Access Has a Back Office

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Tilonia, Rajasthan. 1972.

Sanjit Roy, better known as Bunker Roy, was not an obvious person to end up here. He came from an elite Bengali family, an uncle who was India's first Air Chief Marshal, a mother who served as a trade diplomat in Moscow. He went to Doon School, India's answer to Eton, then to St. Stephen's College in Delhi. He was on India's champion national squash team three years running, good enough to represent the country internationally in sport and profession.

In 1966 he traveled to Bihar to help with famine relief and was so changed by that experience that he came home and told his mother he wasn't taking the civil service job waiting for him. He went to Rajasthan instead and spent five years digging open wells alongside villagers: unpaid, technically unskilled, learning about the skills and knowledge people in that village held.

By 1972 he had surveyed a hundred drought-stricken villages and found hand pumps sitting broken, sometimes for years, because the certified engineer who is supposed to fix them lives in a city hours away and has no reason to stay to do so.

He tries the obvious fix. Send trained, credentialed engineers to the villages.

They do not stay. A young man with a diploma and options leaves for the city within a year. The pump breaks again. The village is right back where it started.

So Roy changes what counts as expertise. He creates a college to train specialists from the village. He also changes who gets to decide who qualifies to attend this college. In his July 2011 Ted Talk, he describes the qualified person as, “a cop out, a wash out, or a drop out.”

He designs a body called the Village Energy and Environment Committee. One of their roles is to pick the trainees, and to look straight past the normal college candidate. It picks, on purpose, against the obvious choice. It steers toward illiterate and semi-literate grandmothers and middle-aged women. A young man with a new technical skill and a piece of paper tends to leave for the city within a year. A fifty-year-old grandmother has spent a lifetime investing and building in a community she only wants to see grow and succeed is identified as the ideal candidate. He moves this model into multiple villages.

Once selected, getting her to Tilonia at all is its own fight. In many of these communities, a woman has never traveled without her husband or sons, let alone left for six months to learn a trade no one in her village has ever practiced. Some families refuse outright. Roy is told this will not work for a second reason entirely. Solar wiring requires literacy. It requires a technical degree. It requires standards no illiterate grandmother has ever met.

But Roy spent five years learning how people know, learn, and grow even without a degree. He builds around the requirement instead of arguing with it. Circuits taught by color, not by manual. Components taught by hand signal, not by language. Six months of training, then home, to the village.

Alongside the wiring, the women go through a second course called Enriche— covering rights, reproductive health, basic enterprise, digital literacy. A woman goes home able to fix a circuit, and also willing to speak in a village meeting she used to sit through in silence.

None of it works, though, without a third piece of infrastructure most people never hear about. Before a woman leaves for training, her village has to agree to run the system once she's back. The same committee that chose her collects a small monthly fee from every household, set to roughly what they used to spend on kerosene, candles, and batteries. That fee pays her salary for maintaining the system and sets money aside for replacement parts. The village isn't a recipient. It's the utility.

Over the decades since, more than seven hundred of these women, Barefoot College calls them solar engineers, have wired more than twenty thousand homes for power across seventy of the world's least developed countries. None of them carries a diploma. All of them draw a wage from the community that trained and depends on them. The College expanded into a physical site that models sustainability for energy, education, democratic processes, economics, and health.

But those lights going on change more than the electric bill. Shops that used to close at dusk can stay open after dark, increasing revenue. Children study past sunset. And the same men who refused to let a woman leave the village for training are, in village after village, the first to say the community's whole future now runs through what she learned there. Nobody engineered that as an outcome. It happened because competence is hard to argue with once it's the only thing keeping the lights on.

A region that started with broken pumps and no one willing to stay ends up with its own engineers, living there, paid there, respected there, wiring the villages that trained them, that they come from, that they built. Not because a certified expert finally agreed to move to Tilonia. Because the village that built the whole system—technical, financial, and social—needed to stop waiting for one.

2026 US healthcare doesn’t, on the surface have much in common with rural India. We have telehealth, e-prescribing, insurance portals, apps that put a prescription on a doorstep in a plain box. The front door of health care has gotten better for a lot of people, and gotten better fast.

But I keep coming back to this story because of a sentence I read a few weeks ago, buried in the fine print of an overview of a venture-backed women's health company promoting their services as access: the company does not bill Medicaid or other government insurance.

Not a scandal. Not even unusual. Most people wouldn't blink.

But it named something. The company had built a genuinely good front door. For people who could already reach a front door.

Here's why I stared at that sentence in 18 different ways and then went and did a quick look at some other digital healthcare companies and how they talk about access and who they serve.

The population most of these platforms are built to serve is insured: higher income, digitally connected, already has the best-resourced maternal health experience available in this country. And that experience still isn't something to aspire to.

The US spends close to 18 percent of its GDP on health care, nearly double the average among wealthy nations. Its maternal mortality rate is still more than three times the rate in most other high-income countries.

That gap doesn't close at the top of the income ladder. It just gets harder to see there.

So when we say access, we should ask access to what. An outcome that already falls short by international standards isn't a finish line. It's the floor we've agreed to call success. We should want more than a faster door into a house that isn't as safe as the people building these platforms like to believe it is. As safe as those of us in the provider role know it could be. As safe as patients who tell their stories of shock and disappointment and the weight and drag of how let down they feel by their pregnancy, birth, postpartum, and women's health care experiences. Even when they had access to what was billed as "the best care." They express a desire to access more.

Somewhere in the last few years, the word access stretched to cover two very different problems, and we stopped distinguishing between them.

In healthcare, access is used to describe the removal of a structural barrier: distance, cost, discrimination of every kind, a system that wasn't built for you. Now it just as often describes the removal of an inconvenience: a wait, a drive, an awkward conversation at a front desk.

Both are real. Neither is small. But they are not the same problem, and solving one doesn't touch the other.

Here's the principle, stated plainly: access measures who can reach a system we've already decided to build. It says nothing about who that system was never built to hold.

I have sat in enough independent clinics and birth center back offices to recognize what this looks like from the inside.

It is rarely a decision made in a boardroom. It's a slow accumulation of small events. A biller appealing the same denial for the third time. A credentialing process that takes months before a new provider can see a single Medicaid patient. Another burdensome report to a funder due the same week as three deliveries. An endless supply of non-billable services to patients because doing the right thing is the core value of both the model of care provided and the kind of providers holding the space.

Every one of those hours is defensible on its own. Together, they are the reason a practice that wants to serve everyone ends up serving whoever is easiest to bill, not by policy, but by attrition.

Nobody in that clinic decided to exclude anyone on a whim or out of bias against the people on the other side of the MCO. The exclusion accumulated, form by form, appeal by appeal, additional need by additional need.

I've watched countless times, and I have been a midwife who spent six hours before and after work trying to pull threads to get a family housing, food, clothing, pediatric care so that children can be cleared to attend school, and making introductions and connections to help with a job search. On more days than I can count. I've watched patients wait for hours in the waiting room for a ride back to a shelter or home after an appointment. Do you have any idea how uncomfortable and stressful it is to sit in those chairs for hours on end as a pregnant person with a family to care for? How many times a midwife passing by, seeing that patient between visits again and again, goes to the staff lounge to scrounge up water and a healthy snack, takes a pillow off an exam table and puts it behind her back, offers words of kindness and support? How many times the front desk team will re-call the agency that is supposed to provide that ride? How diminished is human dignity in this setting, because of a lack of access to what we know as the social drivers of health? On top of which all of the day-to-day infrastructure and operational burden that agency holds for every patient, they hold for this one, too.

All of which means that access has a back office. We rarely talk about it that way. Maybe we should, because every administrative hour spent surviving the system is an unreimbursed hour that can't be spent serving the patient in it.

The disability justice movement drew this same line, in a different context entirely, years before women's health borrowed the word.

Patty Berne, Mia Mingus, and Stacey Milbern, who founded the disability justice collective Sins Invalid, separated access from inclusion on purpose. Access is a door that opens. Inclusion is whether the room on the other side was built with you in mind, whether you can stay, participate, and be safe once you're through it.

A ramp is access. Whether the meeting still runs on a clock nobody adjusted for you, whether the only accessible bathroom is a floor away, whether anyone waits for you to finish a sentence, that's inclusion. You can have one without the other.

A few years ago I partnered with the disAbility community here in Washington State to look at access to gynecologic and obstetric care. I ran a literature review and surveyed local practices with a group of nursing and health studies students. One finding stayed with me: many clinics, although not nearly all, have an accessible front door, built to accommodate wheelchairs, but few of those have the equipment or training to lift a woman from her chair onto the exam table.

The question on most credentialing forms is whether the clinic offers access. Access? Yes. Inclusion? No.

I met women in their fifties who had never had a pap smear. Blind women who found the support so thin once inside the door that they'd gone thirty years without engaging with healthcare at all. Women with spinal cord injuries who couldn't find an exam table that would hold them at the right angle long enough to stay conscious through the exam.

Compliance can satisfy a checklist and still leave someone stranded just inside the door.

Women's health didn't invent this pattern. It borrowed a word from a movement that had already spent decades warning us the word alone isn't enough.

So here's the rule: access without inclusion is illusory. It widens the margins even as it announces that it's closing them.

And here's its limit. This isn't an argument that convenience doesn't matter, or that the people building these companies are acting in bad faith. Getting birth control without missing a shift, asking a menopause question without a three-month wait, these are real gains for real people, and we all want more of them, not fewer.

The rule doesn't say don't build the front door. It says stop mistaking the front door for the whole house.

Here's the reframe I am ruminating on.

We tend to ask access questions from one seat at a time.

Ask the patient what's stopping her from getting care: transportation, childcare, cost, a shift she can't leave, undignified experiences in healthcare, a provider she can't find or none in her network that look trustworthy.

Ask the provider why they can't see more patients: not enough hours, too high a collateral workload per patient, not enough staff, another prior authorization, another denial, another credentialing process, another reporting requirement competing with the actual work of caring for people.

Ask the system why access varies so dramatically by geography, income, insurance status, race, disability, or ZIP code: reimbursement, workforce shortages, network adequacy, state policy, federal policy.

Three seats. Three sets of metrics. Three task forces. Three grant applications.

But I don't think these are three separate problems.

I think they are three views of the same problem.

A patient misses an appointment because she cannot leave work. That looks like a patient access problem. But perhaps the clinic doesn't offer evening appointments because it cannot afford another shift. That looks like a provider capacity problem. But perhaps it cannot afford another shift because a significant portion of its patients are reimbursed below the cost of providing their care, while the clinic also pays staff to navigate the administrative machinery required to collect even that reimbursement.

Now we are sitting in the system's seat.

Move around the table and the problem changes names. The constraint does not.

And this is where I want to come back to those two meanings of access. The newer one—making care faster, easier, more private, more convenient—is real access. I don't want to diminish it. A better front door is crucial and we want to build towards that as a new normal. But when we use the same word for making an existing system easier to reach and for making care possible for people the system has never adequately held, we can start to confuse progress on one with progress on the other. They require different interventions, different capital, and probably different measures of success.

And the reason this matters is because we keep trying to solve access at the point where the patient experiences it, rather than upstream where some of that scarcity is being produced.

What would happen if we worked backward instead?

If we stripped unnecessary administrative weight from independent women's health clinics and birth centers (the compliance workload, the denial management, continuous quality improvement, the reporting burden), what would become possible on the other side?

Would fifteen recovered staff hours become evening appointments? Would fewer denials and more recovered revenue make it possible to accept more Medicaid patients? Would a birth center that no longer needed to spend scarce operating dollars proving the same things to five different entities be able to keep another midwife on staff? Would infrastructure built to make the organization more capable ultimately make care more reachable?

I don't know.

And I think that is precisely the experiment worth funding.

Convenience access has attracted enormous creativity and capital because its gains are visible. I wonder what we might discover if we brought some of that same imagination to the infrastructure underneath structural access.

Because there is another possibility. The savings could become margin. They could disappear into the next reimbursement shortfall. They could simply allow an exhausted organization to survive another year. Removing burden does not guarantee that the recovered capacity reaches patients.

But that shouldn't end the inquiry. It should sharpen it.

What would we have to build, and what conditions would we have to attach to the investment, so that increased operational capacity becomes increased capacity for care? That is a different proposition for capital.

Don't only fund another front door and count how many people walk through it.

Fund the infrastructure underneath independent women's healthcare and ask whether strengthening the provider changes what becomes possible for the patient. Measure the administrative hours recovered. Measure the Medicaid patients added. Measure the appointments opened, the clinicians retained, the quality and learning achieved, the inventory precision, the services that no longer have to be subsidized somewhere else. Follow the capacity all the way back to the woman it was supposed to reach.

Access has three seats at the table: the patient, the provider, and the system. An intervention that changes only one of them may simply move the constraint to another chair.

Infrastructure may be one of the most underfunded access interventions in women's health precisely because it doesn't look like access. It happens in the back office. And nobody holds a press conference when a denial doesn't happen.

I think about Tilonia again here.

Roy didn't wait for the credentialing rules to change before he started. He built a new and rather unglamorous piece of infrastructure, six months of color-coded training, an energy committee willing to collect a monthly fee, a woman willing to go home and wire her own village and be paid for keeping it running and he let the outcomes make the argument the credential couldn't.

Decades later, nobody was measuring how many villages could reach a certified engineer. They were measuring how many homes had power, and who had wired them.

That's the metric I want us chasing now. Not who we reached. Who we stopped accepting as unreachable, and what we were willing to build, one rather unglamorous mile at a time, to get there.

This was for the first 10 episodes, the cue that I’m about to drop something extra for the listener. But I am so grateful for the feedback, suggestions, and support I’ve received for these Field Notes and I had one reader ask if I could write out my finale since she found herself in places she could read, but not listen. So I have decided to add them here after I record, since I really enjoy the telling of the story without edits:

When I opened my first private practice, I had a whiteboard on the wall.

I kept the dates of the new and full moons on it because, like generations of midwives before me, I was curious whether they would tell me anything about when the babies might come (which they always did). I wrote my goals for the week. And in one corner, I kept a longer-term goal that stayed there for years.

Open a maternity hospital where the first rule is: Be Kind.

I had arrived at licensure believing pretty deeply that love, justice, and health care were one thing, and that part of my work as a provider was to find the places where they intersected in the community I was serving. I was living and raising my children in a community with enormous gaps in women's and maternal health care. I could see what was missing. I could also see, or thought I could see, what might exist instead.

The hospital in my imagination wasn't simply a place to have babies. It was a place where women could receive the care they needed across their lives, with prevention and well-being treated as seriously as illness. Kindness would not depend on whether you happened to encounter a kind person that day. And time would not be the primary mechanism by which we rationed attention, compassion, or care.

That last part matters deeply to me.

I have spent more than twenty-five years in and around maternal and women's health care, and I have known extraordinary clinicians, nurses, midwives, physicians, front desk teams, social workers, and administrators who practice this way. But I have never seen an entire system designed to make it possible, sustainable and even reward them to practice this way.

There is a difference between kindness as a personal virtue and kindness as an operating principle.

Watching Bunker Roy's TED Talk again after all these years brought me unexpectedly back to that whiteboard.

What moves me about the physical building of the Barefoot College isn't only that women without formal education became the engineers of their communities or that children who had to tend to the family animals during the daytime could suddenly attend school at night and participate in a living model of democracy, or that they have 4 years of water in a cistern under the building because they never lose a drop of rainwater. It is that Roy seems to have looked at a collection of things everyone else regarded as fixed and asked whether they actually were. Who counts as an expert. Who can learn. What education must look like and convey. Who holds value in a community. Who should be trusted with important work. What a village can provide for itself.

And then he built around different answers.

For years, I used to ask people I admired in health care a version of the same question: If the walls of health care were only figments of our collective imagination, if we had simply agreed they were there but they are not really there, what would you build?

I loved hearing their answers and feeling that sense of camaraderie.

But I think the harder question is the one The Barefoot College leaves me with now.

What if we stopped treating the walls as imaginary only during the thought experiment?

I can still see that building.

Over the years, I have sat with architects and students and peers and other people willing to imagine it with me. I can picture the physical space. I know what I want it to feel like to walk through the door. I know that women would be understood not simply as patients passing through episodes of illness or pregnancy, but as anchors of families and communities whose health has consequences far beyond themselves. I know that the people working there would need to be held with the same dignity they would extend to everyone who came for care.

And I know the first rule.

Be kind.

What I don't know yet is exactly how to build the rest of it.

Usually, I try to end One More Signal with something I have figured out. This one? I haven't. I'm still in the noise of this one.

But maybe there is something worth saying before the answer is fully formed.

Some visions stay with us for a very long time. They survive different jobs and different versions of ourselves. We become more practical. We learn how reimbursement works and how buildings get financed and how staffing models break and all about cost overruns and the complications of humans working together, and how much stands between an idea and a functioning health care organization. We learn enough about the walls to become very good at navigating them.

And occasionally someone reminds us that knowing where the walls are is not the same thing as accepting that they have to stay there.

More than twenty years later, I still want to build that place.

I think that is the signal I'm going to leave here for now.

Seen this pattern where you work? Hit reply and tell me. That's the harvest.

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