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Topics: Health

Georgians Speak on Health
Georgia Health Decisions (GHD) Community Forums Bring Georgians' Values to Health Debate

"Georgians 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.


Case Study Plus: Georgians Speak Out on Health Care: What They Want and What They are Willing To Do

Case Study Plus: Georgians Speak Out on Health Care: What They Want and What They are Willing To Do

Georgians 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 health care.

This report 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 change—helping 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 Health Decisions.


Two years 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.

This is 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 them.

Listen 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 their goals.

This picture—reasonable citizens carefully weighing different points of view—may 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:

Where Georgians agree. On many key issues, Georgians arrive quickly at agreement and stand ready to act.

Where Georgians 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 decisions—indeed, they may resist moves toward action.

Where Georgians 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.

Throughout 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.

Foundation 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 care—for 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 care—not 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.

Decision values, which are also important to Georgians, are those that force people to make hard choices and tradeoffs.

When listening 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 weight.

In this 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 deals—where they seek to balance competing interests in order to achieve what they consider most important.

The Approach

Georgians 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.

This research 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.

The Story

This story 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.

The Starting Point: Mistrust & Broken Relationships

"First 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

When you 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.

When you 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 it serves.

A Dunwoody 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."

Georgians 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."

Some Georgians 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."

"We can 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."

Indeed, 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."

This is 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.

A System That Cares for Everyone

"The bottom line is that everybody should have health care. Everybody should have access to health care."

- Cedartown Woman

Georgians 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 system—a 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.

To Georgians, 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.

Care for Everyone

"What kind 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 America!"

Georgians think it is wrong that so many people now lack access to health care services. "There is an inherent inequity—human 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."

Georgians 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.

"Care shouldn't 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!"

Access to the Same Quality Care

Not only 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."

A Columbus 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 you're getting."

But many 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."

For Georgians, 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.

Most Georgians 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 without."

But when 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.

In another 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."

An exchange 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 care:

Woman: 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?

Man: Health care is one thing, but a fertility expert?

Woman: Does that mean I should be denied a child because I can't afford to go to a fertility specialist?

Man: 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.

Woman: 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.

Georgians 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?"

An Augusta 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."

Georgians agree on the central issue in this discussion—that 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.

Reasonable, Fair, and Consistent Prices

Georgians 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."

Georgians 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.

People tell 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:

Just 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.

An Aragon woman who has no insurance also expressed concern that she could not afford to see her doctor:

I 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.

There are 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.

Many Georgians 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."

Even Georgians 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."

Georgians 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 it.

Georgians 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.

Georgians 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.

An Emphasis on Prevention

Georgians 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 sense—it 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."

Many Georgians 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."

Georgians 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 responsibility."

"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," 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."

But Georgians 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."

Despite 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 sense—they 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 care—they 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:

They're 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."

Indeed, 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.

These concerns 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.

A System Where People Do Their Part

"We are going to have to make some sacrifices and trade-offs...to pay for this system."

- Cascade Heights (Atlanta) Man

Georgians 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.

Here are 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.

Contributions from Everyone

Georgians 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:

I 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.

Georgians 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."

Some Georgians 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."

Georgians want contributions to the health care system to be based on a sliding scale—if 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."

Finally, 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.

"I realize 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.

However, 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.

This discussion 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 system.

Use of Alternative Providers

People say 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 physicians—they reach agreement on this point only after much discussion and consideration.

Georgians 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."

But Georgians 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 doctor—even 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.

The people 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."

Accepting 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 with you."

Georgians 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 teeth—they 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."

Overall, 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 costs—they only want to ensure that certain conditions will be met if they are to make this tradeoff.

Georgians 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."

They also 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 more—if 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."

Georgians 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.

Tradeoffs. on Access to Care

While Georgians 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 costs—although 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.

Initially, 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:

We 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 here.

People talk 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]?"

These Georgians 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.

Even as 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."

To resolve this dilemma, people suggest making a deal: if some communities—rural, urban, or suburban—must 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.

Another 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?"

Georgians 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."

People also 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.

Limits on Malpractice Awards

Most Georgians 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.

Indeed, 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:

We 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.

Georgians 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."

One answer 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.

Georgians agree to these caps—albeit when flexibility is built in—even 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.

Still, people 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:

I 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.

Indeed, 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 voices—from 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.

A System Where People Take Responsibility

"Everyone 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

To realize 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.

The responsibilities 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 role.

Reduce Abuse of the System

Georgians 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."

Most Georgians 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."

A Fayetteville 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."

Live Healthier Lifestyles

In addition 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.

Georgians also agree that those people who damage their health through poor habits should contribute more for their health care—perhaps 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."

Many Georgians 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."

Beyond higher 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."

Georgians 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 lifestyles."

What Georgians 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 healthy habits:

Man: (innocently) How are we going to enforce that?

Woman: (sarcastically) Have spies in people's houses checking... to see if they are drinking alcohol!

Man: Why is being responsible for yourself such a horrible thing?

Woman: I am not saying that being responsible for yourself is bad, I am saying, how do you enforce this responsibility?

Man: A cop pulls you over for drinking and driving that is sort of the equivalent of saying that you are not being responsible.

Woman: He's got proof. He's got a breathalyzer and a test.

Man: The doctors have the same thing.

Woman: 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.

If Georgians 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.

Become Better Consumers

Not only 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."

Many other 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 pays off.

But most 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,

When 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.

The same Atlanta man later commented, "You don't even know what you are paying until you get the bill afterwards. Then you are kind of stuck."

Indeed, Georgians argue that people often do not know the prices they are charged until it is too late—which 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:

There 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."

Georgians 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."

Georgians want to be able to shop around; what they need is the information to do so.

Share Responsibility

Although 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 others—family 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 system.

Georgians 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."

But Georgians quickly add that the days of The Waltons are gone. Many people say they want—and are ready—to 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:

My 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].

What's more, 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 help out."

Georgians 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."

Georgians' 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 everyone else."

Indeed, 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.

A System That Provides Personal Control

"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."

- Atlanta Man

This comment 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.

There is 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.

Control Over Health Care

In discussions 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 health care.

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.

But despite 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.

Georgians 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."

But once 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."

End-of-Life Decisions

One area 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.

Georgians 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 their own.

Georgians 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:

I 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.

A conversation 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:

Man: 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.

Woman: 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.

Man: 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."

Georgians 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:

I 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 reservations about.

Living Wills

One way 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,

It's 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.

A Cedartown 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."

People throughout 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 face.

Conclusion: A Time for Change

"Change is key...we have got to be willing to accept some change. "

—Richmond Hill Resident

Georgians 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.

But these 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 face.

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.

Indeed, 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 regulation—and it will be their last attempt to make the system respond.

Grasping for Regulation

Georgians 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 just ridiculous!"

Georgians 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.

Georgians 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 proper care."

Some Georgians 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.

In this 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."

But there is concern among Georgians that doctors be treated fairly—even 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."

Another 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."

Along with 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.

Georgians 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.

Seeking the Possibility for Change

The issue 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."

Georgians 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 said:

When 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.

Georgians 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:

I 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.

Appendix A: Georgia Health Decisions' Background

Georgia 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.

Although 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.

The purpose 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.

In June 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.

To outreach 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 population.

To statistically 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.

This exercise 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.

Appendix B: Research Methodology

In assessing 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.

Community Forums

A community 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.

To coordinate 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.

Special 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.

Research Methodology

For gathering 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 health care.

Focus groups with citizens of Georgia were used throughout this project. These group discussions of ten to twelve people enabled citizens to:

  • think about various health care issues over the course of the conversation;
  • respond to the give and take of other people in the discussion and hear different perspectives;
  • talk about their views and feelings in their own words; and
  • have the opportunity to change their minds and clarify their positions throughout.
  • Through 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.

    A statewide 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 would support.

    A "citizen 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.

    Together, these research methods provided a range of qualitative and quantitative information that creates a detailed picture of Georgians' views on health care.

    Focus of the Research

    Georgia 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 themselves—in 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 population.

    Concerned 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.

    Research Step 1: Initial PRIZM Focus Groups

    Georgia 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 clusters—two 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.

    The purpose of the PRIZM focus groups was to understand how Georgians perceive the current health care system and what values they hold about health.

    Trained 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.

    Forty-six 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.

    Research Step 2: Focus Groups to Check the Values

    Georgia 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:

  • learn how each supercluster talks about the values;
  • check if the values identified in Dr. Dever's focus groups were the core values; and
  • identify the tensions, choices, and conflicts involved with each value.
  • Eight focus groups were held—two 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.

    Research Step 3: Focus Groups to Find Some Answers

    Four focus groups were conducted by The Harwood Group—one with each supercluster—to 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.

    Research Step 4: Statewide Survey

    A statewide 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 citizens.

    Telephone calls were made over five nights. In sum, 10,125 telephone calls were attempted to give a total of 800 completed interviews.

    The overall 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.

    Research Step 5: Citizen Panel

    The final 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.

    Through 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 reform.

    More Information

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