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

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

C. Specific Suggestions

The Health Care Community Discussion groups provided a wealth of specific ideas in their reports. These ideas encompassed a wide range of topics including establishing health insurance exchanges, decreasing the cost of prescription drugs, developing methods to enhance and promote high-value health care, developing ways to upgrade and simplify information technology, improving health and wellness through education, encouraging healthy lifestyles, and expanding the health system's capacity.

Health Insurance Exchange

Some Health Care Community Discussions focused on how people access health insurance and supported the "establishment of a Federally-sponsored health insurance cooperative or insurance exchange that allows individuals to purchase affordable group coverage." A group from Redondo Beach, California, discussed health insurance exchanges and felt, "All individuals with employer based packages seemed to like the idea of options to utilize insurance exchange[s] or public insurance, depending on the cost of the program(s)." Participants in a Health Care Community Discussion in Potomac, Maryland, agreed, "The group seemed receptive to the idea of something like the Federal Government negotiating for rates and policy qualifications as it does within OPM [Office of Personnel Management] for Federal employees and offering the choice of those plans universally at cost."

Similarly, Health Care Community Discussion participants discussed the potential for small businesses to form coalitions to obtain purchasing power and reduce the cost of health care insurance for their employees. At a home gathering in Saylorsburg, Pennsylvania, the group reported, "There were a number of thoughts about what might be done to help contain costs. For one thing, small employers and individuals must be able to buy as part of a larger group and benefit from that group's purchasing power. A woman who is a realtor noted that she must pay a particularly high price for insurance because she has no large group in which to buy." Other groups found the complexity of insurance exchanges undesirable. As a group of consumers from Ithaca, New York, noted, "Getting health care through an insurance exchange would be too complicated; we want a simple system."

Reducing Prescription Drug Costs

As noted earlier, many Health Care Community Discussion participants viewed the high cost of prescription drugs as a major problem. A group in Pennsylvania, comprised of a broad cross-section of the community, wanted the government to more actively negotiate prices: "We recommend using the vast purchasing power of the Federal government to negotiate with pharmaceutical companies and with lobbyists over fee schedules to lower costs on drugs and tests and raise reimbursement for people-driven care." Attendees at a gathering in Sebastopol, California, stated that "pharmaceutical costs are too high and do not appear to be associated with reasonable research and development costs. Pharmaceutical costs should be standardized and decreased through a government acquisition program. Pharmaceutical companies have become too involved in directing health care."

Participants in a Health Care Community Discussion in South Trail, Florida, recommended reimportation of prescription drugs from other nations. They explained, "There is something wrong with a system that requires a prescription for a drug that costs upwards of $100 for a one-month supply that can be obtained from Canada for pennies on the dollar. The citizens of America are fed up with the exorbitant cost of purchasing drugs in the very same country where the research, development and manufacture of these medications occurs."

In debating other ways to reduce the cost of prescription drugs, many groups suggested that the government regulate the amount of pharmaceutical company advertisements. A Health Care Community Discussion in Kent, Washington, argued the need to "stop advertising by drug companies [and] [u]se the savings to lower the cost of drugs. Participants agreed advertising incentives increased the cost of medicine." Another group in Welaka, Florida, echoed these thoughts, saying, "Most STRONGLY felt commercial advertising of most prescription drugs should be stopped. All strongly felt that there is a serious lack of ethics in the way drugs are pushed at Doctors. All feel there must be an overhaul of drug company marketing techniques and drugs from other countries should be easier to obtain." Some groups suggested limiting pharmaceutical representatives' influence as a way to control costs. In Millerton, Pennsylvania, participants agreed that "pharmaceutical companies should not be allowed to wine and dine the medical offices. Many medical offices have lunch brought in (paid by a pharmaceutical company) every day. Are the doctors prescribing medication because it is the best for the patient or because they are getting incentives from these companies?"

Research, Standards, and Promoting High-Value Health Care

Several Health Care Community Discussion reports discussed the importance of research, standards, and promoting high-value health care. Some groups discussed specific research programs that should be enhanced. A university health council in Wisconsin urged the "[i]nfusion of major research dollars into the National Institutes of Health, Centers for Disease Control, and the Environmental Protection Agency to understand the relationship between disease, environment, and behavior and develop/implement effective strategies to achieve healthy people in healthy communities."

Some Health Care Community Discussion groups discussed how high quality care requires better quality measures and more accountability from providers. A Chesapeake, Virginia group, who gathered to talk about improving care for individuals with intellectual disabilities, suggested, "A quality scorecard should be designed to measure: quality of service, timeliness of service, ability to listen to patient, knowledge of medical condition, pain management and cleanliness of medical facility and staff. The scorecard should be submitted to a neutral agency." In Del Mar, California, a group of both providers and consumers concurred, "...that it would be helpful if the government could figure out a way to provide some sort of rating system with objective information available that would aid consumers in determining the quality of a physician." In Mesa, Arizona, "A majority of [graduate health] students supported the idea of a public rating system for providers to promote improved quality and efficiency in the system." A group meeting in Rutland, Vermont, commented favorably on Pennsylvania's rating system, saying, "In Pennsylvania, doctors are rated and that information is available for public consumption."

In addition to quality reporting, Health Care Community Discussions also recommended cost reporting. At a Colorado Discussion, participants stated, "[P]ublic policy can create a data base to compare providers and their costs for basic services. In this database can be a listing of their filed complaints or some type of review (maybe similar to the Better Business Bureau) where consumers can know if they are seeing a quality provider or not (rather than relying on the insurance company to tell them who they get the best rates from). Providers would ultimately benefit because patients would migrate to those more efficient/better outcome providers."

Other Health Care Community Discussions recommended going a step further by having a public or independent organization produce such information and recommend what works best in health care. A Health Care Community Discussion in Harrisburg, Pennsylvania, sponsored by a Pennsylvania underwriting organization, suggested implementing a national cost containment council as a way to rate and better manage the health care system. Describing a similar initiative in Pennsylvania, the group explained, "It compares procedure frequency, cost, etc at most of the state's hospitals. It also lists general cost." A forum in Binghamton, New York, focused on disseminating best practices. This would, in their assessment, "Standardize care delivery from state to state and county to county... [e]specially interpretation of regulations and definitions of terminology. That being said, there must be some appreciation for local differences in terms of availability of service and allowance for creative ways to build long term care plans that include local services." A group in Solana Beach, California, declared, "We should consider taking health care out of politics by having the details of the system controlled by a National Health Care Board with Regional Health Care Boards in various parts of the country, similar to the Federal Reserve Board."

Some Health Care Community Discussion participants also thought that scaling back coverage of expensive procedures with limited benefits could be one avenue to pursue high-value care. A group in Sherman Village, California, met on a Saturday morning and highlighted, "While the concept of 'rationing' is anathema to most Americans, there nevertheless needs to be discussion around and decisions about cost-benefit analysis: if an expensive procedure is likely to prolong life only for a short time, then perhaps the same health care dollars should be used on a patient who has a reasonable expectation of improvement or at least longevity." A group that met in Silver City, New Mexico, suggested, "[A] 600-gram preemie would receive all appropriate care whereas a 90-year-old cancer patient would receive appropriate palliative care but would likely not receive a bone marrow transplant."

According to roughly 11 percent of Health Care Community Discussion groups, reforming the medical malpractice system would promote high-value care and reduce costs. Some groups suggested tort reform to standardize award regulations and "no fault" compensation. At a meeting in Arlington Heights, Illinois, the group concluded, "Medical mal-practice should be managed like workman's compensation, i.e., fixed payment schedules for bad outcomes. Medical professionals, hospitals and pharmaceutical companies would contribute to a workers' compensation type system. Payouts would be based on fixed schedules." A participant at a meeting in Bellaire, Texas, felt that "the legal punishment system for suing doctors/hospitals needs to be overhauled, perhaps putting variable monetary caps on liability. Too many doctors are quitting because of insurance/litigation issues. An issue of 'fairness' needs to be established."

Simplification and Information Technology

As described in a previous section, Health Care Community Discussion participants felt that the current health care system is antiquated, which raises costs and lowers the quality of care. Many of the reports (15%) named information technology as a solution and some offered specific suggestions to address this issue. Participants who attended a forum in Prior Lake, Minnesota, recommended that the government: "Simplify medical records. Pass transactional regulations at the federal level to decrease records keeping and billing costs and develop a national standard for billing, coding and record keeping. Make medical records truly portable for patients. Make a national medical database available to providers to identify 'best practices' and 'medical trends.'"

Several forums supported national disease registries and electronic medical records. The attendees at a meeting in Visalia, California, felt a need to "establish a universal health care data base for sharing of medical information between doctors. The group discussed how pharmacists have a similar system and that it is important for doctors to be able to pull up a name and see where, why and how a patient has been treated." Group reports suggested that this would ensure higher quality care by synthesizing patient medical history and prior testing, but cautioned that sufficient privacy measures must be undertaken. In Springfield, Missouri, a diverse gathering of health care providers and several uninsured individuals agreed, "Health records should be standardized, made electronic and secure. This will promote coordination of care, enhanced quality, and create a safer patient environment." In Aptos, California, a registered nurses' family gathering discussed how, "[r]equiring the use of electronic medical records should also do a great deal to promote quality health care, as long as confidentiality is protected." Another group from Lexington, Mississippi, agreed with the idea that "all clinics, hospitals, doctor offices, pharmacies and specialty centers" should be required to have electronic medical records. EMRs [electronic medical records] can prevent duplication of services and prescriptions for conflicting medications." A group in New Jersey suggested a "Smart Card" to "track use of medical care ... (similar to today's Veteran's Administration system)." Another group in Colorado Springs, Colorado, expressed, "We were impressed by the way the Veteran's Administration already serves as a successful model, by sharing a patient's medical information between its facilities all across the country. For example, an older veteran we know recently was given a CD of all his current VA medical records that he was able to take with him when he moved to another state and applied there for medical care. The VA is a system already in place that could show us how this sharing can work successfully."

Participants also suggested that an online and standardized billing system would help alleviate high health care costs by eliminating unnecessary variation and confusion. At a gathering in Cheyenne, Wyoming, a group of health care providers, consumers, and community leaders agreed that there is a need to "reduce the cost of health care administration [and create a] uniform billing system; electronic claims processing; standardized health insurance industry forms and physician credential; [and] smart card technology."

Education on Health and Wellness

Many Health Care Community Discussions emphasized the importance of education on health and wellness. Discussants believed that health reform should raise awareness about health and the health care system, support media campaigns, and train people with chronic illnesses to better manage their own care. Over one-quarter of the 3,276 reports (27%) suggested education as a health reform priority.

Roughly 12 percent of Health Care Community Discussion group reports suggested enlisting the public education system to help with disease prevention and promote healthier lifestyles. Comments centered on an underlying assumption that if people have the tools to live a healthy life, they will utilize costly medical care more appropriately. A group of 45 attendees at a Saint Louis University gathering in St. Louis, Missouri, emphasized preventive health care in schools. The group concluded, "Education about the benefits of diet, lifestyle and related approaches needs to start early – as early as grade school. Following this comment, several people spoke about the importance of the public school system as a place where such education should begin and where good habits should be formed." A meeting moderated by a physician and attended by 150 Tallahassee, Florida residents also reported, "The participants suggested promoting healthier lifestyles by stressing this subject in the public school system, including teaching healthy eating habits, exercise, encouraging walking/biking and consuming healthy foods."

Health Care Community Discussion groups also suggested that education on health and wellness should not be limited to children. A pharmacist in Pinole, California, strongly advocated, "Public policy can promote healthier lifestyles by educating the public on disease prevention by providing workshops and seminars on health-related issues, promoting proper diet and exercise, and alerting the public on the health risks involved with obesity, smoking, alcohol-consumption, and other disease-causing factors." Discussants at a home in New York, New York, also felt as though this was an important aspect to health care reform, noting: "We further believe that meaningful health care reform must include an emphasis on health education – throughout the life course – focusing on prevention and wellness. The goal is to teach people what they need to know to stay healthy and give them enough knowledge to make informed choices when they need medical care."

In addition to school- and workshop-based education, various groups advocated for promoting healthier lifestyles through public ad campaigns and bans on "unhealthy" habits. A group of health care consumers in Arlington, Virginia, felt a need to "develop an effective health literacy campaign aimed at all segments of the population, especially parents and children. Obesity and diabetes are major areas of concern." Likewise, in Glenwood, Colorado, participants sought to "make available free of charge to all parents information, in many formats and easily accessible, on the effects of poor lifestyle choices in food, thought and exercise and how they control what they bring into the house and what their children watch on TV."

Several Health Care Community Discussion groups recommended targeting education on health and wellness where it may be especially beneficial. In Geneva, Illinois, a group of friends recommended implementing one Illinois program on a national scale: "Healthy Families Illinois and similar home visiting programs...provide voluntary 'parent-coaching' to moms and dads of very young, at-risk kids – everything from helping parents learn how to better foster their children's optimum growth and development, to helping them track down community-based health services they might not know about otherwise." A Health Care Community Discussion group in Napa, California, felt as though "every hospital should have community outreach teams that teach chronically ill patients how to self manage to avoid future emergency room trips."

Other Policies to Promote Healthy Lifestyles

Numerous Health Care Community Discussion participants recommended reaching beyond education to use policy tools to promote healthy lifestyles. In particular, groups focused on the role of healthy food and exercise in reducing obesity and preventable chronic diseases. Suggestions included providing healthier food in institutions, improving the clarity of nutrition labels, eliminating agriculture tax subsidies for unhealthy products, taxing unhealthy products, and promoting physical fitness. Health Care Community Discussion participants frequently recommended promoting access to healthy food; it was a topic of discussion in 13 percent of groups. A group of 31 people in York, Pennsylvania, elaborated, "We discussed the school lunch program and agreed that it fails miserably in providing nutrition and instilling proper eating habits. School lunches should be part of the learning curriculum, and not for profit." Similarly, Americans meeting in Oaxaca, Mexico, agreed, "Unhealthy foods should be removed from institutions such as schools, prisons, medical facilities, etc." A home gathering in Larchmont, New York, reported, "The group agrees that the country needs to treat obesity as an epidemic taking over the nation. Every dollar we spend putting apples in the hands of our youth will translate into hundreds of dollars saved in diabetes treatments, etc." In addition to schools, discussants suggested that faith-based and social service organizations need to play a role in reforming health care. A group from Long Beach, California, stated, "Food Pantries/Food Banks - churches can provide healthy food to communities that need fresh produce and other dietary needs in place of cheap fast food."

Some participants also provided national-level food policy recommendations. At a meeting in Boston, Massachusetts, a group of co-workers felt a need to "mandate transparent and simple to-read and understand food labeling (include visual health rating on each product label, include markings of organic and genetically modified foods, include listing of all artificial ingredients, etc.)." Targeting agricultural subsidies was raised at a Health Care Community Discussion held in a St. Louis, Missouri restaurant: "Public policy can promote healthier lifestyles by eliminating agricultural subsidies to unhealthy crops (such as tobacco, sugar and starchy grains), increasing agricultural subsidies to healthy food crops (such as vegetables and fruits), taxing unhealthy food ingredients (such as sugar and high fructose corn syrup), promote the practice of eating unprocessed foods, promote healthy nutrition beyond the standard food pyramid, promote exercise in the workplace and homes and schools, and promote the idea that people are responsible for their health."

Numerous Health Care Community Discussion reports suggested financial incentives for healthy behaviors and for the use of proven prevention methods. Although there was no consensus on who should receive incentives (such as employers, employees, providers, or consumers) or the type of incentive (such as tax breaks, payment incentives, lower insurance premiums/deductibles, gifts, or awards), the Health Care Community Discussions addressing this point believed that groups and individuals should be rewarded for promoting health and preventing disease. A group from Warrenton, Virginia, suggested, "The Government can offer tax deductions for healthy lifestyle choices such as health club memberships. The tax laws could be changed to 'help' health clubs and employer benefits such as sick days with pay and relaxation and recreation days off with pay. Employers could be offered incentives to create offices close to employees' homes. This promotes more healthy lifestyles."

Participants at a home in Glastonbury, Connecticut, considered changes to the health insurance system, recommending, "the new financing system will need to build in incentives that promote prevention for people across the lifespan: e.g., no co pays for preventive services; premium or co pay discounts for consumers who get the required screenings, vaccinations, and other preventive services."

Some Health Care Community Discussions recommended financial disincentives for unhealthy behaviors. In particular, some of these groups noted that since we already have "sin taxes," such as taxes on cigarettes, policy makers could simply make these financial disincentives greater or applicable to more areas, such as unhealthy foods. Participants at a meeting in a café in Staten Island, New York, suggested that "taxes could be raised on certain items like tobacco and sugar saturated items. The revenue raised should be used exclusively to combat these addictions, as well as to prevent, intervene, and treat the diseases they cause." A similar idea was proposed at the Health Care Community Discussion held at a home in Lenoir City, Tennessee, where participants stated that we "need to consider taxation on unhealthy foods as well as tobacco, alcohol. Consider a 'medical' tax on foods and substances that are known to impair health or are known carcinogens. Proceeds could be targeted for associated treatments or research efforts."

However, other groups expressed concern about the use of financial disincentives. A group in Grand Rapids, Michigan, noted that "Good health should be rewarded, but poor health should not be punished by health cost or discrimination." Participants at a Topeka, Kansas, Health Care Community Discussion held at a local public library thought that: "The poor often have diet and stress they cannot control... [and] should not be punished for what they cannot control" and were also concerned about "possible discrimination against individuals with special health care needs and disabilities that cannot be address[ed] through prevention activities." A Governor's Island, New York, Health Care Community Discussion attended by health care and pharmaceutical consultants acknowledged the possible criticisms of financial disincentives and recommended that "Rewarding patients who lead healthier lives is more effective than punishing patients who engage in unhealthy habits (ie, healthier people pay lower premiums will be more effective v. making smokers pay higher premiums)." Others cautioned against penalizing people for problems out of their control (e.g., triggered by genetics or the environment).

A number of Health Care Community Discussion groups encouraged the promotion of physical fitness. A group of friends in Salt Lake City, Utah, suggested, "Require mandatory physical education in schools. Physical education and health classes should be required beginning in preschool and continuing through high school and perhaps college." Participants at a health care brunch in Rockaway, New York, supported "[requiring] physical education 5 days a week in the public schools." Recommendations extended to communities as well. In Fort Worth, Texas, discussants agreed that we need to "make neighborhoods safer so people can get out and walk; put in sidewalks in all communities; have community facilities aimed at teaching healthy behaviors."

Expanding Health System Capacity

Delivering high-quality, affordable care to all Americans requires new insurance options, financing, and – as many Health Care Community Discussion participants noted – greater health system capacity. Reports suggested shortages in the number and types of our nation's health care providers. Groups recommended finding ways to train more providers, to encourage them to practice in underserved areas, to expand the roles of existing providers, and to support additional community based services.

A number of groups suggested making professional training more affordable. At a Health Care Community Discussion in Cary, Illinois, participants urged policy makers to, "Improve access to medical schools. Medical schools are so expensive that our group believes that only those in middle/ upper middle class families actually aspire, and become doctors. Thus the pool of competition is decreased. Also people from more depressed areas, who might be happy to work in their childhood neighborhoods, are not as likely to become doctors." A Health Care Community Discussion in Sacramento, California, with participants of all ages, commented, "One solution would be for the government to pay for medical school, as they do in France, so that more doctors will choose Family Practice."

Some groups suggested that a program should be established to provide tuition reimbursement for community service work. A Health Care Community Discussion held by a long-term care county agency in Binghamton, New York, favored this idea, "[Creating] a 'Teach for America' in the health professions. College graduates could work in community health programs to pay back loans. They could work as aides in nursing homes and home care." A group in the San Fernando Valley, California, also advocated this approach: "Create a 'Health Corps' or 'AmeriCare' (along the lines of the Peace Corps) not only providing new jobs but also creating a network of health care providers across the country that can deliver affordable care, conduct community outreach for education, prevention, and wellness, and flag emerging health problems as they arise." A state psychological association held a Health Care Community Discussion in Albany, New York, and suggested, "[o]rganizing psychologists for pro bono mental health services, such as the 'Give an Hour' program for members of the military and their families."

Nurses, pharmacists, and other providers who participated in the Health Care Community Discussions advocated for expanding their roles to expand primary care capacity. As articulated by a Health Care Community Discussion hosted by a chronically ill nurse in South Pasadena, California, "While doctors are a critical part of the health care system, and provide the diagnosis, treatment, and specialized knowledge that helps save lives, nurses are at the backbone of the broader health care safety net. Nurses carry their skills and knowledge wherever they go – whether into the schools, libraries, churches, mosques, parks, or neighborhoods. While there is a shortage of nurses in the country, we are a powerful enough force to effect change for the public good in a cost-effective way." A pharmacist from El Sobrante, California, pleaded, "Please, please, as a pharmacist I ask you to engage the profession of pharmacy more in helping to promote safe, effective use of medications and minimize over-spending on medications for the entire health care system. Please use pharmacists as a very accessible entry point for many patients." A Health Care Community Discussion group comprised of providers in Santa Fe, New Mexico, agreed with this sentiment, "Remove barriers to practice for professional providers, such as CNMs, NPs, PAs [Certified Nurse Midwives, Nurse Practitioners, and Physician Assistants], nutritionists, dental hygienists, and acupuncturists."

Other methods of increasing capacity suggested by the Health Care Community Discussion groups included providing additional free or low-cost clinics and increasing funding for social services that target underserved areas. At a meeting in Kirksville, Missouri, participants suggested building on existing clinics, noting: "Currently one of the most effective approaches to providing universal care is that of community health centers designed to provide care for the underserved. Many of these, including our Northeast Community Health Council, are delivering quality services in a highly cost effective manner. Rather than attempting to shift the underserved en bloc into other systems, it would be more effective to selectively build on what is already in place." A group in Valley Village, California, favored the "Creation of a widespread network of free or low-cost community clinics staffed by paid professionals and volunteers and funded by government funds, employer contributions, and private donations." A group in Wailuku, Hawaii, also advocated for "more community health clinics." Participants in Bethesda, Maryland, recommended a similar idea, saying, "Hospitals should have clinics attached to them or there should be free-standing clinics (e.g., there are currently such clinics in Boston and elsewhere that are available on a walk-in basis to diagnose minor illnesses at a low cost and either treat or recommend specialty or hospital services if necessary)."