Examining health care, what's the public's prescription?

Results from Citizen Forums
Examining Health Care
What’s the Public’s Prescription?
A Kettering Foundation Report
September 2004
prepared by Paul Werth Associates

Copyright © 2004 by the Kettering Foundation
The Kettering Foundation, chartered in 1927, is an operating foundation —
not a grant-giving foundation — rooted in the American tradition of
inventive research. Its founder, Charles F. Kettering, holder of more than
200 patents, is best known for his invention of the automobile self-starter.
He was interested, above all, in seeking practical answers to “the problems
behind the problems.”
The foundation today continues that tradition. The objective of the
research now — the study of what helps democracy work as it should. Six
major Kettering programs are designed to shed light on what is required
for strengthening public life. Kettering is a nonprofit 501(c)(3) research
corporation supported by a $260 million endowment. For information about
the Kettering Foundation, contact the foundation at 200 Commons Road,
Dayton, Ohio 45459-2799. Phone: 800-221-3657.
The Kettering Foundation does not make grants but welcomes partnerships
with other institutions (or groups of institutions) and individuals who are
actively working on problems of communities, politics, and education.
The interpretations and conclusions contained in this publication, unless
expressly stated to the contrary, represent the views of the author or authors
and not necessarily those of the foundation, its trustees, or officers.
www.kettering.org

A Public Prescription for Health Care 1
Introduction: Overview of Approaches 3
Executive Summary 4
An Overview of Americans’ Discussions about Health Care
and the Tradeoffs They Are Considering 6
Tradeoffs Involving Cost, Quality, and Access 6
• Coordination of Care vs. Cost of Care
• Quality of Care vs. Increase in Number of Covered Lives
• Quality of Care vs. Cost of Care
• Access to Care vs. Increase in Number of Covered Lives
• Patient Privacy vs. Coordination of Care
• Quality of Care vs. Medical Lawsuits
• Physician Autonomy vs. Cost of Care
• Increase in Taxes vs. Increase in Covered Lives
• Competition vs. Collaboration
Shifts in Citizen Thinking 10
Specific Findings 11
Citizens Are Frustrated by the Lack of Action
to Improve the Health Care System 11
• Passionate Interest in Improving Health Care
• Industry Should Be Working Together
• Personal Sacrifice for Improved Care for Others
• Unknown Effects of Changing the System
• Personal Accountability and Responsibility,
Along with Government Interaction
Contents
(Continued on next page)

Citizens Want an Ombudsman to Help Them Navigate the System 14
• Absence of a Global Perspective
• Defining Industry Terms
• Abusing the System
• Unqualified for Personal Accountability
• Physician Impact on Citizen Opinion
• Better Communication and Collaboration Needed
throughout All Health Care Entities
• Physician and Patient Partnerships
• Supporting Physicians with Other Health Care Professionals
• Insurance Company and Pharmaceutical Company Partnerships
• Ombudsman or Advocate Organization Needed
Citizens Suggest Rewarding Healthy Behavior
and Penalizing Unhealthy Behavior 19
• Preventive Care Should Be Encouraged by Insurance Providers
• Skepticism about Health Care Education
• Rewarding Healthy Behavior and Penalizing Unhealthy Behavior
• Struggling with “Appropriate Care” for Everyone
• Appropriate Use of Resources
• Universal Health Care System
Common Ground for Action 24
Several Action Steps Are Considered 25
Appendix 26
Methodology 26
Questionnaire Results: Demographics 28
Other Notables 30
Analysis of Post-Forum Questionnaires 31
About National Issues Forums 33
About Paul Werth Associates 34
Contents (continued)

Examining Health Care 1
Health care policy in America is a maze
of contradictions. Our system offers some of
the most advanced medical treatments and
technologies in the world, yet more than 43
million Americans have no health insurance
of any kind. Each year, as a nation, we
spend more than twice as much per person
on health care as most other industrialized
countries yet rank below them not just
in key health indicators such as infant
mortality, but also in access to services —
with lower numbers per capita of everything
from doctors and nurses to machines for
Magnetic Resonance Imaging.
The sense of frustration is growing. Wary
of misunderstanding the public’s wishes,
policymakers propose little more than
piecemeal programs — lower drug costs
for senior citizens and expanded health
insurance coverage for low-income children —
that fail to address the problem in its entire-
ty. Weary of working in an increasingly
unworkable system, a small, but growing
number of physicians across the country
are simply closing their clinics and walking
away. The demands on the health care
system, meanwhile, are steadily growing.
While layoffs and the soaring costs of
coverage steadily add to the ranks of the
uninsured, our aging population creates an
ever-increasing demand for care. In 2003,
the U.S. spent nearly $1.5 trillion on health
care, roughly 14 percent of the gross
domestic product. By 2013, that figure is
expected to more than double. Without
public action, the only sure thing about the
health care crisis is that it will surely only
get worse. What should we as a nation do?
For politicians and government officials,
health care reform is a seemingly thankless
task. The public, or so conventional wisdom
goes, has no useful input to offer: it simply
wants the best care possible with no
additional taxes or cost. It is unable to truly
engage the issue or make tough tradeoffs.
This report, however, presents a radically
different view.
What follows is not a product of traditional
opinion polls or the finding of a blue-ribbon
study panel. It is the result of something far
more powerful: public deliberation — the
collective judgment and insights of citizens
as expressed in dozens of locally organized,
nonpartisan National Issues Forums.
Forum participants care passionately
about health care. Not only are they ready
to come to the table to think about tough
tradeoffs and consider new approaches,
they are also increasingly angry that
others — health care providers, insurance
and pharmaceutical companies, and
policymakers — seem unwilling to join them.
Solving the health care crisis, they believe,
will require the input of everyone, citizens
included. Rather than the specific details of
plans, they are more interested in process.
They want to make themselves heard as well
as hear what others have to say. What is
missing, they suggest, is a process that
actually engages the public — one that not
only respects their values, but also demands
that they take responsibility. Forum partici-
pants, as Kettering Foundation President
David Mathews has noted, recognize “that
good health begins with personal decisions”
and that they “could do something about costs
by changing lifestyles.” That notion of public
responsibility, in turn, has important policy
implications when it comes to health care.
A Search for Common Ground
This report is an attempt to bring those
kinds of public ideas to the forefront.
Prepared by Paul Werth Associates, it brings
a uniquely public perspective to the health
care debate. Health care is an issue that
touches all Americans. And as we, as a
nation, attempt to fix its problems, the ideas,
insights, and beliefs of everyday Americans
are all-important.
Involving more than 1,000 citizens in 44
different states, the forums covered a wide
range. They included physicians and high
school students, as well as retirees and
public officials. Some participants had
comprehensive medical coverage. Others had
none at all. But regardless of background,
all came with personal stories: the struggles
of a loved one with a life-threatening illness,
worries about limited care in the future,
or the frustrations of dealing with an increas-
ingly complex and costly system. From
personal insights, however, forum participants
quickly shifted their conversation to the need
for finding common ground as they wrestled
with the tradeoffs involved in balancing the
problems of quality, access, and cost. How
can we make health care more affordable?
How can we make it more accessible? How
can we make it more effective?
Building Relationships
Although forum participants often started
their discussions by sharing personal
experiences and frustrations, their discussions
A Public Prescription for Health Care
Kenneth A. Brown

2 Kettering Foundation
soon switched to the need for developing
relationships: not just between doctors and
patients, but within the health care system
as a whole — insurance companies and
policymakers as well as the pharmaceutical
industry. Whether the problem was finding
a doctor or filing an insurance claim,
participants found the system so complicated
and confusing that they wished for a
personal guide, or ombudsman, to help them.
Taking Responsibility
While participants initially blamed a
specific part of the system — HMOs, insurance
companies, doctors, or overly demanding
patients — as they began to talk, they quickly
changed their view. Rather than finding
fault, they began to see the problem as
one that stretched across the health care
system as a whole. While forum participants
wanted government agencies and insurance
companies to do more, they also suggested
that private citizens needed to take more
responsibility for their health. They felt that
all citizens should be more informed about
both their own health problems and those
of the health care system at large. Forum
participants favored both private and public
insurance programs that encouraged healthy
behavior. They saw the need for a system
that focused as much on preventing disease
as it did on treating it.
Making Change Possible
When it came to making health care more
available, most expressed a willingness to
make sacrifices. Some forum participants, for
example, suggested that they would be willing
to sacrifice a portion of their health care
benefits for others if they believed the help
would really arrive where it was needed. But
they saw little evidence that professionals
and businesses in the field were willing to
make similar sacrifices.
Above all, forum participants believed
that the process of developing a real solution
to the health care crisis could begin only
if everyone made his or her way to the table.
While the proper level of government control
was a topic they were still “working through,”
almost all of those in the forums believed that
the government would have to play a leading
role in starting the conversation. Frustrated
with nearly a decade of inactivity, they were
clearly ready for action. All were interested
in changing the current health care system.
None was interested in seeing it stay the way
it is. Real change, however, was seen by forum
participants as something that would have to
occur from the bottom up — beginning with
people at the local level.
Bringing People Together
In an era of rising civic detachment and
declining voter participation, public
deliberation helps bring citizens together to
search for solutions to common problems.
National Issues Forums have helped isolated
rural communities come together to build
health clinics and inspired troubled inner-city
neighborhoods to address the problem of
crime in their schools and streets. For many
groups, however, a forum’s most important
product is simply the sense of community it
engenders — the way it brings people together.
Putting the Public into Public Policy
These kinds of deeply felt public judgments
need to be part of our current debate on
health care. Most important public policy
decisions are really questions of value — what
we as citizens hold most dear. And revealing
common values is what forums are all about.
The findings detailed in the following pages
are important because they represent far
more than just a collection of competing views
and opinions. Forums are not popularity
contests. Participants do not merely argue or
vote. Instead, they work together, carefully
weighing the costs and benefits of different
approaches, struggling to define a collective
course for action.
For both the press and political leaders
alike, these conversations offer a glimpse
into our nation’s most deeply held public
beliefs and desires — invaluable information
whether one’s goal is covering the news or
developing policy.
Making Democracy Work as It Should
A healthy democracy depends on public
participation, not just in regularly scheduled
elections, but in the ongoing and much
harder business of finding solutions to
difficult public problems. For far too long,
developing public policy has been seen as a
job solely for professionals and political
leaders. The public need not apply.
By offering a framework for public delibera-
tion, the NIF network helps citizens find
solutions to common problems that concern
them. It helps connect them both with others
in their community and with their elected
officials. People cannot act together until they
decide together. Deliberation is not just about
talking over issues, but about deciding what
to do — bringing divided interests together to
find common ground for action.
Kenneth A. Brown is a program officer with the
Kettering Foundation. He works regularly with the
NIF Network on outreach and research.

INTRODUCTION: Overview of Approaches
Approach 3: Care for All,
Not Just for Some
This approach holds that we need to
set new priorities aimed at providing
Americans the health care they need
when they need it. We need to seal up
the cracks in the system so that people
don’t fall through. We need an unflagging
commitment to providing the medical
treatment that each person needs. This
is the best way to improve individual
health and prevent illnesses that are
more difficult and expensive to treat.
The participants in this year’s
forums deliberated using the NIF
Issue book Examining Health Care:
What’s the Public’s Prescription?
This book provides participants with
a framework for dealing with the
issue of health care, outlines the
issue in a nonpartisan way, and
then presents for public deliberation
three approaches for addressing it.
The approaches are not mutually
exclusive. Instead, each presents
a variety of ideas and options
for participants to consider and
deliberate about so that they may
construct their own approach to
the issue.
Approach 1: Connected
Parts, Not Fragmented Pieces
This approach says the most effective
way to improve health care in America
is to take firm hold of it and make it
run like a true, well-coordinated system.
We need to take the existing, unwieldy
collection of health care fragments and
fashion them into a connected web of
health care services, within which
information flows readily between the
pieces and they work in concert.
Coordination is the best way to curb
costs and provide health care in a
timely way.
Approach 2: Partners,
Not Just Patients
This approach states that we need
to create new relationships in health
care within which consumers and
professionals work hand-in-hand so
that people become partners in their
own health care. We must take time to
communicate, to help people make
informed decisions, and to educate for
healthy lifestyles. This is the best way
to improve the health of Americans and
lay a firm foundation for personal
responsibility and prevention that will
result in long-term savings.

Executive Summary
Overview
Over the past 12 months, more than
1,000 citizens from across 44 states
have participated in 2-hour discussion
forums on the topic of health care. These
forums took place in small and large
cities throughout the nation. Citizens
discussed what ails the health care
system and what they are willing to do
to fix it.
In the forums, participants shared
their opinions, their concerns, their
experiences, and their knowledge of
health care. With the help of moderators
and issue books, participants weighed
several possible ways for society to
address the health care system’s
problems. They analyzed each choice,
the arguments for and against it, and
the tradeoffs and other implications of
their choices. Moderators encouraged
participants, as they gravitated to one
option or another, to examine their
basic values as individuals and as
community members.
Report Methodology
This report is based on an analysis
of what happened in 40 of the hundreds
of forums that have taken place, and
continue to take place, across the United
States. The report describes what
happened as diverse groups of people
came together and deliberated about
issues related to health care.
Participants were recruited to take
part in the discussion through a variety
of media, including direct mail, newspaper
articles, newspaper advertisements, Web
site postings and word-of-mouth. Every
person who was interested was allowed
to participate in the forums.
To complete the report, Paul Werth
Associates used five research methods.
The process consisted of 5 interviews
with the committee members who
designed the issue book (a nonpartisan
overview of the issue), 29 in-depth
interviews with moderators who lead
forums, observing 5 live forums,
interviewing dozens of forum participants,
reviewing reports from 17 completed
forums, and analyzing survey results
from 1,027 participants. The research
took place from January 2003 through
March 2004. To ensure consistency,
all aspects of the research process were
completed by the same individual at
Paul Werth Associates.
The research process and report were
sponsored by the National Issues Forums
Institute and the Kettering Foundation.

Executive Summary
Key Findings:
Three Themes
Three key themes resonated through-
out the forums. These themes, described
below, are organized according to the
order in which they were discussed.
1. Citizens Are Frustrated by the Lack
of Action to Improve the Health Care
System
Citizens in the forums recognize
there are problems with the health care
system, and many are frustrated over
the unrecognizable improvements
under way. Many participants want
representatives from specific health
care constituent groups (for example,
insurers, providers, and policymakers)
to be part of further discussions to
ensure action is taken.
Citizens who participated in the
discussions also recognize the need to
change the current health care system,
and many would consider making
personal changes to help in the process.
They are disappointed other entities
in the system do not share the same
passion and are not making a concerted
effort to better the system as a whole.
Participating citizens believe that
though personal accountability and
responsibility are critical for change to
occur, the government must take an
active role in the process of changing
the health care system.
Forum participants comprehend that
by changing the health care system,
patient access, privacy, quality of care,
and overall health care costs may be
at risk. They understand that making
changes will require considering some
tradeoffs. However, all still believe
change must occur.
2. Citizens Want an Ombudsman to
Help Them Navigate the System
Citizens in the forums acknowledge
that multiple organizations and
components are part of the health care
system and that each deserves both
credit and blame for the current status
of health care in America. Participants do
not, however, understand the health care
system as a whole. Many want an entity
or individual to personally help guide
them through the complete process from
first accessing care through payment
for services.
Citizens who participated in the
discussions suggested several actions to
improve communication and collaboration
within the health care system. The actions
are aimed at improving the patient
experience. Participants recognize these
actions may lead to an increase in cost.
Steps such as increasing
the number of midwives,
dieticians, and nutrition-
ists to support patient
care were suggested. Also,
encouraging patients and
physicians to form stronger
partnerships, founded in
education, was thought to
lead to better health care
and a healthier population.
3. Citizens Suggest
Rewarding Healthy
Behavior and Penalizing
Unhealthy Behavior
Citizens in the forums
believe preventive care
should be acknowledged
and rewarded since it
should lead to a reduction
in health care costs. They perceive the
current health care environment as
focused on reacting to existing health
problems instead of rewarding those who
take a proactive approach to anticipate
potential health problems. Many
suggested initiating a system that rewards
people who take precautionary health
care measures and behave in a healthy
manner. Many also suggested a financial
penalty for those citizens who knowingly
behave in an unhealthy manner.
Most citizens who participated in the
discussions believe every person should
have access to some level of quality
health care but believe employers and
taxpayers should not be additionally
burdened with paying for this care. A
common definition of a minimum, or an
acceptable, amount of health care still
needs to be “worked through.”
Key Findings:
1. Citizens Are Frustrated
by the Lack of Action
to Improve the Health
Care System
2. Citizens Want an
Ombudsman to Help
Them Navigate the
System
3. Citizens Suggest
Rewarding Healthy
Behavior and Penalizing
Unhealthy Behavior

An Overview of Americans’ Discussions about
Health Care and theTradeoffsThey Are Considering
Interest in changing the health care
system is at an all-time high. Many
citizens believe the health care system
is near catastrophe and are waiting for
it to crumble. They are frustrated with
increasing costs, increasing restrictions
on care, longer waits for care, the
unpredictability of their coverage, and
most of all, the perceived lack of action
under way to fix the problems.
Throughout the discussion, citizens
revealed an impressive understanding
of several aspects of the health care
system. They considered numerous
tradeoffs during deliberation. Most
tradeoffs included some combination of
cost, quality, and access to health care.
Tradeoffs Involving Cost,
Quality, and Access
Citizens comprehend that by changing
the health care system, patient access,
privacy, quality of care, and overall
health care costs may be at risk. They
understand that making changes will
require considering some tradeoffs.
However, all still believe that change
must occur.
Throughout the forum, citizens
weighed numerous points of view on a
variety of health care issues. They
grappled with the consequences each
action could produce.
The following is a
summary of the
tradeoffs citizens
considered.
Coordination of Care
vs. Cost of Care
While participants
agreed that more
coordination among all
stakeholders (patients,
families, physicians,
and insurance
providers) is essential,
they questioned what would happen to
the cost of care if this occurred. Some
believed a more integrated health care
system would lead to more efficiency and
ultimately drive down the cost. Others
believed that there would need to be a
“Full access
to marginal
health care
is common
in other
countries.…”
significant investment in infrastructure
to help the health care system become
more integrated. Those participants
thought the investment would be passed
on to the consumer, resulting in higher
health care bills.
Quality of Care vs. Increase in
Number of Covered Lives
Participants questioned whether
enabling everyone access to health care
would sacrifice or improve the quality of
care. Some reasoned that health care
providers would master their skills
because they are exercising them more
frequently. This would increase the
quality of care they provide. On the other
hand, some thought extending access to
health care could overburden the system.
This would force physicians to spend less
time with each patient, and the quality of
care would decline. Some also suggested
that an increase in demand, given the
same number of physicians, would cause
existing physicians to perform services
for which they were less qualified. This
would negatively affect quality of care.
“If a system [were] in place to connect all
the health care parts, the quality of care
could decline. Caregivers would not have
an incentive to treat anyone better,
differently, or uniquely. Everyone would
meet the minimum standards.”
Charleston, SC
“Full access to marginal health care is
common in other countries. If everyone
here had full access, what would the
quality of health care look like?”
College Park, MD
A brief discussion between participants
reveals that they understand a complex
relationship exists between quality of
care and the number of people with
access to care.
“If everyone can get care, then demand
will increase. An increase in demand
will lead to lower reimbursement rates.
Lower reimbursement rates will keep
physicians from investing in their
practices. Long term, this will reduce
quality of care.”

“And, physicians will not have an
incentive to see as many patients. This
may jeopardize the quality of care too.”
Dell Rapids, SD
Quality of Care vs. Cost of Care
There is a belief that while the quality
of care is very good in the United States,
citizens who want higher quality may
need to pay more for their care. Also,
with the continuing reduction in
reimbursement, physicians will need
to push more patients through their
practices to maintain their standard of
living. This action could negatively
affect quality of care. Reimbursement
reduction trends could also lead to fewer
people pursuing degrees in medicine.
This would affect the supply of quality
physicians and ultimately the quality of
patient care. Ultimately, if costs continue
to rise while reimbursement remains
stagnant or declines, citizens believe
health care quality is at risk.
“I’m willing to pay more for better
quality.”
College Park, MD
“Hospitals and doctors cannot afford to
provide high quality of care with low
reimbursement. It is easy to realize this
business model won’t last long.”
Estherville, IA
“How will people receive quality of care
with a shortage of physicians and nurs-
es? The idea of a nationwide reimburse-
ment system and/or further reductions in
reimbursement could scare physicians
away.”
Columbus, OH
Access to Care vs. Increase in
Number of Covered Lives
Participants contemplated whether
expanding citizen access to health care
would increase the waiting time to see
a health care provider. Some thought
enabling more people to receive health
care would raise the demand and would
ultimately increase the time people had
to wait to see a health care provider.
Alternately, others thought that if
patients knew they could receive health
care any time they need it, they would
be less likely to abuse the system and
would seek health care only when it was
needed, thus making the overall demand
more consistent and predictable.
“I would expect to have less say and
participation in my care if everyone had
equal access.”
Charleston, SC
Patient Privacy
vs. Coordination
of Care
Participants explored
whether their privacy
would be compromised
by a more integrated
health care system. The
majority was willing
to sacrifice some level
of privacy for a more
integrated system. The
concept of a personal ID
or health care card was
discussed as a way to
improve coordination of
care, and it met with
much interest. This was
seen as one tool to
streamline the process
of receiving health care.
Some citizens were
concerned that an ID
card could lead to less
personal service from
providers and an
increase in patient costs
while providers paid
for their card-reading
systems. Others
cautioned that insurance
companies could use the
information to penalize
patients and increase
costs. Overall, citizens
were in favor of a health
care card.
Tradeoffs Involving
Cost, Quality, and
Access
1. Coordination of Care vs.
Cost of Care
2. Quality of Care vs.
Increase in Number of
Covered Lives
3. Quality of Care vs. Cost
of Care
4. Access to Care vs.
Increase in Number of
Covered Lives
5. Patient Privacy vs.
Coordination of Care
6. Quality of Care vs.
Medical Lawsuits
7. Physician Autonomy vs.
Cost of Care
8. Increase in Taxes vs.
Increase in Covered Lives
9. Competition vs.
Collaboration

“Malpractice
suits are
just getting
ridiculous.”
“The health care passport idea is good.
It will encourage a better use of the
system.”
Sioux Falls, SD
“I’ve moved several times, and there is
a tremendous advantage to having my
family’s medical records in one place.
This outweighs my fear of other people
accessing my information.”
Sussex, DE
A few comments and a brief dialogue
between citizens shows the connection
and importance of security and personal
service associated with health care.
“It would be wonderful if physicians
and hospitals could share information.
However, every office has different
technology and systems. It would be very
expensive to get everyone on the same
system and keep it up to date. Who
would pay for this?”
Dell Rapids, SD
“If a health care card is adopted, the
primary care provider or a statewide
organization should be responsible for
developing and maintaining a database
of your health care history. Insurance
companies should not be involved.”
Harding, AR
”The health care passport sounds
convenient and could be a lifesaver, as
long as I carry the card and no one else
has access to it.”
“However, I don’t just want to be seen
as a number. The more impersonal the
care is, the more likely they are to miss
something.”
Minneapolis, MN
Quality of Care vs.
Medical Lawsuits
Citizens struggled to determine
whether medical malpractice suits
contributed to the rise of health care
costs or whether they were necessary to
ensure that patients received quality
health care. Many were disgusted with
the number of malpractice suits because
they believed that medical lawsuits
contributed to the rise in health care
costs. However, most realized that while
they are costly and burdensome, they are
necessary to ensure the quality of care.
Ultimately, citizens understand that
patient care, patient access, and costs
are affected by lawsuits.
“Medical lawsuits are necessary to make
a point, but they drive costs way up.
Common sense needs to intervene.”
Sioux Falls, SD
“Malpractice suits are just getting
ridiculous. If you are going to do punitive
damages, give some of the money back
to the system in general. This would
really improve the health care of many
by the mistakes of a few.”
Santa Fe, NM

“I’m willing
to give some
things up or
pay more to
help change
the system.…”
“There should be a cap on malpractice
suits. Physicians are leaving their
practices and this impacts my ability
to receive care when I need it.”
Minneapolis, MN
“Physicians are ordering more tests
than what may be necessary to protect
themselves legally. Now our health care
costs are higher than necessary.”
Madison, WI
“Physicians are being placed in a
position where patient care and access
is being impacted by rising insurance
costs.”
Carbondale, IL
Physician Autonomy vs.
Cost of Care
Participants grappled with who should
determine what kind of health care
patients receive. Many thought health
care decisions should be left to the
physicians who are providing the care.
They did not like insurers controlling a
patient’s coverage. On the other hand,
participants thought that giving all the
control to physicians could drive up the
cost of health care. They cited examples
of physicians who took advantage of
their patients’ health care coverage by
performing expensive tests.
“I want the physician to determine how
long the hospital stay should be, not
the insurance company. We will just
need to make sure all physicians have
guidelines to work within so that costs
do not spiral out of control with
unnecessary procedures.”
Dell Rapids, SD
Increase in Taxes vs. Increase
in Covered Lives
paying more taxes would improve quality
and access to care. Some were willing
to pay more taxes to increase the quality
and availability of health care. However,
they wondered whether it would work.
Others speculated that, in theory, more
money could make health care available
to more people without sacrificing
quality, but if nothing were done to
change the health care system, it might
not be effective. Instead, they would
be contributing more dollars to an
ineffective cause.
“I’m willing to give some things up or
pay more to help change the system, I
just don’t know how much and if it is
worth it. How much will it cost? Will it
really make a difference? We need more
information on this idea.”
Charleston, SC
Competition vs. Collaboration
Several citizens weighed their opinions
to determine whether a more competitive
health care system would lead to lower
costs. Some favored a more competitive
health care system to increase the
quality and drive down the cost. They
compared this theory to the capitalistic
approach used in other industries.
However, other participants noted that
health care is the only industry in which
costs have risen, not declined, because
of competition. Instead, they believed
there should be more collaboration
across the health care system.
“In the past we approached health care
by introducing more competition. It has
not worked. Costs continue to rise.
Why not try collaboration? Why not
work together?”
Minneapolis, MN

Three shifts in thinking occurred over the
course of the forums. The shifts did not
always occur at the same time, and not
all participants demonstrated a shift in
thinking. Some participants dramatically
changed their perception, while others
shifted their thinking only slightly, and
some did not change their perception at
all. Regardless, the areas in which a shift
occurred are listed below.
1. Physician-patient
transaction •
Developing physician
relationships •
Developing relation-
ships with other
aspects of the health
care delivery system.
When participants
first explored the topic
of health care, many
considered it transaction
based. They believed their
role in the health care
system was to visit the
doctor only when they
were sick. Over the
course of the discussion,
many citizens recognized
the value of developing
a relationship with their
doctor. They began to
realize the benefits of
taking a more proactive
approach to care.
Some citizens applied this approach
to the entire health care system and
concluded that patients should develop
relationships with other stakeholders
in the system, such as their health
insurance providers.
Shifts in CitizenThinking
Three Shifts
in Thinking:
1. Physician-patient
transaction •
Developing physician
relationships •
Developing relationships
with other aspects
of the health care
delivery system.
2. General complaints
and blame about the
system • Government
responsibility •
Personal responsibility
3. Unwieldy national
crises • Localized issue •
Citizens can make a
difference.
2. General complaints and
blame about the system •
Government responsibility •
Personal responsibility
The forum began with intense
passion and emotional stories about
how the health care system had failed
participants. Many shared personal
tragedies and complaints and pointed
fingers about who was responsible for
the demise of the health care system. As
the conversations evolved, participants
began to realize that problems in the
health care system couldn’t be attributed
to any one individual or single entity.
They recognized that health care
problems are not always someone’s fault,
but instead, the problems cross the entire
system. As the discussions progressed,
participants began to acknowledge they
were personally responsible for staying
healthy and receiving quality health care.
3. Unwieldy national crises •
Localized issue • Citizens can
make a difference.
At the beginning of the discussions,
many participants felt a sense of doom.
They thought the health care system
could not be improved because the
problem was too big and too complex.
However, as they discussed the issue
further, they began to explore how
providers could improve health care at
a local level. They began offering ways
the health care system could be improved
locally. The conversation, in some cases,
evolved even further to identify ways
individuals could improve the health
care system.

Citizens Are
Frustrated by the
Lack of Action to
Improve the Health
Care System
Citizens recognize there are problems
with the health care system, and many
are frustrated over the unrecognizable
improvements under way. They are
disappointed that other entities in the
system are not making a concerted effort
to better the system as a whole. Many
participants want representatives from
specific health care constituent groups
(for example, insurers, providers, and
policymakers) to be part of further
discussions to ensure action is taken.
Passionate Interest in Improving
Health Care
Citizens were very aware of the
issues facing the health care industry.
Many cited national news stories about
health care in America, demonstrating a
general awareness of the issue. However,
participants were most often able to
relate to the local news and stories about
how community employers were affected
by issues addressed nationally. Many
took the issue one step further by
applying local stories to personal
accounts about themselves or people
close to them who were affected by the
health care system.
Most discussions began with
tremendous emotional and personal
interest and gradually evolved into
more holistic conversations about
better health care and how the health
care industry could be improved to
better society as a whole. Participants
began thinking beyond their personal
experiences and started recognizing the
different components that make up the
health care system. Furthermore, in
Specific Findings
“I would like
to have a
discussion
like this and
include a
medical doctor
and insurer
in the room.”
their discussions, many considered the
points of view of the following health care
system stakeholders:
• Accountants
• Attorneys
• Families
• Government
• Insurance Providers
• Patients
• Physicians
• Schools
After considering other points of
view, numerous participants recognized
the significance of each stakeholder’s
contributions to the health care system.
Many citizens wanted to hear and learn
directly from other stakeholders to make
the deliberative process more meaningful.
“I would like to have a discussion like
this and include a medical doctor and
insurer in the room. I’m sure they have a
point of view I’m not considering.”
Sumter, SC
Overall, the discussions seemed to
forge a greater understanding of the
scope of the problem with the health
care system. Citizens appreciated being
part of the discussions.
Industry Should Be Working
Together
When participants began to identify
the problems in the health care system,
they soon realized the need for change.
Furthermore, they acknowledged that the
multiple stakeholders (patients, families,
physicians, insurance providers, and
others) who comprise the system also
recognize the need for change. This
caused them to feel angry because they
believed no true efforts had been made
to change a system everyone recognizes
is not working properly.
“Our health care system is not set up
to place blame or identify who is
responsible for making changes. Where
does the responsibility to improve it lie?”
Dell Rapids, SD

Specific Findings
Participants
realized that
regardless
of how
involved the
government
is, they as
individuals
are also
responsible
for changing
health care
at a local
level.
From a national perspective, citizens
noted the failure of the health care
reform legislation sponsored by Senator
Hillary Clinton while serving as
First Lady. From a local
perspective, they shared stories
about their insurance providers,
physicians, and community
hospitals complaining about
losing money because of the
health care system, but none
of them had attempted to work
together to fix the problem.
They noted that while the
stakeholders, legislators in
particular, were looking out for
themselves no one appeared
to be working together for the
betterment of the system.
A brief dialogue between
two participants reveals the frustration
with how health care organizations
are not working together to address a
known issue:
“We are all in this together. Health care
professionals, providers, and residents
all want the same thing — better
health care.”
“You are right.… As a country, we are
not willing to have a serious discussion
on this subject. Hillary’s plan was
squashed. It was not even considered.”
Sioux Falls, SD
Other discussions highlighted citizens’
concerns about relying on legislators to
change the system.
“Federal employees have wonderful
health care benefits. How can they relate
to us? Why do we expect them to make
changes to the system?”
“I believe there is too much reliance on
the legislation in our country to make a
difference. Medical providers, insurers,
and pharmaceutical companies are
the biggest founders of legislation. Do
they really act in the best interest of
the system as a whole? Can we really
count on them to work together for our
benefit?”
Estherville, IA
“Our legislators and policymakers get
their health care taken care of. Why do
they get to decide what kind of care I
receive? This seems inappropriate.
Everyone should have a health care
plan as good as their representatives.”
Minneapolis, MN
Personal Sacrifice for Improved
Care for Others
Citizens struggled to determine
whether making a personal sacrifice
would help improve the health care
system. Several participants weighed the
pros and cons of limiting their care or
giving unused portions of their insurance
to help the uninsured. However, most
were unwilling to make a commitment
because they did not believe it would
make a difference, given the current
health care environment.
“I would opt out of some insurance
company benefits to give my neighbor
more health care if I knew [he or she]
would receive it.” Minneapolis, MN
“If I give something up, how do I know it
will actually benefit anyone else?”
Washington, DC
Some citizens were very protective of
their health care benefits, and the idea
of sacrificing their options was new to
many. Even if they did not currently use
all their health care, the concept of giving
up their prized possession made several
citizens uncomfortable.
Two participants had a brief dialogue
that summarized this opinion.
“It is not right for some people to not
have health care and others to have too
much. However, this is such a coveted
benefit, it is difficult for me to give any
part of mine up.”
“As citizens we have not really thought
about what we could and would let go of
in order to have quality of care for more
people. The idea seems so foreign and
very scary.”
Norman, OK

Specific Findings
“The system
is so
complicated,
if we make
a change,
we really
don’t know
what will
happen
long term.”
Unknown Effects of Changing
the System
The conversation among participants
often evolved into questioning how any
change, such as giving up portions of
their health care, would affect the overall
health care system. Participants thought
the system was so complex that it
would be difficult to understand the
long-term effects brought about by any
modification. Even if change were made
with good intentions, participants
thought the system was so convoluted
that it would be difficult to understand
how any change affected it. This does
not mean participants did not want
change, just that they were unsure what
would happen if changes occurred.
“The system is so complicated, if we
make a change, we really don’t know
what will happen long term. What else
will occur that we cannot predict?”
Washington, DC
“A small change in one part of the
system will have unknown ripple effects.
Any changes that are made will likely
have larger consequences we cannot
predict. We need to proceed but proceed
with caution.”
Carbondale, IL
Personal Accountability and
Responsibility, Along with
Government Interaction
Citizens believe that though personal
accountability and responsibility
are critical for change to occur, the
government must take an active role in
the process of changing the health care
system because of the size of the issue
and because the government regulates
Medicare and Medicaid. However,
opinions varied as to the degree of
government involvement. Some wanted
the federal government to have total
control of the health care system, while
others wanted only minimal control even
at the local level. In addition, participants
also realized that regardless of how
involved the government is, they as
individuals are also responsible for
changing health care at a local level.
“We are all responsible for making
the health care system better. The
government will need to be involved
because they have control at a state
level. However, we (the people) are
the government, and we can make a
difference if we try.”
Minneapolis, MN
“Local government needs to solve issues
ourselves because we don’t believe
people at the federal level will ever come
together to solve this real issue. We
cannot hold our breath and wait for
others to change things.”
Estherville, IA
“We need a local champion, not the
government, to keep the momentum.
If no one leads the charge locally, this
will go nowhere.”
Norman, OK
“Having the government change the
system will be like waiting for a glacier
to melt. It will eventually happen, we just
don’t know when and we may not be
around when it happens.”
Charleston, SC
In addition to citizens being personally
responsible for making changes to
the health care system at a local level,
many participants commented that
they as individuals needed to be more
accountable for their own health care.
The belief is that the more control people
take over their health care, the more
responsible they will be with their health
care resources.
“People just need to take responsibility
for themselves.”
Santa Fe, NM
“Each person should ultimately
be responsible for deciding what care [he
or she] need[s]. People need to take
greater responsibility for their health.”
Ellensburg, WA

Specific Findings
Citizens
acknowledge
that multiple
organizations
and
components
are part
of the health
care system.
The following dialogue between two
participants reveals citizens’ interest in
being more responsible for their health.
“People go to the doctor too soon. We
overmedicate. This creates unnecessary
expense and immunity to diseases. Long
term this will put more stress on the
health care system.”
“If we just did the simple things
ourselves, it could improve the entire
system. If everyone drank a big glass
of water every day, who knows how
healthy we would be!”
Youth Development Center, SD
Citizens Want an
Ombudsman to Help
Them Navigate the
Health Care System
Citizens acknowledge that multiple
organizations and components are part
of the health care system and each
deserves both credit and blame for the
current status of health care in America.
Citizens do not, however, understand the
health care system as a whole. Many
want an entity or individual to personally
help guide them through the complete
process from first accessing care through
payment for services.
Absence of a Global Perspective
Though participants attempted to
understand the health care system
through deliberation and by examining
other points of view, the process still
raised numerous questions and
concerns. It appeared as though the
more participants discussed the topic,
the more they realized they did not
understand the health care system well
at all. Some believe the United States
does not have a health care system, just
components they access when they need
them. Others believe there is a system
but that no one knows how to navigate
it because they are missing a global
perspective.
During this portion of the deliberative
process, the interaction often moved
from between the participants and the
moderator to an interactive discussion
among participants.
“We always look at health care in
tunnels. We never look at it as an entire
system for the holistic needs of the
people.”
Estherville, IA
“I think there is a health care system
in the United States. It’s complex,
inefficient, and in places broken, but
there is a system.”
Norman, OK
“I don’t see it as a health care system.
Health care is a service I access through
my employer.”
Oklahoma City, OK
A brief dialogue between participants
revealed different opinions about the
same frustrations.
“There is an assumption that there is
a health care system in place already.
If this is true, it’s up to each person
to figure it out.”
“I believe all the components of the
health care system are there; they have
to be for how much health care costs.
It’s figuring out how to access them and
move between the components that is
the challenge.”
Minneapolis, MN
Defining Industry Terms
Part of the confusion is a result of
inconsistent definitions for many
industry terms. While attempting to
examine health care, participants noted
that the industry uses terms that evoke
different meanings among people, which
caused them to become confused. For
example, they questioned the word
“access” and determined that “access” to
health care could have several meanings.
One person might think “access” means

Specific Findings
Common terms
that confuse
citizens:
• “Access”
• “Necessary care”
• “Provider”
“I work the system by going to the
emergency department. If I took the
proper route, it takes me all day to get
an appointment. However, if I go to the
emergency room, it is more expensive,
but someone will see me.”
Sioux Falls, SD
“I’m constantly trying to navigate the
system and work it in my favor. It seems
like a big game, but I am gambling with
my health.”
Minneapolis, MN
“Emergency rooms eliminate the need to
understand the health care system. You
don’t have to find a doctor, worry about
insurance, or even make an appointment.
Sure it is expensive, but the convenience
is hard to beat.”
Dell Rapids, SD
“I go to Canada for drugs. I feel like I’m
doing something illegal and could go to
jail. This does not seem right. I don’t
want to feel guilty about making sure my
family and I are healthy.”
Minneapolis, MN
Unqualified for Personal
Accountability
Citizens became increasingly
frustrated when discussing their
personal role in the health care system.
They think patients have to take an
active role in a process they do not
understand to ensure they get the care
they need and are not overcharged.
They believe patients are held personally
accountable (since they receive a bill)
for identifying and fixing problems they
encounter, even though they are not
responsible for the problem. For
example, if patients experience a denial
of an insurance claim, they have to
fix the problem themselves, even if
they do not understand the system
or did not cause the problem.
affordability. Another person could
apply “access” to being insured.
Someone else might think it means to
be geographically accessible to care.
Other questionable terms were
“emergency,” “necessary care,” and
“provider.” Citizens noted that the
definition of “emergency” is relative,
based on an individual’s perception.
They examined the word “provider,”
which could refer to nurses, physicians,
or insurers. Citizens concluded that
having terms with multiple meanings
is a significant problem the health
care industry should address before
undertaking any change.
“The definition of necessary care and
emergency care is completely dependent
on the individual.”
Santa Fe, NM
“Everyone needs to agree on the same
vocabulary. Otherwise, who will know
what everyone is talking about?”
Dell Rapids, SD
Abusing the System
While participants wanted to follow
the appropriate processes when seeking
care, several admitted to manipulating
the system to receive their care in a
timely fashion. Participants admitted to
learning and using phrases to get an
appointment more quickly. For example,
they would learn and use a buzzword
such as “chest pain” that is used to
describe a life-threatening emergency.
As a result, they would be given a higher
priority and reduced waiting time for the
doctor. They also admitted to going to
the Emergency Room for care, even
though it was not necessary because
they wanted their problem addressed
more quickly. Others revealed their trips
to Canada and Mexico to purchase
prescriptions. Citizens acknowledged
their behavior was not ideal (some were
even embarrassed), but they did not
appear willing to change until the rules
and regulations of the health care system
made sense for their family.

Specific Findings
“The billing
system puts
the burden
on the patient
to create
efficiency.
It’s up to me
to straighten
things out.”
Physician Impact on
Citizen Opinion
Adding to participants’ confusion,
several noted, was the direct impact of
their physician’s opinion of the health
care system. Many participants place
trust in their doctors and rely on them
as their sole advocate in navigating the
health care system. When a doctor
shares his or her lack of confidence in
the system or process with a patient,
then the patient’s confidence erodes.
This creates even more bewilderment.
“I don’t believe anyone is acting in
my interest except my primary care
physician. However, even they are having
difficulty with the system.”
Oklahoma City, OK
“Many health care providers don’t
know their way around the system.
Their frustration rubs off on me.”
Minneapolis, MN
Better Communication and
Collaboration Needed throughout
All Health Care Entities
Citizens suggested several actions
to improve communication and
collaboration within the health care
system. The actions are aimed at
improving the patient experience, and
participants recognize these actions may
lead to an increase in cost. Steps such
as increasing the number of midwives,
dieticians, and nutritionists to support
patient care were suggested. Also,
encouraging patients and physicians
to form stronger partnerships, founded
in education, was thought to lead to
better health care and a healthier
population.
Participants were frustrated because
there is no entity that fully understands
the system and can advocate on their
behalf. This frustration has led some
citizens to take a more active, and more
risky, role in their health care.
“Billing issues are one of the greatest
sources of confusion. They are also the
most stressful. The billing system puts
the burden on the patient to create
efficiency. It’s up to me to straighten
things out. I’m the least qualified to
navigate the billing system.”
Sioux Falls, SD
“It takes a lot of time to take care of
payments. I feel I am on the edge of
being taken advantage of. I don’t want
to overpay or not pay enough. This is a
very stressful situation.”
Norman, OK
“I want to be a partner (in the health care
process), but I am uncomfortable that
doctors and insurers will always act in
my best interest. I don’t trust the system
to take care of me.”
Oklahoma City, OK
“Complementary payments, referrals for
care, limited stays in hospitals, limited
benefits … it is a full-time job for people
to sort out care for themselves and their
family. One minute you understand
whom to call. The next it changes. It
keeps you off balance as you sort
through the health care maze.”
Ellensburg, WA
“The system has created so many
obstacles and barriers, people are
starting to organize their own care to
make sure they get what they believe is
best for them. Many are willing to risk
not knowing what they really need in
order to have some sense of control.”
Philadelphia, PA

Specific Findings
Given the
restrictions on
physician
time, numerous
participants
suggested using
other health
care experts
(nurses,
dieticians,
nutritionists,
and others)
to help with
education,
communication,
and
collaboration.
Supporting Physicians with
Other Health Care Professionals
The topic of physician/patient
partnerships often led to deliberation
about the role of other health care
professionals in the health care system.
Given the restrictions on physician
time, numerous participants suggested
using other health care experts (nurses,
dieticians, nutritionists, and others)
to help with education, communication,
and collaboration. These other
professionals are thought to be experts
at navigating the system, and they
have the added benefit of providing
quality patient care.
“Dieticians, nutritionists, and physician
assistants need to be in place to increase
education. We do not have enough
doctors to begin with, so let’s use other
resources to help educate patients.”
Carbondale, IL
“Nurses and midwives could be used
to educate and care for people in the
community.”
Ellensburg, WA
“Professional nurses should be included
in the process of increasing preventive
services.”
Sioux Falls, SD
“If physicians do not have time, care
could be provided through schools if local
clinics partner with school nurses.”
Norman, OK
Physician and Patient Partnerships
Most participants understood the
value and would appreciate having a
good relationship with their physician.
However, they also acknowledged how
physician time and payment limitations
hinder this opportunity. They fear that
with a true physician/patient partner-
ship, authority and accountability are at
risk. Also, several citizens commented
that patients would need to be more
active in the health care process if a
partnership were developed.
“Having a partnership with my physician
is easier said than done. The current
health care environment restricts whom I
can see and how long they can spend
with me. There are too many demands
on my doctor’s time to develop a true
relationship with me.”
Santa Fe, NM
“This will never truly be a balanced
partnership. Some people won’t
participate. Others will ignore advice.
When the physician has all the
knowledge, there really is no balance.”
Harding, AR
“The patient must be capable of helping
or participating in decisions about their
health. Education levels will need to be
increased for this to occur.”
Carbondale, IL
“Having a partnership is a great idea.
But who is the final expert? Who has the
final decision? Out of everyone in the
health care system, who is the most
qualified to provide the best advice?”
Ellensburg, WA
“If the patient and physician have the
opportunity to develop a relationship, it
will result in better care. However, this
relationship takes time to develop. Why
can’t we afford something like this that
seems like a no-brainer? We know it’s
right. The physician knows it’s right.
Even the insurance company knows it’s
right. Why don’t we work together and
do it then?”
Minneapolis, MN
Corbis

Specific Findings
“Doctors should not be told what types
of care they should provide. Insurance
companies are dictating the types of care
people receive. People don’t feel you can
partner with an insurance company.”
Santa Fe, NM
reveals that citizens believe insurance
companies have too much authority
in health care decisions. Citizens also
believe that if insurance companies
really wanted to improve the system,
they have the resources to do so.
“Insurers should get out of the way
and let the doctors decide what care is
needed.”
“If they want to make a difference in
the system, what if they did not send
me ten pieces of paper each month, but
instead, had a nurse call me each
quarter to make sure I was following
instructions and staying healthy?
I think the call is much more helpful
than a newsletter.”
Minneapolis, MN
Another short discussion reveals that
citizens link medical lawsuits to higher
insurance company premiums. There is
a desire to control lawsuits and stabilize
insurance premiums.
“As an employer, it is difficult to afford
offering insurance to my employees.
It’s too expensive. However, I lie awake
at night thinking of the consequences of
not offering them some sort of coverage.”
“What if there [were] a cap on medical
lawsuits? Would this not allow
physicians to offer services at lower
rates? I’m not sure they would always
pass along these savings, but in
theory it makes sense.”
Dell Rapids, SD
revealed that participants do not believe
education has to come solely from their
physicians.
“Physicians could serve as the
information conduit for the system.
However, this increase in responsibility
would reduce the number of patients
they can see.”
“What if interns were placed in physician
offices to help with education and
communication?”
Sumter, SC
Insurance Company and
Pharmaceutical Company
Partnerships
As in previous research, insurance
companies and pharmaceutical
companies are criticized for restricting
patient access and increasing the cost
of care, respectively. Citizens do not
believe these companies are interested
in a partnership. However, they believe
they are an important part of the
partnership concept and could use their
resources more effectively to improve
health care if they so desired.
“For a partnership to work within the
health care system, all parties need to
have a mutually beneficial relationship.
We already have patients developing
relationships with physicians and
physicians with hospital relationships,
but no one seems to have a good
relationship with insurers. This is where
the idea of partnership will have
trouble.”
Charleston, SC
“Who is in control of our health care
system? It’s not the doctors. It’s the
pharmaceutical companies and insurance
companies. One is making medical
decisions for us and one is increasing
demand for care. They do not seem to
want to be a partner with anyone.”
Harding, AR

Specific Findings
Citizens Suggest
Rewarding Healthy
Behavior and
Penalizing Unhealthy
Behavior
Citizens believe preventive care should
be acknowledged and rewarded since it
should lead to a reduction in health care
costs. They believe the current health
care environment is focused on reacting
to existing health problems instead of
rewarding those who take a proactive
approach to anticipate personal health
problems. Many suggested incorporating
a system that rewards people who take
precautionary health care measures and
behave in a healthy manner. Many also
suggested enacting a financial penalty for
those citizens who knowingly behave in
an unhealthy manner.
Preventive Care Should Be
Encouraged by Insurance Providers
Citizens believe preventive care should
be acknowledged and rewarded since it
should lead to a reduction in health care
costs. Many citizens believe the industry
is too fixated on the treatment of illness.
They would like more focus on prevention
and education. Specifically, they would
like preventive care to be covered by their
insurance. There is a widely held belief
that proper education and prevention
could lessen the demand on the health
care system. Citizens also discussed
altering the reimbursement process so
that physicians were paid for having
healthy patients.
“If they want
to make a
difference
in the system,
what if they
did not send
me ten pieces
of paper each
month, but
instead, had
a nurse call
me each
quarter.…”
Ombudsman or Advocate
Organization Needed
Numerous citizens suggested the need
for one entity that could be responsible
for the entire health care system and be
an advocate on behalf of patients. They
believed that each stakeholder in the
health care system looked out for itself
and that no single entity looked at the
big picture. Citizens discussed the
creation of an oversight organization to
serve as an ombudsman among all the
stakeholders, especially patients. The
advocacy organization would be charged
with understanding all the components
that comprise the health care system.
The organization could help all the
stakeholders navigate the health care
system.
“There will always be someone who will
abuse the system. We need someone or
some organization to oversee people’s
health care.”
Minneapolis, MN
“People need health care advocates,
someone to chaperone them through
the health care process. This will be
expensive at first. But long term it could
improve health care, increase access,
and save money.”
Estherville, IA
“The system is so fragmented now that
it is too intense to navigate. No one ever
tries to coordinate what is in the best
interest of patients. People are too busy
doing what is mandated or regulated to
do what makes common sense. A patient
advocate could help people receive better
care.”
Dell Rapids, SD
“Ombudsmen should be built into the
health care system to review all aspects
of individual patient cases and identify
where the system may be breaking
down.”
Carbondale, IL

Specific Findings
Many believe
education
will not be
enough to
change
behavior
because there
are no
financial
consequences
for being
unhealthy.
“People need information about the
impact their lifestyle has on their health.
It should be infused into their curriculum
at grade school. Well-educated children
can be healthier.”
College Park, MD
“Many people think that education is
the key to healthier people. Do we really
think we are smart enough to educate
people and change their behavior to eat
better and exercise more? It’s no mystery
that smoking kills, yet we have more
people smoking now than ever before.
Instead of educating the abusers,
let’s reward those who act healthy.”
Estherville, IA
“Education does not always change
behavior. We have seen many attempts
and lots of money spent on education
that results only in minimal change.”
Dell Rapids, SD
“People have the right to behave anyway
they want. They can disagree with
recommendations from their doctor and
do their own thing. Our ability to choose
ultimately impacts the success of any
health care programs.”
Dell Rapids, SD
Rewarding Healthy Behavior and
Penalizing Unhealthy Behavior
A complement to the point of view that
prevention is critical is that participants
feel passionately that people who
engage in unhealthy behavior should be
penalized. In general, individuals who
knowingly act in an unhealthy fashion
should be held accountable by paying
more for their health care. While
additional discussion is needed to reach
consensus on determining specific
actions for which people could be held
accountable (for example, being
overweight and smoking), many believe
individuals should pay for care based
on a tiered approach. Those who
participate in unhealthy behavior should
be responsible for paying for care
“Why won’t insurance companies pay for
preventive care? Why do I have to be
sick to get anyone to care about my
health?”
Oklahoma City, OK
“Preventive medicine is not covered or
reimbursed. I am sure doctors would
rather get paid to keep people healthy
than to treat them when they are ill.”
Estherville, IA
“The current health care system pays
hospitals and doctors when you are sick,
not when you are well. Health care
professionals need to be paid for keeping
people healthy.”
Dell Rapids, SD
“A true health care system includes more
than just receiving care when you need
it. It needs to promote a healthy lifestyle,
education, and prevention.”
Madison, WI
A conversation between two
participants illustrates the desire for
more education and preventive health
care programs.
“We don’t have a health care system for
those who are educated and healthy.”
“I agree; the current system is for sick
people. The ideal health care system is a
combination of prevention, education,
insurance, and hospital care.”
Ellensburg, WA
Skepticism about Health Care
Education
Despite an interest in following an
educational approach to lessen the
burden on the health care system, forum
participants demonstrated significant
skepticism about the potential
effectiveness of current educational
practices. Many believe education will
not be enough to change behavior
because there are no financial
consequences for being unhealthy.

Specific Findings
Individuals
who knowingly
act in an
unhealthy
fashion should
be held
accountable
by paying
more for their
health care.
Struggling with “Appropriate Care”
for Everyone
Most citizens believe every person
should have access to some level of
quality health care but believe employers
and taxpayers should not be additionally
burdened with paying for this care. A
common definition of a minimum, or an
acceptable, amount of health care still
needs to be “worked through.”
While almost every participant agreed
it would be nice for everyone to have
access to some level of quality health
care, there were mixed reactions to
whether or not health care was a right
of every citizen. Several participants
commented that “just because we have
such good health care resources, it does
not mean everyone can and should use
them.” Setting expectations about what
type and quantity of health care people
can have access to was important to
participants.
Everyone was concerned over how to
pay for health care for more citizens.
Many were not willing to bankrupt the
current system to extend care to more
people. And others commented that
raising taxes or asking employers to pay
more was not appropriate since they are
burdened enough. There was also a belief
that unless the health care system was
changed dramatically, applying more
money to the same system would not
lead to better care.
beyond a “normal amount.” And, those
who participate in healthy activities
should be rewarded for their efforts.
They noted the current health care
system does not acknowledge or reward
those who live a healthy lifestyle.
“Insurance companies try to encourage
healthy behavior with lower premiums.
What if the state or my employer did the
same?”
Oskaloosa, IA
“I resent paying more and paying for
people who smoke and have unhealthy
lifestyles.”
Minneapolis, MN
“People with addictions use a lot of
health care. Who should pay for those
who do not take care of themselves?”
Santa Fe, NM
“Some people drink, smoke, and do
drugs. They will never be partners in the
system. They will only abuse it. They
should pay more.”
Dell Rapids, SD
“There are many people who make bad
choices in life and have more health care
costs because of this. Why should I have
to pay more if I am healthy and take care
of myself?”
Madison, WI
“Citizens should pay for care based on
a graduated payment plan.”
Sumter, SC
“Everyone should understand the
importance of making responsible
decisions. Paying more for irresponsibility
would help in the learning process.”
Madison, WI
“There needs to be some sort of
consequence for those who choose to
engage in unhealthy behavior, possibly
charging higher insurance rates.”
Dell Rapids, SD

Specific Findings
“We expect
the best care
possible. As
a country, we
cannot afford
the best care
for everyone.”
A dialogue between two participants
reveals deep concern over both the
allocation of health care resources and
the financial burden associated with
offering care for more people.
“How much care can you give and still be
financially viable? Where do you draw
the line? What are the criteria you use to
determine who gets what care?”
“We can’t go broke saving lives. The
country should not be willing to accept
financial crises to give more people care.”
Santa Fe, NM
“How do you determine how much to
spend on each person? Who determines
what is necessary and what is vital?
These are questions that need to be
addressed, but many are not qualified
to answer.”
Youth Development Center, SD
Discussion among multiple partici-
pants shows the difficult dilemma
citizens struggle with when discussing
who can receive care and how much
care they should have access to. No
consensus was reached on this topic.
“We expect the best care possible.
As a country, we cannot afford the best
care for everyone.”
“Half a person’s health care costs occur
in their last 30 days of life. How
do you decide when and when not to
provide care?”
“But should we put people lower on the
list [to receive care] because they choose
unhealthy lifestyles? Somehow we have
to prioritize.”
Estherville, IA
“We need to rethink costly procedures
that prolong life for short periods of time.
Heroic procedures for those who will
not benefit long term are a source of
great controversy.”
Norman, OK
The deliberation surrounding
responsibly allocating health care often
led to a discussion about whether
denying care is appropriate, and if so,
“The United States has enough health
care capacity to care for every citizen
already. The resources are already in
place. We just need to manage it better.”
Carbondale, IL
“Health care should be considered a
national right. Without health, you cannot
pursue happiness, and this is in our
Constitution.”
Minneapolis, MN
“Health care is not a right. We are a fee-
for-service economy. Those who want
something realize they have to pay
for it.”
College Park, MD
“We need to examine our expectations of
health care and the health care system in
America. Are they realistic?”
Harding, AR
A brief dialogue between two citizens
reveals how a definition of basic care or
coverage is necessary before an in-depth
discussion of a national health plan
can occur.
“We don’t need socialized medicine.
Medicaid is already available. I would
like to see more universal care.”
“Before we do this, we really need to
decide what the definition of coverage is.
We could all have basic coverage. But
what constitutes “basic”?
Charleston, SC
Appropriate Use of Resources
everyone should receive all the health
care he or she needs. They recognized
that the United States has the best
health care in the world but debated
whether that meant all care should be
made available to everyone in the
country. No solution was reached.
However, there was universal concern
over how to pay for care for more
citizens, and many participants were
nervous about how to responsibly
allocate available health care to those
who need it.

when care should be denied. Citizens
discussed the moral and ethical
dilemmas health care stakeholders face.
They questioned whether health care
should be denied to someone because
of age or health status. They also
confronted whether a price tag should
be put on human life. In the end, no
citizen was willing to take a stand or
offer a solution to this highly
controversial topic.
Tension exists and citizens struggle
with how to approach individuals with
preexisting conditions and conditions
they cannot control. Some believe that
since these individuals will require
more resources than others they should
pay more for their care. However, most
recognized that these issues were
beyond people’s control and they should
not be held financially accountable
for something they cannot control.
Most believe this point deserves more
discussion by all health care
professionals.
Citizens also grappled with whether
people predisposed to health problems
should be penalized and asked to pay
more because they will have more health
care needs. While many thought this was
an unfair practice, most participants
were not willing to personally financially
supplement the additional costs to cover
those predisposed to health problems.
Specific Findings
“I would like
to have care
for everyone,
but I am tired
of paying
more each
year for the
same care I
currently
receive.”
Universal Health Care System
Overall, participants agreed that they
would like everyone in the United
States to have health care and that a
universal health care system was one
option to consider. However, most
believed employers and the general
public should not have to pay for it.
They believe these groups are already
paying for health care for many and
should not be penalized by paying
more to ensure everyone else has
health care coverage. Due to the
length of most forums, this section of
the issue book did not receive as
much time for discussion as others.
“I would like to have care for everyone,
but I am tired of paying more each year
for the same care I currently receive.”
Oklahoma City, OK
“How would you pay for universal health
care? There is no universal health care
system that runs in the black.”
Santa Fe, NM
“I like the concept, but offering care to
everyone will make the working adults
pay more for others without jobs.”
Dell Rapids, SD

Common Ground for Action
Though various points of view, ideas,
and topics were discussed, citizens
reached consensus on several issues
regarding the health care system in the
United States. In general, citizens
believed that since a big change to the
system may not occur, many little
changes might create incremental
improvement.
• Regardless of each
person’s approach
to solving problems
across the health
care system, every
one agreed that
health care will not
improve unless
everyone and every
organization
involved is held
individually
accountable.
• All participants agreed that
government would need to play
some kind of role in improving the
health care system.
• Everyone believes that the system
would take too long to change if the
change occurred from the top. They
agreed that change needs to happen
from the bottom up. In other words,
change needs to occur at the local
level.
• All participants had an interest in
improving the health care system.
None wanted it to remain the same.
• Health care will
not improve unless
everyone and every
organization involved
is held individually
accountable.
• Government would
need to play some
kind of role in
improving the health
care system.
• The system would
take too long to
change if the change
occurred from the
top.… Change needs
to occur at the
local level.
• All participants
had an interest in
improving the health
care system.
Corbis

Several Action Steps Are Considered
Deliberation seems to have created a
connection among a number of health
care issues. For many participants, the
discussions appeared to support their
perspective that the health care system
is reaching a crisis point.
During the deliberation process,
participants offered ideas and potential
actions to address parts of the issue.
These suggestions usually did not evolve
into significant conversations but were
of interest to the group in which the
topics were raised. The ideas for
potential action included:
Public Policy at the State or Federal Level
• Share personal concerns with
legislators/representatives.
• Draft petitions that explain
frustrations with insurance
companies.
• Send local representatives to
Capitol Hill to promote changes
to the system.
• Develop fact sheets that show
health care’s impact on and
importance to each local
community.
• Research “socialized medicine”
health care systems to find best
practices and suggest a pilot
program within the United States.
Local or Personal Actions
• Hold and attend more forums
on the subject, and involve
community leaders and health care
professionals in the discussions.
• Pay more attention to national and
local health care issues and how they
may have a personal impact on area
families.
• Promote local health care successes
so others can learn from good fortune
and best practices.
• Develop a “new resident to the
community” program to educate
newcomers about the local health
care system and how to access it.
• Respond to community health needs
faster.
• Learn more about the health care
system and environment in general.
Additional education was thought to
lead to more ideas.
• Begin an initiative to improve
health care education in local school
systems. The program could
encourage children to be healthier.
• Suggest local schools make their
lunches healthier. Partnering with
area hospitals to provide more
nutritious meal ideas to schools
could be helpful.
• Train local doctors to be well versed
on prevention and education, in
addition to their training on treating
the ill.

Methodology
The following five research
methods were used:
Issue Book Framing Committee
Interviews
• Barb Brown
• Patty Dineen
• Betty Knighton
• Renate Pore
• Taylor L. Willingham
• Ruth Yellow Hawk
Moderator and Convenor Interviews
• American Association of Family and
Consumer Sciences (AAFCS),
Alexandria, VA
• Avera Hospital, Dell Rapids, SD
• Center for Community Leadership
Development and Public Policy,
Montgomery College, Montgomery, MD
• Central Washington University,
Ellensburg, WA
This report is based on an analysis of what happened in 40 of the hundreds of
National Issue Forums that have taken place, and continue to take place, on this issue
across the United States. It describes what happened as diverse groups of people came
together and deliberated about issues related to health care. Forum participants
represented in this report came from the states indicated on the map.
• ChangeWorks of the Heartland,
Columbus, OH
• Custer Youth Development Center,
Pierre, SD
• East End Listening Project, East End
Family Resource Center, Charleston,
WV
• Estherville Community Center,
Estherville, IA
• Florence County Library, Florence, SC
• Harding University, Searcy, AR
• Iowa State University Extension,
Ames, IA
• Learn and Serve America, Project 540,
Oklahoma State Department of
Education, Oklahoma City, OK
• Mahaska County Extension,
Oskaloosa, IA
• Mahaska County ISU Extension
Auditorium, Des Moines, IA
Appendix

Moderator and Convenor Interviews
(continued)
• Minnesota Humanities Commission,
St. Paul, MN
• Norman Planning Committee, Norman
Public Library, Norman, OK
• Root Cause, Austin, TX
• Santa Fe Community College,
Santa Fe, NM
• Skyway Senior Center, Minneapolis, MN
• Sumter County Library, Sumter, SC
• Sussex County Librarians, Sussex, DE
• The Columbus Council for Public
Deliberation, Columbus, OH
• The South Dakota Issues Forums,
Sioux Falls, SD
• Tri-County Rural Health Network’s
Community Connectors, MO
• University of Hawaii, Manoa, HI
• University of Maryland Extension
Program, College Park, MD
• University of Maryland,
College Park, MD
• Washington Affiliation of Family
Community Service (WAFCS)
• West Virginia Center for Civic Life,
Charleston, WV
Forum Observation
• Avera Hospital, Dell Rapids, SD
• Avera Hospital, Sioux Falls, SD
• Iowa Community Center, Estherville, IA
• Skyway Senior Center, Minneapolis, MN
• Worthington Public Library,
Worthington, OH
Questionnaire Results
After the forum, participants were asked
to complete a questionnaire that frames
the issue and identifies key tradeoffs for
different choices. In preparing this report,
Paul Werth Associates analyzed the 1,027
surveys received by May 12, 2004.
Moderator Reports
• Avera Health, Health Care Report, Dell
Rapids, SD
• Class IX of the Randolph County
EXCEL, Inc., MO
• Democratic Deliberation: Our Delta
Experience, The Tri-County Rural
Health Network’s Community
Connectors, MO
• Examining Health Care, Mahaska
County Health Care Forum, IA
• Examining Health Care, Norman
Planning Committee, Norman Public
Library, Norman, OK
• Examining Health Care, Northwest
Library, Columbus, OH
• Examining Health Care,
State College, PA
• Examining Health Care, Sussex County
Librarians, August 21, 2003,
Georgetown, DE
• Examining Health Care, The Columbus
Council for Public Deliberation,
Columbus, OH
• Examining Health Care, University of
Hawaii, College of Social Sciences,
Manoa, HI
• Iowans Talk About Examining Health
Care: What’s the Public’s Prescription?
Iowa Partners in Learning,
Des Moines, IA
• Report for Council on Public Policy
Education Cooperative Agreement (Ref.
25.30.05), University Extension,
Missouri Community Development,
Columbia, MO
• Report on Health Care Forums in
Texas, Austin, TX
• South Dakota Issues Forum Report,
Aberdeen, SD
• The American Association of Family
and Consumer Sciences (AAFCS) Public
Policy Committee, Alexandria, VA
• West Virginia Center for Civic Life,
Charleston, WV
Special Thanks to:
Sue Adams, Kellen Barnhart, Priscilla
Bondhus, Don Bower, Bonnie Braun,
Judy Breiland, Barb Brown, Jane
Cunningham, Dave Dillon, Patty Dineen,
Lloyd Eisenberg, Karen Felton, Sadie
Flucas, Steve Herminghausen, Sandra
Hodge, Helen Jenkins, Janelle Jones,
Chris Kloth, Betty Knighton, Sue Miles,
Patty Miley, Amy H. Nossaman,
Dave Patton, Renate Pore, Julie Pratt,
Lisa Pryor, Bruce Robb, Mary Ellen
Saunders, Michelle Scott, Douglas
Scutchfield, M.D., Harris Sokoloff,
Meredith Southerd, Roxanne Trees,
Kristi Wagner, David Wilkinson,
Sue E. Williams, Taylor L. Willingham,
Beth Wilson, Ruth Yellow Hawk
Appendix

Appendix
Questionnaire Results: Demographics
Below are summary statistics that describe the participants. Percentages may not total 100 due to rounding.
Table 1
Percent
of Total
Your employer 54%
Medicare 18%
Medicaid 2%
You/Self-pay 35%
Other 1%
I have no health insurance 5%
No answer 6%
* Participants can select more than one option. Therefore, the total is greater than 100 percent.
Table 3
Table 2
Percent
of Total
Rural 16%
Small town 41%
Large city 19%
Suburban 19%
No answer 6%
Percent
of Total
17 or younger 3%
18-30 17%
31-45 16%
46-64 39%
65 or older 22%
No answer 4%
How old are you?
Where do you live?
Who pays for your health insurance?*

Appendix
Table 8
Are you thinking differently about this issue Percent
now that you have participated in the forum? of Total
Yes 41%
No 48%
No answer 11%
Table 7
In your forum, did you talk about aspects of Percent
the issue you had not considered before? of Total
Yes 67%
No 24%
No answer 9%
Table 6
Percent
of Total
1-3 82%
4-6 6%
7 or more 3%
Not sure 4%
No answer 6%
Table 4
Percent
of Total
African American 4%
Asian American 2%
Hispanic 2%
Native American 3%
White/Caucasian 81%
Other 3%
No answer 6%
Table 5
Percent
of Total
Male 30%
Female 65%
No answer 5%
How many forums have you attended?
Are you male or female?
Race

Appendix
Movement between Issues Was Primarily Complementary
Throughout the course of the forum, participants engaged in fluid discussion
with minimal disagreement. For example, the options offered in the issue book were
discussed with no significant controversy. Because all the options presented were
thought to be complementary, participants did not need to debate over which one to
choose.
The Issue of Health Care Was Too Large for a 90-Minute Discussion
Because of the complexity and the magnitude of issues surrounding the health care
industry, participants were not able to thoroughly address the issue in a 90-minute
forum. Because the first third of many forums was spent bringing everyone up to
speed with the industry and its issues, the forum primed participants for further
discussion. Some participants suggested a series of three forums on the topic. Each
forum would tackle one approach.
Localized Stories Have More Impact Than National Statistics
National stories about issues in health care made little or no impact on participants.
Instead, local and personal stories piqued their interest and created very emotional
responses.
Much Interest in Opinions from Different Perspectives
Participants and moderators were interested in learning the opinions of those
in areas with unique health care needs. For example, they would like to seek the
opinions of those affected by health care in Florida, Texas, and the West Coast —
all of which have unique health care environments. In addition, participants were
curious about the views of African Americans, Hispanics, and people from other
diverse ethnic backgrounds who were not equally represented in the forums.
Almost everyone who participated had access to health care. Very few admitted to
not having access to care when they needed it. Citizens would like to involve in future
discussions those who do not have health care.
Other Notables

Appendix
The issue book contained a single questionnaire that participants were asked to
complete at the end of each forum. In the following tables, we provide the tabulations
from the 1,027 questionnaires completed as of May 12, 2004.
Please note that those who filled out a questionnaire were a self-selected group
and thus the findings should not be construed as polling data. These results should
be interpreted in the context of the qualitative analysis presented in this report to
understand better how a particular diverse set of Americans felt about health care
after deliberating the issue.
Analysis of Post-Forum Questionnaires
Overall, participants in the forums believe that citizens should have access to some
kind of health care insurance or coverage and that doctors should treat their patients
as partners in their health care. This is directly supported by discussions occurring
throughout the forums. Of note is that while citizens believe Americans should have
some kind of health insurance, there are mixed opinions on the need for universal
care and how this coverage should be paid for.
A little more than half of the participants believe minorities do not receive the
same quality of care as whites. Primarily African Americans and Hispanics believe
there is inequality in care. Also, African Americans, more so than other races, believe
patients often have no one to oversee their entire health care experience. Nonwhite
participants more strongly favor the public having access to information about
doctors’ mistakes.
Percent Percent Total
“Somewhat “Strongly Percent
Agree” Agree” “Agree”
23% 69% 92%
30% 61% 91%
38% 50% 88%
30% 53% 83%
41% 37% 78%
32% 25% 57%
Do you agree or disagree with the statements below?
All Americans should have some kind of health insurance.
Doctors should treat patients as full partners in their
own health care.
Patients dealing with many parts of the health care system
often have no one to oversee the whole picture.
Huge malpractice awards are driving up the
cost of health care.
The public should have easier access to information
about doctors’ mistakes.
Regardless of income, minorities do not receive the
same quality of health care as whites do.
Table 1
Level of agreement on key issues facing the health care industry

Appendix
Percent Percent Total
“Somewhat “Strongly Percent
Favor” Favor” “Favor”
33% 52% 85%
40% 43% 83%
47% 34% 81%
37% 39% 76%
29% 46% 75%
51% 20% 71%
42% 28% 70%
47% 14% 61%
32% 35% 67%
Do you favor or oppose each of these actions?
Expand Medicare to include prescription drugs.
Require doctors to be retested periodically
to ensure that they are still competent.
Create local and regional health care systems
to make doctors and hospitals share services and equipment.
Make people whose choice of behavior threatens their own
health pay more for insurance.
Set caps on awards for medical lawsuits.
Doctors should spend more time with their patients,
EVEN IF this raises the cost of health care.
All Americans should have access to basic health care services,
EVEN IF this means cutting coverage of some costly treatments.
Health care providers should coordinate and share facilities and
resources, EVEN IF patients would have to wait longer for some
services.
Provide health care to all Americans through
a government-funded system.
Table 2
Reactions to Proposed Health Care Solutions
Analysis of Post-Forum Questionnaires
Of the proposed actions, forum participants are most in favor of expanding Medicare
to include prescription drugs, requiring doctors to be retested, and making doctors
and hospitals share services and equipment. Two thirds of the participants, mainly
African American and Hispanic, are in favor of a government-funded system.
More than three-fourths of the participants believe that citizens who act in
unhealthy manners should pay more for their insurance. This is consistent with
numerous comments made throughout the forum.

Appendix
National Issues Forums bring together
citizens around the nation to discuss
challenging social and political issues of
the day. They have addressed issues such
as the economy, education, health care,
foreign affairs, poverty, and crime.
Thousands of civic, service, and
religious organizations, as well as libraries,
high schools, and colleges, have sponsored
forums. The sponsoring organizations
select topics from among each year’s
most pressing public concerns and then
design and coordinate their own forum
programs, which are held through the
fall, winter, and spring.
A different kind of talk
No two forums are alike. They range
from small study circles to large
gatherings modeled after town meetings,
but all are different from everyday
conversations and adversarial debates.
Since forums seek to increase
understanding of complicated issues,
participants need not start out with
detailed knowledge of an issue. Forum
organizers distribute issue books such
as this one, featuring a nonpartisan
overview of an issue and a choice of
several public responses. By presenting
each issue in a nonpartisan way,
forums encourage participants to take a
fresh look at the issues and at their
own convictions.
In the forums, participants share
their opinions, their concerns, and their
knowledge. With the help of moderators
and the issue books, participants weigh
several possible ways for society to
address a problem. They analyze each
choice, the arguments for and against it,
and the tradeoffs and other implications
of the choice. Moderators encourage
participants, as they gravitate to one
option or another, to examine their basic
values as individuals and as community
members.
The search for common ground
Forums enrich participants’ thinking on
public issues. Participants confront each
issue head-on, make an informed decision
about how to address it, and come to
terms with the likely consequences of
their choices. In this deliberative process,
participants often accept choices that
are not entirely consistent with their
individual wishes and that impose costs
they had not initially considered. This
happens because the forum process
helps people see issues from different
points of view; participants use discussion
to discover, not persuade or advocate.
The best deliberative forums can help
participants move toward shared, stable,
well-informed public judgments about
important issues.
Participants may hold sharply different
opinions and beliefs, but in the forums
they discuss their attitudes, concerns,
and convictions about each issue and, as
a group, seek to resolve their conflicting
priorities and principles. In this way,
participants move from making individual
choices to making choices as members
of a community — the kinds of choices
from which public action may result.
Building community through
public deliberation
In a democracy, citizens must come
together to find answers they can all
live with — while acknowledging that
individuals have differing opinions.
Forums help people find the areas where
their interests and goals overlap. This
allows the emergence of a public voice
that can give direction to public policy.
The forums are nonpartisan and do
not advocate a particular solution to any
public issue, nor should they be confused
with referenda or public opinion polls.
Rather, the forums enable diverse groups
of Americans to determine together
what direction they want policy to take,
what kinds of action and legislation they
favor and what, for their common good,
they oppose.
Moving to action
Forums can lead to several kinds of
public action. Generally, the public voice
that emerges helps set the government’s
compass, since forum results are shared
with elected officials each year. Also, as
a result of attending forums, individuals
and groups may decide individually or
with others to help remedy a public
problem through citizen actions outside
of government.
About National Issues Forums

Appendix
About Paul Werth Associates
Paul Werth Associates is a full-service public relations, public affairs, and
marketing communications firm that provides research, strategic counsel,
and implementation of results-driven communications programs to help
clients build successful relationships with their constituents. The firm has
attained a national reputation for its high-quality, pragmatic approaches to
communications challenges.
As a result, the firm has won numerous awards from professional associations
for campaigns carried out on behalf of clients. Paul Werth Associates is the only
public relations firm with headquarters in Ohio to have won the prestigious Silver
Anvil Award — the highest national honor of the Public Relations Society of
America — nine times.
Founded in 1963, Paul Werth Associates is a founding member of the Council of
Public Relations Firms, and the firm’s president sits on the executive committee.
Research Services
Werth’s in-house Research Services division provides clients with integrated
solutions in support of their communication efforts. The group specializes in the
management and execution of complex research challenges in areas ranging from
public opinion sampling and marketing image studies to employee and customer
satisfaction assessments. Services include research, survey design, interview
execution, data analysis and interpretation, presentation of research findings,
and action planning.
Research Lead
Scott Zunic is vice president of Research Services for Paul Werth Associates.
Zunic has successfully managed more than 250 marketing research projects
for both professional and consumer audiences throughout the country. Typical
research projects include brand development (for product launches), company
and product positioning, brand character/personality creation and measurement,
message and concept testing, registry and e-commerce development, customer
segmentation, customer satisfaction, ROI measurement, and others.
In Zunic’s 12 years of health care marketing research experience, he has
consulted with, planned, and implemented marketing research with numerous
companies including Abbott Labs, AstraZeneca, Cardinal Health, Children’s
Hospital, CINGA, Eli Lilly, Duke University Medical Center, Genentech, Johnson
& Johnson (EES), Medicis, Merck, Pharmacia, Procter & Gamble, Roche, Ross
Laboratories, OhioHealth System, Ohio Department of Insurance, Ohio State
Medical Association, The Cleveland Clinic Health System, The Ohio State
University Medical Center, United HealthCare, and University Hospitals Health
System. Zunic has also performed advanced marketing research with one-third
of the health plans in the United States.
He completed his B.S. in Marketing from The Ohio State University and his
M.B.A. from Franklin University. He has 148 hours of additional marketing
research education at the A.C. Nielson/Burke Institute. Topics of study
included Market Research, Market Analysis, Advertising Research, Focus
Group Facilitation, and Introductory and Advanced Questionnaire Design.
Zunic teaches undergraduate and graduate Marketing Research courses
at Franklin University and serves on the advisory board for their Marketing
Department.

200 Commons Road, Dayton, Ohio 45459-2799 (937) 434-7300; (800) 221-3657
444 North Capitol Street, N.W., Washington, D.C. 20001 (202) 393-4478
6 East 39th Street, New York, New York 10016 (212) 686-7016
www.kettering.org

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