July 2008

Executive Summary

Georgia Health Decisions conducted a qualitative research study with selected residents from across the state of Georgia to understand residents’ attitudes on a range of health related topics. This research sought to:
•    Identify  and describe issues of health care access and health insurance coverage
•    Discover attitudes about universal health coverage and access to health services
•    Understand perceptions of quality of health care services received
•    Explore participants’ knowledge regarding healthy living and gather personal assessments of healthy lifestyles
•    Understand Georgians’ awareness of, experience with and attitudes toward Georgia’s PeachCare program

A total of 114 focus group participants from 12 counties attended 12 focus group discussions. Georgia Health Decisions utilized the Demographic Profiles of Georgia developed by the Georgia Division of Public Health as the methodology for identifying and recruiting participants for the focus groups. The Demographic Profiles methodology creates Georgia-specific demographic clusters from census data variables including: age, income, family structure, housing value and housing type, education and employment type. This report details the findings from the focus groups conducted across the State of Georgia.

Insurance Coverage

Participants were asked about the current status of health coverage for themselves and their children.   Forty-five percent of participants had employer-sponsored health insurance, although several of these participants said their children were covered by either Medicaid or PeachCare.   There was at least one uninsured person in 11 of the 12 groups.  In total, 29 percent of participants were uninsured.  Participants recognize the importance of health insurance. Parents participating in the focus group discussions felt very strongly about ensuring that their children had health insurance coverage, and most participants felt that having insurance coverage themselves was important as well. Multiple participants described career choices as being dictated by the cost, quality and availability of health coverage for themselves and their families. Participants across the 12 focus groups recognized the tenuousness of having health coverage tied to their employment and many were concerned about losing coverage.

Across the 12 groups, four parents reported having uninsured minor children. One mother insisted that she could not afford health insurance coverage for herself or her children but had not explored the cost of such coverage in some time nor explored the option of having her children covered under the PeachCare program. A Dougherty County mother and her three children had been left uninsured due to her recent separation from their father who had changed jobs and no longer had employer sponsored coverage. She had applied for PeachCare for her children but been denied. A man who holds Canadian residency decided not to include his children in the employer sponsored policy he has for himself because the coverage for his children is too expensive. They have lived in Georgia for three years, but his children receive their primary care in Canada.  A Dekalb County woman reported having been unable to pay the monthly PeachCare premium for her children after she fell behind on her bills and was waiting out the three month freeze to be able to reapply for benefits for her children.

Experiences with and Attitudes about PeachCare

In all 12 focus groups, at least one participant indicated having experience with the PeachCare program either through current or previous coverage for their children. These parents recognized the importance of health coverage for their children and often expressed gratitude for their access to the PeachCare program. For many, PeachCare has been the sole source of coverage, and their children have remained on the program consistently for a number of years. Others viewed PeachCare as a method for covering their children only during lapses in their ability to provide private insurance coverage for them. A few parents reported choosing PeachCare coverage over their employer-sponsored plan in order to save money, oftentimes because the employer-sponsored health plans are outside their reach financially. Many parents learned about PeachCare through the school system, the Department of Children and Family Services or through their employers.   

The majority of participants who had experience with PeachCare described the benefits as excellent, often better than those offered through private insurance plans. Many appreciated the dental coverage and pharmaceutical benefits. However, some participants, especially those in more rural areas of the State, described struggles with locating physicians who would accept PeachCare and many had to travel long distances to access specialists for their children. A few parents perceive that their children do not receive the same quality of care and bedside manner because they are on PeachCare rather than on a private insurance plan. Hassles with the PeachCare application and renewal processes constituted the majority of the complaints expressed by parents in attendance at the focus groups. Their primary issues were with the amount of paperwork that is required and delays in responses to applications.

Most participants without personal experience with PeachCare were somewhat familiar with the program but did not know the specifics of who could qualify, what type of coverage was available, or how one would apply for the coverage. With few exceptions, participants in all 12 groups voiced their support for the concept of a government-sponsored health insurance program for children and expressed no concerns about their tax dollars being spent to take care of the health of children in Georgia.   

The Issue of the Uninsured in Georgia

When questioned about their perceptions of uninsured Georgians, participants were empathetic toward those who lack health insurance coverage. Almost one-third of focus group participants were uninsured at the time the focus groups were held and many more indicated that they had been uninsured at one time or knew of family members or friends that were uninsured.  When asked who were most likely to be uninsured in Georgia, focus group participants noted that a health care system based on employer-provided insurance meant that the unemployed, the self-employed and those with part-time jobs were most likely to be uninsured because they did not have access to affordable coverage.    

The high cost of health insurance premiums was by far the dominant reason given for why so many Georgians go without health insurance coverage. A recent job loss was the second most frequent reason given as to why participants in the focus groups were uninsured.  

Several uninsured participants readily discussed the impact that being uninsured has had on their health and their finances. Multiple uninsured participants reported going without needed medications, or foregoing accessing health care services for fear of incurring substantial debt or of uncovering a health issue that they would be unable to get treated without health insurance to help cover the cost of care.   

Universal Access and Health Care Coverage

The Georgians who took part in these 12 conversations were clearly conflicted in their views and attitudes regarding access to care and health care coverage for everyone. With only a few exceptions, participants strongly believed that everyone should receive the health care services they need regardless of their ability to pay.  While there was some debate as to what is meant by the term “need,” participants universally agreed that everyone should be treated for serious illnesses and provided necessary medications for chronic conditions. Additionally, most saw the value in long-term savings by providing preventive services and routine primary care. However, these Georgians were equally strong in their assertions that everyone should also pay something for their care. Participants talked about “sliding scale” services as a way to ensure that people were taking responsibility for their own health and participating in their care, rather than depending on someone else to provide their health care for them.

These Georgians’ assertions that everyone should receive the health care services they need do not necessarily translate into a support for “universal health care.”  In every group, a few participants were either in solid support of or adamantly against the concept of universal health care. Those who support universal health care saw it as “fair” and consistent with the United States’ values of democracy and equality. Some participants who support universal health care noted that money currently being spent abroad would be better spent on health care domestically.  Those who immediately rejected the concept of universal health care often used terms such as “socialism” and “government controlled” to express their opposition.  Those participants equated “universal health care” with nationalized health care paid for and administrated by the government and expressed concern about the consequences of having government control exerted over their choice of physicians as well as government-controlled access to care.  

The majority of participants in these groups were undecided but willing to discuss what might be the positive and negative aspects of universal coverage.  These participants liked the idea that everyone would be covered but shared several of the concerns of those that were adamantly opposed to universal health care related to fears of “government-controlled health care” and how it might be paid for.

Participants had a similar debate about individual mandates to purchase health insurance, although many more were willing to consider this possibility over a government-run health care system. Because residents would be able to maintain their private insurance plans, the issues of loss of quality care and long waits did not emerge in the discussion about individual mandates. Those that expressed reservations were more concerned about losing their freedom to make a choice about purchasing insurance and the price tag that would be associated with providing assistance to those with low incomes.  

Quality of Health Care

Focus group participants were asked to describe their experiences with the health care system. Across the state, participants were tepid in their responses when asked about the quality of care they receive from physicians and other health care providers and facilities. While some were quick to say that they receive excellent or good care, most were less enthusiastic. Participants often associated quality of care with the relationships they have with their physicians, and they perceive pressure from their doctors to be in and out of the examining room quickly.   

Participants’ harshest criticisms were directed toward hospitals, with those in more rural parts of the state being most critical of the quality of care provided by their local hospitals. Several told personal stories of themselves or a family member having received negligent care. A few were adamant in their assertions that they would never be a patient at certain hospitals because of their perceptions of the quality of care provided at the facility.

Personal Choice in Health Care

With the exception of those who were uninsured, all participants acknowledged the limitations on their choice of physicians, hospitals and other health care providers placed on them by their insurance companies.  However, within these limitations, participants do exercise personal discrimination when making their choice of physicians.  “Word of mouth” and “references from friends” were most often cited as the factors in making such decisions.  A number conducted research through the internet before deciding on their physician.  Participants use less personal discretion when deciding on their hospitalizations, noting restrictions by insurance companies and the necessity to utilize the hospitals of their physicians’ choice.

Cost of care is rarely a factor in participants’ health-related decisions. Most participants are unaware of the cost of their care and do not know how to access that information. Some participants noted that they would be hesitant to go for the “cheapest” health care, citing concerns about quality.  

Health and Healthy Living

Participants were asked to describe what they understood to be the components of a healthy lifestyle.  The majority held a similar concept of what it means to lead a healthy lifestyle; they mentioned eating right, exercising, getting sufficient sleep, managing stress, getting annual physicals and avoiding drugs, tobacco and excessive alcohol. Participants across the groups assessed their own health and lifestyles and described barriers to healthier living. The barriers to living a healthier lifestyle include: lack of time due to demands from work and family, cost, the school system and lack of motivation.

Lack of time: Participants reported working long hours and multiple participants work more than one job to support themselves and their families. Their work load leaves them feeling stressed and exhausted at the end of the day and unable to carve out time to exercise on a regular basis. Coupled with long work days, many parents in the focus groups described the time and energy required to keep up with their children’s busy activity schedules (e.g. sports games, classes, and other after school activities). These demands on families’ time often lead participants to make meal choices based more on convenience than nutrition. Many described stopping at a fast food restaurant between activities to pick up dinner for the family.

Cost: For a large number of focus group participants, the cost of healthy foods such as fresh fruits and vegetable and lean meats and fish is prohibitive. In every focus group, participants observed that a meal from a fast food restaurant is significantly cheaper than buying vegetables from the grocery store to make a salad. Cost is also a factor in people’s access to physical activity opportunities. Multiple participants noted that most families cannot afford to join a gym.

School system:  Parents often cited schools as barriers to their children’s healthy behaviors. Throughout the state, they complained about the quality and nutritional value of the food served in school cafeteria and vending machines. Much of the food served, they observed, is fried and high in fat and calories. In addition, schools are cutting physical education classes and recess. Parents stated that schools should be playing a more active role in teaching children healthy behaviors.

Lack of motivation: In many cases, participants acknowledged that they could overcome external barriers to living healthier lifestyles, but lacked the discipline and the motivation to do so.

When asked what might motivate them to take steps towards leading a healthier lifestyle, participants most often responded that “more time and more money” would be the greatest motivators. Multiple participants observed that they are not likely to make lifestyle and health-related behavior changes until they are faced with a health issue. Across the state, participants reported that having a heart attack, developing diabetes or high blood pressure, or having someone close to them fall ill would most likely motivate them to change their health-related habits.  Education on strategies for disease prevention and healthy living was also mentioned as key to motivating healthier behaviors. Participants stressed the importance of teaching good habits to children early and expressed their hope that schools might take a more active role in instilling those good habits.  Participants across the state said that decreases in insurance premiums and employer incentives for healthy living would be strong motivators to change their lifestyles. Environmental factors like more access to safe recreational spaces in their communities and community-wide health information campaigns and challenges were also cited as potential motivators.

Personal Responsibility for Health

Participants discussed the role of personal responsibility in maintaining a healthy lifestyle. While most believe that the ultimate responsibility for maintaining their health and healthy lifestyles lies with each person, participants acknowledged that other individuals and institutions play a role in enabling and supporting healthy habits.  Parents and spouses have a lot of influence on health-related behaviors, as do employers. Participants expressed the desire to see their medical providers take a more active role in supporting healthy living by spending more time with them and providing them with education and strategies to improve their health that go beyond a pill. The majority of participants was resistant to the idea of the government playing a role in people’s lifestyle choices, but did see a place for government in the promotion of health and healthy living through educational campaigns and the protection of the food supply.

When asked whether individuals who lead unhealthy lifestyles should be penalized, there were strong opposing positions across the state. Several participants felt that people who have unhealthy habits like smoking should be required to pay more for their health insurance coverage. They view this as fair given that individuals chose to engage in unhealthy behaviors and should have to face the consequences for those behaviors by paying higher premiums.  Others disagreed, calling such a penalization “unethical” or “discriminatory.”  They expressed concern about how and when the penalties might be applied. While participants seemed to accept the argument of penalizing smokers, they were less clear on how to determine whether someone was overweight, or suffered from hypertension or diabetes, due to lifestyle choices or genetics.  Participants across all 12 focus groups seemed more comfortable with the idea of rewarding those who live healthy lifestyles with reduced insurance premiums or employer incentives rather than penalizing those who do not.

Setting Priorities

During the focus groups, participants discussed at length three major topic areas related to health and health outcomes:
•    Access to health care
•    Quality of health care services
•    Leading healthy lifestyles

When asked which issue they thought was most important for the State of Georgia to address, sixty-five percent of participants felt that finding ways to expand coverage for the uninsured should be the state’s top priority.  They saw this strategy as a way to drive down the cost of health care for everyone else and would be more likely to ensure better health outcomes in the state. Twenty-nine percent of participants want the state to focus on promoting healthy lifestyles. They argued that keeping people healthy would reduce the cost of insurance as well as the demand for health services, making insurance more affordable and expanding access to coverage for those currently unable to afford it. Finally, sixteen percent of participants felt that improving the quality of care was the most important issue to address. The strongest support for this focus came from residents in rural Georgia, many of whom had higher levels of dissatisfaction with the quality of care they receive in their communities.