Speak on Health
Georgia Health Decisions (GHD) Community Forums Bring Georgians'
Values to Health Debate
Speak Out on Health Care: What They Want and What They are Willing
To Do" is a 35-page report on the community meetings, focus
groups, and citizen panels that GHD sponsored in 1991-93. Citizens
articulate their concerns and values in their own language, and
reason together about how they might make difficult tradeoffs
in ways that are consistent with those values. ©1993. Case
Study Plus: Georgians Speak Out on Health Care: What They
Want and What They are Willing To Do
Study Plus: Georgians Speak Out on Health Care: What They Want
and What They are Willing To Do
Speak Out on Health Care is the result of two years of intense
research by Georgia Health Decisions, an independent, nonprofit,
nonpartisan organization. Georgia Health Decisions was founded
in 1990 by a group of citizens concerned about rising health care
costs and the increasing numbers of people who lack access to
was prepared for Georgia Health Decisions by The Harwood Group,
a public issues research and innovations firm located in Bethesda,
Maryland. The work of the firm centers on social changehelping
public and private-sector organizations to define complex issues,
understand the attitudes and perspectives of people and organizations
affected, and design processes, mechanisms, and strategies that
promote sustainable change. This report was prepared by Richard
C. Harwood, President, Michael J. Perry, Project Manager of The
Harwood Group, and Beverly Tyler, Executive Director of Georgia
ago, Georgia Health Decisions (GHD), an independent, nonprofit,
nonpartisan organization, set out to discover what Georgia's citizens
think about health care. GHD observed that the public had been
missing from the debate on health care, a key issue that touches
the lives of every citizen. It decided to fill that gap by spurring
Georgians to talk to one another about their hopes, dreams, fears,
and concerns on health care. These conversations were compelling,
reasonable, and at times, surprising.
the story Georgians tell when given the chance to speak out on
health care. It is told in their voices and it draws on their
life experiences and ideas. The people in these conversations
are not health care experts, but citizens from across the state
who came together to talk about an issue that is important to
these voices and you will hear the citizens of Georgia balance
their idealism with a hard-nosed pragmatism. You will hear them
move from cynicism and mistrust to a guarded hopefulness. You
will hear people weigh different issues, respond to different
points of view, and make thoughtful judgments. And you will find
a remarkable amount of common ground among Georgians about what
they want in health care and what they are willing to do to achieve
citizens carefully weighing different points of viewmay
contradict the images you have seen of the health care debate.
Those images portray citizens as apathetic, not caring enough
or knowing enough about the issues to be active participants.
And often, when citizens do participate, they are portrayed as
"uninformed," "selfish," and "unreasonable." Yet we found Georgians
to be quite different.
As you listen
in on these conversations, look for points:
agree. On many key issues, Georgians arrive quickly at agreement
and stand ready to act.
are still undecided. On some issues, Georgians remain undecided
and want more time to work through what they believe. They want
to talk to the people they trust and respect before making up
their minds. They do not want to be "pushed " to make final decisionsindeed,
they may resist moves toward action.
are prepared to strike deals and make bargains. On many issues,
Georgians are able to balance different priorities and make compromises
in order to achieve something they consider important. But they
place conditions on these deals; if the conditions are not met,
the deals fall through.
the course of these conversations the members of Georgia Health
Decisions came together to consider what they were hearing. They
noticed that important themes were woven into every conversation.
These themes comprised a set of values that Georgians care deeply
about and that they want to drive their health care system. Two
types of values emerged: foundation values and decision values.
values are the guiding principles Georgians want to shape their
health care system. These values are fundamental in defining what
they expect from the system and from themselves. On these values,
there is no disagreement.
As you listen
to Georgians speak out on health care, you can hear these foundation
values. You can hear a desire for honesty and trust to be the
cornerstone of the system. You can hear a call for more compassionate
and humane carefor each person to be treated as an individual,
not as a faceless "case number." You can hear a demand that all
people be accorded dignity and respect regardless of who they
are or how much money they have. You can see a concern for others
that leads to a desire for the system to meet the health care
needs of everyone in the state. When Georgians describe the system
they want, you can hear a desire for all Georgians to receive
high-quality carenot the most expensive care, but the appropriate
care. And you can hear their preference that prevention be stressed
as much as cure and for all citizens to take greater responsibility
for maintaining their own health.
values, which are also important to Georgians, are those that
force people to make hard choices and tradeoffs.
to Georgians discuss health care, you can hear these decision
values. You can hear them talk at great length about the importance
of fairness in the system, not just for themselves but for everyone.
They wrestle with how to implement a fair system. You can hear
that Georgians want to retain the power to choose in health care,
and at the same time, you hear them search for ways to reduce
health care costs and consider options that may in fact limit
some of their choices. You hear a desire for reasonable cost and
efficiency in health care and a willingness to make tradeoffs.
to achieve these. You hear Georgians' sense of shared responsibility
in health care and their desire that everyone pull his or her
story, you will hear Georgians talk about health care in ways
that reflect how they think about these values. You will hear
their own words whenever possible. And, while you may not always
hear them talk explicitly about values, values underlie those
areas where Georgians find common ground. They are present even
where Georgians disagree. And they are present where Georgians
strike dealswhere they seek to balance competing interests
in order to achieve what they consider most important.
Speak Out On Health Care is the result of two years of intense
research by Georgia Health Decisions, an organization founded
in 1990 by citizens concerned about rising health care costs and
the increasing number of people without access to health care.
is based on both open, public discussions and rigorous, scientifically
valid research. More than 200 individuals have served on Georgia
Health Decisions' fifteen regional boards. The voices of over
6,000 Georgians were heard through 257 community forums in 104
counties, 60 focus groups, and a random sample survey. In addition,
two "citizen panels" were conducted at which citizens representing
a cross section of Georgians met for one-and-a-half days to work
through various health care choices and tradeoffs. On three occasions,
80 regional board members of Georgia Health Decisions came together
for a three-day retreat to review the research data and find common
ground for moving forward.
unfolds in much the same way Georgians talk about the issue of
health care. The next section, The Starting Point: Mistrust and
Broken Relationships, discusses the mistrust and the fears that
Georgians bring to the table when they begin a conversation about
health care. The next three sections outline the type of health
care system that Georgians want and discuss the tradeoffs. they
are willing to make and the shared responsibilities they are willing
to accept in order to have that system. A System that Provides
Personal Control addresses Georgians' strong desire to retain
a large measure of personal control over their health care. The
concluding section conveys the sense of hopefulness that Georgians
have that change indeed can occur.
Starting Point: Mistrust & Broken Relationships
what we need to do is wreck the house and accept the fact that
the system is literally coming apart at the seams.... Change
is key. We have got to be willing to accept some change. We
cannot keep the status quo."
Richmond Hill Resident
open a discussion with Georgians on health care, they begin by
telling you what's wrong. They list problems. They tell personal
stories about the negative experiences they have had. They show
you medical bills they brought along to demonstrate how expensive
health care has become. They are cautious and wary, and they fear
they will be asked to give up something or make more personal
tradeoffs. in the name of change.
get beneath the surface, you quickly learn that the real problem
is that Georgians hold a deep mistrust of their health care system.
In talking about doctors, insurance companies, drug companies,
and elected officials, Georgians portray a system fraught with
a lack of honesty. They don't believe that anyone looks after
the interests of people like themselves. What they describe is
a broken relationship between the health care system and the people
man called doctors "greedy," adding greed is something "they are
taught in medical school." A Felton man felt insurance companies
were "making all the money" and should not have "as much authority"
over the health care people receive. A Jonesboro resident said
that the prices drug companies charge are "outrageous," suggesting
that "we should cap the profit of these pharmaceutical companies."
And a Monroe resident alleged that "a lot of health professionals
milk the insurance companies instead of giving people proper care."
describe a health care system they perceive to be stacked against
them. They fear there is no one on their side looking out for
their interests. A Cedartown man put it this way: "You have insurance
companies and you have these Senators and they are working hand
in hand, one pocket passing to the other, and it is our money
that they are padding it with." A Pooler resident said, "The people
who make up the rules make a whole lot more money than we do....
They live next door to the doctors. They sell them the Porsches
they drive. It is a different lifestyle than what we live." A
man from Felton concluded, "Insurance companies don't have the
community at heart."
feel powerless to change this situation. A woman from Cascade
Heights in Atlanta commented, "We have lost control ... in the
health care arena. We are not in control of anything."
sit here and talk about it, but you can't beat the system," said
a Rockmart man. "Everywhere you go... it is still going to be
the same thing," he continued. "I'm sorry to say that, no matter
which way you go, they are going to take you at the door." An
Atlanta resident said that the only solution to this problem was
an "open system where we could see everything happening."
Georgians want change. "First what we need to do is wreck the
house and accept the fact that the system is literally coming
apart at the seams," said a Richmond Hill resident. "Change is
key. We have got to be willing to accept some change. We cannot
keep the status quo." An Augusta woman agreed, "We need a change.
I mean the system is not working now." She continued, "Let's go
ahead and try something new to see if it works and, if it doesn't,
then we will work for something better." A Riverdale man summed
up a view that is held deeply by many people: "The system is not
working. We all need to make changes."
Georgians' starting point on health care: They see a broken relationship
and deeply mistrust the system. But when given the opportunity
to talk in depth with others about health care, they move beyond
mistrust. When listening to each other, they begin to imagine
a new relationship. They envision opportunities for bringing about
change, and they can suggest approaches for achieving it. They
reach beyond their own self-interests and consider what is best,
not only for themselves but for their neighbors and for all Georgians.
And when they are given the chance, they readily talk about the
tradeoffs. they are willing to make in order to realize the health
care system they want.
System That Cares for Everyone
line is that everybody should have health care. Everybody should
have access to health care."
say they want a health care system that provides care for everyone.
They emphasize the word "care," which to them means more than
just providing services. It speaks to the relationship they want
to have with the systema relationship based on dignity,
respect, and compassion. They want a system in which people are
treated as individuals, not as faceless case numbers. A Pooler
woman wants the system, as she put it, to "stop treating people
like numbers and dollar signs and look at them as people." Georgians
want a system in which health care providers can act more often
as care givers.
a caring system is one that provides health care services to all
citizens, including the unemployed and those with preexisting
medical conditions. It is a system that ensures that all people
receive the same high-quality care regardless of how much money
they have or who they are. It is a system that charges reasonable,
affordable, and consistent prices. And, Georgians say, a caring
system is one that emphasizes preventive care to help people stay
healthy and avoid illness.
of society are we if we don't, if we can't, take care of each
other's health?" asked a Woodstock woman. A Felton woman commented
similarly, "I think in America, a person has to be able to go
to the doctor and be tended to." She concluded firmly, "This is
think it is wrong that so many people now lack access to health
care services. "There is an inherent inequityhuman beings
dropping dead because they didn't go to see a doctor," said an
outraged woman from Cascade Heights in Atlanta. An angry Columbus
resident pointed out, "People are being turned away because they
don't have any insurance... you have people dying." This led another
Columbus resident to conclude, "I think we are in crisis... I
wouldn't want to be in a situation where I did not have insurance."
do not believe that anyone should be turned away without receiving
care. "People cannot be rejected," said a Marietta resident, "that
is not fair." A Cedartown woman said, "The bottom line is that
everybody should have health care... Everybody should have access
to health care." People feel strongly about this: they believe
everyone should have access to medical care, whether they are
poor, elderly, unemployed and whether they have a preexisting
condition or are in need of long-term care.
go just to those who can afford it," said a Columbus resident.
A Rockmart man agreed, "If a man hasn't got anything to pay, he
should still have coverage." A Monroe woman said, "I might be
the oldest person here, but I feel that I should be able to get
some kind of insurance regardless of my age or though it might
cost me more." And a woman from Augusta talked about the unemployed:
"[If] you are in between jobs, you should be able to keep your
coverage, but maybe you could pay in other ways like volunteer[ing]."
A Hogansville woman captured a belief held by many people when
she said, "Some people can't help that they are sick because of
genetics or whatever." A Cedartown woman summed up most people's
bottom line: "If there is going to be a health care plan for everyone,
then it is going to be for everyone!"
to the Same Quality Care
do Georgians believe that health care should be available to everyone,
they believe that everyone in the state should have access to
the same high quality of care. "It doesn't matter if you are on
welfare or if you are the President, I think each person deserves
the same quality care," an Augusta woman remarked. A woman in
another discussion agreed: "Just because I am poor and someone
else is rich, why should their care be better than mine?" A Ludowici
resident took the argument even further: "Why should a millionaire
be able to have a longer life span than I do simply because he
has a million dollars?... It is not right or fair."
resident said the health care system should "treat people the
same" and not give "better service to one than another." A Fayetteville
man agreed: "Just because you have different kinds of situations,
you shouldn't receive different health care." He added, "Everybody
is equal...everybody should receive the same [care]." A Morrow
woman remarked, "In reality, you're no better than I am, so somewhere
a person should be able to go to obtain just as good as care as
Georgians believe that the current health care system does not,
in fact, provide the same quality of care to everyone. A Ballground
woman said, "I don't know why they can give one person so much
more [care] than the next person." To her and to most Georgians,
this seems unfair. A Monroe woman summed up many people's feelings
when she said, "Quality should be the same for everybody... it
should be standard procedure."
then, a caring health system must provide everyone with the same
high-quality care. On this, they are agreed. But how to achieve
this goal is not so clear. Georgians are wrestling with tough
issues. For instance, does providing the same quality of care
to all Georgians mean that everyone should have access to exactly
the same medical services? Or, should people who can afford to
buy more services be allowed to do so? Georgians go back and forth
on such issues.
agree with an Atlanta man who said that providing every medical
service to everybody would "bankrupt us." People believe that
we must make hard choices and set priorities, providing only those
services that are necessary for people to maintain good health
and prevent illness. "There is a certain amount of minimal care
that should be provided to everyone," was the opinion of a man
from Cascade Heights. "Some [medical services] are going to have
to go," said a Rockmart man. He advised, "You've got to get into
your mind what you want to keep and what you would want to go."
And an Augusta woman remarked, "Life is full of priorities...
I mean, there are certain things that need to be taken care of
first." She concluded, "There are some things you can really do
Georgians attempt to define what care is necessary, they quickly
run into problems. They cannot agree on a set of health care services
that they would consider necessary. Most people refuse to label
as unnecessary such services as organ transplants because in some
cases these services may be the only way to save a person's life.
A Ballground man was struggling with these issues when he commented:
If it was
myself, my daughter, my wife, or my father or mother, certainly
I would want them to have the heart transplant or liver transplant
or whatever it took to keep them alive. But at what price? Is
it right to say that we are going to spend $500,000 on one person?
I don't know.
discussion, one woman explained why she found this issue difficult:
"What might be [necessary] care for me, might be totally wrong
for this gentleman here." A Forest Park woman was concerned that
if you only provide necessary health care services then some people
would be "unable to afford a lot of the things that [they] need."
between two Augusta residents shows the difficulty Georgians have
in defining "necessary care." At issue in this conversation is
whether seeing a fertility specialist should be considered necessary
If you need to go to a fertility specialist, why should poor people
have to suffer and not be able to have children because you can't
afford to go to a fertility specialist?
Health care is one thing, but a fertility expert?
Does that mean I should be denied a child because I can't afford
to go to a fertility specialist?
No, not that you should be denied a child. [But] I think the first
thing that should be considered is taking care of what is necessary
and making sure that you are in good health.
But for me, [seeing a fertility expert] is necessary.
In the end,
Georgians had a difficult time taking various medical services
off of the list of what they considered "necessary." "Did we ever
say that anything is not necessary care?" asked a Bremen woman
at the conclusion of one such discussion.
also argued strenuously over whether people who can afford it
should be able to buy more care. Some said that it is not fair
to those with fewer financial resources if the wealthy can purchase
certain services that others can not. This arose in the conversation
recounted above, when the Augusta woman asked, "Why should poor
people have to suffer and not be able to have children because
[they] can't afford to go to a fertility specialist?"
man voiced concern that allowing people to purchase additional
care would lead to two health care systems: "If [there is a private
medical system], then that allows the rich to have a separate
medical system from us." He compared this to the current situation
in education, under which he believes "private schools have better
education." He concluded that if there are two systems "all these
doctors are going over to [the private one]."
On the other
side are those Georgians who ask simply, since Americans with
more money have always been able to buy more of everything, why
shouldn't they be able to buy more health care too? These Georgians
say they are just being realistic. "I think [buying out of the
system] should be allowed," said a Marietta man. "If he's got
that kind of money, let him do what he wants to do." An Atlanta
man shared this view: "The world isn't fair. People who are rich
have more things than people who aren't rich.... It is always
going to be that way whether it is housing or health care." A
Cedartown man made a similar point, "Some people eat steak and
some people eat hamburger...If you just had the one system, there
are always going to be doctors who will take care of people with
money, regardless." He concluded, "So you can't have your one
system... you should have your basic care and then if anybody
wants any extra, then go ahead and pay for it."
agree on the central issue in this discussionthat everyone
must receive the same high quality of care. They share the belief
that people should not receive better care simply because of who
they are or how much money they have. But Georgians do not appear
ready to decide how such a system should look: they are trying
to balance their desire to be fair with their concern about what
is affordable and realistic. A participant in one discussion said
she wanted to talk with her husband and minister before she could
make up her mind.
Fair, and Consistent Prices
believe that an essential characteristic of a caring health care
system is that prices for services are reasonable, fair, and consistent.
Most Georgians agree that health care prices are too high. "The
point that everybody has universally complained about here is
the high medical fees that are being charged," said a Macon resident.
"We think they are not necessary."
believe that many people do not receive care because they cannot
afford it. They consider this to be unfair, and they are angry
about it. "Nobody in the U.S. should have to say, 'I can't afford
to go to the doctor' " said a Smyrna resident.
personal stories of not being able to afford medical care. An
Augusta woman told of postponing a visit to her doctor because
of the cost:
last week, I had strep throat and I waited a whole month before
I would go to the doctor. By the time I went to the emergency
room with 104o temperature and two knots on my glands, I was having
chills. I was laid up for three days because I could not afford
to [see my doctor]. I was hoping that it would just go away...
that maybe it was my sinuses and I wouldn't have to go spend that
money I didn't have.
woman who has no insurance also expressed concern that she could
not afford to see her doctor:
have worked all my life... Now I don't have any income at all.
A doctor will not see you unless you have money. I have tried
to get Medicaid and cannot get [it], but I am not able to work.
This is really terrible.
other stories too. There was an Augusta woman who worried about
how she was going to pay for her children's health care when they
become ill. And a Cedartown woman who is diabetic and said she
cannot afford the medication she needs.
worry about their security and their ability to continue to afford
health care. "If you live paycheck to paycheck and if your child
is sick or if you are sick, where do you come up with $40 or $50
to go to the doctor?" a Macon woman asked. An Augusta woman, who
doesn't have health insurance because she works part-time, explained,
"It would cost me $60 a month to pay for my health insurance.
That means that I would bring home $200 and something dollars
a month." She just hopes she doesn't become ill. A Ringgold man
described how he must "wait until payday to see the doctor."
who feel they make good money and have good health care plans
say they feel the squeeze. A businesswoman from Cascade Heights
described how she could no longer afford to buy health insurance
for her employees: "I had my staff on health insurance and we
had to drop it just to make the bills." A self-employed Decatur
woman considers insurance costs "out of sight," and said she and
her husband "practically can't afford to have any health insurance."
say something is wrong with a system that allows such situations.
One frustrated Ludowici resident concluded, "Society must develop
a system of providing [health care] that is not based on cost"so
that you can still receive health care even if you cannot afford
complain not only that health care prices are too high, but also
that they are inconsistent. Different prices just don't make sense,
and these Georgians believe they are wrong. "You go to a health
clinic and [immunizations] are $10 and you go to the doctor's
office and [they are] $80," according to a Dunwoody woman who
said this was unfair. A Riverdale woman agreed, "There are so
many doctors out there, and one might charge you $35 and the other
might charge you $100" for the same procedure.
are suspicious about these inconsistent prices, and they believe
greed is the cause. An Atlanta man said that it doesn't seem fair
that when his mother buys her medication "through a doctor or
pharmacy, it could be $20, but if she goes through a mailing service,
it is the same drug for about $2 or $3." As he angrily pointed
out, "That is a big difference!" A Morrow woman complained, "I
don't think I should have to pay more at one hospital than at
another." Of course, people recognize that costs will vary according
to geographic location, but they cannot understand the vast differences
that exist today.
Emphasis on Prevention
believe that another key element of a caring health care system
is a greater emphasis on preventive care. They want a system that
cares for people's health all of the time, not just when they
become ill. They say preventing illness and maintaining good health
just makes common senseit will save lives and money. "It
would catch more diseases...and, overall, you would save much
more money," said one man. A woman from Jonesboro said that more
preventive care for cancer victims "could possibly get rid of
it at an earlier stage." She pointed out that, "if you catch [cancer]
at the beginning, you have a greater chance of overcoming it."
point out the potential cost savings from an emphasis on prevention.
A Jonesboro man said that preventive care, "helps you detect things
in early stages where it's less costly to [treat]." A Ballground
resident said that if more preventive care were available, "children
could get immunized and older people could be helped by blood
pressure checks before it becomes something serious," concluding,
"That could save everybody money." A woman in another discussion
said that "preventive medicine has been proven" to save money.
She explained, "If you get a problem before it gets started, then
you're not going to have the high costs." A Cedartown woman echoed
a common belief that preventive care will lead to "cost savings
in the long run."
are quick to point out that everyone needs to take personal responsibility
for making preventive care work. "I think preventive care makes
sense, but the individual needs to take responsibility," said
one man. "If there is a high-risk individual for heart attacks,
you've got to teach that person what to eat and not to eat and
what weight levels you can be... They've got to share in that
every person should have the responsibility of getting a physical
once a year so they will know if there is a major problem and
maybe prevent an expensive procedure down the line," said a Nahunta
resident. "Through education and changing your lifestyle... you
could beat an [illness] early on." A Riverdale man said that making
more preventive care available will "trigger a lot more people
to take a little bit better care of themselves."
want the health care system to provide more information and education
in order to help people take better care of their own health.
The Riverdale man who said that more preventive care might "trigger
people" also proposed "more education in schools, to give [kids]
an opportunity to learn how lifestyles relate to being healthy."
A Cedartown man called for a "center where you can teach people
how to care for their bodies and try to help themselves stay well."
And a Rockmart man said, "you need to be educated on things that
are good for you and bad for you too... a lot of what would fall
under preventive maintenance."
their strong support for preventive care and their desire to take
more responsibility for their own care, Georgians also express
a great deal of concern that preventive care might be embraced
too quickly. Indeed, they place important conditions on moving
ahead. They want more preventive care only when it makes sensethey
do not want to make every test and procedure available regardless
of cost. And, over time, they want to see some real pay-off from
providing more preventive carethey want to see evidence
that it is a good investment. One woman fears that pursuing preventive
care too hastily, could "open up a can of worms." She explained:
going to be doing things that aren't necessary. They're going
to be doing things that are potentially harmful and damaging.
At that, you can throw out any savings. There must be guidelines...
guideposts. You can't just go blindly blundering off the cliff.
A man from
Cascade Heights expressed concern that an emphasis on preventive
care would lead to use of every test and procedure, even when
the best course might be a closer look at "a patient's dietary
habits... and getting people doing more to eat right." A Morrow
woman warned that preventive care "is not a panacea," and expressed
concern that the system might go overboard, providing screening
tests to everyone regardless of whether it is needed. She fears
the system might work like this: "Okay, you're 35, now here's
what is available to you... You go back at 38, and now you get
this [test] done."
throughout these conversations, Georgians suggested a cautious
and responsible approach to providing preventive care. An Atlanta
man urged that we don't overuse technology just because it exists
"doesn't mean we can always afford to give it to everybody." A
Marietta man recommended a study to prove the ability of preventive
care to offer savings, "not just in money, but in lives also."
Another Georgian suggested a time limit within which there should
be clear evidence of cost savings so that people could see progress.
were expressed consistently by Georgians from across the state.
They illustrate the balance Georgians seek between creating a
caring system and taking a reasonable and pragmatic approach.
System Where People Do Their Part
going to have to make some sacrifices and trade-offs...to pay
for this system."
Cascade Heights (Atlanta) Man
see health care as a two-way street: achieving an affordable health
care system that provides quality care to all and emphasizes prevention
will require everyone to make tough choices and accept tradeoffs.
Indeed, Georgians neither expect a free ride nor want one. They
are self-reliant, independent people. They are willing to make
the hard decisions in order to achieve the health care system
they want. They are prepared to change their relationship with
the health care system, if the system will change along with them.
the choices and tradeoffs. Georgians are ready to make. They believe
people should pay every time they receive health care, that everyone
must contribute something to the system. Under certain circumstances,
they are willing to use alternative health care providers and
accept some limits on their choice of doctor. They will accept
tradeoffs. on their access to care, even if this involves traveling
farther or waiting longer for care. And they are prepared to place
limits on how much they could receive for malpractice claims if
this would help reduce health care costs.
feel strongly that everyone should contribute something for their
health care. And they attach great importance to self-reliance
when it comes to paying for health care. "I don't want to see
any system that gives something for nothing," said one Smyrna
resident. "Somebody said that there was no free ride, and I believe
that," asserted a Boston man, "You have a responsibility somewhere
down the road." This was echoed by a Nahunta resident: "There
is absolutely nothing in this world that is free," and that includes
health care. A Forest Park woman put it plainly: "I believe that
you [should] put into it what you expect to get out of it." And
a Twin City woman commented:
think that everybody ought to receive [health care] but I think
that they should put their fair share in. It makes me mad as the
dickens to pay my doctor bill and dish out $7,000-8,000 to have
a child... and some folks have a baby and don't pay a penny.
say that people should pay each time they use the system even
if it is only $1. An Atlanta man insisted that it is only fair
for people to pay something, "no matter how small," each time
they receive a service. A Morrow man said simply, "I mean, if
you're going to receive something, pay for it." A Decatur man
contended, "there has to be some personal costs" if people want
to receive health care services, because a person will "think
twice about just coming in [to see their doctor] if he has to
cough up $10 each time."
believe that expecting people to contribute would help to stem
abuse of the system. "If you could just go any time that you wanted
to and not pay a penny, then I think there would be abuse," said
one woman. An Atlanta man warned that people could "grow up believing
that there is a free lunch every day " if they are not asked to
make a contribution. And the Twin City woman who was "mad as the
dickens," said that people would be less likely to abuse the health
care system when "they've got to dish out money for it."
want contributions to the health care system to be based on a
sliding scaleif you can afford more, you should contribute
more to the system. "Everyone should pay a certain percentage
and it depends on your income," suggested one woman. One man in
another discussion said that the contributions should be "a percentage
paid on your income or amount of money that your household has...
That way it would cost the people who could afford it more and
the people who can't afford it less." A Marietta woman said it
is only fair that "a person who makes more money has more to put
into the system than a person who doesn't make enough money."
people in the state believe that citizens who cannot afford to
pay anything for their care should be encouraged to make an alternative
contribution to the system, such as community service. This suggestion
emerged in almost every discussion, and it came from people of
all income levels and races, and from all types of communities.
Their goal was not to overburden those who were less fortunate,
but instead to implement their strong belief that there should
be no free ride in Georgia.
that there are some people who can't do it, but I believe that
[everyone] should contribute money or community service or something
like that," was how an Augusta woman expressed it. One man said
that people with no money should "not have to pay in dollars,
but I think they should have to pay for it through services."
He saw a need for some mechanism "for reimbursing the government
or public for the services" these people receive. "I think we
should find some equitable way that [people] can contribute either
in time or service or in dollars... a payback somewhere," said
an Atlanta woman.
most people agreed that community service should not be made mandatory.
"I think people below [a certain income] can contribute if they
want to," said a Marietta woman. Georgians are concerned about
what's fair, but they also have doubts about whether such a program
would even work.
about the need for people to contribute underscores Georgians'
desire to have responsibility, self-reliance, and independence
be fundamental aspects of their relationship with the health care
of Alternative Providers
they are ready to make changes in their relationship with health
care providers. Indeed, they view change in this relationship
to be essential if the health care system is to become more efficient
and if costs are to come down. Yet, some changes come easier than
others. For example, people are ready to agree to see nurses,
nurse practitioners, or physician assistants before they see physicians,
and they are ready to see their primary care doctors before going
to specialists. They find it harder to agree to give up their
current doctors and choose from lists of physiciansthey
reach agreement on this point only after much discussion and consideration.
are ready to see nurses, nurse practitioners, or physician assistants
before seeing their doctor. This makes good sense to them. "If
a nurse can take care of you when you have a cold, or recognize
when you need to be sent to a doctor, I wouldn't have a problem
with it," said a Dunwoody man. Georgians believe that these providers
can offer competent, quality care. A Riverdale man said that at
his doctor's office, "the nurse has a good idea of what's going
on" because she is experienced. "Nurses or doctors' practitioners
have had to go to school to learn the exact same things a doctor
had to learn," said a Forest Park resident. A Cedartown woman
made the same point, "There are some R.N.s that can do the same
as doctors." An Aragon man told of the high quality care he had
received from nurses: "[If] I needed something, I would go to
a nurse, not a doctor... your nurses can help you a lot of times
better than a doctor can."
set important conditions on making this change. They want all
assistants closely supervised by their doctors. A Rockmart woman
said she would see a nurse "as long as there was someone there
to give a second opinion." A Cedartown man said, "doctors should
set guidelines for nurses" to follow. People also don't want to
be charged twice if they need to see their doctors. A Morrow woman
was concerned that if she agreed to see a nurse first, she might
"double pay" if the nurse sends her on to the doctor. And when
Georgians are very sick, they want to be able to go straight to
the doctor. "If you have had a back injury and you are in pain...
I think the practitioner is not going to be able to write you
a prescription to relieve the pain," said a Felton man, "Some
cases should merit seeing a doctor right off the bat." Finally,
Georgians want to be able to make the final decision about whether
to see a doctoreven against the recommendation of the nurse,
nurse practitioner, or physician assistant. "I think it should
be left up to us...to make the choice if [we] want to see a doctor
or not," said an Atlanta woman.
of Georgia have no reservations about seeing a primary care doctor
before a specialist. They consider it logical for a person to
go first to his or her own doctor, who will know the person's
medical history and can help identify what is wrong. "If you don't
go to your own doctor first because you get an earache, and you
go rushing off to a specialist, he tells you that you have an
earache and you could have seen your doctor," explained a Cedartown
man. An Augusta woman offered another example: "Your own doctor
knows everything that has happened to you, the drugs you are taking...
You are breaking into a rash... your [doctor] might say, 'it is
an after-effect from a drug I gave you last week.' But the specialist
wouldn't know that." A Cedartown man concluded, "You should be
referred to a specialist by your doctor. But let him treat you
at his level [first]. If it does no good then, sure, send him
on to a specialist."
limits on the choice of doctor is a more difficult change for
Georgians to make. Many Georgians hold positive feelings about
their own doctors, despite their mistrust of the health care system.
"I have had five back surgeries and I wouldn't trust nobody else
to do nothing else on me," said a Rockmart man. A Felton man said
it is hard to give up a doctor "when you have been going to [him]
for years and years and he has your complete history and is familiar
are concerned about narrowing their choice of doctors. For example,
they worry that if they agree to select a doctor from a list,
their selection of doctors might not be wide enough. "What I hear
is that HMO doctors in Rome is sort of like hen teeththey
are often damn scarce," said a Cedartown man, who said he believes
"90 percent of [doctors] won't participate" in a plan. Other people
want to be reassured that accepting limits will actually produce
cost savings: "They would have to prove to me that there was a
cost savings, not specifically to me, but to the whole plan of
things in general," said a Marietta man. Some Georgians are concerned
that the quality of their health care may decline. "If they got
only certain doctors that you can see, who knows, the doctor might
not be that high of quality," explained a man from Cedartown.
An Augusta woman expressed concern that doctors on the list would
be the ones who are "desperate for business" rather than those
of high quality. And another Augusta woman recalled her negative
experiences of participating in an HMO: "I couldn't understand
anything the [doctor] said... I didn't care for him at all."
however, these concerns do not stop the majority of Georgians
from agreeing to accept limits on their choice of doctor in order
to reduce health care coststhey only want to ensure that
certain conditions will be met if they are to make this tradeoff.
want assurances that they will continue to receive high-quality
care. "I personally don't have any problems with seeing a [doctor]
from a list of physicians if they are qualified," said a Macon
man. Georgians even offer suggestions for how to ensure the quality
of their care. A Riverdale man wanted to rate doctors by quality:
"If we could review doctors, different aspects of what they do,
then that would help," he said. A Forest Park woman would want
to know "that the [doctors on the list] were board certified."
One man pointed out that you can find quality doctors if you just
"go through several doctors before" settling on the one you like.
And a Rockmart man suggested that his current doctor could help
ensure that he was receiving quality care: "If my doctor told
me that one of the doctors on the list was good, then I would
go to them."
set some other conditions. They want a wide selection of doctors
from which to choose: "If I had a wide choice of [doctors], and
I thought the doctor was qualified, you know, sure I wouldn't
mind," said a Bremen man. They want to ensure that there would
be cost savings resulting from a narrowing of people's choices.
A Decatur man would agree to accept limits on his choice of doctor
if someone could first "prove to us that we profit by making these
compromises," he said. A Jonesboro woman wanted the same assurance:
"I need more information on how that's going to save you money
in the long run." And finally, Georgians want to retain the option
to go back to their own doctor even if they must pay moreif
they can't find a doctor they like. "I wouldn't mind trying it,
but if I didn't like it, I would go to my own doctor," said a
Monroe man. An Augusta woman agreed, "If you were not satisfied
with the doctor [from the list], I think that you should be able
to go and participate somewhere else."
believe that these are all conditions that can be met. And they
say that once they are met, they will be willing to accept limits
on their choice of doctor in order to reduce health care costs.
on Access to Care
want care available to everyone, they are willing to do without
a hospital in every community or around every corner if this would
help reduce health care costsalthough this is not an easy
tradeoff. for them to make. As on choice of doctor, people want
certain conditions to be met before they will accept this tradeoff.
Georgians find it easier to accept waiting longer to receive routine
care or expensive and sophisticated tests.
Georgians believe that it is unfair for rural areas and small
towns to have to do without hospitals or even local physicians.
This was the point made by a Ballground resident:
had an accident at the Post Office, which was not really serious...he
cut his head when he fell. It really concerned me that we had
to take him to Canton to the hospital. Sometimes I just feel that
if we had a local physician...it could have been taken care of
about the difficulty some Georgians face in even getting to the
nearest hospital. "There is a lot of elderly that can't drive
and they don't have any means of transportation [to the hospital],"
said another resident of Ballground. They are angry that some
areas lack hospitals, while larger cities seem to have hospitals
on every block. "I could pass several hospitals before I got to
the one I wanted," said a Morrow woman. "I don't see why they
can't put in an instant care unit here and get more doctors here
instead of shipping us to Rome," said a Cedartown man. A Rockmart
man wants to turn the tables on the big cities: "Why not take
doctors out of Atlanta or out of the metropolitan cities and bring
them out to the rural [areas]?"
believe that they are entitled to the same quality care that people
receive in larger cities. "If I went to a hospital here, I should
get exactly the same treatment that you would get in a larger
hospital in a larger city," an Aragon woman asserted. "Rural hospitals
should be just as up to par as the largest hospitals," stated
a Cedartown woman.
they make these comments, however, these people believe that it
would not be feasible to have a hospital in every community. Indeed,
they consider that perhaps urban or suburban areas might need
alternatives to hospitals as well. "For them to have intensive
care units and things like that [here], it is not really feasible,"
said a Bremen man. One Fayetteville man agreed that it wouldn't
be affordable to keep hospitals in rural areas "if there's not
enough patients to keep it going." A Ballground resident explained
the dilemma: "I know that we would all like to have a [hospital]
closer, but realities being what they are, a lot of them are folding
now because they can't keep enough patients."
this dilemma, people suggest making a deal: if some communitiesrural,
urban, or suburbanmust do without a hospital, then preventive
and routine care should be made available through a clinic or
mobile medical unit. An Aragon woman stated that her community
"has got to have basic care... that is important. That's first."
An Augusta woman agreed: "Every area should at least have a clinic...
you have to provide that necessary care." A Forest Park man said
he could live without a hospital in his community as long as there
was a "clinic or medical center" that provided basic care.
part of the deal would be that efficient emergency transportation
should be provided to communities that do not have a hospital
nearby so that people can receive timely care. A Cedartown woman
explained, "I have seen it take 30 to 40 minutes for an ambulance
to get to the scene of an accident... by then, it is too late."
A Rockmart man suggested that the answer is "good ambulance service,"
adding, "maybe a helicopter or something to get there quick."
An Atlanta man said that if hospitals can't be provided in every
community, "the next best thing is to put emergency equipment
where they can get to you with a quick response." And Georgians
recognize that there may be costs associated with such a deal:
"Who is funding this stuff?" asked one man, "Who is going to pay
for the helicopter service?"
feel no need to strike such a deal before they agree to wait longer
for routine care or for use of expensive technology or equipment.
"If it is something like a skin cancer that you've had for two
or three years anyway, it is not going to hurt you to [wait longer]."
commented a Felton woman. An Augusta woman offered a similar example:
"If you need corrective [eye] surgery and you have been seeing
through your glasses for years, I would wait." But she added,
"If [I'm] in pain, I'm not waiting." Another woman drew a similar
distinction between preventive care and acute care: "For preventive
maintenance, I would be willing to wait longer... But if I'm sick,
I want to be seen right there... right then... now."
are willing to wait longer to receive expensive or sophisticated
tests. One Hogansville woman said, "I think that if it is going
to enable more people to have access to an [expensive test] they
need, then I would be willing to wait." A Felton man agreed: "[If]
the doctor just wants to see how much your arthritis has progressed,
then you can wait a bit of time [to use an expensive test]." But
again, most Georgians are unwilling to wait for care when there
is an emergency or a serious illness.
on Malpractice Awards
in these conversations agree with this comment by a Ballground
resident: "We have become such a litigious society, where every
time something doesn't turn out right at the doctor's office,
we want to sue them for a billion dollars." This leads many to
support the idea of limits on the awards they could receive from
a malpractice claim in order to help reduce health care costs.
"There should be some legislation introduced to control frivolous
lawsuits," suggested a Hepzibah man.
Georgians are angry about the large malpractice settlements they
hear about. "These suits are getting way out of hand and outrageous,"
said a Riverdale man. "Just looking at the newspaper, a person
made an incision wrong and someone got $10 million off the stupid
thing," he said. A Twin City resident had this to say:
should have some type of legislation to adequately protect hospitals
and doctors from the high [malpractice] awards. Take out the [awards]
for pain and suffering...you can be awarded for your actual loss,
but these high awards for pain and suffering just get completely
out of line.
also are angered by the number of unnecessary tests they believe
doctors perform purely because of their fear of malpractice lawsuits.
"You can go to the doctor and he runs all of these tests whether
you want them or not," said a Hepzibah man. A Dunwoody man said,
"I think some of the [malpractice] awards have caused doctors
to provide too many testings just to cover themselves, which has
increased costs and paperwork." A Twin City resident observed:
"The doctors are performing many more tests than they have done
in the past... to protect themselves in case something happens
and the patient wants to sue them." A Nahunta resident concluded
that more tests are performed "to protect the doctor making the
diagnosis [because] of liability" and fear of malpractice lawsuits,
a point echoed by a man from Decatur: "We need to do [something]
because doctors are practicing [defensive] medicine because they
are afraid of being sued."
to the problem of malpractice lawsuits, Georgians say, is to set
caps on the awards people can receive when they are injured. "Put
a cap on malpractice lawsuits," proposed an Augusta woman, "Sixteen
million dollars is not going to bring a child back if the child
dies." An Augusta man commented: "I think there should be a rate
set where the person could continue to live in their accustomed
lifestyle." Another woman noted, "I agree that there should be
caps" on malpractice, but like many other Georgians she insists
that such limits be fair and reflect the seriousness of different
injuries: "There should be limits in commensurate amounts, depending
on the extent of the injury or damage." A Decatur man also suggested
that any limits "have flexibility" to treat each situation fairly.
agree to these capsalbeit when flexibility is built ineven
though they know it may limit their own ability to sue if injured.
"If we are trying to get doctors' prices down, it is only fair
to have caps on what we can get from malpractice lawsuits," said
an Augusta woman.
express concern about who would set limits for such awards, and
this concern speaks to their deep mistrust of the entire health
care system. They fear that the interests of citizens will not
be protected unless a cross section of people is involved. An
Atlanta woman commented: "I guess I don't like the idea of one
person deciding... I like the idea of a group. It should be unbiased."
One Atlanta man suggested a committee be formed:
think I would include a number of people. Probably somebody from
the local health department who has some overall view of the community
health standards. But, along the same line, I think ministers,
certainly nurses, need to be on there. Also, I feel strongly that
this needs to be localized.
throughout the conversations, Georgians raised the idea of establishing
a panel or committee to make important decisions about health
care, including caps on malpractice awards. Such a committee would
be representative, with members from a range of fields, not just
health care. "I think there should be a committee of citizens,
government, and doctors... and pharmacists... in each state" making
decisions, stated an Augusta woman. An essential component would
be the inclusion of different voicesfrom religion, the community,
medicine, and elsewhere. People's desire for this broad-based
group reflects their view that health care is not merely a science,
but an activity of "caring " for people.
System Where People Take Responsibility
has a right [to health care]. But there are obligations also.
You've got to put the two together. Every right carries a responsibility."
Twin City Resident
the kind of health care system they want, Georgians are willing
to do more than just make tradeoffs.they say they must accept
greater personal responsibility for their behavior and their interaction
with the health care system. They believe that if the system is
to be made more accountable to them, then they must become more
accountable to the system.
they discuss include reducing abuse of the system, living healthier
lifestyles, becoming better health care consumers, and accepting
greater responsibility for others. How Georgians talk about these
responsibilities also has important implications for what the
system must do to encourage and help people to embrace this new
Abuse of the System
agree that, too often, people go to their doctor when it is not
medically necessary and that this costs everyone money. "I've
seen people with young children who just get a sniffle and they
run to the doctor," explained a Bremen woman. She recalled, "When
we raised our children and I had to pay the bill... I took my
kids when they were sick, but I knew pretty well when they were
sick enough to go." A Riverdale woman said, "I know someone personally
who, if their child sneezes, they're in the emergency room." An
Atlanta woman suggested that there would always be "hypochondriacs
that are going to run to the doctor [when] a lot of times they
don't need to." A Nahunta woman concluded, "We as a society appear
not to think twice about going to see a physician for extremely
minor ailments, because we know that after we pay our deductible,
that most of the [cost] is going to be covered."
consider making such unnecessary office visits to be an abuse
of the health care system. They believe that people need to take
more responsibility in deciding when to seek care. "A person should
be responsible for taking care of a cold... they have some responsibility
for themselves," said an Albany woman. A Twin City resident commented,
"Every person has the responsibility to stay as healthy as he
can before running up doctor and hospital bills." An Atlanta woman
agreed: "If I go [to the doctor] five times a year and it isn't
medically indicated, then it is my fault and my problem."
man proposed one way to discourage abuse and help people take
greater responsibility: "You would have to draw some sort of boundary...
to see what constitutes excessive treatment." He warned that with
no boundaries, "You could have everybody and their mother going
to their doctor for every little thing." An Augusta woman pointed
out that there is a role for doctors in encouraging greater self-responsibility:
"I mean, just kind of monitor and if I am coming every other day
and you have done every test possible, then kind of monitor that
and find [me] counseling."
to monitoring how people use the health care system, Georgians
call for everyone to take responsibility for living a healthier
lifestyle. Recall the discussions about preventive care, in which
a Nahunta resident said, "I think every person should have the
responsibility of getting a physical once a year so they will
know if there is a major problem and maybe prevent an expensive
procedure down the line." Another man remarked, "I think preventive
care makes sense, but the individual needs to take responsibility,"
and he provided an example: "If there is a high-risk individual
for heart attacks, you've got to teach that person what to eat
and not to eat and what weight levels you can be." He concluded,
"They've got to share in that responsibility." And there was the
Riverdale man who believed that having more preventive care available
might "trigger a lot more people to take a little bit better care
of themselves." Finally, there was the Twin City resident who
said, "Every person has the responsibility to stay as healthy
as he can before running up doctor and hospital bills." Georgians
agree that they need to take better care of their health.
also agree that those people who damage their health through poor
habits should contribute more for their health careperhaps
through higher insurance premiums or so-called sin taxes. During
this conversation, people focused on smoking and drinking as examples
of poor health habits. "Alcohol and tobacco, that is a high risk
automatically," said an Aragon woman, "Anybody who is doing that
is jeopardizing their health and should have to pay more." About
people who smoke or drink, a Morrow man said, "They're willing
to cause problems to their body by smoking and drinking... so
I feel like they should be willing to pay a little more." A man
from Cedartown agreed in principle, but would prefer giving a
rebate to those who live healthy lifestyles: "I smoke myself,
but I think we should give breaks to the people who don't."
also support the idea of a "sin tax" on products such as cigarettes
and alcohol. A Fayetteville man said that people who smoke and
drink should "be willing to pay a little more for that product."
"I smoke and I know I should quit. But if I had to go and pay
twice as much, maybe I'd quit," he predicted. A Marietta man said,
"I think for smoking and drinking, [it's] easier to make people
pay externally, put taxes on cigarettes and on liquor and you
make some of that go toward health care."
premiums or taxes, Georgians resist any and all attempts to restrict
or limit the care available to people who practice poor health
habits. They react strongly to the idea that a smoker might be
turned away from health care services because of recurring health
problems due to continued smoking. "What are you saying?" asked
a Dunwoody man, "That a smoker's life is less valuable than a
non-smoker's life?" A woman from Marietta contended that this
would constitute discrimination and that she doesn't "believe
in discrimination in any form... under any condition, any lifestyle,
nothing!" A Riverdale woman remarked: "Granted, people make mistakes,
but I think they should be given a chance. I overeat, but I don't
think you should count that against me or let this person over
here that didn't overeat get [care] before me."
also react strongly to attempts to identify other habits and behaviors
that might be considered unhealthy. A Decatur man questioned whether
he would have to pay more because he has a risky hobby: "I rappel
and go caving all the time. I am putting myself at risk in the
same sense that a smoker does." A Cedartown man also worried that
such attempts could go too far: "We all abuse something... We
all have bad habits, whether it be smoking, drinking, or other
fear most is "Big Brother" interfering too much in their lives.
This is the point made by an Atlanta woman: "You just can't get
that invasive, even if you wanted to." An exchange between two
citizens illustrates the difficulty Georgians foresee in enforcing
(innocently) How are we going to enforce that?
(sarcastically) Have spies in people's houses checking... to see
if they are drinking alcohol!
Why is being responsible for yourself such a horrible thing?
I am not saying that being responsible for yourself is bad, I
am saying, how do you enforce this responsibility?
A cop pulls you over for drinking and driving that is sort of
the equivalent of saying that you are not being responsible.
He's got proof. He's got a breathalyzer and a test.
The doctors have the same thing.
Well no. The doctor might prove that you've got a bad heart, but
he can't necessarily prove why you have a bad heart.
are going to do their part to live healthier lifestyles, they
say that they must have help from the system. Recall again the
discussion about preventive care: Georgians want more information
and education to help them live healthier lifestyles and care
for their own health. There was the Riverdale man in that conversation
who wanted "more education in schools, to give [kids] an opportunity
to learn how lifestyles relate to being healthy." A Cedartown
man proposed a "center where you can teach people how to care
for their bodies and try to help themselves stay well." And a
Rockmart man said that "you need to be educated on things that
are good for you and bad for you too... a lot of what would fall
under preventive maintenance." In all, Georgians say that if they
are to live healthier lives, then the system must help enable
them to act in informed ways.
do Georgians say they need to live healthier lifestyles, they
also believe they need to become better health care consumers.
"Consumers are very ignorant," said a Richmond Hill man, "We don't
ever ask our doctors any questions... We trust our doctors implicitly
to make sure that [we] don't have to pay more than [we] can afford
to pay. But that is not the case," he said sadly. A Forest Park
woman made the same point: "I think that as consumers we do not
do any shopping around." She felt that "if I were to get on the
phone and do a little leg work before I hunt down a doctor, I
might find someone who's in my price range."
Georgians agree that if more people were to shop around before
settling on a doctor or an insurance plan or when buying medication,
prices would come down. Some Georgians say they are already doing
this. An Augusta woman looks around "to find which pharmacy has
the best prices." Another Augusta woman said she demands that
her doctor "tell me everything before it is done," so that she
doesn't have "any surprises." These Georgians say this approach
Georgians see obstacles to becoming better health care consumers.
They say health care is different from other products and, that
when it comes to your own health or that of your family, you don't
negotiate or look for bargains. As an Atlanta man explained,
you go in there for a health problem and it is your family's health
that is concerned, you don't feel like negotiating... I am in
business and people try to negotiate with me all day long. [They
say], "You are charging me too much and this and that." You don't
tell a doctor that, unfortunately.
Atlanta man later commented, "You don't even know what you are
paying until you get the bill afterwards. Then you are kind of
Georgians argue that people often do not know the prices they
are charged until it is too latewhich makes it impossible
to compare prices and shop around. An Atlanta man argued, "I don't
know what a norm on a price should be... I don't even know when
I am being ripped off." A Decatur man gave this explanation: "I
think the system is set up where it is made almost impossible
to [shop around]... A lot of doctors will not even tell you what
their fees are until you are in the door and sitting there in
their office." A man from Cascade Heights related his own experience:
is no rate schedule. I don't even know what my doctors charge
on an hourly basis and I have been going to one since [I was]
13 and the other for 12 years, with my 13-year-old. If one doctor
charges $50 an hour versus another doctor charging $100, I don't
know where that information is, first of all, and I don't know
what we would do with it as consumers.
A man from
Cascade Heights said that when it comes to health care, the "market
forces don't work." He explained, "We don't shop for our doctors
as we shop for a loaf of bread or something we are very price
conscious of." A Decatur woman said that a person is "not just
going to keep hopping from one doctor to the next, [because] you
want to build up a rapport and have a relationship with the person."
She said people are not willing to say to a doctor, "Your [prices]
were too high on the sore throat so we are going to try somebody
down here." And a Nahunta man stated that the "delivery of product
and services is backwards" in the health care system: "The people
who do the paying have no control over the [health care] services"
they receive. All of this led a Marietta man to conclude that
consumers are "at a disadvantage in the competitive environment."
believe that people should shop around and become better consumers.
But they say the system must help them to do so. They want prices
to be published so that people can know up front what they are
being charged. One woman suggested, "I think you [should be able]
to go to any doctor that you want and when you walk in there,
you should know what you are going to pay." An Atlanta woman agreed:
"I think [doctors'] fees should be published," that we should
have "access to their fees." Another woman suggested that doctors
publish their costs "at least once or twice a year... so the public
can see...Like the airlines." A woman from Jonesboro added to
this chorus, "I think there should be some sort of list of prices
saying this is what [the doctor] is going to charge." A Marietta
man argued for "guidelines... so that if you have a procedure,
you know what it is supposed to cost."
want to be able to shop around; what they need is the information
to do so.
most of the increased responsibility Georgians feel they must
take for health care involves changes in their own behavior and
lives, they also are ready to accept greater responsibility for
each other. Throughout these discussions, Georgians expressed
an abiding concern for othersfamily members, neighbors,
or people they don't even know. They want this shared sense of
concern to be central to the design of a "caring" health care
speak at great length about their strong sense of responsibility
for their families. This is an immediate issue of concern for
the many Georgians who now face decisions about how to care for
elderly parents, for example. "I think that it is my responsibility
as a daughter to try to work it out among our family and take
care of [my parents] at home," said one Augusta woman. A Cedartown
woman commented that "if [people] care anything at all about their
parents, they should be willing to do whatever they can." A Decatur
man also expressed a strong sense of responsibility: "I already
feel like I ought to take care of my parents." A man from Felton
said, "The family should take care of their own." And a Cedartown
woman reminisced about the way things used to be: "It was not
so long ago that when you married, you moved in with either his
family or your family... kind of like The Waltons scenario...
There wasn't a problem of who was going to take that person, because
they were already there."
quickly add that the days of The Waltons are gone. Many people
say they wantand are readyto take more responsibility
for family members, but they simply cannot afford to do so. As
they listened to one another's stories, it became clear to many
Georgians that the real issue is economics, not a sense of responsibility
for their family. "Some people want to do it, but they just can't
afford to," said one woman. "If you have money and you love your
parents and you don't want them to be institutionalized, then
you can take care of them," said a Dunwoody man, although he concluded
that for most people that is an impossibility. "You're not able,
financially, to take somebody in," said a Newnan woman. "Some
people don't have the luxury to take care of their parents," observed
an Atlanta woman, "They have to take care of their own family
[first]." This was the case with an Augusta woman: "It's like
[my mother] has Alzheimer's. I can't see after her because I have
to work." A woman from another discussion said, "I would be willing
to bring my parents home and feed them, but their medical bills,
I couldn't handle that." This story told by an Augusta woman illustrates
a dilemma faced by so many people:
mamma has diabetes and she couldn't get health insurance so she
wants to come live here with me. My fear is... the only one who
works in my house right now is my husband. We live paycheck to
paycheck. I tell him he is going to have to supply her with diabetes
treatments, shots, and all that... and we can't. I don't mind
giving, but I don't have [the money].
a Cedartown woman pointed out, the health care system discourages
people from trying to care for a family member at home: "If I
would have put her in a nursing home, Medicaid would have stepped
in and [helped pay]. But as long as I kept her at home, they wouldn't
believe this situation needs to change. They want the system to
help enable more people to take responsibility for family members
who become ill. "I look at the United States as being one of the
richest countries in the world and we should be able to take care
of our own," said an Atlanta man, "Putting people in homes just
doesn't wash with me." A woman from Augusta argued that caring
for a sick family member "shouldn't be a financial burden on the
family," and she supports the idea of financial incentives such
as tax breaks to help families afford to provide home care. "I
think there should be a financial incentive to people... it would
save money if they kept them at home," said a Marietta man. A
Cedartown man agreed that incentives would "be encouraging something
that most people believe is a good thing anyway."
sense of responsibility extends beyond their families and includes
their fellow citizens. Throughout their discussions, Georgians
expressed their concern for one another: "You have to start thinking
about everybody rather than, `What's in it for me?'" said a Jonesboro
man, "You've got to think about what's in it for everybody else."
A Nahunta resident said, "You have responsibilities to your neighbor.
We are a society. Society has responsibilities to everyone in
that society... like it or not." A Woodstock resident asked, "To
me, what kind of society are we in if we don't, if we can't, even
take care of each others' health?" An Atlanta resident expressed
a similar sense of obligation: "Individualism is not a way of
life for me... you have to help your brothers and sisters." A
Dunwoody resident expanded on this point: "In the '90s, we are
moving toward interdependence... all are dependent on each other
in spite of our own specialties or strengths... we need each other."
And a Smyrna resident concluded, "Everybody's existence affects
Georgians feel strongly about helping out people who are less
fortunate than themselves. "We have a responsibility, as a responsible
people and as a government, to help those who need help," said
a Madison resident. An Augusta woman, herself struggling to make
ends meet, said that if she could "pay $10 a month to help somebody
else [receive health care] I would, because I could be standing
in their shoes." A Trenton woman expressed the same sentiment:
"The problem with saying that we don't have any responsibility
for [those less fortunate] is that tomorrow, it could be any one
of us." An Aragon woman spoke from experience: "We have hungry
people and we have sick people who are not getting care... I know,
I have seen them... I live around them." A Savannah resident offered,
"I wouldn't mind paying more taxes if I really knew it was going
to help poor people get care." Georgians want this concern for
others to guide changes in their health care system.
System That Provides Personal Control
not saying that doctors and hospitals shouldn't tell them that
this procedure's going to cost X amount of dollars...But you give
them the facts, and you let [the patient]make the decision."
illustrates the strong desire of all Georgians to make their own
health care decisions. They want to retain personal control over
key aspects of their health care. Indeed, the issue of personal
control runs throughout Georgians' discussions of health care.
This issue emerges when people discuss using alternative providers
or choosing doctors. Recall that even though Georgians are ready
to accept some limits on their ability to make choices in these
areas, they seek to exercise control by insisting that important
conditions be met before they make such changes.
one area, however, in which Georgians will not accept any limits
on their choices: end-of-life decisions. In such matters, they
say, the individual should make all the decisions. But in declaring
this position, they also speak to the kind of relationships they
want with health care providers and, more generally, with the
health care system. Moreover, they demonstrate both their desire
for control and their strong sense of personal responsibility:
they call on all Georgians to have a Living Will so that they
can guide their end-of-life decisions themselves.
Over Health Care
recounted previously, Georgians revealed their willingness to
make changes in their relationships with health care providers
in order to make health care more efficient and to bring down
costs. They said they were willing to accept some limits on their
choice of provider, but they set important conditions that would
have to be met before they accepted such limits. These conditions
underscore their desire to retain personal control over their
On the question
of seeing a nurse, nurse practitioner, or physician assistant
before a doctor, Georgians believe that this tradeoff. simply
makes good sense. Recall the Dunwoody man who said, "If a nurse
can take care of you when you have a cold, or recognize when you
need to be sent to a doctor, I wouldn't have a problem with it."
In fact, some Georgians believe their care would improve by seeing
one of these providers before a doctor: "[If] I needed something,
I would go to a nurse, not a doctor... your nurses can help you
a lot of times better than a doctor can," said an Aragon man.
their willingness to accept this tradeoff., Georgians want several
important conditions to be met first. They want close supervision
of nurses, nurse practitioners, or physician assistants in order
to ensure quality care. And they want the final say over whether
they eventually see their doctor. "I think it should be left up
to [me]... to make the choice if I want to see a doctor or not,"
said an Atlanta woman. Both of these conditions speak to people's
desire for control.
attach similar conditions when they contemplate accepting limits
on their choice of doctor. Some Georgians start such conversations
by emphasizing how much they value their current doctors. Remember
the Rockmart man who said, "I wouldn't give up my doctor... I
have had five back surgeries and I wouldn't trust nobody else
to do nothing on me." And the Felton man who said how hard it
is to consider giving up a doctor "when you have been going to
[him] for years and years and he has your complete history and
is familiar with you."
they have set some conditions for making such a tradeoff., Georgians
say they are ready to accept some limits on their choice of doctor.
Among the conditions they impose is an assurance that they will
have a wide selection of doctors from which to choose; that they
will have information on the quality of those doctors; and that
they will retain the ability to go back to their own doctors if
they can not settle on one of the doctors "off the list." Recall
the Monroe resident who said, "I wouldn't mind trying it, but
if I didn't like it, I would go back to my own doctor."
in which Georgians will accept no limits on their personal control
is in making end-of life choices. "I think that it should be left
up to an individual," said one man, "If they don't want that treatment
anymore and just let it go natural, then let them have that choice.
But if they want to pursue having treatment, then they should
have the treatment." In another discussion, one woman asserted
that end-of-life decisions "need to be personal." A Morrow man
made the same point, "It's up to the individual whether he wants
to be hooked up to life support or [not]." Georgians around the
state share this view.
initially resisted having a conversation about the issue of whether
or not the cost of care should enter into end-of-life decisions;
they feared that cost concerns would override all concerns for
care. Still, they are reasonable and pragmatic people, and they
don't want a health care system that ignores cost. A Riverdale
man, who thinks that cost should be considered, drew on his own
experience: "My grandmother is dead technically and I think it
is putting a heavy burden on the taxpayer and on the Medicare
system. I think there has to be a point where we just say it's
time to let go." A man from the same town echoed this concern:
"I think 80 percent of all of your medical costs come in the last
six months of your life... I think the time is coming where they
are going to have to say, `We should let him go and keep him as
pain-free as possible, and let him die with dignity.'" But he
quickly added, "It's up to the individual to decide."
In the end,
Georgians want cost to be a consideration in end-of-life decisions,
but they do not want it to be the decisive factor. They believe
that people will act reasonably and make the right decisions on
also are clear on the role they want health care providers to
play in end-of-life decisions. Indeed, their discussion provides
a good example of the relationships they seek with providers and
the dignity and respect they want to undergird such relationships.
Georgians say they want their doctors to actively advise them
on what they should do, as long as the final decision still rests
with the patient and family. According to one Hogansville woman:
think the responsible attitude from doctors and the health care
providers is to provide the family with the good information and
the bad information. But... it is strictly the patient's family's
decision... I don't think that the hospital, the doctor, the health
care provider, should be the one to make [it], or even insinuate.
between a Decatur man and this same Hogansville woman illustrates
the tension involved in discussing this issue and the relationship
people want with their providers:
If a health care provider came up to me and said: "Your mother
is very ill, but you need to consider this is going to cost a
lot. Do you really want to spend that kind of money?" It would
start putting a price tag on how much a [person's] worth... "Is
my mother worth it or is my husband worth it, or is my wife worth
it?" I don't like that.
We can't be responsible for how the doctor tells you this. But
as a responsible health care provider, I think cost, whether we
like it or not, is a major factor within health care. And from
a responsible point of view, they need to appraise you, no matter
whether it's a pleasant communication or not.
I'm not saying that doctors and hospitals shouldn't tell them
that this procedure's going to cost X amount of dollars. But...
you give them the facts, and you let [the patient] make the decision.
In a different
discussion, one woman discussed the kind of dialogue she would
like to see between doctor and patient: "The doctor is not going
to just come in here and say, `Well, this is this,' and just walk
away. It should be a little bit more interactive than that." An
Augusta woman pointed out, "If you are fighting a losing battle,
then maybe someone else could help you make the decision."
draw the line on setting standards or limits on how far patients
can pursue care. They also reject the idea of having people pay
out of their own pocket if they want to pursue care beyond what
is advised. They feel both measures would effectively place too
many limits on people's personal control over end-of-life decisions.
An Atlanta man expressed such concerns:
think all of us have reservations about setting standards [at
the end of life] because who would determine the standards? If
a person is too far gone, can the system say, "No. If you don't
have money, tough luck." I think that's what everybody has some
Georgians see to retain personal control over end-of-life decisions
is to have a Living Will. This issue exemplifies how important
they consider the role of both personal control and self-responsibility
in health care. Georgians raised this issue in every meeting,
without exception. They strongly support the idea that everyone
should draft a Living Will. "I believe that everybody should have
a Living Will and have on there what you want," is how one woman
put it. A Hogansville woman explained,
just a really tough place to be, when the doctor walks into the
room, and [says], "We've got a problem. We need to talk." I've
been there before... I think at [age] 18 each individual needs
to accept responsibility for what they want done and not throw
it onto someone else.
woman summed up the discussion on Living Wills when she said,
"I think if something in that respect were done [to encourage
people to have Living Wills], it would at least place the responsibility
where it should be, and that's with each individual person."
the state said over and over again that every adult should have
a Living Will. They believe that through a Living Will, people
can achieve personal control and take personal responsibility
for some of the most critical health care decisions they will
A Time for Change
is key...we have got to be willing to accept some change. "
start their discussions about health care from a position of deep
mistrust. They say the system lacks honesty and that health care
providers and others are motivated too often by greed. They believe
no one is looking out for the interests of people like themselves.
They describe a broken relationship between themselves and their
health care system.
are only the starting points. Beneath these negative attitudes
lies a hopefulness that trust can be restored and that new relationships
can be struck. When talking with one another, Georgians are able
to imagine a different kind of health care system: A health care
system that delivers care to everyone, efficiently and at reasonable
prices. A system in which citizens expect to make tradeoffs. and
assume greater responsibility. And a system in which citizens
retain personal control over the key health care choices they
And so Georgians
end their conversations on health care full of hope about the
possibility for change. But another message also is clear: If
Georgians do not see the health care system respond to their needs,
then their current sense of mistrust will deepen further. They
will go back to their homes, lock their doors, and resist making
the tradeoffs. that might be needed to bring about change.
in order to gain control over the health care system, Georgians
may even support policies and changes that conflict with their
most strongly held values. This possibility was evident in discussions
around the state on the issue of price controls. Georgians clearly
prefer a health care system that is based on competition and a
free market, but they are losing faith that the current free-market
system can police itself and control rising costs. For this reason,
they suggest they would support price controls and regulation
if that became necessary to reign in the system. They have doubts
about whether this approach is fair or even efficient; but if
they don't see changes in the system soon, Georgians will call
for regulationand it will be their last attempt to make
the system respond.
started this two-year discussion about health care by agreeing
that prices are too high and that health care needs to be made
more affordable. This was a recurring theme throughout the conversations.
"I think prices [hospitals charge] are outrageous and should be
brought down," said a Cedartown woman. According to a Marietta
woman, "The cost of medication is just outrageous when it is compared
to whatever it costs to produce it." Recall the businesswoman
from Cascade Heights who said, "I had my staff on health insurance
and we had to drop it just to make the bills." An Augusta woman
said, "When my daughter went to the emergency room, her bill was
$70 and he looked in her mouth less than two minutes... This is
complain not only that prices are too high, but also that they
are inconsistent from doctor to doctor, hospital to hospital.
Remember the Dunwoody woman who complained about going to a health
clinic and paying $10 for an immunization that cost $80 at her
doctor's office. And the Riverdale woman who observed that, "there
are so many doctors out there, one might charge you $35 and the
other might charge you $100." People cannot understand these differences.
think that greed and a desire for profit are at the root of these
high and inconsistent prices. Recall the Dunwoody man who called
doctors "greedy" saying that greed is something "they are taught
in medical school." An Atlanta woman made a similar point: "I'm
not saying that [doctors] shouldn't get a good amount of money,
but I don't think the guarantee of a fancy car and all these other
things go along with it." A Twin City resident described the problem
of greed as going beyond health care providers to include patients:
"Greed is the main thing for health care providers... and also
patients are greedy in trying to find some reason to sue to get
extra money." Remember the Felton man who said that insurance
companies were "making all the money" and should not have "as
much authority." And the Monroe resident who said, "a lot of health
professionals milk the insurance companies instead of giving people
believe that the only way we may be able to make health care prices
more affordable and to stem this greed is to cap fees and regulate
prices. They talk about regulating the prices that doctors, insurance
companies, and drug companies can charge.
context, their discussions about capping doctors' fees most clearly
captures the issues they are trying to sort out. "Doctors control
everything" said a Rockmart man. "They control prices, your treatment,
your medication and they aren't going to lower prices on their
own... We are going to have to make them [do it]." A Marietta
woman supported caps on fees because "physicians are making by
far the highest salaries that they have ever made." She saw this
as a problem because, "if they make more money, it costs the public
more and more to finance it." These Georgians believe that caps
on doctors' fees will also ensure that prices are consistent from
one doctor to the next. "Put a price ceiling on the prices that
doctors charge," said a Hepzibah man, "because you've got one
set of prices... and everyone pays the same thing."
is concern among Georgians that doctors be treated fairlyeven
among those people who complain vehemently about them. Indeed,
this discussion demonstrates Georgians' strong sense of fairness,
not just for themselves but for others too. If there are going
to be caps, they should be set at a price that is "reasonable
for everybody," said a Marietta woman. An Aragon woman said, "doctors
put a lot of time and a lot of money into their education and
it takes us so long to pay [them]." She pointed out, "They are
middle-aged before they start out." A Cedartown woman thinks that
doctors are already doing their share and shouldn't be penalized
by caps: "[Doctors] are greatly underpaid because they try to
help the public and poor people." She went on to explain: "I have
seen a lot of these people go to the doctor [and say], `I don't
have anything to pay you today' and they might have a $3,000 bill
there. But they still go back."
reason why many Georgians are concerned about capping doctors'
fees is that they believe such caps might lead to a decline in
the quality of care. An Augusta woman worried that capping doctors'
fees would mean that she would have less time with her doctor:
"I went to a doctor... and he saw me for five minutes and I got
a bill for $200... If we put a cap there and he would charge me
only $50, he will spend [only] one minute because he has got to
get those $200 in the same amount of time." Quality also concerns
a Marietta man, who worried that if a "doctor knows that he is
only going to get paid a certain [amount] for a procedure, then
he may not do as good a job." An Atlanta resident explained, "You
aren't going to get somebody who is willing to work for less...
the money attracts the brains."
concerns about fairness and quality, an even more fundamental
reason underlies Georgians resistance to regulation: they believe
inherently in competition. An Atlanta man argued that "caps are
another form of price control and it has never worked before and
I think that it is not going to work again." He continued, "I
believe in the free market attitude." Many Georgians believe that
the way to bring down prices is by increasing competition, rather
than limiting it, in order to force doctors, hospitals, and insurance
and drug companies to become more efficient. "There's got to be
some kind of way to build in real competition into the system
that will control costs," said a Macon resident. A Decatur man
argued that if we "privatize, the [health care industry] remains
healthy and becomes more efficient." An Atlanta man explained
that competition provides incentives to doctors and drug companies
to work harder and be more efficient: "I think the benefit to
the guy who has to work hard is that he is going to make more
money" than the next guy. Competition leads to lower prices, explained
a Marietta man, because "if one doctor charges $100 for a heart
check-up and another charges $50... then more people would go
to the guy who charges $50." But, Georgians point out, they need
information on prices in order to shop around.
end up wanting a health care system based on competition, but
they are ready and willing to support regulation if they do not
sense the system will make changes to respond to their needs.
the Possibility for Change
of regulation should serve as a warning to everyone concerned
about health care in Georgia: citizens are frustrated with the
current system and demand that changes be made. Listen to their
calls for change. "First what we need to do is wreck the house
and accept the fact that the system is literally coming apart
at the seams," said a Richmond Hill resident. "Change is key...
we have got to be willing to accept some change. We cannot keep
the status quo." A Nahunta resident called for change because
"the [current] system is so bad and has gone so far that it isn't
salvageable as it is." An Augusta woman agreed: "We need a change.
I mean the system is not working now... Let's go ahead and try
something new to see if it works and, if it doesn't, then we will
work for something better." A Madison resident said that we needed
to "throw out" the current health care system and "start again."
A Riverdale man remarked, "The system is not working. We all need
to make changes."
believe a first step toward creating change is simply to get more
people talking about change. They believe that citizens need to
come together across the state to discuss these issues and consider
different points of view. "The people are going to have to get
together and demand a stop to this outrageous thing that is going
on," said a Cedartown woman. "It just has to be talked about,"
said an Atlanta man, "It is just something that people don't talk
about... But if people openly discussed it, I think the attitudes
would change." This opinion is shared by a Morrow resident, who
you have a group discussion like this, it tends to enlighten you
on the way that other people feel about the issue. It may alter
your decision. I know that I felt one way when I first came into
these [discussions]. But now I have changed the way that I think
about certain things. Other people's conversation is sparking
other things. You may look at it a little differently and understand
something a little bit better.
strongly believe in the common sense and intelligence of their
neighbors. They believe that if citizens were to talk about health
care, they would develop a clearer understanding of the changes
that should be made in the health care system and of what they
would be willing to do to achieve them. "I think that we gained
more knowledge from hearing other people and I think that is mighty
important," said one woman. "Somebody might have a different view
than I do and if they explain why they feel the way they do, I
can say that I never thought of it that way." She concluded, "I
think these [discussions] are great." Finally, a Morrow man said
that this approach is different from the way most issues get settled:
think one thing we need to understand is that this is going to
be unchartered waters. We are setting out doing things that have
never been done. But it can't be the status quo. We're going to
change things. It's got to be something entirely different.
A: Georgia Health Decisions' Background
Health Decisions was founded in 1990 by a group of individuals
concerned about the rising costs of health care. Years before
health care reform was on the national agenda, this group, led
by Dr. Nicholas Davies, believed the health care system must be
reformed to reflect the values of the people it served. Lacking
a national health care policy, Dr. Davies' group recognized the
need for a fundamental review of the role of health care in our
society, rather than a modification of the existing system.
several members of the group were associated with the health care
industry, they believed the provider community was not the appropriate
vehicle for defining the goals of a reformed system. With each
vested interest group developing its own proposal for reform,
a consensus was not forthcoming. The missing voices in the health
care discussion were those for whom the services exist: the citizens
of Georgia. The members of the group pledges to come together
as completely unbiased individuals, leaving their professional
and institutional affiliations aside, to form Georgia Health Decisions
as a nonprofit organization strictly reflecting the voice of the
people of Georgia.
of Georgia Health Decisions is to assess the values of Georgians
through public discussion and scientifically valid research. Such
values represent the criteria against which any health care system
should be evaluated in terms of meeting the expressed will of
the people of Georgia. The results of the study will be made available
to the public as a tool for assessing reform proposals and to
public policy makers for use in devising health care reform. It
will be the foundation of a process for Georgians to monitor and
influence the future delivery of health care in the state.
1991, Georgia Health Decisions received its initial funding from
the Whitehead Foundation. Committed to a nonpartisan, unbiased
orientation, Georgia Health Decisions h as received 96 percent
of its funding from philanthropic foundations.
at the grassroots level and ensure true representation, Georgia
Health Decisions established volunteer Regional Boards of Directors
in 15 districts across the state. More than 200 individuals have
served on these boards, conducting 257 community forums in 104
counties, including 4,760 citizens from all sectors of Georgia's
sample the population, Georgia Health Decisions has held more
than 60 focus groups, with each group representing specific demographics.
Additionally, a random sample phone survey was conducted to quantify
the results of the focus group study.
has been the largest and most comprehensive study of Georgians'
health care values ever undertaken. Through the process, Georgia
Health Decisions has become a national leader in defining the
public's views on health care. Many other states now are developing
similar studies. This unique research puts Georgia at the forefront
in its ability to shape a health care system responsive to the
needs of its citizens.
B: Research Methodology
Georgians' health care values, Georgia Health Decisions set two
primary goals: 1) To provide a public process for Georgians to
discuss health care issues and voice their opinions, and 2) To
undertake a rigorous process for collecting statistically valid
data. Different approaches were required to achieve each goal.
forum format was developed for public outreach. The purpose of
the community forums was to educate participants about the health
care crisis, to create the opportunity for dialogue about health
care among participants, to engage participants in activities
that required thinking beyond the current health system, and to
build a network of concerned citizens interested in health issues.
community forums statewide, Georgia Health Decisions established
volunteer Regional Boards of Directors in fifteen districts. These
boards organized and conducted community forums in their areas.
From March through October 1992, 257 community forums were held
in 104 counties, attracting more than 4,670 participants. Community
forums were held in a variety of settings, including churches,
homes, community centers, public housing projects, professional
and civic organizations, hospitals, and schools.
attention was given to the inclusion of ethnic minorities. Forum
materials were translated into Spanish and Korean for use with
Hispanic and Asian-American groups. African-Americans comprised
23 percent of forum participants.
statistical data, research was conducted through a four-step,
integrative approach. The nature of this project and the quality
of information sought dictated that Georgia Health Decisions use
a combination of research methods designed to build on one another
to create a clear and coherent story of what Georgians think about
with citizens of Georgia were used throughout this project. These
group discussions of ten to twelve people enabled citizens to:
focus groups, it is possible to identify the language that people
use to talk about health care and learn more about how people
from different or similar backgrounds interact. The types of insights
that can be gained through focus groups are essential to understanding
why Georgians hold the views they do on health care, how deeply
they hold these views, and the directions they want health care
reform to take.
random-sample survey also was conducted as part of this project
The survey provides a quantitative look at the attitudes of Georgians
on health care and the directions for making changes that they
panel" was held at the end of the project to probe deeper into
those issues that remained unclear and to shape the research findings
into a coherent story. The citizen panel was an in-depth, day-and-a-half-long
conversation on health care with Georgians from diverse backgrounds
who had participated in earlier focus groups on this issue.
these research methods provided a range of qualitative and quantitative
information that creates a detailed picture of Georgians' views
on health care.
of the Research
citizens were the focus of this research. To ensure an accurate
representation of all segments of Georgia's population, the PRIZM
Cluster sampling technique was adopted. PRIZM, developed by Claritas
Corporation, classifies American households into one of forty
different "clusters" based on two factors: where they live and
what they buy. The basis for this approach is that people tend
to live with immediate neighbors who are very much like themselvesin
their lifestyle, experiences, and values. Each cluster has a distinctive
demographic profile, but the clusters are not defined by their
demographics and there is significant overlap. Twenty clusters
were identified that represent approximately 92 percent of Georgia's
that this methodology might exclude some sections of Georgia's
ethnic and minority populations, supplemental focus groups were
held with migrant farm workers, the homeless, Hispanics, the disabled,
and recent Chinese and Korean immigrants.
Step 1: Initial PRIZM Focus Groups
Health Decisions commissioned Dr. Alan Dever, Grassman Chair of
Rural Health at Mercer School of Medicine in Macon, Georgia, to
conduct focus groups with the clusterstwo focus groups per
cluster. Dr. Dever identified zip codes throughout the state that
showed concentrations of 85 to 100 percent of the targeted cluster.
Ten to twelve participants from these areas were recruited to
participate in two-hour focus groups.
of the PRIZM focus groups was to understand how Georgians perceive
the current health care system and what values they hold about
facilitators led groups in conversations to determine how the
public started talking about health care issues. During this phase
of research, no attempt was made to push participants to resolve
issues or to set priorities.
focus groups produced more than 3,500 pages of transcripts, which
Dr. Dever analyzed using a content analysis method of coding the
transcripts. Through his analysis, Dr. Dever determined that many
groups held similar attitudes and opinions about health care.
He was able to combine the twenty individual clusters into four
superclusters based on these similarities.
Step 2: Focus Groups to Check the Values
Health Decisions commissioned The Harwood Group, a public issues
research firm located in Bethesda, Maryland, to take the core
values emerging from Dr. Dever's research and conduct focus groups
with citizens from the four superclusters in order to:
groups were heldtwo with each supercluster. Citizens were
recruited from each individual cluster in proportion to their
share of the supercluster population. Participants were recruited
from communities with 100 percent concentrations of these clusters.
An average of twelve people participated in each discussion.
Step 3: Focus Groups to Find Some Answers
groups were conducted by The Harwood Groupone with each
superclusterto learn how Georgians resolve the tensions
involved with each of their core values. Claritas Corporation,
the creator of the PRIZM methodology, provided zip code maps of
the four superclusters, and Metromail produced a targeted recruitment
list of individual households that were identified as supercluster
members. Participants representative of their superclusters were
recruited by combining these lists with the demographic profiles.
Participants discussed a series of health care issues for three
hours on two consecutive evenings, for a total of six hours of
conversations. The trends emerging from the focus groups served
to frame the questions for a statewide survey.
Step 4: Statewide Survey
random-sample survey of Georgia citizens was conducted. The sample
of respondents was representative of the overall demographic profile
of the entire state. Adults aged 18 years and older participated
in the survey, which was designed by The Harwood Group and fielded
by Communications Center, Inc., of Washington, D.C., using a list
of names and telephone numbers of a representative sample of Georgia
calls were made over five nights. In sum, 10,125 telephone calls
were attempted to give a total of 800 completed interviews.
margin of error for the survey is < 4 percent. Within the demographic
cells, the margin of error varies up to 10 percent. Each interview
lasted an average of twenty minutes. The responses to the survey
were weighted for income, education, race, and age to match the
actual demographic mix in Georgia.
Step 5: Citizen Panel
step of research was a citizen panel conducted by The Harwood
Group. The purpose of the panel was to get reactions, insights,
and a deeper understanding of the survey findings. Thirty-two
Georgians who had participated in the previous focus groups were
recruited in order to form two groups of sixteen people. The goal
was to create a mix of participants who represented the superclusters
found in Georgia. Using previous research participants enabled
Georgia Health Decisions to build on their knowledge level and
awareness of health care issues and to probe deeper into core
values and attitudes.
this research, Georgia Health Decisions has discovered how typical
Georgians work through very complicated health care issues, what
priorities they set, and which pacts they are willing to make
with providers, payers, and government to achieve health care
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