Appendix G: Response to Comments on the Interim Recommendations

Overview of changes

As a result of comments from the public and its own deliberations, the Citizens’ Health Care Working Group has made several modifications to its Interim Recommendation report. These changes were made to clarify the Working Group’s intent, provide additional details, and better convey the urgent need for reform that the Working Group has heard from the American public.

First and foremost, the Working Group has restructured its report to make emphatic its major message: to achieve “Health Care that Works for All Americans,” it should be public policy, enacted in law, that all Americans have affordable health care. The revised report stresses the goal of affordable health care for all, explains how the individual recommendations work together as a package leading to that goal, sets a target date of 2012 for full implementation, and acknowledges the need for new revenues. The graphic at the start of our report illustrates the relationships among the recommendations and the timeline for their implementation. To further convey the need for immediate action, the report explains what will result if nothing is done.

In this section of the report, The Working Group makes clear its vision for the health care system, a system which is easy to navigate and in which everyone participates. Its services and benefits are determined through a transparent and accountable process that draws on best practices and these benefits and services are available regardless of changing personal circumstances. These concepts were included in the earlier draft but are emphasized here as is the date for full implementation—2012. There are differing views as to the role government would play in this system: over the comment period we heard from many individuals and groups who advocated for a government-managed health care system financed by taxes. At the same time, we heard from others reluctant to assign additional responsibilities to government. The Working Group does not propose a specific model for achieving what it heard the American people want. While there is great agreement on the ultimate destination, how to get there needs to be determined through ongoing dialogue and action by the Congress and the Administration.

This recommendation was listed first in the revised materials posted on the Working Group’s web site on July 18. This was a concern to many readers who believed beginning the report with the ultimate goal was important. As noted above, the order of recommendations was revised, and additional language was added to make it clear that protection from very high costs was an initial step toward core benefits and services for all. To address the many questions the Working Group received about how this program would work, this report offers two illustrative examples for consideration. The first is a market-based approach; the second is federally-run program based on a social insurance model. The principles, that everyone participates and government funded subsidies are available based on need, remain unchanged. We have also added language to better explain the relationship we see between this recommendation and the integrated community health network recommendation which follows. The Working Group sees these two proposals—protection against very high health care costs and reforming the health care delivery at the local level—as building blocks for an improved health care system and key steps that can be taken immediately.

In the revision of the discussion of this recommendation, the Working Group makes it clear that the networks it envisions are meant for anyone in the community. While the Working Group sees these networks as a sound way to improve care in localities where need is great, it does not see these networks as a form of second-tier care for low-income people, as some writers suggested. To make our intentions more clear, this revision includes more detail on the Working Group’s vision for these networks. The discussion provided here places a stronger emphasis on prevention than the earlier draft.

We received many comments from individual community health centers and their associations asking us to remove the proposal to “expand and modify the Federally Qualified Health Center concept” to allow additional providers to qualify for some of the benefits now limited to community health centers and certain other providers. Most of these letters focused on the important role of these centers’ citizen governing boards. By statute, at least 50 percent of the members of these boards must be users of the centers’ services. We have, however, retained the proposal. The Working Group acknowledges the valuable contributions the community health center program has made in providing care to low-income people over its 40-year history and the central role of community governance in the program. In no way does this recommendation seek to undercut either the program or its structure. The Working Group notes, however, that the organization of health services at the local level varies from community to community. Other successful models of care delivery can be found in many localities. To the extent that these providers are doing similar work for groups of people much like those served by community health centers, they should be encouraged through federal incentives.

The Working Group has expanded the discussion in this section to clarify that core benefits and services would be determined through an open, participatory consensus process. Decisions on inclusion would be based on demonstrated medical effectiveness as well as impact on individual and community health. Additional discussion is provided on the interrelationship of core benefits, evidence-based practice, and incentives that can increase the efficiency of health care delivery. This section also now addresses some important implications of a core set of benefits and services for current coverage in public and private insurance programs.

This recommendation is fundamentally unchanged. Its accompanying narrative has been expanded to add supporting data and examples of efforts now underway in the public and private sectors.

The Working Group added a discussion of professional and family caregivers to the narrative accompanying this recommendation. The narrative now also puts more emphasis on best practices and the need for better demographic, clinical, and epidemiological data to inform policy-making.

The Working Group has expanded its discussion of financing and now places it in a separate section. The final report offers a set of principles it believes must guide sources of financing for these recommendations. First, financing methods must be fair: they should not place undue burdens on the sick; responsibility for financing should be related to a household’s ability to pay; and all segments of society should contribute to paying for health care. Second, financing methods should increase incentives for economic efficiency in the health sector and the larger economy. Finally, the methods should be able to generate funds sufficient to pay for the recommendations. The report discusses potential ways its recommendations could be financed, beginning with savings recovered from better management of existing resources. A second source would be the curtailment of subsidies in the current tax code that do not meet the fairness test. If after these two approaches have been taken and additional funds are still needed, this section offers brief examples of policy options for generating new revenues that were mentioned at Working Group meetings or in its online comments.

Summary of Comments

We received about 7,500 comments from individuals on the interim recommendations, including about 3,400 comments from June 2 through July 18, 2006, and over 2,600 through the end of the public comment period on August 31 submitted via the Internet. In addition, about 350 people sent comments via email, and over 100 on paper, including complete versions of the online evaluation form, as well as letters, notes, and postcards. We have also received and reviewed comments on the Interim Recommendations from about 1,000 people who responded directly to the Catholic Health Association web site. An additional 80 individual letters were sent to the Working Group by members of The American Federation of State, County and Municipal Employees. Several other organizations also submitted sets of comments on recommendations or petitions from individuals affiliated with local chapters, including the Universal Health Care Action Network (North Carolina) and Grass Roots Organizing (Missouri).

The comments were grouped into two sets, because the additional text was posted on July 18 and the order of the recommendations listed on the Internet was changed. Because the additional material may have altered the way the public viewed the recommendations, we compared responses from each time period separately. Our analysis included a review of a sample of all the comments, but a particular focus on the comments of those who expressed disagreement with the recommendations. We also analyzed a representative sample of all the comments on discussion issues of financing included in the Interim Recommendations.

Overall, the comments reflected the same perspectives and concerns that the Working Group has heard in the community meetings and in the comments and poll results over the past nine months. More than three in four people who provided written comments on each of the six recommendations expressed agreement with the recommendations.

The proportion of people agreeing with the recommendations did not change markedly after July 18, but a slightly higher proportion of individuals providing comments via the Internet indicated agreement with several of the recommendations (Figure G-1). The additional discussion posted on the Working Group web site may have been a factor in this change. A minor format change may have also affected how people provided input. After July 18, the comment page included a one-click box where individuals could indicate whether they agreed or disagreed with each interim recommendation, in addition to the free text area for comments. In the pre-July 18 period, only the free text fields were provided, and agreement was determined by Working Group staff who read the responses in full. After July 18, about two-thirds of those who indicated whether they agreed or disagreed with the Interim Recommendations also provided explanations of their views in the free text fields.

Individuals who provided input via the Catholic Health Association indicated strong levels of support for the recommendations. The letter from the members of the American Federation of State, County and Municipal Employees stated support for most of the recommendations, but also raised some concerns, similar to many others we heard, about “not going far enough.”

graphic: Percent of Internet comments stating agreement with CHCWG Interim Recommendations

The major points raised by those commenting on the individual Interim Recommendations reflected some common themes, reflecting views about the role of government and social and personal responsibility:

Establish Public Policy that All Americans Have Affordable Health Care
Guarantee Financial Protection Against Very High Health Care Costs
Foster Innovative Integrated Community Health Networks
Define a Core Benefit Package for All Americans
Promote Efforts to Improve Quality of Care and Efficiency
Fundamentally Restructure the Way End-of-Life Services Are Financed and Provided
Comments on financing and broader concerns

Comments addressed a range of issues, including health care costs, the role of government, the type of system that should be put in place, and how reforms should be financed.

Among those commenting on the type of system that should be put in place, most of those commenting favored a single health care system, Medicare for all, or another form of government-organized system that included public and employer-based health care coverage.

  1. About one-third of the comments focused on placing primary importance on personal responsibility:
  2. One third advocated public/government responsibility to ensure access to health care for all: and
  3. The remainder raised issues of shared responsibility among individuals, employers, and government for ensuring health care for all.

Community Meetings

Fourteen community meetings were held during the comment period on the Working Group’s interim recommendations, which began June 2, 2006. They varied in size, sponsorship, and direct Working Group involvement. Three of the meetings were formally organized by the Working Group: two public meetings in Oklahoma City and Milwaukee, and a meeting held at the PayPal campus in San Jose, California for employees of eBay and PayPal. The Mississippi Extension Service, out of Mississippi State University, which earlier in the year had organized meetings across that state, and held meetings on the interim recommendations in Jackson, Hattiesburg, and Greenville which were facilitated by a Working Group staff member. The Dade County Health Department and the Health Foundation of South Florida organized a meeting in Miami that a Working Group member facilitated. Finally, in Muncie, Indiana; Corvallis, Oregon; Cleveland, Ohio; Columbus, Indiana; and Birmingham, Alabama, local groups organized meetings. Two meetings were held in both Columbus and Birmingham. In all, over 700 people attended these meetings.

While a few of these meetings used the structure of the earlier community meetings and were organized around the four congressional questions, the vast majority focused exclusively on the Working Group’s Interim Recommendations. The participants in the meetings varied: attendance at some meetings was dominated by people who work in health care. In general, as at the Working Group’s earlier community meetings, many attendees were well-educated, middle-aged women. The Oklahoma City meeting was notable for its over 300 participants and diversity of views.

Public reaction to the interim recommendations from these meetings was consistent with the messages it received on the internet and in the mail. The sentiment among participants was that the American health care system is in trouble and needs change. Some participants saw health care as a global issue, where we have much to learn from other countries. In general, there was strong support for the recommendations, individually and as a package, but a common reaction among participants was that while they agreed with the recommendations, they did not go far enough. A significant percentage of participants, averaging around 20 percent at some meetings, did not support the recommendations, while others were not sure.

At most of these meetings, there was vocal endorsement of “universal health care,” which was often coupled with support for a single payer system. At many meetings, there was also an articulate minority concerned about current costs and the damage that failure to address these costs could inflict on American competitiveness.

At many meetings participants had trouble with the recommendation proposing protection against high health care costs and wondered why the Working Group had this limited focus. The Working Group saw this measure as an immediate first step toward the availability of a core set of services for all in 2012, and has clarified both the recommendation on protection against high health care costs and its relationship to the ultimate goal in its final report.

At the well-attended Oklahoma City meeting, the Working Group member and staff were gratified by participants’ unexpectedly enthusiastic reaction to two recommendations, Integrated Community Networks and Restructuring End-of-Life Care. Each of these recommendations calls for a rethinking of the status quo with a focus, in major part, on better integration of services at the local level. The response in Oklahoma City suggests the reservoir of energy, imagination and expertise that exists in communities across the country that can be brought to bear on these two recommendations in particular.

Comments from Organizations

The Working Group received over 100 comments on its Interim Recommendations during the public comment period from organizations. Collectively these organizations spoke on behalf of consumers, health care and other professionals, health care organizations, business, labor, insurers, and religious groups. The city of Philadelphia and the Cherokee Nation provided comments. David Walker, Comptroller General of the United States, also provided comments. Several organizations who advocate for low-income people commented, as did groups that have been formed to pursue health system change. Some organizations provided detailed critiques of each recommendation; others focused on one or two. Some of these organizations represent thousands, even millions of individuals. In some cases local chapters of organizations reiterated or expanded upon the views of their national organization. Some organizations compared the Working Group’s recommendations to their own established positions, sometimes enclosing documents spelling out their views.

A summary of individual comments received from organizations follows. The individual letters can be viewed on the Working Group’s website

The general response to the Working Group’s recommendations was positive, and when organizations were critical, more often than not, it was because the writers believed that the recommendations could have gone further. Several organizations questioned the reordering of the recommendations that took place on the Working Group’s website about halfway through the comment period. In that revision of the recommendations, to make clear the sequence of implementation steps, the Working Group made the “Guarantee Protection against Very High Health Care Costs” its first recommendation because it could take place relatively quickly. Commenters believed that this move led to a loss of focus on the Working Group’s call for affordable health care for all by 2012.

About one in four of the comments from organizations were submitted by federally-funded Community Health Centers or state or national membership organizations representing these centers. These comments were generally supportive of the Working Group’s Interim Recommendations with one significant exception. These organizations opposed the proposal to “Expand and modify the Federally Qualified Health Center concept to accommodate other community-based health centers and practices.” They noted that community-based, user-dominated governance has been a hallmark of the Community Health Center program since its inception forty years ago and a source of patient empowerment unique in the health care system which should not be modified.

Of comments received from organizations, about one-quarter focused on advocating for universal comprehensive health care. Some praised the Working Group’s recommendations as a “strong call for health care coverage for all” but more frequently commenters believed that the recommendations did not go far enough. In all over one-fifth of the organizations commenting called for some form of a national comprehensive tax-payer financed health care system. Many of these commenters cited the Working Group’s polls and community meetings to support their views and voiced the belief that the Working Group’s recommendations did not accurately reflect public input.

In contrast to these comments, the Working Group received four comments that were very critical of its Interim Recommendation because of the increased emphasis they perceived in them on government’s role in health care and lack of emphasis on market-based approaches. One of these organizations challenged the Working Group’s findings because its public outreach efforts did not reach “a representative cross section of the public” and failed to capture the views of the middle class.

A number of comments were received from professional associations representing various types of health care provider or service. In addition to making more general comments, they often argued for adequate attention to their particular interests, such as the health care needs of children, reproductive health, dental health, mental health services, palliative care and HIV care.

Summary of Organization Feedback on Interim Recommendations
Common Themes

  • Community health center advocates expressed concern about expanding and modifying the Federally Qualified Health Center concept.
  • Many advocacy organizations were disappointed that the recommendations emphasized protection from high cost care rather than access to high quality care for all.
  • These same advocacy organizations criticized the recommendations for not going far enough in recommending universal comprehensive health care coverage for all.
  • Other groups emphasized the need for free market health care reforms and did not support increased government involvement in health care.
  • Groups representing specific populations highlighted the needs of the people they represent and urged inclusion of provisions that would specifically address their concerns.
  • Various professional associations who work within the health care system advised including specific health services or references to specific providers in the recommendations.
Common theme: focus on integrated community health networks
Access to Care
Westchester, Illinois
• Strongly agrees with community networks recommendation to broaden the FQHC concept to include community-based health centers and programs serving under-served populations

• Advocates consideration of their model of care which uses private physicians in their own clinics rather than designated public health clinics
Numerous Community Health Centers and related organizations
(see list of commenting organizations at right following summary of comments)
• Expresses concern with proposal on expanding and modifying FQHC concept

• Argues that patient-dominated health clinic boards are a unique and important feature of the successful Community Health Center program

• Urges retention of current FQHC legislation and seeks independent provisions for expanding providers in community networks

• Argues that the community networks recommendation does not reflect the majority sentiment expressed in Working Group community meetings

Commenting Community Health Centers and related organizations:

Allen Hospital, Iowa Health System, Waterloo, Iowa
Association for Utah Community Health, Salt Lake City, Utah
Avis Goodwin Community Health Center, Rochester, New Hampshire
Bi-State Primary Care Association, Concord, New Hampshire
Colorado Community Health Network, Denver, Colorado
Community Health Center of Burlington, Inc., Burlington, Vermont
Community Health Care Association of New York State, Albany, New York
Community Health Center of Rutland Region, Bomoseen, Vermont
Community Healthcare Network, New York, New York
Coos County Family Health Services, Berlin, New Hampshire
Decatur County Community Services, Leon, Iowa
The Georgia Association for Primary Health Care, Decatur, Georgia
Community Health Centers of Southern Iowa, Leon, Iowa
Hometown Health Centers, Schenectady Family Health Services, Schenectady, New York
Hudson River Healthcare, Peekskill, New York
The Institute for Urban Family Health, New York, New York
Lamprey Health Care, Newmarket, New Hampshire
Lutheran Family Health Centers, Brooklyn, New York
National Association of Community Health Centers, Inc., Washington, D.C.
New Jersey Primary Care Association, Princeton, New Jersey
Oak Orchard Community Health Center, Brockport, New York
One World Community Health Center, Inc., Omaha, Nebraska
Oregon Primary Care Association, Portland, Oregon
People’s Community Health Clinic, Waterloo, Iowa
River Hills Community Health Center, Ottumwa, Iowa
William Ryan Community Health Center, New York, New York
United Community Health Center, Storm Lake, Iowa
Whitney Young Jr. Health Services, Albany, New York
National Assembly on School-Based Health Care
Washington, D.C.
• Advocates for integrating school-based health care into national health care and education systems

• Advises securing a consistent funding stream for school health centers by authorizing school health centers as part of the health care safety net and ensuring that the public health insurance program reimburse SBHC services
Common theme: advocating for universal comprehensive health care
American Federation of State, County, and Municipal Employees
Washington, D.C.
• Argues consideration of different language in the catastrophic coverage recommendation to prevent employers from shifting costs of mandating insurance onto employees

• Urges Working Group fulfill its mandate and provide a stronger endorsement of a comprehensive national health care system to reflect the majority public opinion from community meetings and polls

• Requests exploration of public catastrophic coverage

• Argues that quality and efficiency recommendation uses too broad a definition of fraud and waste, urges specifying “fraud, waste, and abuse in the system as a whole as it relates especially to for-profit providers of prescription drugs and health care

• Argues that report should include explicit language to support government’s use of purchasing and regulatory powers to rationalize prescription drug prices and control profits of insurance companies and other corporate entities
Catholic Health Association of United States
Washington, D.C.
• Strongly supports universal health care for all Americans, but must include non-citizens as well

• Urges Working Group to define “affordable,” in relative terms

• Asks clarification of definitions of palliative, chronic, hospice, and end-of-life care

• Advocates for explicit language in the report condemning physician-assisted suicide
Center for Medicare Advocacy, Inc.
Washington, D.C.
• Advocates for a universal single payer health care system

• Asserts that high deductible coverage is only a stop gap measure and leads to the “doughnut hole” effect
Coalition for Democracy of Central New York
Bovina Center, New York
• Argues that recommendations were too vague and need to include provisions for simplifying the health care delivery and financing

• Advocates for a health care system that mirrors the Canadian one
United States Conference of Catholic Bishops: Department of Social Development and World Peace
Washington, D.C.
• Praises inclusion of a strong call for universal health care coverage with access to a core set of services and financial protection against high health care costs

• Observes that the most striking outcome from the Working Group’s outreach efforts is that 90 percent of the public who responded to the Internet poll and/or participated in community meetings agreed that affordable health care for all should be public policy

• Urges that procedures such as abortion and euthanasia, that they describe as morally objectionable, be excluded

• Reaffirms their position that “health care is a fundamental human right and reform of the nation’s health care system must be rooted in values that respect human dignity, protect human life, and meet the needs…[of the poor].”
Family Planning Advocates
Albany, New York
• Advocates for universal single-payer health care for all, including non-citizens living in U.S.

• Urges Working Group to expressly advocate for comprehensive reproductive health services

• Asserts that “affordable” health care needs to be more explicitly defined

• Argues for increasing reimbursement rates for neighborhood clinics

• Says report should explicitly address high profit margins of health insurance companies and drug companies

• Urges inclusion of abortion services
Health Care for All/NJ
Hoboken, New Jersey
• Argues interim recommendations do not accurately reflect citizen feedback from the public at community meetings

• Asserts that congressionally mandated questions were biased — leading respondents to discuss the need for “core” rather than comprehensive coverage

• Believes recommendations should advocate explicitly for a national, universal single-payer health care system to accurately reflect citizen feedback
Health Care for All/Washington
Seattle, Washington
• Argues interim recommendations do not accurately reflect citizen input at community meeting and advocates for comprehensive national health care for all
Institute of Social Medicine and Community Health
Washington, D.C.
• Argues recommendations be revised to reflect public feedback and advocate for a comprehensive health care package for all as soon as possible

• Supports a civil rights approach to health care processes

• Urges clarification of process for arriving at universal health care
International Association of Machinists and Aerospace Workers
Upper Marlboro, Maryland
• Asserts that affordable health care for all Americans should be the first recommendation

• Argues for adding “to not harm” to the core values and principles section

• Asserts that core benefits package should be broadened to include comprehensive benefits

• Urges explicitly clarifying that protection against high costs is an incremental step toward health care for all

• Expresses concern that the public-private partnerships discussed in the community networks recommendation will lead to for-profit entities misusing tax dollars
League of Women Voters Health Care Working Group
Medfield, Massachusetts
• Urges reordering of recommendations so that public policy recommendation is first — reflecting community feedback and support

• Argues for stronger endorsement in the report for national health care plan, financed by taxpayers, that gives all residents equal quality of care
National Coalition of Mental Health Professionals and Consumers
Commack, New York
• Advocates ensuring that mental and substance abuse services are not relegated to a low priority in the recommendations

• Argues that the interim recommendations do not reflect public sentiment from community meetings and poll results

• Asserts the common message was for a universal, comprehensive system

• Argues that rising costs in the health care industry come from high prices for care, administrative costs, and too many basic services performed in a clinical setting
Michigan Legal Services
Detroit, Michigan
• Asserts that focus of recommendations should shift from covering high-cost care to providing universal comprehensive health care coverage

• Advises keeping the basic structure of federally funded health care centers

• Argues for focus on reducing administrative costs and highlighting preventative services and primary care and focusing on the delivery system instead of financing
Michigan Universal Health Care Access Network
Detroit, Michigan
• Argues interim recommendations do not go far enough and should include rating criteria for judging a new health care system

• Advocates for reducing health care administrative costs and inefficiencies

• Argues for financing health care through a new progressive income tax rather than the current fragmented payment system

• Argues for a need to address how our current system decreases nation’s global economic competitiveness

• Asserts that health care should be viewed as a public good

Follow-up letter: Asserts frustration that recommendations do not advocate for a progressive tax to finance publicly a national health care program; emphasizing protection against high health care costs will be costly and inefficient but applauds Working Group’s commitment to comprehensive health care for all
Midwives Alliance of North America
Fairfax, California
• Argues that report needs to reflect citizen feedback at community meetings and advocate for universal national, single-payer health care for all — financed partially by taxpayers

• Agrees with promotion of evidence-based medicine, expansion of community health clinics, and emphasis on home-based end-of-life care

• Argues for inclusion of midwifery services in core package of services
National Association of Free Clinics
Washington, D.C.
• Urges inclusion of a definition of “high out of pocket costs”

• Argues that the report does not tackle non-citizens’ need for health care

• Advocates for including vision and hearing services in the core benefits package

• Expresses a strong need to make a distinction between free clinics and federally funded health care centers and offers suggestions aimed specifically at free clinics

• Argues that health care reform needs also to address potential public health crisis crises (e.g. New Orleans after Hurricane Katrina)
National Advocacy Center, Sisters of the Good Shepherd
Silver Spring, Maryland
• Praises Working Group recommending affordable health care for all Americans by 2012

• Advocates reordering the recommendations so that this recommendation comes first
Washington, D.C.
• Advocates for affordable and accessible health care for all by 2012—calls for a transformation in health care based on social justice
Public Citizen
Washington, D.C.
• Argues that Working Group needs to expressly advocate for a single-payer system in the recommendations

• Provides arguments on benefits of single-payer national health care model
Philadelphia Area Committee to Defend Health Care
Philadelphia, Pennsylvania
• Argues that interim recommendations do not reflect public sentiment at community meetings because they do not advocate for a single payer universal national health care system

• Urges Working Group to draft stronger recommendations that reflect majority opinion at the community meetings
Universal Health Care Action Network
Cleveland, Ohio
• Divides critiques into three broad categories: how the recommendations are framed, concern about how accurately they reflect public feedback, and a set of comments on the feasibility of individual recommendations

• Argues that recommendations are inter-related and need to be debated as a comprehensive reform package rather than separately

• Asserts that American health care system is not a system but is a “collection of loosely linked systems”

• Argues that interim recommendations do not accurately reflect the majority who provided feedback to the Working Group and asked for a national health plan, financed by tax payers.
Universal Health Care Action Network of Ohio
Columbus, Ohio
• Advocates for changing the order of the recommendations so that Affordable Health Care for all recommendation comes first

• Argues that protection against high health care costs should be broadened to include nominal costs for low income persons

• Asserts that integrated community health networks should be available to all

• Urges more aggressive measures to curtail waste

• Argues for eliminating tax cuts for the wealthy
Reach Out America
Great Neck, New York
• Disagrees with protection against high health care costs, affordable health care, and a core benefits package in lieu of a universal, publicly financed system of health care
Washington, D.C.
• Advocates reordering recommendations to place affordable health care for all as number one

• Argues that the timeline needs to be added to spur Congress and the Executive Branch to act
The Workmen’s Circle
New York, New York
• Disagrees with the revised order of the recommendations and advocates for retaining affordable health care for all as the first recommendation

• Argues that the integrated community health network recommendation fails to address the current two-tier system of health care

• Disagrees with including “core” benefits package and protection against high health care cost recommendations as they deflects from the ultimate goal of providing comprehensive health care for all
Washington State Ad-Hoc Coalition on the Citizens Health Care Working Group
• Urges shortening the Values and Principles section to the first three bullets

• Argues first recommendation should be “It should be public policy that all Americans have affordable health care

• Advocates second recommendation should read, “There should be a national health plan, financed by taxpayers, in which all Americans would get their health insurances

• Argues third recommendation should read, “A sufficiently comprehensive benefits packages for all Americans should be defined

• Proposes additional changes to other recommendations

Follow up letter: argues for removing “core” and replacing it with “comprehensive” benefit package

• Advocates for not allowing insurance companies and employers to be decision makers in creating the core benefits package

• Reiterates Working Group should advocate for comprehensive health care in response to public response through surveys and community meetings
Common theme: Promote a free market health care system
Association of American Physicians and Surgeons
Tucson, Arizona
• Disagrees with the interim recommendations in favor of private market approaches and believes that universal coverage leads to restricted access to care
ERISA Industry Committee
Washington, D.C.
• Argues that Working Group should differentiate health care from health insurance arguing that Americans already have access to free health care

• Asserts that free health care insurance for all would place an undue burden on taxpayers and lead to rationing

• Asserts that a tax-payer system will lead to moral hazard

• Argues for restricting unnecessary medical liability lawsuits

• Urges Working Group to promote incentives for providers who provide high quality and efficient care
Health Care America
Washington, D.C.
• Asserts that the Working Group report is not practical because it does not discuss how to implement the recommendations

• Argues that report implicitly calls for increase in the government’s role in national health care coupled with a tax increase, which they assert most Americans do not support

• Suggests community meetings failed to capture a representative sample of America’s middle class

• Argues that greater health care coverage does not imply greater access to care

• Supports market competition between health plans and packages as the best approach for consumers to enjoy choice in health care

• Advocates for four solutions to limit increases in health care costs, including: redirecting non-emergency care to more appropriate locations, enacting medical liability reform, encouraging electronic health records, and introducing pay-for-performance incentives to reward providers for high quality services

• Argues that recommendation for integrated community health networks is not notably different from the current system
Institute for Health Freedom
Washington, D.C.
• Uses Medicare as a case study to argue that universal, single-payer national health care is not effective in improving health indicators, poverty rates, provider choice, and health privacy
Common theme: all have a special focus
American Academy of Actuaries
Washington, D.C.
• Asks the Working Group refer to their publications as resources for information on a variety of health care issues

Special focus:: Argues that actuaries provide unique expertise and perspective on issues related to risk and contingent events
American Academy of Pediatrics
Elk Grove Village, Illinois
Special focus:: Focus on unique health needs of children

• Advocates for increasing Medicaid reimbursements for pediatric services

• Argues that integrated community networks recommendation should explicitly refer to children and promote the “child medical home”

• Urges development of specific pediatric care quality measures
American Chiropractic Association
Arlington, Virginia
• Concludes that health care system needs to shift focus from caring for the seriously ill to disease prevention, early disease detection, and positive lifestyle changes

Special focus: Argues chiropractic care is a major component of efficient quality health care and should be fully integrated into the medical delivery system
American Dental Association
Washington, D.C.
• Strongly supports inclusion of dental services in definition of core health services

Special focus: Argues oral health is an important component of health
American Hospital Association
Washington, D.C.
• Presents results from its own independent “listening sessions” held to discuss health care reform with key stakeholders resulting in 10 principles that typify what healthcare should be in America.

Special focus: Concludes its vision of health care reform is parallel to the Working Group’s interim recommendations
American Psychological Association
Washington, D.C.
Special focus: Concerned that the core benefits package will not include adequate mental health services

• Argues that “evidence-base care” in benefits section needs to reflect different diagnostic approach for mental health services

• Recommends replacing the term “medical” with “clinical” to be more inclusive in treatment by both physicians and non-physicians
Association of Clinicians for the Underserved
Tysons Corner, Virginia
Special focus: Advocates for health care reforms that increase underserved community access to care

• Encourages greater financial incentives for clinicians to provide preventative care and health education services
Ascension Health
Saint Louis, Missouri
Special focus: Praises recommendations and provides a strong endorsement for affordable health care, integrated community health networks, and restructuring end-of-life care
Seton Healthcare Network
Austin, Texas
Special focus: Reiterates Ascension Health’s comments
Associations of Professional Chaplains
Schaumburg, Illinois
Special focus: Argues for greater emphasis on mental, emotional, and spiritual health elements of health care
California Pan-Ethnic Health Network
Oakland, California
• Encourages Working Group to add a new recommendation addressing racial disparities in health

Special focus: Endorses recommendations but argues for greater emphasis on communities of color
Catholics for a Free Choice
Washington, D.C.
• Concurs with finding that the health care system is in desperate need of overhaul

Special focus: Argues that core benefits package should include services and medicines based on the needs of the patient not the ideological beliefs of the hospital or provider
Cherokee Nation
Tahlequah, Oklahoma
• Argues that the unique relationships with tribes must be honored, Indian Health Service, Tribal Programs, and Urban Indian Clinics (I/T/U) system remain intact and federal funds be used to cover health care expenses imposed on eligible American Indians and Alaskan Natives

• Advocates that community health networks include health care services for Indian country

• Argues that the I/T/U system should be a critical focus in a new initiative to improve quality and efficiency

Special focus:: Carefully take into account how proposed health care reforms will impact the current American Indian and Alaska Native health care system and ensure that any changes have a positive effect on Native Americans and Alaskan Natives
Clinical Social Work Association
Seattle, Washington
Special focus: Argues to include physical, mental, dental services in the defined core benefits package
Clinical Social Work Guild
Arlington, Virginia
Special focus: Advocates for benefits parity for mental and physical services and incorporating language that emphasizes importance of psychosocial aspects of mental and physical health
Congreso de Latinos Unidos
Philadelphia, Pennsylvania
Special focus: Argues community-based organizations should be considered as potential outpatient and health and wellness providers/educators especially in communities that frequently encounter obstacles to health care due to language and cultural barriers
Consumers Union
Washington, D.C.
• Praises interim recommendations

Special focus: Emphasizes need for evidence-based medicine
End-of-Life Nursing Education Consortium
Washington, D.C.
Special focus: Suggests integrating end-of-life and palliative care issues throughout all recommendations rather than addressing the issue in a separate recommendation
HIV Medicare and Medicaid Working Group
On behalf of 32 organizations from across the country
• Argues that the “core” benefits package should meet the needs of people living with HIV and AIDS

• Advocates for explicit measures to protect against high cost out-of-pocket expenses

• Strongly supports integrating health networks, including HIV centers of excellence, and ensuring patients have more choice over their end-of-life care, treatment, and environment

Special focus: Strongly supports the CHCWG interim recommendations and its call for all Americans regardless of income to have affordable and comprehensive health care
Lourdes (Ascension Health)
Binghamton, New York
Special focus: Suggests clarifying high cost in relation to income, otherwise generally supports the recommendations
National Athletic Trainers’ Association
Dallas, Texas
Special focus: Advocates for supporting policies that enhance injury and illness prevention and preventative care

• Argues for policies that address the shortage of health care workers
National Association of Dental Plans
Dallas, Texas
Special focus: Argues dental benefits companies are the most effective entities to provide dental coverage with input from dental providers
National Association of Health Underwriters
Arlington, Virginia
• Advises Working Group to address high health care costs with the private marketplace subsidizing individual policies and increasing federal subsidies for high risk pools

• Urges Working Group to encourage Americans to purchase long term care insurance in their report

Special focus: Advocates for retaining the national private health care insurance market
National Association of REALTORS
Washington, D.C.
Special focus: Urges support for federal legislation that would authorize the creation of small business health plans through trade organizations

• Suggests the small business community be represented on any independent, non-partisan, private-public group called for in the final report
National Committee for Quality Assurance
Washington, D.C.
• Recommends supporting pay-for-performance programs for prevention and chronic conditions

• Supports recommendation that enhances patient education opportunities

• Recommends making organizations who provide the core benefits package responsible for measuring and reporting quality measures

Special focus: Supports recommendation on improving quality and efficiency in health care
National Consensus Project for Quality Palliative Care
Pittsburgh, Pennsylvania
• Argues that palliative care should be explicitly included as a core benefit

• Urges health care policymakers to focus more attention on palliative care to ensure higher quality and more efficiently in care

Special focus: Advocates for placing greater emphasis on palliative care
Planned Parenthood Federation of America
New York, New York
Special focus: Advocates for CHCWG to address the need to increase funding for public programs that provide low-income women with comprehensive reproductive health services, as well as pre- and post-natal care services
Provena Central Illinois Region
United Samaritans Med. Ctr., Danville, Illinois; and Covenant Med. Ctr., Urbana, Illinois
Special focus: Supports recommendations to provide protection against high health care costs, making affordable health care public policy, and reforming end-of-life care to support the wishes of the patient
Providence Hospital (Ascension Health)
Mobile, Alabama
Special focus: Generally supports recommendations
Religious Coalition for Reproductive Choice
Washington, D.C.
Special focus: Concerned that the content of the core benefit package may be determined by ideological factors and not respect diverse beliefs

• Argues for addressing the inequities in medical care and coverage within the system

• Advocates for including comprehensive reproductive services and pre-post natal care in the core benefits package
St. Vincent Health (Ascension Health)
Indianapolis, Indiana
Special focus: Praises recommendations, placing particular emphasis on protection against high health care costs, integrated community health networks, and improving the quality of care
Supportive Care Coalition
Portland, Oregon
• Concerned that emphasis on preventative care will force Americans living with chronic illness to be fully responsible for their own care

• Advises the CHCWG to include spiritual and bereavement services in core benefits package

Special focus: Urges CHCWG to integrate end-of-life services into the other recommendations, where appropriate
United University Church
Los Angeles, California
Special focus: Concerned that delivery of controversial core services such as HIV prevention education, abortion, emergency contraception, condom distribution will be hindered at faith-based medical facilities
Vista Care
Scottsdale, Arizona
Special focus: Agrees wholeheartedly with recommendations, especially end-of-life
Common theme: Comprehensive comments on recommendations
American Academy of Physician Assistants (AAPA)
Alexandria, Virginia
• Supports health care delivered by qualified providers in physician-lead teams that are accountable to high professional standards
• Advocates for incentives to control costs through optimal use of primary care (e.g. health promotion and disease prevention), reducing administrative costs, eliminate cost shifting, and creating greater incentives for providers to give patients appropriate care
• Argues that fair and comprehensive medical liability reform is needed
• Endorses system reform that enhances the patient-provider relationship— and when appropriate—defer to the patient’s family to make decisions regarding patient care
American College of Physicians
Washington, D.C.
• Agrees with recommendations on moving toward universal access to care, creating a non-partisan, public-private group to create the core benefits package
• Argues for the need to identify target populations that are the most in need of health care coverage, access, and care
• Urges inclusion of explicit language on how to make prescription drugs more affordable
• Emphasizes need to make reimbursement levels for covered services fair and appropriate
• Argues for including explicit provisions on eliminating disparities in health care based on social, ethnic, racial, gender, sexual orientation and demographic differences
• Advocates for stronger emphasis on basic consumer protection rights, including rights to information
• Argues for ongoing evaluations of health care reforms
• Asserts need to respect individual choice of providers
Washington, D.C.
• Strongly supports end-of-life, integrated community networks, and public policy recommendations
• Argues that $4,000 deductible for high health care cost protection is still too high for poor Americans and would discourage necessary care
• Advocates for stronger language on greater transparency for insurance “purchasers” not just “consumers”
• Argues for quality and efficiency recommendation to endorse payment systems to reward high quality care and improvements in care”
• Strongly endorses the core benefits package and argues the recommendation is in contrast to the model of care implicit in the high deductible plan
American Medical Association
Chicago, Illinois
• Argues that the best method of expanding health care coverage is to cap or revoke the subsidy of employment-based coverage with the addition of a federal tax credit or premium subsidy for the uninsured
• Supports legislation to allow individuals to “buy in” to state employee purchasing pools
• Argues that emphasis on safety net in community health networks recommendation will undermine proposal to expand coverage to the uninsured
• Supports price transparency, health information technology improvements and a greater emphasis on community-based and home health alternatives for end-of-life and long term care
• Disagrees with defining a core benefit package and instead argues that benefit mandates should be minimized to allow markets to permit a wide choice of coverage options
American Medical Student Association
Reston, Virginia
• Asserts that recommendations would be strengthened if they included financial and long-term outcome projections
• Argues that high cost recommendation implies every American needs catastrophic coverage, when what they need is comprehensive care including the preventative and chronic care management health care service noted in the community network recommendation
• Argues that if federally funded health care centers are expanded to include new providers, they should be required to meet current federal guidelines
• Advocates for including all providers—not just federally subsidized programs—in provisions to improve quality and efficiency and increasing Medicare funding to address demographic changes in aging
• Advocates for single payer system to finance comprehensive national health care
• Stresses that the core benefits package recommendation must include a continuing evaluation component to review/revise benefits as necessary
American Nurses Association
Silver Spring, Maryland
• Praises Working Group support for affordable, quality health care for all
• Urges acknowledgement of discrepancies between community meeting input and the recommendations
• Argues the recommendations should have more explicit language on health care as a right for all—citizens and residents
• Advocates including more explicit language on controlling long term costs through emphasis on primary care and health maintenance
• Asks CHCWG to clarify whether protection against high care costs includes long term care
• Asserts that the community health networks need to be integrated with social services
• Advises against consumer-driven healthcare because of underlying assumption that patients are able to make the appropriate medical choices
• Urges integration of end-of-life services throughout the recommendations
• Advocates for explicit language on chronic pain management within section on palliative care
• Asks recommendation on affordable health care policy to include language on “removing financial barriers to care”
• Requests the CHCWG make a clear distinction between health services and health insurance
• Advocates including specific mention of “single payer” as a preferred path to financing reform
• Requests that insurers not play a role in defining the core benefits package as reflected in public feedback
American Osteopathic Association
Washington, D.C.
• Advocates for the creation of a national data bank that evaluates adverse medical events to improve quality of healthcare
• Advocates for focusing more on long-term impact of medical interventions on the patient’s quality of life as opposed to controlling costs
• Disagrees with the core benefits package, arguing it is not feasible
American Public Health Association
Washington, D.C.
• Advocates for guaranteeing basic health coverage rather than protection against very high health care costs
• Stresses including guaranteed Medicaid funding to federally funded health care centers in integrated community network recommendation
• Recommends changing current Medicare payment policy for hospice care
• Argues that data and specific details are needed to support the recommendation on affordable health care
• Requests more specifics on expert group who establishes core benefit package
Cincinnati USA Regional Chamber
Cincinnati, Ohio
• Urges CHCWG to quantify affordable health care and clarify who is calling for this recommendation
• Argues for more explicit language for each of the recommendations
City of Philadelphia
Department of Public Health

And additional letter endorsed by 17 organizations and 39 individuals
• Argues highlighting the importance of state and local government, business and labor, faith-based groups, payer organizations, and representatives for the public in defining a core benefits package
• Suggests using Philadelphia’s Health Leadership Partnership (HLP) as a model for building and integrating community health networks
• Second letter: Reiterates City’s support of community networks recommendation and urges use of HLP as a national model
General Accountability Office (GAO)
Washington, D.C.
• Urges Working Group to explicitly explain their method of incorporating public feedback and expert opinion when developing recommendations
• Critiques public policy recommendation for not addressing implicit fiscal challenge of charge
• Argues that recommendations need to make clear whether core benefits package will replace Medicare and Medicaid
• Advocates for separating the core benefit package into two levels of benefits—one universal, government basic coverage (preventative, some wellness, and catastrophic coverage) and the other— supplemental, private insurance to cover non-essential services
• Argues for using Medicare/Medicaid as explicit “prototypes” when promoting affordable health care
• Advocates for establishing national ‘medical best practices’
Health Care Leadership Council
Washington, D.C.
• Encourages greater emphasis on consumer education and outreach
• Advocates for government-financed private sector health Information technology investment to spur innovation
• Encourages Working Group to argue for medical liability reforms
Independent Living Resource Center San Francisco
San Francisco, California
• Disagrees with any recommendation using income as a determinant policy because that promotes a two-tiered system
• Concerned that the public/private partnerships discussed in the community networks recommendation will lead to corrupt and wasteful government contracts
• Proposes offering free tuition in exchange for M.D.s working in low resource locations
• Argues that greater emphasis in the report needs to be placed on independent living for people with disabilities
• Argues that consumers need options in a core benefits package that fit their needs
Mid-Valley Health Care Advocates
Corvallis, Oregon
• Urges recommendations to emphasize protection from high health care costs for all citizens, not just low-income families
• Disagrees with new order of recommendations
• Concerned that the integrated community network will create a two-tiered system of healthcare
National Coalition on Health Care
Washington, D.C.
• Advocates for inclusion of language specifying all Americans should have access to health care insurance and timely access to care
• Argues that rising healthcare costs need to be reduced to the annual increase in GDP per capita through limits on increases in insurance premiums for core benefit coverage and rates for reimbursing providers
• Supports a $1 billion federal investment in improving national health care quality and efficiency
• Urges combining high cost care and affordable health care for all recommendations into one
National Health Law Program
Los Angeles, California
• Advocates for clarifying values and principles, explaining how the recommendations will be implemented, and resolving potential inconsistencies between the terms “medically” effective and “evidence-based”
• Supports inclusion of comprehensive women’s health and language services
• Urges recommendation to protect low-income individuals during the transition to health care reform
• Advocates for broadly defining the standards and evidence that will be acceptable to determine core benefits
• Argues for a financing system in which the government is the single payer
• Advocates for financing strategies that consider low-income individuals’ existing tax contributions and relative burdens
• Urges replacement of all references to “citizens” with “Americans” with “Americans” defined to include immigrants
• Argues that report should state that health is a human right
• Advocates for spending what is necessary to attain the highest standard of health for everyone
• Asks for clarification that “right care at the right time” means that low-income individuals can receive medically necessary services at no cost without delay without cost-sharing
• Urges a distinction between “define set of benefits” and the “set of core health services”
• Argues that recommendations should explicitly state coverage of health service will not be linked to health status or behavior
• Suggests adding “quality” to the principle of affordability to guarantee “quality, affordable health care coverage”
• Urges clarification of the appointment process for the private-public group to minimize political influences
• Argues for coupling the proposal to expand health centers with the commitment to provide sufficient resources for the task
• Advocates for maintaining the requirement that patients occupy a majority of seats on an organization’s governing board as a condition of Federal funding
• Suggests the Working Group define length and scope of end-of-life services expansively with full funding by the federal government
• Argues for prioritizing the collection of racial, ethnic, and language data as the new health information systems are implemented
National Small Business Association
Washington, D.C.
• Argues for requiring that everyone have healthcare coverage and providing federal subsidies for low income individuals and
• Advocates for pay for performance incentives for health care providers based on outcomes rather than procedures
• Suggests the individual tax exclusion for health insurance coverage should be limited to the value of a basic benefits package
• Argues health services to be added to the core benefits package undergo cost/benefit analysis
Schuylkill Alliance for Health Care Access, Inc.
Pottsville, Pennsylvania
• Advocates for patient incentives to induce healthier lifestyles
• Argues patient out-of-pocket expenses should be based on a sliding scale
• Advises using sin taxes for financing
• Argues government health agencies need to improve coordination
Service Employees International Union
Washington, D.C.
• Asserts importance of retaining 2012 timeline for implementing recommendations
• Argues that more attention in the recommendations needs to be given to protecting Americans from high health care costs
• Advocates for including preventative services, long term care, and provider choice in the core benefits package