Will the insured sacrifice to help cover the uninsured? New study suggests the answer may be yes

Jul 21 2004

One of the biggest questions facing Americans as the 2004 elections approach involves a tradeoff: Will those who currently have health insurance be willing to sacrifice in order to insure the 44 million people who don't?

The answer may turn out to be yes, according to the results of a new research study published in the August issue of the Journal of General Internal Medicine, especially if citizens have a chance to get together and talk about how coverage for the uninsured might affect them personally and society as a whole.

To explore whether the insured would help cover the uninsured, the research team based at the University of Michigan didn't turn to an opinion survey. Instead, they asked 322 insured people to play a board game that's a cross between Monopoly and the Game of Life, but with a focus on health and insurance.

Called CHAT, for Choosing Healthplans All Together, the game gives players a limited number of pegs (dollars) to allocate to many categories of insurance coverage, including funding to help the uninsured. Then, randomly drawn cards representing health problems and crises show players how the health plan they designed would work in the case of an illness or injury to themselves or others.

By watching what choices the 322 players made when they were designing health plans for themselves, and listening to the conversations the players had when they had to work together as a group to design a health plan for their community, the researchers saw and heard how players regarded coverage for the uninsured.

At the start of the game, just over half of the players said they'd use at least 4 percent of their own family's insurance spending to help fund insurance for the uninsured. The majority of them chose to cover only uninsured children.

When groups of eight to 15 players got together to design community-wide health plans, though, all of the groups elected to cover the uninsured in some way – and 76 percent chose to cover both adults and children.

They reached these decisions after spirited discussions that often touched on the ways in which coverage for the uninsured might affect the common good, might be abused by some, or would be available to the insured if they ever lost their insurance.

“For many, offering coverage was like insuring themselves against becoming uninsured,” says lead author and CHAT co-inventor Susan D. Goold, M.D., MHSA, M.A., director of the U-M Bioethics Program.

She adds, “Many of these employed, mostly well-off people thought, ‘It could happen to me.' They talked about being uninsured themselves in the past, or about people they knew who didn't have insurance. They also talked about the impact of health insurance on the community as a whole, and of course about helping the less fortunate. On the other side of the debate were arguments about personal responsibility and concerns about ‘free riders.'”

The discussions that led to the group decisions also appeared to affect individuals' decisions when they were asked again to design a health plan for their own families. On this second time around, 66 percent of players chose to pay some portion of their health insurance costs to cover the uninsured, and just under half of those players chose to cover both adults and children.

Goold and her co-authors caution that their results are based on a non-representative sample of people from one state – Minnesota . The players were largely white and employed, and most earned more than $35,000 a year. But the researchers say the findings offer evidence that group deliberation may make it possible for the public to better appreciate the situation facing the nation.

“Extending coverage to the uninsured will, ultimately, involve some tradeoffs,” says Goold, an associate professor of internal medicine at the U-M Medical School. “The question is, what are the American people willing to give up in order to have universal coverage? Our results suggest that, particularly when groups of citizens deliberate on this issue, even those who have insurance recognize and are willing to accept tradeoffs between having more generous health benefits coverage and having coverage for all.”

In an accompanying editorial, Laura Sessums, M.D., J.D., of the Water Reed Army Medical Center in Washington, DC notes that the “surprisingly positive results suggest there may be a hitherto unexplored place for altruism in the effort to cover the uninsured.” She suggests that grassroots efforts to engage the public in debates about the uninsured may want to draw on the CHAT model.

Goold and CHAT co-inventor Marion Danis, M.D., of the Section on Ethics and Health Policy of the National Institutes of Health, have seen their board game and its computerized version used by more than 2,000 people in eight states and two foreign countries in the last five years.

The research just published won the 2002 Marc S. Ehrenreich Prize for Research in Healthcare Ethics, and the CHAT game received the 2003 Paul Ellwood Award from the Foundation for Accountability.

Many employers, governments and non-profit organizations have hosted CHAT sessions to get a sense of the health insurance priorities of their employees and stakeholders. For instance, employers and state health agencies have been able to see and hear how people view different levels of shared cost and access restrictions for office visits and hospitalizations, or how they value traditionally optional benefits such as vision and dental coverage.

CHAT has 16 categories of coverage and each player receives 50 pegs to “spend” in those categories. There are a total of 99 peg holes in the board.

For major categories such as primary and specialty care, pharmacy, long-term care and hospitalization, they can choose from three levels of coverage, depending on how fully they want services to be covered and how much they're willing to pay in terms of cost-sharing, limitations on choice of provider, and convenience.

Categories for tests, scans, mental, dental, rehabilitation, infertility and “last chance” treatment such as transplants have two levels of coverage, as does coverage for the uninsured. Vision, complementary medicine and “quality of life” treatments that aren't medically necessary have one option. Players can opt to forego coverage in any category.

After the health plans are locked in, the health event cards distributed to players give them a sense of how different health situations would be covered – or not.

For instance, those who chose not to cover the uninsured might find that their decision would result in some people having to resort to gas station coin collection cans to raise money for treatment. Or a player who elected to cover uninsured adults and children would find that his laid-off next-door neighbor would be able to receive treatment for a broken leg.

From reading the transcripts of the group discussions and evaluating the types of arguments made in each group session, Goold says the bottom line for many people ended up being the good of the community and caring for the worse-off – mixed in with concern that they or their loved ones might find themselves uninsured some day.

That's not too far-fetched, she adds, citing other studies that 44 million Americans are uninsured at any time, and about a quarter of the insured are worried they will lose their insurance.

In the end, this mix of public-mindedness and self-interest, if brought out through group discussion, might drive national attitudes toward covering the uninsured. “We must recognize the group nature of insurance, with the necessity of interpersonal tradeoffs, and we must use reasons and arguments for and against different policies in an informed and cooperative process,” she says. “We must go beyond what people decide and look at how and why they decide it, both on the individual and group level.”

In addition to Goold and Danis, the paper's authors are Stephen A. Green, M.D., M.A., of Georgetown University; Andrea K. Biddle, Ph.D., MPH, of the University of North Carolina, and Ellen Benavides, a health care consultant who oversaw the project in Minnesota.

Reference: Journal of General Internal Medicine, Vol. 19, August 2004, pp 865-871, posted online at www.jgim.org.