Americans Speak on Health Reform: Report on Health Care Community Discussions

IV. Solutions to the Problems in the U.S. Health Care System

The Health Care Community Discussion groups did not pinpoint one specific problem with the American health care system, but rather described an array of cost, access, and other systematic problems. Each group also offered solutions in response to the central questions of health reform. In rebuilding this system, what values should be prioritized? What roles and responsibilities should each actor assume? What specific ideas should be tried or adopted? Finally, at the end of the day, what should this system look like? Health Care Community Discussion reports offered thousands of solutions, which were often similar, to these questions.

A. Principles for a Reformed U.S. Health Care System

Many of the Health Care Community Discussions focused on the aspirations for the health system, suggesting that its performance would improve if it adhered to guiding values and principles. Among reports discussing solutions, participants wanted a system that is fair (36%), patient-centered and choice-oriented (19%), simple and efficient (17%), and comprehensive (15%) (see Figure 8).

Fair

Fairness was a common theme among Health Care Community Discussions and motivated many to call for a health system that insures all Americans. A number of Health Care Community Discussion reports explained how the group came to this conclusion. For example, the moderator of a Health Care Community Discussion at the St. Louis University School of Medicine in St. Louis, Missouri, comprised of forty-five members of the community, noted, "One of the attendees stated strongly that health care should be a 'right' rather than a privilege. After a brief subsequent discussion, I asked for a show of hands. Virtually everyone present agreed that health care should be a right and equally available to all citizens of all ages." A Health Care Community Discussion at a hospital in Asheville, North Carolina, took a theoretical approach, "The fundamental policy question to be addressed is, 'Is health care a public right?' If health care is a right, then solutions to paying for health care will require a public solution. If not, then the market will only allow those who can afford care to access it as is the case with other commodities." In Devon, Pennsylvania, "The group agreed unanimously that some type of a universal care model not only should be 'on the table' as a philosophical option, but should be the preferred model and starting point of discussion."

A commonly expressed recommendation among Health Care Community Discussion participants was to make health insurance inclusive of people with health problems or risks. As a report from North Brunswick, New Jersey, explained, "People who have the pre-existing conditions are the ones who need the insurance the most yet most of their time is spent fighting with the insurance company on what is covered and what is not covered. Tests, which are recommended by doctors, are not covered by the insurance company. This kind of power in the hands of the insurance company should be taken away. Any insurance carrier which provides coverage in the US (travelers, third party insurance companies, or local insurance companies) should be mandated to cover every preexisting condition at the same premium."

For some participants, the principle of fairness was less about helping the uninsured than about preventing their own high costs or compromising their own health. A group of community leaders and non-profit workers from a Charleston, South Carolina Health Care Community Discussion explained how the uninsured affect health costs. They said, "The nation needs some form of universal health care. The failure to insure that every citizen has access to affordable health care is a major reason for the chaos and fragmentation of the delivery of health care in this country, and goes a long way towards explaining why our country ranks below many others in the overall health and longevity of its citizens." One parent who attended a meeting hosted by a health organization in Arlington, Texas, explained, "If someone is sick, they should receive medical care, regardless of whether or not they can pay. If my daughter is in school and she's sitting next to someone who is ill, but whose parents don't have insurance so she's not receiving the care she needs, then my daughter could contract her illness. I don't want that. It's not the kids' fault. Everyone should be afforded health care."

Participants in Health Care Community Discussions had different interpretations of what "covering" all Americans means. Some reports advocated that everyone should have minimum catastrophic insurance to prevent bankruptcy related to unexpected health events. As a group of diverse community members who met at a home in Albany, Georgia, stated, "There should be basic universal coverage for all or at least catastrophic coverage for all or a national pool." In San Jose, California, a group of friends and neighbors echoed this suggestion, "The delivery of that system should be through a universal health care baseline insurance program with options for individuals and/or employers to add increased benefits or lower deductibles at an additional affordable cost. Those who have existing coverage through employment or retirement should not be forced into the universal system. The coverage should be transportable and without regard to pre-existing conditions." Participants at a Health Care Community Discussion group in New York, New York, urged looking less at insurance when contemplating a fair and inclusive system and more at the content and quality of care. They advocated, "Insurance should not only be about getting access to treatment, but equally good treatment for all...In other words, it is not about minimum care but excellent care."

Patient-Centered and Choice-Oriented

Numerous Health Care Community Discussion groups believed that any reformed or new health care system should have the patients' needs as a central focus. A small group from North Scituate, Rhode Island, met at a home and described this demand, saying, "We want a system that encourages engagement between people and their primary care practices and other health providers; that is patient centered, which means meeting people where they are, as they are, and giving them services that actually improve their health." A group of community members who met in Pittsburgh, Pennsylvania, on a Saturday morning conveyed a similar sentiment. They noted, "The consensus was that the definition of 'preventive care' must be expanded to include not just routine medical screenings such as mammograms, but also, more broadly, a model of patient-centered care in which primary care and people's personal relationships with caregivers are encouraged and incentivized, as opposed to the current system that most profitably rewards specialized and catastrophic care."

Choice emerged as a strongly held value in the Health Care Community Discussion reports. For example, many participants wanted the ability to choose their own provider and felt current insurance networks forced them to choose providers in-network regardless of quality or personal preferences. A group that met at a library in Richmond, Virginia, explained, "In terms of public policy, we want the flexibility to choose physicians (including specialists) outside of our insurance plan or networks without paying a high cost. It was a unanimous decision that we should not continue to allow health insurance companies to select our doctors." A gathering at a small apartment in New York City advocated a similar position, "People, the general public, does not want a choice of insurers, we want a choice of providers."

Groups also expressed that they wanted the option to upgrade from a basic plan to one that covers additional care. For instance, a group from rural Kunkletown, Pennsylvania, noted, "A choice of policies, and upgrades to the basic policy should be available so that individuals or employers who want more than the basic policy may purchase it at additional cost. Most people want a choice, and allowing insurers to offer different policies will cause them to compete, which should be beneficial. Upgrades and alternatives to a basic policy might include such things as lower co-pays, coverage of procedures not covered in the basic policy, access to a greater choice of providers, and/or extra services such as dental and vision."

Simple and Efficient

Many Health Care Community Discussion participants felt that a more user-friendly private and public health care delivery system would yield to greater efficiency. At a meeting at the Saint Louis University Medical School in St. Louis, Missouri, the participants agreed, "People need a few choices they can understand...." Local physicians gathered at a Huntsville, Alabama medical center for a Health Care Community Discussion reiterated this sentiment, "The system should be made less complex so that less educated patients are able to understand how to access good health care/benefits." A participant from Trenton, New Jersey, relayed her father's experience to emphasize the importance of an easy-to-navigate system. She said, "We need to make the health care system more user-friendly. The health system is very difficult to navigate. Recently, my father (a retiree...) was informed that [his employer] was canceling health care benefits for retirees. It was very stressful for him to figure out what he needed to do in order to purchase health care insurance for himself and my mother. He talked to friends, health insurance salespeople, etc. and everyone told him something different. This is a lot to ask a 75-year-old person to do!"

Participants from a Health Care Community Discussion at a Baptist church in Sterling, Virginia, concurred that simplifying health care options improves outcomes. They concluded, "Looking at the number of options health care plans offer, this group suggested that the plans be streamlined so that the everyday consumer can better understand the language, reduce the number of redundant options, and be held accountable to pay for services they have initially contracted to pay." In Merrick, New York, a group concluded, "The amount of increased paperwork and need for doctors to hire people to take care of it was cited as wasteful, a result of our present insurance environment, and the feeling that the money spent on that be put where it can increase the quality of care for everyone. Paperwork needs to be streamlined because it becomes the focus of care instead of the patient."

Comprehensive

Numerous reports urged policy makers to ensure that insurance is comprehensive enough to protect against catastrophic health care costs. A mix of health care professionals, health care technology employees, and health care consumers at a Health Care Community Discussion in Madison, Wisconsin, reported, "The middle class, however, often has insufficient coverage, high deductibles, high co-pays, and/or limited catastrophic coverage, leading to years of harassment by collection agencies and, in many cases, personal bankruptcy." A conversation in Longmont, Colorado, pointed out, "Medical savings accounts sound like a good idea, but with very high deductibles and still high premiums, they can only serve the wealthy."

About 11 percent of groups recommended improving the comprehensiveness of benefits covered by health insurance plans to include, for example, mental health coverage, dental care, alternative medicine, and vision care. A group of community members in Springfield, Virginia, elaborated on the need to cover mental health services, noting, "The medical community recognizes that mental health is largely dependent on biological processes. It is abhorrent that the United States stigmatizes and leaves out the mentally ill. Due to their conditions, the mentally ill find it difficult to maintain regular employment. It is time to stop making these people fend for themselves, often in the frigid doorways of inner cities, and to provide the medical treatment they need and deserve. With treatment, the mentally ill are more likely to end up working and paying taxes, as opposed to ending up in shelters and jails." Some participants, such as those at a Health Care Community Discussion in Stafford County, Virginia, recommended, "Alternative treatments (massage, acupuncture, chiropractic/body work, naturopathy, nutrition services) need to become part of [the] mainstream medical community, and more of their costs covered by insurance" and urged that any health system should "include dental and vision care as part of basic coverage." In Southwest Durham, North Carolina, a group spoke about the potential impact of covering alternative medicine, saying that it "would drive costs down by allowing people to choose care that was not as intrusive as traditional western." Another group in Fairbanks, Alaska, also voiced their frustration over the inadequate coverage with alternative medicines by stating, "We want the freedom to continue to choose what alternative modalities we wish including naturopathic medicine, auryuvedic medicine, homeopathy, herbology, Chinese medicine."