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Dialogue With the American People

This chapter highlights public input on the four questions Congress specified that the Citizens’ Health Care Working Group ask the American people. The Working Group has reviewed, and will continue to examine, all input it has received from community and other meetings, by Internet, by mail, in person, or by phone. Particular emphasis in this section has been given to information gathered in community meetings held throughout the nation, which Congress directed the Working Group to conduct before preparing its Interim Recommendations. Other survey data sources are discussed throughout this section, and they will also be highlighted in the Final Recommendations to Congress.

This chapter follows the organization of the “typical” meeting, which always began with a discussion of participants’ underlying values. The 31 community meetings varied slightly from site to site, reflecting differences in the participants’ interests and preferences. While the general structure of the meetings was similar, it evolved over time as the Working Group attempted to find more effective ways to gather the desired information. Meetings varied in length, with most meetings either three or four hours long, although some were shorter and a few longer. At all these meetings, discussions centered on the four legislatively mandated questions:

I. What health care benefits and services should be provided?

II. How does the American public want health care delivered?

III. How should health care coverage be financed?

IV. What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high-quality health care coverage and services?

Summary of Findings

The following common themes emerged from the community meetings and other sources of information collected from the American public by the Working Group:

Values

• Underlying the discussion of the four legislative questions is the belief by virtually everyone in attendance at each community meeting that the health care system has at least some serious problems.
• Over 90 percent of participants at community meetings and respondents to the Working Group’s Internet poll believed that it should be public policy that all Americans have affordable coverage.

I. What health care benefits and services should be provided?

• A clear majority of participants preferred that all Americans receive health care coverage for a defined level of services.
• People at the community meetings frequently expressed strong support for increased focus on wellness and prevention services as part of "basic" coverage, rather than focusing only on treating sickness.
• Participants at meetings continually emphasized the importance of a strong education component in health care and the management of health.
• Individuals voiced support for a fairly comprehensive basic benefit design.
• Although many participants recognized the need to do more to ensure that the health care provided is appropriate and delivered efficiently, they were also concerned about arbitrary limits on coverage and were not comfortable with bare-bones benefit packages.
• Despite the reluctance of many to limit benefits, participants at meetings supported limiting coverage to services that have proven medical effectiveness.
• Participants expressed some level of support for the idea that some people could pay for additional services outside the basic benefit package.
• People wanted consumers to play an important role in deciding what should go into a basic benefit package.
• Participants in some meeting sites discussed a potential role for a local board or other quasi-governmental entity in defining the basic level of services.
• Participants expressed the desire to be involved in the management of their own health care and were willing to accept some responsibility for their medical decision-making.

II. How does the American public want health care delivered?

• Affordability of care is a primary concern among participants.
• Participants were troubled that many people did not have access to the health care they need.
• Many participants cited complexity of the system as a contributing factor to the problems with the health care system.
• Linked to confusion about the health care system was the lack of useful information to help individuals navigate the health care system.
• Participants mentioned that they or others were not always treated with respect or dignity.
• Participants frequently cited barriers to care related to private health insurance.
• Participants told the Working Group that they want to feel secure knowing that when they or their families need care, they can get it without becoming impoverished.
• Participants wanted all Americans to be able to get the right health care, at the right time, in a respectful manner.
• Participants noted that being able to choose and maintain a stable, long-term relationship with a personal health care provider was critical.
• At the community meetings, individuals asked for a delivery system that is secure, transparent, easy to navigate, and treats the “whole person.”

III. How should health care coverage be financed?

• Although the results differed across meeting sites, a majority of participants (ranging from 55 percent to 88 percent in the community meetings) believed that everyone should be required to enroll in either private or public “basic” health care coverage.
• In almost every community meeting, a majority of participants supported the notion that some individuals should be responsible for paying more for health care than others. The most commonly mentioned criterion for paying more was income, but varying payment by income was supported by the majority of participants in fewer than half of the meetings where this question was discussed.
• Views about employer-based coverage did not generally reflect a deep distrust of employers, but instead were intertwined with broader concepts of health reform.
• At most meetings, participants stressed the importance of preventive care to reduce health care costs.
• Participants at most meetings believed that individuals have a responsibility to manage their own care and use of services.
• In many meetings, participants mentioned that individuals have a social responsibility to pay a fair share for health care.
• Participants frequently stated that the problems of high costs rest with “price setters”—namely, prescription drug companies, insurers, and for-profit providers.
• A commonly expressed view was that a simpler system would result in lower administrative costs.
• Some support exists for investment by providers and the private sector in health information technology to increase system efficiency.
• Participants expressed general support for individuals’ playing their part in controlling utilization and costs.
• Individuals would like information about how to use health care better and more effectively.
• At some meetings, participants supported providing incentives to patients to engage in healthy behaviors.
• Participants expressed preferences for using medical evidence to decide which services are covered and provided.
• There was general support for controlling prescription drug costs by limiting direct-to-consumer advertising of prescription drugs and using more generic drugs.
• Support also existed for limiting expensive yet “futile” end-of-life care and instead providing palliative care.
• In almost all community meetings, participants expressed the belief that changing the culture from sick care to well care—namely, by focusing on prevention, wellness, and education (in general, and health education in particular)—will reduce health care costs.
• A commonly expressed view was that better use of advanced practice nurses and other non-physicians could save money and improve quality.
• Participants believed that investing in public health would pay dividends in terms of reducing health care costs.
• Support for limits on malpractice was expressed at some community meetings.

IV. What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high-quality health care coverage and services?

• In most meetings as well as on the Internet poll, a majority of participants expressed a willingness to pay more to assure that everyone had access to affordable, high quality health care. Overall, about one-third said they were willing to pay $300 or more per year.
• When asked to rank or choose among competing priorities for public spending on health, individuals—with few exceptions—were most likely to rank “Guaranteeing that all Americans have health coverage/insurance” as the highest priority.
• When asked to evaluate different proposals for ensuring access to affordable, high quality health care coverage and services for all Americans, individuals at all but four meetings ranked “Create a national health insurance program, financed by taxpayers, in which all Americans would get their insurance” the highest. Three other options generally ranked in the top four choices at the community meeting locations and in the Internet poll: “Expand neighborhood health clinics”; “Open up enrollment in national federal programs like Medicare or the federal employees’ health benefits program”; and “Require that all Americans enroll in basic health care coverage, either private or public.”

Detailed Description of Findings

Values

Before focusing on the four legislative questions, all meetings began with a discussion of individuals’ underlying values and perceptions that generally centered on three questions:

• When asked how they would describe the U.S. health care system today, 97 percent of attendees at the community meetings selected “It is in a state of crisis” (64 percent) or “It has major problems” (33 percent). In each of the 31 community meetings, at least 88 percent selected one of these options. Overall, only two percent said “It has minor problems,” and one percent either said “It does not have any problems” or had no opinion. Underlying the discussion of the four legislative questions is the belief by virtually everyone in attendance at each community meeting that the health care system has at least some serious problems.

• When meeting participants at all meetings were asked, “Should it be public policy that all Americans have affordable health care coverage?”, 94 percent overall said “yes.” Similarly, in the Working Group’s Internet poll, 92 percent either strongly agreed (80 percent) or agreed (12 percent) with this statement. Over 90 percent of participants at community meetings and respondents to the Working Group’s Internet poll believed that it should be public policy that all Americans have affordable coverage. As stated by participants in the Orlando community meeting, “Health care is a right and not a privilege.” Seattle, Denver, and Philadelphia meeting participants, among other locations, desired “cradle to grave” access to health care.

• At many of the community meetings, participants were asked what they believed was the most important reason to have health insurance. Although the results varied by meeting site, individuals were more likely to choose the response “To protect against high costs” than they were to choose the response, “To pay for everyday medical expenses.” A national poll conducted in 2003 found that 71 percent on adults said that the most important reasons to have health insurance is to protect against high costs.[1]

Figure 1 illustrates how participants’ responses varied across community meeting sites and the Working Group Internet poll:

Figure 1:
Which do you think is the most important reason to have health insurance?
(Lowest and highest rankings at community meetings, average, and
Internet ranking)

Note: This question was not asked in Los Angeles, Albuquerque, Hartford, Las Vegas, San Antonio, Fargo, Lexington, Little Rock, or Sioux Falls. Eugene and Baton Rouge were the meeting sites where “Pay for everyday medical expenses” ranked as the lowest among the cities where the question was asked, while Philadelphia and Providence were the meeting sites where that option ranked as the highest. The meeting average reflects a weighted average of all meetings where this question was asked.

I. What health care benefits and services should be provided?

Some common themes have emerged from the community meetings regarding what health care benefits and services should be provided. In the community meetings, discussion of this question generally revolved around three core questions.

The first of these questions is discussed below:

“Health care coverage can be organized in different ways. Two different models are: (1) Providing coverage for particular groups of people (e.g. employees, elderly, low-income) as is the case now; (2) Providing a defined level of services for everyone (either by expanding the current system or creating a new system). Which of the following most accurately reflects your views?”

In response to this question, a strong preference emerged:

A clear majority of participants preferred that all Americans receive health care coverage for a defined level of services. In response to the question, the vast majority (between 68 percent and 98 percent) of participants at all community meetings have said that we should provide a defined level of services for everyone. The highest level of support for a defined set of services was in the community meetings that were held in Philadelphia and New York, and the lowest in the Baton Rouge meeting (Figure 2).

Figure 2:
Which statement best describes your views on how health care coverage should be organized?

In the Internet poll, 85 percent of participants answered the question this way. These findings are also consistent with the results of other national polls asking similar questions. In surveys conducted by other organizations, a clear majority have expressed the opinion that all Americans should have health insurance. For example, a poll conducted by Harris Interactive for the Wall Street Journal in September 2005 found that 75 percent of U.S. adults somewhat favored (23 percent) or strongly favored (52 percent) universal health insurance.[2] More recently, a New York Times/CBS poll conducted in January 2006 found that 62 percent said that they think the federal government should guarantee health insurance for Americans; 38 percent said this was not the responsibility of the federal government.[3]

Discussions at community meetings teased out variations in how people conceptualize health coverage. For example, some participants indicated that it was hard to make a choice between the answers without knowing who was providing the coverage, or what would be covered. Many tended to view access to health care as a basic right, and they conveyed a willingness to contribute to the success of a system that would facilitate health care for all.

• In the Baton Rouge community meeting, where the smallest percentage of people opted for providing a defined level of services for everyone, participants still concluded that a defined level of services for everyone was “more fair and equitable” in the face of the current system that was “failing.”
  
• In the Detroit community meeting, some participants worried that the issue of discrimination needed to be addressed, regardless of the system design. Just like the current system of providing coverage for particular groups of people (such as Medicare or Medicaid for elderly, disabled persons or low-income populations, or group coverage organized through employment), a system providing a basic level of care for everyone ran the risk of not providing sufficient levels of care for all. Participants expressed concern that any system reform must avoid creating different levels of care for different subsets of the population.
  
• At the two largest community meetings in Los Angeles and Cincinnati, fewer than 10 percent of participants favored the current system that provides coverage according to a person’s affiliation with a particular group. These participants, like those at the other meetings, cited problems with the current system, including:
  • It excludes the unemployed and others who are not part of a particular group.
  • The system is high cost, complex, and not uniform across groups.
  • Mobility and flexibility are a problem.
    
• About 90 percent of participants supported the option of providing a defined level of benefits for everyone, rather than the current system of coverage for certain groups. The virtues of implementing a system of coverage for all that were mentioned included:
  • Reduced overall and administrative costs;
  • Decreased hospitalization and emergency room use;
  • Access for all;
  • Covered prevention and immunization; and
  • Improved level of national health care.

However, participants also expressed potential concerns about such a system, such as: What is the defined level of services? Who will be denied access to care if costs are too high, and who will make these decisions? Who will pay?

• At all locations, participants emphasized the importance of involving consumers in the development of a basic benefit package. Because consumers can articulate what services are necessary at various stages of life, their participation in the development of the plan could help contain costs. In the Phoenix community meeting, for example, participants wanted a basic plan that would vary based on age and gender, and that could be added to if desired. Participants at most meetings recognized that the current system does work for some, and allows for a richer benefit than might be available otherwise, but that it does not work for everyone. They expressed a desire to build upon the current system, changing it into something that is more inclusive and provides a level of care for all Americans. Everyone would contribute to this system based on their ability to pay. However, for those people who are unable to afford the cost, government subsidies should be provided to allow access to a basic package.
  
• In the San Antonio community meeting, participants expressed interest in an approach that would provide a basic level of care for everyone combined with personal responsibility.
  
• In a number of community meetings, including Lexington, Eugene, Sioux Falls, and Cincinnati, participants commented that the United States should learn from other countries that have covered all or most of their citizens.

The second structured question delved into how to define the specific level of benefits:

“It would be difficult to define a level of services for everyone. A health plan that many people view as ‘typical’ now covers these types of benefits, many of which are subject to co-payments and deductibles: preventive care, physicians’ care, chiropractic care, maternity care, prescription drugs, hospital/facility care, physical, occupational, and speech therapy, and mental health and substance abuse. How would a basic package compare to this ‘typical’ plan? Are there benefits that you would add or would take out?”

Although the discussion differed by meeting location, some common themes emerged:

• People at the community meetings frequently expressed strong support for increased focus on wellness and prevention services as part of “basic” coverage, rather than focusing only on treating sickness. According to participants at meetings throughout the country, individuals have a responsibility to be good stewards of their health and health care resources (preventive care/screenings/use of services). They also viewed an emphasis on wellness and prevention as a way to reduce health care costs, as discussed in the Financing section. According to these participants, disease management should also be a part of the focus. In the Internet poll, over 90 percent of respondents indicated that annual physicals and preventive care should be part of a “basic” or “essential” benefits package, a level of support that was similar to that for hospital stays, prescription drugs, and lab tests.

• Participants at meetings continually emphasized the importance of a strong education component in health care and the management of health. To be good stewards of their health, individuals need to be educated about wellness and prevention. People thought information about how to use health care better and more effectively was important, but not information on cost. Broader issues of general education also came up in some meetings. Participants talked about the importance of beginning early, in grade school, to focus on basic skills that are prerequisites to literacy and health literacy. Fargo meeting participants expressed a preference for “school-based health promotion programs” for those in kindergarten through grade 12.
  
• Individuals voiced support for a fairly comprehensive basic benefit design. Benefits that a number of participants in meetings throughout the country viewed as important components of a basic benefit package included—but were not limited to—dental care, vision, hearing, care by non-physician providers such as nurse practitioners, long-term care, mental health, and hospice care. Some meeting participants also desired coverage of complementary and alternative medicine (for example, acupuncture).
  
• Although many participants recognized the need to do more to ensure that the health care provided is appropriate and delivered efficiently, they were also concerned about arbitrary limits on coverage and were not comfortable with bare-bones benefit packages. A participant in the Eugene community meeting made the point, “There’s a need for definition because we can’t afford it all.” Still, when pressed to make decisions about what services to drop from basic coverage, many respondents told the Working Group “None,” which was the most popular response in some locations.
  
• Despite the reluctance of many to limit benefits, participants at meetings supported limiting coverage to services to those that have proven medical effectiveness. They expressed a certain level of comfort with decisions that could affect utilization, if they were based on medical evidence. Just over half of the Internet poll respondents agreed (36 percent) or strongly agreed (15 percent) that health plans or insurers should not pay for high-cost medical technologies or treatments that have not been proven to be safe and medically effective, and nearly a quarter were neutral on the subject; responses in the March University town hall meeting were similar (see text box below), with 58 percent agreeing (36 percent) or strongly agreeing (22 percent).

• Participants expressed some level of support for the idea that some people could pay for additional services outside the basic benefit package. For example, in Kansas City, participants favored allowing individuals to purchase additional coverage of chiropractic care or fertility treatments. Charlotte participants were willing to pay more for an “a la carte” plan that would allow people to add services to the basic plan, which could vary by life phases and would be most cost effective for each age group. At virtually every meeting, attendees expressed concern about coverage for “futile” care at the end of life.

Results of the Internet poll question about the importance of including each of 23 specific benefits can be found in Appendix C (Question 4 of the Internet poll).

The next question in this section of the community meetings asked participants for their views on who should decide which benefits would go into the basic benefit package:

“How much input should each of the following groups have in deciding what is in a basic benefit package (federal government, state and/or local government, medical professionals, insurance companies, employers, consumers)?”

Some common themes emerged in response to this question:

• People wanted consumers to play an important role in deciding what should go into a basic benefit package. In meetings throughout the country, the majority of participants consistently answered that a combination of consumers, medical professionals, federal government, state and local government—generally in that order—should be responsible for having input into these decisions. Some participants indicated that employers and insurance companies should also play a role, but one that is more limited.
  
  In the majority of meetings, participants were asked, “On a scale of 1 (no input) to 10 (exclusive input), how much input should each of the following have in deciding what is in a basic benefit package?” When participants were asked the question in this way, the highest rating was always for input from consumers, and it was always followed by “medical professionals.” Responses to this question are illustrated in Figure 3.
  
  

  “Some new entity or process needs to be created that includes all the relevant stakeholders, the foremost of which would be the consumer.” “[There should be] a ‘quasi-governmental’ entity representing all groups, including us, the people.” “One way to organize this would be to create an entity very much like the Federal Reserve Board with appointed individuals who are professionals in their field and whose activities are generally public so it has to come under the Federal government but wouldn’t be the government as we generally think of it.” (Orlando meeting)

  
  In some meetings and on the Internet poll, individuals were asked which party or parties they would prefer to make the decision regarding what services are covered in the basic health insurance plan. At least 60 percent of Internet poll respondents and participants in the half dozen community meetings in which the question was asked this way chose the “some combination” option (of consumers, employers, government, insurance companies, and medical providers; the question did not identify which specific combination people preferred).
  
  In the Sioux Falls meeting, participants were also asked to rate the “degree of involvement” government, medical professionals, insurance companies, employers, and citizens should each have in determining what is included in a basic health care package using the scale: major role, minor role, and no role. Consistent with other findings, 88 percent of participants voted that citizens should have a “major role,” and 73 percent indicated that medical professionals should have a “major role.” Participants generally believed that government (72 percent) and employers (64 percent) should play a “minor role”; insurance companies received a mixed response, with 55 percent saying they should play a “minor role” and 42 percent saying they should play “no role.”

Figure 3:
On a scale of 1 (no input) to 10 (exclusive input), how much input should each of the following have in deciding what is in a basic benefit package?

• Participants in some meeting sites discussed a potential role for a local board or other quasi-governmental entity in defining the basic level of services. For example, participants in the Memphis community meeting strongly supported the concept of defining the basic level of service using a “grass roots” method through regional or state boards. In these discussions, participants emphasized the need for a publicly accountable body.
  
• Participants expressed the desire to be involved in the management of their own health care and were willing to accept some responsibility for their medical decision-making. Meeting participants felt that consumers played an important role in decision-making. This opinion was expressed both by individuals who sought a larger role for government and those who preferred that government have a limited role.

II. How does the American public want health care delivered?

In general, community meeting discussions of how the public wants health care delivered have been structured around two central questions. The first is discussed below:

“What kinds of difficulties have you had in getting access to health care services?”

Individuals at the community meetings discussed a number of problems they or their family members have had in getting access to health care services. Some common themes emerged that are summarized below.

• Affordability of care is a primary concern among participants. At meetings throughout the country, individuals discussed how costs had prevented them or others from getting needed care. Costs of care generally referred to their (or their family’s) costs, including co-payments, deductibles, and health insurance premiums, rather than system-wide costs. Participants in different cities indicated that the high costs of prescription drugs were a particular concern. Participants in the Salt Lake City meeting discussed how “people are being priced out.”

  National polls have shown that the cost of health care overshadow concerns about quality. In fact, almost three-quarters (73 percent) of those surveyed in a 2005 Gallup Poll said they were greatly concerned about cost, with no other item receiving even majority support.[4] Other surveys show that many American are concerned about not being able to pay medical costs for a serious injury or accident,[5] and almost one fourth of those responding to another 2005 national poll reported problems paying medical bills in the previous year.[6] Surveys have also found great concern about having families’ savings wiped out by the high costs often associated with end of life care.[7]

• Participants were troubled that many people did not have access to the health care they need. Access to care includes access to both facilities and health care providers, including specialists. Participants in community meetings nationwide highlighted problems with access to health care in rural areas, including lack of transportation to providers or facilities located far away. The lack of public transportation was brought up as an issue not only for rural areas, but for urban areas as well. Others described problems finding an accessible provider who was willing to accept their insurance, particularly Medicaid. Providers and facilities tend to be concentrated in suburbs and more populated areas. For example, in the Phoenix community meeting, individuals noted that most providers and specialists were concentrated in the Phoenix area, and it was difficult to access care in other areas of the state.

• Many participants cited complexity of the system as a contributing factor to the problems with the health care system. A number of issues related to complexity were discussed. Some participants noted that a lack of transparency in insurance coverage and reimbursement policies contributed to the problems. In the Memphis community meeting, the discussion of the complexity of the insurance system emphasized the problems created by multiple payers. Related to the concept of multiple payers, participants in the Denver community meeting discussed how the “labyrinthine scheme of Medicare and Medicaid” sets up a system especially hard to navigate by or on behalf of elderly patients. In the Providence, Philadelphia, and Sacramento community meetings, the new Medicare prescription drug benefit (Part D) was cited as an example of the complexity of the health care system.

• Linked to confusion about the health care system was the lack of useful information to help individuals navigate the health care system. Individuals wanted to have access to understandable medical information to help them make educated decisions about their health care. Many participants discussed their desire to partner with their health care provider in making health care decisions. Participants noted that sometimes it was very hard to find any information, although we also heard from some participants that information was available if one knew where to look. People often were not sure where to go to find what they needed. The desire for information is not unique to Working Group community meeting participants. According to a 2005 Gallup Poll, a slim majority (51 percent) of individuals said they do not have enough information about hospitals and other health care facilities to make educated choices for health care services.[8]

• Participants mentioned that they or others were not always treated with respect or dignity. Examples of problems people encountered included a lack of effective communication, discrimination by race or ethnicity, long wait times, and overcrowded emergency rooms. In a number of locations, meeting participants discussed how they had encountered or knew of barriers due to race or ethnicity, language, lack of cultural sensitivity, and lack of health insurance.

• Participants frequently cited barriers to care related to private health insurance. People in community meetings mentioned that they have experienced problems getting care due to health insurance rules. For example, some services were not covered due to preexisting conditions. Participants also discussed problems related to needing to go through an insurer’s gatekeeping requirements to receive referrals that sometimes were denied. A number of participants spoke of problems with the portability of health insurance under the current system.Within the employer-based health insurance system, someone who changes jobs might be forced to switch insurance and could lose access to their health care provider if that provider is not in the new network. Participants in the Billings community meeting noted that limited provider networks created access problems in Montana, a large but lightly populated state. In the Baton Rouge community meeting, participants noted that the experience from the hurricanes in the summer of 2005 brought to the forefront the need for major emergency preparedness in all aspects of the health care system, including among insurance providers.

The second question asked of community meeting participants about health care delivery relates to their priorities for getting needed care:

“In getting health care (choosing a physician, health care provider, or health plan), what’s most important to you?”

The responses to this question built on the answers to the previous question about problems getting care. The primary themes related to affordability, accessibility, and fairness.

• Participants told the Working Group that they want to feel secure knowing that when they or their families need care, they can get it without becoming impoverished. Discussants frequently mentioned that it was important that their out-of-pocket costs for health care not be unreasonably high. Participants said people should have to pay some amount, but they generally also said that patients of all income levels should be able to receive needed care without costs being a barrier.

• Participants wanted all Americans to be able to get the right health care, at the right time, in a respectful manner. Access for everyone emerged as a common theme across meeting sites. Some meeting participants said that receiving “the right health care” meant that medical decisions would not be based on factors such as a person’s age. Many participants decried making medical decisions on the basis of cost rather than medical need, they did want the care they receive to be delivered in a cost-effective manner. Participants expressed the need to have care received in a coordinated and timely manner. Among other factors, getting the right care in a respectful manner involved having a provider who was courteous and could communicate well. As stated in meetings from Charlotte to Seattle, participants believed that care should be sensitive to the needs of different cultures. The desire to be treated with respect has also been shown to be highly valued in other national surveys. A 2004 Wall Street Journal/Harris Interactive poll asked what qualities people believed were extremely important from the doctors that treat them; some of the most popular responses related to the medical provider’s interpersonal skills—such as being respectful (85 percent) and listening carefully to health care concerns and questions (84 percent).[9]
  
• Participants noted that being able to choose and maintain a stable, long-term relationship with a personal health care provider was critical. Individuals at meetings throughout the nation reiterated the importance of the provider-patient relationship that they believed should not be affected by whether a person switches jobs or changes health insurance. In the Phoenix community meeting, participants valued being able to choose a provider that would listen to them and provide “true” care, rather than just writing out a prescription. They wanted to be able to keep their health care provider even if they changed insurance carrier. In a number of locations (such as at the meetings in Orlando and Detroit), participants also discussed the importance of choosing a specialist. Participants at the community meetings told the Working Group that they placed a high value on having a “medical home” in which they can spend individual time with a provider. On the other hand, some participants at other meetings, such as San Antonio, expressed a willingness to forego some choice of primary care physician in exchange for lower costs or higher quality care.

• At the community meetings, individuals asked for a delivery system that is secure, transparent, easy to navigate, and treats the “whole person.” Having a continuing relationship with a personal physician is just one component of a stable system, according to the participants. Confidentiality of medical records was mentioned as another important component of a good health care system. Individuals expressed a desire for a system that is holistic, treating the whole person rather than just treating “a bundle of symptoms,” as described in the Denver community meeting.

III. How should health care coverage be financed?

Community meetings tended to devote a substantial amount of time to questions related to financing health care and controlling health care costs. The first of five questions that were commonly used in community meetings asks participants their opinion on whether everyone should be required to enroll in basic health care coverage:

“Should everyone be required to enroll in basic health care coverage, either private or public?”

Meeting participants had interesting discussions in response to this question:

• Although the results differed across meeting sites, a majority of participants (ranging from 55 percent to 88 percent in the community meetings) believed that everyone should be required to enroll in either private or public “basic” health care coverage. In each community meeting, over half of the participants supported the notion that everyone should be required to enroll in some form of basic health care coverage (Figure 4). Fewer than half (46 percent) of the Working Group Internet poll respondents agreed or strongly agreed with requiring everyone to enroll in health coverage, and another 21 percent said they were “neutral.” Over 80 percent in the University town hall meeting said everyone should be required to enroll in basic (public or private) health care coverage.

Figure 4:
Should everyone be required to enroll in basic health care coverage, either private or public?

Note: Los Angeles, New York, and Hartford are not included in this table. In the Los Angeles meeting, the responses were modified based on participants’ comments in the meeting. As a result, only 16 percent answered “yes” to the question, while 78 percent of the participants chose a third option that was offered by participants—that everyone automatically would have coverage under a national system, so, according to participants, the question was not applicable. For the same reason, the question was not completed in the New York meeting. In the Hartford meeting, the majority of participants abstained.

Several common themes emerged when individuals discussed why they supported requiring everyone to have health care coverage. Some participants expressed the opinion that those who are able should pay their fair share. At meeting sites throughout the country, individuals made the analogy to the law that requires everyone who drives to have automobile insurance. They believed that health coverage should be treated similarly since everyone uses health services. Additional analogies included laws requiring seat belt use and vaccinations, as expressed by meeting participants in Miami. Participants in community meetings in places such as Jackson and Denver that supported an “individual mandate” (in other words, a law requiring all individuals to have health insurance coverage) said it would be consistent with the philosophy of individual responsibility.

Although strong support for an “individual mandate” was found at each of the meetings, some participants disagreed. Others objected to the way the question was worded since they said it assumed implicitly that a national health care system would not exist. In fact, at the community meeting in Los Angeles, the vast majority of participants supported a new “third” option: that everyone automatically would have health coverage and access to care under a new national system. Participants who disagreed with the individual mandate concept expressed concerns that it would give greater power to the government and would undermine concepts of individual freedom. Someone at the Billings meeting noted, “[Montanans] don’t like to be told what to do.” Meeting participants also expressed uncertainty about how undocumented persons or non-citizens would be treated in the individual mandate system, with some saying these individuals should receive care, while others maintaining that non-citizens should not be entitled to coverage.

The next commonly asked question related to whether people should pay more for health care and, if so, whether the amount they should be required to pay should be influenced by income or other factors:

“Should some people be responsible for paying more than others? What criteria should be used for making some people pay more?”

• In almost every community meeting, a majority of participants supported the notion that some individuals should be responsible for paying more for health care than others. The most commonly mentioned criterion for paying more was income, but varying payment by income was supported by the majority of participants in fewer than half of the meetings where this question was discussed. (See Figure 5.)

However, in many community meetings, no consensus emerged regarding who should pay more, as shown in Figure 6.

• The most popular choice of criteria was income. In other words, those with higher incomes should pay more than those with lower incomes. Some participants argued that those with very low incomes should not have to pay anything for their care.
  
• The next most popular criterion often was health behaviors. Such a system could be structured either by reducing health insurance costs for those who practice healthy lifestyles (for example, exercising regularly, not smoking, wearing seat belts, etc.) or by increasing health care co-payments or premiums for those who practice unhealthy behaviors, such as smoking. (In three of the community meetings, the choice “other” was changed to “other/combination of factors,” which could include both income and health behaviors, as well as other factors.)

As with the previous question, some meeting participants expressed frustration with the way the question was worded and refused to answer. These individuals told the Working Group that they felt the questions implied continuation of the current delivery system. If a universal, possibly single-payer system were implemented, their argument went, these questions would be irrelevant.

Figure 5:
Should some people be responsible for paying more than others?

Note: This question was asked only in the above cities. In most meetings where this question was asked, participants were also asked which criteria should be used. In some meetings, however, only the question about criteria was asked. See the next question below.

Figure 6:
What criteria should be used for requiring some people to pay more?

Note: Figures may not add up to 100 percent due to rounding. Question was not asked in Kansas City, Seattle, Miami, Albuquerque, Hartford, Las Vegas, Eugene, Sacramento, San Antonio, New York, Lexington, or Cincinnati.

Over 80 percent of respondents in the University town hall meeting said that some people should be responsible for paying more for coverage than others, and about 71 percent said income should be used as a criterion for making people pay more.

On the Working Group Internet poll, there were multiple questions about how higher income people might pay more for coverage. Almost 40 percent (38 percent) of respondents agreed or agreed strongly that everyone should pay the same for health insurance; 38 percent agreed or strongly agreed that people with higher incomes should pay higher premiums for employer-sponsored health insurance, and 35 percent agreed or strongly agreed that higher income people should pay higher premiums for health insurance they buy themselves. The finding that higher-income people should pay more for health insurance they purchase themselves was similar across education levels of the people responding to the Internet poll. These findings may reflect the view, also heard at many meetings and in comments submitted via the Internet, that while there is support for higher contributions from higher-income people, there is less support for direct income-related cost-sharing or premiums than for contributions to a national coverage system through some form of progressive tax, as discussed below.

The following question generated substantial debate at many of the meetings:

“Should public policy continue to use tax rules to encourage employer-based health insurance?”

As shown in Figure 7, the percent of individuals who agreed with this question varied greatly from meeting site to meeting site. In the Detroit community meeting, only 23 percent of participants supported a continuation of the use of tax rules to encourage employer-based health insurance, while 87 percent of those at the Baton Rouge community meeting agreed with the policy. In a number of meetings, some participants abstained from answering the question, in many cases because of frustration with the way the question was worded, as was the case with the previous two questions. In five of the community meetings, an “abstain” option was provided to participants.

A different question, focusing on whether employers should be given additional incentives to expand coverage, was asked in both the Working Group’s Internet poll and the University Internet town hall meeting. Support for tax incentives for employer-sponsored coverage as a means of expanding coverage was relatively high. Almost 70 percent (69 percent) of Internet poll respondents and 61 percent of University town hall meeting respondents agreed or strongly agreed with the strategy.

Figure 7:
Should public policy continue to use tax rules to encourage employer-based health insurance?

Note: Question was not asked in Sacramento, New York, or Sioux Falls. * “Abstain” option provided.

Views about employer-based coverage did not generally reflect a deep distrust of employers, but instead were intertwined with broader concepts of health reform. The extent to which participants at a meeting may have been more heavily focused on fundamental reform, like a single-payer system, affected the group discussions about employer-based coverage. An analysis of Internet and mailed-in, open-ended responses to the question about changing the way health care is financed, as well as comments from participants at some community meetings, revealed at least four—sometimes overlapping—categories of responses.

• “The current system should be maintained or bolstered, either on an ongoing basis or as part of a more comprehensive system.” Some meeting participants supported a clear role for employers and a continuation of the current tax rules for employers. Some participants who supported retention of these tax rules argued that they needed to be applied fairly, with small businesses needing additional incentives. Meeting participants who supported comprehensive reform through some type of national plan told the Working Group that, in the absence of a national plan, employers would need to be responsible, with tax breaks provided to assist small businesses. Without a national plan, participants worried that people across the country would lose coverage through employers dropping insurance. In the community meeting in Los Angeles, participants who supported continuing the current tax system did so because they believed it encourages employers to provide coverage that they might otherwise not have an incentive to provide. They also felt that the system leads to higher employer productivity and helps promote shared responsibility.
  
• “Employer-based insurance is not sustainable and is too expensive.” Many participants felt the nation should move away from current tax rules. Even with the current tax breaks, health care costs continue to rise rapidly, and both businesses and employees are footing ever larger and unsustainable expenditures. Some meeting participants believed that the system of employer-based health insurance needs to be replaced to make U.S. industries more competitive. At least one person noted that the employer subsidies were invisible to the average citizen, unlike Medicare or Medicaid, whose costs are frequently cited. Other participants noted that they were afraid to leave their jobs because of fear of losing health insurance or paying higher premiums. Those who opposed the current tax breaks cited a lack of equity in the current employer-based insurance system, a system that, as long as it exists, means that health care, as stated by someone at the Indianapolis meeting, will be, “an imperfect patchwork full of gaps.”

• “The whole system should be changed fundamentally, but employers should contribute through some form of taxation or contributions to a pool.” Other participants indicated an interest in a non-employer based system, but one in which the employers are still involved. For example, in the Des Moines community meeting, a participant referred to the employment-based system as “…outdated and the money saved from not having an employer-based system could go towards higher salaries and/or taxes to create a new system.” Some participants at different meetings supported fundamental change to the system, but believed that a transition period should be implemented during which employers would still contribute to the system.

• “Employer-based insurance is unfair, inequitable, and inadequate.” A number of participants discussed other aspects of the employer-based system that were not working. For example, participants brought up the fact that some employers are going around the current tax system by hiring only part time employees, to whom they are not required to offer full benefits. In the Los Angeles meeting, many participants supported a government-run universal health care system because they felt that the current employer-based system is unfair. They expressed concerns that it excludes self employed, unemployed, and part-time workers, and favors large corporations. These participants supported replacing the employer tax incentive with another type of tax (such as an income or payroll tax). A large number of participants expressed the opinion that access to care should not be tied to insurance coverage.

“What should the responsibilities of individuals and families be in the health care system?”

Three of the most common answers heard by the Working Group in response to this question were the following:

• At most meetings, participants stressed the importance of preventive care to reduce health care costs. Preventive care includes getting important screenings, exercising regularly if possible, and following a healthy diet. Some individuals said that practicing preventive care would lower health care costs.
• Participants at most meetings believed that individuals have a responsibility to manage their own care and use of services. Participants told the Working Group that doing so involves educating oneself, possibly through attending health education classes. It also involves being proactive in seeking better care and becoming wise, informed consumers of health care services and following treatment regimens. However, a number of participants noted that some people are better equipped to be informed consumers than others.
• In many meetings, participants mentioned that individuals have a social responsibility to pay a fair share for health care. Participants in the Memphis and Las Vegas meetings, among others, mentioned that, in a universal health system, this would include paying appropriate and possibly additional taxes.

The Internet poll also shows some support for strategies that focus attention on the costs and appropriate use of health care. A majority of respondents either agreed (36 percent) or strongly agreed (19 percent) that we should all pay for part of our health care costs so that we will be more careful about how we use health care services.

The next “typical” meeting question asked participants about ideas for reducing the growth of health care costs in this country:

“What can be done to slow the growth of health care costs in America?”

Participants had a variety of ideas about how they would slow the growth of health care costs. Throughout the meetings, common themes emerged:

• Participants frequently stated that the problems of high costs rest with “price setters”—namely, prescription drug companies, insurers, and for-profit providers. In meetings throughout the country, participants mentioned the desire to limit profits in the health care sector. Some participants also noted that allowing the government broader authority to negotiate prices with pharmaceutical companies would reduce Medicare costs. The Internet poll showed strong support for government setting limits on prices for health care products such as prescription drugs or medical devices; just over 70 percent of respondents strongly agreed (40 percent) or agreed (32 percent) with these government-set limits. The general lack of trust of for-profit health care expressed in the community meetings is consistent with other national survey findings. For example, a December 2003 Wall Street Journal Online Health Care Poll found that most of the public do not view health care as a business that should be driven by the profit motive, and only 22 percent would prefer that for-profit insurance provide most health insurance; the findings indicated a preference for government (31 percent) or non-profit organizations (25 percent).10

• A commonly expressed view was that a simpler system would result in lower administrative costs. Participants believed that a more straightforward health care system would reduce administrative costs by eliminating duplication of services. At a number of meetings throughout the country, many individuals advocated a single payer system to eliminate the middleman, possibly one structured like Medicare or similar to the public school system. Under this type of system, everyone would pay taxes to support the system, even though, as with education, they might not use the services. Participants advocating the single payer concept said it would be the most efficient way to organize health care.
  
• Some support exists for investment by providers and the private sector in health information technology to increase system efficiency. At a number of meetings, participants supported increasing the availability of electronic medical records. Greater investment in health information technology and moving to an integrated system of electronic medical records could improve administration and treatment and reduce medical errors, according to views commonly expressed at the meetings. More than 70 percent (72 percent) of respondents to the Internet poll supported more investment by doctors, hospitals, and other providers in health information technologies as a means to improve quality and increase administrative efficiency. (By comparison, a 2005 Wall Street Journal Online/Harris Interactive poll found that 78 percent of the public supported doctors’ use of electronic medical records.[11])

A concern discussed at some meetings was privacy of the electronic medical records, which is highlighted in recent national surveys. For example, a 2005 Harris Interactive poll found that 70 percent of Americans are very or somewhat concerned that personal medical information might be leaked due to weak data security, and the public was evenly divided on whether the potential benefits of electronic medical records outweigh the potential risks to privacy.[12]

Public investment in health information technology was not identified as among the priorities for public spending on health and health care by most Internet poll respondents (see Appendix C).

• Participants expressed general support for individuals’ playing their part in controlling utilization and costs. Individuals have a responsibility to be informed health care consumers and comply with recommended treatments. To this end, participants suggested several related ideas:
  • Individuals would like information about how to use health care better and more effectively. For example, those with chronic diseases could use more information to properly manage their treatments.
  • At some meetings, participants supported providing incentives to patients to engage in healthy behaviors. Some participants supported the idea of rewarding people who practice healthy behaviors (for example, not smoking, or getting recommended health screenings). On occasion, participants also discussed the notion of penalizing people who engage in unhealthy lifestyles. The type of unhealthy behavior in question affected participants’ opinions, consistent with other national surveys. According to a 2005 Wall Street Journal Online/Harris Interactive poll, the majority of Americans supported the idea of smokers, those who do not wear seat belts, and those who drink alcohol heavily paying more in health insurance costs; however, the same poll found strong opposition for charging more to those who are overweight or who do not exercise regularly.[13]
  • Participants expressed preferences for using medical evidence to decide which services are covered and provided. Many participants discussed the importance of focusing on evidence-based medicine.
  • There was general support for controlling prescription drug costs by limiting direct-to-consumer advertising of prescription drugs and using more generic drugs. Participants at many meetings expressed the desire to limit or prohibit direct-to-consumer advertising of prescription drugs, which could reduce the over-use of heavily-advertised drugs and slow the growth of health care costs. Some people mentioned ideas to make generic drugs available more quickly in the market; for example, Orlando community meeting participants suggested reducing the length of time of the exclusive patent rights of pharmaceutical companies.

• Support also existed for limiting expensive yet “futile” end-of-life care and instead providing palliative care. Participants at meetings generally recognized the high costs associated with certain end-of-life services, some providing little value to the patient despite their high costs. At the same time, they stressed the importance of pain management, hospice care, and other support services to improve the quality of the last days of life. Better communication with patients near the end-of-life was considered to be an important step in controlling these costs. Participants in some meetings stressed the importance of living wills and medical directives that detailed people’s wishes for treatment if they were too ill to communicate. At many meetings, similar concerns were expressed about the effectiveness and costs of care for very fragile newborns.

• In almost all community meetings, participants expressed the belief that changing the culture from sick care to well care—namely, by focusing on prevention, wellness, and education (in general, and health education in particular)—will reduce health care costs. Participants broadly supported greater emphasis on prevention as part of a “culture of wellness” in the health care system. A number of participants in community meetings across the nation (including Des Moines, Fargo, Salt Lake City, Las Vegas, and others) emphasized the need for education of both children and adults to make this culture possible.
  
• A commonly expressed view was that better use of advanced practice nurses and other non-physicians could save money and improve quality. In some meetings, participants supported the increased use of care provided by health professionals other than physicians including greater use of home-based care.
  
• Participants believed that investing in public health would pay dividends in terms of reducing health care costs. Some people discussed providing more funding for community health centers and for public health more generally. They believed that doing so could reduce racial differences or disparities in health care, and could effectively reduce overall system costs.
  
• Support for limits on malpractice was expressed at some community meetings. Some participants discussed decreasing malpractice costs.

IV. What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high-quality health care coverage and services?

The last of the four questions that the legislation directed the Working Group to ask the American people is about trade-offs they are willing to make so that everyone has access to affordable, high quality care. In community meetings, the “typical” structure was to ask participants to discuss their willingness to pay to achieve this goal, evaluate the most important priorities for public spending on health care, consider specific trade-offs the public would be willing to make, and then to evaluate potential approaches for improving access to affordable, high quality health care for all Americans. In many meetings, time constraints or the desire by participants to reiterate their support for broad system reform precluded discussion of some of these questions.

Many comments submitted to the Working Group via the Internet provide additional context for understanding what we heard about tradeoffs. Although worded in a variety of ways, the single most common response to the question about trade-offs can be summarized as “No trade-offs.” The discussions at the community meetings provided context for what people really were saying, which is far more complicated.

The discussion at meetings was divided into several parts. One set of deliberations at the meetings focused specifically on paying for expanded coverage.

“How much MORE would you be willing to pay (taxes, premiums,…) in a year to support efforts that would result in every American having access to affordable, high quality health care coverage and services?”

• In most meetings as well as on the Internet poll, a majority of participants expressed a willingness to pay more to assure that everyone had access to affordable, high quality health care. Overall, about one-third said they were willing to pay $300 or more per year. Sizable shares of participants expressed a willingness to contribute some additional amount each year toward the stated goal. (See Figure 8.) Although the size of the groups varied, some participants at all meetings said they would be willing to pay an additional $1,000 or more in a year. The Internet poll indicated that 12 percent would be willing to pay $1,000 or more per year (in taxes, premiums, or deductibles) to support efforts that would result in access to affordable, high quality health care services and coverage for all, and 18 percent would be willing to pay an additional $300 to $999. Another 19 percent said they did not know, and 12 percent said they would not be willing to pay anything extra. In the Internet poll, the amount they were willing to pay was fairly consistent across age; however, persons with the highest levels of education (those with graduate degrees) were more likely to be willing to pay $1,000 or more than those with less education, a finding that could indicate that those likely to have more money are willing to pay more. It may also reflect that those with higher levels of education typically have richer employer-sponsored insurance packages, face lower out-of-pocket payments, and therefore have not already reached their limit in terms of willingness to pay. At the meeting with realtors (see “Hearing from self-employed small business owners” text box presented earlier), where few have any employer-sponsored insurance and face high premiums in the individual market, a large percentage were not willing to pay anything more, even though they earn relatively high incomes. Even so, in the 28 meetings where the question was asked, at least 43 percent of participants indicated some willingness to pay more to achieve this goal.

Figure 8:
Amount Willing To Pay in a Year So That Every American Has Access to Affordable, High-Quality Health Care

Notes: Figures may not add up to 100 percent due to rounding. Question was not asked in the Seattle, Miami, or Sacramento community meetings.

The next question asked the public about its views on what should be the most important priority for public spending for health care:

“Considering the rising cost of health care, which of the following should be the most important priority for public spending to reach the goal of health care that works for all Americans?”

At community meetings throughout the country, participants were asked to consider a list of possible priorities for public spending to reach the goal of health care that works for all Americans. In some of the meetings, participants were asked to give the most important priority of those listed, while in other meetings participants were asked to rate each priority on a scale from 1 (low) to 10 (high). The list presented at the meetings generally included the following items: guaranteeing that there are enough health care providers, especially in areas such as inner cities and rural areas; investing in public health programs to prevent disease, promote healthy lifestyles, and protect the public in the event of epidemics or disasters; guaranteeing that all Americans have health insurance; funding the development of computerized health information; funding programs that eliminate problems in access to or quality of care for minorities; funding biomedical and technological research; guaranteeing that all Americans get health care when they need it, through some form of public or private program, including “safety net” programs for those who cannot afford care otherwise; and preserving Medicare and Medicaid.

Although the phrasing of the question and the options given were not exactly the same across the community meeting sites and the Internet poll, the highest priority was consistent:

• When asked to rank or choose among competing priorities for public spending on health, individuals—with few exceptions—were most likely to rank “Guaranteeing that all Americans have health coverage/insurance” as the highest priority.
  
• Other spending priorities in the list that tended to score high included:
  • Investing in public health programs to prevent disease, promote healthy lifestyles, and protect the public in the event of epidemics or disasters;
  • Guaranteeing that all Americans get health care when they need it, through some form of public or private program, including “safety net” programs for those who cannot afford care otherwise;
  • Guaranteeing that there are enough health care providers, especially in areas such as inner cities and rural areas; and
  • Funding programs that eliminate problems in access to or quality of care for minorities.

It is important to note that each of the eight options provided by the Working Group likely would receive support from the public if polled separately, even if it did not rank as the highest priority among the group. For example, “funding the development of computerized health information” and “funding biomedical and technological research” generally did not rank amongst the highest priorities, though discussions at Working Group meetings frequently emphasized their importance. Similarly, individuals selecting other options as most important (such as “guaranteeing that all Americans have health insurance”) would likely be in favor of strengthening Medicare and Medicaid as part of the broader health care structure that would cover all Americans.

It is also important to note that support for any of the particular proposals could change dramatically when the list of potential priorities was modified, as occurred in two meetings. In the Hartford meeting, where participants were asked, “Which is your first priority?” Discussants there added a ninth priority to the list: “Guaranteeing that all Americans have quality health care.” When this option was included in the list of options, a full 80 percent of participants selected it rather than the options ranked highly elsewhere. For example, although the option, “Guaranteeing that all Americans have health coverage” ranked as the second highest priority in the list, it was selected by only 8 percent of participants. “Guaranteeing that all Americans get health care when they need it” also was selected by 8 percent of respondents, and no other option generated more than one vote. Similarly, in the Billings meeting, audience members requested a word change of one of the choices to include “Guaranteeing that all Americans have health care.” In this meeting, participants were asked to rate each priority on a scale from 1 (low) to 10 (high). When this option was added, it ranked higher than any other option.

The next question often asked at community meetings was met with resistance at most meetings, sometimes by many of the participants:

“Some believe that fixing the health care system will require tradeoffs from everyone—for example, hospitals, employers, insurers, consumers, government agencies. By ‘tradeoff’ we mean reducing or eliminating something to get more of something else. On a scale from 1 (strongly oppose) to 10 (strongly support), please rate your support of each of the following trade-offs. What are some other examples of trade-offs that you would support?”

In many of the meetings, the Working Group provided a list of specific trade-offs for participants to evaluate:

• Accepting a significant wait time for non-critical care to obtain a 10 percent reduction in health care costs;
  
• Paying a higher deductible in your insurance for more choice of physicians and hospitals (or paying a lower deductible with less choice);
  
• Paying more in taxes to have health care coverage for all. This could mean limiting coverage to high deductible/ catastrophic care or, if you were willing to pay more, a more comprehensive package;
  
• Expanding federal programs to cover more people, but providing fewer services to those currently covered in those programs;
  
• Limiting coverage for certain end-of-life care of questionable value in order to provide more at-home and comfort care for the dying;
  
• Having government define benefits and set prices versus relying on free market competition by doctors, hospitals, other health care providers, and insurance companies.

In a number of meetings, participants voiced support for limiting coverage for end-of-life care of questionable value in order to provide more at-home and comfort care for the dying. This option received strong support in both the Working Group Internet poll and the University town hall meeting—61 percent and 63 percent, respectively, agreed or strongly agreed with the proposal. The proposal generally receiving the lowest level of support was “expanding federal programs to cover more people, but provide fewer services to persons currently covered by those programs.” In the Working Group Internet poll, for example, only 17 percent of respondents agreed or strongly agreed with this proposal. In the University town hall meeting, 24 percent agreed or strongly agreed.

Individuals at many, if not all, community meetings argued that there were enough resources in the system already to achieve a goal of health care that works for all Americans, that resources just need to be redistributed. Most, however, did not think that the resources needed to be redistributed away from services provided to them; rather, they wanted to see reductions in waste, fraud, and (unnecessary) profit. In other cases, participants thought that the tradeoffs should come from outside the health arena. For example, at the Los Angeles community meeting, participants developed and voted on their own list of specific tradeoffs they would be willing to support. The only two choices that garnered majority support were: (1) No tradeoffs—the American people already pay more than enough to fully fund a single payer universal plan; and (2) Trade war for health care—cut from defense and homeland security budgets. In Las Vegas, the participants opted for “re-evaluating federal spending priorities.”

Despite the resistance to this particular question, the meeting participants did discuss various tradeoffs (without using that term) in previous sections of the meeting. For example, as noted above, many participants expressed a willingness to pay more so that everyone had care. Many participants also told the Working Group that individuals should play a larger role in their health and health care. More than one in three people filling out the Working Group’s Internet poll said they would be willing to pay a higher deductible in exchange for more choice of provider and services. This level of support for a trade-off of out-of-pocket costs for choice was actually slightly higher than the 2004 National Opinion Research Center at the University of Chicago (NORC) national survey finding that 27 percent of respondents would be willing to accept a higher deductible in exchange for fewer restrictions on use. The NORC results varied by income: 40 percent of Americans with household income of $75,000 or more would accept a higher deductible, compared with 23 percent with income below $25,000.[19] The Working Group was not able to analyze the relationship of income to its participants’ responses.

The final substantive question at meetings asked people for their opinions on a range of fairly specific yet broad proposals for ensuring access to affordable, high quality health care coverage and services for all Americans:

“If you believe it is important to ensure access to affordable, high quality health care coverage and services for all Americans, which of these proposals would you suggest for doing this?”

As with the previous question, participants at the community meetings were asked to evaluate a list of proposals. In this case, participants were asked to evaluate ten proposals on a scale from 1 (low) to 10 (high). Proposals included: offer uninsured Americans income tax deductions, credits, or other financial assistance to help them purchase private health insurance on their own; expand state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program (SCHIP), to provide coverage for more people without health insurance; rely on free market competition among doctors, hospitals, other health care providers, and insurance companies rather than having government define benefits and set prices; open up enrollment in national federal programs like Medicare or the federal employees’ health benefits program; expand current tax incentives available to employers and their employees to encourage employers to offer insurance to more workers and families; require businesses to offer health insurance to their employees; expand neighborhood health clinics; create a national health insurance program, financed by taxpayers, in which all Americans would get their insurance; require that all Americans enroll in basic health care coverage, either private or public; and increase flexibility afforded states in how they use federal funds for state programs—such as Medicaid and SCHIP—to maximize coverage.

As with the question on priorities for public spending, preferences varied somewhat in different meetings and on the Internet poll. Once again, however, a clear consensus emerged amongst these options:

• When asked to evaluate different proposals for ensuring access to affordable, high quality health care coverage and services for all Americans, individuals at all but four meetings ranked “Create a national health insurance program, financed by taxpayers, in which all Americans would get their insurance” the highest.
  
• Three other options almost consistently ranked in the top four choices at the community meeting locations and in the Internet poll:
  • Expand neighborhood health clinics;
  • Open up enrollment in national federal programs like Medicare or the federal employees’ health benefits program; and
  • Require that all Americans enroll in basic health care coverage, either private or public.

These options received high levels of support, in the community meetings as well as the Internet poll. The support for neighborhood health clinics and for opening up enrollment in Medicare or the federal employees’ health benefits program was consistently high and in line with the strong support for the Medicare program that was expressed in meetings across the country. The responses to both the Working Group Internet poll and the University town hall meeting were similar to each other, as shown in Figure 9 below. There was, however, stronger support for expanding state programs such as Medicaid or SCHIP in the poll and the University town hall meeting than in the 31 community meetings. The level of support in the Internet poll and University town hall meeting for opening enrollment in national programs such as Medicare or the federal employees’ health benefits program was in line with a 2005 national survey by the Employee Benefit Research Institute that found 76 percent strongly or somewhat favor allowing uninsured people to buy into government programs such as Medicare and Medicaid, or into the one in which members of Congress participate.[20]

In the community meetings, the individual mandate (in other words, requiring that all Americans enroll in basic health care coverage, either private or public) was included as one of the options. Regardless of when in the meeting the question was asked, this option had a fairly high level of support, although the explanation of the concept differed from discussion to discussion. This option ranked third in popularity in the University town hall meeting, and, in several community meetings, it ranked higher than all other options. However, its support in the Working Group Internet poll was below 50 percent.

Figure 9:
Responses to Tradeoff Questions on Working Group Internet Poll and from University Internet Town Hall Meeting

The open-ended comments submitted to the Working Group provide some additional insight into how people view the health care system, how they want it changed, and what tradeoffs they are willing to make. More than 4,000 people (4,075 through May 9) wrote responses, sometimes fairly long, to the general questions on both the Internet as well as on paper forms sent to the Working Group.

In general, responses to the open ended question about paying for health care were very similar to responses to the questions regarding tradeoffs and recommendations. There are comments from a small number of individuals who are strongly opposed to major changes to the current system or to any changes that would increase the government’s role in health care, but these were not the typical comments we received or what we heard in meetings or from the Internet poll.

As illustrated in Figure 10, analysis of the comments shows that when asked about what kinds of changes should be made to the way we currently pay for care, most wrote about the need for a single health care system. We know from the comments submitted as well as the discussions at the meetings that the notion of a single health care system means a number of different things to different people. For some, the most important issue clearly was the need for a government-run program. For others, it was an administratively simple program that would be available to everyone but provided in the public and private arenas. Among the 1,841 respondents who wrote about the need for a single health care system in response to an open-ended question about how health care should be financed, 46 percent recommended a single payer system, while 27 percent discussed national health care and 14 percent discussed universal health care. The remainder discussed the ideas of universal Medicare, universal coverage, universal basic care, or universal access.

Figure 10:
Our current way of paying for health care includes payments by individuals, employers, and government. Are there any changes you think should be made to this system?

And, while a minority expressed the view that market reforms and advancements in technology could help to control costs and lead to better access to care, most of the people we heard from want more fundamental change.

The same notion—the need for a single national health care system—dominated the responses to the final question that asked people for the single most important recommendation for improving health care for all Americans. See Figure 11.

Figure 11:
What is your single most important recommendation to make to improve health care for all Americans?

There is a great deal of diversity in the ways people envision a reformed system. They believe this can be accomplished, and most believe that the resources are already there in our current system to achieve this goal. A selection of sample comments is provided below.

Endnotes

1 ”Kaiser HealthPoll Report Featured Topic (September/October 2004). Source data from the Kaiser Family Foundation Health Insurance Survey, 2003, conducted April 30-July 20, 2003 among 2,507 adults ages 18-64.

2 Wall Street Journal Online/Harris Interactive Poll of 2,242 U.S. adults, conducted online by Harris Interactive September 6-12, 2005. See The Wall Street Journal online (October 20, 2005), “Poll Shows Strong Public Support For Range of Health Practices.”

3 The New York Times/CBS News Poll of 1,229 adults, conducted January 20-25, 2006.

4 Gallup Poll of national random sample of 1,010 U.S. adults age 18+, conducted in September 2005. See The Gallup Poll (November 1, 2005), “Healthcare Panel: Costs More Troubling Than Quality.”

5 CBS News/New York Times Poll of 1,111 adults, conducted June 10-15, 2005.

6 USA Today/Kaiser Family Foundation/Harvard School of Public Health: Health Care Costs Survey (August 2005) conducted by telephone by ICR/Harvard University between April 25 and June 9, 2005, with 1,531 adults age 18 and over responding.

7 Lake Snell Perry & Associates national poll of 1,002 adults conducted August 30—September 1, 2002. See Journal of Pain & Palliative Care Pharmacotherapy, Vol. 17(2) 2003.

8 Gallup Poll of national random sample of 1,010 U.S. adults age 18+, conducted in September 2005. See The Gallup Poll (November 22, 2005), “Healthcare Panel: More Information, Stat.”

9 Wall Street Journal Online/Harris Interactive Health-Care Poll of 2,267 U.S. adults conducted online by Harris Interactive between September 21 and 23, 2004. See The Wall Street Journal online (October 1, 2004), “Doctors’ Interpersonal Skills Valued More than Their Training or Being Up-to-Date.”

10 Wall Street Journal Online/Harris Interactive Health-Care Poll of 2,587 U.S. adults conducted online by Harris Interactive between November 13 and 17, 2003. See The Wall Street Journal online (December 4, 2003), “Most People Uncomfortable with Profit Motive in Health Care.”

11 Wall Street Journal Online/Harris Interactive Health-Care Poll of 2,048 U.S. adults conducted online by Harris Interactive September 30-October 4, 2005. See Harris Interactive (October 14, 2005), “New Poll Shows U.S. Adults Strongly Favor and Value New Medical Technologies in Their Doctor’s Office.”

12 Harris Interactive telephone survey of 1,012 Americans age 18+ between February 8-13, 2005. See Alan F. Westin testimony at the hearing on privacy and health information technology (February 23, 2005) www.patientprivacyrights.org, under News Room.

13 Wall Street Journal Online/Harris Interactive Health-Care Poll of 2,007 U.S. adults conducted online by Harris Interactive between December 12-14, 2005. See The Wall Street Journal online (January 6, 2006), “Kicking a Bad Habit Could Pay Off.”

14 Lake Snell Perry & Associates national poll of 1,002 adults conducted August 30—September 1, 2002. See Journal of Pain & Palliative Care Pharmacotherapy, Vol. 17(2) 2003.

15 Gerstein/Agne. Survey Report, national survey of 1,104 adults, November 15-22, 2005.

16 The Pew Research Center for the People and the Press (May 10, 2005). “Beyond Red vs. Blue.” The 2005 Political Typology Survey is a national telephone interview sample of 2,000 adults age 18 and over; the Typology Callback Survey conducted in March 2005 obtained 1,090 respondents from the initial December 2004 survey. The national sample of 1,284 adults in the 2003 survey was conducted by Princeton Survey Research Associates between July 14 and Aug 3, 2003.

17 Kaiser Family Foundation, Harvard School of Public Health (November 2004). “Health Care Agenda for the New Congress Survey.” National sample of 1,396 adults between November 4 and 28, 2004.

18 ABC News/Washington Post Poll, with a national sample of 1,000 adults, was conducted from October 9-13, 2003.

19 NORC at the University of Chicago survey, implemented by International Communications Research (ICR), of random sample of 2,024 respondents between August 4-10, 2004. Schur, CL, Berk, ML, and Yegian, JM. (November 10, 2004). “Public Perceptions Of Cost Containment Strategies: Mixed Signals For Managed Care.” Health Affairs Web Exclusive: W4-516 – W4-525.

20 Mathew Greenwald & Associates, Inc., and Employee Benefit Research Institute (August 9, 2005). “2005 Health Confidence Survey: Wave VIII, June 30-August 6, 2005.”