One of the biggest questions facing Americans as the 2004 elections approach involves a tradeoff: Will those who 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, 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, according to the results of a study published in the August issue of the Journal of General Internal Medicine.
To explore whether the insured would help cover the uninsured, the research team based at U-M 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 players had when they worked together as a group to design a plan for their community, the researchers saw and heard how players regarded coverage for the uninsured.
At the start of the game, just more than 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 coverage.
“For many, offering coverage was like insuring themselves against becoming uninsured,” says lead author and CHAT co-inventor Dr. Susan Dorr Goold, director of the Bioethics Program and associate professor of internal medicine at the Medical School.
“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,” Goold says. “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.
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 more on CHAT, visit http://healthmedia.umich.edu/chat/index2.html.
