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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:


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?

Detailed Description of Findings


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)

Figure 1: Most important reason to have health insurance (data in App. B)

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?

Figure 2: 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.

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?

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:

“All people should have the same coverage that the President, Vice President, and Congress have…”
(Phoenix meeting)

“We agree that there should be a basic level of services for everyone- everyone has a right to that care. But our concern is that neither of those- what we have now, or a basic plan for everyone - will work until it’s a consumer-driven choice and not a corporate solution that values profits above everything else. The consumer should be driving the choices- not like the way the culture is now. There should be more of a balance.”
(Charlotte meeting)

“Every citizen has a basic right to have basic health care, and it can’t be based on the type of job they have.
(Salt Lake City meeting)

University Virtual Town Hall Meeting:
“A National Conversation on Health Care”

On March 22, 2006, 22 universities participated in a simultaneous discussion on health care. Sponsored by the Big Ten Conference and the Association of Schools of Public Health, and hosted by the University of Michigan, this virtual town hall meeting provided a forum for individuals across the country to voice their opinions on health care.

Broadcast via satellite from the University of Michigan, individuals participated in this event either by gathering at various university sites, or by logging onto the forum through the Internet. Interactive technology allowed various locations to call in with questions and comments, and individuals submitted their feedback through email to be read during the live event. The 21 simultaneous meetings held in addition to the host meeting were organized by their respective university communities, and followed the same format. Participants at these meetings received the standard Community Meeting Discussion Guide and a Health Care Poll, specific to this event, which included the majority of questions asked on the Working Group’s own Internet poll (as well as in many of the Working Group Community Meetings). The separate meetings also had access to a local faculty expert who assisted in sending comments and questions to the national coordinator at the University of Michigan. After the event, the completed Health Care Polls were coded (772 from 22 of the webcast sites) and entered into a data set that was made available to the Working Group for analysis (See Appendix D for a complete summary of the results). Participating schools were:

Boston University Purdue University
Drexel University Tulane University
Emory University University at Albany
George Washington University University of Arkansas
Indiana University University of Illinois
Johns Hopkins University University of Iowa
Louisiana State University University of Louisville
Michigan State University University of Michigan
Northwestern University University of Minnesota
Ohio State University University of South Carolina
Penn State University University of Wisconsin

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:

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?

graphic: Fig. 3 table; link to tabular data

Mental Health Meeting

At its Boston meeting in August 2005, the Citizens’ Health Care Working Group heard from a panel made up of the Director of Mental Health Services for Massachusetts, a representative from a managed behavioral health care plan and an advocate for the mentally ill. As members of the Working Group attended other community meetings, they heard how access to mental health services was a significant issue to many participants. In order to delve more deeply into issues related to mental health, the Working Group sponsored a meeting focused on this topic in Atlanta, Georgia on May 22, 2006, at Skyland Trail, a mental health facility which offers long- and short-term residential care and community-based therapy, with the National Mental Health Association of Georgia as a host.

The participants at this meeting were knowledgeable about mental health. They included providers and consumers of mental health services, family members and advocates for the mentally ill and other health care providers. The meeting format was a mix of questions used at other community meetings and questions specific to mental health.

Attendees believed that the value most fundamental to a health care system “that works for all Americans” is universal access, with health care as a right. Other important values are affordability and equal quality of care for all. In considering what was most important to the delivery of mental health care services, universal access was also the most important value, accompanied by integration of mental health into primary health care, parity for mental health care and eliminating the stigma attached to mental health.

The issue participants believed most important to address in getting mental health care services is the lack of parity in insurance treatment of mental illness. Other problems that are priorities for action include the need for more funding for mental health services, the stigma associated with mental health conditions, continuity of care and the need for education to help people “know what is wrong and where to go for help.” The inappropriate criminalization of mental health behaviors was also identified as a problem.

When asked about the delivery of mental health services within the overall health care system, a majority of attendees embraced this vision which was developed by one table of participants:

A comprehensive delivery system through primary care to include addictive disease, mental illness and all other physical illnesses with:

  • Education for all providers on mental illness;
  • A robust referral system; and
  • Access to services driven by consumer choice.

Ultimately, attendees wanted a system of “any door” access to services where dollars follow the consumer, and there is a focus on wellness recovery and resiliency.


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.

“More than anything at our table we have been talking about the cost of the health care – cost is keeping people from getting the care.”
(Phoenix meeting)

“We want health care delivered equitably at the community level by people we trust.”
(Memphis meeting)

“We have rural areas here in Indiana where you can’t even get a paramedic.”

“We have lost time-intensive care. Providers right now don’t have time to spend with us! You only get two minutes with your doctor.”

“Culturally competent care-funding to encourage more minority physicians and providers. If I want an African American dermatologist, I have to search high and low.”
(Indianapolis meeting)

“You can’t get through this system without luck, a relationship, money, and perseverance.”
(Salt Lake City meeting)

“Care should be delivered at the most local level possible.”
(New York meeting)

Consolidated Tribal Health Project, Redwood Valley, California

“I don’t have money to get my kids milk and you want me to take them to the dentist?”

“Society preaches prevention—but a doctor isn’t going to see this young lady’s kids for preventive care. She might get in at a walk-in clinic, but what’s the quality of care? Is the waiting room safe? Is the provider credentialed? Are they culturally sensitive to your needs? We get referred to the outside world where they assume you can read and write and just have you signing forms and don’t take the time to explain it to you.”

Native Americans (both tribal and non-tribal members) met in Redwood Valley on April 20, 2006, at the Consolidated Tribal Health Project to provide an open, honest, and often emotional insight into the barriers they face in accessing even basic primary medical, mental and dental health care. Participants expressed their desire for everyone to have access to health care, both in terms of geographic distance and ability to access providers.

They felt that “health care is not a privilege, it’s a right and we don’t receive that right…not only as Native Americans, but as rural citizens.” Individuals addressed the issue of access as a multi-pronged problem. One woman said “When they can afford to purchase gasoline, their tires are in good shape, and they aren’t in too much pain, they can make the long drive for care.” If the primary care reveals a need for specialty services, they face an even greater hurdle.

Individuals talked about how they valued culturally competent care with providers who took the time to explain medical terminology and did not assume literacy. One person noted that “[health] professional people are so professional that they don’t know how to relate to us nobodies. They don’t know how to tell us the simple things.” Participants at this meeting emphasized the importance of the government recognizing its duty to the Native American population and honoring the trust relationship that is established in law.

Mississippi Listening Sessions

Eleven listening sessions organized by faculty of the Mississippi State University Extension Service were conducted between March 21, 2006 and April 20, 2006. These sessions were held across the rural areas of the state and included a diverse mix of geographies and cultures. Altogether, 138 people participated in the sessions. The majority of participants were college graduates, many with post-graduate education, and most had some form of health coverage. Many of the participants were health care providers or administrators, or business people actively involved in their communities, and most were knowledgeable about the problems facing low-income and underserved rural Mississippi communities. A major thought expressed across the rural sessions was that many problems with the health care system in rural areas tend to be very different from those found in more urbanized areas. Lack of physicians and other health care professionals, distances to services, transportation issues, high cost, and lack of insurance were strongly recurring themes across the state.

Across the sessions, values regarding affordability and quality of care ranked highest among participants. Accessibility ranked third in urgency, but the total number of specific issues related to this concept dominated the discussion. Choice of care rounded out the list of values articulated at the sessions.

Those observing the sessions noted that there were marked differences in the views expressed in the meetings, reflecting at least in part, differences in culture, but also the recent major devastation caused by Hurricane Katrina. Participants from the state’s southern regions, hardest hit by the storm, talked about problems they still face getting health care. Doctors left and patient records were destroyed or disappeared. And when some doctors attempt to return, they are finding that their patient base is scattered and possibly gone for good. Concerns were also expressed in the other regions of the state focused on the influx of Katrina and Rita evacuees (many of these evacuees are either uninsured or are covered by Medicaid) and the accessibility barriers that these people faced. Other storm concerns involved the lack of generators for respirators and difficulty accessing medication. One person who became the guardian after the storm of a 3-year old child who is covered by Medicaid seemed overwhelmed: “I don’t know what to do or how to access the system.” Another left the same session highly distressed contending that, in light of this system’s inability to quickly respond to Katrina, we had no business focusing on health care issues that will take years to address, and that we should instead focus our attention on the possibility of other natural disasters, a potential pandemic, or a bioterrorist attack.

In other sessions, people talked about more pervasive problems, including delays in the ability to schedule an appointment, and physicians who are unwilling to accept Medicaid or Medicare patients. Problems related to communicating with the system led one participant to advocate the establishment of patient navigators. One session in Hattiesburg focused on small businesses’ and independent contractors’ inability to secure reasonable group rates; it was mentioned that 28 percent of National Association of Realtors members have no health care coverage.

Most participants (78 percent) agreed with the statement, “It should be public policy that all Americans have affordable health care.” Compared to other meetings, however, participants expressed a stronger interest in focusing on personal responsibility (including taking advantage of educational opportunities) to improve health care and control health care costs, investing in public health infrastructure, and expanding safety net programs in order to ensure access to care. There was also a greater emphasis on expanding existing public programs and bolstering the employer-based health care system to address gaps in coverage, rather than initiating new programs or making fundamental changes to the health care system. The most resounding dialogue the group facilitators recalled at all the sessions focused on the availability of health care services.

“It’s so complex. You wake up one day and your contract has been renegotiated, your numbers have changes, and your providers have changed. There are too many rules and too much bureaucracy to go through.”
(Las Vegas meeting)
“It’s often more stressful to deal with the insurance company than it is to deal with the disease.”
(Des Moines meeting)

“There should be no waiting period before becoming eligible for coverage.”
(Lexington meeting)

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.

“I feel like we are only as good as our weakest link, and so many people can’t afford care.”
(Fargo meeting)
“When you change insurance, you should be able to keep your doctor.”

“Primary care doctor—I like that relationship and I don’t want to see that go away.”
(Charlotte meeting)

“It is an accident of history that medical insurance is attached to the place of employment, only to be lost or changed if jobs change or are lost.”
(Comments submitted to CHCWG Internet “What’s Important to You?”)

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:

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

graphic: Fig. 4 table; link to tabular data

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.

“Enrolling everyone in a single pool would spread costs and yield savings.”
(Providence meeting)

“There should be progressive rates for health care, based on ability to pay, through income taxes, as part of a single payer system.”
(Hartford meeting)

“All individuals should carry their own health insurance as they do for car and property. Insurance companies should be forced to insure individuals rather than corporate entities and employer groups.”
(Comments submitted to CHCWG Internet “What’s Important to You?”)

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.

Younger Americans Weigh in on the Issues

Over 100 students in an undergraduate public health class at Purdue University participated in the University town hall meeting as part of a class assignment. They completed the University town hall poll, and explained their responses to questions about policy options in essay questions.

Compared to older respondents, the students were less likely to describe the health care system as being in a state of crisis (6 percent) or having major problems (61 percent). Most (88 percent) agreed or strongly agreed that it should be public policy that all Americans have affordable health care insurance or other coverage, and most (72 percent) said coverage should be provided for everyone, for a defined level of benefits. The students also opted, by a majority of 70 percent, for mandatory enrollment in some form of public or private coverage.

The majority (57 percent) thought some people should be responsible for paying more for coverage than others, with respondents most likely to state that the criteria for paying more should be either health behaviors or income. The most important priorities identified by the students for public spending on health and health care in America were guaranteeing that all Americans get health care when they need it through some sort of private or public program and investing in public health programs to prevent disease, promote healthy lifestyles, and protect the public during epidemics and disasters.

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?”

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

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?

graphic: Fig. 5 table; link to tabular data

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?

graphic: Fig. 6 table; link to tabular data

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?

graphic: Fig. 7 table; link to tabular data

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.

“I do believe all employers large and small should give their workers insurance. There should be programs or better tax cuts for those employers.”

“[Expand] tax incentives for companies that provide health care benefits for their employees. Small companies should be able to join together to take advantage of group rates. Corporations like Wal-Mart should be penalized for not providing decent health care benefits for its employees.”

“If employers are to continue to provide coverage, all employers must participate, nationwide.”

"I think that placing the burden of health care on employers makes American businesses less competitive in the global market. At the same time, I think that placing the burden of paying for health care on individuals will ultimately drive up the cost of care by forcing the poor and middle-income among us to rely on costly emergency services that hospitals cannot ethically deny based on inability to pay, rather than cheaper preventive care which they can."

“We must sever the relationship between health insurance and employment. Employers should not bear the cost; it is impacting our competitiveness in the global market and it leaves huge gaps in which persons not employed in a company providing health insurance, are forced to bear huge costs of non-group insurance or, most likely, go without insurance at all. The rising percentage of uninsured is a tragedy in itself because these people frequently go without needed health care until they reach crisis. In addition, we all pay for the uninsured through higher and higher insurance premiums. Our system must be completely overhauled and redesigned to provide universal coverage with buy-in by all who have the means and a safety-net for those who can not.”

(Comments submitted to CHCWG Internet “What’s Important to You?”)

"We need to have one single pool of Americans who are insured. This would help spread their risk and everyone could be covered. Employers could contribute to the costs, but individuals should be able to contribute on their own."
(Comments submitted to CHCWG Internet “What’s Important to You?”)
“Employer-sponsored insurance worked when it was a perk, an extra offered by employers. But now coverage is a necessity, not a privilege.”
(Billings meeting)


At some meetings, participants were asked what the responsibilities of individuals and families should be in a health care system. Although some of these topics will be discussed under the next question typically asked in community meetings (“What can be done to slow the growth of health care costs?”), the following section provides a brief summary of three of the most common responses to the question:

“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:

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.

Hearing from self-employed small business owners

The National Association of Realtors hosted a community meeting during their annual legislative conference on May 16, 2006, in Washington, DC, to enable the Citizens’ Health Care Working Group to hear from these self-employed small business owners from around the country. Participants at this meeting sought to identify solutions for the problems specific to self-employed small business owners. They recognized that more than one in four of the nation’s 1.2 million realtors have no health care coverage, while many others are only a single health incident away from having their livelihood destroyed by high health care costs.

Recurring themes in this meeting included a desire to have protection from financial ruin, having access to affordable care, and increasing the information available for patients on cost and quality to enhance their decision making capabilities. They emphasized the need for a level of security in the health care system, saying that “we need something that ensures that if we become very ill, it doesn’t take away our livelihood or what we’ve worked to earn so hard all our lives.” While most participants agreed that everyone should have access to basic health care services, they were rather evenly divided on whether or not people should be required to have health care coverage. One participant said that “at first I was going to say no (to a requirement), but then I thought, if they aren’t required to sign up for it than the only time they will get in the system is when there is emergency care and that will cost us more.” Desiring to keep health care “in the competitive arena,” participants talked about the need to have greater transparency in costs, standardization of forms, and understandable information to enable them to be better patients. There was a clear sentiment at this meeting to limit government involvement, with participants asking “has it ever improved anything if the government gets involved and standardizes it?”

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:

“I paid over $12,000 in expenses (not including legal fees) to collect $12,500 in medical expenses because insurers were arguing about who was responsible. Everyone wants to avoid paying. It would be vastly cheaper to adopt any of the European systems.”

“I think we'll finally, inevitably, follow the lead of every other Westernized nation and institute some form of extensive public health care system – I think it's the most efficient system, and the one that gives the best care to the most people. The biggest problem I see with the system as it now stands is that we as a society spend a huge amount of money putting a profit in the pockets of the ‘middleman’ in the system—the insurance companies. That's why we spend 50% more of our GNP on health care than other nations do while getting worse care, and it's absurd."

(Comments submitted to CHCWG Internet “What’s Important to You?”)

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).

“We should have the decency to honor end of life by not pumping millions into the last days but rather encouraging high quality comfort care.”
(Sioux Falls meeting)
“If we want to bring the cost of health care down, then ultimately, we need to reduce the burden of disease. We need to reduce the need to spend money rather than figuring out how to redistribute the money. Otherwise the system will remain broken regardless of how we want to pay for it.”
(Indianapolis meeting)

End-of-life care has surfaced at virtually every community meeting as an issue that encapsulates many of the frustrations with health care in America. Across the nation, Americans are dissatisfied with the care dying people receive: a 2002 national poll found that nearly six in ten respondents rated our current health care system as fair or lower at end-of-life care.[14] Sometimes meeting attendees discussed the need for hospice care in the basic benefit package. Sometimes participants talked about exchanging expensive measures of questionable efficacy for the dying for general improvements in access to care. Usually, the speaker raising the issue has been a bit tentative. “I’m not sure how to phrase this…” or “This sounds clumsy…” Death is a difficult topic among family and friends; it’s also difficult in a policy context.

At its Boston hearing, the Working Group heard a panel of experts on end-of-life care. This discussion was compelling, and members asked that a community meeting be held on the topic (information on the presentation can be found in Appendix E). This special topic meeting was held March 31, 2006 in Hanover, New Hampshire. About 120 people attended.

“Living Well through the End-of-Life” was the theme of the meeting. The last chapter of many people’s lives requires support and assistance, but often what is needed to live well is not medical in nature. Transportation, personal care, and help with meals and cooking are all needed. What people attending the meeting feared most about their final days (or those of someone close to them) were intractable pain, “prolongation of death,” and losing personal control. They identified potential challenges related to “getting the system to work for you when you are dying” or “graceful surrender.” What people wanted most from the medical system was to have their choices honored, good pain relief, and respect from health professionals so they could maintain their dignity.

The majority believed that family and friends are the primary source of such help, but that some paid assistance should also be available. People would like respite services for the principal care provider and a contact person for coordination of community help. “Care has to be taken out of the medical system and accommodate what happens in the community.”

Most people (69 percent) wanted to die at home. Close to 85 percent believed that other choices could be acceptable if certain elements of care were well managed.

When asked what policy advice they’d give their Senators, participants had many specific suggestions, such as realigning financial incentives so that physicians could be encouraged to spend more time talking to patients and a request to revisit Medicare hospice payment practices. However, suggestions quickly began to mirror what has been heard in other meetings. “As a health care consumer, I want appropriate, timely, comprehensive care from conception to death and I would be willing to pay an additional modest percentage of income across my working life to achieve this.


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.

“That is too broad a question. There is the wealthy American public who have lots of options right now. There is the less wealthy American public who have enough income to take some of the available options. There is the working American public who can just barely afford any available options. And there is the American public who can not afford any of today's health care options. And each group will have very different ideas about what they are willing to give up or ‘trade-off’ to get affordable, good quality health care. Even the concept of ‘quality’ health care is a relative term -- any reasonably trained and mostly competent doctor looks good when your choice is that doctor or no treatment at all. What all Americans should want is at least the quality and availability of care that countries like Canada, France, England, etc. offer.”
(Comments submitted to CHCWG Internet “What’s Important to You?”)

“Eliminate profits in the health care system to pay for universal coverage.”
(New York City meeting)

“Eliminate medical middlemen (insurance companies) and direct-to-consumer advertising by pharmaceutical companies in exchange for universal health care.”
(Hartford meeting)

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?”

“For those that already have health care, I believe many are willing to pay a little more for that benefit if they can be guaranteed that the extra would be put towards providing health care for those less fortunate - most of us have been in the position of having no health care at one time or another in our lives. For those that don't currently have health care, there can't be much they can trade”.

"I think that most people would be willing to accept a national value added or national sales tax to fund a nationalized medical system that treats all legal citizens fairly and equally, without financial or any other kind of discrimination."

“Phase it in. Universalize a small sector of health care -- for example, preventive care -- before trying to redo the entire system. If the public learns to trust a small sector of tax-financed health care, it will be more open to greater change.”

"It should be underwritten by the government, with sliding scale of payments made by individuals through taxes - people who make the most should pay the most to insure that health care is available for all; employers should also contribute through the taxes they pay."

(Comments submitted to CHCWG Internet “What’s Important to You?”)


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

graphic: Fig. 8 table; link to tabular data

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:

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.

Paying More Taxes for Health Care for All:
Evidence from Other National Polls

  • A national survey conducted in November 2005 found that 59 percent of adults would “Support reforming our health care system to provide affordable health coverage for all Americans if it meant that you would have to pay more in taxes” compared to 35 percent who would not (Gerstein/Agne Communications).[15]
  • A poll conducted in December 2004 found that 65 percent of Americans favor or strongly favor the U.S. government guaranteeing health insurance for all citizens, even if it meant raising taxes (Pew); a poll conducted in August 2003 by the same polling group also found that 67 percent favored guaranteeing health insurance to all citizens even if it meant raising taxes.[16]
  • A 2004 poll found that while 64 percent said that it is the responsibility of the federal government to make sure all Americans have health care coverage, only 45 percent of those agreeing would be willing to pay higher taxes or premiums to increase the number of Americans with health insurance (Kaiser Family Foundation).[17]
  • A 2003 poll found that 79 percent of Americans believed it is more important to provide health care coverage for all, even if it means raising taxes (ABC/Washington Post).[18]

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:

“I would be more willing to pay more in taxes to assure that everyone has access to good healthcare if I could be assured that the medical care system was based on fair practices and was not influencing politics. I would be thrilled to see Americans embrace a healthier lifestyle. That is a tradeoff that doesn't cost much. People seem to believe that they can just take a pill or wait for some breakthrough to solve their health problems. Public schools need to bring back physical education and increase activity, cities need to become more pedestrian/bicycle-friendly. This country can help provide the opportunity to MAINTAIN good health instead of fixing the problems of poor health - it would be a lot cheaper. I'd be willing to pay more in taxes for things like that.”

(Comments submitted to CHCWG Internet “What’s Important to You?”)

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:

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

Graphic: Fig. 9 table; link to tabular data

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?

Figure 10: What changes should be made to the health care payment system - Internet Comments

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?

Figure 11: Single most important recommendation - Internet comments

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.

The Working Group Heard Many Views about How to Make Health Care Work for All Americans: Examples

"We need a single-payer system to control costs and promote efficiency, and it has to be universal."
“I think the only thing that will work is creating a system that includes everyone at a basic level of care with significant incentives for preventive care. It could be done through a system of clinics located near grocery stores (or WalMart-type stores), in schools and community heath centers.”

“Let's just do Medicare for everyone. And establish a universal standard of electronic record keeping. Then everybody can go to the doctor of their choice, when they need to, and nobody falls through the cracks. And our health care system can focus on getting the right treatment to people the best way, and the healthcare database can track what treatments works best for whom, in the most cost effective way. Until we have a system that guarantees universal, complete coverage, we will never be able to track what basic, effective health care really costs or establish mechanisms --or even rationing (which I don't think we need)-- that does what is best for all”.

“Everyone pays a fair share, everyone has health care benefits.”

“A non-profit single payer system that covered everyone would be the best solution. This would save billions in the total cost of health care in America. This plan could buy drugs with huge bulk discounts like Medicare & Congressional, & veterans plans do.”

“Require all Americans to choose a health care option and allow health care choices. Then let the free market reduce the costs. The default option is a free Medicaid type program that only provides emergency and preventative care.”

“I believe if Americans see that financing is more fair (rich paying more than the poor, the young contributing to the care of the elderly, the healthy paying for the sick) and all according to their level of income, this would be the first step in Americans accepting financial tradeoffs. If the financing is not transparent and fair, there will be perpetual resistance. Secondly, I believe there must be set up a public infrastructure for setting standards of coverage and the availability of services that we are willing to fund. Such a public commission would include both citizens and representatives of all health care professions meeting apart from state or federal government. Such Commission governance should be on the state, not federal, level so that local management is undergirding the system. Health resource management is local. When American citizens see that a public entity is taking the time and expertise to decide transparently what should and will be covered according to some stated ethic and philosophy of health care goals, tradeoffs become more easily acceptable because the public is involved (not private corporations or remote federal agencies making such decisions). And finally, the public and local health care professionals should have the right and access to express their opinions and desires to such a public commission. There is a decision-making infrastructure that carries real authority and control but that is also permeable and open to citizen and professional input.”

"All insurance should be tax deductible whether employer provided or individually purchased, as well as health expenses should be deductible below the 7.5% threshold. More transparency in both quality and cost so that people can truly become health care consumers. Government plans need to provide BASIC coverage and support care through community health centers as most efficient way for free care to be administered."

“I believe people should have a choice in selecting and paying for their healthcare. However, I believe the government should provide catastrophic coverage for all people. It will pay for itself in reduced neglect and dependency on government welfare and other programs.”

“Put everyone in one risk pool and have a publicly financed, privately delivered system instead of paying high administrative costs for private insurance companies.”

“Develop a coordinated system through the government that assures access for all, including focusing on preventive care. Health care should be regulated -- like utilities are regulated. The private sector system is not working for the US. Every other developed country has figured out a system; why can't we?”

“A single payer system with a massive investment in information technology that provides universal access to patients as well as providers.”

“Enact a single payer system of national health insurance with national standards and a global budget in which inequalities in health care delivery would be monitored and reported by race, ethnicity, income, and disability status at the state and community levels to identify inefficiencies that could be reduced by incorporating non-discrimination standards into the regulatory structure at the federal and state levels.”

"We need to set up a system like Social Security, where all working people pay into it, but all get equal coverage. We also need to tax not-for-profit institutions and systems that are currently acting very much like for-profit systems to cover insurance costs for the uninsured, the elderly, and disabled. If these systems are competing with one another, and they are, they must contribute to the community need through tax dollars, since they are duplicating services and keep building facilities that are not needed."

"Medicare and the VA are and have been working. They are cheaper than other options already in place and are more efficient in administrative costs than many other options.”

“A non-mandatory, semi-private, semi-government run health insurance/free (or at least affordable, possibly based on income levels) health care program to everyone in the country. A health care program completely run by the government wouldn't work, but neither would one that was privately run - something comparable in theory to the FEHBP. And it should be either free service (paid for by taxes) for the patron, or be priced according to income and possibly 'risky' behaviors.”

"In addition, we need a system where health care is provided by those best able to do it most efficiently including the highest quality. There is too much reliance on physician specialists and not enough on family physicians and nurse practitioners, nurse-midwives, nurse anesthetists, etc."

"I like the idea of the health savings accounts -- but the people that need the help can't afford the cost of the high deductible insurance, so how can they afford to put $2500 or so a year in the savings portions? Paying medical expenses from an account that they manage, might make people monitor their health care costs. I do believe that people on SSI - Medicaid overuse the system. But -- how can they not. They don't have any experience with the health care system, having put off all but the most critical care all of their lives. They only know the emergency room, because they have only sought medical care in extreme emergency in the past. To make the health savings account work, I think the government should put the $2500 into the health savings account, for all individuals below a certain income level."

“Create a system that seamlessly covers individuals from birth to death. Health care is about the individual, not whether they work, or have a disability, or fall within a certain age range. We keep everything in this country piecemeal and segregated by false categorization and because of that ensure a fragmented system with lots of individuals falling through the cracks. Get rid of the fractured system based on the private market. It doesn't work. It is costly and creates too many gaps in care.”

"There needs to be some combination of these things to allow coverage for all Americans. Maybe we could expand Medicare/Medicaid, or allow people without coverage to enroll in the Federal employees’ plan, with a premium based on a sliding fee scale, so all pay something."


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.”