Sunday, October 22, 2006

Healthcare and the American Public

Dear Friends and Colleagues;

Americans say that high costs and the lack of insurance and access to care are the most pressing health care problems for government to address, Robert Blendon and coauthors report in an article published October 17 as a Health Affairs Web Exclusive.
Writing a month before the 2006 congressional election, the researchers also say that health care overall is a "second-tier issue" for the American public, ranking behind Iraq, the economy, and gasoline prices as a priority for government action. However, health care still ranks higher today than issues such as education, the environment (including global warming), Social Security, poverty, and crime.

Understanding The American Public’s Health Priorities: A 2006 Perspective

Health issues are on Americans’ minds,but they are not the top priority in 2006.

by Robert J. Blendon, Kelly Hunt, John M. Benson, Channtal Fleischfresser, and Tami Buhr


Opinion surveys conducted in 2006 show that health care is an important but second-tier issue in terms of priorities for government action. Americans’ top health care concerns are mostly related to economic insecurity: rising costs and the problems of the uninsured. The biggest perceived health threats are cancer, HIV/AIDS, and avian flu. Although most Americans do not think that the health system is in crisis, the public remains dissatisfied with both the country’s health care and public health systems. These attitudes are likely to create a climate that is supportive of increased health spending and substantial policy changes. [Health Affairs 25 (2006): w508–w515 (published online 17 October 2006; 10.1377/hlthaff.25.w508)]

This is the fifth in a series of essays published by Health Affairs examining Americans’ health and health care priorities.1 As in our earlier reviews of this subject, findings show that the American public has a clear set of priorities for the country, which have changed over time in response to specific events and the emergence of new health concerns. Public priorities typically emerge either when an issue is high on policymakers’ agendas and written up regularly in the popular press or when it represents a serious, real-life problem that people experience. Immigration, for example, rose to become one of the top three public priorities in April 2006, while it was high on policymakers’ agenda and written about daily in the newspapers.2 On the other hand, some issues, such as health care, that are part of people’s everyday lives remain much more enduring concerns in poll findings.

The Role Of Public Opinion

Over the past thirty-five years, there has been a huge jump in the number of polls conducted by decisionmakers in U.S. society, to monitor public opinion on a variety of topics.3 These include polls paid for by the media, political parties and leaders, interest groups, and foundations.4 Studies have shown that politicians continually monitor public opinion, attempt to shape it, and enlist it to gain leverage over other political actors. For example, research shows that polling done for U.S. presidents has gone from a relatively rare activity to a continuous information-gathering effort.5 Public opinion surveys provide politicians with information about what their constituents want across a wide variety of issues. This might lead them to be more responsive to general public opinion or to some subset such as members of their own political party or so-called swing voters.

Notwithstanding this substantial increase in monitoring of public opinion by decisionmakers, the role that public opinion actually plays in leaders’ ultimate policy decisions is not completely clear. There is general but not complete consensus among political scientists that public opinion plays a role in government decision making in certain circumstances and on certain issues, but not in all. But there is no agreement among all scholars about the particular circumstances and issues where decisionmakers pay attention to or ignore public opinion.6 What the research does show is that if an issue is salient to the public (a subject we examine in this paper), decisionmakers are more likely to pay attention to public opinion than they are for issues that are not very salient to the public.7

Research has shown that both the president and Congress respond to public opinion on issues that rank high in public concern or that people confront in their day-to-day lives.8 Health care is one such issue. Decisionmakers show greater responsiveness to public opinion when determining government spending on health care than in policy areas that are more remote from people’s daily lives, such as foreign aid.

In this paper we examine Americans’ health priorities along six dimensions: (1) the relative importance of health care as an issue for government to address, (2) the top health care issues for government, (3) views on national health spending and health care costs, (4) current ratings of the health care system and personal experiences with health care, (5) top general health concerns for future government action, and (6) ratings of the nation’s public health system and the general health conditions in their communities.

Study Data And Methods

To present a comprehensive picture of the public’s health priorities in 2006 and the changes that have taken place over time, this paper analyzes polling results from nineteen national opinion surveys conducted between 1940 and 2006. We pay particular attention to trends since the time of the Clinton health reform plan (early 1990s).

The survey data are from two main sources. The first consists of two Harvard School of Public Health/Robert Wood Johnson Foundation polls. International Communications Research (ICR) conducted fieldwork for both polls via telephone. For “Americans’ Views of the Healthcare System,” ICR conducted interviews 5–9 April 2006 with a nationally representative sample of 1,108 adults (age eighteen and older). For “Americans’ Views of Public Health,” ICR conducted interviews 31 March–4 April 2006 with a nationally representative sample of 1,107 adults. The margin of error for the total samples in each survey was plus or minus three percentage points at the 95 percent confidence level.9

The second source consists of seventeen other national opinion surveys that contain current and historical data. The criteria for inclusion in the paper are that the poll questions (1) reflect the public’s current priorities and the salience of the issues; (2) are the most current on a particular issue; or (3) represent trends that shed light on the public’s views and priorities over time. A number of organizations conducted these polls: Harris Interactive, Gallup, ABC News/Washington Post, the Pew Research Center, and the National Opinion Research Center/General Social Survey. All of the surveys were conducted by telephone, except for a 1940 Gallup poll and the General Social Survey, which were conducted in person. The sample sizes range from 1,000 to 1,500. The margin of error (at the 95 percent confidence level) for a sample of 1,000 is plus or minus three percentage points; for a sample of 1,500, it is plus or minus 2.5 points.

Survey Findings

Relative importance of health care as an issue for government to address. Elected officials can work on only a limited number of major issues at one time. To ascertain what the public thinks the priorities for government action should be, respondents were asked in August 2006 to say in their own words what they considered the top two issues for government to address. The results suggest that in terms of priority for government action, health care is a second-tier issue (Exhibit 1). Today it ranks as the fourth most important issue for government to address, behind the war, the economy, and gasoline/oil prices/energy. This is a lower ranking for health care than in 1993, a time of major national debate about health care reform. In the 2006 survey, health care was one of the top two issues for 13 percent of the population. This compares to 31 percent in 1993, when it was ranked second, and 9 percent in 2002, when it also ranked fourth.10
The list of the most important issues for government to address often corresponds the public’s ranking of issues that they say will be most important in their voting choices. In August 2006, health care ranked fourth when respondents were asked which of six issues would be most important in their vote for Congress. Once again, health care ranked behind Iraq, the economy, and gasoline prices, but ahead of terrorism and education.11

Of note, although health care is not among the top-priority issues for government action, it ranks higher today than many other national problems often identified as being very important. Health care issues rank higher than terrorism, the top issue in late 2001, as well as education, the environment (including global warming), Social Security, poverty, crime, and problems in the developing world.12 This consistent rating of health care among the top four concerns signifies that it is an issue of ongoing concern for the public, regardless of how high a priority policymakers make it.

Top health care issues. More specifically, respondents were asked to say, again in their own words, what they thought were the two most important health care problems that government should address. Health care costs and the lack of insurance/access to care were the most frequently cited (Exhibit 2). Medicare and the prescription drug benefit, the subject of current national attention, ranked third but well behind these other two. Quality of care, an issue of considerable concern to many national health policy leaders, ranked fourth.13

These priorities correspond with the public’s assessment of the state of health care in the country. In November 2005, only 20 percent of Americans were satisfied with the cost of health care, and only 21 percent rated health care coverage in this country as excellent or good.14 In April 2006, about four in ten Americans (41 percent) approved of the Medicare prescription drug program.15 And in November 2005, just over half (53 percent) rated the quality of health care in the United States as excellent or good.16

Views on national health spending and health care costs. Multiple survey results show that the public favors increased health spending in the years ahead but is concerned about the impact of rising health care costs on the financial situation of American families. In 2004, 78 percent of the public thought that national spending to improve health was too low; only 4 percent said that it was too high.17 Similarly, in 2006 a survey asked specifically about overall national spending on health care and national health care spending by government. The majority of respondents (57 percent) thought that the United States as a country was spending too little on health care in the aggregate, and 70 percent said that government health care spending was too low. Only 26 percent thought that the country as a whole was spending too much, and 11 percent thought that the government was spending too much. Around one-tenth of Americans thought that these spending levels were “about right” (9 percent, nation as a whole; 11 percent, government).18

What concerns Americans is not aggregate spending, but the perceived negative impact on American families of their direct health care outlays (insurance premiums, copayments, deductibles, and direct payments for services and products). When asked about spending for health care by average Americans in 2006, 65 percent of respondents said that the average American spends too much, while only 17 percent said too little.19 (Twelve percent felt that the level of spending was “about right.”) This is what Americans mean when they list health care costs as the top health care priority for government action.

Ratings of the health care system and their own care. As of spring 2006, most Americans were dissatisfied with the state of the U.S. health care system. About seven in ten respondents (69 percent) rated the nation’s system for providing medical care as fair or poor (Exhibit 3).20 Furthermore, in August 2006, only about four in ten respondents expressed “a great deal” or “quite a lot” of confidence in the health care system, a level that has remained relatively constant for more than ten years.21

Although the public is critical of the health system, only 22 percent think that it is in a state of crisis. However, this is a much higher proportion than in 2002 (11 percent). Most people think that the system has major problems, a view that has remained relatively stable since 1994 (Exhibit 4).22

In contrast to their views on the health system, most Americans are satisfied with their own most recent medical care experiences. Three-fourths of respondents had received medical care in the past year. Of those who received care, more than four in five people said that the services (84 percent) and physician care (85 percent) they received were excellent or good.23 This pattern has appeared in multiple surveys in previous years.24

A likely reason for the difference in opinions about the overall health system versus personal health care experiences could be that general health system questions tend to measure broader public concerns about the insecurity of health insurance coverage, high prices, bureaucracy, waste, and disparities in access to care in the United States. Measures of personal experiences are narrower and reflect individuals’ mostly positive recent experiences with care received from doctors and nurses; they do not take into account these other perceived societal problems.

Top general health concerns for government action. Respondents were also asked to state in their own words what they thought were the two most important diseases or health conditions for government to address. Cancer (51 percent) and HIV/AIDS (41 percent) were the top two health priorities stated.25 Smaller percentages also identified avian flu (21 percent), heart disease (16 percent), and diabetes (11 percent) as top priorities. Of interest, a parallel question asked respondents about the diseases and health conditions that posed the greatest threats to the American public. On this question, the rankings were essentially identical to the findings about priorities for government action, except that obesity tied with diabetes for fifth place. This suggests that a share of the public sees obesity as a serious national health concern but not as a current top priority for government action (3 percent), even though almost half (47 percent) see obesity as a major problem in their communities.26

Of historical note, these health priorities can change markedly over long periods of time. In 1940, Americans were asked to name the most serious health problem from a list of diseases considered very important at the time. Syphilis was the public’s top concern (46 percent), followed by cancer (29 percent), tuberculosis (16 percent), and polio (9 percent).27

Ratings of the public health system and health conditions in their communities. The country faces a number of public health threats that have emerged since 2001, such as severe acute respiratory syndrome (SARS), anthrax, smallpox, avian flu, and obesity. These threats have raised concerns about the adequacy of the U.S. public health system. When asked their assessment, the majority of respondents reported that they were not satisfied with the nation’s current system for protecting the public from these threats and preventing illness. Just over half of respondents rated the public health system as fair or poor, while fewer than half rated it as excellent or good (Exhibit 3).28

More Americans report satisfaction with the public health conditions in their own communities than with the overall public health system. About three-quarters of respondents gave excellent or good ratings to the quality of life in their communities (76 percent). The majority gave excellent or good ratings to the quality of emergency services such as police, fire, and ambulance (78 percent), as well as to air quality (69 percent), the availability of preventive health services (69 percent), the quality of drinking water (67 percent), and the availability of recreational facilities (65 percent). In addition, respondents were asked about whether health conditions in their community had changed during the last two years. Almost seven out of ten (69 percent) reported no change. Relatively small percentages thought that conditions had gotten better (14 percent) or worse (13 percent).29

Discussion And Conclusions

Most U.S. news coverage about medical care issues during the past year has concentrated on Medicare’s new prescription drug benefit, while many in the research and professional community have focused on the nation’s quality-of-care problems. What is important to recognize is that these are not the American public’s top health care priorities today. Americans want their government to do something about their rising health care costs and the problems of the uninsured. When Americans talk about health care costs, however, their concern is not for the share of the nation’s gross domestic product (GDP) going toward health care, but rather the financial impact on their own families.

Also important to recognize is that cancer and HIV/AIDS are the public’s top priorities as health threats that they want government to address. Even though there have been no human cases of avian flu in the United States, that emerging disease has now joined this list. Cancer has remained a major health concern to the American public for more than sixty years. Although there have been major medical advances in cancer care, it is still an issue that worries many Americans.

Another issue that could become more important to the public in the future is obesity. Although it has emerged as a major concern for the public in general and in their communities, the government role in obesity prevention is unclear for many Americans. This could change over time, as obesity receives more attention from the media and health professionals.

The public considers the wars in Iraq and Afghanistan to be the top issues for government. But the survey findings also indicate that from a public perspective, health issues are very likely to remain prominent on the national agenda. Although health care is not the top issue for Americans, it consistently ranks among the top five issues for government to address. In addition, contrary to the concerns of many experts, the public continues to favor more rather than less health spending in the aggregate.

Moreover, although most Americans do not think that the health system is in crisis, the public remains dissatisfied with the country’s health care and public health systems. These attitudes are likely to create a climate supportive of both increased health spending and substantial change in the years ahead.

This work was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.


1. R.J. Blendon et al., “Americans’ Health Priorities: Curing Cancer and Controlling Costs,” Health Affairs 20, no. 6 (2001): 222–232; R.J. Blendon et al., “Americans’ Health Priorities Revisited after September 11,” Health Affairs 20 (2001): w96–w99 (published online 13 November 2001; 10.1377/ hlthaff.w1.96); R.J. Blendon et al., “The Impact of Terrorism and the Recession on Americans’ Health Priorities,” Health Affairs 21 (2002): w420–w425 (published online 17 January 2002; 10.1377/ hlthaff.w2.420); and R.J. Blendon et al., “The Continuing Legacy of September 11 for Americans’ Health Priorities,” Health Affairs 21 (2002): w269–w275 (published online 14 August 2002; 10.1377/hlthaff.w2.269).
2. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low,” Harris Poll no. 30, 19 April 2006, (accessed 13 September 2006).
3. J.G. Geer, From Tea Leaves to Opinion Polls: A Theory of Democratic Leadership (New York: Columbia University Press, 1996).
4. Our search of the iPOLL database at the Roper Center for Public Opinion Research, the country’s largest archive of public opinion data, found a steady growth in the number of polling questions asked during each successive election cycle: from 8,752 questions in 1980, to 14,132 in 1988, to 19,458 in 1996, to 22,448 in 2004. See also E.C. Ladd and J.M. Benson, “The Growth of News Polls in American Politics,” in Media Polls in American Politics, ed. T.E. Mann and G.R. Orren (Washington: Brookings Institution, 1992), 19–31.
5. R.M. Eisinger, The Evolution of Presidential Polling (Cambridge: Cambridge University Press, 2003).
6. J. Manza, F.L. Cook, and B.I. Page, eds., Navigating Public Opinion: Polls, Policy, and the Future of American Democracy (Oxford: Oxford University Press, 2002); R.S. Erikson, G.C. Wright, and J.P. McIver, Statehouse Democracy: Public Opinion and Democracy in American States (New York: Cambridge University Press, 1993); L.R. Jacobs and R.Y. Shapiro, Politicians Don’t Pander: Political Manipulation and the Loss of Democratic Responsiveness (Chicago: University of Chicago Press, 2000); A.D. Monroe, “Public Opinion and Public Policy: 1980–1993,” Public Opinion Quarterly 62, no. 1 (1998): 6–28; and J.A. Stimson, M.B. MacKuen, and R. Erikson, “Dynamic Representation,” American Political Science Review 89, no. 3 (1995): 543–565.
7. B. Canes-Wrone and K.W. Shotts, “The Conditional Nature of Presidential Responsiveness to Public Opinion,” American Journal of Political Science 48, no. 4 (2004): 690–706; J. Manza and F.L. Cook, “A Democratic Polity: Three Views of Policy Responsiveness to Public Opinion in the United States,” American Politics Research 30, no. 6 (2002): 630–667; and C. Wlezien, “Patterns of Responsiveness: Dynamics of Public Preferences and Policy,” Journal of Politics 66, no. 1 (2004): 1–24.
8. B. Canes-Wrone, Who Leads Whom? Presidents, Policy, and the Public (Chicago: University of Chicago Press, 2006); Canes-Wrone and Shotts, “The Conditional Nature”; and Wlezien, “Patterns of Responsiveness.”
9. Harvard School of Public Health/Robert Wood Johnson Foundation, “Americans’ Views of Public Health” poll (Storrs, Conn.: Roper Center for Public Opinion Research, 31 March–4 April 2006); and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll (Storrs, Conn.: Roper Center, 5–9 April 2006).
10. For 1993 and 2002, Harris Interactive, “The National Mood Changes as Ratings of Bush, Cabinet Members and the Congress Fall Sharply—TABLES,” Harris Poll no. 34, 24 July 2002, 2002/july_24_2002.htm (accessed 13 September 2006); for 2006, Harris Interactive, “Democrats Continue to Hold Substantial Lead over Republicans in Race for Congress,” Harris Poll no. 63, 11 August 2006, (accessed 13 September 2006).
11. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 3–6 August 2006).
12. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low”; for 2001 results, see Blendon et al., “The Continuing Legacy,” w270.
13. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
14. Gallup poll (Storrs, Conn.: Roper Center, 7–10 November 2005).
15. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 6–9 April 2006).
16. Gallup poll, 7–10 November 2005.
17. J.A. Davis and T.W. Smith, General Social Survey (Chicago: National Opinion Research Center, 2004).
18. Pew Research Center for the People and the Press poll, “March 2006 News Interest Index, Final Topline,” 8–12 March 2006, (accessed 13 September 2006).
19. Ibid.
20. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
21. Gallup Poll, “Confidence in Institutions” (Princeton, N.J.: Gallup Organization, 14 August 2006).
22. Gallup polls (Storrs, Conn.: Roper Center, 6–7 September 1994, 11–13 September 2000, 11–14 November 2002, 3–5 November 2003, 7–10 November 2005); and HSPH/RWJF poll (Storrs, Conn.: Roper Center, 10–15 August 2006).
23. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
24. R.J. Blendon, M. Brodie, and J.M. Benson, “Health Policy,” in Polling America: An Encyclopedia of Public Opinion, ed. S.J. Best and B. Radcliff (Westport, Conn.: Greenwood Press, 2005), 289–291.
25. HSPH/RWJF, “Americans’ Views of Public Health” poll.
26. Ibid.
27. Gallup poll (Storrs, Conn.: Roper Center, 8–13 March 1940).
28. HSPH/RWJF, “Americans’ Views of Public Health” poll; and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
29. HSPH/RWJF, “Americans’ Views of Public Health” poll.

Robert Blendon ( is a professor of health policy and political analysis at the Harvard School of Public Health (HSPH) in Boston, Massachusetts. Kelly Hunt is senior program director at the New York State Health Foundation, in New York City. At the time the study was conducted, she was a research officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. John Benson is managing director, Channtal Fleischfresser is a research assistant, and Tami Buhr is assistant director at the Harvard Opinion Research Program, HSPH.

DOI: 10.1377/hlthaff.25.w508

Tuesday, October 17, 2006

Oppose Resolution 06-5 And Preserve Medicare Reimbursement

Dear Friends and Colleagues:

At the upcoming FMA Board of Governors & Council Days Joint meeting(October 19-22,2006) in Miami Resolution 06-5 (Medicare Reimbursement) will be discussed. This resolution calls upon the FMA to ask the Center for Medicare & Medicaid Services to make Florida a single geographic locality for physician reimbursement.

The supporters of the resolution claim that the resolution has three intentions:


“when people have the same interest they work together for the common good.Currently our (FMA) members have been divided by CMS into three camps. We want to become one camp…to assure that our FMA represents the interests of all physicians of Florida, not just a minority. Only then can we be assured that our congressional delegation has the same interest to fight for Medicare patients.”


“ we have to make sure that Medicare patients have access to doctors all over the state. There are areas in the state where Medicare patients cannot find doctors.”


“ all physicians in Florida should be paid the same for the same work and the same standard of care. It is increasingly more expensive to live and work all over the state , not just in some small areas. Parity is the reason so many states long ago changes to one locality.”

Attached you find a recent letter from the CMS Presidents of Dade,Broward and Palm Beach addressed to the Florida Board of Governors and the Council on Medical Economics OPPOSING the proposed resolution.

The South Florida Caucus including the Dade, Broward, and Palm Beach Medical Society stand opposed to Resolution 06-5.

We agree that the current reimbursement formula does not fairly or accurately address the costs of operating a medical practice.

We agree with and support current FMA and AMA policy and efforts to FUNDAMENTALLY reform the formula on which physicians’ reimbursement is based by either abandoning, replacing or reforming the flawed Sustainable Growth Rate (SGR).

We believe strongly, however, that the Medicare physician reimbursement formula must take into account geographic disparities in reimbursement and expenses (i.e. housing, practice lease, salaries, and insurance).

These disparities are real. Professional liability rates are not only significantly higher in South Florida, but notoriously among the HIGHEST in the nation. Other professional practice expenses such as salaries, leases and rents, non – PLI insurance (Property, Windstorm etc.), as well as general living expenses are SUBSTANTIALLY higher for physicians and their staffs in South Florida than in other areas of Florida.

Ignoring these realities and suggesting non-differential reimbursement is neither fair nor reasonable and it is thus unacceptable.

Other large and small businesses have differential financial structures based on location as evident with professional liability insurers. No doubt, South Florida physicians would embrace the lower PLI rates available in other parts of Florida and the nation, but that is not reality.

To raise North Florida Medicare rates, as presumably aspired to by this resolution, CMS would have to lower South Florida rates to maintain budget neutrality.

If this were to pass, South Florida physicians would not accept such a rate reduction on top of the accepted Medicare physicians’ reimbursement cuts and lobby openly against it to CMS.

Clearly, this would become a highly divisive issue for physicians and for the FMA and could impact its political credibility, agenda and membership.

Asking CMS to make Florida a single geographic locality for physician reimbursement does NOT guarantee as hoped for, an increase for North Florida physicians. Asking CMS to pay Florida doctors at one rate regardless of geographic and economic disparities,would likely result in CMS choosing the LOWEST current rate for EVERYONE. In fact, we would be sending the message to payers that physicians again would be willing to accept a lower fee schedule at a time when rates are already subject to annual REDUCTIONS.

Any lowering of Medicare rates would have a ripple effect on managed care rates and cause them to drop as they reimburse at a percentage of Medicare. This would impact ALL Florida physicians even the ones NOT caring for Medicare patients, such as pediatricians.

Further any lowering of Medicare rates in South Florida would create an economic incentive to leave South Florida and relocate to other parts of Florida or the US where cost of living expenses are less.

In the unlikely scenario that CMS would increase North Florida rates without lowering those in South Florida, it would invite the unintended and undesirable consequences of increasing managed care penetration in North Florida as HMO income also is tied to Medicare rates.

Again, with regard to fairness, if Medicare were to pay all physicians at the same rate, then the same should apply for managed care which, again is not consistent with reality. Similarly, professional liability rates should be the same all across the state, which they are not.

Finally, any decreases in Medicare rates equals reduced access to care for patients, because physicians in South Florida will reach an economic tipping point and have to drop or limit Medicare patient services

Thus, instead among ourselves over the geographic factor, which, at least, is based on economic disparities across the state, we must continue UNITED and TOGETHER in our annual struggle to correct the terminally FLAWED SGR formula and increase reimbursement fairly FOR ALL physicians.

We hope and respectfully request that the Council on Medical Economics and the FMA Board of Governors will vote down Resolution 06-5 to preserve access, parity and unity.

Friday, October 06, 2006

Health Plan from the Candidate for Governor Charlie Crist

Dear Friends and Colleagues:
Attached you find Charlie Crists "Prescription for a Healthy Florida" outlining his Healthcare proposals.
The plan contains many positive elements, but lacks certain important component(s) such as health information technology, funding for primary care sustainable health insurance beside of HSA's
I have added some of my comments and look forward to your input.



Policy Overview

Charlie Crist knows that Floridians’ health is crucial to every person’s quality of life and paramount to the vitality of our state. Florida is a leader in biomedical innovation, consumer-driven healthcare and Medicaid reform. But great challenges are ahead.
Health insurance, for many, is unaffordable and healthcare, including prescription medications, unavailable; emergency rooms are overcrowded; and there has been an increase in the prevalence of preventable diseases. Charlie Crist will reorient Florida’s healthcare system by focusing on the individual, lowering drug costs, and providing better access to doctors and medicine.

Comment: providing accessible and affordable primary care services for all Floridians.

Highlights of the Crist Prescription to Keep Florida Healthy

1. Making Health Care Affordable

o Lower the cost of prescription drugs for working families and seniors.
o Make health insurance affordable.
o Reform the public health system to lower costs, empower recipients, and
maximize KidCare.

Comment: to expand access a defined set of primary health care services at affordable prizes, empower healthcare consumers, and maximize KidCare.

2. Increasing Access to Care

o Increase health care options so that emergency care is not the only choice.
o Increase healthcare resources in rural communities.
o Train more doctors, nurses and health practitioners for Florida’s patients.

3. A Commitment to Prevention

o Refocus the Department of Health to be headed by the State Surgeon General
as a leading advocate for wellness.
o Promote healthy lifestyles in schools and in the workplace.
o Advocate early intervention in substance abuse and mental illness
Comment: and provide community-based in- and outpatient treatment facilities for those suffering from the disease of addiction.

4. Improving the Quality of Care through Innovation

o Create (Comment: objective) standards for best practices to reduce hospital-acquired infection rates and improve outcomes in hospitals, clinics, and doctors’ offices.
o Provide Floridians with more information and control regarding healthcare
decisions and costs.

Specific Policy Proposals


Lowering the Cost of Prescription Drugs

As our Governor, Charlie Crist will continue his longstanding commitment to lowering the costs of prescription drugs for all Floridians. As Attorney General, he fought for cheaper medicine by taking action against drug companies that kept low cost generics off the market, and brought suit against companies for falsely reporting their wholesale prices. He also launched, a website that allows Floridians to compare and shop for the very best price on their medicines. Already, this has reduced price disparities between drugs at some neighboring pharmacies.

His initiatives to lower the cost of prescription drugs as Governor will include the

• Leveraging the power of Floridians to negotiate better prices for prescription drugs for seniors and working families ( Comment:for all Floridians). As Governor, Charlie Crist will negotiate with the drug industry to get volume discounts on their drugs. He will pass these savings on to (Comment:all Floridians) working families and seniors who are struggling to pay for prescription drugs by providing them with discount prescription drug cards. He will then partner with pharmacies throughout the state so that these participating pharmacies will accept these discount cards to provide drugs at a lower cost. This could save eligible consumers as much as 40% on the cost of their prescriptions.

• Encouraging competition in the private marketplace to benefit all consumers.
Already, major retail companies are offering hundreds of generic drugs for $4.
Charlie Crist applauds these market-based solutions and will continue to encourage these companies to continue treating their customers fairly.
Comment: These low-cost prescription options are currently only offered in certain markets and will be expanded gradually depending on the companies perception of its market value,

• Providing more information to them about drug costs. He will expand the number of drugs presented for comparison on; and will expand search options on the website so that consumers may order lower-priced prescriptions from pharmacies across the state that offer mail delivery services. Crist will also partner with private companies that provide online tools for consumers to learn about additional prescription discount programs.

• Working with Congress to create conditions for the safe and affordable importation of drugs from Canada. Crist believes that if Floridians can purchase safe drugs from Canada, they should be able to do so. As Attorney General, he secured the passage of a bill to ensure drugs are tracked from the manufacturer to the drug store to guarantee their safety. He will work with experts in Washington to create an international methodology to maintain safety and consumer protection.
Comment: a very noble idea, but its often forgotten that MOST of the medications imported from Canada come from all over the world increasing the risk of adulterated or counterfeit drugs. At a time when FDA faces more challenges than ever in keeping America’s supply of prescription drugs safe and secure, legislation to liberalize drug importation could cause additional drug safety concerns. The volume of importation could easily overwhelm our already heavily burdened regulatory system. Increased rug importation would require to provide the FDA with adequate authority or resources to establish and regulate the distribution system for incoming foreign drugs - manufactured, distributed, labeled, and handled outside of our regulatory system - or even to ensure their safety.


Health Insurance Solutions for All Floridians

The Crist Administration will make it a top priority to increase the access and
affordability of health insurance for all Floridians. The uninsured suffer poorer health status and become dependent on emergency rooms and on state assistance for their care. Everyone benefits when more people are insured: enrollment drives down costs and reduces state spending on care. Charlie Crist will take immediate action to improve private health coverage through the following measures:

(A) Free-market solutions for small businesses: Florida is rated one of most
expensive states for small businesses seeking family healthcare policies. Small
businesses are at a disadvantage because they cannot spread their risk over large numbers of employees and insurance companies compensate by charging these businesses higher per-employee premiums. Another cause of high premiums is that state law is rigid with respect to small group policy design and benefit requirements. Charlie Crist will work to increase the flexibility and affordability of health plans for small groups by:

• Permitting more flexible plan and benefit designs: Charlie Crist believes that when it comes to healthcare coverage, Floridians should not have to choose between “all or nothing.” Rather than requiring rigid plan structures, he believes that Florida should allow the market to sell individualized benefits packages that will serve health needs while being more affordable. Charlie Crist will encourage flexibility in plans so that policies can be tailored to employers’ and employees’ needs and budgets.
Comment: An excellent idea and I hope that Governor Christ will have the backbone and stamina to overcome the resistance by insurance companies.

• Permitting small groups to join together to leverage purchasing power: Charlie Crist will work on improving the efficiency for small businesses to achieve lower employee premiums when they join together to leverage their buying power.

(B) Consumer-driven healthcare options for all Floridians: For most patients, health bills are paid for primarily by a third-party insurer or the government. This gives consumers little incentive to make cost-conscious decisions, and gives practitioners little incentive to offer competitive rates. Charlie Crist will move Florida in a direction where consumers gain more control over their healthcare decisions and spending, and where market dynamics keep costs affordable. One such opportunity exists through the increased use of Health Savings Accounts (HSAs). HSAs allow individuals and employers to pay into tax-free savings accounts while being enrolled in high-deductible health plans with catastrophic coverage. Unlike traditional policies, HSA owners control money in their accounts: funds may be invested, balances roll over year to year, and
funds are portable through job changes. Employers also contribute funds into employee accounts without having to pay high premiums. As Governor, Charlie Crist will promote the expansion of Health Savings Accounts, through increased awareness about how the plans work and how Floridians may benefit from these options.

Comment: HSAs are attractive and interesting options, but not suitable for everone and therefore should not be offered as the only or most important tool to achieve consumer driven healthcare solutions.
The advantages of HSAs include:
• Empowerment. HSAs allow patients and doctors more control over health care decisions because HSA dollars may be spent on any qualified medical expense, without regard to networks, utilization review, or other elements of managed care.

• Carryover. unused HSA funds may be used in subsequent years.

• Access to Funds. Individuals may withdraw funds from their HSAs at any time and for any purposes, although taxes and penalties apply if the distribution is not used for qualified medical expenses.

• Potential to Lower Employer Health Care Costs. HSAs make high deductible health plans more attractive to employees and give employees an incentive to be prudent with their health care expenditures.

• Tax Savings. Employees benefit from deductible individual contributions, tax-free employer contributions and tax-free earnings. Employers may deduct contributions and avoid payroll taxes on HSA contributions.

The disadvantages of HSAs include:
• Limits Health Plan Choice. Individuals who establish HSAs must participate in high deductible health plans (HDHP) that may not be suitable for all individuals.

• Nondiscrimination Requirements. Employers that contribute to employees' HSAs must comply with the HSA nondiscrimination requirement and face an excise tax penalty for failure to do so.

• Contribution Limits. The current HSA contribution limits combined with the HDHP participation requirement may make it difficult for employees to accumulate funds in their HSAs. Individuals who incur significant health care expenses will not find HSAs to be attractive.

• Adverse Selection. An employer that offers an HSA / HDHP option and a more comprehensive health plan option may experience a migration of healthy employees to the HSA / HDHP option, leaving less healthy employees (but fewer premium dollars) in the comprehensive health plan thereby undermining the premise that the premiums of healthy participants pay for the expenses for sick health plan recipients. Eventually, this will jeopardize the financial stability of such plans.

(C) Achieving federal participation in providing for the uninsured: The problem of covering the uninsured is not just a matter for individual states. Charlie Crist will take the lead nationally to bring federal funding to states that develop strategies for covering the uninsured. These coordinated federal and state efforts must:
• Encourage personal responsibility and consumer-driven healthcare;
• Strengthen the private insurance market and offer free-market solutions;
• Cover catastrophic events and preventative care; and
• Redirect state dollars toward primary care medicine.

Further, Charlie Crist supports interstate purchasing pools, called Association Health Plans, which would allow organizations like the Chamber of Commerce to negotiate on an interstate basis on behalf of their members. Achieving this will take Congressional action, and Charlie Crist will work with Florida’s delegation to achieve this agenda.
Comment: Excellent idea!!!


Building Networks of Care

Charlie Crist believes that every Floridian should have a “medical home” with a primary care doctor. He is committed to shifting the delivery of healthcare from the ER to doctors’ offices. He will work to reduce hospital crowding, increase Floridians’ access to primary and preventative care, and modernize care networks for the poor. To achieve this, the Crist Administration will:

(A) Increase health care options so that emergency care is not the only choice:
County Health Departments provide various health services, and many communities also have locally funded healthcare clinics. These facilities can fill an important role in providing care to the underserved but are underutilized. In addition to increasing awareness about these options, Charlie Crist will encourage partnerships between private health clinics and hospitals so that patients know where they can receive reatment outside of emergency rooms.

(B) Strengthen health in our rural communities: Many rural hospitals suffer from mismanagement, outdated infrastructure, and difficulty recruiting skilled staff. This year, two rural hospitals were closed by the state for failing to keep even minimal levels of quality. In some areas, women must drive an hour away to deliver a baby. Charlie Crist knows that this is unacceptable. He will help rural communities with capital improvements and developing coordinated delivery systems, including shared management, workforce recruitment, and long-term planning with hospitals.

(C) Increase the quality of emergency care: Federal laws currently prevent hospitals from forming regional on-call networks of emergency specialists. Charlie Crist will work to change these laws. This would permit EMS drivers and patients to know where to go for certain kinds of emergencies, and would increase the efficiency of care. Further, the
Crist Administration will work to increase the availability of emergency specialists by evaluating and building on medical malpractice reforms.

(D) Minimize red tape in the building of new health facilities: Charlie Crist will reform the process by which new facilities are approved. When the need for a hospital or nursing home is established, red tape should not prevent their opening.

(E) Increase the availability of Home & Community Based Services (HCBS):
Charlie Crist believes that the home is often the best place to receive continual care. He will work to increase the availability of HCBS options, where Floridians can avoid seeking institutional care and maintain independence and comfort.

Providing More Healthcare Practitioners for Florida’s Patients

Florida faces critical shortages of nurses and specialists. For example, while Florida’s demand for nurses will increase by 40% by 2020, the number of nurses is expected to grow by only 6%. The average age of nurses in Florida has increased as well, which means Florida has a shortage of nursing instructors. Consequently, nursing programs must turn away thousands of qualified applicants due to the lack of staff. A similar problem exists for physicians and specialists. While Florida’s population has exploded in the past ten years, our medical school enrollment has not increased at all. Charlie Crist
believes that we must attract and retain healthcare practitioners, and believes that the key to this is education. Charlie Crist will focus on developing the state’s higher education capabilities in math and science, and will further promote the development of public universities in Florida that will focus, or increase their focus, on math and science. This emphasis will create the workforce that Florida needs to fulfill our growing healthcare workforce needs.

• Attract students to healthcare professions: Charlie Crist will work to attract more
young people, minorities and men to healthcare professions through scholarship
programs and outreach to students in middle and high school. Further, Charlie Crist believes that it is important that more healthcare personnel are defined as “essential service personnel” by local affordable housing boards so that they may qualify for housing assistance.

• Increase residency opportunities for Florida medical students: Florida just
established two new medical schools at FIU and UCF. Charlie Crist will push for
additional residency spots in order to keep new doctors in Florida and benefit from our investment in their training.
Comment: Excellent idea!!!
Unfortunately, the plan does not address how to retain doctors in Florida. Problems include: high costs of living, high costs for medical practice, high professional liability, unfavorable medico-legal environment (just to mention a few)

Empowering & Improving the Medicaid System

(A) Eradicating fraud: The costs of Medicaid fraud are enormous and the eradication of fraud should be a top priority. As Attorney General, Crist aggressively investigated and prosecuted Medicaid fraud and abuse. He filed lawsuits against drug manufacturers for inflating prices, prosecuted doctors who were diverting controlled substances or billing illegally. These efforts recovered over $150 million to taxpayers, in contrast to only $6 million recovered in 2002 prior to Crist’s Administration. Charlie Crist will maintain focus on preventing and penalizing fraud.

(B) Evaluating and expanding Medicaid reform: In only seven years, the Medicaid budget more than doubled. Today, it consumes a quarter of the state budget, up from ten percent ten years ago. Governor Bush and the Legislature responded to this broken system by passing a Medicaid reform package designed to use the power of consumer choice to improve care and efficiency. Charlie Crist believes that these reforms must continue. This year, the new Medicaid plan offered expanded services without costing the taxpayers an additional dime; offered aged and disabled people home delivered meals after discharge from the hospital; provided adults with preventive dental care,
paid for over-the-counter drugs and more. With the initial implementation, there have been very few complaints. Now, we must watch, learn, and adjust as issues arise. Crist will evaluate Medicaid Reform as it develops in Broward and Duval Counties, will improve aspects that need development, and will implement further reforms to ensure hat all patients have access to the best care.

(C) Maximizing Florida’s KidCare resources: The Florida KidCare program provides insurance to qualifying children as a safety net for families who work hard but do not earn enough to purchase private policies. Enrolling the maximum number of eligible children in KidCare promotes the future of Florida. The Bush Administration increased funding for KidCare and Medicaid for children by more than 85%, and increased enrollment in KidCare by nearly 94%. Charlie Crist will work to make the application
process less complicated by unifying the process to a single application for all child services, so that parents do not need to approach multiple programs to determine eligibility. He will also encourage schools and Pre-K programs to boost awareness about KidCare, will use all available federal funds, and will work to permit the use of funding from local governments to open up more slots.


The Sunshine State should be a healthy state. Public health challenges such as obesity, Alzheimer’s, and emergency preparedness are eminent. For example, from 1997 to 2004, diabetes has increased by 40%. Thousands of Florida’s children have early stages of diabetes without diagnosis, and they will face serious health problems by the time they are 30. We must be aggressive in tackling these problems, and Charlie Crist proposes a comprehensive approach involving the following initiatives:

(A) Refocus the Department of Health to be headed by the State Surgeon General
as a leading advocate for wellness: Florida needs a strong advocate so that all Floridians will achieve a lifetime of wellness. Charlie Crist will refocus the role of the Secretary of the Department of Health to be the State Surgeon General. Florida’s Surgeon General will act as the leading voice on wellness and disease prevention and will focus on advocating healthy lifestyles, prevention of substance abuse, suicide and mental illness, and personal responsibility in disaster preparation.

(B) Promote school and workplace-based fitness and nutrition initiatives: Charlie Crist will emphasize fitness and nutritional awareness in schools and in the workplace.

• School-based obesity & healthy eating initiatives: Charlie Crist believes that every child should have physical activity every day, and he will seek to integrate fitness into educational opportunities inside and outside the classroom. He will also seek legislation requiring every school district to maintain an independent physical fitness advisory panel to assess the school environment using the Centers for Disease Control and Prevention’s School Health Index to determine further recommendations or student fitness testing every year beginning in the first grade. Those panels will provide input to a volunteer panel of physical fitness experts that will serve as the Governor’s Commission on Physical Fitness. Finally, nutritious food options should be available in Florida schools. Charlie Crist will promote school districts to partner with Florida agriculture to offer salad bars with fresh produce and meats. These partnerships will nourish both student health and the vitality of Florida’s food

• Workplace obesity & healthy eating initiatives: In 2006 the legislature passed a law equiring state agencies to develop strategies for promoting healthy lifestyles among
employees. Charlie Crist will require systematic evaluation of these programs to
determine which strategies are most effective; and will then publish model policies for other agencies as well as private companies to learn from and adopt.

Comment: excellent ideas that require SUSTAINABLE FUNDING!!!

(C) Encourage early intervention & awareness about substance abuse and mental illness:

• Integration of mental health services: The President’s New Freedom Initiative is an important guide for how to modernize our mental health system, and the Florida Substance Abuse Mental Health Corporation provides guidance in these matters. Crist will appoint people to this board who believe in community-based and integrated treatment, to develop a roadmap to independence for the mentally ill.
Comment: I would separate mental health and substance abuse issues. Addiction illness is a clearly defined complex medical illness comparable to Diabetes or Hypertension. It requires focused attention on disease management and relapse prevention. Many of those suffering from substance abuse problems are concerned that they are being stigmatized suffering from a mental illness or that the fact that they are being treated indicates active disease often leading to denial in life-, disability and even health insurance.

• Suicide prevention: Suicide is the third leading cause of death for 15-24 year olds in Florida. The suicide rate is more than twice that of homicide but is often treated as a private matter relating only to affected families. Governor Bush’s Task Force on Suicide Prevention recommended greater early intervention and screening efforts, and Charlie Crist believes that Florida must move forward in these efforts.


The Charlie Crist Quality Care Initiative

Measuring quality and rewarding performance provide better results for patients, lessen the duration of illness, and reduce costs for care. The Crist Quality Care Initiative brings new focus to healthcare quality and is based on two sound principals:

(A) Create standards for best practices to reduce hospital-acquired infections and improve outcomes in all healthcare settings: Most adverse events in medicine are preventable. For instance, hospital-acquired infections are responsible for an estimated 103,000 deaths each year in the U.S. Reporting systems that collect information on
errors are essential to improve the safety and quality of care. For example, by
participating in one national pilot program, Tallahassee Memorial Hospital reduced mortality after strokes by 41% and for pneumonia by 32% in a two-year period by adopting best practices and establishing better communication between emergency room doctors and specialists. The Crist Administration will utilize improved measures of healthcare performance and will encourage the collection of data on mistakes or oversights. These measures allow researchers to develop best practices, avoid future mistakes, and provide important information for consumers.
Comment: these measures should be coordinated with the Florida Medical Association and other entities involved in patient safety and quality improvement and not being directed by a government agency.

(B) Provide more consumer healthcare information: Floridians should have as much information as possible when making healthcare decisions. Charlie Crist has been at the forefront of making Florida a national leader in such transparency efforts. As Attorney General, he launched the pharmacy pricing website,, where consumers compare drugs prices between pharmacies. These programs make Florida a national leader in transparency efforts; however, we can do more to empower consumers. Today, three websites present data to consumers on the quality and cost of healthcare, and Crist will integrate them into a user-friendly This site will offer a greater scope of information that is meaningful to patients, such as data on patient satisfaction at facilities, a comparison of provider performance between health plans and an expanded drug price component as described above.

Even though I cautiously support the ideas outlined above I am surprised that the Crist team has omitted to mention the importance of health information technology including Electronic Health Records for doctors office and no mention is being made of how (or if) Governor Crist would support the development of Regional Health Information Organizations (RHIOs) and allocate sufficient funding to these projects.
Health Information Technology (HIT) solutions will provide the data and information flow across the horizontal and vertical spectrum of healthcare providers to guarantee the optimal utilization of health care resources, to reduce duplication of diagnostic testing, to guarantee patient safety and quality of care.

Comments by Bernd Wollschlaeger,MD,FAAFP

Sunday, October 01, 2006

Reform Americas Health Care System

Dear Friends and Colleagues;
Attached you find an opinion piece from the Miami Herald endorsing the recommendations from the report issued by the "Citizens for Healthcare Working Group".
This working group was established by the US Congress as part of the Medicare Prescription Drug, Improvement, and Modernization Act Of 2003 and charged to address the following issues:

* Provide for a nationwide public debate about improving the health care system to provide every American with the ability to obtain quality, affordable health care coverage.
* Develop an action plan for Congress and the President to consider as they work to make health care that works for all Americans.

The Working group as citizens through an open and transparent process to answer the following questions:

1. What health care benefits and services should be provided?
2. How does the American public want health care delivered?
3. How should health care coverage be financed?
4. What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high-quality health care coverage and services?

Over nearly eighteen months, the Working Group engaged thousands of Americans, including:

* About 6,650 people attending 84 community meetings across the nation as well as meetings organized by individual Working Group Members and other organizations by the end of May, 2006, and input from over 700 people attending 14 meetings after the Interim Recommendations were published on June 2nd, 2006
* Over 14,000 responses to the Working Group Internet poll; and another 6,000 sets of responses to open-ended questions about health care in America
* Over 500 descriptions of experiences with the health care system submitted via the Internet or on paper, and about 400 email letters, handwritten notes, letters,essays, and copies of reports that people sent to the Working Group.
* About 7,300 individual email and written comments on the Working Group’s Interim Recommendations

The Working Group released an Interim Report in June 2nd 2006 and a final report on September 25, 2006.
In its Executive Summary the Working Group points out a consistent response that:

Americans should have a health care system where everyone participates, regardless of their financial resources or health status, with benefits that are sufficiently comprehensive to ensure access to
appropriate, high-quality care without endangering individual or family financial security.

The final recommendation are as follows:

* Recommendation 1: Establish Public Policy that All Americans Have Affordable Health Care
* Recommendation 2: Guarantee Financial Protection Against Very High Health Care Costs.
* Recommendation 3: Create Innovative Integrated Community Health Networks
* Recommendation 4: Define Core Benefits and Services for All Americans
* Recommendation 5: Promote Efforts to Improve Quality of Care and Efficiency

As physicians we should fully endorse those principles and focus our efforts on reforming and rebuilding our FAILING healthcare system.
Yes, our health care systems fails to deliver comprehensive, high quality care for all Americans.
Since 911 our country has spent over 500 Billion Dollars on the war on terror. We have proved that we can mobilize financial resources for our nations defense. Why should we not make similar efforts to rebuild Americas healthcare system?
I think we could if we wanted to. The problem is that we elect and reelect politicians that failed to represent our interests.
In November we have a change to vote those politicians out of office. What are we waiting for?

Yours truly

Posted on Sat, Sep. 30, 2006

Toward universal healthcare that works


Below are excerpts from ''Healthcare That Works for All Americans,'' a report issued this week by the Citizens' Health Care Working Group (www.citizenshealth

Americans want a healthcare system that works for everyone. But the reality is that the healthcare system that captures vast amounts of America's resources, employs many of its talented citizens and promises to both promote health as well as relieve the burdens of illness is failing far too many of us.

Over the past year, the number of uninsured has grown by more than one million, and tens of millions more are underinsured and at immediate risk of financial ruin if they are seriously ill or injured.

Individuals, families, employers and every level of government are feeling the financial pressure of rising healthcare costs. More often than not, people do not receive the best care that science has to offer. Many are bewildered by the complexity of healthcare and insurance coverage. As one citizen voiced to us, you cannot ``navigate the healthcare system without luck, a relationship, money and perseverance.''

The need for change is clear, but transforming healthcare so that it works for all Americans is a daunting prospect. It will involve difficult decisions about how healthcare is organized, delivered and financed.

The Citizens' Health Care Working Group was established by Congress to ''engage in an informed national public debate to make choices about the services they want covered, what healthcare coverage they want and how they are willing to pay for coverage.'' What we heard was that many Americans believe that public policy designed to address the growing crisis in healthcare cannot succeed unless all Americans are able to get the healthcare they need, when they need it.


• Establish public policy that all Americans have affordable healthcare. This public policy should be established immediately and implemented by 2012.

• Guarantee financial protection against very high healthcare costs. A national public or private program must be established to ensure participation by all Americans, protection against very high out-of-pocket medical costs; financial assistance to pay for this coverage based on ability to pay.

• Foster innovative integrated community health networks. The federal government will provide leadership and financing for a national initiative to develop integrated public/private networks of healthcare providers.

• Define core benefits and services. Establish a nonpartisan public/private group to define America's core benefits and services and update them on an ongoing basis. Core health services will cover the continuum of care throughout the individual's life span.

• Promote efforts to improve quality of care and efficiency.

• Restructure end-of-life care so that people of all ages have increased access to these services in the environment they choose.