In 2002, Connecticut is home to close races for Governor and two Congressional seats as well as a handful of competitive races for State Senate and House seats garnering national attention. Health care and, more specifically the uninsured, rate highly among voter concerns. To explore public opinion about the issue and current proposals, the Connecticut Health Policy Project conducted a focus group study among likely voters in four Connecticut towns.
Four focus groups were held during the week of September 23, 2002 in Canton, Groton, Cheshire and Putnam, CT with a total of 33 participants. Both Democratic and Republican campaigns for Governor and the 2nd and 5th Congressional Districts were contacted; the draft focus group discussion guide was offered to each. Input from two campaigns.
The groups included only likely voters. Of the 33 participants, 32 plan to vote on Nov. 5th, 32 know their polling place and 31 have voted within the last year. All but four of the participants were women. Eighteen are registered Democrats, 10 Republicans, 2 Independents and one of another party. All are currently insured. Nineteen have never been without insurance, fourteen have. Twenty-six personally know someone who is uninsured, five do not. By design, incomes varied a great deal among participants from one participant with a family income under $25,000 to eight over $1000,000/year. The most common response was between $25,000 and $50,000. Occupations also varied widely including artist, bookkeeper, attorney, librarian, and day care provider. One group had a large number of retirees. Health care professionals were concentrated in one group. Another group included staff from a private human service agency.
Participants rated the issue of the uninsured and access to health care very highly in strong responses. This initial question elicited animated discussion immediately. "The whole system is out of whack." "No matter how you look at it, someone has a stranglehold on you." From a woman with a pre-existing condition insured under an individual policy, "I have barebones coverage that doesn't cover my bones. The policy for which I save carefully every week and spend a fortune on is completely irrelevant to me, it doesn't cover the problems I have."
Participants noted large increases in their costs for health care due to unemployment or pre-existing conditions. Rising deductibles were mentioned in two groups as a significant barrier. Stories included a friend who married a "jerk" for health insurance, people going to work at "crummy" jobs for health benefits, several stories of uninsured people who could not get treatment which caused far more serious and expensive problems, families declaring bankruptcy due to medical bills, and people who hit their lifetime caps unaware that they were subject to one. Two groups raised the strong belief that the uninsured receive poorer quality care. There was considerable concern for small businesses and the high costs they face.
In all groups the issue rated equal to or higher than education, the environment, energy, and transportation. The vast majority rated it as equal to or higher than the economy and unemployment. The only two participants who rated the economy higher were both men. All groups believed that the issue of the uninsured is strongly linked to the economy and found it difficult to consider them separately. Most participants rated the war on terrorism as equal to the uninsured, but in weak, ambivalent responses. Several noted that they really didn't like the question. Again, the only two participants who eventually rated terrorism higher than the uninsured were men.
Participants felt very strongly that campaigns were not paying enough attention to the issue. All but four participants had heard nothing on the issue at all from candidates. When asked, participants give Democrats than Republicans more credit for working on the issue, but the response was very weak in all groups. Comments included, "They all talk a good game, but no one makes it a priority" and it is "just a war of words." Of the four participants who believed that they had heard something on the issue, three heard it from a Republican candidate.
When asked on the initial questionnaire, "How confident are you that your coverage will meet all your and your family's health care needs into the future?" answers varied widely. The lowest income group was least likely to feel confident and the highest income group of mainly health care professionals was most likely to feel confident of coverage.
Participants were very strong in their responses that government is not doing enough for the uninsured or underinsured. Typical responses were "No way" and "It always takes a back seat to other issues." This sparked long, animated discussions.
Participants universally prefer a single, specific proposal from candidates rather than broad commitments or intentions. One commented, "No more committees, no more broad generalities." While they were generally skeptical that candidates would follow through on promises, they tend to believe a candidate with a realistic proposal. One group felt that it is "easier to hold them to" a specific proposal. They were less enthusiastic to hear about a candidates' prior record. One commented "Everyone and his brother is taking credit for HUSKY." One felt strongly that any proposal should address the perspectives of each stakeholder group. "While I may not like what they decide, I want to be sure that they know how it will affect each of us."
While none made this issue their only priority in voting, many noted that a well-reasoned, thoughtful proposal would appeal to them and would indicate a level of consideration and research that they would presume extends to other areas. Participants universally prefer a single proposal from candidates rather than a list of plans.
Universally, participants believe strongly that special interests have considerable influence in health care policy. The most common and strongly cited interest was pharmaceutical companies. Profits at the expense of care, benefiting from publicly funded research, long patent periods, and excessive spending on lobbyists were mentioned. Next in order of blame were insurance companies. Several participants noted wasted time and paperwork burdens on patients and providers, and insurers' inefficiency and high salaries as reasons for skyrocketing health care costs. Other interests cited were oil companies, providers, labor, tobacco, casinos, and big businesses.
All participants were aware of the HUSKY program, but most were not well informed about the details of the program. It was very well regarded in one group (retirees), poorly regarded in another (mixed income group) and lukewarm in the other two. In all groups it was noted that the program is not reaching everyone it should ("outreach was botched") and that it can be difficult to find participating providers. All four groups felt that it was a good program overall and many felt that it was better than nothing. HUSKY expansions were noted by some as potential solutions to the uninsured and that was positively, but weakly, received by most groups. However, one commented "Why expand it, if it's not working now, and just make a bigger mess." Most felt that the program needs to be both fixed and expanded to new populations. Health professionals in two groups noted that fees to providers in the program do not meet the costs of providing care. Two groups noted income cliffs in eligibility that forced people they know to quit jobs to keep coverage. They would like to see the program fixed so that there is no disincentive to working.
ConnPACE was generally well regarded by participants, though more weakly than HUSKY. Most had not heard of it and were unaware that the state offers prescription assistance to seniors, even among the group with retirees. It was characterized as only for very low-income seniors. Most felt that eligibility needs to be expanded.
One participant felt strongly that the state does not hold itself to the same standards as it imposes on the private sector. There was some anger (reluctantly expressed) by some participants that some very low-income consumers expect every available treatment without regard to cost or whether it is medically appropriate. This sentiment was mixed with a great deal of compassion for people in need and for the middle class who is not as well protected and is being squeezed.
We tested several current proposals on the uninsured. Despite the fact that the groups were very well informed about health care issues in general, few had heard of these proposals. There were many questions and little enthusiasm for most options. A few were concerned about the costs of each proposal and increased taxes in particular. Many stressed the need for improved accountability on all parties. One group believed that people should pay something for their healthcare, even a small amount for people at low income. "You value what you pay for."
Tax credits for individuals This received a very negative reaction in one group (mixed income). Many felt that it wasn't feasible, there would be too much paperwork, and that the people who really needed it wouldn't benefit. Other groups were lukewarm. One participant thought it was a very good idea.
Tax credits for small businesses This was better received by all groups and one of the more popular options. There was general recognition that small businesses are less likely to offer health benefits and are charged more for coverage.
Reducing mandated benefits Initially, this idea received weak positive responses. However as they explored what benefits might be excluded, support for the idea eroded. Several noted that the cost for those who need an excluded service could become extremely high. One commented that insurers would include the least that they were required. Eventually most participants were ambivalent to negative about the idea.
Defined Contributions This elicited the most questions and wariness among proposals. No participant was aware of this option and all found it confusing. All participants recognized the financial risks to consumers but varied in recognizing the segmentation of markets and loss of risk-sharing. One compared it to privatization of Social Security (an unflattering comparison). Some were concerned that consumers could make inappropriate choices, run out of money, and costs would be shifted to the public sector. They acknowledged the increase in consumer control as a positive aspect, but overall did not feel that it outweighed the risks. One participant called it "anarchy".
Premium assistance under HUSKY This proposal received mixed reviews. None were strongly positive or negative. Some felt that it could help some people, others felt that it would only help a favored few. Some worried that it allows employers to reduce their commitment to workers. Another felt that it would harm the traditional HUSKY program. Concerns were raised that the state could not administer it (this was the group most negative on the current HUSKY program). Most felt that it would be of marginal help, at best.
COBRA assistance All participants were aware of COBRA and its details. Most are aware that it is expensive; "it costs a fortune." Concerns were raised that it could be abused and that any assistance should be need-based. Overall, it received a weak positive response.
Expansions of public programs Moderately positive responses generally to expansions of HUSKY, more positive to ConnPACE expansions. Two groups suggested motivations and/or requirements for providers to take HUSKY patients.
Expansions of clinics and safety net providers This was the only option that received enthusiastic positive reviews in all groups. Participants noted that this reaches the uninsured who don't qualify for programs, promotes personal responsibility through sliding fees, and is more efficient in cutting out layers of bureaucracy. One group noted that they must be high quality centers that are integrated within their communities to avoid the stigma of second-tier care. That concern was not persuasive in other groups. There were many positive remarks about local safety net providers.
Programs to encourage providers who volunteer their services This received negative reviews in one group. "They will come until it interferes with a ski trip." Other groups were more positive, although very weakly. None found this a serious, compelling proposal.
Cost controls This elicited strong reactions - both negative and positive. Some favored free markets and entrepreneurship; some felt that regulation was necessary to stop "price gouging" and "profiteering." Cost controls on drugs and insurers had the most support. There was little support for controls on physicians or hospitals. One health care administrator stated that for many providers the state already controls costs by setting fees.
Universal health care This also elicited strong reactions as well as many questions and lively, wide-ranging discussions. Two groups noted reports of busses of Americans going to Canada for cheaper prescriptions passing buses of Canadians entering the US for our world-class health care. This option was raised at several points in the discussions as inevitable and the best solution. Several participants were very negative, suggesting that it would limit care and reduce quality.
Groups were asked near the end of the discussion, on a scale of 1 to 10, whether they favor private sector (1) or public sector (10) solutions to the problem of the uninsured. The most common response was 5, however there were only three responses less than 5. The average overall was 5.9. Discussions centered on a need for market-based options that reduce overall health care costs and encourage access for everyone. But most acknowledged that it will require government oversight and funding.
At the end of the groups, participants were asked, "If you could say one thing to candidates about the uninsured, what would it be?" Remarks included
The participants were remarkably well informed about health care including insurance, managed care, malpractice insurance problems, end of life costs, and public policy. They were interested in the topic, and eager to discuss it. In each case, they were reluctant to stop and several stayed after the meeting to discuss the issue further. Most had stories to tell illustrating points about the uninsured and access to care. They enjoyed being asked for their opinion and were excited that several campaigns were waiting to hear their answers.
The uninsured is an important issue for these voters. They are hearing very little from candidates and they want to hear more. Even if they are cynical about campaign promises, specific proposals would help persuade them of a candidate's sincerity and credibility in addressing this problem and other social issues.
These are complex issues and there is clearly a need for more public education on possible solutions and their implications. Overall, they prefer simpler options and prefer a candidate to give their one best idea. While baby steps are acceptable, they want to reach as many people who need help as possible. They are insistent that there be accountability and blame a good share of current health care problems on a lack of it. Small businesses are favored, drug companies are not.
The only specific option that received universal support, and with some enthusiasm, is support and expansion of clinics and safety net providers. For one group, it was critical that any expansion address the stigma of accessing safety net care.
There was significant variability within and between groups, not generally corresponding with income or personal familiarity with the uninsured. Only a few men participated in these groups and, in some cases, their perceptions were markedly different from the rest of the group. It was not clear whether this was a result of group dynamics or a real difference.
The Connecticut Health Policy Project wishes to express thanks to the League of Women Voters of Cheshire and New London/Groton, the ARC of Quinebaug Valley and a very generous individual for help in recruiting for these groups. The Project also wishes to thank the individuals who shared their time, their opinions and their stories on sensitive issues.