The American Public On Health Care

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					The American Public On Health Care:

THE MISSING
PERSPECTIVE
2
Contents
Introduction                        02

Executive Summary:
The Missing Perspective             04

Voices From the Town Hall           06

What We Learned                     12

Messages on the Public’s Agenda     22

What We Did                         24

What We Learned:
Results in Detail                   28

Anxiety About Cost                  30

The Power of Information            34

A Tale of Two Health Care Systems   40

Coverage for the Uninsured          45

Priorities for the New President,
Changes America Wants, and
The Role of Government              48

The Changes America Wants           53

Messages on the Public’s Agenda     58

Appendix                            62




                                         1
Introduction
November, 2008


Health care is one of the most pressing issues on the minds of Americans today.
It’s at the center of debate at every level of the political arena, and one of our nation’s
most critical public policy concerns.

But in the debate regarding health           Over the last eight months, we worked       While the voices and opinions within
care today, we rarely hear the perspective   together to review survey data and          the health care debate are numerous
of real people—consumers, patients,          other research on public attitudes and      and varied, the most important—
and average citizens. Until now.             reform proposals from a variety of          and often missing voice—is that of the
This report explores the challenges          perspectives.                               American people. This report outlines
facing health care in America—the            We also worked with Gallup to conduct       their thoughts, details the specific
problems and the trade-offs—through          new local and national survey research on   challenges the American health care
the lens of the people most touched          the public’s views of health care. Most     system faces now and in the future,
by it. What are their experiences, their     importantly, we visited three cities—       and offers suggestions for everyone
expectations, their worries? What            Miami, Detroit, and San Francisco—to        who has a stake in the system: our new
information do they want and need            hear directly from the people in animated   President, government leaders, health
in order to make more informed               town hall discussions.                      care providers, employers, and the public.
decisions about their own care? What         The results of our national poll—           We are very grateful to the many
is their agenda for health care reform?      released here for the first time—echo       individuals and organizations that took
To get to the heart of Americans’ views      the themes we heard from community          part in this initiative, and we are pleased
on health care, a unique initiative—The      members across the country. With            to offer the missing perspective—
American Public on Health Care: The          health care costs on the rise and more      the views and voices of the American
Missing Perspective—was launched by          than 45 million uninsured Americans,        people to help focus the health care
the Council for Excellence in Government     there is a palpable anxiety over cost       debate on their questions and concerns.
with support from the Accenture              and access to care. There is widespread     The public perspective must be a
Institute for Public Service Value and       uncertainty over how plans for reform       critical driver of successful reform.
expert guidance from the Institute of        would actually affect regular people.       Patricia McGinnis
Medicine at the National Academies.          And there is strong interest in the power   President and CEO
                                             of information to help transform            The Council for Excellence
                                             the system.                                 in Government




2
Council for Excellence                       Acknowledgements                              In addition, Matthew Kohut and
in Government                                We would like to express sincere              Samantha Dodge from InFact
                                             gratitude to Ken Dineen, Greg Parston,        Communications, Greg Gersch from
Founded in 1983, The Council for
                                             Susan Nealon, Cindy Hielscher, Sharon         EyeBeam Creative, Vince Aurilio from
Excellence in Government (www.
                                             Spigelmyer, Peter Soh, and the rest of        Creative Media Communications, and
excelgov.org) is a nonprofit, nonpartisan
                                             the staff at Accenture for their thought,     Lisa Riolo and her team at closerlook
organization that works to improve
                                             leadership, and support of this initiative.   all contributed their creative talents to
government performance and citizen
                                                                                           this project and report.
participation. The Council’s successful      The Council for Excellence in
initiatives to examine homeland              Government is extremely grateful to           We would also like to thank the
security and American jobs from the          Dr. Harvey Fineberg, President of the         community media partners in Miami,
public perspective have set the standard     Institute of Medicine, as well as the         Detroit, and San Francisco who helped
for authentic public town hall meetings.     IOM staff including Christine Stencel         us reach and engage people throughout
                                             and Lauren Tobias, and the many               their metropolitan areas in the town hall
Accenture Institute                                                                        discussions.
                                             members of the IOM who helped to
for Public Service Value                     guide this project.                           Special thanks to the hosts and panelists
The Accenture Institute for Public                                                         in our town hall meetings. A full list
                                             In addition, we would like to thank
Service Value (http://www.accenture.                                                       is available in the Town Hall Spotlights.
                                             Darby Miller-Steiger and Helen
com/Global/Research_and_Insights/
                                             Musara from Gallup for their ideas            Finally, and most important, we are
Institute_For_Public_Service_Value/
                                             and stewardship of the survey research.       grateful to the hundreds of people in
default.htm) is a research and
development center that helps public         Frank Sesno continued to contribute           the Miami, Detroit, and San Francisco
service organizations create value           his unique talents to the Council’s town      metropolitan areas who took time out
and improve social outcomes for their        hall practice, expertly serving as a          of their busy schedules to come to the
citizens by advancing high performance       tour guide through the many complex           town hall discussions and share their
in public service delivery, policy, and      and contentious issues surrounding            personal stories, their suggestions, and
governance.                                  the topic.                                    their questions for the new President
                                                                                           and other leaders in the vast American
                                             The Council staff who organized
The Institute of Medicine                                                                  health care enterprise.
                                             and orchestrated this effort deserve
of the National Academies
                                             huge thanks: David Roberts, Samantha          Patricia McGinnis
The Institute of Medicine of the             Donaldson, Bryan Klopack, and                 President and CEO
National Academies (www.iom.edu)             Diane Freeman.                                The Council for Excellence
serves as adviser to the nation to improve                                                 in Government
health and provides independent,
objective, evidence-based advice to policy
makers, health professionals, the private
sector, and the public. The mission of
 the Institute of Medicine embraces the
health of people everywhere.




                                                                                                                                       3
ExECuTIVE SuMMARy:
THE MISSING PERSPECTIVE




4
5
VOICES FROM THE TOwN HALL
We rarely hear from the millions who use it, the untold numbers who
are either uninsured or inadequately covered, those who forego doctor’s
visits and preventive care because they can’t afford it, and those who
fear the unintended consequences of the reforms that might be on the
way. The purpose of this initiative is to add their views—the missing
perspective—to this critical debate about our health and health care.




There is no shortage of discussion           We rarely hear from the millions who
today about the problems of the health       use it, the untold numbers who are
care system in the United States.            either uninsured or inadequately covered,
Voluminous research demonstrates             those who forego doctor’s visits and
that the U.S. spends more on health          preventive care because they can’t afford
care than any other nation, yet still        it, and those who fear the unintended
under performs on many dimensions.           consequences of the reforms that might
Doctors, hospital administrators,            be on the way. The purpose of this
insurers, employers, government leaders,     initiative is to add their views—the
economists, and a host of other experts      missing perspective—to this critical
debate solutions from their various          debate about our health and health care.
perspectives. Health care reform was a       We listened to the people who partici-
top priority for political candidates this   pated in the town hall meetings
election year, though many questions         we organized across the country. We
remain about how plans might work            tested what we heard through local
in practice.                                 and national opinion research and the
The voices missing in these debates,         experience of community leaders and
though, are those of the American            experts. We learned a great deal about
people, the ultimate stakeholders in         the public’s top concerns and its desire
the health care system.                      for change.




6
VOICES FROM THE TOwN HALL



A Miami woman lost her health insurance when she was
divorced four years ago. She just could not afford to buy insurance
while she was in school, ironically earning a nursing degree.
“I haven’t had a mammogram… because I couldn’t do anything
about it if I found out I had cancer.”

A young mother in San Francisco quit her job when her
son was diagnosed with a brain tumor so her family income
would be low enough to qualify for Medicaid coverage.
She and her husband had insurance coverage but could not
afford the thousands of dollars a year in out-of-pocket
expenses. “If you have a low enough income, you can be
on Medi-Cal and that’s how we got through this.”
A physician in Miami described one of his first patients as an
intern. “She was uninsured and presented to the hospital with
abdominal pain, which had been going on for a year. She came
when she couldn’t take it anymore and we diagnosed her with
colon cancer, which was advanced, and she died under my care.
I remember being very depressed… it happens all the time.”

A dean of a nursing school in Miami points out,
“Health care is the only thing that you buy and you have
no idea how much it costs. You walk into a hospital and
no one gives you a menu of prices… we should know that
an appendectomy costs X, not $1,000 here, $2,000 there,
$3,000 there. I think it should be transparent.”


8
A mother who owns a small business in Miami discovers that
her four year-old son has reached his lifetime cap for insurance
coverage one month after being released from a hospital.
“You don’t always look at every single one of those details
because you don’t expect a crisis, a trauma… you don’t know
that you’re going to cap out in a month.”

A retired woman describes her “problem with portability.”
Her family has moved, but “if I want to move, I will
not be able to. I can’t take my insurance to another state.”
A student at the University of Miami worries about the cost of
health care, not for himself, but for his grandparents who cannot
afford the co-payments or their medication.

A man in San Francisco who was born and raised in
Ireland says, “I never thought of not having health care
because I grew up in a country that has universal health
care run by the government. It is not perfect, but my mom
and dad (78 and 82 years old) never, ever worry… my
dad just had an infection in his foot, was in the hospital
and never worried about it.”
A mentally ill young woman in Detroit died, according to her
mother, because “she was receiving so much fragmented care in
the system… she didn’t see one psychiatrist on a regular basis…
she was hospitalized in many facilities… she didn’t get the care
she needed… for five or six years. It was tragic for our family—
we were unable to get her the care she needed.”
                                                                    9
“If we are going to solve the healthcare problem in this country, we must
  take account of the real health needs of people all over the country.
 The Council has made a great contribution to the healthcare debate by
  bringing forward the citizen’s perspective, and the Institute of Medicine
  is pleased to have been a partner in these Town Hall Meetings.”
 Dr. Harvey Fineberg
 President, Institute of Medicine




 These are the stories of people we met      Their words animate the results of our
 in town hall meetings across the country.   survey research and analysis of health
 The reaction they provoke is one of         care in their communities and in the
 recognition: “Something like that           U.S. compared to other countries. This
 happened to someone I know.” These          report includes the findings of our
 experiences and many others bring           national survey, which was informed by
 to life the everyday failures of the U.S.   and conducted after local polls and town
 health care system in a way that            hall meetings in the metropolitan areas
 statistics—about rising costs, the number   of Miami, Detroit, and San Francisco.
 of uninsured, quality indicators, and
 other key measures—cannot convey.




10
wHAT wE LEARNEd
We have known for some time about the rising cost of health care and
the tragically large number of uninsured people in the United States. We
were, however, surprised by two main findings and the changes people
want government to lead.




01: Anxiety About Cost
We learned through our town hall                                        While cost is the top concern for all                                   Most uninsured Americans surveyed
discussions—and confirmed it through                                    surveyed, those ages 40 to 64 are far                                   (57%) say they simply cannot afford
local and national opinion research                                     more concerned about cost (56%) than                                    coverage. Another 30% cite reasons
—that there is palpable anxiety about                                   are their younger (18-39) and older                                     having to do with employment: they’re
the affordability of health care                                        (65+) counterparts (47% each). There                                    not employed (14%), their employer
among Americans from all walks of life,                                 is widespread disillusionment with                                      does not offer coverage (9%), or they
including people who have health                                        the financial hardship associated with                                  are between jobs (7%) (see Figure C ).
coverage and those who do not. The                                      health care: according to our national                                  More than 1 in 4 Americans (26%)
bottom line is that we spend twice                                      survey, two-thirds of Americans                                         have put off medical treatment within
as much per person on health care than                                  (65%) express negative views about the                                  the last 12 months because they could
other developed countries and yet we                                    affordability of health care in their                                   not afford it, including 58% of those
have lower life expectancy, lower infant                                area, and in the surveys conducted in                                   who are currently uninsured. Even those
survival, and higher death rates due                                    the metropolitan areas where we held                                    who currently have health insurance
to treatable diseases like diabetes.1                                   town halls, these percentages are even                                  are feeling the crunch, with 20%
When Americans think about health                                       higher (see Figure B ).                                                 reporting that they too have put off
care, they worry first and foremost                                                                                                             treatment because they could not afford
about its cost. Whether rich or poor,                                                                                                           the out-of-pocket costs. Age is also a
young or old, insured or uninsured,                                                                                                             factor— just 11% of those over age 65
cost dominates their concerns                                                                                                                   have put off treatment compared to
(see Figure A).                                                                                                                                 29% of those age 18 to 39 (see Figure D).




1 “Chronic diseases as tracer conditions in international benchmarking of health systems: the example of diabetes.” McKee M, Nolte E, Bain C; Academy Health. Meeting (2005: Boston, MA.) Abstract accessed at:
  http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=103622970.html


12
Figure A. Biggest Health Care Concern




      51%                                         30%                       9%                                  10%




Cost                                Quality                  Ability to get                       Something
                                                             health care                          else




Figure B. Afforability of Health Care Only Fair/Poor                Figure C. Main Reason for Not Having Health Insurance

                                                                    Cannot afford it                                  57%
100
                                                                    Not employed                       14%
80               73% 76%              71%
                                                                    Employer does
                                                                    not offer it
                                                                                                    9%
        65%
                                                                    In between jobs                7%
60
                                                                    Do not think I need           5%
                                                                    it /do not want it
40
                                                                    Lost coverage                 3%
20                                                                  Pre-existing                  2%
                                                                    condition

                                                                    Other                         2%
 0
       National San       Detroit    Miami
                Francisco                                                                    0          20       40   60         80   100




Figure D. Americans who have put off medical treatment in the past
12 months because they could not afford it



Overall                                 Insurance Status                                  Age
                                        Insured         Uninsured                         18–39              40–64         65+




      26%
                                        20%             58%                               29%                28%           11%




                                                                                                                                      13
“The complexity of the American health care system is well known,
 but we must hear the stories of individuals challenged by health
 problems to fully understand the urgent need for reform. The voices
 in the town halls were those of real people and any solution has to
 answer the questions we heard. Access, quality and portability of
 coverage are among the demands our leaders must address.”
 Dr. Paul Volberding
 Professor and Vice Chair, UCSF Department of Medicine
 Chief, Medical Service SF Veterans Affairs Medical Center
 Co-Director, UCSF-GIVI Center for AIDS Research




 02: The Power of Information
The second surprising finding concerns                Contrary to conventional wisdom           Majorities think it could improve their
the power of information. The people—                 about privacy concerns, most              quality of care (59%) and help them
health care consumers—believe that                    Americans see the benefits of sharing     better manage their own health (53%).
information has the power to help                     health data. Three-quarters of the        Nearly half (48%) are interested
improve the quality and efficiency of                 public (78%) favor giving physicians      because they believe using an EHR
the health care system, and they want                 the means to share access to their        could reduce the cost of their health
to know more about both the cost of                   medical records, while two-thirds (66%)   care (see Figure H).
care and the performance of their                     see the value in including their own      The public’s willingness to share
providers. They are willing to share                  information anonymously in a large        health information for research could
their health information among their                  database that would help researchers      revolutionize the practice of “evidence-
doctors and researchers to improve the                understand more about the effectiveness   based medicine,” which enables health
quality of care.                                      and possible side effects of various      care providers to make diagnoses and
 When evaluating the criticality of                   treatments or prescription drugs          recommend courses of treatment based
 information about doctors and hospitals,             (see Figure G ).                          on data about what has worked in
 the public prioritizes two performance               The public’s views on the power of        thousands or even millions of cases
 measures above others: their records of              information extend to their attitudes
 medical mistakes, and whether they                   about electronic health records.
 consistently follow established standards            While less than a quarter (23%) of
 and guidelines in diagnosing and                     Americans currently use an electronic
 treating patients. (see Figure E, F ).               health records (EHR) system, nearly
                                                      twice as many (44%) would be interested
                                                      in using EHR if it were available.




 14
Figure E. Desired Critical Information about                              Figure F. Desired Critical Information about
Quality/Performance of Doctors                                            Quality/Performance of Hospitals

Their record of medical mistakes .................       62%              Their record of medical mistakes .................        59%
If they follow established standards                                      If they follow established standards
and clinical guidelines in diagnosing                                     and guidelines for care..............................     57%
and treating patients ................................   54%              Their experience and track record
Information about their education, training,                              with specific procedures ...........................      53%
and professional accomplishments ...............         40%
                                                                          Accreditation   ......................................... 33%
Patient satisfaction survey results ................     33%              Patient satisfaction
How many years they have been                                             survey results.........................................   31%
practicing in their area .............................   31%
The average number of
patients they see daily ..............................   24%


Figure G. Information Sharing


       Favor giving doctors shared access                                 Favor including information in large
       to medical records                                                 database to help researchers
100                                                                 100


80
        78%         74%         77%         77%                     80
                                                                            67%         65%
60                                                                  60                              57%          59%

40                                                                  40


20                                                                  20


 0                                                                   0
       National San       Detroit          Miami                           National San       Detroit          Miami
                Francisco                                                           Francisco




Figure H. Americans agree that EHR would:




  59%                                              53%                               48%




Improve quality of care                        Help you better                    Reduce cost of care
                                               manage your health




                                                                                                                                          15
The Changes America wants
While many worry about                 Public Menu Of Costs                        Americans are also
the unknown and unintended             75% agree that government should            in favor of adopting
                                       require that healthcare providers
consequences of health                 publish their costs (58% strongly agree).   electronic health records
care reforms, a majority of                                                        systems and are willing
                                       Pre-Existing Conditions
Americans voice support                75% agree that government should            to share their health
for a number of reform                 require healthcare providers to cover       information, but only under
                                       pre-existing conditions (54% strongly
concepts:                              agree).                                     certain conditions.
Portability                                                                        Health Information Sharing
                                       Employer-Based Care
78% favor allowing Americans to take                                               78% of Americans favor giving doctors
                                       72% agree that government should
their health care coverage with them                                               the ability to share access to their
                                       require all large employers to provide
when they leave a job.                                                             medical records, if it is done with their
                                       health insurance coverage to all full-
                                                                                   permission.
                                       time employees (54% strongly agree).
When it comes to the role
                                       Competition Across                          Evidence-Based Medicine
of government in reforming
                                       State Lines                                 66% favor having health information
the system, America’s                                                              shared in a large database to help
                                       71% agree that government should
voice is clear.                        create national or regional healthcare      researchers understand and compare the
                                       exchanges to allow insurance to             effectiveness and possible side effects of
Performance Ratings                    be purchased across state lines (52%        various treatments or prescription drugs,
                                       strongly agree).                            if no patient names were used in the
81% agree that government should
                                                                                   database.
require that performance ratings
on doctors and hospitals be publicly   Assistance For Low-Income
available (60% strongly agree).        69% agree that government should
                                       provide assistance to low income
                                       individuals and families to buy health
                                       insurance (52% strongly agree).




16
Priorities for the President, Changes America
wants, and The Role of Government
Americans across the nation—including       • Providing insurance for all
those who currently have health cover-        children (83%).
age—are deeply worried about the            • Controlling costs (81%).
affordability and quality of health care.   • Improving the quality and safety
They know the current system is on an         of care (77%).
unsustainable course, and that it needs     • Improving prescription drug
to be reformed to deal with issues of         coverage (74%).
cost and performance. They are eager        • Providing health insurance for all
for pragmatic solutions that will             uninsured Americans (68%).
address the realities of their lives.       They are also eager for more answers
                                            to their questions.
Priorities for the
                                            • 74% say more information on how
New President
                                              reform plans would be paid for.
People have been tuned in to the            • 70% want more information about
debate about health care on the               costs to taxpayers.
presidential campaign trail. Roughly        • 68% want to know how reform plans
half (48%) paid close attention to the        would control the rising costs of care.
candidates’ positions on health care,
and 31% paid very close attention.

The public has a clear sense of what
the new president’s major health care
priorities should be.The top agenda
items include:




                                                                                        17
 wHAT wE LEARNEd

“Health care policy, like health care delivery itself, is at its best when
 the consumer is informed, engaged, and empowered. The Council
 for Excellence in Government’s recent town hall series invited those
 most affected by health policy into the conversation. What we heard
 from patients and consumers in those town halls will influence the
 course of health care reform in state capitols and in Washington.”
 Daniel Zingale
 Senior Advisor to Governor Arnold Schwarzenegger




 Portability                                                         Majorities strongly favor government           It’s noteworthy that one proposal for
 Americans favor making it easier for                                involvement in requiring health care           expanding coverage for the uninsured—
 those who have coverage to take it with                             providers to publish their performance         allowing anyone to buy Medicare
 them when they move or change jobs.                                 ratings and costs for procedures and           coverage at group rates, regardless
 The concept of “portability” receives                               services.                                      of age—gets significantly less strong
 very strong support, with more than                                 Another priority for government                agreement than any other policy
 three-quarters (78%) favoring the right                             involvement is in guaranteeing access to       prescription surveyed. This is consistent
 to take their health care coverage with                             health coverage through employers.             with Gallup poll results over many
 them when they leave a job (see Figure I ).                         The public favors government requiring         years which show that the public has a
                                                                     large employers to provide insurance.          preference for maintaining a system
 The Role of Government                                              They also want government to require           based on private insurance rather than
 The American people have definite ideas                             that insurers cover pre-existing conditions,   a government-run health care system2
 about the role that government should                               and to create national or regional health      (see Figure J ).
 play regarding health care. Reflecting                              exchanges to allow insurance to be
 the public’s understanding of the power                             purchased across state lines. Government
 of information, a top priority is guaran-                           assistance to low-income individuals
 teeing access to quality and cost data.                             and families is also a priority to expand
                                                                     coverage to the uninsured.




 2 Accessed at: http://www.gallup.com/poll/4708/Healthcare-System.aspx


 18
Figure I. Favorability      Figure J. Americans that agree with government involvement in healthcare
towards new flexibilities
                                                                       Agree        Strongly agree

                            Requiring that performance                                                           81%
                            ratings on doctors and
                            hospitals be publicly available                                          60%
                            Requiring healthcare providers                                                  75%
    78%                     to publish their costs
                                                                                                     58%
                            Requiring healthcare providers                                                  75%
                            to cover pre-existing conditions
                                                                                                54%
Favor the right to take
their health care
                            Requiring all large employers to                                               72%
                            provide health insurance coverage
coverage with them          to all full-time employees                                          54%
when they leave a job
                            Creating national or regional health                                           71%
                            care exchanges to allow insurance
                            to be purchased across state lines                                52%
                            Providing assistance to low                                                   69%
                            income individuals and families
                            to buy health insurance                                           52%
                            Allowing everyone to buy                                                  60%
                            Medicare coverage at group
                            rates, regardless of age                                        43%
                                                                   0           20      40            60     80         100




                                                                                                                             19
wHAT wE LEARNEd


While the American people are very aware of the disparities in
access to care, they also know that there will be a significant cost
involved in expanding coverage among the uninsured, and most
are not willing to pay more in taxes to cover uninsured Americans.




Other Key Findings
A Tale of Two Systems                        Concern About the Cost of
Most Americans are aware of a                Expanding Coverage
distressing discrepancy between the          While the American people are very
excellent health care accessible to          aware of the disparities in access to
some and the poor care available to          care, they also know that there will be
others (see Figure K ).                      a significant cost involved in expanding
Income is a huge driver in how people        coverage among the uninsured, and
perceive the availability of quality         most are not willing to pay more in
care in their area or community. 75%         taxes to cover uninsured Americans
of those who earn $75k or more rate          (see Figure M ).
the availability of care in their area       Willingness to pay more in taxes varies
as Excellent (32%) or Good (43%)             by both age and income. Younger
compared to just 54% of those who            people and those with annual incomes
earn less than $35k (15% excellent,          above $75,000 are the most willing to
39% good) (see Figure L).                    pay more (see Figure N, O).
Two-thirds of Americans (65%) rate           Of those who are willing to pay higher
access to care for the uninsured as poor     taxes, nearly half (48%) would pay up
(36%) or fair (29%), while only 10% say      to $100 per year or more (see Figure P ).
it is excellent. Some regional differences
are apparent: Southerners are more
likely than those in the Northeast to say
access for the uninsured is poor in their
area (41% vs. 30%).




20
 Figure K. Quality and accessibility of healthcare                                            Figure L. Rating the availability of quality
                                                                                              health care by income level

100%                                                                                         100%


                           80                           17
  80      77                                                      77                          80
                                              72
               65
                                 60                57
  60                                                                   56                     60

                                                                                                                             43
  40                                                                                          40
                                                                                                                       39 40
                    35
                                                                                                                 32
                                      25                                    25                              23                         24 27
                                                                                                                                                         21
  20                                                                                          20       15                                          14
                                                                                                                                                              10 10

  0                                                                                            0
         National         San                 Detroit             Miami                               Excellent        Good            Only Fair         Poor
                          Francisco

 % saying excellent or good                                                                         Income level
        Quality of own health care                                                                     Under $35,000          $35,000 –$75,000           More than $75,000

        Availability of quality health care

       Access to care for the uninsured




 Figure M. Willing to pay more in taxes to cover the uninsured                                Figure N. Willing to pay more in taxes to
                                                                                              cover the uninsured, by age

                                                                                                                                           50%                           Yes
                                                                                              18–36
                                                                                                                                           50%                           No

       43%                                      57%                                                                                      45%
       YES                                      NO
                                                                                              40–64                                          55%
                                                                                                                              31%
                                                                                              65+                                                             69%
                                                                                                       0              20          40                60           80            100




 Figure O. Willing to pay more in taxes to cover the                                         Figure P. Amount willing to pay more for the uninsured
 uninsured, by annual income

                                                 44%                             Yes          Up to $5 per year ................................15%
 Under
 %35k                                              56%                           No
                                                                                              Up to $25 per year..............................22%
 $35k–%75k                                      42%
                                                     58%                                      Up to $50 per year .............................14%
 More than                                         50%                                        Up to $100 per year ............................22%
 $75k                                              50%
                                                                                              More than $100 per year...................26%
               0            20             40                60             80         100


                                                                                                                                                                             21
MESSAGES ON THE PuBLIC’S AGENdA
TO LEAdERS, PROVIdERS, EMPLOyERS
ANd CONSuMERS
Americans across the nation—including those who currently have
health coverage—know the current system is on an unsustainable course.
They are eager for pragmatic solutions that will address the realities
of their lives.




Messages to the                                A majority of the public says that           Specifically, the public believes that
New President and                              answers to the following questions are       government should:
Government Leaders                             critical to help them understand where       • Require publicly available performance
                                               you stand on health care reform:               ratings of doctors and hospitals.
The American people say that your
major priorities regarding health care
                                               • How will you pay for what you              • Require health care providers to

should be:                                       propose?                                     publish the costs of all services and
                                               • How much will it cost taxpayers?             procedures.
•   Cover all uninsured children—              • How will your plan control the cost        • Require all large employers to provide
    83% say a major priority should be           of health care?                              health coverage to full-time employees.
    to cover all children; 68% say covering    • How will it help cover the                 • Require health care providers to cover
    all who are uninsured should be a            uninsured?                                   pre-existing conditions.
    major priority.                            • How will it improve the quality of         • Create national or regional health
•   Control the rising costs of health care.     health care?                                 care exchanges so insurance can be
•   Improve the quality and safety of care.                                                   purchased at competitive rates across
                                               Americans want their government                state lines.
•   Improve prescription drug coverage.        leaders to improve accountability, control   • Provide assistance to low-income
The public is listening to what you are        costs through market improvements, and         individuals and families to buy health
saying about health care and looking           expand coverage by helping those with          insurance.
to you to find practical solutions that        low incomes obtain health insurance.
reflect their priorities.




22
Messages to Health Care                      •   Improve communications and               Messages to the Public
Providers                                        information about costs, benefits, and
                                                                                          Faced with a health care system
                                                 choices. This information should be
Americans want health care value and                                                      plagued by cost increases and significant
                                                 clear, concise, and consumer friendly.
believe that information has the power                                                    gaps in coverage, it is up to the
to improve the quality and efficiency        •   Increase accountability of providers     American people to take ownership of
of the health care system. They want             for quality and performance, rather      their “health care destinies” by becom-
access to understandable information             than the quantity of procedures and      ing better informed consumers and
about performance and costs to increase          paperwork.                               voters. Ask the new President and your
the accountability of their health care      •   Spread risks by expanding pools          representatives in Congress— in person
providers. When evaluating the criticality       beyond state lines through national or   if you get the chance or send an email
of information about doctors and                 regional health exchanges.               or letter—to explain their reform
hospitals, the public prioritizes two                                                     proposals: how much will they cost,
                                             •   Improve incentives for prevention and
performance measures above others:                                                        how will they pay for them, how will
                                                 treatment based on the best evidence
                                                                                          they control costs, and what will be the
•   Records of medical mistakes.                 of effectiveness.
                                                                                          impact on the quality of care and
•   Whether they consistently follow                                                      coverage for the uninsured. Become
                                             Messages to Employers
    standards and guidelines in diagnosing                                                a better consumer by requesting
    and treating patients.                   The American people believe in
                                                                                          information from your providers about
                                             employer—based health care and most
Contrary to conventional wisdom, most                                                     their performance and the costs of
                                             favor government involvement to require
Americans are willing to share their                                                      services.
                                             employer-based coverage. At the
health information among their doctors                                                    Raise your voice and communicate your
                                             same time, they want to see the rising
and researchers to improve the quality                                                    priorities to candidates for public office,
                                             costs contained. You, as employers, have
of care. Most favor the use of electronic                                                 your elected leaders, your providers, your
                                             an opportunity to engage your employees
health records systems to:                                                                employers and your insurance companies.
                                             in open, fact-based discussions about
•   Give doctors shared access to their      the trade-offs you face and their choices    Insist on the information you need to
    medical records, with permission.        in that context. Faced with costs that are   make good decisions about your health
                                             rising at unsustainable rates, employees     and your health care and hold leaders
•   Give researchers their health informa-
                                             should have choices that reflect             accountable for keeping their promises
    tion anonymously in large databases to
                                             their values.                                and commitments to improve the
    study and compare the effectiveness of
                                                                                          quality, cost and access to care.
    specific interventions and treatments.   For example, if the threshold for
                                             employer-based coverage is basic and         It is imperative that your perspective—
Messages to Insurers                         catastrophic care, beyond that employ-       the missing perspective—be heard and
Most Americans who are insured are           ees could choose to pay the additional       heeded to achieve health care reform
satisfied with their coverage—with the       cost for more extensive coverage or          that reflects your priorities and fairly
exception of the cost. To improve the        greater choice of doctors and other          addresses your concerns.
value proposition, insurers should:          providers. Employers should clarify the
•   Work with employers, government,         costs, benefits and trade-offs involved in
    and providers to address current and     selecting various types of health care
    future customer concerns.                plans (HMO, PPO, Fee for Service, etc.).
                                             If employee questions are answered,
                                             their input invited, and if employers are
                                             clear about the trade-offs, options and
                                             solutions can be more easily evaluated
                                             from both perspectives.




                                                                                                                                   23
wHAT wE dId
Beginning in the summer of 2007, the Council for Excellence in
Government, with support from the Accenture Institute for Public Service
Value and with guidance from the Institute of Medicine, reached out to
understand the public perspective on health care concerns and priorities.




•   We organized town hall meetings in        •   The Gallup Organization conducted             Our goal is to bring the voices of the
    Miami, Detroit, and San Francisco to          a capstone national survey, which             public—the missing perspective—into
    hear real-life stories of the American        added depth to the themes uncovered           the debate about health care reform as
    people’s interactions—both positive           through the town hall meetings and            we elect a new president and welcome
    and negative—with the health care             local surveys.                                new leaders at all levels of government
    system. These town halls featured         •   The Accenture Institute for Public            across the country.
    panels of local subject matter leaders        Service Value conducted a study on
    to provide expertise and help respond                                                       Survey Research
                                                  international comparisons of consumer
    to the audience—our true “stars of            health information. This research was         Gallup conducted a nationwide survey
    the show.”                                    invaluable, and appears throughout            among 1,000 adults in June 2008.
•   In each town hall location, we                the report. This report is the product        The survey was conducted by tele-
    partnered with local broadcast and            of those collaborative efforts. It includes   phone and data were weighted to
    print media to invite the public to           stories and statistics, anecdotes and         reflect U.S. Census Bureau estimates.
    participate and to give visibility            analysis, and promising practices in          The margin of sampling error is
    to their perspective.                         the health care arena here in the U.S.        +/- 3.1% for the overall sample, and
                                                  and in other countries.                       is larger for subgroups.
•   The Gallup Organization conducted
    focus groups, followed by local surveys   This report is the product of those               Prior to each of the town hall meetings
    in each of the town hall cities to        collaborative efforts. It includes stories        Gallup also conducted surveys in the
    provide quantitative context to the       and statistics, anecdotes and analysis,           three town hall host cities. Each of
    town hall discussions.                    and promising practices in the health             these surveys was conducted by
•   The Institute of Medicine co-hosted       care arena here in the U.S. and in other          telephone and data were weighted to
    the town hall meetings and helped         countries.                                        reflect the U.S. Census Bureau esti-
    design the survey research and inform                                                       mates. The margin of sampling error is
    the development of the final report.                                                        +/- 4.9% for the overall sample, and
                                                                                                larger for subgroups.



24
• Miami: polled 401 area residents,          The Council formed community                 Lillian Rivera
  including Miami-Dade, Broward, and         partnerships with local media outlets        Administrator
  Palm Beach counties; late January, 2008.   that were very helpful in identifying        Florida Department of Health
• Detroit: polled 402 Detroit area resi-     possible panelists and outlining unique      Dan Rosenthal
  dents, including Wayne, Macomb, and        local stories. Newspaper partners            CEO
  Oakland counties; February 2008.           donated advertising space for ads            UnitedHealthcare of South Florida
                                             inviting the public to attend each event.
• San Francisco: polled 402 San                                                           Detroit
  Francisco area residents, includ-          Television and radio broadcast partners
                                             ran public invitations on air in the weeks   Dr. Kimberlydawn Wisdom
  ing Santa Clara, Alameda, Contra                                                        Surgeon General, State of Michigan
  Costa,Marin, San Francisco, and San        leading up to the event.
  Mateo counties; March 2008.                All of the events were open to the           Vernice Davis Anthony
                                             public, and there was no fee to attend.      President & CEO
Town Hall Meetings                                                                        Greater Detroit Area Health Council
                                             Town Hall Panelists included:
Town hall meetings were held in Miami,
                                             Miami                                        David Cole
Florida (February 13, 2008); Detroit,
                                                                                          Chairman
Michigan (March 26, 2008); and San           Dr. Donna Shalala
                                                                                          Center for Automotive Research
Francisco, California (June 17, 2008)        President, University of Miami
and were moderated by veteran journal-                                                    Janet Olszewski
                                             Dr. Victor Herrera
ist Frank Sesno.                                                                          Director
                                             Chief Medical Resident
                                                                                          Michigan Department
The host cities for the town hall meet-      Jackson Memorial Hospital
                                                                                          of Community Health
ings were chosen based on a number of
criteria including demographics and                                                       Gail Warden
unique health care challenges and                                                         President Emeritus
innovations.                                                                              Henry Ford Health System




                                                                                                                               25
San Francisco                               The second working group was held on        Ms. Christine Broderick
Dr. Mitchell Katz                           July 17, 2008. Attendees reviewed the       Health Policy Analyst
Director of Health                          results of the national survey, and         National Partnership for
City and County of San Francisco            discussed additional topics for inclusion   Women and Families
                                            in this report.                             Dr. Molly Ann Brodie
Dr. Ana Valdes
Medical Director                            Co-Chairs                                   Vice President
St. Anthony Free Medical Clinic                                                         Director Public Opinion and Media
                                                          .
                                            Dr. Harvey V Fineberg                       Research, Kaiser Family Foundation
Daniel Zingale                              President
Senior Advisor to                           Institute of Medicine                       Mr. Kenneth Dineen
Governor Schwarzenegger                                                                 Global Managing Director
                                            Ms. Patricia McGinnis                       Public Service Health, Accenture
Dr. Paul Volberding                         President and CEO
Chief of Medical Service for the            The Council for Excellence in               Dr. Arthur Garson, Jr.
San Francisco VA Medical Center             Government                                  Executive Vice President and Provost
                                                                                        University of Virginia
Roundtable Discussions                      Roundtable Participants
                                                                                        Dr. Helene D. Gayle
The Council partnered with the              Dr. Regina M. Benjamin                      President and CEO
Institute of Medicine at the National       Founder and CEO                             CARE USA
Academies to hold two working group         Bayou La Batre Rural Health
meetings throughout this process. The       Clinic, Inc                                 Dr. Roger Herdman
first was held on December 19, 2007. At                                                 Director, National Cancer Policy Forum
                                            Ms. Sara Black                              Director, Board on Health Care Services
this meeting attendees reviewed the find-
                                            Outreach Consultant                         Institute of Medicine
ings of the Gallup focus groups and
                                            Consumers Union
identified additional areas to explore in                                               Mr. John K. Iglehart
the survey research and town hall           Dr. Jo Ivey Boufford                        Founding Editor, Health Affairs
meetings.                                   New York Academy of Medicine                and National Correspondent
                                                                                        The New England Journal of Medicine

26
Ms. Diane Jones                        Ms. Julie McQueen                          Mr. Frank Sesno
Director Industry Relations            Director of Research                       Special Correspondent
Health Solutions Group, Microsoft      Accenture Institute for                    CNN
Mr. Larry Kocot                        Public Service Value                       Dr. Donna E. Shalala
Deputy Director, Engelberg Center      Ms. Darby Miller-Steiger                   President
for Health Care Reform                 Senior Research Director                   University of Miami
The Brookings Institution              The Gallup Organization                    Mr. Eric Sildon
Ms. Nicole Duritz                      Dr. Arnold Milstein                        Senior Manager
Senior Project Manager                 Medical Director                           State Government Relations
AARP                                   Pacific Business Group on Health           Accenture
Dr. Alain Enthoven                     Ms. Helen Musura-McCarty                   Gail Warden
Graduate School of Business            Associate Partner                          President Emeritus
Stanford University                    The Gallup Organization                    Henry Ford Health System
Mr. Alan I. Leshner                    Ms. Susan Nealon                           Mr. Bill Vaughan
Chief Executive Officer                Director of Marketing                      Senior Policy Analyst (Health)
American Association for the           Accenture                                  Consumers Union
Advancement of Science                 Dr. Greg Parston                           Dr. Paul Volberding
Dr. Rose Marie Martinez                Director, Accenture Institute for Public   Professor and Vice Chair
Director, Board on Population Health   Service Value                              UCSF Department of Medicine
and Public Health Practice             Dr. Judith A. Salerno                      Chief, Medical Service
Institute of Medicine                  Executive Officer                          SF Veterans Affairs Medical Center
Dr. J. Michael McGinnis                Institute of Medicine                      Co-Director, UCSF-GIVI Center for
Senior Scholar                                                                    AIDS Research
Institute of Medicine


                                                                                                                       27
wHAT wE LEARNEd:
RESuLTS IN dETAIL
Americans across the nation—both those who have health coverage
and the uninsured—are deeply worried about the affordability and
quality of health care. They believe that information has the power to
help improve the quality and efficiency of the system, and they have
clear priorities about the kinds of changes they would like to see and
the role government should play.
ANxIETy ABOuT COST
Figure Q. Americans who have put off medical treatment in the past 12 months because they could not afford it



Overall                                                                Insurance Status                                   Age
                                                                                                                          18–39                     40–64                      65+
                                                                       Insured                   Uninsured




         26%                                                           20%                       58%                      29%                       28%                        11%




When Americans think about health                                    “Even though I have the health coverage,                               “I haven’t had a mammogram in
care, they worry first and foremost                                   I cannot afford the $10 to go see the                                  like three years because I couldn’t do
about its cost. Finding ways to pay for                               doctor for the co-pay,” she says.                                      anything about it if I found out I had
health care is changing the way some                                 “I think it’s very poor because health                                  cancer.”
Americans live.                                                       care should not cost over fifty percent                                And some, left uninsured by changing
In San Francisco, a mother quits her                                  of your budget.”                                                       forces in the economy, wonder how this
job because lowering her income to                                    More than 1 in 4 Americans (26%)                                       can be allowed to happen in an
qualify for state aid is the only way she                             have put off some sort of medical treat-                               advanced society like the United States.
can afford health care to treat her                                   ment within the past year because they                                 Detroit, hit hard by job losses and
child’s brain tumor. In her community,                                couldn’t pay for it, including 58% of                                  benefits cuts in the auto industry, is
some wonder,                                                          those who are currently uninsured.                                     home to many who feel abandoned by
“Why should we have a society that                                    Even those who currently have health                                   a system that now leaves them unable
 forces a working mother with a child…                                insurance are feeling the crunch, with                                 to afford basic care. While auto
 to purposefully leave her job and go                                 20% reporting that they too have                                       companies once offered such generous
 on welfare so that she can become                                    put off treatment. Just 11% of those                                   benefits that workers and retirees alike
 eligible for health insurance?”                                      over age 65 have put off treatment                                     came to expect premium health care
                                                                      compared to 29% of those age 18-39                                     as a condition of employment, these
For others, cost is the barrier to the
                                                                      (see Figure Q).                                                        long-term liabilities caught up with the
most basic care.
                                                                      After her divorce, a middle-aged Miami                                 industry, forcing them to make painful
A mother of two who has insurance                                                                                                            changes to a contract that workers
                                                                      nursing student loses her insurance
cannot afford to see a doctor because                                                                                                        viewed as a lifetime guarantee. Today,
                                                                      coverage and cannot afford the most
her monthly premiums eat up more                                                                                                             the Big Three automakers estimate that
                                                                      basic care.
than half of her income.



3 Eduardo Porter, “Japanese Cars, American Retirees; Makers Put Health and Pension Burdens Squarely on the Workers” New York Times, May 19, 2006. Accessed August 30, 2008 at: http://query.nytimes.com/gst/
fullpage.html?res=9B01E5DF133EF93AA25756C0A9609C8B63


30
 Figure R. Biggest Health care concerns                              Figure S. Affordability of health care only fair/poor


                                                                     100



              51%                           30%                       80                73% 76%         71%
                                                                            65%
                                                                      60



Cost                          Quality                                 40



                                                                      20



                                                                       0
                                                                           National San       Detroit   Miami
             9%                             10%                                     Francisco




Ability to get                Something
health care                   else



health care costs add between $1,100          For ordinary Americans, “the cost of            Mandatory out-of-pocket expenses
and $1,500 to the cost of a new               health care” is not an abstract number          can make treatment a financial burden
vehicle.3 The aftershocks from these          that represents the aggregate total             for people who are already paying
cutbacks have left many with a sense          spent across the nation on health care          significant insurance premiums.
that the system has failed them.              each year. It is the out-of-pocket cost         Those on government-sponsored plans
                                              each time they go to the doctor’s office        such as Medicare also face difficulties
“I’m a United States citizen,” says one       or pharmacy. It is the deduction from
 woman from Detroit, “and I feel like…                                                        covering their share of the bill.
                                              each paycheck as they contribute to an
 it’s only right that a person is able to     employee health benefit program. It is          Citizens can see the effect of increased
 get help or health care when they            the thousands they spend each year              costs throughout their communities.
 need it and when they’re sick.”              buying private insurance if they are not        There is widespread disillusionment
Whether rich or poor, young or old,           part of a group plan. And for the least         with the financial hardship associated
insured or uninsured, cost dominates          fortunate, it is the staggering bills they      with health care: two-thirds of
their concerns (see Figure R).                face—sometimes for years—after a                Americans (65%) express negative
                                              procedure or hospitalization that was           views about the affordability of health
While cost is the top concern for all                                                         care in their area, and in some areas
                                              not covered by any insurance.
surveyed, those ages 40 to 64 are                                                             these percentages are even higher
far more concerned about cost (56%)           Among the uninsured, 57% cite cost              (see Figure S ).
than are their younger and older              as the main reason they don’t have
counterparts (47% each).                      coverage. Even those with medical
                                              insurance are also concerned about
                                              the costs and worried about future
                                              increases in their out-of-pocket costs.




                                                                                                                                     31
 ANxIETy ABOuT COST

 Figure T. Critical information for understanding
 candidates’ positions on health care


100%            How candidates will                      How much plan will
                pay for their plan                       cost taxpayers

  80
          74%                                                                                   72%
                     70%           67% 68%                   65% 66%                  66%
  60



  40



  20



   0
          National                San Francisco             Detroit                  Miami




 The average cost of health insurance                                 What can be done to contain costs                                     Americans evince a healthy skepticism
 premiums in the U.S. has doubled since                               for individuals and the nation as a                                   about the solutions proposed by
 1999, rising from $5,791 then to                                     whole? There are no simple solutions.                                 politicians to rein in health care costs.
 $12,680 in 2008, according to a new                                  Fragmented costs and excessive spend-                                 In our town hall discussions and polls,
 study by the Kaiser Family Foundation—                               ing permeate the system. According                                    the public made it clear that the new
 far outpacing wage growth and general                                to the Committee for Economic                                         President must give top priority to
 inflation. Deductibles have also risen                               Development, it is “a ‘cost unconscious’                              controlling the cost of health care.
 sharply, leading an anxious public (over                             environment. ” The U.S. spends more
                                                                                    9
                                                                                                                                            They are eager for more details to help
 80%) to say that controlling health care                             for hospital care, outpatient care, drugs,                            them understand the candidates’ plans.
 costs should be a major priority for the                             administration, and insurance than is                                 They want specifics. They want to
 new President.                                                       expected for a country of its size and                                know how plans will be paid for
 But the growing problem for individuals                              wealth: $480 billion more.9 This is                                   (74%) and how much the plans would
 is rooted in the overall cost of health                              complicated by the fact that, because                                 cost individual tax payers (70%)
 care in the United States, which is                                  of its unique for-profit elements and                                 (see Figure T ).
 spiraling upward. The country spends                                 complex insurance/administrative
                                                                      structures, the U.S. system attracts a                                The current forecast for health care
 16% of its gross domestic product                                                                                                          costs is: expensive today, more expen-
 (GDP) on health care—nearly twice as                                 multitude of costs not seen in other
                                                                      countries. Factors ranging from drug                                  sive tomorrow. Unless something
 much as in European countries—yet                                                                                                          changes, the numbers will continue to
 the quality of care and access to care                               prices to medical litigation to higher
                                                                      costs for hospital and outpatient care                                climb: by 2017, the U.S. health care
 are no better, and in many cases                                                                                                           burden is expected to more than
 actually worse here than elsewhere, as                               all contribute to the high cost of health
                                                                      care in the U.S.10                                                    double, reaching $4 trillion, or roughly
 evidenced by life expectancy rates and                                                                                                     20% of the nation’s gross domestic
 infant mortality rates.7                                                                                                                   product (GDP).11
 4 The Kaiser Family Foundation and Health Research & Educational Trust, “Employer Health Benefits Annual Survey 2008,” p.1. < http://ehbs.kff.org/images/abstract/7791.pdf>, September 2008, 7 Robert
 Wood Johnson Foundation, “Overcoming Obstacles to Health,” p. 12. < http://www.rwjf.org/files/research/obstaclestohealthhighlight.pdf>, February 2008, 8 Committee for Economic Development, “Quality
 Affordable Health Care for All,” <http://www.ced.org/docs/report/report_healthcare200710.pdf>, October 2007, 9 McKinsey & Company, “Accounting for the Cost of Health Care in the United States,” p. 9
 <http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp> January 2007, 10 McKinsey p. 8, 11 RWJF.org; 2017 estimates from Centers for Medicare and Medicaid Services: http://www.
 cms.hhs.gov/apps/media/press/release.asp?Counter=2935

 32
Case Study:

Cost Containment Through
the Power of Information
The Department of Veterans        emphysema, cutting pneumonia
Affairs’ (VA) model system of     hospitalizations in half and
electronic health records,        reducing costs by $40 million
known as VistA, has enabled       per year. A RAND study found
the VA to reduce costs and        that the VA outperformed all
errors while increasing safety    other sectors of American
and efficiency. Patient waiting   health care across a spectrum
times have declined while         of 294 measures of quality in
customer service improved,        disease prevention and treat-
and access to care has in-        ment. As of 2006, the VA had
creased because of on-line        led private-sector health care
availability of health informa-   in the independent American
tion. It has helped the VA to     Customer Satisfaction Index
save 6,000 lives by improving     for six straight years.
rates of pneumonia vaccina-
tion among veterans with




                                                                   33
THE POwER OF INFORMATION
The American people believe that information has the power to improve
the quality and efficiency of the health care system. They want to know more
about both the cost of health care and the performance of their providers.
They want access to better information about quality and cost, and they
are willing to share their own health and medical data to improve quality
and accountability throughout the system.




The Need To Know:
More About Performance And Cost
A young man in Miami wants                                               The public’s concerns about quality                                      United States, good information is
some way to know if he really needs                                      of care are well-founded: a 2003                                         available on access and wellness, but
the medication he is being prescribed.                                   RAND Corporation study found that                                        information on cost and on quality
A woman takes the point one step                                         U.S. patients received only 54.9% of                                     of care is significantly lacking. All of
further: she wants to know about                                         the recommended care for their health                                    the countries have their strengths and
CT scans and blood tests.                                                conditions12(see Figure U ).                                             weaknesses but, by a narrow margin,
                                                                         The quality of care provided by                                          the United Kingdom emerges from
“I want to know what exams are being                                                                                                              this study as the strongest performer.
                                                                         hospitals is also highly valued. Again,
 sent to me because the doctor’s                                                                                                                  Its approach to the provision of
                                                                         the public wants to know first and
 afraid of a future malpractice as                                                                                                                information has placed great emphasis
                                                                         foremost about records of medical
 opposed to because I really need                                                                                                                 on individual choice and the informed
                                                                         mistakes and adherence to clinical
 that exam.”                                                                                                                                      consumer as a means of improving
                                                                         guidelines and standards. Information
Americans are concerned about the                                        about experience with specific surgical                                  health and health care; consumer
performance of their health care                                         procedures is also considered critical                                   information on health care coverage,
providers. When evaluating the                                           by a majority of Americans (see Figure V ).                              cost, and quality is good.
criticality of information about doctors                                                                                                          The Accenture study suggests that
                                                                         The public currently lacks ready access
in their health plan, the public priori-                                                                                                          information for health care consumers
                                                                         to the information it wants. The
tizes two performance measures above                                                                                                              should be locally relevant, with data
                                                                         Accenture Institute for Public Service
others: doctors’ record of medical                                                                                                                on area health care providers. At the
                                                                         Value recently conducted a study of
mistakes, and whether they consistently                                                                                                           same time there must be consistency in
                                                                         health practices in six countries—the
follow standards and guidelines in                                                                                                                the volume and quality of information
                                                                         United States, the United Kingdom,
diagnosing and treating patients.                                                                                                                 available across the country. In the
                                                                         Australia, Germany, Canada, and New
                                                                         Zealand—and determined that in the                                       United States, this is not the case.




12 McGlynn, Asch, Adams, et. al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine 384:26, June 26, 2003, pp. 2641-2642.


34
Figure U. Importance of critical information about doctors in health plan


Their record of medical mistakes
                                                                                 62%
Follow established clinical
guidelines and standards for care                                       54%
Education, training, and
professional accomplishments                                      40%
Patient satisfaction surveys
                                                         33%
Years practicing in the area
                                                        31%
Average number of patients
seen daily                                         24%

                                         0    20             40             60         80   100




Figure V. Importance of information about hospitals in health plan


Record of medical mistakes
                                                                             59%
Follow established clinical
guidelines and standards for care                                           57%
Experience/record with
specific surgical procedures                                            53%
Accredited by independent
professional health care organizations                   33%
Patient satisfaction surveys
                                                       31%

                                         0    20            40              60         80   100




                                                                                                  35
THE POwER OF INFORMATION


 Americans need better resources for information on procedures
 and treatments covered by insurance plans and on the cost of care.




One physician in San Francisco is                                      information. Gaining access to care is                                  Accessing information about cost is
concerned.                                                             easier in the U.S. than in many other                                   complicated by the fact that, according
“How does a consumer know and make                                     countries. However, Americans need
                                                                                 13
                                                                                                                                               to one survey, two-thirds of physicians
                                                                       better resources for information on                                     indicated they do not want information
 rational choices about the provider
                                                                       procedures and treatments covered by                                    on cost of services or quality of care
 or the hospital in which you get care?”
                                                                       insurance plans and on the cost of care.                                to be made available to the public.15
A woman from Detroit says that                                         One group found that only 12-16% of                                     In addition, information regarding
getting information isn’t as simple as it                              people had received any information                                     coverage—that is, which health
may sound.                                                             from doctors or hospitals about the cost                                insurance plans cover what procedures
“Consumers do not really have                                          of their treatment.14                                                   by which physicians—can be hard to
 access to good quality information                                    A dean of a nursing school in Miami                                     uncover. The health insurance companies
 on hospitals, doctors, or plans.”                                     points out,                                                             stand by with phone help lines to assist
                                                                                                                                               members. However, there are no
Some of the information Americans                                     “Health care is the only thing that you                                  comprehensive national services to
want is currently available. For example,                              buy and you have no idea how much it                                    compare coverage across plans.
America outshines the United                                           costs. You walk into a hospital and no
Kingdom, Australia, Canada, Germany,                                   one gives you a menu of prices… we
and New Zealand in providing wellness                                  should know that an appendectomy
                                                                       costs X, not $1000 here, $2000 there,
                                                                       $3000 there. I think it should be
                                                                       transparent.”




13 Accenture Institute for Public Service Value, “Study of Consumer Health Care Information: An International Comparison,” pp. 22, 24, September 2008, 14 Accenture, p. 23, 15 Audet et al., “Measure, Learn,
And Improve: Physicians’ Involvement In Quality Improvement,” Health Affairs, 24, no. 3 (2005): 843-853 Accessed at: http://content.healthaffairs.org/cgi/reprint/24/3/843


36
Case Study:

Leader in Consumer
Health Care Information:
The united Kingdom
According to the Accenture      Their system emphasizes
Institute for Public Service    individual choice, underscoring
Value study, the United         the perspective that an in-
Kingdom has the strongest       formed consumer better
approach to providing           manages their own care,
consumer health information     resulting in healthier out-
that is accessible and useful   comes. U.K. information
in making informed decisions    about coverage, cost, and
regarding care.                 quality of care is superior to
                                that in other countries studied,
                                including the U.S., Australia,
                                Canada, Germany, and New
                                Zealand.




                                                                   37
THE POwER OF INFORMATION

Figure W. Information Sharing

        Favor giving doctors shared                                           Favor including information in large
100     access to medical records                                             database to advance research


80       78 %                          77 %          77 %
                        74 %
                                                                               67 %          65 %
60                                                                                                          57 %          59 %

40



20


  0
        National       San       Detroit            Miami                     National      San       Detroit             Miami
                       Francisco                                                            Francisco




The Need To Share:
To Improve Quality And Accountability
Contrary to conventional wisdom                                       appointments, and get insurance                                      provider, each hospital, and each state
about privacy concerns, most                                          authorizations, show that these patients                             has a different system and different
Americans see the benefits of sharing                                 are satisfied with the process.16                                    regulations regarding medical record
health data. Three-quarters of the                                   To provide citizens with better access                                keeping. That, in part, may be why
public (78%) favor giving physicians                                 to some of the clinical information                                   90% of physician offices and 80% of
the means to share access to their                                   they need, many countries are intro-                                  hospitals still use paper records.19
medical records, while two-thirds (66%)                              ducing universal electronic medical                                  “Can you imagine going to your bank
see the value in including their own                                 record keeping systems,17 as are                                      and having them write out your
information anonymously in a large                                   some American states. Some countries                                  account, keeping track of it by pen
database that would help researchers                                 already have national medical                                         and paper and then you go to another
understand more about the effective-                                 records networks in place. For example,                               bank and they do not have that
ness and possible side effects of various                            in Germany, people can have all of                                    record… we would not tolerate it.
treatments or prescription drugs                                     their health records on a single                                      So why do we tolerate a health care
(see Figure W).                                                      computer chip that they can carry with                                system that does not have the most
As Americans have increasing                                         them.18 Introducing such systems is                                   basic thing of a national electronic
opportunities to incorporate informa-                                more manageable in countries with                                     medical records system?”
tion technology in the management of                                 a single-payer system (typically the                                  asks a health care provider from
their health care, there is good evidence                            government), in which the cost of                                     California.
to suggest that they will look favorably                             implementing and maintaining the
                                                                                                                                           The American public’s views on the
on these advances. Studies of existing                               system is the responsibility of one party.
                                                                                                                                           power of information extend to their
patients who engage in online interac-                               The situation in the U.S. is more                                     attitudes about electronic health
tions with their health care providers to                            complex: the multiple-payer system                                    records. While less than a quarter
receive prescription refills, make                                   means that each health insurance


16 Robert Wood Johnson Foundation “ Health Information Technology in the United States, 2008,” p. 6, <http://www.rwjf.org/files/research/062508.hit.exsummary.pdf>, June 2008, 17 RWJF HIT, p. 8
18 Catherine Rampell, “Your Health Data Plugged Into the Web,” Washington Post, September 5, 2007, p. D-1. Accessed at: http://www.washingtonpost.com/wp-dyn/content/article/2007/10/04/
AR2007100400984.html, 19 Washington Post, p.1


38
Figure X. Interest in EHR                                                                                                                      Figure Y. Americans agree an
                                                                                                                                               EHR would:
100
               Have heard of                   Likely to use an                Currently use an
               EHR                             EHR system                      EHR system
                                                                                                                                                                 59 %
 80



 60
         52 %                             55 %                             53 %
                                                                                                                                                                Improve quality of care
                                                                                                            49 %
                   44 %
 40                                                 39 % 37 %                       38 %
                                                                                                                     32 %
                            23 %                                                              24 %
 20                                                                                                                            16 %                              53 %

  0                                                                                                                                                             Help you better
         National                        San Francisco                    Detroit                           Miami                                               manage your health




                                                                                                                                                                 48 %


                                                                                                                                                                Reduce cost of care




(23%) of those surveyed currently use                                  However, a recent national survey                                       for a nation-wide EHR system and
an electronic health record (EHR)                                      estimated that only 4% of U.S. doctors                                  who would institute and maintain
system, nearly twice as many (44%)                                     currently possess a fully functional                                    the standards for such a system must
would be interested in using such a                                    EHR system. Many more physician
                                                                                     20
                                                                                                                                               be determined before the country as
system if it were available (see Figure X ).                           practices are interested in using an                                    a whole can move forward.
Majorities think it could improve their                                EHR system, but cost and complexity                                     For now, according to the Accenture
quality of care (59%) and help them                                    are barriers to adoption.                                               Institute for Public Service Value study,
better manage their own health (53%).                                  Studies have suggested that sharing                                     Americans have “the largest amount
Just under half (48%) are interested                                   health records through electronic                                       of information available to them.” On
because they believe using an EHR                                      systems could save the health care                                      the other hand, they also face “the
could reduce the cost of their health                                  system as much as $80 billion per year                                  most complex task in finding answers to
care (see Figure Y ).                                                  while reducing medical errors and                                       their questions” compared with the five
Some in Detroit are familiar with the                                  increasing the quality of care.21 A key                                 other countries examined in the study.23
benefits of EHR:                                                       to achieving these efficiencies is the                                  The public’s willingness to share health
                                                                       development of national standards for                                   information is a major asset that could
“The organizations that have a fully                                   EHRs that address existing technological,
 developed electronic health record,                                                                                                           revolutionize the practice of “evidence-
                                                                       legal, financial, and organizational                                    based medicine,” which enables health
 one in which they’re able to document                                 barriers to their wider use.22 Our
 everything about an individual patient,                                                                                                       care providers to make diagnoses and
                                                                       current multiple-payer system makes                                     recommend courses of treatment based
 where the patient can access their                                    it difficult to coordinate access, whether
 physician by email, where their drugs                                                                                                         on data about what has worked in
                                                                       for patients to make informed decisions                                 thousands or even millions of cases.
 can be prescribed by email, it does                                   about their care or for providers to
 make a huge difference.”                                              assess a patient’s health on a broad
                                                                       scale. Questions about who would pay


20 RWJF HIT, p. 1, 21 RWJF HIT, p. 6, 22 RWJF, Health Information in the United States: The Information Base for Progress, pp. 5:42-5:47, 23 Accenture, p. 21


                                                                                                                                                                                          39
A TALE OF TwO HEALTH CARE SySTEMS:
MINE VERSuS OuRS
Most Americans are aware of a distressing discrepancy between the
excellent health care accessible by some and the poor care available
to others.




A San Francisco man sees the inequity        At the same time, two-thirds (65%)          Miami, where people are just as likely
within his own family:                       consider access to care for the             to rate their own care as excellent or
“It’s tough knowing that my sister           uninsured poor (36%) or only fair (29%).    good (77%) as to say that access to care
 doesn’t have health care right now.”        In the metropolitan areas where the         for the uninsured is only fair or poor
                                             town hall meetings were held, survey        (75%). In Detroit, a city hit hard by
An electrician who has excellent health      respondents gave much lower ratings to      the recent economic downturn, people
insurance through his union realizes         the access to care for the uninsured in     report slightly lower quality ratings
that most Americans are less fortunate       their communities. Some regional            of their own health care (72% excellent
than he is.                                  differences are apparent: Southerners       or good) and slightly higher negative
“It’s a very comprehensive plan, but I       are more likely than those in the           ratings for access to care for the
 know that that’s not the case for           Northeast to say access for the uninsured   uninsured (83% fair or poor).
 probably the majority of Americans,”        is poor in their area (41% vs. 30%).        A woman from Florida coins a phrase
 he says.                                    This duality is consistent across the       that captures the dichotomy:
More than three-quarters of                  country. In San Francisco, of those         “The health care in the United States
Americans (77%) express positive views       who have insurance, 80% are pleased          is a tale of two systems. We have
about the quality of their own health        with the quality of their own health         the best at the high end, and we have
care, with 37% rating it as excellent        care, yet nearly as many (75%) say           the worst at the low end for people
and 40% saying it is good (see Figure Z ).   access to health care in their area is       who are uninsured. And that’s a big
                                             poor or fair. The same holds true in         challenge that needs to be addressed.”




40
 Figure Z. Quality and Accessibility of Healthcare

100                                                                                                               % saying excellent or good
                                                                                                                      Quality of own healthcare
80          77 %                            80 %                                             77 %                     Availability of quality
                                                                      72 %                                            healthcare
                     65 %
60
                                                     60 %                      57 %                 56 %              Access to care for the
                                                                                                                      uninsured

40                            35 %
                                                            25 %                                           25 %
20                                                                                    17%

 0
           National                        San Francisco             Detroit                Miami




 A physician from California finds                                 decisions.29 Patients who have health
 the same disparity in his part of                                 insurance plans may feel entitled to
 the country:                                                      care—regardless of cost— if they
“I think the problem we see is that some                           believe they are already paying for it
 people have great access to great                                 through their insurance premiums.
 care… [while] many other people have                              Providers, who are paid for their services
 either no access to care or are being                             and are often stakeholders in the very
 cared for in a system that does not                               facilities their patients visit, have little
 deliver the quality they expect.”                                 financial incentive to limit a patient’s
                                                                   treatments or visits.30 Finally, adminis-
 How has our society become a land of                              trative costs in the U.S. are six times of
 haves and have nots when it comes to                              that seen in comparable nations.31
 health care? The current system offers
 few incentives for any party—patient,
 insurer, or provider—to be value-
 conscious when making health care




 29 McKinsey p. 8, 30 McKinsey, p. 14, 31 McKinsey, p. 16


                                                                                                                                                  41
COVERAGE FOR THE uNINSuREd:
CHILdREN FIRST, BuT wHO wILL PAy?
The number of Americans without health insurance stands at 45.7 million
(15.3%).32 To put that number in perspective: it exceeds the total population
of medium-sized countries such as Spain and South Africa.




A Detroit woman in nursing school                                    The Uninsured: Causes                                                employed (14%), their employer does
who currently has no health insurance                                and Consequences                                                     not offer coverage (9%), or they are
captures the paradox of the system:                                                                                                       between jobs (7%) (see Figure AA).
                                                                    Why are people going without insurance?
“We are the future of health care, and                              Again, cost is the common denomina-                                   This widespread lack of health
 we have no health insurance.”                                      tor. Often it’s a matter of what people                               insurance is a grave concern because
                                                                    need most: food or shelter versus                                     of the deep impact it has on personal
The uninsured are working Americans:
                                                                    medical care.                                                         health. The uninsured are less likely
overwhelmingly they are U.S. citizens
                                                                                                                                          to get preventative care, which in turn
(78%)33 who come from families in                                    One physician in California who treats
                                                                                                                                          makes them more likely to need
which one or more member works full                                  the uninsured population explains:
                                                                                                                                          hospitalization for what could have
time (70%). They are not uniformly                                  “I see people who have to make                                        been avoidable health problems. Their
poor: two in ten are from families with                              trade-offs between eating and health                                 diseases are generally diagnosed at
annual incomes greater than $50,000.34                               care. I see people who have to make                                  later stages, making treatment more
While adults make up 80% of the unin-                                trade-offs between being housed and                                  difficult—and costly—or impossible.38
sured,35 children are at particular risk:                            health care. And when it comes down                                  The percentage of Americans who
nearly one in five American children                                 to having to choose between basic                                    reported not getting or delaying needed
living in poverty (19%) are uninsured.36                             survival needs and health care, health                               medical care increased by 64% in the
Minority communities are hit particu-                                care is always last.”                                                last four years, from 36 million in 2003
larly hard: nonwhites are more than                                                                                                       to 59 million in 2007.39 A study by the
                                                                    Most uninsured Americans (57%) say
twice as likely as whites to lack insurance.37                                                                                            Kaiser Commission on Medicaid and
                                                                    they simply cannot afford coverage.
                                                                    Another 30% cite reasons having to                                    the Uninsured suggests that having
                                                                    do with employment: they’re not                                       health insurance could reduce mortal-
                                                                                                                                          ity among the uninsured by 10-15%.40



32 Accessed at: http://www.census.gov/hhes/www/hlthins/hlthin07/hlth07asc.html, 33 Kaiser Family Foundation, “The Uninsured: A Primer” <http://www.kff.org/uninsured/upload/7451-03.pdf>, p. 4,
October 2007, 34 “The Real Census Story,” The Wall Street Journal, Accessed at: http://online.wsj.com/article/SB121979631879074825.html, 35 Kaiser, p.5, 36 Census, 37 Kaiser, p. 5


42
Figure AA. Main Reason for Not Having Health Insurance


Cannot afford it                                                                          57%
Not employed                                   14%
Employer does                             9%
not offer it

In between jobs                         7%
Do not think I need                   5%
it /do not want it

Lost coverage                       3%
Pre-existing condition             2%
Other                              2%
                              0                   20                 40                   60                  80                 100




But it isn’t simply a problem for the                                 drives up your premium costs, my                                      The impact on the health care system is
uninsured. Across the country,                                        premium costs, and it crowds and                                      profound. A study by the Henry J.
Americans understand that this critical                               closes our emergency rooms. If you                                    Kaiser Family Foundation has esti-
issue affects every one of us, regardless                             believe that, then you see we have a                                  mated that health care spending for the
of income or health insurance status.                                 shared interest in all of us having                                   uninsured in 2008 will total $86 billion.
As one woman in Detroit puts it,                                      insurance.”                                                           The uninsured will pay $30 billion out
                                                                      There is a growing recognition that, in                               of their own pockets, leaving the
“We can’t afford not to cover everyone…
                                                                      addition to driving up overall costs, the                             balance of “uncompensated care” costs
 If we think we’re not paying for it now,
                                                                      high number of uninsured degrades                                     divided among hospitals, community
 we are. We’re paying for it in the most
                                                                      the system’s ability to function.                                     health centers, physicians.and govern-
 inefficient, expensive way possible.
                                                                                                                                            ment. The study finds that the
 People who don’t have coverage don’t                                  “I think that the uninsured is a huge
                                                                                                                                            government ends up picking up $43
 get care early, they don’t go to the                                 problem,” says the CEO of one of
                                                                                                                                            billion of the $56 billion in uncompen-
 doctor… so the diabetes gets worse,                                  South Florida’s largest insurers,
                                                                                                                                            sated costs. In short, this cost-shifting
 the heart disease gets worse, they’re                               “whether it’s the 47 million across the
                                                                                                                                            illustrates the problem of having
 served in the emergency room.”                                       country or the 600,000 that we have
                                                                                                                                            millions of uninsured: we all get stuck
                                                                      here in south Florida in the Miami-
A San Franciscan agrees: “Covering the                                                                                                      with the bill.
                                                                      Dade area. It’s a major problem for us,
six million [Californians] who are                                    it’s a problem not only for us as a
uninsured will actually bring costs                                   community but it’s a problem for the
down for all of us. This is true because                              health insurance industry as well
six million now go to the worst possible                              because when you have that many
place for the highest possible care,                                  people that don’t have insurance, the
which is the emergency room. So it                                    system doesn’t work well.”



38 Kaiser Family Foundation, “The Uninsured: A Primer,” p. 1, January 2006 Accessed at: http://www.kff.org/uninsured/upload/7451.pdf, 39 Accessed at: http://www.rwjf.org/pr/product.jsp?id=32191
40 Kaiser 2006, p. 7


                                                                                                                                                                                                    43
44
Figure BB. Coverage expansion priorities for political candidates

100                                                                                              Providing health insurance
                                                                                                 for all children
      83 %                  83 %                     85 %                   84 %
                                                                                                 Providing health insurance
80                                 75 %                       72 %                               for all uninsured Americans
             68 %
                                                                                                 Providing access to health
60                                                                                               care for non-U.S. citizens

                                           42 %                                                  N/A
40
                    27 %                                             26 %
20



      National             San Francisco            Detroit                 Miami




Children First...
So what can be done to improve the                A medical researcher at the University      To address this concern, a majority
situation? Americans believe the top              of Miami says,                              (68%) says that expanding health
priority is children.                                                                         insurance to all uninsured Americans
                                                  “…I think putting a cap on a four year      should be a priority for the new
A mother of a four-year-old in Miami              old kid and not allowing the kid to
explains how the coverage she and her                                                         President. The exception to the
                                                  have any more treatment in the future       public’s coverage expansion priorities
husband chose for their small business            is not right.”
proved inadequate when her child needed                                                       is ensuring that non-citizens have
extensive post-hospitalization care:              More than eight in ten (83%) surveyed       access to health care. At a time when
                                                  say that ensuring health coverage for all   immigration is a hot button issue in
“…as soon as we got out of the                    children should be a major priority for     American politics, just over one-quarter
hospital he capped out within a                   political candidates (see Figure BB).       (27%) cite this as a major priority.
month… he is capped out for life at
four years old.”




                                                                                                                                    45
COVERAGE FOR THE uNINSuREd


The Cost of Covering the Uninsured: According to estimates by the
Henry J. Kaiser Family Foundation, the cost of expanding coverage
to the uninsured would increase total health care spending by $122.6
billion or 5.1%, which is less than the average 7.6% annual increase
in health spending since 200142.




But who will Pay?
But even as most Americans aspire to                                  Among those willing to pay more in
help their fellow citizens, they know that                            taxes to expand coverage, nearly half
there will be a significant cost involved                             (48%) would be willing to pay up to
in expanding coverage among the                                       $100 a year or more in additional taxes
uninsured, and most are not willing to                                to help cover the uninsured.
pay higher taxes to do so (see Figure DD).                            Americans know that there will be a
Older Americans are significantly less                                cost involved in expanding coverage
likely to be willing to pay more in taxes                             among the uninsured, and most are not
to help cover the uninsured than their                                willing to pay higher taxes to do so.
younger counterparts (see Figure EE ).                                To meet this need, nearly half (48%) of
Willingness to pay more in taxes varies                               those willing to pay more in taxes to
by both age and income. Younger                                       expand coverage would be willing to pay
people and those with annual incomes                                  up to $100 a year or more in additional
above $75,000 are the most willing to                                 taxes to help cover the uninsured
pay more (see Figure FF).                                             (see Figure FF).




42 Kaiser Family Foundation, “Covering the Uninsured in 2008,” p.11. Accessed at: http://www.kff.org/uninsured/upload/7810.pdf


46
Figure CC. Amount willing to pay more for the uninsured

                                                 San
                                National         Francisco         Detroit           Miami

 Providing health insurance
 for all children               83%              83%               85%               84%
 Controlling rising health
 care costs                     81%              86%               85%               N/A
 Improving the quality
 and safety of medical care     77%              86%               82%               N/A
 Improving prescription
 drug coverage                  74%              68%               80%               N/A
 Providing health insurance
 for all uninsured Americans    68%              75%               72%               N/A
 Helping Americans to adopt
 healthier lifestyles           64%              71%               69%               N/A
 Providing access to health
 care or non-U.S. citizens      27%              42%               26%               N/A




Figure DD. Willing to pay more                                               Figure EE. Willing to pay more in taxes
in taxes to cover the uninsured                                              to cover the uninsured, by age

                                                                                                                       50%                    Yes
                                                                             18–36                                                            No
                                                                                                                       50%

   43%                              57%                                                                             45%
                                                                             40–64
   YES                              NO                                                                                 55%
                                                                                                          31%
                                                                             65+
                                                                                                                                    69%
                                                                                     0           20           40            60           80    100




Figure FF. Willing to pay more in taxes to cover                             Figure GG. Amount willing to pay more to cover the unin-
the uninsured, by annual income                                              sured
                                                                             Up to $5 per year ....................................... 15%
Under                               44%                      Yes
$35k                                  56%                    No              Up to $25 per year..................................... 22%

$35k–$75k                           42%                                      Up to $50 per year .................................... 14%
                                           58%                               Up to $100 per year .................................. 22%
More than                                50%                                 More than $100 per year ....................... 26%
$75k
                                         50%
            0           20     40          60         80           100




                                                                                                                                                   47
PRIORITIES FOR THE NEw
PRESIdENT, CHANGES AMERICA
wANTS, ANd THE ROLE
OF GOVERNMENT
Americans know the health care system is on an unsustainable
course, and that it needs to be reformed to deal with issues of
cost and performance. They are eager for pragmatic solutions
that will address the realities of their lives.
49
“We are operating under a [health care] system today that was
 devised 40 years ago and yet our social habits, our job locations,
 our mobility, our portability really has changed dramatically. So
 we have a complete disconnect between a system that is really
 outdated with the way our lifestyles have taken us.”
Ken Dineen
Managing Director
Global Public Health
Accenture




Priorities for the New President
People have been tuned in to the         The public has a clear sense of what
debate about health care on the          the new President’s major priorities
presidential campaign trail. Roughly     should be regarding health care. The
half (48%) paid close attention to the   top agenda items include: providing
candidates’ positions on health care,    insurance for all children, controlling
and 31% paid very close attention        costs, improving the quality and safety of
(see Figure II).                         care, and improving prescription drug
                                         coverage (see Figure JJ ).
                                         They are also eager for more details
                                         to help them understand the plans for
                                         reform (see Figure KK ).




50
Figure II. Major health care priorities for political candidates


                                           San
                              National     Francisco Detroit      Miami

 Providing health insurance
 for all children             83%          83%        85%         84%
 Controlling rising health
 care costs                   81%          86%        85%         N/A
 Improving the quality
 and safety of medical care   77%          86%        82%         N/A
 Improving prescription
 drug coverage                74%          68%        80%         N/A
 Providing health
 insurance for all            68%          75%        72%         N/A
 uninsured Americans

 Helping Americans to
 adopt healthier lifestyles   64%          71%        69%         N/A
 Providing access to health
 care or non-U.S. citizens    27%          42%        26%         N/A


Figure JJ. Critical information when trying to understand
candidate’s positions
                                            San
                              National      Francisco Detroit     Miami
 How they would pay for
 their plan                   83%           83%       85%         N/A
 How much the plan will
 cost individual taxpayers    81%           86%       85%         N/A
 How the plan will help
 cover the uninsured          77%           86%       82%         N/A
 How their plan would
 improve the quality of       74%           68%       80%         N/A
 health care

 How their plan would
 control the cost of          64%           N/A       N/A         N/A
 health care




Figure KK. Paying close attention to
positions on health care



 48 %                 51 %                44 %              66 %

National            San Francisco        Detroit          Miami




                                                                          51
“We’ve never elected a President based on health care,” says
 Donna Shalala, President of the University of Miami and former U.S.
 Secretary of Health and Human Services. “I think we send a very
 clear message to the Presidential candidates that this is your first
 priority. That you’ve got to build the [health care] consensus in this
 country, even if you have to scotch tape it together.”
Donna Shalala
President
University of Miami




52
The Changes America wants
While many worry about                 Public Menu Of Costs                        Americans are also
the unknown and unintended             75% agree that government should            in favor of adopting
                                       require that healthcare providers
consequences of health                 publish their costs (58% strongly agree).   electronic health records
care reforms, a majority of                                                        systems and are willing
                                       Pre-Existing Conditions
Americans voice support                75% agree that government should            to share their health
for a number of reform                 require healthcare providers to cover       information, but only under
                                       pre-existing conditions (54% strongly
concepts:                              agree).                                     certain conditions.
Portability                                                                        Health Information Sharing
                                       Employer-Based Care
78% favor allowing Americans to take                                               78% of Americans favor giving doctors
                                       72% agree that government should
their health care coverage with them                                               the ability to share access to their
                                       require all large employers to provide
when they leave a job.                                                             medical records, if it is done with their
                                       health insurance coverage to all full-
                                                                                   permission.
                                       time employees (54% strongly agree).
When it comes to the role
                                       Competition Across                          Evidence-Based Medicine
of government in reforming
                                       State Lines                                 66% favor having health information
the system, America’s                                                              shared in a large database to help
                                       71% agree that government should
voice is clear.                        create national or regional healthcare      researchers understand and compare the
                                       exchanges to allow insurance to             effectiveness and possible side effects of
Performance Ratings                    be purchased across state lines (52%        various treatments or prescription drugs,
                                       strongly agree).                            if no patient names were used in the
81% agree that government should
                                                                                   database.
require that performance ratings
on doctors and hospitals be publicly   Assistance For Low-Income
available (60% strongly agree).        69% agree that government should
                                       provide assistance to low income
                                       individuals and families to buy health
                                       insurance (52% strongly agree).




                                                                                                                                53
“Medicare is an unsung hero… It controls costs better than most
 systems. The quality of care is good. People can rely on it. There is
 a lot to recommend it. I think we have to be realistic though that
 culturally— this may not be true in San Francisco but it is true in
 California and certainly true across the nation —we have a certain
 resistance to an entirely government-run health care system. There
 is something about that that runs counter to the American culture.”
Daniel Zingale
Senior Advisor to Governor Arnold Schwarzenegger




Portability                                                        “Right now we have a ridiculous system:
                                                                    where you work, the size of the
                                                                                                                The Role of Government
One key concern is the lack of portability:                         business you work for, and the type of      Americans have definite ideas about
the ability to maintain one’s health                                business you work at determines what        the role that government should play
insurance regardless of changing                                    type of healthcare you have.”               regarding health care. Reflecting the
circumstances. Right now, most health                                                                           public’s understanding of the power of
insurance is tied to an individual’s place                          Portability receives very strong support,   information, a top priority is guaranteeing
of employment. Leave the job, lose the                              with more than three-quarters (78%)         access to quality and cost data. Majorities
health plan.                                                        favoring the right to take their health     strongly favor government involvement in
                                                                    care coverage with them when they           requiring health care providers to publish
A doctor in Detroit says,
                                                                    leave a job.                                their performance ratings and costs for
“I’m a really frustrated physician trying                                                                       procedures and services.
                                                                    The CEO of a national nonprofit
 to practice under these circumstances
                                                                    organization says,                          The involvement of government in
 where my patients go from having
 insurance, to a possible HMO to having                            “We do not have an absolute prescription     health care elicits strong views from the
 no insurance.”                                                     of exactly how it has to look but it has    public. According to polls conducted by
                                                                    got to involve government. It has got to    the Gallup Organization between 2001
The CEO of a national nonprofit                                     involve business. It has got to involve     and 2007, the public has consistently
organization based in California says the                           individuals. It has got to involve the      expressed a preference for maintaining a
current system places too much emphasis                             healthcare system and everyone has          system based on private insurance rather
on an individual’s employment situation:                            to step up and understand that this is      than replacing the current system with a
                                                                    a shared responsibility.”                   government-run health care system.43




43 Accessed at: http://www.gallup.com/poll/4708/Healthcare-System.aspx


54
 Figure HH. Support for Government Involvement in Healthcare


                                              Agree           Strongly agree

Requiring that performance                                                                  81%
ratings on doctors and hospitals
be publicly available                                                          60%
Requiring healthcare providers                                                        75%
to publish their costs
                                                                               58%
Requiring healthcare providers to                                                     75%
cover pre-existing conditions
                                                                          54%
Requiring all large employers to                                                      72%
provide health insurance coverage
to all full-time employees                                                54%
Creating national or regional                                                        71%
healthcare exchanges to allow insurance
to be purchased across state lines                                       52%
Providing assistance to low                                                          69%
income individuals and families
to buy health insurance                                                 52%
Allowing everyone to buy                                                        60%
Medicare coverage at group
rates, regardless of age                                             43%
                                          0           20        40             60      80         100




The public favors government requiring                     As one woman explains,                       lines to access competitive rates.
large employers to provide insurance.                      “The fundamental idea for health             According to the Committee for
They also want government to require                        insurance, to me, is that the amount        Economic Development, such a program
that insurers cover pre-existing conditions,                that you have to pay for basic coverage     would ideally be overseen by an
and to provide assistance to low-income                     should not depend on whether you            independent group—modeled on the
Americans so they can afford coverage.                      had any pre-existing conditions, what       Federal Reserve—to build faith in the
“The challenge,” says a Californian,                        your risk factors are, or what you          new system among patients, providers,
“for all of us is to figure out how do we                   actually experience after you start in      and insurers.44
 preserve what is good about employer-                      the insurance plan. You ought to have       It’s noteworthy that one proposal
 based coverage because people who                          that basic coverage.”                       for expanding coverage for the
 have insurance through their employer                                                                  uninsured—allowing anyone to buy
 do not want us to abandon that but, at                    Another area for government involve-         Medicare coverage at group rates,
 the same time, we cannot be completely                    ment is expanding health insurance           regardless of age—gets significantly
 dependent upon that because people                        markets across state lines to lower costs.   less strong support than any other
 change jobs now on average every five                     Currently, insurance availability and        policy prescription surveyed. This
 years and sometimes more often.”                          cost vary by region. Insurance in one        suggests reservations about expanding
                                                           state can cost twice as much as a            government’s role as the payer-
                                                           neighboring state, where a larger            of-choice in the health care system
                                                           population may enable insurers to spread     (see Figure HH).
                                                           costs across a larger pool of insured
                                                           individuals. 71% favor creating national
                                                           or regional “health plan exchanges” so
                                                           that they can buy insurance across state




                                                                                                                                            55
Case Study:

The Role of Government
in Massachusetts
In late 2006, Massachusetts                                        •   Creating the Commonwealth                                       Massachusetts, according to the
began implementing compre-                                             Care program, which provides                                    highest estimates. Of the newly
hensive legislation designed to                                        subsidized health coverage for                                  insured, 191,000 found private
provide health care coverage to                                        individuals with income below                                   (or non-government) coverage,
nearly all state residents. The                                        300 percent of the federal                                      159,000 of whom enrolled
legislation made numerous                                              poverty level                                                   through an employer-subsidized
changes, including:                                                •   Creating a Commonwealth                                         plan. Payments to hospitals and
•   Requiring all state residents                                      Health Insurance Connector,                                     health centers for “free care”
    to purchase health insurance                                       which provides individuals                                      services are down by 41% (com-
    coverage                                                           and employers with access                                       paring Quarter 1 of FY 2007 to
                                                                       to easily comparable insurance                                  the same period in FY2008).46
•   Requiring that all employers
    with 11 or more employees                                          products45                                                      The success of the plan in cover-
    make a “fair and reasonable”                                                                                                       ing the uninsured is balanced
                                                                   Since enacting health care reforms
    contribution toward health                                                                                                         by higher than expected cost of
                                                                   in 2006, there are 439,000 newly
    insurance coverage for their                                                                                                       this initiative. The Governor’s
                                                                   insured Massachusetts residents,
    employees                                                                                                                          budget request of $869 million
                                                                   according to the Massachusetts                                      for 2009 is about $400 million
                                                                   Division of Health Care Finance                                     more than that of 2008, and it
                                                                   and Policy. At the time the                                         may still fall short.47
                                                                   reforms were enacted, there were
                                                                   650,000 uninsured people in


45 Accessed at: http://www.kff.org/uninsured/upload/7777.pdf, 46 Accessed at: http://www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default
47 Accessed at: http://www.kff.org/uninsured/upload/7777.pdf


                                                                                                                                                                                                 57
MESSAGES ON THE PuBLIC’S
AGENdA TO LEAdERS, PROVIdERS,
INSuRERS, EMPLOyERS ANd
CONSuMERS
MESSAGES ON THE PuBLIC’S AGENdA




Americans across the nation—including those who currently have health coverage—
know the current system is on an unsustainable course. They are eager for pragmatic
solutions that will address the realities of their lives.

Messages to the                               Americans want their government             Messages to Health Care
New President and                             leaders to improve accountability,          Providers
Government Leaders                            control costs through market improve-
                                                                                          Americans want health care value and
                                              ments, and expand coverage by helping
The American people say that your                                                         believe that information has the power
                                              those with low incomes obtain health
major priorities regarding health care                                                    to improve the quality and efficiency of
                                              insurance. Specifically, the public
should be to:                                                                             the health care system. They want
                                              believes that government should:
• Cover all uninsured children—                                                           access to understandable information
                                              • Require publicly available perfor-        about performance and costs to increase
  83% say a major priority should be to         mance ratings of doctors and hospitals.
  cover all children; 68% say covering                                                    the accountability of their health care
                                              • Require health care providers to
  all who are uninsured should be a                                                       providers. When evaluating the criticality
                                                publish the costs of all services and     of information about doctors and
  major priority.                               procedures.
• Control the rising costs of                                                             hospitals, the public prioritizes two
                                              • Require all large employers to provide
  health care.                                                                            performance measures above others:
                                                health coverage to full-time employees.
• Improve the quality and safety of care.
                                              • Require health care providers to cover
                                                                                          •   Records of medical mistakes.
• Improve prescription drug coverage.
                                                pre-existing conditions.                  •   Whether they consistently follow
The public is listening to what you are       • Create national or regional health            standards and guidelines in diagnosing
saying about health care and looking to         care exchanges so insurance can be            and treating patients.
you to find practical solutions that            purchased at competitive rates across     Contrary to conventional wisdom,
reflect their priorities. A majority of the     state lines.                              most Americans are willing to share
public says that answers to the following     • Provide assistance to low-income          their health information among their
questions are critical to help them             individuals and families to buy health    doctors and researchers to improve
understand where you stand on health            insurance.                                the quality of care. Most favor the use
care reform:                                                                              of electronic health records systems to:
• How will you pay for what you
                                                                                          •   Give doctors shared access to their
  propose?
                                                                                              medical records, with permission.
• How much will it cost taxpayers?
                                                                                          •   Give researchers their health
• How will your plan control the cost of
                                                                                              information anonymously in large
  health care?
                                                                                              databases to study and compare the
• How will it help cover the
                                                                                              effectiveness of specific interventions
  uninsured?
                                                                                              and treatments.
• How will it improve the quality of
  health care?




60
Messages to Insurers                         Messages to Employers                          Raise your voice and communicate
                                                                                            your priorities to candidates for public
Most Americans who are insured are           The American people believe in
                                                                                            office, your elected leaders, your
satisfied with their coverage—with the       employer- based health care and most
                                                                                            providers, your employers and your
exception of the cost. To improve the        favor government involvement to require
                                                                                            insurance companies. Insist on the
value proposition, insurers should:          employer-based coverage. At the same
                                                                                            information you need to make good
•   Work with employers, government,         time they want to see the rising costs
                                                                                            decisions about your health and your
    and providers to address current and     contained. You, as employers, have an
                                                                                            health care and hold leaders account-
    future customer concerns.                opportunity to engage your employees in
                                                                                            able for keeping their promises and
•   Improve communications and               open, fact-based discussions about the
                                                                                            commitments to improve the quality,
    information about costs, benefits, and   tradeoffs you face and their choices in that
                                                                                            cost and access to care.
    choices. This information should be      context. Faced with costs that are rising
                                             at unsustainable rates, employees should       It is imperative that your perspective—
    clear, concise, and consumer friendly.
                                             have choices that reflect their values.        the missing perspective—be heard and
•   Increase accountability of providers
                                                                                            heeded to achieve health care reform
    for quality and performance, rather
                                             Messages to the Public                         that reflects your priorities and fairly
    than the quantity of procedures and
                                             Faced with a health care system                addresses your concerns.
    paperwork.
•   Spread risks by expanding pools          plagued by cost increases and significant
    beyond state lines through national or   gaps in coverage, it is up to the
    regional health exchanges.               American people to take ownership of
•   Improve incentives for prevention and    their “health care destinies” by becoming
    treatment based on the best evidence     better informed consumers and voters.
    of effectiveness.                        Ask the new President and your
                                             representatives in Congress— in person
                                             if you get the chance or send an email
                                             or letter—to explain their reform
                                             proposals: how much will they cost,
                                             how will they pay for them, how will
                                             they control costs, and what will be the
                                             impact on the quality of care and
                                             coverage for the uninsured. Become a
                                             better consumer by requesting informa-
                                             tion from your providers about their
                                             performance and the costs of services.




                                                                                                                                   61
APPENdIx




62
63
TOwN HALL SNAPSHOT:
MIAMI, FLORIdA
On February 13, 2008, the Council          only for us as a community but it’s a          What Matters to the People of
held its first interactive, health care    problem for the health insurance               South Florida?
town hall meeting with more than 300       industry as well because when you have
                                                                                          According to our survey research,
South Florida residents at the             that many people that don’t have
                                                                                          residents of the greater Miami area
University of Miami. Community             insurance, the system doesn’t work well.”
                                                                                          pointed to cost as their biggest health
members, students, and experts packed      The participants were asked to end the         care concern and found information
the Storer Auditorium to discuss the       event with their own messages to the           about the cost and other aspects of
challenges, problems, and trade-offs       Presidential candidates. An unidentified       health care coverage to be complex and
with the American health care system       woman in the crowd expressed her               confusing. They paid close attention to
and identified the key health care         desire for politicians to be held ac-          Presidential candidates on health care
priorities for the upcoming presidential   countable for details on their plans for       and wanted more information from the
election.                                  reform. “They talk about things like tax       candidates about the bottom line cost
The cost of care, and the confusion        deductibility, association health plans,       for them and for the country. They say
surrounding cost information was on        and nobody ever stops and asks them            the top health care priorities for the
the minds of many in the room,             what about people with pre-existing            new President should be to provide
including Nilda P. Peragallo, the Dean     conditions, what about cancer survi-           health insurance to all children,
of the School of Nursing and Health        vors, these people under the types of          improve prescription drug coverage,
Studies at the University of Miami who     plans they talk about can’t get insur-         and control rising health care costs.
said, “Healthcare is the only thing that   ance and I haven’t heard anybody               Residents also gave mixed reviews to
you buy and you have no idea how           actually ask them those questions.”            the quality of health care in the greater
much it costs. You walk into a hospital,   Dr. Donna Shalala, President of the            Miami area, but most were satisfied
nobody gives you a menu of prices.”        University of Miami, took it a step            with their own health care.
Panelist Lilian Rivera also echoed a       further saying “we’ve never elected a
finding in the survey research, pointing   President based on health care. Or             Health Care Spotlight:
out that “…the healthcare in the           rarely on domestic issues, it’s always         Miami, FL
United States is a tale of two systems.    been on the international or national          Miami-Dade County is the most
We have the best at the high end and       security issues. I think we send a very        populous county in the state of Florida
we have the worst at the low end for       clear message to the Presidential              and the eighth most populous county
people who are uninsured. And that’s       candidates that this is your first priority.   in the United States. The county is
a big challenge that needs to be           That you’ve got to find a way to build         home to 28 hospitals and more than
addressed.”                                the consensus in this country, even if         32,000 licensed healthcare profession-
Dan Rosenthal, CEO of                      you have to scotch tape it together,           als, the state’s greatest concentration
UnitedHealthcare of South Florida,         there are some things that we expect           of medical facilities. 2007 Census
continued the discussion of the            during your first couple of years and          estimates show that more than one
uninsured and echoed the thoughts of       this ought to be your number one               in five Florida residents are currently
many when he said “it’s a problem not      domestic priority.”                            uninsured, higher than the
                                                                                          15.3% nationally.




64
date: FEBRuARy 13, 2008
Location: THE uNIVERSITy OF MIAMI




Panelists




Dr. Donna E. Shalala     Dan Rosenthal          Dr. Lillian Rivera       Dr. Victor Herrara
President                CEO                    Administrator,           Chief Medical Resident
University of Miami      UnitedHealthcare       Florida Department       Jackson Memorial
                         of South Florida       of Health                Hospital




Community Partners




                                            !                        !                            !




                                                                                                      65
TOwN HALL SNAPSHOT:
dETROIT, MICHIGAN
On March 26th 2008, the Council held        “They want the best technology, they         Residents paid close attention to
a town hall meeting at the Charles H.        want the best drugs, they want the          Presidential candidates’ positions on
Wright Museum of African American            lowest co-pay and as long as we do that     health care. Their top priorities for
History in Detroit, MI. More than            we’re going to have these inequities        the new President are controlling cost
200 members of the greater Detroit           about the other parts of the population     and providing insurance coverage
community joined in this extremely lively    who don’t have full coverage.”              for children. They also want more
discussion about the state of health care   Facing a difficult economic outlook,         information about the bottom line
in the area and across the nation.          community members like Laura                 cost of reforms for them and for
 The discussion took on a particularly      McKinney took aim at the concept that        the country.
 local flavor with participants focusing    reform would need to be based on
                                                                                         Health Care Spotlight:
 on growing concerns over their own         trade-offs, instead saying “I’m a United
                                                                                         Detroit, Michigan
 personal rising health care costs as a     States Citizen and I feel like we should
 result of current economic challenges      have that. I feel like it’s a human right.   Detroit is the largest city in the state
 in the city. Janet Olszewski noted that    It’s only right that a person is able to     of Michigan, and the Detroit
“we can’t afford not to cover everyone.     get help or healthcare when they need        Metropolitan Statistical Area is the 11th
 If we think we’re not paying for it now,   it and when they’re sick.”                   largest in the country, with a population
 we are. We’re paying for it in the most                                                 of nearly 4.5 million people according
 inefficient, expensive way possible.       What Matters to the People of                to 2007 U.S. Census Bureau estimates.
 People who don’t have coverage, don’t      South Detroit?                               The local economy traditionally draws
 get care early, they don’t go to the       According to our survey research,            its cues from the automotive industry
 doctor… so the diabetes gets worse,        greater Detroit area residents pointed       and affiliated manufacturing jobs, and
 the heart disease gets worse, they’re      to cost as their biggest health care         the city has felt the burden of recent
 served in the emergency room.”             concern and found information about          movement out of the city core and into
                                            the cost and benefits of their health        the surrounding suburbs. Overall, the
 The recent downturn in the automotive                                                   state of Michigan’s uninsured rate is
 industry also caused participants also     plans to be complex and confusing.
                                            At the same time, more than seven            10.4%, below the national figure of 15.3%.
 take a close look at the challenges
 of the current employer-based system.      out of ten rated the quality of their
“As long as we have employer-based          own health care as good or excellent.
 health insurance, everyone who has it      Affordability and access to care for the
 is going to want everything that they      uninsured in the Detroit area were
 can get,” noted David Cole, Chairman       overwhelmingly rated as poor or only
 of the Center for Automotive Research.     fair, with 25% of residents saying they
                                            have put off medical treatment in
                                            the last year because of their inability
                                            to pay.




66
date: MARCH 26, 2008
Location: THE CHARLES H. wRIGHT MuSEuM OF AFRICAN AMERICAN HISTORy




Panelists




Vernice Davis Anthony   Janet Olszewski        Gail Warden           Kimberlydawn Wisdom   David Cole
President and CEO       Director               President Emeritus    Surgeon General       Chairman
Greater Detroit Area    Michigan Department    Henry Ford Health     State of Michigan     Center for
Health Council          of Community Health    System in Detroit                           Automotive Research




Community Partners




                                                                                                            67
TOwN HALL SNAPSHOT:
SAN FRANCISCO, CALIFORNIA
On June 17, 2008, the Council held          Accenture’s Ken Dineen added “Yes.           the region is poor or just fair. In
its third town hall meeting in the          It is completely unsustainable. We are       contrast, 80% said they are pleased
series The American Public on Health        operating under a system today that          with the quality of care they
Care: The Missing Perspective at            was devised 40 years ago and yet             personally receive.
the University of California–San            our social habits, our job locations,
Francisco’s Mission Bay Conference          our mobility, our portability really has     Those surveyed also paid attention to
Center. Cost continued to be a major        changed dramatically. So we have a           the candidates’ positions on health care
theme, with panelists focusing on           complete disconnect between a system         and overwhelmingly say that the new
system inefficiencies and the fragile       that is really outdated with the way         President’s priorities on this issue
nature of the current employer-based        our lifestyles have taken us.”               should be controlling the rising cost of
model. “Those of us who are fortunate                                                    health care (86%), providing health
                                            Zingale ended the meeting with a stark       insurance for all children (83%), and
enough to have insurance understand         message to Presidential candidates:
that it is not secure. We can lose it or                                                 improving the quality and safety of
                                            “I think the most important thing is         medical care (79%). They also wanted
we can get sick and find out that they      a measure of political courage, which
are going to rescind our policy or they                                                  straight answers as far as how reforms
                                            means them telling people what they          would be paid for and how much they
are not going to give us the access to      do not want to hear. They have to tell
the specialists or the care that we need.                                                would cost individual taxpayers.
                                            HMOs that their profits are too high.
So we are all in a crisis. There is no      They have to tell doctors that they          Health Care Spotlight:
question about it,” noted Senior            have to bear some responsibility for         San Francisco, California
Advisor to Governor Schwarzenegger          everybody being covered. They are the
Daniel Zingale.                                                                          The San Francisco Bay Area, with
                                            highest paid profession in the state and
                                                                                         a 2006 population of more than
Institute of Medicine President Dr.         the nation. They have to tell all of us as
                                                                                         7 million, encompasses large cities
Harvey Fineberg added, “we have             patients we have to do better in staying
                                                                                         such as San Francisco, Oakland, and
to figure out how to align all the          well and not just focus on end of life
                                                                                         San Jose, along with smaller urban
incentives so that people get the basic     treatments that are more expensive
                                                                                         and rural areas. Overall, the Bay
coverage that they need, catastrophic       and give us less quality of life. It means
                                                                                         Area consists of nine counties, 101
coverage that everyone deserves, and        staring down every single one of us and
                                                                                         cities, and 7,000 square miles. The
insurance that stays with the individual    the interest group involved and telling
                                                                                         city’s controversial “universal” health
and family when they need it.”              us what we do not want to hear.”
                                                                                         coverage has drawn attention from
The discussion also highlighted                                                          across the country and is one of the
                                            What Matters to the
numerous innovative programs in the                                                      many innovative ideas being put into
                                            People of the Bay Area?
Bay Area including the Veteran’s                                                         practice in the Bay Area.
Health Administration’s VistA system.       According to our survey research, Bay
                                            Area residents expressed concern about
Panelists and participants challenged
                                            the cost and availability of quality
continued to challenge the employer-
                                            health care in the region, with more
based system, but remained cautious as
                                            than seven out of 10 rating the
to what the alternative would look like.
                                            affordability of care as only fair or
                                            poor and nearly half (49%) saying that
                                            access to care for the uninsured in the
                                            area is poor. Four in ten said the
                                            availability of quality health care in




68
date: JuNE 17, 2008
Location: uNIVERSITy OF CALIFORNIA–SAN FRANCISCO




Panelists




Dr. Harvey Fineberg     Dr. Mitchell Katz      Dr. Ana Valdes        Dr. Paul Volberding     Daniel Zingale
President               Director of Health     Director              Chief of the Medical    Senior Advisor
Institute of Medicine   City and County        St. Anthony           Service San Francisco   to Governor Arnold
                        of San Francisco       Free Medical Clinic   VA Medical Center       Schwarzenegger




Community Partners




                                                                                                                  69