Seeing Medicare’s Future Through Public Deliberation


A recent study took a novel approach to federal health care reform and asked the public for answers about how to reform Medicare. Mary Ginsburg of the non-partisan Center for Healthcare Decisions decided to explore Medicare reform by putting hard questions about reimbursement, quality, and coverage in the hands of ordinary Americans. The findings of the California Medicare CHAT Collaborative (MedCHAT) demonstrated that some Americans, or at least the 810 Americans that took place in the study, find a lot of common ground when it comes to redesigning Medicare.


According to the MedCHAT report, MedCHAT is a computer-based interactive simulation where participants are confronted with comprehensive information regarding things like costs, coverage options, and current Medicare spending over a three our public deliberation.  The simulation is premised on the CHAT® (Choosing All Together) exercise. Participants are asked, in a group setting of eight to 15 people, to negotiate the best group of coverage options as well as indicate the reasons for arriving at given conclusions. Additionally, participants are asked to evaluate their decisions as citizens and not as individuals seeking coverage. The MedCHAT simulation is intended to replicate the kinds of decisions that lawmakers undertake when reforming health care programs by requiring participants to impose restrictions in one area any time they want to expand coverage in another area.


One of the key findings of the MedCHAT project was that 82 percent of participants agreed to a network model in place of the traditional Medicare model that provides relatively unrestricted physician choice. A key factor in that choice was the significant cost savings realized through the implementation of a network. In another cost saving measure, 85 percent of participants were willing to reduce spending on current and future Medicare beneficiaries in order to ensure the continued existence of the Medicare program.  Participants also heavily favored value based care, with 88 percent signing on to the idea. Adding additional benefits was another area where the majority of participants agreed. In the case of long-term care, 77 percent of participants agreed to at least one additional year of coverage.  Additionally, 69 percent of participants believed that long-term coverage for treatment of less severe mental health problems was a worthwhile additional benefit to expand what participants considered to be an underfunded and underutilized health care need.  A large majority of participants, about 81 percent, also believed that transportation costs should be an added Medicare benefits for seniors without support networks.

Rewards and Penalties

Latching on to the growing trend among private insurers, 85 percent of participants agreed that it was a good idea to include rewards and penalties as incentives for beneficiaries to improve health status while lowering the cost of health care.  Participants also felt strongly about having higher-income seniors pay higher premiums than they do now.

Weight of Public Opinion

The MedCHAT findings were revealed at a forum held by the American Enterprise Institute and the Engelberg Center for Health Care Reform at the Brookings Institution. The responses from a panel at that forum suggest that the findings might not carry much weight among politicians. According to a Kaiser Health News (KHN) report, John Rother, CEO of the National Coalition on Health Care, cautioned that what took place in California will not be an accurate predictor of how Congress will go about solving the problem. According to KHN, Ginsburg recognizes that Medicare reform will be a slow process; yet, Ginsburg indicated that the MedCHAT program was part of a “gradual process of enlightenment.” Whether the opinions of 810 Californians will have any sway on Capitol Hill remains to be seen. Although the likely influence of the MedCHAT findings is small, the study represents a novel perspective to a difficult question that few want to be responsible for answering.