHS, but not be under government control. The council would not be appointed by presidents or Congress. They'd be elected by the state regions. And then to respect the federal system, the actual system delivery would be in the state and they would set up regional systems in the state that include all geographic areas, rural, urban, and/or suburban. So that health regional council would have a holistic view of health throughout all of the areas, not be able to just focus on one area, for example. So, yes, all the providers would be at the table of this, but I would put the chairs nursing.
Beth Quaas:
I totally agree.
John Silver:
Well, it's the only profession that really has that other focus. The one thing you can say about nursing is we're not exactly greedy.
Beth Quaas:
Right.
John Silver:
You know, we're very mission-driven. Medicine has a lot of self-interest in it. We should be the chair. And then the co-chair would be who whatever that region thought was a real primary concern at that time. And that could be anything from an addiction specialist to an infectious disease doctor, but that region would decide what's critical to them. Mental health could be a mental health thing.
Beth Quaas:
Right.
John Silver:
So then all providers pretty much would be around this table. Physical therapy, EMS, public health would be sitting at this table, university representatives because we want the affiliation with universities so that their providers and their students can go out into all of these zones so that as we're training nurses and doctors, they too develop a holistic view of healthcare in the country, not just in an urban area or wherever their school is. And then we're also being able to get research in and out of that university system almost real time, so that we can start bringing evidence-based practice down at the street level and under 17 years, whatever it takes now.
Beth Quaas:
What's one step that nurses can do today to educate themselves or change?
John Silver:
You know, there's something like 850 different nursing groups in this country. Our political powers are numbers. There's almost four million of us in this country. The ANA represents less than 4% of the nurses in this country.
Beth Quaas:
And why do you think that is?
John Silver:
Because they don't deliver a message nurses want to hear. A couple of weeks ago, there were retired, lucky muck with ANA, and she was very honest about it. The biggest mistake they made was in the '90s when they would not support staffing ratios for nurses. In late '90s, there were 250,000 members of the ANA, but I think a bigger mistake they made was back in the '60s when they started trying to come out with this if you're not a bachelor, then you're not a professional nurse. And, man, membership horded after that, and as working nurses we were out in the field and they're going, why am I spending $200 a month to belong to this organization that does nothing for me? It just doesn't make sense. And again, they have no political power because when I was at Washington and I'd talk to these congressmen and senators and experts, they'd go, they'd look at the organization and go, it has no money, it can contribute and to compete with the other forces and it has no membership representing any kind of voting power.
Beth Quaas:
I completely agree. And I didn't mean to cut off your answer about the one step, but I think that's important for people to know nursing doesn't have one professional organization that they can go to for help for answers for advocacy. So I think I wanted you to explain that as well so that people realize we need that as well.
John Silver:
Well, that's why we set up this group, nurses transforming healthcare, it serves as an umbrella organization where we're not after power or money, our goal is to bring this discussion of actual healthcare reform and a system that will work in this country into the public discussion. So the more and more nurses that join us again, you can go to nursestransforminghealthcare.org. And even if you just sign up, we're not begging for money, although, everything helps, but we're not begging for money or something like that.
Beth Quaas:
Everything helps.
John Silver:
But if we could just get 10% of the nurses in this country to join us, we'd be the largest nursing organization in the world. We'd be able to walk into the international council of nurses. We'd be able to walk into a senator's office or a congressman's office and they'd have to sit down and listen to us.
Beth Quaas:
Absolutely. And I will say, you say you're not begging for money, but I tell you what, money talks. And if nurses would give something, because I also, in my professional organization, the American Association of Nurse Anesthetists, we have the largest pack of all nursing organizations because we give, because we get out there and we ask and people are sometimes turned off by that. And I too, I'm not great at asking for money, but I will tell you, if you don't fund what's important to you, things can't change.
John Silver:
Well, if that 10% joined in and everybody contributed a Starbucks lunch, we'd be empowered to be able to go out into the national media and actually start bringing this discussion public.
Beth Quaas:
Right.
John Silver:
Other organizations charge whatever. The other thing we're trying to reach out to our nursing organizations themselves, the inability or the unwillingness of the nurse practitioner associations to reach out and dialogue with us has been stunning. And I realize they're really focused on their scope of practice thing. And they're still fighting in 24 states to try to get prescriptive authority in independent practice, but still this is a much larger picture of empowering nurse practitioners to actually go out and do what they're trained to do instead of having to work through these medical models that they don't like.
Beth Quaas:
Right.
John Silver:
But you know, your association, the Nurse Anesthetist Association, how many other specialty organizations can you think of that would benefit from having an actual nursing centered and nursing led... I mean, it's not nursing run, it's nursing led health system put in place. I think all of us would.
Beth Quaas:
I totally agree. I love the work that you're doing and I encourage people to check out what you're doing.
John Silver:
Oh, thanks.
Beth Quaas:
Absolutely. The other thing I want you to talk about because I read it and I thought it was so eye-opening was your declaration of independence for nurses. It's amazing. I love it. Talk a little bit about that.
John Silver:
Well, I kind of believe what it talks about in the preamble of this, which is if you're going put out a position, you should explain to the world why you're doing this. And the constant example of this is the declaration of independence the United States wrote where it declared to the world, you know what we're doing, why we're doing it, and how we're going to do it. And so now, you understand I wrote this 20 years ago, that's embarrassing. So I looked at the US declaration of independence and I thought the wording in this is kind of brilliant. And I thought if I could just take that document and change sections of it so that it was applicable nursing, it's a really well laid out argument of why things need to happen this way.
So I did that and actually I got a copyrighted except for all the parts that were written by Thomas Jefferson, which they wouldn't let me copyright. But it does lay out that we're the most trusted profession in the country. Why wouldn't Americans want to trust us to lead this healthcare system? We've earned this respect.
Beth Quaas:
Right.
John Silver:
You know, there's nothing nursing has done that's led Americans to think we're a bunch of radical socialists or communis or anything. They know we're focused on health and healthcare. You know, I say, we hold these truths to be self-evident that the profession of nursing has earned the trust and respect of their country. We have, and I don't see how that's ever going to change. We're still pretty mission driven as a profession.
Beth Quaas:
Yes.
John Silver:
I go into then all the whereas where I talk about why we're doing these things. What's been the abuse and patient of the past. I want to lay out that argument clearly for why nursing needs to become an advocate for a change in direction. Some of them are kind of controversial. You know, I do take on the ANA for example, but I speak in truth. There's nothing historically that I'm trying to warp or move towards some kind of agenda. I'm just speaking truthfully and then lay out what I think are the goals, how we can make those goals. And hopefully, nurses as they read this will go, especially in the whereas is thing go, yeah, this is all true.
Beth Quaas:
Where can people find that and read that?
John Silver:
Well, our website should be getting up pretty soon. We are having a debate because again, we don't want to be seen as gimmicky in trying to get people to pay money, but we want to offer the opportunity for other nurses to come in and actually become signatories on this document. If you get down to the bottom, you see my signature and the signature of other nurses who have joined. If we can make it a contributing thing too, where we all benefit out of this. I mean, if I get 50,000 signatures on this document, that kind of makes it a lot more potent.
Beth Quaas:
Absolutely. Tell us the name of your website again.
John Silver:
Sure. Nursestransforminghealthcare.org.
Beth Quaas:
Perfect.
John Silver:
We're also on all the other media, which I don't use, so.
Beth Quaas:
Wow. I'm with you there. John, tell us something. What kind of advice or tips would you leave for nurses?
John Silver:
I think given all the situations that are going on, we're seeing increasing suicide rates, nurses leaving the bedside, not wanting to work anymore. This to me is a tragedy even as well as I understand why, if we could redirect that energy and redirect the energy of the nurses that are still staying at the bedside trying to slug this out into an actual plan for action. An example, we see a lot of things like innovation meetings and hackathons and all this stuff. This is all driven at the process level. And if you read Donabedian who was system serious back in '40s, '50s, he laid out pretty clearly the system determines the processes driven in any outcomes. If we're all just fighting at the process level, then we're not changing the system. That's going to control that level anyway, let's go after the big goon ,let's go after the system.
I have a system design I think nurses will understand. I think it'll appreciate it, it empowers it. It empowers public health. It empowers medicine to get out of this rut they're in and be able to actually control their medical practice. So it benefits all of us as providers. It aligns the system with the values of the providers. I just think if it's something other nurses read and they could get behind, again, the more empowered we are as an organization at Nurses Transforming Healthcare, the more we're going to be able to bring this message out publicly.
Beth Quaas:
I think that's extremely powerful. I encourage everyone to go look into what John is talking about and you work with other members, correct?
John Silver:
Oh, I have brilliant partners in this. Kathleen [inaudible 00:29:52] had done a Ted talk. She's an avid writer. She's an expert in health culture and a nurse practitioner in Louisville, Kentucky. Who's had her own independent practice for over 20 years. She's an integrative provider and of holistic health. I work with another lady, Cheryl Whit, her specialty is rural, particularly ranchers and how we can deliver health services to some of these rural areas. I work with a nurse practitioner, Beth Haney who's a Councilwoman in California, also a big member of AAN. We have Grant writing expert that we write with or that we work with. So we've got a lot of really good partners. Our think tank, always room for more. If there's any real thinky nurses who want to come help us.
Beth Quaas:
I think we're going to see nurses want to take more on as far as systems change. And I love what you said. You know, fixing the process only gets you so far. You have to change the system to really improve what we're all looking at.
John Silver:
I agree.
Beth Quaas:
I thank you for your time. I think what you're doing is very important work, and I want to continue to follow what you're doing.
John Silver:
Thank you so much. It's been a long struggle to try to get this out and I gave up for a while, but now I'm back.
Beth Quaas:
I'm glad you're back.
John Silver:
Thanks. Thanks, Beth.
Beth Quaas:
Thanks, John. I hope to hear more from you.
John Silver:
Thanks. I hope so. Anytime.
Speaker 4:
(Singing).
Outro:
Donate Your Young was produced in partnership with TruStory FM, engineering by Andy Nelson, music by The Lighthearts. Find the show, show notes, and transcripts at donteatyouryoung.com. If your podcast app allows ratings and reviews, please consider doing that for our show. But the best thing you could do to support the show is to share it with a friend or colleague. Thank you for listening.
Speaker 4:
(Singing).
