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

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

B. Roles in a Reformed U.S. Health Care System

Participants discussed and reported on the roles different actors should play in a reformed health system. Groups recommended collaboration as a way to both improve patient care and achieve reform, and the theme of "shared responsibility" was common. However, groups had differing views on whether the roles of the main actors in the health system – the government, private sector, businesses, and individuals – should expand or contract in a reformed health system.

Role of Government v. Market

The Health Care Community Discussions were designed to solicit ideas for policy makers; therefore, it is not surprising that virtually all participants believed that policy makers and government should have a role in shaping, financing, and delivering health care. Specific suggestions from Health Care Community Discussion reports primarily focused on how to change Federal programs to make the health care system more affordable, accessible, and high-quality (detailed in the next section). There were some skeptics. A group in Middletown, Virginia, reported, "The consensus of the group of 27 neighbors who attended the forum was that most of the problems with the health care system is a result of the complex tangle of Federal government regulations already on the books and that any additional interference would only make matters worse." This opinion was in the distinct minority.

The real debate was over the balance of government versus the market in insuring Americans. Supporters of a single-payer system submitted numerous reports, in part due to the encouragement by advocacy groups to participate in Health Care Community Discussions. Under most versions of a single-payer system, the government would replace private insurers in organizing, financing, and paying for health care. Its specifics, and arguments for and against it, are described below (see Single-Payer System box).

Some participants who did not fully embrace a single-payer system nevertheless expressed concern about the current and potentially expanded role of private insurers. In Emeryville, California, a group comprised of health care professionals and consumers agreed, "Insurance companies should not 'dictate' nor be the final say on medical procedures and treatment." A group in Bend, Oregon, stated, "Insurance companies must not be allowed to insure people capitalizing on health problems to reap enormous profits."

Conversely, a small number of participants expressed concern that a public plan without private insurers would reduce the quality provided by private plans. Participants who met at a Baptist church in St. Louis, Missouri, felt, "[A] major concern with [a] public v. private plan was the quality of care received with a public plan. Private [plan holders] all felt [they] received excellent care. With Private plans there is more to take advantage of for the costs you are paying." A group of health care professionals in Waco, Georgia, explained, "On the whole it was felt that market based forces, rather than government involvement, was the key to the best overall outcome. The idea of a menu driven selection offered through a coordinated commercial effort of several different entities, perhaps under the auspices of the federal government, allowing people to pick and choose the coverage they needed and could afford, taking advantage of the economies of scale to be provided by such a cafeteria style mechanism, might be a viable alternative."

Some groups were divided in their opinions about the role of government relative to the private market. On a Monday afternoon in Bristol, Virginia, "many argued that the insurance industry should be completely removed from the health care delivery system, but others saw how they acted as 'gatekeepers' to control costs, and to offer affordable coverage to some employers."

Other participants spoke about a system with roles for both public and private actors. Some saw the private market's role as an addition to a new public insurance plan. A small and "enthusiastic" group in New York City talked about a two-tiered system over a light supper. They noted, "In addition to this basic system, additional health care products and services (including private insurance) could be purchased by those who have the means and desire for such things. This would allow a free market health care system to exist alongside the basic federal program, as, in fact, exists in many countries which have national health care." A group in Eureka, California, elaborated, "A hybrid system, with single-payer for basic health care and private insurance for catastrophic coverage and those wanting 'Cadillac' coverage (e.g., no requirement for referrals to specialists) might assuage some of the 'free market' advocates as well as address some of the reported shortcomings of pure single-payer systems with respect to rare or very expensive conditions." A group of health care consumers and providers in Springfield, Missouri, suggested that public and private insurers operate side by side, saying, "Private insurance should continue to play a role as an alternative to federally financed or managed insurance programs. Some consumers will opt to pay more for more coverage." Some participants raised policy concerns about public and private plans being offered side-by-side, without more regulation of the private plans. They feared unfavorable risk selection, where the sickest would choose a public plan, making it more costly than the private plan.

A few Health Care Community Discussion participants believed state government should play a larger role in a future health care system by either supplementing or entirely replacing the federal system. Groups implied that this sentiment resulted from a distrust of national solutions and the success of the Children's Health Insurance Program (CHIP) and other state programs. For instance, one participant in Gurnee, Illinois, stated, "I'm much more in favor of health care being addressed at a state or local level (or even a regional level) than a national health care initiative. I'm skeptical of the federal government handling this in an efficient or cost effective manner." Other groups recommended a federal and state partnership and explained, "There was general agreement that health care reform needs to take place at the local level along with whatever programs, policies and funding mechanisms are implemented by the federal government." In Washington, D.C., a group that met with just a few days notice wrote, "First and foremost, participants believe the...Children's Health Insurance Program...works and should be preserved, fully funded, expanded, and indexed to inflation." Participants also recommended a number of other state programs as reform models.

Other Health Care Community Discussion groups praised certain aspects of the Department of Veterans' Affairs (VA) system as a model for the larger health care system. A Health Care Community Discussion held by the Commission on Aging in Ridgefield, Connecticut praised the VA's coverage of hearing aids, dentures, and eyeglasses and suggested using "the VA model to obtain national discounts and supply these appliances." A Redway, California group recommended that America should enact a "public health insurance/health care program similar to Medicare and Veterans Administration programs we already have." However, not all comments were positive. A veteran at an Apollo Beach, Florida Health Care Community Discussion "complained about the decreased access to the VA system at a time when many can no longer afford private health insurance."

Role of Businesses

As discussed earlier in this report, Health Care Community Discussion participants expressed varying views on the role of employers in a reformed system.

Many groups articulated support and even expansion of the current employer-based health insurance system. A group that met in an apartment in Staten Island, New York, reported that, "All feel that all employers should be required to offer some health care plan to employees, that business incentives be given, and that tax free 'Flex Spending' should be available to everyone. There should also be open forums of employees to be able to give input and make decisions regarding their health care plans."

Other groups envisioned employers continuing to help finance health care coverage but playing less of a role in actually providing that coverage. A doctor in Hillsborough, California, hosted a group that argued, "Employers should be involved in paying for health care, but not providing coverage; health care itself should not be linked to employment; [there should be] seamless 'portability' of health coverage." Members of a book group in Seattle, Washington, turned their normal gathering into a Health Care Community Discussion. They envisioned employers still playing a financial role, even in a single-payer system, suggesting "Unlink health care insurance from employers. We shouldn't have to change our insurance and our doctors when we change jobs. But employers could be a source of funding for a single-payer system."

Still others envisioned employers playing a role in improving the health status and wellness of their workers. At a coffee shop Health Care Community Discussion in Baton Rouge, Louisiana, participants expressed, "Employers should promote a healthy work environment and preventive care." A participant at an El Sobrante, California Health Care Community Discussion expanded upon that idea and specifically suggested that public policy should "encourage more companies to incorporate a gym into their facilities so that employees may work out during lunch breaks or before/after work for minimal or no cost."

Role of Individuals

Health Care Community Discussions placed a strong emphasis on the role of average Americans in improving their own health and the health system at large. A significant portion of reports advocated for greater individual responsibility in eating right, exercising, and adopting other behaviors that prevent the onset of disease. Many Health Care Community Discussion participants suggested that education should always be a priority. As a group in Leesburg, Florida, explained, "Educate and prepare people, particularly youth, to take responsibility for their own health thereby empowering them to make healthy choices in areas such as nutrition, sexuality, use of substances including tobacco and alcohol, as well as emotional health. This also needs to include funding for educating parents on how to help their children set boundaries and make healthy choices from infants through the teen years."

A number of participants felt Americans should share the responsibility for healthy living, and this responsibility has been underemphasized. Members of a family medicine residency program in Washington, Pennsylvania, discussed the need for Americans to start practicing healthier behaviors by pressing that, "Individuals need to take more personal responsibility for their health. The health care system is being bankrupted by many things, but one of them is the fact that people are making daily choices that are poor for their health and then expect medical care to make everything all better. You cannot smoke or eat a poor diet or not exercise or abuse substances and expect to have good health." An Indiana group echoed these same thoughts, "Many Americans do not take great enough responsibility for their own health. There is a cultural expectation of medicine to be the 'quick fix.'"

Other groups talked about the role of individuals in financing the health care system. One suggestion was to calibrate individuals' financing of health care with an income-based sliding scale contribution structure. In Kissimmee, Florida, the Health Care Community Discussion host commented, "Everyone in my group voiced they did not want something for nothing but they wanted to be able to pay the cost based on their financial situation." Another group met in the rural town of Saylorsburg, Pennsylvania, and discussed the "overuse" of health care. They suggested, "Co-pays and other charges to individuals should be used to deter individuals from insisting on tests and other procedures which are not medically necessary." Still others discussed the need for individuals who can afford health insurance to purchase it.