Workshops Sample Citizens' Views on How to Cover the Uninsured
From 2002 to 2004, Viewpoint Learning, a San Diego firm that develops specialized dialogues for business and public policy, conducted three eight-hour workshops in early 2004 (in San Diego, Philadelphia and Atlanta) on how to cover the millions of Americans without health insurance.
- In all three workshops, participants determined that their top priority was to ensure that all Americans and legal immigrants have access to affordable health coverage.
- Participants leaned toward a two-tier health care system that would make basic coverage available to all citizens at an affordable price, with enhanced coverage available to those who wish to pay for it.
- Participants agreed that coverage should be provided by a combination of private and public sectors.
- Participants expressed a willingness to give up some degree of personal privacy to achieve equity and efficiency.
- Participants agreed that individuals bear a crucial responsibility for maintaining their own personal health.
- Participants expressed a willingness to pay more in taxes, premiums and co-pays if strong accountability measures were established.
- Participants agreed that fairness should be a basic goal of health insurance reform.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $158,704.
According to the U.S. Census Bureau, an estimated 43.6 million Americans did not have health insurance in 2002. One of the obstacles to covering the uninsured has been a lack of reliable information about which policy reforms the public would be willing to accept. In order to move such a complex issue forward, policy-makers need to be informed about which proposals their constituents would support, and at what cost.
Opinion polls, however, are of limited value as tools for collecting such information, particularly when the issues involved are complex and value laden. Because opinion polls typically do not capture thoughtful responses from people who have weighed the strengths and weaknesses of various proposals, there is often a disconnect between polling results and deeper, informed public opinion.
Viewpoint Learning, a San Diego firm that, according to its Web site, "develops specialized dialogues for business and public policy . to advance a new form of learning learning through dialogue," has developed a program called ChoiceWork Dialogues as an alternative to opinion polling.
These eight-hour workshops begin with facilitators presenting participants with information regarding the scope and ramifications of a particular problem, along with various proposals to help solve the problem. In large discussion groups and smaller breakout sessions, participants then weigh the advantages and tradeoffs of each of the proposals, as facilitators encourage them to reach a consensus about which proposals are desirable and achievable.
Researchers measure the participants' shift in attitudes by comparing questionnaires distributed at the beginning and the end of the workshop.
This project built on the results of the RWJF-funded Covering America initiative, led by the Economic and Social Research Institute, a Washington-based, nonprofit, nonpartisan institute that conducts research directed in part at making quality health care accessible and affordable.
Covering America's goal is to promote consideration of a range of proposals to provide affordable health coverage for uninsured Americans. As part of the Covering America project, RWJF commissioned the Lewin Group (Grant ID#s 042892 and 047456), a health care policy research and consulting firm based in Falls Church, Va., to analyze 10 of the 17 health coverage reform models developed by the Economic and Social Research Institute and prepare estimates of the number of people who would be covered by public and private health insurance and the costs of extending coverage. (See the Lewin Group report on the project Cost and Coverage Analysis of Ten Proposals to Expand Health Insurance Coverage by John Sheils and Randall Haught, October 2003).
This project relates to the goal of RWJF's Coverage Team to develop and provide objective information needed by key audiences about covering the uninsured.
Under this contract, Viewpoint Learning conducted three "ChoiceWork Dialogues" on health coverage issues. Participants in these eight-hour workshops considered a range of models for improving health coverage. The purpose of the project was to help RWJF staff determine the level of public support for four specific coverage reform models.
Project staff worked with RWJF staff and other health policy experts to select the coverage reform models that participants would consider in the workshops. (For a list of other health policy experts that project staff consulted, see the Appendix.) Project staff then developed a workbook for workshop participants that described the four models.
Two of the models provided increased but not universal coverage:
- Leaving current systems in place but expanding Medicaid and SCHIP (State Children's Health Insurance Program) to include more low-income people.
- Giving health insurance tax credits for working Americans who enroll in health insurance through their employer or as individuals to offset the cost of coverage.
The other two models provided universal coverage:
- Restructuring the employer-based system to provide insurance to all people under age 65 either through employers or insurance pools.
- Expanding Medicare to cover all citizens regardless of age or income.
The workbook also included summaries of funding analyses and cost estimates for each of the models, which the Lewin Group had completed as part of RWJF's Covering America initiative. In addition, project staff retained two market research firms Delve, a firm with offices nationwide, and San Diego-based Flagship Research to recruit paid participants in three locations who reflected as a group the demographic characteristics of their cities, such as race, ethnicity, age, gender and income level. Staff from the market research firms chose the participants through random digit dialing.
The eight-hour dialogue/workshops held in San Diego (February 28, 2004); Philadelphia (April 3, 2004); and Atlanta (April 17, 2004) began with facilitators providing background information on the problem of the uninsured. Facilitators then described the four coverage reform models, including their key features, estimated costs and arguments in favor of and against each.
Participants rated their preferences for each model in a questionnaire, and then discussed the models using ground rules that barred debate and promoted dialogue. Participants considered such issues as how to fund the models, their administrative challenges, the effect of each on personal choice and what tradeoffs would be involved in implementing them. At the end of the workshop, participants rated their preferences for each model again in a second questionnaire. Project staff measured the participants' shifts in preferences.
As reported by project staff to RWJF in a 2004 report, the project generated the following findings, based on the consensus reached in all three groups:
- In all three workshops, participants determined that their top priority was to ensure that all Americans and legal immigrants have access to affordable health coverage. They rejected the first two models (expanding existing programs; health insurance tax credits) in favor of the universal coverage offered by models 3 and 4 (expand the employer-based system; Medicare for all).
- Participants leaned toward a two-tier health care system that would make basic coverage available to all citizens at an affordable price, with enhanced coverage available to those who wish to pay for it. As participants saw it, a two-tier system could make it politically easier to achieve universal coverage and introduce choice into the equation in a fundamental way.
- Participants agreed that coverage should be provided by a combination of private and public sectors. They felt that combining the government's ability to provide services fairly with the private sector's efficiency, flexibility and responsiveness could produce a system of checks and balances that blended the best aspects of both sectors.
- Participants expressed a willingness to give up some degree of personal privacy to achieve equity and efficiency. Most concluded that this was a reasonable tradeoff to make, in that it was connected to their willingness to assume more personal responsibility for their health.
- Participants agreed that individuals bear a crucial responsibility for maintaining their own personal health. Participants also agreed that a central responsibility of any decent health care system is to give people the education and prevention tools and information they need to become healthier. In addition, they overwhelmingly opted for a system of incentives and consequences, where people who engage in healthy behaviors would get some kind of financial break while those who do not would pay more.
- Participants expressed a willingness to pay more in taxes, premiums and co-pays if strong accountability measures were established. They also clearly stated that they would be willing to pay for health insurance reform only if mechanisms were in place that would ensure accountability and protect the quality of care. Such mechanisms included watchdog groups and medical oversight boards, performance ratings for providers and easier public access to information about insurers, providers and government agencies.
- Participants agreed that fairness should be a basic goal of health insurance reform. They felt strongly that an equitable health care system was one that covered all Americans, was portable and provided "no free ride" i.e., everybody paying for health care according to their ability to pay.
The project team submitted its project report, Citizen Dialogues on Covering the Uninsured: A Report to the Robert Wood Johnson Foundation, to RWJF in 2004. See the Bibliography for details.
- It is important not to assume general public knowledge of an issue just because the media covers it in depth. Despite ongoing media attention to health coverage, many workshop participants, who represented a cross section of the population, had no idea that at least 43 million people, most from working families, had no health insurance. Participants also thought the United States ranked number one in the world in health coverage, but this is not the case. (Project Director)
GRANT DETAILS & CONTACT INFORMATION
Expanding the Boundaries of the Health Coverage Debate through Innovative Public Opinion Research
Viewpoint Learning (La Jolla, CA)
Dates: September 2002 to June 2004
Health Policy Consultants
Stuart Butler, Ph.D.
Vice President, Domestic and Economic Policy Studies
David Cutler, Ph.D.
Faculty of Arts and Sciences for Social Sciences
Stan Dorn, J.D.
Senior Policy Analyst
Economic and Social Research Institute
Alan Garber, M.D., Ph.D.
Center for Health Policy
Jack Meyers, Ph.D.
Economic and Social Research Institute
Senior Fellow in Health Policy
National Center for Policy Analysis
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Viewpoint Learning, Inc. Citizen Dialogues on Covering the Uninsured: A Report to the Robert Wood Johnson Foundation. La Jolla, Calif.: Viewpoint Learning, July 2004. Available online.
Report prepared by: Nanci Healy
Reviewed by: Robert Crum
Reviewed by: Marian Bass
Program Officer: David Morse