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Community values in Vermont health planning.

Community Values in Vermont Health Planning

Most observers of America's health care system agree that change is necessary. Although we spend more per capita on health care than any other country in the world, the health of our population falls short of many other countries. We are unable to successfully manage costs; and universal access, available in every other industrialized country except South Africa, still eludes us as thirty-one million Americans remain uninsured.

Our public policies are riddled with conflict as a result of the public's own conflict about health care. We expect that the best medical care be provided for all, while we resist with every breath paying the price that such a policy entails.

Vermont Health Decisions, a statewide public education and discussion project sponsored by the Vermont Ethics Network, is designed to explore public attitudes and values that underlie health care and the public's priorities in the allocation of health resources. The Vermont Ethics Network is a group of approximately sixty citizens interested in the ethical issues surrounding the delivery of health care. The Network is sponsored by the Vermont Health Policy Council, Vermont's legislatively created health planning agency.

Launched in late 1988, Vermont Health Decisions was modeled after an earlier

project called. "Taking Steps." This project focused on the need for individuals to make their own treatment preferences known in an increasingly complex, technologically oriented health care system. It involved specially trained discussion leaders, who conducted over 170 community meetings reaching nearly 3,500 people. For Vermont Health Decisions, we recruited twenty-five specially trained discussion leaders from each of the geographic areas of the state, who were then provided with special training during a two-day meeting organized specifically for that purpose. Each discussion leader was given a leadership training package which included professional articles, information about the health care system, and guidance on leading discussions. A professionally produced videotape discussion starter designed to introduce audiences to the topic was prepared, and a questionnaire soliciting participants' opinions on a series of issues on resource allocation in health care was designed. A program brochure was prepared and distributed, and a press conference was called to announce the start of the program. As in the Taking Steps program, meeting scheduling focused on existing community groups which constituted ready-made audiences for the project.

Ethical and Social Issues. For several months prior to the initial two-day training program for discussion leaders, Network members and staff struggled to conceptualize the project. What were the ethical issues in health care policy? How do we design a community discussion when few people have much in-depth understanding of the organization and financing of health care? How do we avoid appearing to promote a specific political agenda or "solution"? How do we avoid focusing exclusively on the current "hot topic" in health care or fixing blame on the current health care villain? How do we address more fundamental, enduring issues?

The project seeks to focus public attention on the following issues and problems:

* political leaders' desire to hear from the general public on health issues;

* the resource allocation crisis in Vermont and the rest of the country, and the rationing involved when the uninsured are excluded from participating in the health care system;

* the need to make explicit choices about health care based on priorities and values;

* the difficulty individuals and employers have keeping up with health insurance costs and that providers face in offering free care;

* the need to examine our own health care values in developing societal goals for health care.

The materials used in the community meetings include the videotape and a budget exercise that focuses participants' choices and values among four competing technologies, each with similar cost but serving different kinds and numbers of patients. A list of values underlying the provision of health care stacks made available, along with a participant questionnaire that solicits opinions on how health care stacks up against other social goods, whether health insurance should cover all services or only a basic package, and a ranking of the most important values that should be met by the health system, among others.

Issues of Process. By mid-March 1990, discussion leaders had held or scheduled seventy meetings out of a minimum of one hundred planned by the project. Time was the major management issue encountered by leaders. Most meetings were scheduled as the "program" part oa regularly scheduled meeting of various community groups, such as the St. Albans Rotary Club, Jamaica Benevolent Society, and Craftsbury Women's Literary Club. A full discussion takes approximately two hours. Many organizations, because of scheduling limitations, were unable to set aside this amount of time. A ranking of project goals was created to aid discussion leaders in modifying the program to accomplish some of the project objectives within available time. And a series of open community meetings have been scheduled to ensure access for any member of the public interested in the topic.

Nonetheless there are limitations inherent in the project, which in turn suggest the need for caution in the use of results. Vermont Health Decisions discussions have not been designated to ensure a representative sample of the Vermont population. Although every effort is made to reach as diverse an audience as possible, the audiences are self-selected. Although all participants are given the questionnaire, completion is voluntary, so a major source of recorded information has known limits. To counter some of these limitations, discussion leaders have been given the task of synthesizing the questionnaire and their own observations of the significant issues raised and common values expressed by discussion participants. In addition, a statewide conference in September 1990 will provide a forum for further debate. Together, the discussion leaders' reports and the conference will form the basis of the final project report.

Relation to Health Policy. Participants often ask about the relation of the Vermont Health Decisions discussions to health policy, whether at the state or federal level. In some ways, the specific answer to this question is unknown as the project and the findings are still incomplete. The question, however, raises the issue of whether the project is primarily focused on public education, or is part of and contributor to changes in health policy. In fact both elements are present. Structurally, the project is housed in the Health Policy Council, which has statutory responsibility for developing health policy through the State Health Plan. The Council hopes to use the results of the project as an underpinning for resource allocation decisions articulated in the State Health Plan, and to create more awareness of the need for choices so that when those choices are made, they are reflective of community values as best understood through this project.

Vermont Health Decisions thus has the advantage of being organizationally linked to a public policy body that has as one of its fundamental roles advancing public participation in the development of health policy. Without this link, grassroots groups will need to take on the additional task of forging a path into public policy debates. On the other hand, the jury is still out on the extent to which the project's results will have utility in making the resource allocation choices that will be faced by policymakers in the 1990s.

A Continuing Challenge. Public expectations and values are increasingly in conflict with policymakers' capacity to respond, exacerbating the crisis in health care that providers, payers, policymakers, and patients increasingly perceive. Our special interest oriented political system limits access by unorganized individuals to the policy-making process. Vermont Health Decisions extends the process out to the genera public, and provides means for the values of the general public to be identified, discussed, and heard. Have the right issues been raised? Has enough time been allotted to develop a reasonable understanding of the ethical dilemmas in the way health resources are allocated? Can the state values of the general public be useful in shaping public policy? These are questions Vermont Health Decisions and similar projects elsewhere are only beginning to answer.

Paul H. Wallace-Brodeur is executive director of the Vermont Health Policy Council.
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Title Annotation:Grassroots Bioethics Revisited: Health Care Priorities and Community Values
Author:Wallace-Brodeur, Paul H.
Publication:The Hastings Center Report
Date:Sep 1, 1990
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