Californians understand the economics of health coverage and they know that something has to give, according to a study released last week.
In general, California patients prefer a no-frills approach to health insurance, and they're willing to trade non-essential coverage for keeping costs down, according to the report "What Matters Most," from the Center for Healthcare Decisions.
"The public does get it," said Marge Ginsburg, executive director of the Center for Healthcare Decisions, a Sacramento-based research organization. "People do understand that health coverage can't be all things for all people because the costs are just too high. When you ask people to decide what's important in the big picture, they start wearing a different hat. They start going beyond the 'What's-in-it-for-me?' approach."
Californians appear almost unanimously to agree that health insurance's most important roles are saving lives, preventing illness and helping to maintain or improve basic functions of life, according to the study.
A little more than a year in the making, the research project included a random-sample telephone survey of 1,019 Californians conducted by Field Research and 15 small-group meetings spanning the length of the state from Ukiah to San Diego.
The survey sought reaction to 19 medical scenarios ranging from a patient with curable cancer to one with mild forgetfulness. Respondents were asked to rank the importance of health care coverage for each condition.
Reminded that more coverage meant higher-priced insurance, respondents were asked to decide which conditions should be covered in basic policies.
'Loud and Clear': Keep Costs Down
"One thing we heard loud and clear is that the public is not willing to share high costs," Ginsburg said. "Most people said they would elect to take more areas of coverage away rather than paying higher premiums and copays. Everybody's very conscious of the fact that if you make cost sharing too expensive, it's counter-productive. It doesn't matter what wonderful things you offer in the way of coverage. If people can't afford it, they just won't use it," Ginsburg said.
For each vignette, respondents answered two questions:
- If you were designing a health plan for California, on a scale of one to 10, how important is this for health care coverage?
- Knowing that the more that is covered, the higher the cost of insurance, should this service be included in that health plan?
Personal responsibility plays a big role in respondents' decisions about coverage, researchers said. Many respondents said medical problems caused by irresponsible behavior should be a lower priority for coverage.
Study May Have National Influence
Len Nichols -- director of the Health Policy Program at the New America Foundation in Washington, D.C. -- said that although the survey was conducted in and for California, the findings could have national influence as Congress begins deliberation on major health reform.
"This is perhaps the best representation we have of the public's view on a lot of these complicated issues," Nichols said. "The information was elicited in an even-handed, authentic process and should be taken as a valid representation of the public's approach to some of the key issues of health reform," Nichols added.
Ginsburg and Nichols pointed to the survey's findings on treatment effectiveness as having a particularly important place in the national debate.
According to the survey, Californians believe the relative or comparative effectiveness of treatment is an important consideration and should be a factor in determining both the course and cost of care. Even high-priority problems got a lower rating from respondents if treatment is only minimally effective, researchers found.
"I think this work makes a profound statement of support for the principles of evidence-based medicine," Nichols said.
"Those principles, which include comparing the effectiveness of various treatments, are often characterized in the public debate as leading to rationing and socialism and all those scary words, but here, in pretty clear and convincing fashion, people are shown to agree with those principles," Nichols said.
Quality of Life Issues
When medical problems do not have a major impact on an individual's functioning or life span, many Californians consider them lower priority, according to the survey.
For example, in a vignette describing a 70-year-old's difficulty having sexual relations with his wife, only 40% of respondents thought medication should be covered by insurance. By contrast, 95% thought a 72-year-old woman should be covered for hip surgery so she could walk again.
While the survey indicated Californians believe lower-priority problems should be treated differently than high-priority problems, respondents for the most part did not wish to exclude lower-priority problems from coverage altogether.
"What we found was that most people believe patients should pay a higher percentage of the cost to treat those lower-priority problems," Ginsburg said.
"This was a good, thoughtful, in-depth process and we found that people are very discriminating in their views. We didn't try to build consensus or figure out how to pay for anything. This was just about setting priorities and we think it presents a clear picture -- perhaps the clearest yet -- about what people consider important," Ginsburg said.
'No Apparent Agenda'
Janet Spaulding of Rocklin, who participated in the survey's focus group discussions, said researchers "did not appear to be pushing any idea or particular point of view."
"I didn't get the feeling that they had an agenda at all," Spaulding said. "They were very good at getting everybody to speak up."
Spaulding said members of her group understood that their opinions might help shape policy.
"I think we all had a level of awareness that this information would probably be presented to policymakers. We definitely had the feeling that this wasn't just for fun and that what we said was important," Spaulding said.
Full Circle for Center
For the Center for Healthcare Decisions, the report marks a full circle from the organization's birth in 1994.
"I was cleaning out some old Clinton-era health files," Ginsburg said, "when I came across some files from our first project. It was a national look at quality of life issues and public priorities, done differently than our 'What Matters Most' project but with some of the same goals in mind.
"Anybody who works in health policy knows there's a lot of circling," Ginsburg said. "Every 15 or 20 years, you can expect to be going over similar ground."
"What Matters Most" was funded by the California HealthCare Foundation, which also publishes California Healthline.