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.”

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

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.

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 www.citizenshealthcare.gov.

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