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Sep 9, 2026
011 · Access Has a Back Office
011 · Access Has a Back Office
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36:35
Transcript
0:00
[intro music] This is Harvest the Signal, where the smallest signals can change the biggest systems. And now, here's your host, Jody Lynn Owen. What is the system trying to teach us?
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That's the question behind every field note, and this week's is Access Has a Back Office. So let's start with a story, as I love to do.
0:30
Let's go to Tilonia, Rajasthan, in, well, let's say mid-'60s to early '70s. And a man named Sanjit Roy, better known as Bunker Roy, was not an obvious person to end up here in Rajasthan.
0:48
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, and then off to St.
1:02
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.
1:14
In 1966, he traveled to Bihar to help with a great famine. He wanted to be part of the relief support.
1:23
And he was so changed by that experience that he came home and told his mother he was not going to take the civil service job that was waiting for him.
1:31
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.
1:46
By 1972, he had surveyed 100 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.
2:04
He tries the obvious fix, which is exactly how most of us would think. Let's send out trained, credentialed engineers. We're going to deploy them out to the villages to fix these wells.
2:15
They are deployed, but they do not stay. A young man with a diploma and options leaves for the city within a year. The pump breaks again, and the village is right back where it started.
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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.
2:42
In his July 2011 TED Talk, he describes the qualified person as a cop-out, a washout, or a dropout. And he designs a body within the village structure that is called the Village Energy and Environment Committee.
2:59
One of their roles is to pick the trainees, and they're to do so by looking straight past the normal college candidate.
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It picks on purpose against the obvious choice and 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.
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But a 50-year-old grandmother who 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.
3:36
Once selected, getting her to Tilonia, the site of the college, is its own fight.
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In many of these communities, women have never traveled without husbands or sons, let alone for six months at a time to go learn a trade nobody in the village has ever practiced, and often even conceptualizing what they are going to learn would be nearly impossible.
4:04
Some families refuse outright. Roy is told this college will not work for a second reason entirely. His plan is to train solar engineers, and solar wiring requires literacy. It requires a technical degree.
4:19
It requires standards no illiterate grandmother has ever met. Most of us have never met, frankly. But Roy spent five years learning how people know, learn, and grow, even without a degree.
4:33
He made an express study of how much people in these villages knew, quite contrary to the belief system that he was raised in. And he builds around the requirement instead of arguing with it.
4:50
You know, so many times we want to fight the question, and he didn't. He just put it aside and built something totally different.
5:00
He taught circuits by teaching what color of circuit goes where, not through a manual that women had to read. There were components taught by hand signals and sign language, not by verbal language.
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They had six months of this training, and then they go home to their village. Now, alongside the wiring, the women also go through a second course called Enrich.
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And this course covers rights, reproductive health, basic enterprise, and digital literacy.
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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 and contribute in new ways to the health and well-being of her community.
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None of this works, though, without a third piece of infrastructure that most people never hear about when they hear this story.
5:49
So before a woman leaves for training, her village has to agree to run the system when she's back.
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That 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.
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And that fee pays her salary for maintaining the system, and it sets money aside for replacement parts. The village isn't a recipient. It's the utility.
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Over the decades since, more than 700 of these women, Barefoot College calls them solar engineers, have wired more than 20,000 homes for power across 70 of the world's least developed countries.
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None of them carries a diploma. All of them draw a wage from the community that trained and depends on them.
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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.
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Shops that used to close at dusk can stay open after dark, increasing revenue.
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Children study past sunset, and the men who refuse to let a woman leave the village for training are, in village after village, the first to say that the community's whole future now runs through what she learned there.
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Nobody engineered that as an outcome. It happened because competence is hard to argue with once it's the best thing keeping the lights on.
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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.
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Not because a certified expert finally agreed to move to Tilonia, but because the village that built the whole system, technical, financial, and social, needed to stop waiting for one. 2026 U.S.
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healthcare doesn't on the surface have much in common with rural India,
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not in the 60s and not now, but we have telehealth, e-prescribing, insurance portals, apps that put a prescription on a doorstep in a plain box for convenience. You know, we have organized the front door of healthcare,
8:13
and it has gotten better for a lot of people, and it's gotten better very rapidly.
8:18
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.
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And the sentence I had to blink twice at after seeing the word access all over their website was that the company does not bill Medicaid or any other government insurance. This is not a scandal.
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It's not even unusual, and most people would not even blink at this. But it names something really important. The company had built a genuinely fantastic front door for people who could already reach a front door.
9:05
Here's why I stared at that sentence about Medicaid 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.
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The population most of these platforms are built to serve is insured.
9:23
Higher income, digitally connected, already has the best resource maternal health experience available in this country, and that experience still is not something to aspire to. The U.S.
9:39
spends close to 18% of its GDP on healthcare, which is nearly double the average among wealthy nations, yet its maternal mortality rate is still more than three times the rate of these other countries.
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That gap does not 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?
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An outcome that already falls short by international standards is not a finish line. It's the floor we've all agreed to call success.
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We should want more than a faster door into a house that is not as safe as the people building these platforms like to believe it is.
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As safe as those of us in the provider role know it could be, or 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 healthcare experiences.
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Even when they had access to what was billed as the best care, they express a desire to access more.
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Somewhere in the last few years, the word access stretched to cover two very different problems, and we stopped distinguishing between them.
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In healthcare, access is used to describe the removal of a structural barrier, distance, cost, discrimination of every kind, a system that was not built for you.
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Now, it just as often describes the removal of an inconvenience, a wait or a drive or an awkward conversation at a front desk.
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Both are real, neither is small, but they are not the same problem, and solving one does not touch the other. Here's the principle stated plainly. Access measures who can reach a system we've already decided to build.
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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.
11:50
Sometimes this is a decision made in an executive level to not take Medicaid because we are going to make
11:57
a hard line about the purpose of the business being business, but business cannot function on a Medicaid reimbursed budget. But I think more often it's not a decision made in a boardroom.
12:09
It's a slow accumulation of small events that Impact an organization's ability to treat all of the patients in the community that it serves.
12:20
This could be 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 both of the model of care provided and the kind of providers holding that space.
12:47
Every one of those hours is defensible on its own, but 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, and that attrition often does lead to policy.
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But 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.
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I have 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 the children can be cleared to attend school, and that allows adults to go to work, and making introductions and connections to help with a job search.
13:45
On more days than I can count, this was the life that I was living. I have watched patients wait for hours in a waiting room for a ride back to a shelter or a home after an appointment.
13:58
And, you know, nobody likes to sit in a waiting room. It's uncomfortable and it's stressful to sit in those hard chairs for hours on end.
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But as a pregnant person with a family to care for and navigating very difficult circumstances, the stress of that space is incredible.
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And how many times I've seen a midwife pass by, you see that patient sitting in that chair between visits again and again. There they are. They're still there. Oh, they're still there.
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And you go to the staff lounge and scrounge up some water and a little snack for them. You might take a pillow off an exam table and put it behind her back, offer some words of kindness and support.
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And this can go on for three or four hours while they're waiting for a ride that was allegedly scheduled. The front desk team gets deployed to call and recall the agency that is supposed to provide that ride.
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And I am shaking my head because human dignity is so diminished in this setting because of a lack of access to what we know as the social drivers of health.
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On top of which, all of the day-to-day infrastructure and operational burden that agency holds for every patient, they hold for this patient too. All of which means that access has a back office.
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We rarely talk about it that way, but maybe we should, because every administrative hour spent surviving the system is an unreimbursed hour that cannot be spent serving the patient in it.
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The disability justice movement drew this same line in a different context entirely years before women's health borrowed the word.
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Patty Berne, Mia Mingus, and Stacy Milbern, who founded the disability justice collective Sins Invalid, separated access from inclusion on purpose. Access is a door that opens.
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Inclusion is whether that 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.
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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 is inclusion.
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You can have one without the other.
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To illustrate this, I'll share that a few years ago I partnered with the disability community, lowercase D, capital A, disability community here in Washington State, to look at access to gynecologic and obstetric care for women living with disabilities.
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I ran a literature review and surveyed local practices with a group of nursing and health studies students. One stark finding stayed with me.
16:44
Many clinics, although not nearly all, have an accessible front door built to accommodate wheelchairs, but very few of those have the equipment or training to lift a woman from her chair onto the exam table.
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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.
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Blind women who found the support so thin once inside the door that they'd gone thirty years without engaging with healthcare at all.
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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.
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Compliance can satisfy a checklist and still leave someone stranded just inside the door. Women's health didn't invent this pattern.
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It borrowed a word from a movement that had already spent decades warning us that the word access alone is not enough. So here's the rule. Access without inclusion is illusory.
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It widens the margins even as it announces that it's closing them. And here's the limit. This is not an argument that convenience does not matter or that people building these companies are even acting in bad faith.
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I don't think they are. 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.
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The rule doesn't say, "Don't build the front door." It just says, "Stop mistaking the front door for the whole house." Convenience access has attracted enormous creativity and capital because its gains are visible.
18:46
I wonder what we might discover if we brought some of that same imagination to the infrastructure underneath structural access. Here is the reframe I am ruminating on.
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We tend to ask access questions from one seat at a time.
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Ask the patient what's stopping her from getting care: transportation, childcare, costs, a shift she can't leave, undignified experiences in healthcare, a provider she can't find, or absolutely none in her network that look trustworthy.
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Ask the provider why they can't see more patients, and you'll hear there's not enough hours, there's too high of 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.
19:37
But ask the system why access varies so dramatically by geography, income, insurance status, race, disability, or zip code, and they'll tell you it's reimbursement or workforce shortages, network adequacy, state policies, federal policies, generally speaking, just the word funding.
20:00
So there's three seats, there's three sets of metrics, there's three task forces, there's three different grant applications. But I don't think these are three separate problems.
20:12
I think they are three views of the same problem.
20:17
And I guess I'm gonna kinda add in here, it's really hard if you are supported by funders, whether that is nonprofit angel investors or VC investors, to find investors who understand that you have to hold all three in one.
20:40
They will ask you, all of them will ask you, "Narrow your focus. Narrow it down. Smaller, smaller, smaller." But you can't separate these three seats from the table that they're at.
20:54
They're all there, and they'll all always be there. Just because you are pulling out a chair for one doesn't mean the other two aren't there. That's a little side note.
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But meanwhile, we have a patient who misses an appointment because she can't leave work, and that looks like a patient problem, so we're gonna solve for that.
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But perhaps the clinic doesn't offer evening appointments because it cannot afford another shift, and that looks like a provider capacity problem.
21:22
But maybe it can't 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 or doesn't pay them to navigate the administrative machinery required to collect even that reimbursement.
21:40
Now we're sitting in the system seat. Move around the table and the problem changes names, but the constraint does not. This is where I want to come back to those two meanings of the same word, access.
21:54
The newer one, making care faster, easier, more private, more convenient, is real access. I do not want to diminish it. A better front door is crucial, and we want to build towards that as a new normal.
22:09
But when we use the same word for reaching a new health tech or virtual service line 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.
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They require different interventions, and most of the time, although I don't agree with it, different capital, and most likely, they have very different measures of what success means.
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And that matters because we keep trying to solve access at the point where the patient experiences it rather than way upstream where some of that scarcity is being produced.
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And what would happen if we work backwards instead?
22:56
Now I realize I'm mixing metaphors because I just told you there's a table with three chairs, and we pull out one chair and we deal with that, and we ignore the other two, and then we pull out one and we ignore the other two.
23:07
That's one metaphor. Now, the other idea that I'm thinking about is that there is downstream, there is in front of the patient, and there's way upstream, and that is way inside the back office.
23:19
So if we stripped unnecessary administrative weight from independent women's health clinics and birth centers, for example, the compliance workload, the denial management, continuous quality improvement, the reporting burden, the regulatory forms, what would become possible on the other side of that?
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Would 15 recovered staff hours become evening appointments? Would fewer denials and more recovered revenue make it possible to accept more Medicaid patients?
23:48
Would, say, 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?
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Would infrastructure built to make the organization more capable ultimately make care more reachable?
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I don't know, and I think that is precisely the experiment worth funding because there is another possibility. The savings could become margin They could disappear into the next reimbursement shortfall.
24:26
They could simply allow an exhausted organization to survive another year. Removing burden does not guarantee that the recovered capacity reaches patients, but that should not end the inquiry. It should sharpen it.
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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.
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Don't only fund another front door and count how many people walk through it.
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Fund the infrastructure underneath independent women's healthcare and ask whether strengthening the provider changes what becomes possible for the patient.
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Measure the administrative hours recovered, measure the Medicaid patients added, measure the appointments opened and the clinicians retained and the quality and the learning achieved.
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Measure the inventory precision, the services that no longer have to be subsidized somewhere else. Follow the capacity trail all the way back to the woman it was supposed to reach.
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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.
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Infrastructure may be one of the most underfunded access interventions in women's health precisely because it doesn't look like access.
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It happens in the back office, and nobody holds a press conference when a denial doesn't happen. So I think about Telonia again, about the Barefoot College here.
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Roy Bunker did not wait for the credentialing rules to change before he started. He built a new and rather unglamorous piece of infrastructure.
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Six months of color-coded sign language-based 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 could not.
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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.
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And for the record, that is a grossly simplified expression of the impact of the Barefoot College on the women who attended, their families, their communities, and society as a whole.
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So it's a story really worth diving into if you are unfamiliar with it.
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But 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.
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One more signal, and this was for the first ten episodes, the cue that I'm about to drop something extra for the listeners.
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But I am so grateful for the feedback, suggestions, and incredible support I received for these field notes.
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And I had one reader ask if I could please, please write out my finale since she found herself in places she could read but not listen.
27:46
So I have decided to add them to the writing in addition to these podcasts, and that's not really gonna impact you, but I just want to say that out loud. If you ever need to read, then you...
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It, it'll be there for you, so you don't have to worry about missing it. But I like to tell this part of the story and complete this part of the podcast without the edits in front of me.
28:08
So I'll complete it here, and then I'll put it in writing into the field notes.
28:14
So when I first opened my private practice, I had a whiteboard on the wall, and I kept the dates of the new moon and the full moon on it because
28:25
midwives have very busy days on new moons and full moons, so I just like to watch it and know where I was in the cycle of the month to sort of anticipate what my schedule would be like, and it always works.
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And I've talked to so many OB nurses who work in huge hospitals who say the same thing. So if you're waiting on a baby, wait on the full moon or wait on the new moon. It's gonna come for you.
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And I wrote my goals on there just for the week, you know, couple of things I wanted to accomplish in the clinic or in the community.
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And across the bottom, I kept a longer-term goal that actually stayed there for years, and that was to open a maternity hospital where the first rule is be kind.
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I had arrived at licensure believing pretty deeply that love and justice in healthcare 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 and living in.
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I was raising my children here, and we had enormous gaps, and still do, in access to women's health and maternal healthcare.
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I could see what was missing very clearly, but I could also see this vision of what might exist instead of a void.
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And I used to talk about this like, what if we turn this healthcare desert into a corridor of health? And I had just this very clear and robust vision for what that would look like.
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But the one thing I was laser-focused on was this idea of a maternity hospital, and the hospital in my imagination wasn't simply a place to have babies.
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It was a place where women could receive the kind of prevention that would change the health of their life story and of their families and of their communities.
30:24
Kindness would not depend on whether you happen to encounter a kind person that day. And time would not be the primary mechanism by which we rationed attention, compassion, or care.
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And that part matters to me very deeply.
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I have spent more than twenty-five years in and around maternal and women's healthcare, and I have known extraordinary clinicians, nurses, midwives, physicians, front desk teams, social workers, and administrators who practice this way.
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But I have never seen an entire hospital system designed to make it possible, sustainable, and even to reward them for practicing this way.
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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.
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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 family animals during the daytime could suddenly attend school at night and participate in a living model of democracy, or that they have four years of water in a cistern under the building because they never lose a drop of rainwater.
31:56
All of that is incredibly moving. But 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?
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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.
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And then he built around different answers than anyone had ever given. For years, I used to ask people I admired in healthcare a version of the same question.
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If the walls of healthcare were only figments of our collective imagination, if we had simply agreed they were there, but they were not actually there, what would you build?
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And I loved hearing these answers and feeling a sense of camaraderie with the vision of so many people who imagined a better healthcare world.
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But I think the harder question is actually the one that Barefoot College leaves me with now, which is this: What if we stop treating the walls as imaginary only during the thought experiment?
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Because I can still see that building in my mind's eye. Over the years, I've sat with architects and students and peers and other people willing to imagine it with me. I can picture the physical space.
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I know what I want it to feel like to walk through the door.
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I know that women would be understood not simply as patients passing through episodes, but as anchors of families and communities whose health has consequences far beyond themselves.
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I know that the people working there would need to be held with the same dignity that they would extend to everyone who came for care. And I know the first rule: be kind.
33:55
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 have not. I'm still in the noise of this one.
34:08
But maybe there's 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.
34:25
We learn how reimbursement works and how buildings get financed and how staffing models break and all about cost overruns and the massive complications of humans working together and how much stands between an idea and a functioning healthcare organization.
34:43
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.
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More than twenty years later, I still want to build that place. And if I do, I certainly hope to carry this paradigm into it. I encourage you to do the same. I think it's a signal I'm going to leave here for now.
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So this is where I encourage you to noodle through these ideas while you're walking the dog or driving home.
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If today's field note changed the way you think about access or makes you want to take a second look at how you're using the word access or companies around us are using the word access, or if you feel inspired to build a maternity hospital with me here in South Seattle, let me know.
35:36
I do read every reply personally. In fact, the next Harvest the Signal may begin with something you've stopped accepting but haven't yet put into words.
35:44
And because so many of you have gotten in touch with me and I'm so enjoying where this is going, if you are interested in being on this show, please let me know.
35:53
I know people have something to contribute from so many different fields, and I'm interested in everything. I would love to keep exploring patterns hidden in plain sight together.
36:06
So please hit subscribe and we'll do it again. I'm Jodi Lynn Owen. Until next time, keep looking for the signal. This has been Harvest the Signal with Jodi Lynn Owen. The smallest signals can change the biggest systems.
36:20
Be sure to like, follow and share so you never miss an episode or the opportunity to compare your field notes with your colleagues. [outro jingle]
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