September, 2006

Introduction

Thirty community forums were conducted in 27 Georgia counties with the goal of educating and engaging business and community leaders in discussions about options for covering the 1.5 million people in the state of Georgia who lack health insurance coverage.  This research was conducted on behalf of the Governor’s Office of Planning and Budget under a State Health Planning Grant awarded by the federal Health Resources and Services Administration, as part of an ongoing research initiative to study the problem in Georgia.  The purpose of these awards has been to collect and analyze data about the uninsured and create mechanisms at the state and local levels for covering those without health insurance.

Four hundred forty-five (445) people participated in the community forums.  Participants included company executives and small business owners, state representatives, county commissioners and mayors, hospital administrators, physicians and nurses, public health officials, attorneys, non-profit directors, community volunteers, members of the media, and others.   A map of the locations where community forums were conducted is provided in Appendix A of this report.

Participants in each community forum were asked to do the following:

•    Rank seven options for covering the uninsured
•    Listen to findings about health status, health care costs and insurance coverage in Georgia, the profile of Georgia’s uninsured population, and trade-offs regarding each of the seven coverage options
•    Engage in a facilitated discussion to gauge the impact of the factual information presented
•    Re-rank the seven options to track changes, if any, in participants’ preferences for covering the uninsured

Through this sequence, the research team expected to learn about community members’ preferences for covering the uninsured and gauge the impact that relevant factual information has on those preferences.

The seven coverage options and their associated trade-offs presented at the community forums are provided in Appendix B of this report.

 
Discussion Dynamics

Following a presentation of data concerning health status, health care costs, and health insurance coverage in Georgia, participants in the community forums were led in a facilitated discussion.

Three specific questions were asked during each community forum:

•    Did any of the information you heard about the uninsured and the health of Georgians surprise you?  What surprised you, and why?
•    Did any of this information make you think differently about the uninsured and how we might expand coverage in Georgia?  In what way?
•    What other information would be helpful to you in making informed decisions about these issues?

Although the questions were targeted to gauge participants’ reactions to the options that had been presented to them, there was little actual discussion on preferences for the options themselves.   The key insights regarding the attitudes of participants about the uninsured that emerged from these conversations are:

•    Most were not surprised by the information
•    Cost is the primary concern
•    Many do not think market forces work in health care
•    They believe focusing on prevention would decrease costs
•    They promote personal responsibility
•    Coverage for the uninsured is clouded by other issues
•    Some say the system is unfair
•    They are frustrated by the options . . . but express a sense of urgency
•    They suggest that the primary question for debate is whether or not health care is a right

Most Were Not Surprised by the Information

Participants were most surprised by Georgia being ranked as the 45th worse state in health status,   A Blue Ridge woman noted, “I’m really shocked about the overall health status of Georgians as compared to the rest of the nation.”  A Savannah man echoed the same sentiment, saying, “I was surprised at how poorly Georgia ranked in each of those categories.”  One woman from Griffin exclaimed, “We’re the wealthiest, most unhealthy country in the world.”  Otherwise, responses to the question of whether they were surprised by the data were unequivocally, “No.”  Even their body language was plain, as participants simply shook their heads in clear disappointment over a health care coverage system that had, in their estimations, gone awry.  As one woman from Jonesboro aptly said, “I would say that I wasn’t shocked, but I was disappointed.”  A Douglasville man stated, “Nothing jumps off at me; I’m an employer, and I can relate to just about everything you said.”   And, a Marietta woman said, “I didn’t think any of it was surprising, but I didn’t know it.  The statistics enlightened me.”

Cost is their Primary Concern

Invariably, the discussion in every group moved quickly to the issue of cost, both of health care services and coverage.  Cost, in fact, was often cited as the primary reason for the large number of uninsured Georgians. 

Costs were bluntly expressed as being “outrageous” and “out of control”, as one Blue Ridge man astutely observed, saying, “We’re paying more for health care than we are for schools now, than for educating our citizens, and there’s something wrong with that.”  A man from Cartersville agreed, saying, “You’re looking at $1.3 trillion this year; that’s 18 percent of the gross domestic product.  More than our national defense is spent on health care.  It’s just spiraling out of control.”  Further, costs were seen as not proportional to the services and products consumers receive.  As a Vienna woman quipped, “If I’m going to give you $500, give me something that’s worth $500.  Don’t charge me $1000 for something that’s only worth fifty bucks.”  And a man from Douglasville complained, “My insurance premiums have gone up a minimum over the last five years of 30 percent a year.  Now there isn’t a human being on the face of this earth who’s going to convince me that the costs have gone up accordingly.  It’s just not possible.”

Others noted the impact of rising health care costs on government and business, as noted by a woman in the Sandersville community forum, who said, “I’m the mayor of a small town with 1500 souls and 35 employees.  We’ve discovered that 100% of our tax dollars, property and ad valorem taxes, go to pay for health care premiums for 35 employees.  Something is wrong with this picture.”  And a man from Vienna observed, “General Motors is paying more for health care than they are for steel.” 

Many expressed their gut-level beliefs that drug companies and insurance companies make too much profit, as one Savannah man implied in commenting that, “It’s not the uninsured that’s causing the premiums to go up, or causing the high cost of pharmaceuticals, or causing physician cost and hospital cost and high technology cost.”  One Perry woman felt that, “our insurance companies are eating us alive, because they’re deciding what we can and cannot have and what the doctors will and will not do for us.”  A man from Tifton observed, “Look at the health care insurers.  For instance, when tort reform was passed here in Georgia, the insurers said, ‘give us tort reform and your malpractice premiums will go down.’  But the malpractice premiums didn’t go down.”   A Columbus man observed that we share in the problem, saying, “We’re subsidizing the hospitals, we’re capping the lawyers, and we’re doing nothing to the insurance companies.”

Others saw rising costs as a function of mandates imposed by state legislation.  As a Jonesboro man questioned, “Mandates drive up the cost of health insurance.  Right now we’re past our childbearing years, but we’re insured for maternity coverage.  I don’t have substance abuse issues, but I’ve got that coverage.  When do we get down to the bare bones of what an uninsured person needs?”  A Marietta man observed, “The concern that my business has, and I think other small businesses have, is that there are 83 mandates on my policy.  I think in this state we should be able to offer a non-mandated plan.”

Participants also acknowledged that an aging population and care add to the problem of rising health care costs.  A Valdosta man stated, “There is tremendous cost in the system that’s related to end-of-life care.  The emergency room is probably number one in cost, but number two is intensive care.  When do you go to the intensive care?  Most of the time it’s in the last six months of your life, or six weeks or six days; and it’s incredible the amount of cost that’s put into that situation, almost to the point of inhumanity at times.”

Doctors’ practicing defensive medicine also was sited as a contributor to the escalating cost of health care services.  A Tifton man posed, “Years ago when you were sick, you went to the doctor and you got a prescription and then you said, ‘Lo and behold, I’m healed.’  But today when you get sick, you go to the doctor and you have to have this test and that test, and a prescription and samples and all sorts of other things.  Is that cost necessary, or is it just covering the doctor?”  The answer to that question was in the affirmative for several participants who blamed malpractice suits and overly-litigious lawyers for causing doctors to perform unnecessary tests.  A man in Lawrenceville observed, “There are lawyers every day on TV that will turn around and sue a hospital if the patient didn’t get good care.”  An Augusta woman questioned, “If my doctor prescribes three tests because of his fear that he’s going to be sued if he doesn’t, what is that doing to the cost of health care?  That would have a much bigger impact than being uninsured.”  And a Sandersville woman charged, “Doctors are not able to use their heads to treat people because of the fear of frivolous law suits.” 

Ultimately, many expressed their fears that rising costs will result in more and more individuals and employers opting out of health insurance coverage.   An Americus woman noted, “Insurance rates are sky high.  It’s no wonder people are just opting out, that they consider not getting insurance.”  A fellow male participant agreed, saying, “Being uninsured is not getting the stigma that it used to have because it’s cheaper for you to just go to the hospital and pay.”  A man in Rome warned, “Employers are very concerned about the rising cost of health care, and some are going to be dropping health insurance for their employees because of that.”  A woman from Augusta agreed, saying, “The costs continue to escalate, and it does get to a point when the larger companies have to take a harder look at it in terms of what (coverage) they can provide.”  A woman from Marietta stated, “I’m a partner in a law firm.  In five years, we just won’t be able to pay what we’re paying now to subsidize our employees.”  And a Valdosta woman summed it up by saying, “Companies are running out of avenues to offer insurance at an affordable price.”

 
Many Do Not Think Market Forces Work in Health Care

A number of participants throughout the community forums pointed out what they considered as a fundamental flaw in the mechanism of the health care system: that market forces do not work, and thus, it is nearly impossible for most people to be wise consumers of health care resources.  Describing the simplicity of buying a home appliance or undertaking a remodeling project – which allows us to make decisions based on our knowledge of costs and benefits – these participants expounded upon the lack of this type of information when it comes to health care.  Their comments included:

“When you go to the doctor, it’s the only place on earth where you don’t know what it’s going to cost you until you leave; you just can’t shop for your medical care like you can everything else.”             Newnan man

“There is no connect between the patient and the cost.”       Hinesville man

 “The health care industry is the one industry that your customers don’t ask what the price is prior to accepting the service.  The rest of us in business have to negotiate a price; the price is always the first discussion.”                                    Albany man

 “There’s no competition between doctors; doctors just say what it is, and we pay it, and we don’t seem to question it.”                   Columbus man

“Demand drives price, and the demand for health care in this country is absolutely, totally out of control.  Everybody just wants everything no matter what the price is, and that is not an economic formula that works.  You break the bank when that happens.”                       Valdosta man

They Believe Focusing on Prevention Would Decrease Costs

Participants throughout these community forums found the overall level of poor health unacceptable and consider this dynamic to be a crucial contributor to the high cost of health care and the number of uninsured Georgians.  As one woman from Savannah observed, “As long as we’re playing catch-up, it’s going to be almost impossible to keep our health care costs under control.  As long as we’re not stressing the importance of prevention and promoting healthy lifestyles, we’ll never be able to afford our health insurance coverage.”  A Columbus woman added, “It’s not always that they don’t have the money to pay the premium, sometimes the insurance companies just won’t take them, because they’re so unhealthy that nobody wants to take a risk.”

These community leaders stressed the need for more emphasis on prevention.   A man in Macon cautioned, “We’re just going to end up going around in circles, because we’re not addressing the true issue, and that’s the health of the population.”  A Lawrenceville man asserted, “I think that everything starts with prevention.”  And, a Savannah woman advised, “Our overall objective should be to make Georgians as healthy as we possibly can, and that’s about prevention.” 

Participants understood the connection between education and health status, and they named education as an essential component in moving Georgians toward healthier lifestyles.  A Thomson woman offered, “There is an absolute correlation in this state between lack of education and health status; no question about it.”  And, a Columbus man observed, “Those that are a little bit better educated understand that there are certain things that you need to do to provide good health care for yourself.  If you’re not educated, you sometimes don’t know certain diseases are going to result form certain types of lifestyles.”  An Albany man asserted, “You have to have a grass roots program to affect how they’re raised and how they’re educated.”  A Savannah woman offered her suggestion, “Right now we’re reaping the problems of children with obesity, diabetes, and all kinds of things, because they’re sitting and sedentary for six hours.  I think we should have statewide intervention and prevention programs.”
                                
They Promote Personal Responsibility

As participants considered the need for better health care education, their conversations inevitably turned to the subject of personal responsibility – both the need for it and the frequent lack thereof.  They did not hesitate to use strong terms and direct language in calling upon each individual to “step up to the plate” and make the lifestyle choices needed to ensure one’s own health and wellbeing and to use health care services wisely.  A Monticello man captured these sentiments when he said, “What we are lacking is individual responsibility.”  Similarly, a Newnan woman said, “I think individual responsibility is the key, at some level people have to be responsible for themselves.”  A Blue Ridge man said, “We ought to, as a society, take responsibility for ourselves.”  And a Valdosta man concurred when he said, “I think you’re going to have to ask people to take some responsibility for their own health.  You can’t let them have a lifestyle that causes the system to spend hundreds of thousands of dollars on them once they’ve reached the crisis stage.”    A Hinesville woman suggested that “everyone needs to buy into being healthier as an effort to decrease health insurance costs and maybe make it more affordable for everyone.”

Participants in several community forums discussed the benefits of offering incentives that would encourage individuals to take more responsibility for their lifestyles.  A Savannah man shared the approach his company has taken, “We are proactively trying to keep cost down by decreasing premiums for our employees that participate in exercise programs, get their blood pressure down, and keep their weight down.”   A Blue Ridge man, agreeing with recent changes to the State of Georgia insurance program, said, “If you smoke, you have to pay more for your premium.  That’s great.”

Coverage for the Uninsured is Clouded by Other Issues

As their conversations developed, participants explored a wide variety of dynamics that clouded their ability to focus on the options presented for expanding coverage for the uninsured.    For instance, when considering that 71 percent of the uninsured lacked coverage either because their employer did not offer them insurance or because they were ineligible for coverage, participants often focused attention instead on the remaining 29 percent of people who do work for companies that offer insurance.  A Rome woman remarked, “Twenty-nine percent of those offered insurance don’t take it; that number is worrisome.”  These participants felt that too many of the uninsured don’t see health insurance as a priority, like the Douglasville man who said, “We have this influx of younger, 30-year-olds who have two incomes, a house note that will choke a mule and two car notes; and they say they can’t afford health insurance.”  Similarly, a Newnan woman commented, “Middle class families are choosing not to pay for health insurance and banking on being healthy.”   A woman from Jonesboro more generously reflected, “Perhaps there are people who are making the choice not to buy insurance but haven’t been educated on the importance of having insurance.”

The problems caused by inappropriate use of hospital emergency rooms and the perilous impact these choices are having on community hospitals arose often.  A Thomson woman explained, “One point I would like to make is that hospitals are the safety net for the uninsured, and we don’t have unlimited war chests to continue to provide the care for those people.  So you’re eventually going to use up or lose a valuable resource in your community if something is not done.”  A man from Sandersville echoed this sentiment, saying, “If we don’t do something about the uninsured, community hospitals will not be able to survive.”

As they reflected upon the issues at hand, some participants were unable to separate their thoughts about the uninsured from those on Medicaid, particularly in terms of perceived abuse and difficulties in navigating the system, as a man from Griffin expressed, saying, “We just went from dealing with one entity for Medicaid and now we’re dealing with three entities through this managed care.”  A man from Dublin reflected, “I think we need to do more investigation into who qualifies for Medicaid and PeachCare.”  And a Jonesboro man summed up, “The hard thing is that Medicaid has a lot of waste, fraud and abuse.” 

Likewise, the pressing issues of undocumented immigrants, who are obviously uninsured, clouded participants’ considerations of uninsured citizens, as demonstrated in these comments:

“Seventeen percent of documented uninsured is a big undercount of  the actual uninsured in the state.  All of the undocumented residents just balloon that number even further.”                  Lawrenceville man    

“How many of the uninsured are illegal aliens?  Is there any data to show how many dollars Georgians have to spend for people who shouldn’t be here in the first place?                             Griffin man

“You have to take undocumented workers into consideration in anything that we do.  More than 50% of the people going to the emergency room don’t have a legal address.”                           Jonesboro man

“There’s a lot in the news right now about illegals, and we have no idea in Dublin, Georgia, how many illegals we have.”             Dublin man

“If you’re an undocumented worker and go to the emergency room, you get all the care you need.  That’s what’s driving up a lot of the cost.”                                             Marietta man

Some Say the System is Unfair

Some participants were able to empathize with the plight of the uninsured, recognizing that there are many low-income workers who simply cannot afford to feed their families and also pay for health insurance.  As one Columbus man explained his view, “Some people don’t have a choice.  They either take a full paycheck home or decide they’re going to pay a big chunk of it for health coverage.”     Many reflected that a system that charges one amount to those with coverage and a far greater amount to those who lacked it, and were probably least able to afford it, is inherently unfair.  A Jonesboro man questioned, 
“Why is it costing somebody that’s uninsured more than it’s costing somebody else?”
An Albany man noted, “If you’re sick and you’re not insured, you pay more than anybody else does.  It’s a very unfair system.”  A Macon woman wondered,  “I have to pay $300 for a physical, but when you have insurance, they only charge the insurance company $75.  How is that justified?”

They are Frustrated by the Options . . . But Express a Sense of Urgency

When participants were pressed to reconsider their preferences for the seven options provided, the vast majority expressed frustration with the options themselves, voicing their opinions that the options are just more of the “same old thing” that has not worked in the past and that nothing new or creative was being offered.

As one woman from Savannah stated, “I’m feeling very frustrated about all those choices.  They’re all just variations on the same theme.  There’s nothing new and helpful.”  And a Macon man tactfully said, “I think we need to be a little more creative in our approach to solving these issues.”

Little hope was given to true cost savings as an outcome of the options presented, as a Griffin man observed, “It’s just a shell game based on what you showed us.  You pay now; you pay later.  You can package it in different ways but you’re not really accomplishing anything.”  An Augusta woman stated frankly, “These (options) just shift cost; they don’t reduce cost.”  And a man from Valdosta felt strongly that discussions about options for covering the uninsured are moot until we get a handle on the cost of care.  He had this to say:

“We all know that (keeping the current system) is not the answer.  Another option would be to reinvent the system and let’s become a proactive system instead of a reactive system, and let’s get control of the cost of health care (first).  Only then can we go back and address individuals who choose not to carry coverage.  Society has got some hard decisions to make.  The solution is not just simply shifting dollars around; the solution is getting control (of health care costs).  It’s an economic equation like any other economic equation. ”

Multiple participants regarded the options with skepticism and expressed a need for more detail, especially regarding the cost versus benefit of each option.  A man in Perry said,   “I think to make a more knowledgeable decision on this, we need more information in regards to cost (of each option).”  A Thomson man requested a “cost-benefit analysis” of each option, a Rome woman felt she could make better decisions about the options if she knew “what an average insurance policy would cost for a family,” and a Lawrenceville man wanted to see the “financial impact of these alternatives.”

However, participants were united in their view that employers cannot  bear the financial burden of covering the uninsured.  As a woman from Tifton observed, “Here in our Chamber, we get a 5% discount on Blue Cross and Blue Shield.   I think we have about 75 people (members) participate.  But even with that discount, some people (businesses) still can’t afford it; it’s still high.  So you can mandate all you want, but if you can’t afford it, you can’t afford it.  A Monticello man said, “Whatever health care decisions we make, they must be made to where our companies can compete in a global marketplace.”  A man from Griffin echoed this train of thought, saying, “Competitiveness of employers in a global economy is a very, very important factor.  If we put too much more health care cost on them, we’re going to cause American businesses to be less competitive.”  A man from Perry summed it up simply by stating, “I’m not for putting it back on business.”

Of note, a number of participants seemed open to considering the single-payer system option, as demonstrated by the following comments:

 “By having national health insurance, you would eliminate 35% of your marketing costs with insurance programs now and it could almost be self-funded through the elimination of marketing costs.”             Monticello man

“In my opinion, I think that the single-payer system would be the most suitable because all Georgians would be covered.”             Milledgeville man

“The single-payer (system) does sound good, as long as it’s tiered to where low income (people) could afford it.”                       Perry woman

“I’m a firm believer that we need to go to a single-payer system.”                                                Savannah woman

“I like the idea of a single-payer system as a way to control health costs.”                                                Tifton woman

 “We need socialized medicine where we all pay taxes and everyone has health care.”                                   Athens woman

Ultimately, all agreed that the system is more than a little complex and that solutions will not be easy to find, as these comments reveal: 

“This thing will have to be worked out through federal, state and local levels.”                                     Sandersville man

“It’s a very complex issue and it’s hard to really come up with anything radical that changes the way you look at it.”                     Griffin man

“This is not an isolated issue.  It’s an issue of how many people can’t get jobs; (it’s an issue of) transportation costs.  All of these things are wound up together.  It’s a very complex issue.”                   Albany man

“Each one of the options we looked at has unintended consequences.  It’s hugely complex and we have to do the research behind it.”
                                        Monticello man

One participant, a man from Newnan, voiced the beliefs of many who felt overwhelmed, saying, “There’s just no magic.  There are just so many working parts, and I can’t get my arms around it.”  A man from Marietta observed, “This is very complex.  No matter what solution you come up with, there are challenges impossible to that solution.”

Participants agreed that a combination of approaches will be necessary, noting, like a Savannah woman did, that, “It’s going to have to be a systematic approach all the way across the board, because it’s not just one problem.”  A Milledgeville woman agreed, saying, “I think the solution is going to be a combination; no one thing is gong to do it.”  A woman from Athens joined this train of thought, stating, “We need to combine several of these options to make a comprehensive, workable plan.”  And a Thomson woman stated, “Clearly the answers lie in some combination of everything that’s on this paper.”

But regardless of the complexity in finding solutions, participants throughout these community forums voiced one message loud and clear – the time for solutions is now, and the need is urgent.  As a Decatur woman said, “Georgia has to make some changes fast.”  A Columbus man aptly stated, “You’d have to live under a rock not to know that there’s a huge health care crisis.”  A woman from Savannah alleged, “Our state needs to do more for health care for the uninsured.  Nothing is being done; no one is looking at the real figures and then putting an action plan in place to do something about it.”  And a Thomson woman said, “The current system clearly isn’t working, and the longer that goes on, the worse that situation gets.”

These community leaders believe that the health care system, as characterized by exorbitant costs and lack of coverage, is a failed system that is “teetering on the brink of collapse,” according to one man from Albany.  “Obviously, something is not working,” said a fellow male participant.  “If we don’t do something, the whole system is going to flop,” a third Albany man agreed.  One participant, a man from Monticello, observed, “If we don’t address the issue of health care, it’s a train wreck waiting to happen.”  A woman from Macon said, “We need to do better; it’s embarrassing to me.”

One man from Savannah observed that, “We’re the wealthiest country in the universe; nobody can touch the resources we have.  And we can manage to find plenty of money to send to Iraq, but we can’t seem to take care of our own people’s basic health care needs.”  A woman from Thomson made this sad indictment: “It shows that our priorities are not on health care.” 

The primary question for debate is whether or not health care is a right

An unanticipated question emerged as participants grappled with the issues presented to them during the community forum:  Is health care a right?  And, if so, at what level?  For many participants, any further consideration hinged on the answer to that fundamental question, and in their views, answering this question must be the first point of debate.

For some, the answer was an unequivocal “Yes,” as expressed by a woman from Athens who said, “Everyone having access to good health care is a right.  Until we decide that, we will get nowhere.”  A man from Milledgeville agreed, saying, “I think all Americans deserve health care.” A Douglasville man joined the chorus, saying, “The nation provides health care for all individuals; I mean, that’s part of our responsibility.  It’s part of our moral responsibility and its part of our social responsibility to see that everyone in this country is healthy.”  And a Columbus man was emphatic when he said, “I believe that everybody deserves adequate health care.  Basic care, as far as I’m concerned, is just an inalienable right.”

Others were less sure in their views, like the Griffin man who said, “The question is whether health care is a right versus something we all have a responsibility to pay for like groceries.  That’s the fundamental question.  Then, what right should exist?  What level of health care?”  A Marietta man lamented, “There’s a desperate need to find out where you draw the line, and say we’ll pay for this but we won’t pay for that.  You’ve got to say ’No’ to somebody at some point in time, and it makes it really challenging for health care.”  A man from Lawrenceville described the dilemma, saying, “I think the elephant in the room is (to define) what coverage is (what we’re going to cover).  Is it catastrophic insurance because I’ve been involved in a motor vehicle accident, or is it a tummy-tuck because I’m overweight?”

Regardless of the surety of their views, most participants agreed that a fundamental exploration of where we stand as a society might be necessary to move forward.

Conclusions

•    Coverage for the uninsured is overshadowed by alarm over rising health care costs.

•    The problems are minimized by a focus only on those who choose not to purchase.

•    Concerns with Medicaid and immigration become co-mingled with and often cloud considerations about the issues of the uninsured.

•    There is a universal recognition that the current health care consumption and coverage system must change, coupled with an acknowledgment that doing so will be extremely complex and difficult.

•    The overwhelming perplexity of the subject leads participants to choose preferences that will bring benefit in the short term, namely making insurance market adjustments and providing tax incentives and subsidies.
 

Options

1.    Insurance market adjustments to encourage change in what and how health insurance is sold in Georgia –
Change the regulations governing health insurance to make it more affordable and easier to purchase, such as, establish a high-risk pool, allow association plans, promote health savings accounts and the like.

2.    Tax incentives/subsidies –
Financially assist employers and/or individuals/families with the purchase of health insurance through direct payments or tax reductions.

3.    Employer mandates –
Require employers of a certain size to offer coverage to their employees.

4.    Individual mandates –
Require uninsured individuals to purchase health insurance for themselves and their families, similar to care insurance mandates.

5.    Public expansion –
Expand tax-funded programs such as Medicare, Medicaid, and PeachCare to cover more low-income Georgians.

6.    Single-payer system –
Establish a system that pays for the health care or health insurance premiums for everyone in Georgia.

7.    Do nothing to expand health insurance coverage –
Keep the current system as is.

Trade-Offs to Consider

1.    Insurance market adjustments to encourage change in what and how health insurance is sold in Georgia –
Making adjustment to how we sell insurance will not disrupt the current system but will enable a relatively small number of Georgians to gain insurance.

2.    Tax incentives/subsidies –
Tax credits and subsidies can help those with low incomes afford coverage.  To be fair, they must be provided to all who are eligible – even those already insured; thus, the overall cost per newly insured is high.

3.    Employer mandates –
Employer mandates may decrease tax expenditures to cover the cost of the uninsured but may also result in lower take-home pay, and that effect may be greater for small employers than large employers

4.    Individual mandates –
Mandating individual coverage would require major changes in the market to make insurance affordable and potentially increase the cost for sicker individuals due to reduced pooling of risks, but it might promote greater individual responsibility

5.    Public expansion –
Public expansion may decrease health insurance premiums and out-of-pocket expenditures for everyone, buy may also increase taxes for everyone

6.    Single-payer system –
A single-payer system may eliminate health insurance premiums and out-of-pocket expenditures for everyone and increase access to primary care, but will increase taxes and may reduce access to some types of specialized care

7.    Do nothing to expand health insurance coverage –
Doing nothing does not disrupt the system, but will result in continued health care cost inflation and more uninsured Georgians