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On December 30, 2008, twenty-eight of us gathered in Staten Island, New York to discuss the problems with the health care system, and to brainstorm what could be done about it. Here are the areas we discussed:

1. What does the group perceive as the biggest problem in the health system?

   The group was most frustrated by the high cost and limited coverage offered by the health insurance industry. Because insurance companies must feed a vast administrative overhead and turn a sizeable profit, too much of the money we pay for health insurance does not go into actual health care. To protect their profits, insurance companies typically don't cover important things, like dental care, and they require us to jump through numerous hoops (forms, referrals, etc.) in order to get the care that they do cover. Doctors and hospitals have to pay too much attention to playing by the insurance companies' rules so that they can receive payment. Therefore, they cannot make their decisions based exclusively on what will best serve our health needs, both short and long term.

   Finally, because health insurance is so expensive, many people don't have it. But, the cost of health care is even higher when you pay out of pocket, since individuals lack the leverage to negotiate prices down.

2. How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers?

   We rely upon a combination of information sources when choosing a doctor or hospital. Some of us simply ask our primary care doctor for recommendations. Some of us use various online sources that rate or evaluate various doctors and hospitals. Most of us don't know where to find reliable information, or even the best questions to ask, in making these decisions.

   What's needed, from a public policy standpoint, is not just more information but better information and more assistance in making use of it. Ranking systems, depending upon how they are determined, not only give misleading information, but can skew the behavior of doctors and hospitals. One member of our group, a local doctor, told us that a local hospital endeavored to maintain it's high ranking for cardiac care by often refusing to take difficult cardiac cases. A different hospital had a much lower ranking precisely because it took on such cases. Ranking systems should be configured to take multiple factors into account in assessing "success rates" or the information they provide will be of little value or even disvalue.

   At the same time, we think that patients have a right to know more about the relative performance of their health care providers. A database of patient evaluations of doctors and hospitals would be an excellent resource. Most people thought thought that providers could benefit from more feedback and transparency. Large providers that disclose errors (at least internally) and track performance electronically, such as the VA and California's Kaiser managed care system, tend to achieve a higher quality of care.

   We also talked about the shortage of primary care doctors in the country. It was pointed out that primary care doctors don't make as much money as specialists, because the fee-for-service scheme that governs most health care favors doctors who perform more complicated procedures.

3. Have attendees or their family members experienced difficulty paying medical bills? How can policy makers address this problem?

   Most of us described having had difficulty paying high medical bills. One of the members of the group, who uses a wheelchair, has coverage that will only supply a new chair every 5-7 years and will not cover repairs in the meantime, which can cost as much as $500. Another group member relies upon an asthma inhaler, which costs approximately $230 monthly. A third member, who is a heart patient, takes about 12 different prescription medications per day, and pays about $3000 annually.

   The consensus was that the best thing policy makers could do is to bring down the costs of health care, and health insurance coverage. Many of us would favor a single payer system, modeled after the VA or Medicare (see answer 4) as a way of lowering costs. Medical providers should be paid on a salary basis, rather than via a fee for service. Minnesota has a lot of salaried providers, and as result pays the least per person of all the states, while New York and Florida, which rely much more heavily on fee-for-service care, pay the most.

   We also agreed that it would be advisable to study the health care systems of other countries that pay much less per capita for health care and tend to have a longer life expectancy.

4. In addition to employer based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

   The group would enthusiastically welcome the creation of larger insurance pools. Most of us would prefer a single-payer system, with everyone part of a common pool, modeled after the VA or Medicare. It was agreed that people who don't currently qualify for these programs ought to have the option of buying into them. Medicare has a much lower overhead than private insurance, and much higher rates of satisfaction. The VA maintains records electronically, tracks performance and errors extremely well, and has very high rates of success and patient satisfaction. Both programs do not withhold coverage based on pre-existing conditions.

   We talked about the possibility of a voucher system (similar to that used to make school choices) as a way to facilitate more choices for consumers and to move toward a more universal system. Everyone supported opening up the health plan offered to federal employees, as Senator Obama has suggested.

5. Did attendees know how much they or their employer pays for health insurance? What should employer's role be in a reformed health care system?

   One of our members was paying $1,500 monthly for a family of four, while most individuals averaged $600-$700. The employer of one of our members, a 26 year old woman with no health problems, was paying $700 monthly for her insurance coverage; as of January, 2009 the premium will be increased by $200 monthly.;

   Many of the participants in the group have health insurance through employers, and some of us are satisfied with the coverage. However, the high cost to employers seems ultimately unsustainable. One of our members owns his own small business and offers health insurance coverage to his employees, but the costs threaten to make his business untenable. A majority of us thought that a large pool public plan should become available, alleviating the need for businesses to offer health insurance. Alternately, it was agreed that there needed to be ways for small employers to band together to create larger pools and bring down costs.

6. Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help?

   Most of the group participants have utilized the preventive services that are recommended. We discussed the importance of measuring the efficacy of preventive screenings, so that resources are channeled into those that are most effective. One of our members, a doctor, pointed out that preventative services do not tend to reduce medical costs – in fact, they often increase them. Follow-up tests, treatments, and medications increase the upfront cost-per-patient considerably, sometimes without saving money down the line. This cost increase seemed worthwhile to the group, so long as the data indicates that they improve the quality of care.

   It was suggested that other types of screenings should be considered and tested. For example, undiagnosed and untreated mental illness creates much unnecessary turmoil, physical illness, and expense.

7. How can public policy promote healthier lifestyles?

   We identified several different mechanisms through which the government could promote healthier lifestyles:

   Education:

   • Healthier lifestyle choices could be better marketed, so as to better compete with the poor choices (fast food, smoking) that currently get ample exposure in the media.
   • We are impressed with the new requirement in New York City that calorie counts accompany all menu items in restaurants, and think that further information should be provided in a similar manner.
   • Children should be taught to adopt healthier lifestyles in the schools. School lunch programs should provide examples of healthier food choices.

   Increase access

   • Fresh fruits and vegetables are not easily accessible to many poorer people in New York.

   Regulate advertising of unhealthy foods

   • Unhealthy foods should carry warning labels and not be permitted to advertise on television, much like cigarette advertising is restricted.

   Tax unhealthy products

   • 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.

   Ban certain items.

   • Most of us approved of New York City''s recent ban on trans-fats.

Here is a photo of some of us at the discussion