|
Topics:
Health
California
Health Care Divide
Involving
the Public in Health Choices
Involving
the Public in Health Choices. California Health Decisions provides
a range of tools to help citizens, providers, the media, and employers
meet their health care challenges by identifying their core values,
working through key issues, choices, and tradeoffs, and building
sustainable solutions. This case study examines how MediCal and
non-MediCal Beneficiaries discussed their health values in focus
groups in Los Angeles and Orange Counties in November 1993, and
the implications for health reform. Case
study plus.
Contents
Case
Study Plus: California Health Care Divide
Case
Study Plus: California Health Care Divide
This
report was prepared by David Mermin and Richard C. Harwood
of The Harwood Group, Bethesda, Maryland.
This project was made possible by generous grants from American
Health Decisions, The California Community Foundation, and the
Irvine Health Foundation. ©1993
by California Health Decisions, Orange, California.
California
Health Decisions (CHD) is a nonprofit, nonpartisan organization
dedicated to involving the public in health choices. CHD provides
a range of tools to help citizens, providers, the media, and employers
meet their health care challenges by identifying their core values,
working through key issues, choices, and tradeoffs, and building
sustainable solutions. Since 1985, CHD has worked directly with
tens of thousands of Californians across the state, and has helped
inform millions more through the media.
Executive
Summary
The contents
of this document are only a summary of CHD's complete, fifty-page
focus group report. An order form is included should you require
the full document.
Background
Californians
face tough choices as they work to build a better health care
system. California Health Decisions (CHD), a private, nonprofit
organization whose mission is to involve the public in health
care choices, believes these choices must be made with full public
participation. CHD's primary objectives are to:
- advance
community understanding of health care issues;
- promote
the community's role in developing health care policies;
- provide
a framework in which community-based health care values can
be expressed to policy makers.
While public
opinion polls on health care abound, MediCal beneficiaries are
routinely left out of the public debate on health care. To shed
light on the views of these individuals and to compare them with
those of other groups, CHD initiated this research.
In focusing
this study on the Medical population, CHD is the first to bring
this group to the table as California moves toward a managed care
system for Medical recipients. This report illustrates that despite
the complexity of health care reform, Medical beneficiaries are
conversant with the system and can clearly articulate what is
important to them. To our knowledge, this is the first time the
opinions and values of Medical beneficiaries have been sought
in a systematic way with the goal of communicating their concerns
to policymakers. It is CHD's hope that this will be only one of
many such efforts to include Medical beneficiaries in the design
and implementation of managed care programs in California.
Methodology
CHD commissioned
The Harwood Group, a Bethesda, Maryland consulting firm, to conduct
six focus groups in Los Angeles and Orange counties in November
1993. Three of the groups were comprised of Medical beneficiaries.
The other three consisted of individuals who are not on Medical,
and who represent a demographic cross-section of the county population.
The objective was to uncover the views of these two groups on
health care issues, and to bring out the core values or principles
that underlie these views.
CHD's focus
on values is an outgrowth of nine years of experience in holding
conversations on health care around the state. CHD has found that
values, the basic principles people hold to be intrinsically important,
such as fairness, responsibility and respect, are inevitably at
the core of health care issues. A values-based approach helps
to "unlock" the conversation on health care, and allows individuals
to move beyond jargon and technical policy debates.
Major
Findings
These key
themes emerged from the focus group findings:
The two
groups have major differences in perspective. Those on Medical
are most concerned about the lack of respect they encounter
and stress the desire to be treated more fairly. The cross-section
groups (non-Medical) focus almost exclusively on the high cost
of health care.
Both groups
are critical of the Medical program. Beneficiaries talk about
their limited access to quality care and dignified treatment.
The program's cost and the perceived irresponsibility and abuse
of the system by beneficiaries are highlighted by the cross-section
group.
There is
a dramatic difference in the way each group views advance directives,
legally binding documents that allow people to specify their wishes
concerning medical treatment if they become unable to do so. The
Medical participants are largely unfamiliar with and suspicious
of advance directives. The cross-section groups are more receptive
to information about these documents.
Despite
the differences, there is common ground between the two groups.
For example, there is agreement on the need to maintain or improve
quality of care, provide access to basic services,
and emphasize preventive care. Although many of the same
values were expressed by both groups, it is clear that the groups
are divided on how to define and prioritize these values.
Next
Steps
CHD believes
these findings can play a vital role in shaping the development,
implementation and operation of Medical managed care systems in
California. Clearly, it is critical to develop a system that "works"
for all stakeholders. The information in this report will be valuable
to:
- Policy
makers charged with designing Medical managed care systems in
California (16 counties have been designated to date);
- governing
boards and staff members of local health systems, as they plan,
develop, implement and manage these new systems;
- health
care professionals who are or will be providing services to
beneficiaries; and
- advocates,
community groups, and other organizations involved with Medical
recipients.
Acknowledgments
California
Health Decisions wishes to thank the funders who made this report
possible:
American
Health Decisions
California Community Foundation
Irvine Health Foundation
505 South Main Street, Suite 400
Orange, California 92668
714-647-4920
I.
Overview
Everywhere
you look, people are talking about health care. On TV and radio
and in newspapers, pundits and advocates for one group or another
debate various proposals to reform the system. Politicians and
lobbyists in Sacramento and Washington clash over legislative
solutions, with each proposal seemingly more complicated than
the one before. There is a cacophony of interest groups clamoring
for attention, each pushing a different agenda and blaming a different
culprit for the problems we face.
The citizens
of California are talking about health care, too. In backyards,
offices, senior centers, and living rooms, people share their
concerns with family and friends: Am I going to lose my health
coverage? How can I afford the care my family needs? How can I
be sure to get high-quality care? What actions should we take
as a state?
With major
changes already underway in the health care system, and more change
inevitable, Californians face some tough choices. Decisions we
make over the next few years will affect our health care system
for decades, perhaps generations. To make sustainable choices
that reflect the will of the people, we need to expand the discussion
beyond the experts and public officials, and to start listening
to our fellow citizens- to their experiences, their values, their
hopes. Building a better health care system will require having
all Californians take part in the conversation about what we value,
the tradeoffs we are willing to make, and why.
The voices
of one group of Californians in particular are rarely heard in
the public debate: people who are covered by the Medical insurance
program. Lacking the resources and formal expertise to be invited
onto the op-ed pages and talk shows, often dehumanized by stereotypes,
these citizens nonetheless have an important perspective on the
health care system and a large stake in change.
To uncover
the views of these Californians on today's health care challenges,
and to compare them to those of other groups, California Health
Decisions commissioned The Harwood Group to conduct a series of
focus groups in Los Angeles and Orange Counties in November 1993.
Half of the focus groups were comprised solely of Medical beneficiaries;
the other half included a cross section of adults who were not
on Medical The conversations were designed to uncover the starting
points of these two groups of citizens on health care issues,
and to bring out the core values that drive those opinions.
Values are
the basic principles people hold to be intrinsically important,
such as fairness, responsibility, and respect. We focused on values
because, in over eight years of holding conversations around the
state, California Health Decisions has found that values like
these are inevitably at the core of health care issues. Talking
about values helps individuals move beyond the jargon of the health
care debate to focus on what they believe to be fundamentally
important. It also exposes the underlying conflicts and tradeoffs
they must face.
We did not
try to resolve these conflicts and tradeoffs in these two-hour
discussions. A much longer conversation will be needed for that.
Instead, we looked for people's starting points—the basic
principles and beliefs that Californians identify as most meaningful
and important in health care. Understanding these starting points
is necessary because they crystallize the conflicts we must address
and the tensions we must work through in order to move forward
together.
In addition
to the broad discussion about values, we sought information on
three specific issues: the two groups' perceptions of each other;
their feelings about "advance directives," which are documents
in which patients make known their wishes about treatment in case
they are incapacitated; and, from the Medical groups, detailed
comments about the Medical program and its services.
This report
is told in the words and thoughts of citizens as much as possible.
While citizens find health care to be a complicated and challenging
subject, they can articulate clearly what is most important to
them. Several key themes emerge:
The
two groups of Californians emphasize starkly different values.
These conversations reveal profound differences in perspective
between the cross-section of Californians and those who are insured
by Medical The Medical groups are most concerned about the lack
of respect they feel and a need to be treated more fairly,
whereas the cross-section groups focus almost exclusively on the
high cost of health care—what they themselves pay
and the overall cost of the system. Both groups tend to link a
wide variety of issues back to these distinctive core values.
Indeed, the groups often use the same words to mean quite different
things. These conversations suggest that significant gaps must
be bridged in order to create common goals for health care reform.
The
Medical program is held in low regard by both groups.
Nobody is fond of Medical, but the nature of the critique
varies. The cross-section groups focus on the cost of the program
and on perceived irresponsibility and abuse by beneficiaries.
The Medical groups are more concerned about the ways in which
the program limits their access to high-quality, dignified care,
and they have many specific criticisms based on their experiences.
Medical
beneficiaries are highly resistant to advance directives.
The Medical groups express a high level of suspicion, unfamiliarity,
and mistrust of the idea of advance directives. Low-income Californians
identified some fundamental barriers that must be overcome before
they will be ready to embrace the concept of advance directives
and actually to fill them out. In contrast, the cross-section
groups are quite receptive to advance directives, and even enthusiastic
about them in some cases.
There
is some common ground between the two groups.
Despite the wide gaps between them, the Medical and cross-section
groups hold certain ideas and values in common. For example,
Californians on both sides of the health care divide place a
high priority on maintaining or improving the quality of care.
People in all of these groups believe everyone must have access
to basic health care services, and they would like to see more
emphasis on preventive care. All Californians express a desire
for more fairness in the health care system (though they often
disagree on what fairness means). And both groups agree
on the need to change the incentives in the system so they encourage
people to make the transition from Medical (and welfare) to
work. Expanding these patches of common ground will be a major
challenge, but they provide an important base from which to
start.
Despite
the wide-ranging nature of these conversations, you will see as
you read this report that the same core values re-emerge again
and again in each group. Whether discussing what is important
to them in a health care system, criticizing the Medical program,
or exploring advance directives, Californians are consistent.
Their comments have an internal logic that keeps tying issues
back to a small set of simple but profound ideas about what is
truly important—for the cross-section groups, affordable
care; and for the Medical groups, the need for respect and fairness.
For those
concerned about the prospects for positive change in our health
care system, the findings reported here raise many challenges.
Like the nation as a whole, California now confronts many tough
choices, including how to restructure the Medical program, extend
coverage to the uninsured, control health care costs, and deal
with new federal mandates. Whatever decisions are made, successful
change ultimately will depend on public involvement in and support
for those decisions.
But building
such public support will require that Californians be able to
work through the tough issues—thinking through both their
private concerns and what we should do as a society. And the sometimes
deep divisions between low-income Californians and their fellow
citizens must be understood and addressed in our public debate.
Only by placing these divisions "on the table" can
the people of our state begin to take the steps needed to bridge
them.
II.
Stark Differences in Health Care Values
When Californians
talk about health care, they don't say much about specific reforms
or legislative changes to the system. They don't use technical
language. Polls indicate that most of them can't explain the difference
between "managed care" and "managed competition."
But their
lack of formal expertise and unfamiliarity with the jargon of
health care financing and delivery should not be mistaken for
ignorance or a lack of concern. Most Californians have firsthand
experience with the health care system; all of them care deeply
about health care, and they have a lot to say.
When you
listen to Californians talk about health care, it becomes clear
that they are looking for something deeper than a package of programs
or reforms. Fundamentally, Californians want a health care system
that embodies a core set of values.
At first,
the two groups engaged here—those covered by Medical, and
a cross-section of other citizens—seem to agree on most of
these core values. For example, all Californians say they want
a health care system that is fair and provides high-quality
care. A desire for choice, affordability, and accessibility
also comes through in discussions among both groups.
But when
the conversation goes a little deeper, striking differences are
revealed. The two groups often use the same words to mean quite
different things. Fairness, for example, seems to revolve
mainly around cost issues for the cross-section groups, who focus
on getting fair value for their health care dollars. In contrast,
the Medical groups discuss fairness in terms of the wide disparities
they see—saying that vast inequalities in respect, quality,
and access to care are inherently unfair.
Indeed,
despite a number of common themes, the stories told by these two
groups diverge in fundamental ways. These two sets of Californians
have different experiences, make different connections, and have
different priorities.
Is it important
that we not turn away from these differences. The fundamental
conflicts and tradeoffs revealed in these conversations need to
be understood in order to clarify the choices Californians face.
Sustainable change is possible if Californians—and their
leaders—make the effort to understand their differences and
work through the tough choices together.
Group Medical
Core Values
RESPECT: Making sure all patients are respected as human beings
and treated with dignity.
FAIRNESS: Reducing the vast inequalities in how different groups
of people are treated and their access to quality care.
Cross-Section
AFFORDABILITY: Keeping the cost of health care down—what
people pay and the overall cost of the system.
CHOICE: Maintaining control over your own health care by being
able to choose your own providers and treatments.
RESPONSIBILITY: Taking responsibility for your own health by practicing
good health habits and not overusing the system.
A.
The Medi-cal Story
"We are
poor, but we do have our dignity."
Medical
beneficiaries need little prompting to launch into an animated,
outspoken discussion of health care issues; their concerns are
immediate and heartfelt. Two values dominate their vision of what's
important in health care: respect and fairness.
These Californians feel they are not respected in the health care
system, and respect lies at the core of what they're looking for
in health care. They also express concern about a pervasive lack
of fairness in the system—referring to what they see as terrible
inequalities between different groups of people in the way they
are treated, the quality of care they receive, and most importantly,
their ability to gain access to the care they need.
These two
values act as the "bookends" of the Medical groups' conversation;
the groups connect nearly every issue raised in their health care
conversations back to one or both of them. Their agenda is summed
up by the L.A. County woman who said, "What we're asking for,
what this is about, is equality and respect and getting health
care, period."
Respect
is the core value
On a wide
range of issues, respect is the crucial starting point,
the touchstone of the Medical groups' concerns about health care.
Other values remain at a lower priority for these Californians
because fundamentally, they feel that their dignity is at stake.
"The
system does not treat us with respect."
The most
immediate concern of people in the Medical groups is the disrespectful
treatment they feel they must endure to get the care they need.
Merely introducing the topic of health care unleashes a flood
of stories about rushed, perfunctory, or rude treatment. They
accuse doctors in particular of making little or no effort to
treat their Medical patients with respect. "The doctor won't even
take the time to explain to you what this medicine is for," says
an LA County man. An Orange County woman has also felt this lack
of personal respect:
If
the doctor walks into the room and doesn't even look at you, just
starts writing right away and asking questions, never looks at
you in the face or in the eye, you're not getting the care that
you need or deserve.
To a person,
these Medical recipients are convinced that they don't get respect
precisely because they are on Medical They say that once they
show the Medical card, they are branded as unworthy of dignified
treatment. An LA County woman recounted her husband's experience
in the hospital: "The nurses, after he had mentioned the Medical,
treated him like a piece of garbage. They wouldn't give him his
meds on time. They just dumped on him." And an LA County man told
of getting rushed, perfunctory treatment: "They're trying to rush
you out of there real quick... They don't take the time to fix
you right... With the Medical, they'll stick a pin in your leg
and you're out the door."
Providers
of medical care also are seen as unwilling to respond to the concerns
and wishes of their patients. These Californians say providers
aren't listening to them, which they consider to be a basic element
of respect. According to one LA County woman, "You tell them...I
don't want that particular treatment, and they say, well, you
take this or you get out." An Orange County woman points out that
it doesn't have to be that way: "When I was paying full price,
I was getting my questions answered." These patients say that
all too often, the questions they ask fall on deaf ears.
Clearly,
most Medical recipients do not feel they are getting the respect
they deserve, and they want that to change. As one LA County woman
suggested: "I still think in training the nurses and doctors,
they should first instill in them to have respect and dignity
with the people because, you know, we are poor but we do have
our dignity."
"Our
time is not respected."
For the Medical
groups, another potent symbol of disrespect they feel is the hours
of waiting they must endure to get care. They see it as a sign
that the system does not take their time or their sickness seriously.
In one LA
County man's experience, "If you go to a hospital, you have to
wait seven hours, eight hours"—which he feels is something
nobody with private insurance would have to endure. Another LA
County man believes the waiting is hazardous: "To have people
waiting three or four hours in that admitting room...They could
be dying." Whether dying or not, these Californians perceive that
their health care needs are treated as a low priority, and it
angers them deeply.
Some Medical
recipients believe they are made to wait on purpose, such
as the LA County woman who stated, "They're just making you wait,
just for the hell of it." According to many, it's pure discrimination:
"They ask, "You don't speak English?" Then you wait. You know,
they send them into the back," reports a Latina woman from LA
County. Whatever the reason, endless waiting for care is an experience
shared by nearly all the participants in the Medical groups.
"Even
when we are treated well, respect is important."
The Medical
groups relate fewer positive medical experiences than the cross-section
groups. When they consider an experience to be positive, very
often it is because they did feel respected. "So far I have been
pretty lucky," said an Orange County woman. "I found a good doctor
at cropp clinic who treats my kids with respect and they give
them the quality care that they need." Another Orange County woman
complimented a doctor who "treats me with respect." The one thing
these Californians seem to be looking for above all else is respect-
and they say it is hard to find.
Fairness
means better access to care
Fairness
is the other "bookend" value for the Medical groups. While respect
is where their conversation starts, fairness is where it
ends up. Most critical to these Medical beneficiaries are the
enormous disparities they see in their access to health care as
compared to others. They consider such large disparities to be
inherently unfair. This definition of fairness is fundamental
to the Medical groups, and it shapes their views on a wide range
of issues.
Their concerns
about access to care are pressing and immediate. They report that
many providers reject them as patients, and that many services
they need are not covered by the Medical program. Without money
to go outside the system, and without a wide range of providers
from which to choose, they often find it difficult to get the
care they need. Often, they punctuate their stories about lack
of access by saying "that isn't right!"—meaning, that isn't
fair. Their bottom line, as expressed by an Orange County woman,
is that "Everybody should get health care. Everybody."
"Many
doctors and hospitals refuse to provide care to Medical patients.
"
According
to the Medical groups, many providers routinely turn away people
who are Medical beneficiaries. An LA County man stated this view
succinctly when he said of most doctors and hospitals: "Because
you have Medical, they won't take you." An LA County woman complains
of being turned away by the hospital near her home: "The valley
hospital is one that...Tells you you have to pay. It's a private
hospital. If you don't have money, you go out." Because she does
not have money, she cannot get care there.
A few people
even report being denied care in emergency situations. For example,
one LA County woman who recounted:
My
nephew got hurt in the go-cart...He crashed and his leg [was hurt].
I...Called 911. The ambulance came on the spot. They was all rushing
to him. When they found out this brother was on Medical [they
said] "We really don't think his leg is broken, ma'am, and I'm
sure it'll be fine. Why don't you put some ice on it?"... I took
him to the hospital myself in the car, and...After they finally
decided to wait on him, he walked out of there in a cast. His
leg was broke.
This woman's
implication is clear: The ambulance crew failed to give her nephew
necessary emergency care because he was on Medical While not everyone
in the group had such stories to tell, nobody seemed surprised
to hear them. They view such occurrences as a logical extension
of the unfairness they believe pervades the system.
Medical
beneficiaries may not be surprised about being denied care, but
they are angry. They tell these stories in a tone of righteous
indignation, enraged by what they see as injustice. Denial of
health care to anyone, by anyone affronts their
basic values. As an Orange County woman said, "If you need any
kind of medical treatment...You should get it. And they should
help."
"Many
services are unavailable because they are not covered by Medical"
In the Medical
groups, any discussion of access quickly comes around to the question
of what services the Medical program covers. This is the one point
in the conversations where these Californians Raise cost
as a significant concern. Medical beneficiaries, who must pay
for any services that are not covered, say that nearly all of
these services are priced well beyond their means.
To people
dependent on Medical, the rules that define what care is available
seem arbitrary and capricious. Many tell stories of going without
necessary care. One LA County woman recounted:
My
husband...Goes without heart pills... He had to just quit and
go cold turkey without taking them for almost half a month, for
two weeks because Medical wouldn't cover it. But if we paid cash,
$300, that's half a month's check.
Another
LA County woman told of a child who needs an operation:
The
[child] with the kidney, she can't even get on the list unless
she can show that she has a minimum of $10,000 to pay for the
operation. There are kidneys available for her, but Medical will
not pay for the operation. She'd have to raise $10,000 to save
this two-year-old girl for her to get on the list. The kidneys
are there. But Medical will not pay for them.
In some
cases, the Medical groups report, when they are not forced to
go without care, they are forced to accept lower-quality
care because the high-quality services they need are not covered.
For example, an LA County woman expressed frustration and bewilderment
that an important dental procedure is not covered:
The
dentist [told me] that tooth can be saved...I can do a root canal
and you're going to walk out of here with your tooth. [But] when
they found out I had Medical, they said, sister, we're going to
pull it out...Because Medical no longer covers root canals. Why
pull my teeth out? You know, i need my teeth.
It makes
little sense to these Californians that certain necessary services
are covered while others are not. They say that cost is an issue,
but when it comes to health care, they believe the right of everyone
to have the care they need takes precedence over cost. For that
reason, most seem to agree with the LA County man who said, "I
think everything should be covered."
"Our
choices are limited."
When the
Medical groups talk about choice, they often connect it
back to their core concerns about access to care—that
there are too few doctors who take Medical An LA County man described
the dilemma: "You can't find a doctor that takes Medical They
want to be paid big bucks."
Limits on
choice also mean a lower level of quality to Medical recipients,
as an Orange County woman lamented:
The
majority of the doctors that accept Medical, I would not select
as a personal physician should I have the money to afford it...
Because they're like the doctor's version of a slum lord, you
know?
She went
on to tie the lack of choice back to the core value of fairness:
They
should have stipulations for all the doctors that they have to
have a certain amount of Medical patients... Everybody deserves
to have good quality care.
Fairness
also means closing the gaps in respect and quality
The Medical
beneficiaries in these conversations are concerned about not getting
the respect and high-quality care they want. In particular, they
see themselves receiving lower quality and a lack of respect in
comparison to what others receive. To them, such wide disparities
in how people are treated are unfair.
"It's
unfair that we are not treated the same."
An LA County
woman spoke for most people in the Medical groups when she said,
"I don't want to be treated any different." Yet these Californians
say they are treated very differently from other patients.
They repeatedly contrast their experiences with those of people
with private insurance. An LA County man told of a woman he knows
who never has to face the long waits and indifference he sees
Medical patients face: "With [private insurance]...They see her
immediately. They don't take no long period of time." An Orange
County woman has observed the same disparity: "They are taken
care of before we are."
These Californians
firmly reject the right of any group to be treated better than
any other, no matter how much they pay. As an Orange County woman
put it, "I feel that whether I'm on Medical or not, I'm entitled
to that 15 minutes [with the doctor]. Period." And an LA County
man asked rhetorically, "We're just as human beings as anyone
else. Why can't we get the same treatment?" To the Medical groups,
fairness means being treated with the same respect others receive.
An Orange County woman put it this way: "I just care about the
Doctor treating me like a normal person, you know, like the other
people."
"Quality
is tied to fairness."
Most people
in the Medical groups believe that the quality of care they receive
is adequate, but They believe their care is not nearly as good
as other people's. And while it is unclear whether these Californians
are demanding equal quality for all, it is clear that they
want the large gap in quality to be narrowed. Right now, they
feel they are at the bottom of the barrel when it comes to quality.
As an Orange County woman described it: "You get low-budget quality
is what you get. Like you are a low-priority item."
Some complain
about having to see inexperienced doctors, such as the LA County
man who insisted: "We don't want any first-year intern medical
student. We want qualified doctors who are experienced in what
they're doing." Others claim that providers just don't make the
effort to provide them with high-quality care. An LA County woman
told the story of a doctor who failed to do his job properly:
My
daughter...Got double pneumonia, and the doctor gave me antibiotics
and told me take her home and bring her back in two weeks. I had
to rush her into the hospital the next day. They said if I would
have waited a few more hours she would have died... [the first
doctor] didn't care, yes. He didn't check it good enough.
In telling
these stories, most people in the Medical group focus on the vast
difference in quality as the real issue. Over and over,
they point to what others receive as an example of the kind of
quality they seek. As an LA County man put it, "They see the county
sticker, you get county treatment. But if you've got kaiser or
anything else, you get quality." And an LA County woman highlights
what she sees as a stark contrast between the facilities she Must
use and those available for privately insured patients:
Downtown
in the county hospital, you go and you wait; you get such lousy
service. Do you know...they've got their Universal Hospital and
all them new buildings back there where they wait on people with
Blue Cross, or whatever... It's just so beautiful. This is like
four blocks away from the county hospital, and the difference
in the services you get.
For all
of the anguish these people express about the disparities in care,
there is a certain tone of resignation in their discussion of
such differences in quality. While their demand for respect is
expressed angrily and is nonnegotiable, their desire for higher
quality care is coupled with little expectation that the situation
will change. As in the cross-section groups, people in the Medical
groups seem to believe that those who pay more will always get
better quality. As an LA County woman explained:
Medical
pays less to the hospitals and doctors than cash-paying customers...
And of course, they're going to do it the cheapest, quickest way
they can, you know, because they're getting half the money.
Responsibility
is a lower priority
When asked,
the Medical groups respond that personal responsibility in health
care is important, but they do not readily bring up this value
on their own. To these Californians—who already convey a
feeling of being victimized by a disrespectful and unfair system—asking
patients to take more responsibility for their own health feels
like just another burden. They would like to see the system
be more "responsible" by helping people take better care of their
health.
"Preventive
care would help people take more responsibility."
Like other
Californians, Medical recipients quickly link the issue of responsibility
to a need for more preventive care. They think having preventive
care more readily available would help patients take greater personal
responsibility for their own health. Some are even willing to
agree to additional regulations if they could get this kind of
help from the system. For example, an Orange County woman suggested:
All
the people that are on Medi-Cal...Should be required to go to
a seminar where they teach on nutrition, on health, maybe on preventive
medicine, that type of thing... That ties in with being knowledgeable
and responsible.
This and
similar comments suggest that Medical recipients want to take
more responsibility for their health, if they get some help. But
that help will probably need to be aggressive in order to cut
through the mixed messages they say they receive. As one LA County
woman complained about the media:
They
said take more responsibility for your health care. In the meantime,
they said drink all the booze you can, all these appetizing things...
They're double standards. They say one time be responsible, and
then next time they're telling you, okay, do your thing.
"The
system should be more responsible."
When asked
about responsibility, the Medical groups often focus on the responsibilities
of providers as well as patients. As an Orange County woman said,
"[we need] the system and the people both to become responsible,
along with the doctors." An LA County woman also emphasized the
doctor's role:
A
doctor can give you a prescription for antibiotics, and [the patients]
go home and do things they're not supposed to do, which just counteracts
the medicine... To me, it comes back to the doctor should explain
to you.
These groups
feel that patients can't be expected to be responsible unless
the system is responsible, too.
Ethnic
patterns
Each of
the three Medical focus groups was made up of a different ethnic
group: an African-American group and a Latino group in LA County,
and a combined white and Asian group in Orange County. While the
substance of what people said was similar in all three
groups, there were striking differences in tone. In the
African-American group, the dominant mood was anger at the injustices
they perceive in the current system. In the Latino group, there
was a greater sense of resignation—a feeling that things
were unlikely to improve much for them. And in the White and Asian
group, people had more of a worried, anxious feeling about the
health care problems they face.
The sources
of these distinctions are unclear, and this study was not designed
to uncover patterns based on ethnicity. Still, the contrast is
noteworthy and may suggest areas for further research.
B.
The cross-section story
"I
think everything comes back to the cost."
For the
cross-section of Californians from LA And orange counties, one
health care value stands out: affordability. They see every
problem in the health care system as revolving around cost, and
they examine every issue through an economic prism. Other values
they identify as vital—choice, quality, responsibility,
and fairness—are somewhat less important than affordability;
indeed, economic issues permeate their discussions of these values.
Finally, respect and accessibility—the fundamental
concerns of the Medical groups—are lower priorities for the
cross-section groups.
The
core value is affordability
Although
the cross-section groups have a wide range of concerns about health
care, one message comes through most clearly: Californians want
affordable health care, and they are angry because they don't
believe they have it. Affordability is what they say they
are driving at, but the word they use most often to get at this
is "cost." To these Californians, every problem with health care
is related to the fact that costs are skyrocketing—both what
they themselves must pay and the overall cost of the system.
"Health
care costs are out of control."
Over and
over, people in the cross-section groups use words like "shocking,"
"outrageous," and "out of control" to describe what they pay for
health care. Everyone seems to have a personal story to underscore
their anger about skyrocketing prices. For example, an LA County
man recounted: "I got the bill for my broken leg and I've never
seen a bill like that. I was shocked... Absolutely everything
except the air I breathe was on that bill."
There is
unanimity on this point among both people who pay most of their
health care bills out-of-pocket and those who receive coverage
through their employer or Medicare. Health costs hit home directly
for many people. As an LA County man said, "I pay insurance every
which way for a million things and, you know, costs are blowing
up every which way." An Orange County woman also was concerned
about her out-of-pocket expenses:
We've
always had to pay...About four [to] five hundred dollars a month.
Then you get that thousand-dollar, fifteen-hundred-dollar deductible.
It seems like we're just paying, paying, paying.
The outrage
of people in the cross-section groups is not limited to the bills
they pay directly. In fact, most do not distinguish between their
actual out-of-pocket health care expenses and the overall cost
of care—it's all discussed as one big problem of "cost."
That is because the cross-section groups gauge the overall cost
of health care through taxes and insurance premiums that seem
to increase continuously. They know that when costs go up, the
money has to come from somewhere- and they believe that "somewhere"
is usually their pockets. One LA County man made this connection
clear when he summed up his story about an elderly acquaintance:
"[Her] bill ran to $87,000. Of course, she didn't have a dime
but somebody had to pay it—The government. And you and me
are the government."
These Californians
see cost as the fundamental problem with our health care system.
An LA County woman summed up this view by saying, "Each year it
keeps going up. It's just too much." And these groups are convinced
that it doesn't have to be this way. Most agree with this Orange
County woman: "It should be [possible] for everyone to get good
health care and have it not cost you an arm and a leg."
"Greed,
waste, and dishonesty in the health care system are driving up
costs."
Adding fuel
to their anger over rising costs is the strongly held belief among
these Californians that much of the rise in costs is unnecessary
or illegitimate. The cross-section groups point their fingers
at doctors, hospitals, lawyers, insurance companies—any group
they think is making excessive profits from the current system.
They are certain that somebody is gouging. "You get two or three
doctors for payments and it's exorbitant," said an LA County man,
claiming that one doctor would be Sufficient in his case. An LA
County woman recounted that "My husband was in the hospital and
they charged all these things that [he] never used. The bill was
just itemized with weird things... It's dishonesty and price gouging."
On those
occasions when people in the cross-section groups have negative
experiences in the health care system, they are often quick to
tie those problems back to greed. An LA County man, for example,
explained long waiting times in this manner: "The doctors are
having their staff overworked [because] they just haven't hired
enough people. The economics are there to hire more people. That's
just money in their pocket." Whether based in fact or not, these
images are appealing: people often look for something or someone
to blame when they are angry, and the cross-section groups are
certainly angry about the cost of health care. These conversations
suggest that any proposed health care "reforms" must squarely
address this perception of greed, waste, and dishonesty, or they
will not be listened to by most Californians.
"Everything
is related to affordability."
With remarkable
consistency, the cross-section groups bring all of their health
care discussions back around to the high cost of care affordability
is the core value they seem to hold most tenaciously, in part
because it is something they believe to be lacking in the health
care they now receive.
For example,
during a discussion of preventive care and personal responsibility,
an LA County man noted, "If you take care of the people properly,
you won't have to spend that much." When asked what issues are
related to fairness in health care, an LA County woman replied:
"How much some of the doctors get paid." Also typical of these
conversations was the following exchange about quality care from
LA County:
Moderator:
[For better quality treatment,] what do we not have that we should
have?
Woman 1: Hospice centers.
Woman 2: In-home care.
Moderator: And what would we have if we had that?
Woman 1: Well, it would cut the cost down...
Woman 2: It's cheaper to have in-home care.
One LA County
woman summed up the views of her fellow citizens when she said:
"I think everything comes back to the cost."
Quality
is important, especially for the future
Like the
Medical groups, the cross-section groups talk a great deal about
the quality of care. All Californians believe in high-quality
health care and want to make sure they and their families receive
it. But on balance, quality does not seem to be as urgent an issue
for the cross-section groups. Rather than being a pressing concern,
quality looms as an issue for the future—something that could
go wrong. Most of these Californians believe they now have access
to high-quality health care, and they want that situation to continue.
"Quality
means caring."
When they
talk about quality, the cross-section groups do not focus on doctors'
expertise or on having the latest technology. More than anything,
they are looking for providers who are caring. To them,
a good doctor is a caring doctor. As an LA County man said, "If
[the doctor] is warm and friendly and congenial, and will sit
down and talk to you and takes a personal interest, I have more
confidence in him." And an LA County woman describes quality care
this way: "The doctor comes in; he talks to me; he shakes my hand...
He looks at me exactly in my eye, and if I feel bad about something,
he'll take a moment and...he comforts me."
These Californians
do frequently discuss more conventional measures of quality, such
as credentials, but they tend to mention such measures and quickly
move on. Caring, on the other hand, is often the focus of discussion.
These groups say they will turn away from providers who don't
provide it. As one LA County woman put it, "If I don't have some
kind of feeling that they're caring, then I really don't want
to deal with them."
"Quality
is not a matter of fairness."
While the
cross-section groups believe everyone should receive adequate
health care, they also expect that there will always be a range
of quality, and that not everyone will get the very best care.
According to these Californians, some people always will receive
better care. And they don't think people should be criticized
for buying the best quality care they can afford: "I think we're
getting better care than [people on Medical], but it doesn't mean
we're selfish just because we're getting better care," said an
LA County woman.
The cross-section
groups believe that everyone should receive adequate care, but
that disparities in quality are acceptable—a view that contrasts
sharply with the Medical groups. An LA County man stated the case
bluntly:
"[Quality
care] is not a matter of fairness. Life isn't fair." While not
everyone is so comfortable with the wide range of quality that
now exists, there is no clamor to change the situation, as there
is in the Medical groups.
"Quality
is not a problem now"
Compared
to the Medical groups, the cross-section groups have relatively
few complaints about the quality of their care. An LA County woman,
for example, highly praises the care she receives: "I enjoy going
to the doctor," she says. An LA County man also finds little to
complain about:
If
I have to go to the hospital and I'm treated and the hospital
is decent, clean, and orderly, there's got to be a point where
you say, hey, this is fine. My wife, god bless her, she had to
go to the hospital twice... and there wasn't really anything I
could say was bad while she was in the hospital.
For most
people in the cross-section groups, poor quality care is not a
concern now; it is something they are worried could
become a concern. For example, an LA County woman expressed her
opposition to standardized health care prices "Because of the
quality of the place. Some doctors are in very poor locations
and [they are] not clean." And an LA County man is afraid of what
could happen: "How do you know what's a good doctor? You hear
about, oh, this doctor is an excellent doctor... then you read
about him in the paper and he's being sued because he left a glove
in there."
Worries
about the quality of care available to them in the future are
pervasive among the cross-section groups. But when people are
pressed for personal experiences with low-quality care, their
conversations usually return to problems with cost, billing, or
insurance coverage.
Choice
is a high priority
The cross-section
groups strongly believe in choice; they want the freedom to choose
their own doctors, hospitals, and treatments. They view choice
as the key to maintaining control over their own health care.
But when choice is juxtaposed against other values, tensions emerge.
Some of these Californians are willing to give up some choice
in order to achieve other goals, such as reducing health care
costs; others are more resistant to considering tradeoffs on choice
in order to satisfy other values.
"Choice
is the key to high-quality care."
The cross-section
groups feel strongly that having a wide choice of doctors, hospitals,
and treatments is the best way to ensure high-quality care. They
express confidence in their own ability to find good care if they
are given a wide range of options. "I could find the right doctor
if I needed to...[As long as I] have the choice," said an Orange
County man. Because of their concern about quality, many people
are worried about the possibility that their ability to choose
may be limited. As an Orange County woman put it, "There's good
doctors and bad doctors, and you should be able to pick."
For many
Californians, the belief in choice seems to go even deeper—it
is an important value in and of itself, something intrinsically
worth having. As one LA County woman put it, "I think that the
choice for the doctor and the hospital—that's the most important."
An LA County man agreed: "The biggest thing would probably be
your choice...being able to choose whatever doctor you want to."
"A
lot of people would give up some choice in order to control costs."
Despite the
widespread support for choice, the conversation about choice becomes
complicated when other values are brought in. As stated, while
some Californians are willing to make tradeoffs, others are not.
Sorting out these Californians' complicated views on choice will
require a longer conversation.
Many view
choice as important but not an absolute. They consider making
tradeoffs, such as giving up some choice in return for lower cost.
One LA County man said:
If
I have a choice, you know, there are some doctors I would rather
go to, but that would be like if you want pellegrino instead of
tap water in the hospital or something. You pay for that.
Others are
willing to give up choice for minor procedures but not for major
ones: "It depends...If you're going out just to get stitched up
for a cut or something like that, it may not matter who the doctor
is," explained an Orange County man.
Still, others
resist the idea that there is a trade-off between choice and,
for instance, affordability; they see them as complementary goals.
In fact, some people are hopeful that finding ways to lower health
care costs might actually increase their range of choices. As
one Orange County man stated, "If the cost was down, then you
could afford to pay a little more, and pick what you want." Others
view choice as a means for keeping costs down. "It goes
right back to pick your own doctor," an Orange County woman said,
"Because if you don't have good coverage, then you're going to
shop for somebody that doesn't charge as much."
In the end,
while most Californians are not happy about the notion of giving
up choice, they are willing to consider it in order to pursue
their more important goal of saving money. The wistful comment
of an LA County woman was typical: "I would like to have my own
choice of doctor, but the cost is really prohibitive." And looking
ahead to possible reforms, an LA County man commented, "I think
a lot of people would trade choice and convenience for [lower]
cost."
Personal
responsibility is stressed
The cross-section
groups are eager to talk about personal responsibility. They see
poor health habits and abuse of the health care system as major
problems that drive up costs, and they want to explore ways to
encourage more responsible behavior. Still, most people direct
their comments toward somebody else's actions rather than their
own.
"People
should take more responsibility for their own health."
Responsibility
is an important value for the cross-section groups. They emphasize
the need for people to take better care of themselves and to be
more responsible about how they use the health care system. An
LA County woman, for example, is upset about an acquaintance who
isn't taking care of his own health:
I
know somebody who has the best doctors in the world, and he smokes
and he drinks, and he knows he shouldn't, and he's going into
emphysema. So what good is a good doctor if you don't listen to
them?
Another
issue that many Californians connect to responsibility is overuse
of the system. They believe that some people are too quick to
use medical services, especially if they do not pay for them.
One Orange County woman warned, "If we're talking about access
for everybody...You have to make sure that somebody wasn't going
in for every cut and scratch and bruise." And an LA County woman
believes that the Medical program is burdened by overuse:
It's
people's fault sometimes when they [have] just the flu or a little
pain and they go right away to the doctor instead of buying medicine
in the pharmacy... Because they have that Medical, they go right
away to the doctor because they're not going to pay.
Some people
in the cross-section groups believe there may need to be some
way to enforce responsibility. "It may come to the point [where]
you actually force people to go for yearly...Checkups in order
to maintain their membership in the health plan," suggested an
LA Man. However, most Californians shy away from compelling people
to do anything; they want people to take responsibility on their
own.
Overall,
the discussion of responsibility in these groups tends to focus
on "them" rather than "me." In order to bear down and focus on
their own personal responsibilities, people may need a longer
conversation, and they may need assurances that they can expect
some benefit in return for taking more responsibility. Nonetheless,
responsibility resonates strongly as a core value, which demonstrates
that people at least want to begin such a conversation.
"Preventive
care would help people take more responsibility."
This is one
point on which the cross-section and Medical groups are in full
agreement. To the cross-section groups, it is common sense that
better access to preventive care and more consumer information
would make it easier for patients to take more responsibility
for their health. They express some annoyance that the system
doesn't provide more such help, which they consider only logical.
As one LA County woman put it:
Because
certain things are not covered, the person cannot be responsible...
[People need] educational facilities to educate them on how to
be a healthier person, such as diet and the right types of food
to eat.
True to
form, the cross-section groups are quick to tie this issue back
to the cost problem. An LA County man spelled out what he sees
as an irrational system:
My
insurance doesn't cover preventive medicine... So [people] let
things go internally and the body will get worse, and then the
insurance company is going to end up having to pay more for the
increased medical care later on to fix the problem, which might
have been caught in the early stages if they had paid for a routine
exam.
An LA County
woman used an automotive analogy to make the same point: "Back
to preventive, you know, it's like a car. If you invest a little
bit for a tune-up you won't have to pay $2,000 for it to break
down on you. It's the same idea." And an LA County man said, "If
you offer [more preventive care] to people, you can probably bring
the cost down." For this bottom-line-oriented group, helping people
be responsible by providing preventive care just makes sense.
Fairness
is tied to economic value
Like the
Medical groups, the cross-section groups have a lot to say about
what's fair in health care. But in talking about fairness,
they almost always tie it to questions of cost—rather
than to respect for patients or access to quality care, as the
Medical groups tend to do. For the cross-section groups, fairness
is measured in economic terms.
"Fairness
means getting your money's worth."
Getting good
value for their health care dollar is a priority for the cross-section
groups. When they feel they are being gouged, they are quick to
call that a question of fairness. "When I had to go to the hospital
they charged me $10 for aspirin. That's not fair," said an LA
County woman.
These Californians
believe that if they pay for care (even when it is an employer
who pays), they are entitled to a high level of service and quality
that reflects the high prices they say they pay. For example,
an Orange County woman, when asked what was unfair about her health
coverage, replied: "If you're being covered and you're paying
for it, then you should be able to see a specialist... You shouldn't
have to wait two weeks to get approval." They believe that the
act of paying creates an obligation on the part of the health
Care system to give them good service, and they think it is unfair
when that obligation is not met. The bottom line, according to
an Orange County man: fairness means "getting your money's worth."
"Maybe
there should be standard prices."
The cross-section
groups are troubled by the wide range of prices people pay for
the same health care services. Many others share the puzzlement
of this Orange County woman over the disparity they see: "When
I...hear people say that they pay five dollars for a prescription
and five dollars for this doctor and here I'm paying the full,
it just doesn't seem to balance." The seeming unfairness of that
situation leads many in the cross-section groups to call for standards
Or regulation of health care prices. For example, an Orange County
woman suggested, "It would be nice if everyone could pay the same
amount and get the same amount." An LA County woman agreed: "There
should be a standard [fee] for a procedure."
However,
when they begin to explore the implications of standards, they
find themselves engaged in a more complicated struggle to resolve
various competing values. As long as the conversation remains
focused on cost, support for standards remains strong. But when
the focus of the discussion turns to quality, most of these Californians
shy away from standards and regulation, fearing they will lose
their ability to choose to pay more for top quality. As An Orange
County man cautioned, "If there are too many controls, you limit
the doctors and the people can't visit the doctors they want to."
These conversations went back and forth on the question of standards,
without resolving this tension between important core values.
"Fairness
means everybody pays something for their care."
Another fairness
issue that emerges in the cross-section groups is a large measure
of resentment against those they say do not pay anything for their
care—specifically, Medical beneficiaries. The comparison
between what they perceive as the outrageous prices they pay and
the free care others receive galls people in these groups. As
an Orange County man put it, "It seems to me that people who don't
have any money get coverage, and the people that are in between...Are
paying an arm and a leg."
This comparison
again points to the importance of cost as a barometer of fairness
to these Californians. At other points in the conversation, many
people in the cross-section groups express a great deal of compassion
for the poor. But when it comes to fairness, they focus on what
they pay, and the idea of others receiving free care doesn't sit
well with them. An Orange County man summed up these views when
he said, "[Medical] is a really good deal. I mean it's everything—plus
it's free for these people."
In addition,
many people perceive a direct connection between the economic
squeeze they feel they are in and the level of care provided by
the state through Medical "We're paying double," says an Orange
County woman. "We're paying for us, and having to work, and we're
paying for them to have a free ride." While not everyone in the
cross-section groups shares that sentiment, those who do are an
angry and outspoken majority.
A tough
question remains unresolved here: how much should low-income people
pay for their care? It is unclear whether the cross-section would
demand that everybody pay equally—but they clearly
believe everyone should pay something.
"Lower-quality
care for the poor is unfair."
As a soft
but insistent counterpoint to the resentment voiced over Medical,
some people within the cross-section groups sympathize with those
who get lower-quality treatment. An LA County man, for example,
worries that "[People on Medical] probably don't get the doctor
availability because there are some doctors that won't take them,
for whatever reasons." Indeed, several participants in these groups
indicated that they believe—as the Medical groups do—that
large disparities in how people are treated are inherently unfair.
But overall, this situation is not at the top of the fairness
agenda for the cross-section groups. They seem to feel that there
is Greater unfairness in the cost of health care, which
affects them more directly and personally.
Access
and respect are minor issues
Two of the
core concerns of the Medical groups—access and respect—receive
much less attention in the cross-section groups. In most cases,
these issues did not arise on their own in the conversations.
When prompted by the moderator, the cross-section groups said
that access to care and respectful treatment are important issues,
but did not explore them deeply.
"I
may be unable to afford care someday."
In contrast
to the Medical groups, the cross-section groups do not describe
a daily struggle to gain access to health care services. Thus,
access is not a top priority. But when they are pushed to explore
their complaints about cost, an undercurrent of fear emerges—a
worry that someday, if the wrong things happen, they could lose
their insurance coverage and be unable to afford the care they
need.
Typical
of that anxiety about the future is this LA County man's comment:
"That supplement I have, it goes up every year and it's going
to price me out." An Orange County man worries about losing his
coverage: "I'd like for them not to be able to drop you just when
you get to the age that you need [health insurance]." Nonetheless,
the concern about access is limited to the future. The more immediate
access concerns voiced in the Medical groups are not shared by
the cross-section groups.
"Respect
is connected to other, more important values."
Another sharp
contrast between the Medical and the cross-section groups is that
the latter rarely raise the issue of respect on their own.
When asked about respect, the cross-section groups say that respect
is important in health care, but then the conversation quickly
turns back to other values such as the cost and quality of care.
Anger and frustration over being treated disrespectfully, which
is a constant theme in the Medical groups, surfaces only rarely.
This is
not to say that the cross-section groups never feel a lack of
respect. They, too, are unhappy with long waits or what seems
like contemptuous treatment. But there are two clear differences
between them and the Medical groups on this issue: they don't
seem to feel disrespect as frequently, and when they do, they
often voice their concerns in terms of "economics"—that time
is money. A good example is an LA County woman who complained
about waiting times: "They book you, say, at nine o'clock in the
morning and you're in for an hour later. I want to send them a
bill and charge them for that time." An Orange County man was
even more direct about the connection: "You have to pay for respect."
The other
key to being treated with respect by providers, according to the
cross-section groups, is choice. Most of these people feel
that they have the power to do something if they are treated disrespectfully.
As an Orange County woman put it, "I have to have respect both
ways and if it's not there, it would be my choice [to go to another
doctor]." Thus, it would be a mistake to conclude that respect
is unimportant to Californians in the cross-section groups. It
seems that by and large, they feel they are getting respect, or
at least know how to go about finding it.
III.
Mutual perceptions
The Medical
and cross-section groups of Californians have plenty to say about
each other. They sometimes sound like mutually opposed, hostile
camps. Their perceptions of the problems with the health care
system—and of the causes of those problems—are often
at odds. But there is some common ground as well. In many cases,
there is sympathy for the difficulties faced by the people in
the other groups, and perhaps even the seeds of a common agenda.
A.
The cross-section groups talk about Medical beneficiaries
"They've
got no incentive to get out of it."
The cross-section
groups are upset about Medical They believe the Incentives are
structured so as to actively discourage people from working and
getting ahead. Some also have very negative things to say about
their fellow Californians who receive Medical; some of their comments
portray Medical beneficiaries as lazy freeloaders. But in the
end, many people in the cross-section groups express sympathy
for low-income people—not only for the "welfare trap" they
believe they are in but also, as noted earlier, for the low-quality
health care they receive.
"The
health care system discourages the poor from working."
The cross-section
groups express a strong belief that the health care system provides
a disincentive to get off Medical and welfare. The problem, in
their view, is that being on Medical is a "better deal" than working
at a low-wage job with no insurance coverage. Thus, there is no
incentive to work.
Often, the
cross-section groups speak sympathetically of those caught in
the system. Many see the choice to stay on Medical as understandable
and reasonable; they think it's the system that is wrong. To an
LA County man, it's perfectly logical: "A lot of people are on
unemployment because they can get care under the welfare system
that they can't get [if] they are the working poor." An Orange
County woman agreed: "As you start to maybe make a little money,
you're losing ground. To me, the whole system works backwards;
it benefits you not to do anything."
Some of
these Californians extend blame for this situation beyond Medi-Cal's
skewed incentive structure to the perceived laziness of Medical
recipients. An LA County man is upset both at the people and the
system:
I
know these folks [on Medical] could go out and find a job, get
some form of work, get some form of coverage on their own. But
being as they've got this deal going, they've got no incentive
to get out of it.
An LA County
woman is similarly piqued: "I think there's something really wrong...
You have people working who can't afford to give their children
the same health care as people who aren't."
Regardless
of whom or what they blame, getting people off Medical is a high
priority for the cross-section groups. They want to talk about
ways to do that, like providing more health coverage to people
in low-wage jobs. In their view, people who are working are the
ones who really need help. An Orange County woman summed up the
approach these Californians support: "you have to help the people
who are really truly trying to get out of there."
"Many
Medical patients abuse the program."
The cross-section
groups believe abuse of Medical is widespread, and they are irate
about it. For them, this is a major issue that cuts to the core
values of personal responsibility, their belief in paying a fair
price for care, and their concerns about the overall cost of the
system. The perception of widespread abuse is particularly strong
in Orange County.
The cross-section
groups believe that the Medical system is chronically overused
by beneficiaries, who they say have little regard for the cost
of the services they receive. An Orange County woman claims to
have witnessed the overuse: "I could remember people bringing,
'Oh my baby's so ill,' and it would have a 99 temperature, not
98."
The anger
at this perceived overuse is double-barreled: not only are the
overusers viewed as irresponsible (not honoring the value of responsibility),
but they also are costing the taxpayers money. For example, when
an Orange County woman talked about a neighbor who is on Medical,
she first emphasized responsibility: "She takes him to the doctor
for every stitch, and there's three little kids, neglected all
the other times." Then she zeroed in on the cost issue: "It's
costing me, what she does."
Perhaps
most grating to the cross-section groups is the idea of people
getting services without having to pay anything for them—and
the belief that this helps to promote widespread abuse. As one
Orange County woman put it, "There are people who are cheating
and they think, why should I care, somebody else is paying it,
not me." A few go so far as to suggest that it's wrong to provide
high-quality care through such a program. For example, one Orange
County woman said, "I think they [Medical recipients] get excellent
care. I think they should be restricted as to what they can get."
"There
has to be some Medical program for people who truly need it."
Despite their
concerns about abuse and their discomfort with the notion that
people would receive free services, a large majority in the cross-section
groups still supports the idea of having a Medical program. A
reservoir of sympathy exists for the poor, and most Californians
do not believe in turning people away when they are truly in need.
Some even question their fellow citizens' perceptions that there
is widespread abuse. As an LA County man argued, "I think there
are a few people who abuse [Medical], but most of the people who
are in the situation of having to use it...have no choice."
Support
for Medical among the cross-section groups often seems to be rooted
in a practical approach to public health. To an LA County woman,
providing care for the poor is just smart public policy:
I
think [Medical] is very good for single mothers on welfare...To
give children good health care, because if you think of a lot
of foreign countries and the children are begging in the streets,
and they don't have their shots... So I think it eliminates all
that.
In the end,
most of these Californians seem to be struggling with competing
feelings about Medical On the one hand, they are angry at abuse,
but on the other, they don't want to deny care to those who need
it. An Orange County woman summed up the dilemma: "There are a
lot of people like you're describing that are abusing the system,
but there is an awful lot of people out there that truly need
help."
B.
Medical beneficiaries talk about other Californians
"I
think that they just take it for granted they get better care."
Overall,
Medical beneficiaries believe people with private insurance are
doing pretty well for themselves, and should acknowledge their
advantages—especially the higher levels of respect and quality
of care they get. The Medical groups particularly resent that
they are stereotyped as lazy freeloaders when most say they are
trying hard to get off Medical and get health insurance through
a job. In fact, they agree with the cross-section groups that
the system's incentives do not encourage making the transition
to work, and they want that situation to change. This is an important
area of common ground between the two groups of Californians.
"People
with private insurance have it pretty good."
To the Medical
groups, anyone who has private insurance is doing pretty well
and ought to acknowledge it. While they recognize that people
with private coverage have complaints, many see those complaints
as unfounded, when in their eyes the care those people receive
is so much better than they receive through Medical Some are surprised
that privately-insured people have any complaints at all. When
asked what he thought the cross-section groups talked about, an
LA County man speculated: "I think people who have better insurance
would probably be stating what they like about it. So they would
have some nicer things to say about it." From the vantage point
of low-income people, most other Californians are "doing just
fine," according to an LA County woman.
What upsets
the Medical groups is that those with more money expect
to be treated better, and don't seem to be bothered by the disparities—some
quite large in their view—that exist. This attitude offends
their definition of fairness: that all people should be
treated similarly. The perceived complacency of other Californians
is seen by the Medical groups as disrespectful to them and the
problems they face. As an Orange County man put it, "I think that
they just take it for granted they get better care...Paying for
it." To the Medical groups, these large disparities are unfair;
and it frustrates them that the more fortunate seem unwilling
to acknowledge the unfairness that they perceive.
"The
stereotypes of Medical beneficiaries are unfounded."
The Medical
groups are keenly aware of how they are perceived by most Californians.
They know that others think of them as freeloaders. An LA County
woman has heard the resentment: "I've heard them say they pay
for all these people on Medical" The stereotype follows them everywhere,
even into the doctor's office, as an Orange County woman recounted:
One
time, I went to get my eyes examined...And this doctor, he says..."All
you people on Medical want free eyeglasses." I say..."I am here
to get my eyes examined, I do not want to walk around wearing
glasses, that is not my choice." He says, "No, I see people like
you all of the time who want free glasses."
This group
finds ludicrous the notion that most Medical recipients overuse
the system. Why, they wonder, would anyone use health care they
don't need? As an LA County woman explained, "Most people don't
go to the doctor until they very, very, very [much] need to go.
People hate going to the doctor." She then brought the issue back
to respect and dignity: "We hate the way we're treated."
The idea
that most of them don't want to work, or have babies to stay on
welfare, is also vehemently rejected. "I've never met anybody
that didn't want to work or do something with their lives," said
an Orange County man. And a hispanic LA County man argued: "There's
all this saying that, especially Hispanics, that they're having
children just to get coverage, which is not true." To the Medical
groups, these views are unfounded and unfair stereotypes.
"There
is abuse, but most are not abusers."
Many people
in the Medical groups agree that there is some abuse of the system.
As one Orange County woman observed, "There are a lot of people
out there who don't care. They'll take what's given to them for
free and not try to improve their situation in life." But most
are quick to point out that only a small portion of Medical recipients
are abusers.
In discussing
abuse, they point to others as the real culprits. A few in the
Medical groups say immigrants are the source of the problem, like
this Orange County woman: "These people from Mexico, these pregnant
women come over here, and have their babies over here and use
our Medi-Cal...so they can stay here and be on our system. That's
abuse."
More frequently,
the Medical groups consider doctors to be the real abusers of
the system. For example, an Orange County woman told of a doctor
who seemed to be running unnecessary tests: "It looked like [the
doctor was] trying to milk as much as she can out of the system...
there is no reason in the world she needed to do a biopsy, when
she could have done a simple test."
In the end,
some Medical recipients tie the question of abuse back to their
concerns about respectful treatment. As one Orange County woman
explained, "If the doctors were more attentive, and spent more
time with their patients, they would be able to weed out the abusers,
and the system would not be taken advantage of."
"The
system discourages us from working."
The cross-section
groups, particularly those who characterize Medical recipients
as lazy, might be surprised to hear strong agreement from the
Medical groups that the system discourages work. If anything,
the Medical groups say that they are even more frustrated about
this situation because they are the ones caught in it.
They insist
that they don't want to stay on Medical But, to them, the system
seems stacked against their efforts to get off the program by
finding a job. An Orange County woman describes the paradox:
I
have a chronic [medical] problem and so I need medical coverage,
and when I do work I can't get medical coverage because of preexisting
[condition]. So I have to stay on Medical, and I don't like that.
An older
gentleman from LA County also is frustrated by what he perceives
to be a perverse incentive: "I can still do work. But if I do
any work, it's going to cut me out of social security and whatever
I've got coming. So why should I mess my Medical up?"
Both the
Medical and cross-section groups clearly share one important goal:
change the incentives. Make it easier for the working poor to
get health coverage, they say, and more poor people will work.
Like their fellow Californians, the Medical groups are strong
proponents of helping those who are trying to get ahead. "I think
the system needs to help us get off being on the system," says
an Orange County man. "They should [arrange it so that] the more
you try, the more you get help."
C.
Mutual understanding
| 
