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Health Care that Works for All Americans

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Citizens’ Health Care Working Group
Public Meeting

Thursday, December 15, 2005

Washington, D.C.




Randy Johnson, Chairperson
Frank Baumeister
Montye Conlan
Joe Hansen
Therese Hughes
Catherine McLaughlin
Deborah Stehr
Chris Wright
Don Young


George Grob, Executive Director
Jill Bernstein
Craig Caplan
Carolyn Dell
Jessica Federer
Margretta Kennedy
Andy Rock
Connie Smith
Caroline Taplin

Other Attendees:

Surjeet Ahluwalia, AmericaSpeaks
Hala Harik Hayes, AmericaSpeaks
Mark Marich, PFI
Jonathan Ortmans, PFI
Tish Tanski, AmericaSpeaks
Carole Reagan, Associate to Joe Hansen

Meeting Summary

Randy Johnson, the Chairperson, began the meeting at 8:50 a.m. with a brief discussion of all the efforts of the Working Group.

Jonathan Ortmans and Hala Hayes provided a Presentation of Questions for Discussions At the Community Meetings (See Power Point Slide Presentation for more detail). The contractors presented the results of their effort, from the previous evening, to incorporate the comments of the Working Group into a draft framework for organizing the discussions at the community meetings:

Discussion Topic: Benefits

  • Categorical eligibility (who is covered) versus universal coverage (what is covered) -- Do you want to have a system of care which is based on providing specific benefits to certain categories of people or do you want to have a system where specific benefits are covered for everyone?
  • Incremental versus comprehensive -- Should we make comprehensive changes to provide coverage for everyone or should we make smaller changes to improve pieces of the system?

Discussion Topic: Delivery

  • Covering the uninsured
  • Expectations for quality -- What can be done to ensure people receive appropriate care?
  • Tort reform
  • Underserved areas -- What can we do to shrink the disparities in care between urban/suburban and rural communities? Or wealthy vs. poor?

Discussion Topic: Finance

  • Universal coverage? Should there be an obligation for everyone to participate? What can be done to increase participation by employees who choose not to be insured?
  • Relative preferences for: Who should pay for health care services? What factors should be used to determine premiums?

Discussion Topic: Tradeoffs

  • Cost versus choice – Are you willing to pay more to have your choice of plans, doctors, or hospitals?
  • Navigating the system – How do you navigate the health care system to get the information you need?
  • Overall quality versus flexibility in treatment – Do you favor use of best practice treatment guidelines?

Additional Topics for Tradeoffs

  • Cost versus quality -- For what improvements in the quality of our system are you personally willing to pay more?
  • Cost versus access -- Are you personally willing to pay more so that others can have access to health care?
  • Privacy versus improvements from electronic records
  • Spending more at national level versus other priorities
  • Willing to pay more now for future guarantee of coverage in the future?

The presented slides also captured the comments from the previous day of the criteria that ought to be used for guiding the development of discussion topics:

  • Bold & Different
  • Well Suited for Community Meetings
  • Key Issues Without a lot of Existing Information
  • Issues that Influence Your Recommendations/ Issues that Working Group Can Actually Influence

Community meetings would address the same broad questions; however, at the sub-question (or probing questions) level and in the discussions, the contents of the community meetings would likely diverge, depending on the participants.

Randy Johnson – Would we need to define a basic benefits package? Would it be the same as catastrophic coverage?

Joe Hansen – A basic benefits package sould include established medical care that covers the gamut; something that would have an 80-20 or 75-25 cost sharing (e.g., the individual pays either the 20 or 25 percent of the total cost of the coverage and an institution/employer pays the rest) with a “stop-loss” element (e.g., costs above some fixed amount are covered by the plan, thereby protecting the individual from unlimited financial risk). Otherwise, it isn’t possible to structure a health insurance plan that would cover everything.

Catherine McLaughlin – I think this is the wrong way to go. I’d rather ask about whether the individual wants want categorical versus universal coverage; then ask them what they’d like; questions should be about who should decide what benefits and coverage we have and what criteria are used for making these choices rather than the details how the benefit plan should be structured.

Frank Baumeister – Oregon did this 10 years ago; the health services commission did this and tweaked the list regularly.

Therese Hughes – I decide on my own health care plan based on cost. I believe the public wants to know what they will be required to pay for under different proportions of cost sharing. People all have budgets. I think we need to have that question included.

Catherine McLaughlin and Frank Baumeister – What we’re talking about here, however, isn’t what individuals have to pay but rather about national health care policy.

Randy Johnson – We don’t know what we’ll recommend or what people will express a desire for. We’ll need to know what they prefer, to help us with our recommendations. If we say that everybody should have coverage then we’ll need to say what that coverage is.

Catherine McLaughlin – These are separate questions about whether we replace major public programs. Universal coverage doesn’t automatically mean that we don’t keep some or all of the existing systems like Medicare, Medicaid or employer coverage. It may mean that we add something to cover the rest of the people not currently covered

Therese Hughes – If you want health care for all Americans, instead of categorical coverage as we have it now, it could mean a single payer or it could mean expansion of current programs.

Catherine McLaughlin – Some people think that, with the availability and use of emergency rooms, we already have de facto universal coverage now. First, we need to ask: “do we want to have a system of rationing services but to which everybody has coverage under?” If people reject that, we still need to ask whether everybody should pay for the services that the current system provides.

Frank Baumeister – This is Joe Hansen’s question from yesterday: “Does America want health care that works for all Americans as public policy?”

Joe Hansen – We need to define the problem before we ask how we’re going to pay for it; otherwise our effort to address problems with the current system will fail.

Catherine McLaughlin – We’re going to have to ration something; the only question is how are we going to ration (e.g., who gets services or what services they receive)?

Randy Johnson – We’ll have to get into how we’re going to finance that.

Joe Hansen – Senators Wyden and Hatch thought there were inefficiencies in the system and that we could pay for what we want with the current level of expenditures.

Randy Johnson – I think I heard Catherine McLaughlin say that the cost of covering the uninsured is not as high as we might think. Brent James said that if we are able to address the problems with inefficiency and administrative ineffectiveness, it would save enough money to go a long way in toward helping finance health care coverage for the uninsured. Those are some of the pieces we can include as we look at cost.

Joe Hansen – In the current system, we’re already paying for people who don’t have coverage because we have to pay for care provided in emergency rooms.

(The Working Group engaged in an extended discussion of how to structure the various questions that would be used in the community meetings. The two meeting contractors, PFI and AmericaSpeaks, were directed to further revise the draft set of questions. Items the Members thought needed to be covered included: broad coverage, delivery, financing, and tradeoffs. There was a discussion regarding the right level of detail into which the community meetings should proceed and whether to emphasize values and preferences at a broad level or on a more detailed level. Members expressed various views on the aspects of quality questions that ought to be included.)

Don Young – Do we maintain the current pluralistic system or come up with a simpler version for consumers? If you change it, what kinds of changes do you make?

Randy Johnson and Joe Hansen – We don’t want either leading or misleading questions included.

George Grob –The discussion guide will consist of two parts, the initial background section and the introduction to the questions.

Don Young – There is a good book “Hovels Persuaded” about the history about health care. The three questions we need to ask are: “Do you want a system controlled by the government?” “Do you want a system in which the government sets the rules but that is separately financed?” And, “Do you want a mix of systems, as we have today?”

Catherine McLaughlin – The questions regarding coverage, benefits, delivery and financing are the same. The first question is whether think the system is okay as it is, whether they want it overhauled, or whether they merely want gaps filled.

(Concern was expressed that if the Working Group makes recommendations to spend more in order to pay for additional levels of coverage that the Congress is unlikely to treat the recommendations seriously. If, however, the recommendations relate to reallocating the way funds are spent, there are still questions of how to allocate the total health care expenditures. In addition, what allocation methods should be used needs to be identified. The Members concluded that it would still be an appropriate question whether people believe that there should be more spent to assure coverage of the uninsured. The Working Group agreed that it doesn’t have to take a stand on how much should be spent but can emphasize where we should gather money from and where it should be spent.)

Jonathan Ortmans and Hala Harik Hayes summarized the questions the Members appeared to agree should be included:

  • Do you want “health care that works for all Americans” as public policy?
  • Do you want incremental versus comprehensive coverage?
  • How do you want to decide who is covered?
  • Who should decide what the basic benefit package is?

It was decided that the Working Group would be engaged in a rapid-response, iterative conversation regarding the discussion guide drafts and the questions to be used in the meetings. The contractors and Staff would prepare drafts; these materials would be shared with the Working Group as soon as possible with a rapid response required for comments to be considered, since there is very little time for preparing this before the first meeting, mid-January, in Kansas City, Missouri. However, it was agreed to clearly that all the Working Group Members would have the opportunity to see and comment on the drafts.

Jonathan Ortmans discussed the Structure of the Community Meetings, (See Power PointSlide Presentation). Briefly:

  • Registration is requested but no one is turned away at the door. People can register on line, by phone, fax, or can contact the regional coordinator.
  • Getting the word out consists of using local media, use of regional coordinators. (Randy Johnson has asked that the process for participant outreach be available to the full Working Group.) For every city, there is a web page set up; there are also lists of the “team” for that city. PFI and AS will provide personalized talking points on each city; a staff list will be provided for each location. Randy Johnson indicated that the Members needed an “execution plan” for each city.
  • When people register, demographic information is gathered; on the day of the meeting, the demographics are retaken on the spot. Efforts are made to stay in touch with the registered participants.
  • It has yet to be decided what follow-up to do with the participants of the meetings or whether to distribute materials to them.

(There was some discussion regarding the advisability of providing time for concluding comments by local dignitaries/VIPs at the end of each community meeting. Working Group Member would provide a brief wrap up. Jonathan Ortmans’ advice was that he, or another person acting as the facilitator, not be the one to provide any concluding comments. If the Working Group Member has the impulse to say something about the discussion that they’ve just heard, this could be valuable. All Members of the Working Group needs to be advised about this discussion. It was suggested that concluding remarks might be along the lines of: “I’ve heard some important things today,” rather than trying to summarize the entire meeting since this may not be the same as what the participants heard, in any case.)

Members expressed the need to make arrangements to enabled unemployed, non-white, disenfranchised individuals to get to the meetings, including transportation issues.

PFI has someone assigned to each city, a person in the city, and an audio-visual staff. Members are interested in recruitment; and if interested in the details of a particular city, the contact person for each city could be put in touch with the Working Group Member.

The length of time each community meeting would run was discussed. The question was posed whether 4 hours was the right amount of time for the staff-assisted meetings. There was no consensus about whether it was too long, just right, or potentially too short. PFI typically holds 3-hour meetings; AmericaSpeaks prefers all-day meetings. Four-hours represented what the two contractors thought a reasonable compromise in order to have the meetings that each supported be comparable.

It was asked whether the longer format would it exclude some people who were either unwilling or unable to spend that much time. It was also asked whether all the staff-assisted meetings were intended to be the same format. Randy Johnson, thought that four hours was too long; Catherine McLaughlin thought that there ought to be variation among the 24 staff-assisted meetings; Joe Hansen thought that 45-minutes per discussion topic for four topics was an absolute minimum and that quality would be lost if the sessions were any shorter.

There was some agreement that the first three staff-assisted meetings in January could be trial runs to see how well the format worked. There was a willingness to consider that there might be differences between the Signature, Standardized and Staff-assisted meetings and that possibly some of the latter could be shorter. Catherine McLaughlin indicated that she thought the Working Group had deliberately agreed that it did not want all the staff-assisted meetings to be the same and that they could have different formats: that Chris Wright has always wanted something on Native Americans; Dottie Bazos, something on end-of-life. George Grob agreed that his assumption was that the staff-assisted meetings could vary and that it had been understood that they need not look the same as either the Signature or the Standardized meetings.

Randy Johnson asked how, if the meetings were not similar, the Working Group would make sure that the input of the participants from the different meetings was treated the same. A response provided was that, while the input from such variable meetings would be treated just as seriously and would be used, it wouldn’t be combined with the data from the standardized meetings.

George Grob mentioned that time constraints during the past two meetings had prohibited covering the topic of how the data would be collected and analyzed and that it still remained to be discussed.

Hala Harik Hayes discussed the two Signature Meetings and the nine staff-assisted meetings that AmericaSpeaks would conduct or support, (See Power PointSlide Presentation).

Members generally agreed that there wouldn’t be a single cookie-cutter design for the meetings.

Frank Baumeister requested that there be ongoing active communications regarding the work that would be proceeding, to keep everyone in the loop.

The meeting closed with the agreement that there would shortly be a schedule update of the activities that would be happening and a series of Emails regarding the discussion guide and the questions.

The Chairperson closed the meeting at 2:30 p.m.