Was invited to give the keynote address at the National Organization of State Offices of Rural Health Region B meeting which was here at the Battle House on Wednesday. Aside from being able to make Fox News jokes from the podium and having a Smithwick beer for $2 at the Royal Street Tavern, I feel like I was able to get information regarding the Patient Centered Medical Home to this influential group. One of the examples I use, North Carolina Community Cares, I have been following for years and have been very impressed with their process and their results. An attendee from North Carolina brought home one of the problems with our crazy, patchwork, health system. It turns out that this very successful program is Medicaid driven. The private insurers, rather than stepping up to the plate and now paying for the enhanced primary care services that are contributing to the improvement in their bottom line, are content to let the state do the heavy lifting and to reap the benefits (presumably for their shareholders). Yet another argument for profound structural reform.