Background and Format

From its founding, the Maryland Citizens’ Health Initiative considered it essential that the voices and concerns of Maryland residents be primary influences in the development of health care for all proposal. As a core component of our grassroots approach to health care reform, the Initiative planned a series of open town meetings across the state. Through these meetings, we hoped to solicit the personal stories and concerns of both coalition members and independent state residents regarding their experiences with the current health care delivery system, as well as their questions about and suggestions for reforms under a new system. The town meetings were to complement input from more informal meetings the Initiative held concurrently with a range of experts and stakeholders.

Eleven sites were selected, to represent all major geographic regions in the state (Western, Central, Southern, Metro, and Eastern Shore areas), as well as urban/suburban and rural counties. Many coalition member organizations co-sponsored the events (see Appendix I), but the Initiative is particularly grateful to local Leagues of Women Voters, which co-sponsored the majority of town meetings. The meetings were each advertised through co-sponsors, local print media, local radio in the case of Baltimore City, and through the Initiative’s website and list-serv to coalition members.

The town meetings followed a common format. First, staff gave a brief history of the Initiative and an update of its progress in developing a draft proposal. An open-microphone request followed for participants to share their stories and perspectives on the current health care system and suggestions for proposed reforms. Each meeting lasted approximately two hours, and was audiotaped and transcribed. A representative of the Technical Advisory Committee and Initiative Board President, Dr. Peter Beilenson, were present at all but two of the meetings to take written notes and communicate findings to other Technical Advisory Committee members. In addition, an Initiative staff member was also present at each meeting.

This summary is based on reviews of both audiotape transcriptions and written notes taken during each town meeting.

Participants

Attendance ranged from 30 in Prince Frederick (Calvert Co/Southern Maryland), to over 100 in Baltimore City and Montgomery County. In total, nearly 750 Maryland residents participated in these town meetings between January and June of 2001, including 325 residents from rural counties and 417 from urban or suburban counties (Table 1). Reflecting state demographics, town meetings participants were predominantly white, with the exception of the Baltimore City town meeting, at which over 50% of participants were African American. Other ethnicities were also represented, particularly in Montgomery County, Howard County, and Baltimore City. Gender representation was approximately equal at each town meeting. While participants were from a wide range of ages (early 20’s to over 80), most town meeting participants were over 45 years old and many were seniors. (This is based on observation since only speakers were asked to share their ages).

Between thirty and fifty percent of attendants at each town meeting participated by speaking. Speakers were more likely to be male, older, and to be affiliated either with the coalition through a member organization or with another professional health care organization. However, a significant minority of speakers were independent state residents, including business owners, employees who work outside the state, physicians, nurses, other care providers, indigent residents, advocates, those with experience in health care administration, and many others with personal experience difficulty accessing quality health care.

Table 1. Number of Town meeting Participants by Geographic Area

Region and Counties	Number of Town meeting Participants
Western
Frederick (R)	70
Washington (R)	65
Central
Baltimore City (U/S)	100
Harford/Baltimore (U/S)	85
Howard (U/S)	97
Southern
Prince Frederick (R)	30
Metro
Montgomery (U/S)	100
Anne Arundel (U/S)	35
Upper Eastern Shore
Kent (R)	35
Middle Eastern Shore
Talbot (R)	80
Lower Eastern Shore
Wicomico (R)	45
Total	742

(R) – rural (U/S) – urban/suburban

Participants’ Perspectives

Many participants simply wanted to tell personal stories of experiencing or witnessing care impaired by deficiencies in the current system. Common concerns included cost and bureaucratic barriers to accessing quality care, fragmentation of care, and the catastrophic consequences of loss of coverage. Others parlayed their experiences into specific suggestions for proposed reforms, including specific benefits, types of coverage they believe are important, and the ideal structural characteristics of a new system. Many speakers had pointed questions about the process the Initiative had created to generate consensus and develop a proposal for reform.

Despite the diversity of views expressed, several coherent themes became apparent as the town meetings progressed, which were important for the Technical Advisory Committee to consider in developing a health care for all plan:

• Consumer choice of provider: Many participants stated that the freedom to choose one’s health care provider was central to ensuring quality care. A complementary issue presented was ensuring the availability and accessibility of providers at different levels of care, including primary care providers, specialists, and mid-level providers.
• Strong cost control: Participants thought that clearly defined and realistic cost-control mechanisms were important in the ultimate success of a new system. Cost controls will guarantee sustainability and avoid spending increases that may force employers to leave the state. However, there was a concurrent consensus that some cost-control mechanisms currently in place, such as high co-insurance or pre-approval rules, create too heavy a hassle/burden on patients to be consistent with true accessibility of quality care.
• Build on existing systems: While we found no clear consensus on the specific structure that participants believe a new system should assume, the majority of participants thought that any new system should build on and supplement strengths of the current system. For example, quality private insurance should remain available to those who have it and government programs that already provide universal coverage for specific populations (such as Medicare and the Maryland Children’s Health Insurance Program, or MCHP) should be augmented rather than dismantled. That said, some participants were disappointed that a single-payer option for universal healthcare was no longer being considered by the Initiative.
• Protection for vulnerable populations: Participants wanted any reforms to take into account the needs of specific vulnerable populations, including children, those with HIV/AIDS, the homeless and the indigent, and those with disabilities. They thought that meaningful reforms should help these populations avoid stigma and ensure their dignity.
• Quality care for the chronically ill: Participants thought that deficiencies in the current system were particularly grave in regard to chronic care, including lacking or inadequate prescription drug coverage, and inadequate coverage for long-term care. While these issues were relevant for many with chronic illness, elderly participants were particularly sensitive to them.
• Inclusion of specific benefits: While town meeting discussions did not allow for in-depth discussions of the ideal level of coverage for specific services, there was a consensus that some categories of services commonly uncovered currently should be covered under a new system. In particular, participants most often mentioned preventive care, translation services for the hearing impaired and speakers of other languages, dental and vision care, substance abuse treatment including tobacco cessation, and mental health coverage on parity with medical care.
• "Seamless" care: Participants were frustrated with problems of fragmented care delivery in the current system, which can directly result in poor health outcomes. Sometimes different providers do not communicate well with each other, for example, indirectly impairing care. Administrative barriers also decrease access to care and allow certain populations to fall through cracks. They called for reforms to maximize administrative unity and coordination of care.

There did not appear to be appreciable differences in the major themes discussed when content was compared between rural versus urban or suburban counties, or between different geographic regions. (Table 2).

Conclusion

The Initiative’s first round of town meetings attracted participation from state residents in geographically diverse areas. Participants had varying levels of experience with health care delivery and access issues and expressed a range of support for the Initiative’s goals from healthy skepticism to calling for abandonment of employer-based health insurance.

Town meeting participants touched upon several common themes including the importance of guaranteeing choice of providers to consumers, imposing strong cost-control mechanisms, building on existing coverage systems, protecting vulnerable populations, improving quality of care for the chronically ill, and including specific categories of benefits in proposed reforms.

While the Initiative recognizes that residents who chose to participate in these town meetings are self-selecting in their investment of time and involvement, they nevertheless had diverse experiences and concerns with the health care delivery system and represented widely varying opinions on potential reforms. These meetings provided rich and valuable insights into the perspectives of Maryland residents that have guided the Technical Advisory Committee in its drafting process. They formed an integral part of the Initiative’s grass-roots approach to health care reform for Maryland.

Table 2. Major Themes Cited During Town meeting Discussions, by Site

County	Choice	Cost control	Build on Strengths	Vulnerable Populations	Chronic Care	Specific Benefits	Seamless Care	Support Services	Limited Coinsurance	Public v Private	Process
Washington (R)	Ï			Ï	Ï	Ï	Ï
Baltimore City (U/S)		Ï		Ï	Ï	Ï	Ï	Ï	Ï
Baltimore/Harford (U/S)	Ï	Ï	Ï	Ï	Ï	Ï	Ï	Ï	Ï
Calvert (R)		Ï	Ï		Ï					Ï
Montgomery (U/S)	Ï				Ï	Ï	Ï		Ï	Ï	Ï
Talbot (R)	Ï	Ï		Ï		Ï	Ï		Ï	Ï	Ï
Kent (R)	Ï	Ï	Ï			Ï			Ï	Ï	Ï
Frederick (R)			Ï	Ï		Ï	Ï		Ï	Ï	Ï
Wicomico (R)	Ï	Ï	Ï	Ï	Ï	Ï	Ï				Ï
Anne Arundel (U/S)		Ï	Ï	Ï		Ï	Ï
Howard (U/S)	Ï	Ï	Ï			Ï	Ï	Ï			Ï

(R) – rural (U/S) – urban/suburban

Our first town meeting was co-sponsored by the League of Women Voters of Washington Co. It took place at the Hagerstown Community College. In attendance were Vincent DeMarco, of the Initiative, Dr. Robert Parker, former Washington County health commissioner, and Dean Diane Hoffman from the University of Maryland Law School representing the Technical Advisory Committee. Over 60 county residents participated, including many unaffiliated county residents as well as a smaller number of coalition members. A local television news reporter was also present.

Those who spoke included small business owners, others who have been homeless and/or uninsured or underinsured, service providers (nurses, physicians, and social workers), advocates, and people with friends and family members who have suffered because of current healthcare system deficiencies. Nine of twenty-two speakers were women, and one-half of speakers had previously held no affiliation with the Initiative and had attended in response to advertisements in local media.

Speakers cited common themes in the problems they have witnessed under the current system. Many spoke of the escalating costs of prescription drugs and the vulnerability of seniors in particular, who sometimes must choose between medications and essentials such as food or housing. Other benefits that speakers wished to see addressed included treatment for addictions, preventive health care, and dental care. Seniors were not the only vulnerable population of concern. Many spoke of the poor and uninsured, those with part-time work, or those working in small businesses, where insurance coverage is often not available. There was widely expressed frustration with the indignities many had to face in trying to obtain needed health care, from overcoming the stigma of poverty, to leaping the endless administrative hurdles required for approval of procedures and specialty care. One small business owner complained that coverage for his employees is unaffordable, which led some to express that health insurance shouldn’t be a business, and that the profit motive interferes with providing adequate coverage for the population.

Participants also had specific concerns they suggested be addressed in any reform proposal. Some mentioned issues of eligibility and coverage, including making coverage portable, accommodating homeless populations in any residency requirements, and covering out-of-state illness episodes. Others mentioned specific benefits, including comprehensive preventive health care, a prescription drug benefit, or even a state-owned pharmacy that could provide medications at a discount. Finally, many who spoke emphasized that any reform should create a more efficient system, where fewer dollars go into program administration. At the same time, they wanted to make sure that choice and quality of care not be sacrificed, for example by including case management strategies in care. Some hoped that state lottery funds could be returned to local communities to cover some of the costs in a new system.

Our second town meeting was held at St. Philip and James Church in Baltimore City and was co-sponsored by the League of Women Voters of Baltimore City. Alfred Sommer, Dean of Johns Hopkins Bloomberg School of Public Health, and Baltimore City Health Commissioner, Peter Beilenson, opened the meeting by welcoming the audience and sharing information on the history of the Initiative. Vincent DeMarco followed by introducing moderator, Robert Walker, and members of the Technical Advisory Committee from Johns Hopkins University, the University of Maryland, and Georgetown University Medical Center. Over 100 people participated in the meeting, including equal numbers of caucasian and african-american residents.

More than thirty people spoke to the group about their concerns with the current system. People who spoke about their health care experiences and suggestions for change included health care providers, advocates, people who have been homeless and/or uninsured, people who are currently underinsured, other service providers, small business owners, and people with friends and family members who have experienced problems with the current health care system. Speakers ranged in age from college students to retirees.

Themes in this meeting were similar to those of the first town meeting: the high cost of prescription drugs; lack of cohesion in the health system leading to loss of insurance coverage when between jobs; concerns for homeless, disabled, and elderly who are especially vulnerable to a fragmented health care system; underinsurance leading to poor resolution of health problems. One individual spoke about the problems facing single women not covered by Medicaid because they are not pregnant noting that women often find out about serious health problems after they become pregnant. This speaker emphasized the need for preventive care in any future system. Health care providers expressed frustration with the complicated current system of reimbursement and referrals, wanting to see a new system with just one set of rules. Many participants had concerns about health problems that currently are not covered by most health insurance plans, such as substance abuse treatment, mental health treatment, prescription drugs, eye exams and corrective lenses, support groups and respite care for caregivers, and dental visits and treatment. Several people mentioned the need for sign language and foreign language interpreters. Underinsurance was also considered to be a big problem, as were high co-payments and other prohibitively high cost-sharing requirements. Some expressed concern about effects changes in the current system would have for people living with AIDS.

Several suggestions were made for improving the current health system. Many spoke about the importance of preventive care as an integral part of the health care system. Speakers also recommended a simplified system to save on administrative costs and reduce complicated referral and reimbursement processes.

The third town meeting was held in Towson for residents of Baltimore and Harford Counties and was hosted by the League of Women Voters of Baltimore County and the Towson Unitarian Universalist Church. Vincent DeMarco opened the town meeting with some background about the Initiative and invited comments from the audience. Drs. Jonathan Weiner and Thomas Oliver from Johns Hopkins University, and Dr. William Sciarillo from the Baltimore City Health Department were present to listen to citizen concerns/suggestions as representatives of the Technical Advisory Committee. Approximately 85 people attended the meeting, including interested county residents and members of organizations who are affiliated with the Initiative.

Twenty-eight people spoke about their concerns regarding the current health care system. Common themes included lack of affordability of health care and prescription drugs even for people who are currently insured; the complexity of the current system creating multiple barriers and making it difficult to obtain quality care; insufficient coverage of particular health care problems in the benefit packages of many current health plans; and the vulnerability of children and the elderly to deficiencies of the health system. Like the two previous town meetings, prescription drug coverage for the elderly and for people with mental health problems was mentioned often as looming problems requiring solutions. Underinsurance was also a major theme of this meeting. One individual spoke about having what he considered to be "cadillac coverage" compared to what others have, but found that when he came down with a serious illness, he still could not afford quality care because of high coinsurance.

Speakers also had specific concerns about potential changes to the current system. Some individuals who had insurance expressed concern about what would happen to their existing coverage if proposed reforms took place. Other concerns included the need for home health care/personal care coverage for people who need that kind of assistance or who are disabled. Other suggestions for improving the current system centered around expanding benefits including dental and vision care coverage, increasing consumer choice, reducing administrative complexity and improving efficiency, and including prevention and education services.

Our fourth town meeting took place at the Calvert Pines Senior Center in Prince Frederick. It was one of our smallest gatherings, of approximately twenty people. Participants included independent community residents (physicians, business people, government employees, and health care consultants) but also representatives of the League of Women Voters, the Calvert County Commission on Disabilities, and statewide provider organizations. Vincent DeMarco represented the Initiative.

Two of the nine speakers were women, and many speakers had significant professional experience in health care. They presented broad and extremely diverse views on the optimal roles of government, the private sector, and volunteerism in health care. Several speakers expressed concerns about a tax-funded, government run, health care delivery system, including that such a program could drive private businesses to leave Maryland. They also thought such a system would be vulnerable to budget cuts in competition with other government spending and that it would likely be bureaucratic and resistant to innovation. These speakers advocated for incremental reforms instead, such as expanding the current MCHP program. One cited deficiencies in the Canadian and British systems as problems to avoid. Other speakers countered that a tax-funded program could still involve private sector providers through contracts, and that such a system could have great innovative potential. They also pointed out that Canadians and the British have not abandoned their more centralized approach, probably because they offered something those democracies decided was worth keeping. As at some other town meetings, one speaker called for cutting the linkage between employment and insurance.

A second theme of this town meeting was the difficulty containing costs of health care. Two speakers gave examples of administrative and clinical waste in the current system, including billing errors and the bureaucratic hassles of multiple payers. Those with long term care experience, as both providers and patients, reiterated concerns we heard elsewhere about prescription drug coverage. One participant with experience as a government administrator in health care pointed out that individual behaviors contribute to higher health care costs. Missing immunizations, reckless driving, and over-reliance on technology at the very end of life have to be confronted by any new system. He urged that cost-control mechanisms avoid putting care providers at direct financial risk. One participant asked about current cost estimates of the new proposal, understanding that it was subject to change.

Our fifth town meeting took place in Wheaton for residents of Montgomery County, and was co-sponsored by the Wheaton Presbyterian Church, Coalition for Universal Health Care, League of Women Voters of Montgomery Co, and Progressive Montgomery. Present to introduce participants were Hal Wallach of the Coalition for Universal Health Care, Patty Snee from the Progressive Maryland, Laura Ryan from the League of Women Voters of Montgomery Co, and Dr. Peter Beilenson from the Citizens’ Initiative. Approximately 100 people attended the town meeting, including equal numbers of men and women. The average age of attendees was higher in Montgomery County than at our previous town meetings. A local newspaper reporter was also present

Thirty-two people spoke, slightly less than half of which were women. Most were caucasian, with one hispanic speaker. Speakers ranged in age from the mid-thirties to early eighties. The majority represented local or national organizations, including the Gray Panthers, Alliance for Democracy, Montgomery Co Coalition of Mental Health Providers, the Takoma Park City Council, and Physicians for a National Health Program. There were also independent resident voices, including social service providers, researchers, nurses, physicians, and religious leaders.

Stories of failures of the current system were rampant. In particular, speakers felt coverage for mental health, substance abuse services, and care of chronic conditions was very poor. Two speakers told stories of organ transplant patients who had care compromised by bureaucracy and underinsurance. Others cited limited choice and access to providers outside of health plan networks. A number of speakers compared current American health care with health care experiences in other countries. One person was injured while in France, received free acute care, and then a seamless referral to a primary care provider for follow-up care. The French system provided her with affordability, equity, and continuity of care, something she does not have at home. There were also stories of how lack of insurance and underinsurance lead to distorted decision-making. For example, a clinic providing free care not joining the Initiative out of fear of alienating pharmaceutical firms giving the clinic free drug samples, or a student whose insurance would not pay for leukemia treatment, who married a friend out of desperation to get spousal coverage.

But unlike our previous town meetings, the majority of commentary in Wheaton was focused on potential features of the proposed plan. Some speakers cited specific benefits they hoped would be included, such as vision care, hearing aids, dental and long-term care. Other major issues were the need for better preventive and mental health services, including family planning, prescription drugs, and equity of benefits and access. Two speakers expressed concern that any proposal spread risk equitably, and include contributions from the wealthy and healthy as well as the poor and ill. A number of speakers were familiar with the Initiative and wanted greater discussion of the rationales behind abandonment of the single-payer approach. They felt strongly that a single-payer system would best guarantee equity, prevent adverse selection, and generate widespread support for the proposal. On the other hand, at least one speaker expressed relief that the proposal would focus on multi-payer approaches as being more politically feasible. Another speaker suggested that Britain’s two-tiered benefits system, "basic" and "luxury," might offer a model to maximize consumer choice. Some speakers also spoke generally of process issues, including how public comment would be incorporated into the final proposal, and how the plan would be evaluated once in place.

This town meeting was co-sponsored by the Talbot Partnership and attracted 75 participants, a disproportionately large number given the county’s rural population. Representing the Initiative were Glenn Schneider, Dr. Peter Bielenson, and Dr. Hoangmai Pham. Participants who spoke included representatives of advocacy and religious organizations, providers (physicians and nurses), community activists, and independent county residents. There was a large contingent of participants from the Deaf and Independent Living Association.

Speakers focused on problems they perceived in the current healthcare system. Many cited lack of access for vulnerable populations, including the hearing impaired, non-English speakers, illegal immigrants, gays and lesbians, and the indigent. Providers who care for indigent patients reported burn-out and low Medicaid reimbursement rates that force them to limit the number of patients they can care for. Many in the audience cited severe provider shortages in Talbot County, resulting in increased difficulty in finding primary care providers, even for those with insurance. One person reported that it took him several months to find a willing primary care provider when he first moved to Easton, despite what he considered good private insurance. Some wondered if increasing coverage in a new system would further overwhelm the inadequate number of available providers. Several people repeated themes heard in other town meetings, including the difficulties that small business owners face in self-insuring or offering coverage to their employees, the vulnerability of unemployed spouses after divorce, high out-of-pocket spending including Medicare copays and prescription drug costs, bureaucratic hassles that frustrate patients and providers, and interference by health plans in professional medical decision-making.

There were a few participants who had specific recommendations for reform proposals. These included coverage of specific benefits, including interpretation services for speakers of other languages and the deaf or hearing-impaired, preventive care particularly ante-, peri-, and post-natally, and improving Medicaid reimbursement rates to increase parity and access for low-income patients. Some participants had concerns about the political hurdles involved in achieving reform, particularly in overcoming the misperceptions of the Initiative advocating socialized medicine. Others were worried that regular and adequate funding for a new system would be vulnerable to political winds, and some felt that a return to traditional fee-for-service coverage was not realistic from a cost-containment perspective.

Our seventh town meeting took place at the Kent County Board of Education in Chestertown, for residents of the Upper Eastern Shore. This meeting was co-sponsored by the League of Women Voters of Kent Co. Approximately thirty people attended and more than half of them spoke during the meeting. Participants ranged in age from approximately forty to eighty years of age.

Unlike at previous town meetings, the majority speakers in Chestertown were focused on the process of developing the Initiative’s proposal and had specific questions about its content and structure. Several people asked about the timing of the proposal’s release relative to the legislative season, when legislators would officially become involved, and the Initiative’s political strategy. Some wanted to know the rationales for abandoning single-payer options. Others asked about how providers would be organized in a new system, how they would be credentialed, and whether existing insurance companies would be allowed to compete in the new system. Many had concerns about costs and funding mechanisms, including whether Blue Cross/Blue Shield conversion monies would be dedicated to broaden insurance coverage, whether there would be lifetime caps on spending, what mechanisms would be in place to curb overuse, and how premiums would be shared between employers and employees. Finally, a few speakers voiced concerns about choice of provider, including whether consumers would have freedom of choice of primary care providers and specialists, and whether they could self-refer to specialists.

Other speakers had concerns about specific benefits that they felt should be included in a new system, including abortion and contraceptive care, vision and dental care, hearing aids, mental health and home health services, experimental therapies and organ transplants, substance abuse treatment. A smaller number of speakers wanted reassurance that services provided out-of-state or out-of-country would be covered, that multiple medical opinions would be covered, and more generally that consumers would have some voice in how the benefit package is structured and modified.

A few speakers had specific suggestions for the proposed plan. One speaker suggested establishing halfway houses for substance abuse patients after they are discharged from the medical facilities and believed that it would reduce costs. Two speakers suggested using co-payment mechanisms to prevent overuse of services. One theme not heard at previous town meetings was the positive managed care experience and good impression about managed care organizations that some participants expressed.

This town meeting took place at Frederick High School, and was co-sponsored by the League of Women Voters of Frederick Co. Representing the Initiative were Vincent DeMarco, Carol Antoniewicz, and Rhonda Van Roekel. Representatives from the Center for Poverty Solutions and the Frederick County Health Department were also present. There were fifty-three community participants, including 40 women, 13 men, 51 Caucasians, and 2 African Americans. Eight participants reported some professional experience in health care. A local TV news reporter was also present.

Speakers included eight men and seventeen women, from 28 to 65 years old. At this town meeting, we again heard about problems that the uninsured face, particularly those who are already disadvantaged, including single parents, those with low-income employment who have to choose between insurance coverage and other basic needs, and the rural poor, for whom there are few services available. But many also emphasized that inadequate insurance can also be catastrophic. One person had high co-insurance that resulted in her having to sell her home to cover $38,000 in health care debt after a car accident.

Other themes were the problem of incomplete family coverage under the current system and difficulty accessing insurance that is available. One speaker endured a long search for replacement insurance after his pension was lost because an employer went out of business. He could not find replacement coverage for his wife. Another pointed out that many parents of MCHP children remain uninsured. Others found the array of frequently shifting options in private insurance confusing and inefficient. And we heard of one small business owner who could not afford to buy insurance for his employees.

Speakers also had specific concerns about proposed changes to the system. While some decried the lack of universal health insurance and one person was disappointed that single payer options were no longer being considered, others wanted reassurance that Medicare benefits would be left intact. One speaker was wary of new taxes to fund expansion of insurance, and skeptical that the coalition could overcome the resistance of small business owners, providers, and insurers in the current system. One speaker suggested that "tobacco funds" from the recent tobacco settlement be used to expand health care.

Among suggestions for changes were two broad themes. First, that a new system should provide seamless coverage, to bridge changes in employment, residence, or illness. Another was that specific benefits be included, such as dental care, complementary and alternative care, and parity for mental health services. Finally, several speakers suggested that the development process include stakeholders not currently supportive of the Initiative, the uninsured, and leaders of successful reform in other states.

This ninth meeting was held at the Salisbury University campus in Salisbury, Maryland. It was
co-sponsored by the Tri-County League of Women Voters, the American Association of University Women (AAUW) and Salisbury University's PACE (Institute of Public Affairs and Civic Engagement). Approximately 45 people attended this meeting. Glenn Schneider, Dr. Peter Beilenson, Chris Beilenson, and Christy Christiansen represented the Initiative. After introductions, welcomes and a briefing, the microphones were open to audience participation.

A total of 16 people spoke at this meeting and most were women who either advocated for or cared for seniors and the poor. Every speaker was over the age of 40. Themes heard throughout this town meeting echo previous meetings. They raised issues including the high cost of prescription drugs, need for dental and vision coverage, need for affordable premiums especially for vulnerable populations (e.g., seniors, migrant population, those with disabilities), and a desire to be able to choose their physician or provider freely.

Some participants suggested that Maryland residents should be allowed to obtain care outside of the State (either when visiting or vacationing in other states) or in Delaware for those living on the Eastern Shore. Because of the close proximity of another state, town meeting participants did not want to be limited in their choice of physicians to just those in Maryland.

In addition, some people also brought up concerns over restructuring the current health care system – wanting to make sure that any new system would allow them to keep their existing coverage if they liked it. And some thought that all Marylanders should have to participate in some insurance plan (public or private) just like is done for automobile insurance.

Medical professionals in the audience asked that systems be developed to monitor utilization, fraud and abuse.

Finally, participants wanted to know how to get involved in the campaign.

Our tenth town meeting took place at Anne Arundel Community College, and was co-sponsored by the League of Women Voters of Anne Arundel Co and the United Black Clergy of Anne Arundel Co. Vincent DeMarco and Dr. Peter Beilenson represented the Initiative. Dr. Laura Morlock from Johns Hopkins University and the Technical Advisory Committee was also present. Thirty-five county residents attended, including six men and twenty-three women.

As at other town meetings, most speakers were over 50 years of age, but unlike at other town meetings, the majority were women and most were independent and not yet affiliated with the coalition. When participants spoke about the current health care system, most focused on escalating costs, both for specific benefits such as prescription drug coverage, and for insurance coverage itself. Employer-based insurance in particular was criticized for both being too expensive for small business owners, and contributing to fragmented care, as insurance during job transitions prove unaffordable or otherwise inaccessible. Participants also cited the complexity of current coverage. One Medicare counselor mentioned billing problems that left liver transplant bills unpaid for a beneficiary. A physician participant called for critical evaluation of managed care cost-control practices.

Turning attention to proposed reforms, participants echoed themes heard in previous town meetings, including whether current government programs such as MCHP would be affected, whether private insurance companies would continue to exist, and when proposed reforms would be implemented. Some were concerned that lower income residents would not be able to afford any insurance without subsidies. Others mentioned specific coverage they wished to have included, such as prescription drug coverage and catastrophic care coverage.

Our last town meeting was held at Wilde Lake Interfaith Center in Columbia and was co-sponsored by the League of Women Voters of Howard Co and St. John’s United Methodist-Presbyterian Church. Dr. Peter Beilenson and Glenn Schneider were present to answer attendees’ questions. Nearly one hundred people participated. Twenty-one people spoke, the majority of whom were not yet affiliated with the coalition. This meeting was unique in that nearly all those who spoke had significant professional experience in health care fields, including nurses, physicians, alternative medicine providers (acupuncturists), and former and current government health program administrators at both the state and federal levels.

Speakers at this town meeting relayed examples of deficiencies in the current system that resonated from previous meetings. In particular, one woman compared the free and smoothly coordinated care she received in Canada to the unexpectedly large bill she received for care of her miscarriage in the U.S. Another speaker who experienced poorly coordinated care from two providers felt fragmented care was costly in time and money. A nurse decried the waste of resources and health maintenance opportunities when patients first receive their health care in emergency rooms. One person also noted the current lack of protection against loss of coverage, for example many spouses lose coverage after a divorce.

Reflecting their breadth and depth of experience in health care, most speakers had specific questions and suggestions regarding proposed reforms. Some were openly skeptical of the political and fiscal feasibility of the Initiative’s broadly defined goals. They asked whether specific public relations strategies had been developed to counter the expected campaigns by insurance companies and other stakeholders who may not benefit from reforms. They asked if Chambers of Commerce would be consulted during the proposal development process. They wanted to know how many General Assembly members were likely to be co-sponsors of legislation. One person felt it was not reasonable to expect employers to be passive while others made decisions regarding the scope of benefits employers are expected to pay for.

Other speakers had specific suggestions regarding the proposal development process. They included including more intensive outreach to inner-city care providers and private practitioners who care for the poor and uninsured and are likely to be supportive of the Initiative’s goals. They also suggested that the Initiative consult with the Center for Medicare and Medicaid Services to enhance chances of necessary Medicaid and MCHP waivers gaining approval.

Finally, many who spoke had suggestions for the structure of reforms. These included specific coverage, such as preventive care, care by mid-level providers, long-term care, comprehensive substance abuse treatment, and community-based services. (One speaker noted that effective cost-control should imply excluding certain "rolls royce" benefits, such as infertility treatments.) But others commented on more general issues. These included how financial incentives for providers would be structured, whether tort reform would be addressed as one means of curbing "defensive medicine" and over-utilization, whether there would be freedom of choice of providers, and how a new system would provide protection against loss of coverage. Several were concerned about cost and financing issues, including whether a successful tobacco tax might not result in dwindling funds over time, and whether potentially higher costs of caring for the previously uninsured had been adequately taken into account.

Washington County League of Women Voters of Washington Co

Baltimore City League of Women Voters of Baltimore City

Baltimore/Harford Counties League of Women Voters of Baltimore Co

Towson Unitarian Universalist Church

Calvert County League of Women Voters of Calvert Co

Montgomery County Progressive Montgomery

League of Women Voters of Montgomery Co

Coalition for Universal Healthcare

Wheaton Presbyterian Church

Talbot County Talbot Partnership for Alcohol and Other Drug Abuse Prevention

Kent County League of Women Voters of Kent Co

Federick County League of Women Voters of Frederick Co

Wicomico County Tri-County League of Women Voters

American Assoc of University Women, Salisbury Chap

Salisbury University PACE (Institute of Public Affairs and Civic Engagement)

Anne Arundel County League of Women Voters of Anne Arundel Co

United Black Clergy of Anne Arundel Co

Howard County League of Women Voters of Howard County

St. Johns United Methodist-Presbyterian Church

In a very special way, the Initiative would like to acknowledge its co-sponsors of these town meetings. Local participation by citizens in any statewide issue like this is a challenge. Without the assistance and grassroots organizing efforts of our co-sponsors, the Technical Advisory Committee would have relied on statistics rather than on the stories and faces of our citizens.

Thanks especially to the League of Women Voters, one of our earliest and most supportive organizational endorsers!