Summary of Findings

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

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

III. How should health care coverage be financed?

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

• free expression of all views, and
• sufficient structure to allow the Working Group to characterize and compare different views in order to reach conclusions based on the dialogue.

• "What’s Important to You" sought responses to four broad questions about people’s concerns about health care in America, views on changing the way health care is delivered or paid for, trade-offs that people would be willing to make to improve health care, and recommendations that people would make to improve health care for all Americans. The responses submitted by over 4,600 people from across the United States were coded into response categories and analyzed. The full text of close to 2,200 hand written responses was also provided to the Working Group for review. The United Church of Christ provided us with about 1,500 hand-written responses from people in about 10 percent of its 5,700 churches across the country to the open-ended questions posted on our Internet site; these are included in our analysis.
• Close to 600 people wrote to the Working Group, via the CHCWG Internet "Share Your Experience" page or in handwritten letters, to tell us about their own stories. Many of these described problems obtaining or paying for adequate health insurance or quality health care; some described very positive experiences with the health care system.
• The Health Care Poll posted on the web site drew over 13,000 responses from January through August 31 (see Appendix C). The Catholic Health Association (CHA) also provided over 1,000 poll responses that were submitted directly to CHA’s web site. These are included in the analysis of poll data; the responses are also presented in Appendix C. A number of organizations, including Communication Workers of America (CWA), Starbucks Coffee Company, The National Health Law Program, the National Assembly on School Based Health Care, Wheaton Franciscan HealthCare, and the American Nurses Association also provided information and links to encourage people to provide input to the Working Group. Many people affiliated with these groups participated in community meetings and via the Internet. More than 500 members of the CWA responded to the Internet poll (see Appendix C). Additionally, many of the organizations that conducted their own meetings sent us paper polls. The Area Agency on Aging in Florida provided about 50 poll responses from seniors in Florida. Written input mailed to the Working Group was coded and analyzed using the same protocols as the electronic data submitted over the Internet.

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

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

III. How should health care coverage be financed?

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

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

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

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

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

• In most meetings as well as on the Working Group poll, a majority of participants expressed a willingness to pay more to ensure that everyone has access to affordable, high-quality health care. Overall, about one in three (28.6 percent of poll participants) said they were willing to pay $300 or more per year.
• When asked to rank or choose among competing priorities for public spending on health, individuals—with few exceptions—were most likely to rank "Guaranteeing that all Americans have health coverage/insurance" as the highest priority.
• When asked to evaluate different proposals for ensuring access to affordable, high-quality health care coverage and services for all Americans, individuals at all but four meetings ranked "Create a national health insurance program, financed by taxpayers, in which all Americans would get their insurance" the highest. Three other options generally ranked in the top four choices at the community meeting locations: "Expand neighborhood health clinics"; "Open up enrollment in national federal programs like Medicare or the federal employees’ health benefits program"; and "Require that all Americans enroll in basic health care coverage, either private or public."

Detailed Description of Findings

Values

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

• When asked how they would describe the U.S. health care system today, 97 percent of attendees across all community meetings selected "It is in a state of crisis" (64 percent) or "It has major problems" (33 percent). In each of the 31 community meetings, at least 88 percent selected one of these options. Overall, only two percent said "It has minor problems," and one percent either said "It does not have any problems" or had no opinion. Underlying the discussion of the four legislative questions is the belief by virtually everyone in attendance at each community meeting that the health care system has at least some serious problems. This same concern has also surfaced in national polls. A January 2006 New York Times/CBS poll found that 90 percent of respondents said that our health care system needs fundamental changes or to be completely rebuilt (56 percent and 34 percent, respectively).1 This finding has been fairly consistent over the past 15 years. However, the Employee Benefit Research Institute’s annual Health Confidencet Survey has found from 1998 to 2004 the percent of respondents rating our health care system as poor has doubled from 15 percent to 30 percent. 2
  
• When meeting participants at all meetings were asked, "Should it be public policy that all Americans have affordable health care coverage?", 94 percent overall said "yes." Similarly, in the Working Group’s poll, 92 percent either strongly agreed (79 percent) or agreed (13 percent) with this statement. Over 90 percent of participants at community meetings and respondents to the Working Group’s poll believed that it should be public policy that all Americans have affordable coverage. As stated by participants in the Orlando community meeting, "Health care is a right and not a privilege." Seattle, Denver, and Philadelphia meeting participants, among other locations, desired "cradle to grave" access to health care.
  
• At many of the community meetings, participants were asked what they believed was the most important reason to have health insurance. Although the results varied by meeting site, individuals were more likely to choose the response "To protect against high costs" than they were to choose the response, "To pay for everyday medical expenses."

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

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

 

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

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

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

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

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

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

• People at the community meetings frequently expressed strong support for increased focus on wellness and prevention services as part of "basic" coverage, rather than focusing only on treating sickness. According to participants at meetings throughout the country, individuals have a responsibility to be good stewards of their health and health care resources (preventive care/screenings/use of services). They also viewed an emphasis on wellness and prevention services as a way to reduce health care costs, as discussed in the Financing section. According to these participants, disease management should also be a part of the focus. In the Working Group poll, over 90 percent of respondents indicated that annual physicals and preventive care should be part of a "basic" or "essential" benefits package, a level of support that was similar to that for hospital stays, prescription drugs, and lab tests.
  
• Participants at meetings continually emphasized the importance of a strong education component in health care and the management of health. To be good stewards of their health, individuals need to be educated about wellness and prevention. People thought information about how to use health care better and more effectively was important, but not information on cost. Broader issues of general education also came up in some meetings. Participants talked about the importance of beginning early, in grade school, to focus on basic skills that are prerequisites to literacy and health literacy. Fargo meeting participants expressed a preference for "school-based health promotion programs" for those in kindergarten through grade 12.
  
• Individuals voiced support for a fairly comprehensive basic benefit design. Benefits that a number of participants in meetings throughout the country viewed as important components of a basic benefit package included—but were not limited to—dental care, vision, hearing, care by non-physician providers such as nurse practitioners, long-term care, mental health, and hospice care. Some meeting participants also desired coverage of complementary and alternative medicine (for example, acupuncture).
  
• Although many participants recognized the need to do more to ensure that the health care provided is appropriate and delivered efficiently, they were also concerned about arbitrary limits on coverage and were not comfortable with bare-bones benefit packages. A participant in the Eugene community meeting made the point, "There’s a need for definition because we can’t afford it all." Still, when pressed to make decisions about what services to drop from basic coverage, many respondents told the Working Group "None," which was the most popular response in some locations.

"All people should have the same coverage that the President, Vice President, and Congress have…" (Phoenix meeting) "We agree that there should be a basic level of services for everyone- everyone has a right to that care. But our concern is that neither of those--what we have now, or a basic plan for everyone-- will work until it’s a consumer-driven choice and not a corporate solution that values profits above everything else. The consumer should be driving the choices, not like the way the culture is now. There should be more of a balance." (Charlotte meeting) "Every citizen has a basic right to have basic health care, and it can’t be based on the type of job they have." (Salt Lake City meeting)

• Despite the reluctance of many to limit benefits, participants at meetings supported limiting coverage to services to those that have proven medical effectiveness. They expressed a certain level of comfort with decisions that could affect utilization, if they were based on medical evidence. Just over half of the Working Group poll respondents agreed (36 percent) or strongly agreed (14 percent) that health plans or insurers should not pay for high-cost medical technologies or treatments that have not been proven to be safe and medically effective, and nearly a quarter were neutral on the subject; responses in the March University town hall meeting were similar (see text box below), with 58 percent agreeing (36 percent) or strongly agreeing (22 percent).

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

On March 22, 2006, 22 universities participated in a simultaneous discussion on health care. Sponsored by the Big Ten Conference and the Association of Schools of Public Health, and hosted by the University of Michigan, this virtual town hall meeting provided a forum for individuals across the country to voice their opinions on health care. Broadcast via satellite from the University of Michigan, individuals participated in this event either by gathering at various university sites, or by logging onto the forum through the Internet. Interactive technology allowed various locations to call in with questions and comments, and individuals submitted their feedback through e-mail to be read during the live event. The 21 simultaneous meetings held in addition to the host meeting were organized by their respective university communities, and followed the same format. Participants at these meetings received the standard Community Meeting Discussion Guide and a Health Care Poll, specific to this event, which included the majority of questions asked on the Working Group’s own Internet poll (as well as in many of the Working Group Community Meetings). The separate meetings also had access to a local faculty expert who assisted in sending comments and questions to the national coordinator at the University of Michigan. After the event, the completed Health Care Polls were coded (772 from 22 of the webcast sites) and entered into a data set that was made available to the Working Group for analysis (See Appendix D for a complete summary of the results). Participating schools were: Boston University Drexel University Emory University George Washington University Indiana University Johns Hopkins University Louisiana State University Michigan State University Northwestern University Ohio State University Penn State University Purdue University Tulane University University at Albany University of Arkansas University of Illinois University of Iowa University of Louisville University of Michigan University of Minnesota University of South Carolina University of Wisconsin

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

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

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

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

Some common themes emerged in response to this question:

• People wanted consumers to play an important role in deciding what should go into a basic benefit package. In meetings throughout the country, the majority of participants consistently answered that a combination of consumers, medical professionals, federal government, state and local governments—generally in that order—should be responsible for having input into these decisions. Some participants indicated that employers and insurance companies should also play a role, but one that is more limited.

In the majority of meetings, participants were asked, "On a scale of 1 (no input) to 10 (exclusive input), how much input should each of the following have in deciding what is in a basic benefit package?" When participants were asked the question in this way, the highest rating was always for input from consumers, and it was always followed by "medical professionals."

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

Responses to this question are illustrated in Figure 3. In some meetings and on the Working Group poll, individuals were asked which party or parties they would prefer to make the decision regarding what services are covered in the basic health insurance plan. At least 60 percent of Working Group poll respondents and participants in the half dozen community meetings in which the question was asked this way chose the "some combination" option (of consumers, employers, government, insurance companies, and medical providers; the question did not identify which specific combination people preferred).

In the Sioux Falls meeting, participants were also asked to rate the "degree of involvement" government, medical professionals, insurance companies, employers, and citizens should each have in determining what is included in a basic health care package using the scale: major role, minor role, and no role. Consistent with other findings, 88 percent of participants voted that citizens should have a "major role," and 73 percent indicated that medical professionals should have a "major role." Participants generally believed that government (72 percent) and employers (64 percent) should play a "minor role;" insurance companies received a mixed response, with 55 percent saying they should play a "minor role" and 42 percent saying they should play "no role."

Figure 3 (table):

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

Location	Federal Government	State/Local Government	Medical Professionals	Insurance Companies	Employers	Consumers
Jackson	3.6	3.0	5.7	1.8	3.6	7.8
Seattle	4.3	4.0	5.9	1.6	2.3	7.3
Denver	4.2	4.0	6.4	2.5	3.8	6.8
Providence	4.1	3.8	6.8	2.3	2.8	8.0
Miami	5.0	4.5	5.5	2.3	3.0	6.9
Indianapolis	4.9	3.9	6.1	2.2	3.3	7.6
Detroit	3.5	3.7	6.8	1.4	2.4	7.6
Phoenix	3.9	3.7	5.2	2.0	3.4	7.7
Des Moines	5.0	4.7	5.4	2.2	2.6	6.7
Philadelphia	4.4	4.4	6.0	1.5	3.1	6.7
Sacramento	3.8	3.8	6.4	2.5	2.9	7.4
Billings	5.1	4.7	6.0	2.4	4.0	6.3
New York	5.2	4.1	6.7	1.4	2.1	7.7
Tucson	3.9	3.4	6.2	2.6	3.2	6.6
Salt Lake City	4.6	4.7	4.9	2.6	3.1	6.8
Average	4.4	4.0	6.0	2.1	3.0	7.2

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

Mental Health Meeting

At its Boston meeting in August 2005, the Citizens’ Health Care Working Group heard from a panel made up of the Director of Mental Health Services for Massachusetts, a representative from a managed behavioral health care plan and an advocate for the mentally ill. As members of the Working Group attended community meetings, they heard that access to mental health services was a significant issue to many participants. In order to delve more deeply into issues related to mental health, the Working Group sponsored a meeting focused on this topic in Atlanta, Georgia on May 22, 2006, at Skyland Trail, a mental health facility which offers long- and short-term residential care and community-based therapy, with the National Mental Health Association of Georgia as a host. The participants at this meeting were knowledgeable about mental health. They included providers and consumers of mental health services, family members and advocates for the mentally ill and other health care providers. The meeting format was a mix of questions used at other community meetings and questions specific to mental health. Attendees believed that the value most fundamental to a health care system "that works for all Americans" is universal access, with health care as a right. Other important values are affordability and equal quality of care for all. In considering what was most important to the delivery of mental health care services, universal access was also the most important value, accompanied by integration of mental health into primary health care, parity for mental health care and eliminating the stigma attached to mental health. The issue participants believed most important to address in getting mental health care services is the lack of parity in insurance treatment of mental illness. Other problems that are priorities for action include the need for more funding for mental health services, the stigma associated with mental health conditions, continuity of care and the need for education to help people "know what is wrong and where to go for help." The inappropriate criminalization of mental health behaviors was also identified as a problem. When asked about the delivery of mental health services within the overall health care system, a majority of attendees embraced this vision which was developed by one table of participants:

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

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

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

 

• At the community meetings, individuals asked for a delivery system that is secure, transparent, easy to navigate, and treats the "whole person." Having a continuing relationship with a personal physician is just one component of a stable system, according to the participants. Confidentiality of medical records was mentioned as another important component of a good health care system. Individuals expressed a desire for a system that is holistic, treating the whole person rather than just treating "a bundle of symptoms," as described in the Denver community meeting.
  
• Affordability of care is a primary concern among participants. At meetings throughout the country, individuals discussed how costs had prevented them or others from getting needed care. Costs of care generally referred to their (or their family’s) costs, including co-payments, deductibles, and health insurance premiums, rather than system-wide costs. Participants in different cities indicated that the high costs of prescription drugs were a particular concern. Participants in the Salt Lake City meeting discussed how "people are being priced out."
  

• Participants were troubled that many people did not have access to the health care they need. Access to care includes access to both facilities and health care providers, including specialists. Participants in community meetings nationwide highlighted problems with access to health care in rural areas, including lack of transportation to providers or facilities located far away. The lack of public transportation was brought up as an issue not only for rural areas, but for urban areas as well. Others described problems finding an accessible provider who was willing to accept their insurance, particularly Medicaid. Providers and facilities tend to be concentrated in suburbs and more populated areas. For example, in the Phoenix community meeting, individuals noted that most providers and specialists were concentrated in the Phoenix area, and it was difficult to access care in other areas of the state. According to a national Wall Street Journal/Harris Interactive survey 56 percent of adults agree that people who are unemployed and poor should be able to get the same amount and quality of medical services as people who have good jobs and are paying substantial taxes. 10

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

"It’s so complex. You wake up one day and your contract has been renegotiated, your numbers have changed, and your providers have changed. There are too many rules and too much bureaucracy."

• Linked to confusion about the health care system was the lack of useful information to help individuals navigate the health care system. Individuals wanted to have access to understandable medical information to help them make educated decisions about their health care. Many participants discussed their desire to partner with their health care provider in making health care decisions. Participants noted that sometimes it was very hard to find any information, although we also heard from some participants that information was available if one knew where to look. People often were not sure where to go to find what they needed. The desire for information is not unique to Working Group community meeting participants. According to a 2005 Gallup Poll, a slim majority (51 percent) of individuals said they do not have enough information about hospitals and other health care facilities to make educated choices for health care services. 11
  
• Participants mentioned that they or others were not always treated with respect or dignity. Examples of problems people encountered included a lack of effective communication, discrimination by race or ethnicity, long wait times, and overcrowded emergency rooms. In a number of locations, meeting participants discussed how they had encountered or knew of barriers due to race or ethnicity, language, lack of cultural sensitivity, and lack of health insurance.

"It’s often more stressful to deal with the insurance company than it is to deal with the disease." (Des Moines meeting) "There should be no waiting period before becoming eligible for coverage." (Lexington meeting)

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

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

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

The responses to this question built on the answers to the previous question about problems getting care. The primary themes related to affordability, accessibility, and forming mutually respectful relationships with providers.

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

"I feel like we are only as good as our weakest link, and so many people can’t afford care." (Fargo meeting)

• Participants wanted all Americans to be able to get the right health care, at the right time, in a respectful manner. Access for everyone emerged as a common theme across meeting sites. Some meeting participants said that receiving "the right health care" meant that medical decisions would not be based on factors such as a person’s age. Many participants decried making medical decisions on the basis of cost rather than medical need, but did want the care they receive to be delivered in a cost-effective manner. Participants expressed the need to have care received in a coordinated and timely manner. Among other factors, getting the right care in a respectful manner involved having a provider who was courteous and could communicate well. As stated in meetings from Charlotte to Seattle, participants believed that care should be sensitive to the needs of different cultures. The desire to be treated with respect has also been shown to be highly valued in other national surveys. A 2004 Wall Street Journal/Harris Interactive poll asked what qualities people believed were extremely important from the doctors who treat them; some of the most popular responses related to the medical provider’s interpersonal skills—such as being respectful (85 percent) and listening carefully to health care concerns and questions (84 percent). 12
  
• Participants noted that being able to choose and maintain a stable, long-term relationship with a personal health care provider was critical. Individuals at meetings throughout the nation reiterated the importance of the provider-patient relationship that they believed should not be affected by whether a person switches jobs or changes health insurance. In the Phoenix community meeting, participants valued being able to choose a provider that would listen to them and provide "true" care, rather than just writing out a prescription. They wanted to be able to keep their health care provider even if they changed insurance carrier. In a number of locations (such as at the meetings in Orlando and Detroit), participants also discussed the importance of choosing a specialist. Participants at the community meetings told the Working Group that they placed a high value on having a "medical home" in which they can spend individual time with a provider. On the other hand, some participants at other meetings, such as San Antonio, expressed a willingness to forego some choice of primary care physician in exchange for lower costs or higher quality care.

• Although the results differed across meeting sites, a majority of participants (ranging from 55 percent to 88 percent in the community meetings) believed that everyone should be required to enroll in either private or public "basic" health care coverage. Support for some form of mandated coverage is displayed in Figure 4. Fewer than half (47 percent) of the Working Group poll respondents agreed or strongly agreed with requiring everyone to enroll in health coverage, and another 21 percent said they were "neutral." Over 80 percent in the University town hall meeting said everyone should be required to enroll in basic (public or private) health care coverage.

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

• The most popular choice of criteria was income. In other words, those with higher incomes should pay more than those with lower incomes. Some participants argued that those with very low incomes should not have to pay anything for their care. A July 2006 Wall Street Journal Online/Harris Interactive Poll found that 39 percent of adults agree that the higher someone’s income is, the more he or she should expect to pay in taxes to cover the cost of people who are less well off and are heavy users of medical services. 13
  
• The next most popular criterion often was health behaviors. Such a system could be structured either by reducing health insurance costs for those who practice healthy lifestyles (for example, exercising regularly, not smoking, wearing seat belts, etc.), or by increasing health care co-payments or premiums for those who practice unhealthy behaviors, such as smoking. (In three of the community meetings, the choice "other" was changed to "other/combination of factors," which could include both income and health behaviors, as well as other factors.) According to a Wall Street Journal Online/Harris Interactive Poll conducted in July 2006, more than one in three agreed (35 percent) but another 35 percent disagreed that it is unfair to require the majority of people who are healthy to pay for most of the cost of treating those who are sick and heavy users of hospitals and doctors. 14

Figure 5 (table):

Should some people be responsible for paying more than others?

Percent Saying "Yes":
Less than 60%	60-69%	70% or More
Indianapolis (58%) Sacramento (43%)	Orlando (64%) Baton Rouge (60%) Memphis (66%) Jackson (60%) Denver (66%) Miami (63%) Phoenix (65%) Tucson (61%)	Kansas City (72%) Charlotte (72%) Seattle (77%) Providence (79%) Detroit (81%) Des Moines (73%) Philadelphia (83%) Billings (76%) Salt Lake City (80%)

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

 

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

Figure 6 (table):

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

Location	None—everyone should pay same	Vary by Family size	Vary by health behaviors	Vary by income	Other	Other/ Combination
Orlando	21%	6%	15%	41%	17%	Not asked
Baton Rouge	6%	15%	27%	44%	8%	Not asked
Memphis	15%	3%	11%	58%	14%	Not asked
Charlotte	12%	1%	27%	32%	27%	Not asked
Jackson	26%	4%	19%	38%	13%	Not asked
Denver	16%	4%	16%	57%	8%	Not asked
Los Angeles	20%	4%	11%	51%	15%	Not asked
Providence	20%	2%	27%	45%	6%	Not asked
Indianapolis	16%	4%	29%	47%	5%	Not asked
Detroit	12%	7%	7%	69%	7%	Not asked
Phoenix	26%	2%	12%	52%	8%	Not asked
Des Moines	17%	4%	16%	61%	3%	Not asked
Philadelphia	8%	5%	7%	70%	10%	Not asked
Billings	12%	7%	29%	44%	8%	Not asked
Fargo	6%	1%	11%	21%	--	61%
Little Rock	11%	5%	6%	15%	--	62%
Tucson	18%	0%	18%	50%	13%	Not asked
Sioux Falls	13%	3%	23%	10%	--	52%
Salt Lake City	9%	4%	23%	59%	6%	Not asked

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

 

On the Working Group poll, there were multiple questions about how higher income people might pay more for coverage. About 40 percent (38 percent) of respondents agreed or agreed strongly that everyone should pay the same for health insurance, while 44 percent disagreed or strongly disagreed. When asked whether people with higher incomes should pay higher premiums for employer-sponsored health insurance, 37 percent agreed or strongly agreed, while 43 percent of respondents disagreed or strongly disagreed. Moreover, about one-third (34 percent) of respondents agreed or strongly agreed that higher income people should pay higher premiums for health insurance they buy themselves, compared to 45 percent who disagreed or strongly disagreed.

The level of support for higher-income people paying more for health insurance they purchase themselves was similar across education levels of the people responding to the Working Group poll. A large share of respondents disagreed or strongly disagreed. These findings may reflect the view, also heard at many meetings and in comments submitted via the Working Group poll, that there is some support for higher contributions from higher-income people, but there is less support for direct income-related cost-sharing or premiums than there is for contributions to a national coverage system through some form of progressive tax, as discussed below.

According to a recent Los Angeles Times/Bloomberg survey 34 percent of adults believe that it is the government’s responsibility to ensure that all citizens have health insurance and income for retirement, while 28 percent believe that it is the employer’s responsibility and 28 percent believe that it is the individual’s responsibility.15

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

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

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

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

Figure 7:

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

Percent Saying "Yes":
Less than 30%	30-49%	50% or More
Memphis (29%) Providence (27%) Detroit (23%) Hartford* (15%; 41% abstained) Des Moines (24%) Las Vegas (25%) San Antonio* (14%; 48% abstained)	Kansas City (36%) Seattle (32%) Denver (39%) Los Angeles (37%) Indianapolis (31%) Albuquerque (39%) Philadelphia (32%) Eugene (32%) Billings (46%) Fargo* (44%; 27% abstained) Little Rock* (42%; 23% abstained)	Orlando (60%) Baton Rouge (87%) Charlotte (62%) Jackson (72%) Miami (67%) Phoenix (53%) Lexington* (63%; 18% abstained) Cincinnati (50%) Tucson (50%) Salt Lake City (53%)

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

 

"I do believe all employers large and small should give their workers insurance. There should be programs or better tax cuts for those employers." "[Expand] tax incentives for companies that provide health care benefits for their employees. Small companies should be able to join together to take advantage of group rates. Corporations like Wal-Mart should be penalized for not providing decent health care benefits for its employees." "If employers are to continue to provide coverage, all employers must participate, nationwide." "I think that placing the burden of health care on employers makes American businesses less competitive in the global market. At the same time, I think that placing the burden of paying for health care on individuals will ultimately drive up the cost of care by forcing the poor and middle-income among us to rely on costly emergency services that hospitals cannot ethically deny based on inability to pay, rather than cheaper preventive care which they can." "We must sever the relationship between health insurance and employment. Employers should not bear the cost; it is impacting our competitiveness in the global market and it leaves huge gaps in which persons not employed in a company providing health insurance, are forced to bear huge costs of non-group insurance or, most likely, go without insurance at all. The rising percentage of uninsured is a tragedy in itself because these people frequently go without needed health care until they reach crisis. In addition, we all pay for the uninsured through higher and higher insurance premiums. Our system must be completely overhauled and redesigned to provide universal coverage with buy-in by all who have the means and a safety-net for those who can not." (Comments submitted to CHCWG "What’s Important to You?")

• Views about employer-based coverage did not generally reflect a deep distrust of employers, but instead were intertwined with broader concepts of health reform. The extent to which participants at a meeting may have been more heavily focused on fundamental reform, like a single-payer system, affected the group discussions about employer-based coverage. An analysis of Internet and mailed-in, open-ended responses to the question about changing the way health care is financed, as well as comments from participants at some community meetings, revealed at least four—sometimes overlapping—categories of responses.
  
• "The current system should be maintained or bolstered, either on an ongoing basis or as part of a more comprehensive system." Some meeting participants supported a clear role for employers and a continuation of the current tax rules for employers. Some participants who supported retention of these tax rules argued that they needed to be applied fairly, with small businesses needing additional incentives. Meeting participants who supported comprehensive reform through some type of national plan told the Working Group that, in the absence of a national plan, employers would need to be responsible, with tax breaks provided to assist small businesses. Without a national plan, participants worried that people across the country would lose coverage through employers dropping insurance. In the community meeting in Los Angeles, participants who supported continuing the current tax system did so because they believed it encourages employers to provide coverage that they might otherwise not have an incentive to provide. They also felt that the system leads to higher employer productivity and helps promote shared responsibility.
  
• "Employer-based insurance is not sustainable and is too expensive." Many participants felt the nation should move away from current tax rules that favor employer-sponsored coverage. Even with the current tax breaks, health care costs continue to rise rapidly, and both businesses and employees are footing ever larger and unsustainable expenditures. Some meeting participants believed that the system of employer-based health insurance needs to be replaced to make U.S. industries more competitive. At least one person noted that the employer subsidies were invisible to the average citizen, unlike Medicare or Medicaid, whose costs are frequently cited. Other participants noted that they were afraid to leave their jobs because of fear of losing health insurance or paying higher premiums. Those who opposed the current tax breaks cited a lack of equity in the current employer-based insurance system, a system that, as long as it exists, means that health care, as stated by someone at the Indianapolis meeting, will be, "an imperfect patchwork full of gaps."
  
• "The whole system should be changed fundamentally, but employers should contribute through some form of taxation or contributions to a pool." Other participants indicated an interest in a non-employer based system, but one in which the employers are still involved. For example, in the Des Moines community meeting, a participant referred to the employment-based system as "…outdated and the money saved from not having an employer-based system could go towards higher salaries and/or taxes to create a new system." Some participants at different meetings supported fundamental change to the system, but believed that a transition period should be implemented during which employers would still contribute to the system.

"We need to have one single pool of Americans who are insured. This would help spread their risk and everyone could be covered. Employers could contribute to the costs, but individuals should be able to contribute on their own." (Comments submitted to CHCWG Internet "What’s Important to You?")

• "Employer-based insurance is unfair, inequitable, and inadequate." A number of participants discussed other aspects of the employer-based system that were not working. For example, participants brought up the fact that some employers are going around the current tax system by hiring only part time employees, to whom they are not required to offer full benefits. In the Los Angeles meeting, many participants supported a government-run universal health care system because they felt that the current employer-based system is unfair. They expressed concerns that it excludes self-employed, unemployed, and part-time workers, and favors large corporations. These participants supported replacing the employer tax incentive with another type of tax (such as an income or payroll tax). At several meetings and in Internet comments, some called for a national value added tax(1) or national sales tax. A large number of participants expressed the opinion that access to care should not be tied to insurance coverage.

"Employer-sponsored insurance worked when it was a perk, an extra offered by employers. But now coverage is a necessity, not a privilege." (Billings meeting)

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

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

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

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

The Working Group poll also shows some support for strategies that focus attention on the costs and appropriate use of health care. A majority of respondents either agreed (37 percent) or strongly agreed (19 percent) that we should all pay for part of our health care costs so that we will be more careful about how we use health care services.

Hearing from self-employed small business owners

The National Association of Realtors hosted a community meeting during their annual legislative conference on May 16, 2006, in Washington, DC, to enable the Citizens’ Health Care Working Group to hear from these self-employed small business owners from around the country. Participants at this meeting sought to identify solutions for the problems specific to self-employed small business owners. They recognized that more than one in four of the nation’s 1.2 million realtors have no health care coverage, while many others are only a single health incident away from having their livelihood destroyed by high health care costs. Recurring themes in this meeting included a desire to have protection from financial ruin, having access to affordable care, and increasing the information available for patients on cost and quality to enhance their decision-making capabilities. They emphasized the need for a level of security in the health care system, saying that "we need something that ensures that if we become very ill, it doesn’t take away our livelihood or what we’ve worked so hard to earn all our lives." While most participants agreed that everyone should have access to basic health care services, they were rather evenly divided on whether or not people should be required to have health care coverage. One participant said that "at first I was going to say no (to a requirement), but then I thought, if they aren’t required to sign up for it then the only time they will get in the system is when there is emergency care and that will cost us more." Desiring to keep health care "in the competitive arena," participants talked about the need to have greater transparency in costs, standardization of forms, and understandable information to enable them to be better patients. There was a clear sentiment at this meeting to limit government involvement, with participants asking "has it ever improved anything if the government gets involved and standardizes it?"

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

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

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

• Participants frequently stated that the problems of high costs rest with "price setters"—namely, prescription drug companies, insurers, and for-profit providers. In meetings throughout the country, participants mentioned the desire to limit profits in the health care sector. Some participants also noted that allowing the government broader authority to negotiate prices with pharmaceutical companies would reduce Medicare costs. The Working Group poll showed strong support for government setting limits on prices for health care products such as prescription drugs or medical devices; just over 70 percent of respondents strongly agreed (39 percent) or agreed (32 percent) with these government-set limits. The general lack of trust of for-profit health care expressed in the community meetings is consistent with other national survey findings. For example, a December 2003 Wall Street Journal Online Health Care Poll found that most of the public do not view health care as a business that should be driven by the profit motive, and only 22 percent would prefer that for-profit insurance provide most health insurance; the findings indicated a preference for government (31 percent) or non-profit organizations (25 percent).16
  
• A commonly expressed view was that a simpler system would result in lower administrative costs. Participants believed that a more straightforward health care system would reduce administrative costs by eliminating duplication of services. At a number of meetings throughout the country, many individuals advocated a single-payer system to eliminate the middleman, possibly one structured like Medicare or similar to the public school system. Under this type of system, everyone would pay taxes to support the system, even though, as with education, they might not use the services. Participants advocating the single payer concept said it would be the most efficient way to organize health care.

"I paid over $12,000 in expenses (not including legal fees) to collect $12,500 in medical expenses because insurers were arguing about who was responsible. Everyone wants to avoid paying. It would be vastly cheaper to adopt any of the European systems." "I think we'll finally, inevitably, follow the lead of every other Westernized nation and institute some form of extensive public health care system – I think it's the most efficient system, and the one that gives the best care to the most people. The biggest problem I see with the system as it now stands is that we as a society spend a huge amount of money putting a profit in the pockets of the ‘middleman’ in the system—the insurance companies. That's why we spend 50% more of our GNP on health care than other nations do while getting worse care, and it's absurd." (Comments submitted to CHCWG Internet "What’s Important to You?")

• Some support exists for investment by providers and the private sector in health information technology to increase system efficiency. At a number of meetings, participants supported increasing the availability of electronic medical records. Greater investment in health information technology and moving to an integrated system of electronic medical records could improve administration and treatment and reduce medical errors, according to views commonly expressed at the meetings. More than 70 percent (71 percent) of respondents to the Working Group poll supported more investment by doctors, hospitals, and other providers in health information technologies as a means to improve quality and increase administrative efficiency. (By comparison, a 2005 Wall Street Journal Online/Harris Interactive poll found that 78 percent of the public supported doctors’ use of electronic medical records.)17
  
  A concern discussed at some meetings was privacy of the electronic medical records, which is highlighted in recent national surveys. For example, a 2005 Harris Interactive poll found that 70 percent of Americans are very or somewhat concerned that personal medical information might be leaked due to weak data security, and the public was evenly divided on whether the potential benefits of electronic medical records outweigh the potential risks to privacy.18
  
  Public investment in health information technology was not identified as among the priorities for public spending on health and health care by most Internet poll respondents (see Appendix C).
  
• Participants expressed general support for individuals playing their part in controlling utilization and costs. Individuals have a responsibility to be informed health care consumers and comply with recommended treatments. To this end, participants suggested several related ideas:
  • Individuals would like information about how to use health care better and more effectively. For example, those with chronic diseases could use more information to properly manage their treatments.
    
  • At some meetings, participants supported providing incentives to patients to engage in healthy behaviors. Some participants supported the idea of rewarding people who practice healthy behaviors (for example, not smoking, or getting recommended health screenings). On occasion, participants also discussed the notion of penalizing people who engage in unhealthy lifestyles. The type of unhealthy behavior in question affected participants’ opinions, consistent with other national surveys. According to a 2005 Wall Street Journal Online/Harris Interactive poll, the majority of Americans supported the idea of smokers, those who do not wear seat belts, and those who drink alcohol heavily paying more in health insurance costs; however, the same poll found strong opposition for charging more to those who are overweight or who do not exercise regularly.19 According to a 2006 Wall Street Journal Online/Harris Interactive poll that compared results from the same poll in 2003 to the results in from the 2006 poll, in 2006 53 percent of adults agreed that it is fair to ask people with unhealthy lifestyles to pay higher insurance premiums than people with healthy lifestyles; while in 2003 only 37 percent of adults agreed.20
    
  • Participants expressed preferences for using medical evidence to decide which services are covered and provided. Many participants discussed the importance of focusing on evidence-based medicine.
    
  • There was general support for controlling prescription drug costs by limiting direct-to-consumer advertising of prescription drugs and using more generic drugs, when medically appropriate. Participants at many meetings expressed the desire to limit or prohibit direct-to-consumer advertising of prescription drugs, which could reduce the over-use of heavily-advertised drugs and slow the growth of health care costs. Some people mentioned ideas to make generic drugs available more quickly in the market; for example, Orlando community meeting participants suggested reducing the length of time of the exclusive patent rights of pharmaceutical companies.
    
  • Support also existed for limiting expensive yet "futile" end-of-life care and instead providing palliative care. Participants at meetings generally recognized the high costs associated with certain end-of-life services, some providing little value to the patient despite their high costs. At the same time, they stressed the importance of pain management, hospice care, and other support services to improve the quality of the last days of life. Better communication with patients near the end of life was considered to be an important step in controlling these costs. Participants in some meetings stressed the importance of living wills and medical directives that detailed people’s wishes for treatment if they were too ill to communicate. At many meetings, similar concerns were expressed about the effectiveness and costs of care for very fragile newborns.

"We should have the decency to honor end of life by not pumping millions into the last days but rather encouraging high quality comfort care." (Sioux Falls meeting)

• In almost all community meetings, participants expressed the belief that changing the culture from sick care to well care—namely, by focusing on prevention, wellness, and education (in general, and health education in particular)—will reduce health care costs. Participants broadly supported greater emphasis on prevention as part of a "culture of wellness" in the health care system. A number of participants in community meetings across the nation (including Des Moines, Fargo, Salt Lake City, Las Vegas, and others) emphasized the need for education of both children and adults to make this culture possible.

"If we want to bring the cost of health care down, then ultimately, we need to reduce the burden of disease. We need to reduce the need to spend money rather than figuring out how to redistribute the money. Otherwise the system will remain broken regardless of how we want to pay for it." (Indianapolis meeting)

• A commonly expressed view was that better use of advanced practice nurses and other non-physicians could save money and improve quality. In some meetings, participants supported the increased use of care provided by health professionals other than physicians including greater use of home-based care.
  
• Participants believed that investing in public health would pay dividends in terms of reducing health care costs. Some people discussed providing more funding for community health centers and for public health more generally. They believed that doing so could reduce racial differences or disparities in health care, and could effectively reduce overall system costs.
  
• Support for limits on malpractice was expressed at some community meetings. Some participants discussed decreasing malpractice costs.

End-of-life care has surfaced at virtually every community meeting as an issue that encapsulates many of the frustrations with health care in America. Sometimes meeting attendees discussed the need for hospice care in the basic benefit package. Sometimes participants talked about exchanging expensive measures of questionable efficacy for the dying for general improvements in access to care. Usually, the speaker raising the issue has been a bit tentative. "I’m not sure how to phrase this…" or "This sounds clumsy…" Death is a difficult topic among family and friends; it’s also difficult in a policy context. At its Boston hearing, the Working Group heard a panel of experts on end-of-life care. This discussion was compelling, and members asked that a community meeting be held on the topic (information on the presentation can be found in Appendix E). This special topic meeting was held March 31, 2006 in Hanover, New Hampshire. About 120 people attended. "Living Well through the End-of-Life" was the theme of the meeting. The last chapter of many people’s lives requires support and assistance, but often what is needed to live well is not medical in nature. Transportation, personal care, and help with meals and cooking are all needed. What people attending the meeting feared most about their final days (or those of someone close to them) were intractable pain, "prolongation of death," and losing personal control. They identified potential challenges related to "getting the system to work for you when you are dying" or "graceful surrender." What people wanted most from the medical system was to have their choices honored, good pain relief, and respect from health professionals so they could maintain their dignity. The majority believed that family and friends are the primary sources of such help, but that some paid assistance should also be available. People would like respite services for the principal care provider and a contact person for coordination of community help. "Care has to be taken out of the medical system and accommodate what happens in the community." Most people (69 percent) wanted to die at home. Close to 85 percent believed that other choices could be acceptable if certain elements of care were well managed. When asked what policy advice they’d give their Senators, participants had many specific suggestions, such as realigning financial incentives so that physicians could be encouraged to spend more time talking to patients and a request to revisit Medicare hospice payment practices. However, suggestions quickly began to mirror what has been heard in other meetings. "As a health care consumer, I want appropriate, timely, comprehensive care from conception to death and I would be willing to pay an additional modest percentage of income across my working life to achieve this."

A value added tax is a tax, levied at each stage of production, on the added value in each stage as firms produce goods or services. It is similar in some respects to a sales tax. Many industrialized nation employ various types of value added taxes. (See Bickley, James M. CRS Report for Congress Value-Added Tax: A New U.S. Revenue Source? Washington D.C: Congressional Research Service, August 22, 2006. Accessed at http://opencrs.cdt.org/rpts/RL33619.pdf.)

• In most meetings as well as on the Working Group poll, a majority of participants expressed a willingness to pay more to assure that everyone had access to affordable, high quality health care. Overall, about one in three (29 percent) said they were willing to pay $300 or more per year. Sizable shares of participants expressed a willingness to contribute some additional amount each year toward the stated goal. (See Figure 8.) Although the size of the groups varied, some participants at all meetings said they would be willing to pay an additional $1,000 or more in a year. The Working Group poll indicated that 12 percent would be willing to pay $1,000 or more per year (in taxes, premiums, or deductibles) to support efforts that would result in access to affordable, high-quality health care services and coverage for all, and 17 percent would be willing to pay an additional $300 to $999. Another 19 percent said they did not know, and 13 percent said they would not be willing to pay anything extra.

In the Working Group poll, the amount they were willing to pay was fairly consistent across age; however, persons with the highest levels of education (those with graduate degrees) were more likely to be willing to pay $1,000 or more than those with less education, a finding that could indicate that those likely to have more money are willing to pay more. It may also reflect that those with higher levels of education typically have richer employer-sponsored insurance packages, face lower out-of-pocket payments, and therefore have not already reached their limit in terms of willingness to pay. At the meeting with realtors (see "Hearing from self-employed small business owners" text box presented earlier), where few have any employer-sponsored insurance and face high premiums in the individual market, a large percentage were not willing to pay anything more, even though they earn relatively high incomes. Even so, in the 28 meetings where the question was asked, at least 43 percent of participants indicated some willingness to pay more to achieve this goal.

Notes: Figures may not add up to 100 percent due to rounding. The "don’t know" data for the Working Group poll includes the one percent that did not respond. Question was not asked in the Seattle, Miami, or Sacramento community meetings.

• When asked to rank or choose among competing priorities for public spending on health, meeting participants—with few exceptions—were most likely to rank "Guaranteeing that all Americans have health coverage/insurance" at the top of the list. In the Working Group poll, 64.6 percent chose this as among the top three priorities for public spending on health.
  
• Other spending priorities in the list that tended to score high included:
  • Investing in public health programs to prevent disease, promote healthy lifestyles, and protect the public in the event of epidemics or disasters
    
  • Guaranteeing that all Americans get health care when they need it, through some form of public or private program, including "safety net" programs for those who cannot afford care otherwise
    
  • Guaranteeing that there are enough health care providers, especially in areas such as inner cities and rural areas , and
    
  • Funding programs that eliminate problems in access to or quality of care for minorities.

• A poll conducted in December 2004 by The Pew Research Center for the People and the Press found that 65 percent of Americans favor or strongly favor the U.S. government guaranteeing health insurance for all citizens, even if it meant raising taxes (Pew); an earlier poll conducted in August 2003 also by Pew from the same polling group also found that 67 percent favored guaranteeing health insurance to all citizens even if it meant raising taxes. 21
  
• A 2003 CBS News/New York Times poll showed that 81 percent of respondents favored using potential tax cut money to ensure all Americans have access to health insurance, whereas 14 percent indicated a tax cut should be a higher priority. 22
  
• A 2003 poll found that 79 percent of Americans believed it is more important to provide health care coverage for all Americans, than to hold down taxes. (ABC/Washington Post). 23

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

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

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

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

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

In a number of meetings, participants voiced support for limiting coverage for end-of-life care of questionable value in order to provide more at-home and comfort care for the dying. This option received strong support in both the Working Group poll and the University town hall meeting—59 percent and 63 percent, respectively, agreed or strongly agreed with the proposal. The proposal generally receiving the lowest level of support was "expanding federal programs to cover more people, but provide fewer services to persons currently covered by those programs." In the Working Group poll, for example, only 17 percent of respondents agreed or strongly agreed with this proposal. In the University town hall meeting, 24 percent agreed or strongly agreed.

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

Despite the resistance to this particular question, the meeting participants did discuss various trade-offs (without using that term) in previous sections of the meeting. For example, as noted above, many participants expressed a willingness to pay more so that everyone had care. Many participants also told the Working Group that individuals should play a larger role in their health and health care. More than one in three people filling out the Working Group’s Internet poll said they would be willing to pay a higher deductible in exchange for more choice of providers and services. This level of support for a trade-off of out-of-pocket costs for choice was actually slightly higher than the 2004 National Opinion Research Center at the University of Chicago (NORC) national survey finding that 27 percent of respondents would be willing to accept a higher deductible in exchange for fewer restrictions on use. The NORC results varied by income: 40 percent of Americans with household income of $75,000 or more would accept a higher deductible, compared with 23 percent with income below $25,000.24 The Working Group was not able to analyze the relationship of income to its participants’ responses.

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

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

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

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

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

These options received high levels of support, in the community meetings as well as the Working Group poll. The support for neighborhood health clinics and for opening up enrollment in Medicare or the federal employees’ health benefits program was consistently high and in line with the strong support for the Medicare program that was expressed in meetings across the country. The responses to both the Working Group poll and the University town hall meeting were similar to each other, as shown in Figure 9 below. There was, however, stronger support for expanding state programs such as Medicaid or SCHIP in the poll and the University town hall meeting than in the 31 community meetings. The level of support in the Working Group poll and University town hall meeting for opening enrollment in national programs such as Medicare or the federal employees’ health benefits program was in line with a 2005 national survey by the Employee Benefit Research Institute that found 76 percent strongly or somewhat favor allowing uninsured people to buy into government programs such as Medicare and Medicaid, or into the one in which members of Congress participate. 25

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

Figure 9:

Responses to Trade-off Questions on Working Group Poll and from University Internet Town Hall Meeting

How much do you agree or disagree with the following options to assure coverage for all Americans? % who "Agree" or "Strongly Agree"	Working Group Poll	University Town Hall Meeting
Offer uninsured Americans income tax deductions, credits, or other financial assistance to help them purchase private health insurance on their own	42%	35%
Expand state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program, to provide coverage for more people without health insurance	68%	71%
Rely on free market competition among doctors, hospitals, other health care providers and insurance companies, rather than having government define benefits and set prices	23%	16%
Open up enrollment in national federal programs like Medicare or the federal employees’ health benefit program	64%	63%
Require businesses to offer health insurance to their employees	56%	47%
Expand neighborhood health clinics	73%	79%
Create a national health plan, financed by taxpayers, in which all Americans would get their health insurance	70%	78%
Require that all Americans enroll in basic health care coverage, either private or public	47%	74%
Increase flexibility given states in how they use federal funds (such as Medicaid and the State Children's Health Insurance Program) to maximize coverage	55%	58%
Expand current tax incentives available to employers and their employees to encourage them to offer insurance to more workers and their families	69%	61%

The open-ended comments submitted to the Working Group provide some additional insight into how people view the health care system, how they want it changed, and what trade-offs they are willing to make. More than 6,000 people (6,224) wrote responses, sometimes fairly long, to the general questions on both the Internet as well as on paper forms sent to the Working Group.

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

As illustrated in Figure 10, analysis of the comments shows that when asked about what kinds of changes should be made to the way we currently pay for care, most wrote about the need for a single health care system. We know from the comments submitted as well as the discussions at the meetings that the notion of a single health care system means a number of different things to different people. For some, the most important issue clearly was the need for a government-run program. For others, it was an administratively simple program that would be available to everyone but provided in the public and private arenas. Among the 2,511 respondents who wrote about the need for a single health care system in response to an open-ended question about how health care should be financed, 43 percent recommended a single-payer system, while 24 percent discussed national health care and 18 percent discussed universal health care. The remainder discussed the ideas of universal Medicare, universal coverage, universal basic care, or universal access.

Figure 10:

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

(Working Group Comments on Open-Ended Questions)

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

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

Figure 11:

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

(Working Group Comments on Open-Ended Questions)

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

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

"We need a single-payer system to control costs and promote efficiency, and it has to be universal."

"I think the only thing that will work is creating a system that includes everyone at a basic level of care with significant incentives for preventive care. It could be done through a system of clinics located near grocery stores (or WalMart-type stores), in schools and community heath centers."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Endnotes

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

2 Employee Benefit Research Institute and Mathew Greenwald & Associates, Inc. 1998-2004 Health Confidence Surveys. “Public Attitudes on the U.S. Health Care System: Findings from the Health Confidence Survey” EBRI Issue Brief No. 275. November 2004. See Figure 5: Rating of Health Care System in America Today, 1998-2004.

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

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

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

6 Employee Benefit Research Institute and Mathew Greenwald & Associates, Inc. 1998-2004 Health Confidence Surveys. “Public Attitudes on the U.S. Health Care System: Findings from the Health Confidence Survey” EBRI Issue Brief No. 275. November 2004. See Figure 19: Confident in Selected Aspects of the Health Care System, 2004.

7 USA Today/Kaiser Family Foundation/Harvard School of Public Health: Health Care Costs Survey (August 2005) conducted by telephone by ICR/Harvard University between April 25 and June 9, 2005, with 1,531 adults age 18 and over responding. See Chart 6: Trends in Ability to Pay for Health Care. Additional survey sources include The Gallup Organization and Pew Research Center.

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

9 The Pew Research Center for the People and The Press Poll of 1,405 U.S. adults from March 8-12, 2006. “March 2006 News Interest Index.”

10 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325 U.S. adults conducted by Harris Interactive between July 11 and 13, 2006. See the Wall Street Journal Online (July 31, 2006), “Higher Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent of U.S. Adults.”

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

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

13 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325 U.S. adults conducted by Harris Interactive between July 11 and 13, 2006. See The Wall Street Journal Online (July 31, 2006), “Higher Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent of U.S. Adults.”

14 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325 U.S. adults conducted by Harris Interactive between July 11 and 13, 2006. See The Wall Street Journal Online (July 31, 2006), “Higher Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent of U.S. Adults.”

15 Los Angeles Times/Bloomberg Press of 2,563 adults conducted by Roper Center for Public Opinion Research between February 24 and March 5, 2006.

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

17 Wall Street Journal Online/Harris Interactive Health Care Poll of 2,048 adults conducted online by Harris Interactive between September 30 and October 4, 2005. See The Wall Street Journal Online (October 7, 2005), “Poll Indicates Strong Support for New Medical Technologies.”

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

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

20 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325 U.S. adults conducted by Harris Interactive between July 11 and 13, 2006. See The Wall Street Journal Online (July 31, 2006), “Higher Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent of U.S. Adults.”

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

22 The New York Times/CBS News Poll of 1,229 adults, conducted January 20-25, 2006. See CBS News Online (May 13, 2004) “Poll: Economy Remains Top Priority.”

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

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

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

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