One week ago today, on a rainy post-snowstorm Sunday afternoon, Sarah and Tas Philp of West Seattle welcomed about a dozen people into their home — not for a holiday party, but for a discussion to help the incoming White House administration decide how to handle an issue that truly touches us all: Health care.

It started with a page on Change.gov, the transition website set up by President-Elect Barack Obama‘s administration, asking for volunteers to hold meetings about health-care reform (here’s the transition’s official page for that issue in general).

The open invitation came from an Obama Administration nominee with West Seattle ties – Health and Human Services Secretary designate Tom Daschle, whose brother Steve Daschle runs Delridge-based Southwest Youth and Family Services. (The former senator keynoted last year’s fundraiser breakfast for SWYFS; here’s our coverage.) He attended a few of the meetings in other areas of the country: here’s a slideshow from Change.gov (looks like a much more formal roundtable – the one we covered was more like a conversation salon):

The Philps are especially interested in the topic — particularly since Sarah works as a family-practice doctor — so they volunteered, and set the date for last Sunday (the deadline was “any time before December 31st”). They invited friends, relatives, even WSB’ers (via a last-minute Forum post). They believe this might have been the only such gathering held in the Seattle area. (Change.gov published an update on some of the meetings held elsewhere in the country; you can see that update here.)

Once they signed up to host the meeting, they received a packet from the transition team, with ground rules and suggested discussion topics. The Philps decided to split the gathering into two groups; we observed one group’s discussion but also received a copy of the full report they sent to the transition team a few days later, so we could share it with you (later in this story, or jump to it directly now).

At the table we observed: Tas, as moderator/note-taker; Mick and Larry, two members of his family; neighbor Monica; friend Janine; visitor Diane.

The group first talked casually about their impressions of major problems with the way health care works — or doesn’t work — in the U.S. now. Mick noted that while he’s “always had pretty good health insurance,” he’s “struck by how much money we spend on health care and how little we get in return.” Janine, who was expecting to lose her insurance soon because of a status change – but ironically is going to work in the health-care industry in the future – noted that being without insurance tends to mean, “You neglect your health.”

Monica had a unique perspective, having lived for 2 1/2 years in France, which has universal health care. “They pay a lot in taxes, but their quality of life is much better,” she recalled. “If you have an ache in your stomach, you go to the doctor and get it taken care of – you don’t put it off.”

Talk next moved to what might be the reason for inefficiencies and high costs of health care in the current system. Several participants suggested that many doctors may be overpaid, while acknowledging that they are aware of the expenses involved with the profession, such as malpractice insurance. Monica wondered why she’s been charged the same whether she sees a doctor or a nurse practitioner, suggesting that she would expect cost savings from consulting with the latter. Diane shared a similar experience, and mentioned a health-insurance plan that had required her to see a doctor even though she could have seen a nurse practitioner instead.

Steering the discussion further toward a search for solutions, participants lamented the lack of focus on preventive care, which could ultimately save some of the money spent on expensive “reactive care” when a preventable condition is finally diagnosed.

Prevention was a big theme for Larry in this part of the discussion. He brought up memories of the President’s Physical Fitness Challenge in the ’60s, with Mick chiming in that people are too sedentary and need to “get moving again.”

Later in the gathering, prevention surfaced again, and it was suggested that certain preventive procedures should be universally offered, regardless of insurance — flu shots, for example. “That costs money,” Mick noted. “But how much are you saving,” Diane countered, “if you’re stopping people from getting sick and dying?”

However, Monica cautioned, it would be important that universal access not translate to universal mandate. Reminders, the group agreed, would be beneficial, rather than requirements.

Another discussion question from the packet: What should an employer’s role be?

Monica said she considers it “weird” that the responsibility falls on employers: “It’s really annoying to have to change providers whenever you change jobs,” especially when you have built a relationship with a health-care provider.

From the employer’s view, Mick suggested that providing insurance can be costly enough to jeopardize a company’s economic health: “If you are a small business person, it can be a backbreaker.”

Larry observed that “we have a 1940s, 1950s system … (but) people are living longer now.”

Diane suggested that health-insurance security could stimulate entrepreneurialism: “We need to feel free to start businesses and know we’ll still have insurance.”

Most agreed that the system needs to be coordinated, so it’s more seamless if you have to change providers (or if you change jobs; there were no kind words for COBRA, which is difficult for people to afford once they have left a job, voluntarily or involuntarily). While privacy concerns were raised, it was also suggested “the sensitive information gets shared anyway.”

Coverage equality also came up. As Mick put it, “Why should ANYBODY have better insurance than anyone else?” He said this has occurred to him while working at his teaching job – looking at the kids in his class, knowing their families have different economic circumstances, and therefore the kids likely have different levels of coverage — “why?” he asked, again.

Ultimately, this group agreed, it’s not the government’s ultimate responsibility to make sure everyone’s healthy – a “cultural shift” toward personal accountability should be encouraged too. They also expressed optimism that, as Larry put it, “The new administration DOES seem to be listening.” (Change.gov solicits opinions on a variety of topics – here’s one jumping-off page.)

As mentioned earlier, the Philps put together a summary to send to the Obama transition team, as per the ground rules of the meeting. Here’s what they assembled from the notes of both groups’ discussions last Sunday afternoon:

Summary of Responses from Discussion Questions:

1. What does the group perceive as the biggest problem in the health system?

Group 1 Our group could not agree on a single “biggest” problem in health care, but instead chose to focus on three: costs, structure and “morals.” We agreed that a more organized, national system could control costs by reducing paper work, controlling medication costs and curbing the influence of profit-driven insurance companies. One participant thought that a careful analysis of the costs of the current system would be a helpful guide. Another thought the very high salaries some specialist doctors receive must add to costs. We also discussed how using lower-trained providers when appropriate (and doing so consistently) could reduce costs. As for structure, we would like to be able to use what works in other national systems, focus on prevention, have a consistent set of rules that everyone follows, allow for longer appointments and improve communications between doctors and patients. We discussed how the current system discourages people with insurance from taking a risk or changing jobs. One participant pointed out that simply spending money is not the solution, but eliminating waste and focusing on results is more important. As for morals, we feel that it is wrong to have a system that excludes some while allowing others to consume resources so flagrantly.

Group 2 The lack of a coordinated system of any kind has led to wasteful utilization and poor access and outcomes. There is no “system” at the level of the individual, community or nation. As a result, access, prevention, public health and other low-cost high-yield interventions have been overlooked. What we have instead is a specialty and disease-oriented patchwork based on a business or profit model which has an interventional bias the patient does not typically want or need.

2. How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers?

Group 1 Our group chooses doctors in a range of ways, from word of mouth to interviews to having the choice made for them by their insurance plan. We discussed how a standardized rating system (based on outcomes and perhaps also on patient reviews) would be very helpful. Such a system would need to be carefully structured so that variables (types of patients, practice setting, specialty, years of experience etc) would not hurt a doctor’s rating. Rating the group a doctor belongs to would help. An outcome-based rating system for hospitals would also be useful.

Group 2 Three participants chose a doctor by looking at the doctor’s on-line or published philosophy of care or personal interests. Two participants used location primarily or stated they didn’t actively choose their provider. One thoroughly researched the doctor through local “top doctor” articles and carefully matched the provider’s attributes to his own preferred specifications. The group did not believe that public policy needed to promote quality care providers apart from promoting medical education, including lowering the cost for same.

3. Have attendees or their family members experienced difficulty paying medical bills? How can policy makers address this problem?

Group 1 Most in our group either had personal experience with difficulty paying bills or knew someone who did. Policy makers need to provide a good basic health plan for all Americans so they can avoid the potential financial disaster of being uninsured.

Group 2 Insurance should be required so there are no unaffordable bills for unexpected illness or injury. Insurance choices and coverage options should be simple and easy to understand, no more complicated than a typical recipe.

4. In addition to employer-based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

Group 1 Our group was a little confused by this question. We couldn’t tell if it was asking if we wanted the option of a non employer-based plan or of an employer-based plan with the option for additional coverage. Either way, we would like to see a basic plan for everyone and options for additional services to be paid for out of pocket (or as an additional employee benefit). As a practical issue, optional additional coverage will most likely be needed to sell the plan to the American public.

Group 2 The group wanted multiple viable options, including employer-based coverage, private individual plans (as above) and public plans. Coordination of services was again encouraged. The development of the Health Center, which would house services for people of a community regardless of their coverage, was recommended. This could include mammography, immunizations, health promotion and prevention efforts and events, etc. The concern was raised that public systems are often confounded by special interests and that efforts would need to be made to prevent this.

5. Did attendees know how much they or their employer pays for health insurance? What should employer’s role be in a reformed health care system?

Group 1 Most of the people in our group did not know precisely what their coverage cost their employers. We did not have a strong opinion about the role of employers in providing care, but did feel that any large burden might make employers less likely to take on new employees and that this could hurt the economy. Also, any employer-based plan would need to be transferable in the event of changing jobs.

Group 2 Half the participants knew the cost of their health care. Employers should participate in incentives for healthy habits among their employees. Example: Day off to participate in an athletic event. Bonus $ or time for those achieving health goals. There was a general sense that as non-employer based plans were made available that some employers would eventually stop giving health care as a benefit.

6. Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help?

Group 1 Our group identified preventative care as a major shortfall of the current system. Many in the group were not receiving consistent preventative care. One felt that inexpensive but important treatments (such as flu shots and cholesterol screening) should be more accessible. We also felt that an important component to preventative care should be education, and that this education should take cultural differences (region, ethnicity, education level etc) into account. Perhaps some of this work could happen in schools.

Group 2 See Below

7 How can public policy promote healthier lifestyles?

Group 1 We were very excited about this last question. We discussed how a “cultural shift” is necessary to change general attitudes about health. We’ve seen this before with attitudes toward smoking, seat belts and drunk driving. Americans put a man on the moon, why can’t we provide good basic health care for all of our citizens? One participant referenced the Kennedy-era school fitness programs as a good example. Another participant would like to see a focus on obesity, smoking and alcohol use. We discussed how policies could reduce the amount of junk food in schools. We also discussed how government subsidies for farmers, at some level, contribute to the poor diet of Americans by making corn syrup (and other processed food ingredients) so cheap. We also discussed changing laws to make it harder for drug companies to produce confusing direct marketing to patients. This culture shift could be achieved by a mixture of legislation, educational programs and publicity.

Group 2 The group combined Questions 6 and 7, as prevention and healthier lifestyles can be promoted similarly by public policy. Suggestions included placing preventive services and health promotion education within communities at the above-mentioned “Health Center” and/or within schools, current community centers, grocery stores or any other place to boost ease of access to same. Fitness incentives (like gym membership discounts and prizes for attaining goals) and disincentives for bad choices (like cigarette taxes) were suggested. It was agreed that some other countries do a very good job of this and should be studied. There are also good examples of our own country effectively marketing social change (such as reduction of cigarette smokers- we’ve all seen the black lungs!). The group also wanted to note that public policy choices that include war directly reduce the available resources for public health.