While Congress and President Barack Obama try to craft some version of his campaign promises into health care policy, dedicated people in Durham are working to expand coverage here and now, rather than waiting for help from Washington. At a March 24 “Cover the Uninsured” forum organized by the Partnership for a Healthy Durham, a coalition of public and private entities coordinated by the Durham County Health Department, health insurance advocates celebrated local initiatives and called for action on a broader stage.

Gina Upchurch, director of PharmAssist, a program that helps older citizens purchase medications, embodied the ethos of local solutions to the health care crisis. “I don’t think we need to be sitting around waiting,” she said. “Because we never have in Durham. We wouldn’t have what we have if we’d sat around waiting on federal or state reforms.”

But at the same time, she said, events are conspiring to make real reform possible. “When things are going well, the status quo reigns,” she said, quoting economist and health care expert Uwe Reinhardt. “Now that we have some chaos, it’s time to stir things up at the national level.”

As part of the statewide Healthy Carolinians program, the Partnership for a Healthy Durham is tasked with an extremely ambitious goal: 100 percent health insurance coverage for all adults in Durham County by next year. Healthy Carolinians was established in 1992, with a set of health objectives for the year 2000; after the turn of the millennium, 2010 became the new target.

Meanwhile, the ranks of the uninsured have surged alarmingly in recent years: The percentage of adults in Durham County without health insurance has jumped from 20 percent in 2004 to 31 percent in 2007, according to the state Department of Health and Human Services. That’s roughly twice the national rateand for local providers, it’s more than just a dry statistic.

At the forum, Dr. Ted LaMay, the chair of the Emergency Department at Duke Regional Hospital, offered some chilling numbers. The emergency room is no one’s idea of an ideal venue for routine, non-emergency medical services, but for the uninsured, it’s often the option of first and last resort.

The Duke Regional emergency room, “designed to treat 35,000 patients annually,” surpassed that capacity years ago; last year it served 59,000 patients, LaMay said. At the current rate, he expects that number will soon top 75,000. The strain on his staff and resources, as well as the chances that a true life-or-death situation will be jeopardized by the glut of basic-care seekers, are rising at a rate that’s “not sustainable.”

More sobering news was offered by Hank Scherich, president of Durham-based Measurement Inc., which employs more than 375 full-time staff members. The company has won numerous awards for its labor-friendly practices, but when it comes to providing health insurance for workers, even the most humane CEOs face hard choices today.

Last year, Measurement Inc. saw an 8 percent increase in insurance premiums. Its plan costs $5,000 annually for each employee, and to save money in these uncertain economic times, leaders considered switching to a plan that would raise deductibles from $500 to $1,000, or require employees to foot part of the bill.

“Our higher-paid employees could pick up the difference… They’d grumble and they wouldn’t like it,” Scherich said. “But our lower-paid employeesthose that are having to make choices between medical bills, electric bills, groceries and new shoessometimes their paycheck runs out before their bills do. If they still have to pay part of a health insurance premium, they’re likely to gamble. We didn’t want them to have to make that choice.”

Measurement Inc. decided to pay the extra premiums to keep their employees on the more generous plan. But whether it can continue to do so year after year, and remain in business if costs keep rising, is another question. “If the playing field isn’t level, some companies will gain an edge by not providing health insurance,” Scherich said in a subsequent phone interview. “If we’re competing with someone who doesn’t provide it, we may not win the contract.”

As fewer companies offer comprehensive health care benefits, and a tanking economy keeps shedding workers, the ranks of the uninsured will only continue to grow. Forty-six million Americans are currently without health insurance. If enough Americans start living that statistic, they may demand a change in our for-profit health care apparatus, which increasingly places basic medical insurance out of reach for those with “pre-existing conditions” and the working poor.

In the meantime, Durham’s community leaders are working to provide what state and federal governments won’t. If the poor and uninsured in Durham lack services, it’s not for lack of effort by Dr. Evelyn Schmidt, director of Lincoln Community Health Center for almost 40 years. She described record patient loads at her clinic, but she seemed almost to relish the challenge of serving increasing numbers of the community.

The last speaker at the forum was Dr. Jonathan Kotch, president of Health Care for All N.C. He argued strenuously for a national single-payer health plan. Citing three promising bills introduced by members of Congress that would move the country toward that goal (none of which are co-sponsored by representatives from North Carolina), he noted witheringly that in the current political climate, such bills can’t get a fair hearing even in the Democratic-controlled Congress; Max Baucus, chairman of Senate Finance Committee, declared single-payer “off the table” before negotiations started.

“Whatever comes out of the Obama administration is going to cost more and is going to cover fewer than any of the three serious health care reform proposals already introduced in Congress,” Kotch said.

Kotch and his group have charted out a workable single-player plan for North Carolina. If the deep-pocketed insurance lobby can keep Washington from considering genuine alternatives to our broken system, the thinking goes, perhaps innovation can come at the state level. Massachusetts was the first to try, and the nation is watching to see whether its experiment in mandating the purchase of insurance accomplishes its goals. The plans now under consideration in Congress are of a similar design.

Critics of the Massachusetts plan, however, point out that its main effect so far has been to enrich the private insurance industry there. Indeed, the difficulty in introducing any sort of single-payer health plan even at the state level was vividly illustrated two weeks before the forum, when Dr. Nortin Hadler, author and professor of medicine at UNC-Chapel Hill, spoke at the Regulator Bookshop in Durham.

His talk covered the overtreatment of fully insured Americans (the subject of his recent book, Worried Sick: A Prescription for Health in an Overtreated America) and the difficulty of comparing one nation’s health care system with another’s. One of his anecdotes concerned a project he worked on to cover the uninsured in Arkansas, which he called “the one state that allows innovative health care for the uninsured worker.”

The program he described was a blend of pooled risk and private choice, with a rational system to distribute medical services and a mix of patient- and care-centered incentives, all while cutting costs. “But when we came all the way through it,” Hadler said, “it was Blue Cross Blue Shield that blocked this. And this was for the uninsured worker. It’s very hard to do anything innovative in our country, even where it’s not going to cost you anything.”