July 2009 Data Brief Commission on a High Performance Health System Health Care Opinion Leaders’ Views on Health Reform K ristof S tremikis , K aren D avis , S ara R. C ollins , and C athy S choen The mission of The Commonwealth ABSTRACT: Leaders in health care and health care policy believe that Americans should Fund is to promote a high performance have a choice of public and private health insurance plans, and two-thirds believe the pub- health care system. The Fund carries lic plan should incorporate innovative methods for paying providers, including global fees, out this mandate by supporting according to the latest Commonwealth Fund/Modern Healthcare Health Care Opinion independent research on health care issues and making grants to improve Leaders Survey. A large majority of opinion leaders supports the establishment of a national health care practice and policy. Support health insurance exchange with strong authority to enforce standards of participation, set for this research was provided by rating rules, standardize benefits, and review or negotiate premiums. A majority thinks the The Commonwealth Fund. The views standard required benefit package should be similar to the Federal Employees Health presented here are those of the authors Benefit Program’s standard BlueCross BlueShield option, although one-third support a less and not necessarily those of The generous benefit package. Whatever their views concerning the details of health reform, Commonwealth Fund or its directors, officers, or staff. two-thirds of respondents (68%) agree upon the urgency of enacting comprehensive changes, including an expansion of insurance coverage, this year.      For more information about this study, Overview please contact: In the United States—the only major industrialized country that does not guaran- Kristof Stremikis tee health insurance coverage for its citizens—an estimated 46 million people are Research Associate 1 The Commonwealth Fund uninsured and another 25 million are underinsured. These numbers have ks@cmwf.org increased markedly since 2000, and they are projected to rise steadily through the next decade. Even before the current economic downturn, the number of 2 uninsured was projected to grow to 61 million by 2020. President Obama has repeatedly called on Congress to deliver compre- hensive health reform legislation this year that extends affordable health insur- ance coverage to all Americans. During his presidential campaign, he called for To learn more about new publications creation of a national health insurance exchange, a public health plan option for when they become available, visit the the under-65 population, and a requirement that employers provide coverage or Fund's Web site and register to receive 3 Fund e-mail alerts. contribute to a fund to finance coverage. As president, he has articulated a set of Commonwealth Fund pub. 1304 principles for health reform, leaving the details to Congress. Major proposals are 4 Vol. 16 currently under consideration in the House of Representatives and Senate. 2T he  C ommonwealth F und In the latest Commonwealth Fund/Modern The Health Care Opinion Leaders Survey Healthcare Health Care Opinion Leaders Survey, lead- The Commonwealth Fund and Modern Healthcare ers in health care and health policy were asked for recently commissioned the survey research firm Harris their views on a number of key health reform issues. Interactive to solicit the perspectives of a diverse A large majority of respondents supported the central group of health care experts on their priorities for components of leading health reform proposals, expanding health care coverage. The 208 individuals including the creation of a national health insurance who took part in the survey—the 19th in a continuing exchange, a choice of private and public plans to series of surveys assessing the views of experts on key employers and individuals through the exchange, a health policy issues—represent the fields of academia requirement that employers provide or contribute to and research; health care delivery; business, insurance, coverage, and innovative provider payment methods and other health industries; and government, labor, and within the public plan. Respondents differed on the advocacy groups (see Methodology, Appendix A). details, including the appropriate level of payment for providers under the public plan, and whether condi- Seven of 10 survey respondents think individuals tions of participation should be linked to Medicare. should have a choice of public and private plan Nonetheless, more than two-thirds of opinion leaders options within a national health insurance feel it is urgent to enact comprehensive health care exchange. Sixty-nine percent of opinion leaders sur- reform this year. veyed believe that people buying coverage through a These views are in line with the recommenda- new national health insurance exchange should have tions of the Commonwealth Fund Commission on a the option to purchase coverage through either a pri- High Performance Health System, whose mission is to vate plan or a new public plan (Figure 1). Those who promote better access, improved quality, and greater support this most strongly are members of academic efficiency across the U.S. health care system. The and research institutions (79%) and health care deliv- Commission has put forward an integrated set of insur- ery organizations (77%) (Table 1). Opinion leaders in ance, payment, and delivery system reforms with the business, insurance, and other health care industries potential to extend affordable health insurance to all are least supportive, but nearly half (45%) support Americans and slow growth in health care spending by offering a choice of private and public plans. Only one 5 $3 trillion through 2020. By encouraging the delivery of five opinion leaders think that the options offered of more effective and efficient care, the Commission’s within a national health insurance exchange should be proposals could yield greater value for health spend- limited to private plans only. ing, return substantial savings to families, businesses, and the public sector, and provide affordable health insurance coverage to all. A bout the H ealth C are O pinion L eaders S urvey The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey was conducted online within the United States by Harris Interactive on behalf of The Commonwealth Fund between June 8, 2009, and July 8, 2009, among 585 opinion leaders in health policy and innovators in health care delivery and finance. The final sample included 208 respondents from various industries, for a response rate of 36 percent. Data from this survey were not weighted. A full methodology is available in Appendix A. H ealth C are O pinion L eaders ’ Views on H ealth R eform 3 Figure 1. Choice of Public and Private Plan Options Figure 2. Provider Payment Methods in a Public Plan “A key issue is whether to include a new public health insurance plan choice for the under-65 population within the national insurance exchange. People “If a public plan is offered, what do you think provider payment buying coverage through the exchange would have the option to select either a methods in the public plan should be based on?” private or a public plan. Members of Congress have proposed different approaches and regulatory strategies in designing this option. Do you think that the plans offered should include:” Not sure Other 3% Not sure 7% Whatever methods New innovative 4% Only public plans private plans elect to payment methods that 7% use and negotiate with incorporate global providers fees for care over time 13% or acute episodes of Only private plans Both private and care rather than Medicare’s current payment based solely 20% public plans methods and any 69% on fees for individual modifications that services build on this basic 65% structure 13% Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. Nearly two-thirds of opinion leaders think a public (31%) or at Medicare levels (20%) (Figure 3). Twenty- plan should incorporate innovative payment methods. seven percent of respondents feel the rate should be Sixty-five percent of opinion leaders believe a new negotiated with providers. public plan should reimburse health care providers A recent report by the Commonwealth Fund using a “bundled-payment” method, which provides a examined the implications of these various payment single payment for health services related to an epi- rate policies on health system spending, savings, and 6 sode of care, or for services rendered over a specified coverage. Three scenarios were considered: one with period. Rather than rewarding providers for providing a public plan paying at Medicare rates, another with a a higher volume of services—as fee-for-service pay- public plan paying between Medicare and commercial ment does—a bundled-payment approach would rates, and one with only private plans. The scenario encourage providers to take broader responsibility for paying at Medicare rates was projected to achieve the their patients’ care and outcomes, and might also be an greatest health system savings over the 2010–2020 effective way to control health care costs while main- taining or improving quality of care (Figure 2). In the Figure 3. Initial Level of Provider Payment in a Public Plan survey, support for bundled payments was substantial, “If a public plan is offered, at what level do you think provider payment even among those responsible for delivering care in the public plan should initially be set?” (60%) (Table 2). Small minorities of respondents favor Not sure the way private plans pay or the way Medicare pays. Other 2% 6% Medicare levels A majority supports setting provider payment rates 20% in a public health insurance plan at Medicare levels, Negotiated with or between Medicare and commercial plan levels. A providers controversial component of the health reform debate is 27% the rate at which a new public health insurance plan Between Medicare and commercial plan levels should pay health care providers. Half of opinion lead- Commercial plan levels 31% ers believe that provider payment rates should be set 13% either between Medicare and commercial plan levels Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. 4T he  C ommonwealth F und Figure 4. Linking Providers’ Participation in a Public Plan Figure 5. Triggering the Creation of a Public Health Insurance Plan with Participation in Medicare “Coverage expansions and insurance market reforms can be designed to “If a public plan is offered, do you think provider participation slow the growth in health care costs. Please indicate the extent to which you in the public plan network should be:” support or oppose ‘triggering’ the creation of a public health insurance plan if certain expenditure targets to reduce health care costs are not met.” Not sure 11% Strongly support 15% Strongly support/ 45 Support Support 23% 38% A condition of participating in 18% Somewhat support Medicare 45% Oppose 19% Strongly oppose/ Oppose 35% Strongly oppose 16% Not linked to Medicare 43% Not sure 10% Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. period, with cumulative savings of $3 trillion. This policymakers have proposed “triggering” the creation was followed by $2 trillion saved under a public plan of a public plan, so that one would be created only if option paying intermediate rates, and $1.2 trillion certain expenditure targets or geographic coverage 7 saved under a scenario involving only private plans. A conditions are not met. Thirty-eight percent of health national insurance exchange, reform of Medicare pay- care opinion leaders support or strongly support the ment policy, and other system reforms were common trigger approach, while 35 percent oppose or strongly to all three scenarios and yielded most of the savings oppose the idea (Figure 5). Those in business, in the private plan scenario. insurance, and other health care industries support the trigger strategy at lower levels (35%) than those in Opinion leaders are divided over provider partici- health care delivery (45%) (Table 5). pation rules. Forty-five percent of respondents believe that participation in Medicare should be conditional on Most are in favor of a national health insurance participation in the public plan network—roughly the exchange with strong authority. Seven of 10 opinion same proportion of respondents who believe that par- leaders favor a new national health insurance ticipation in the public plan should not be linked to exchange, including the creation of a governing body participation in Medicare (43%) (Figure 4). Support with the authority to enforce standards of participation for delinking participation in Medicare and the public by carriers, standardize benefits, set rating rules, and plan option is highest among those in health care review or negotiate premiums (Figure 6). Support for a delivery (54%) (Table 4). new governing body with these functions is lowest among those in business, insurance, and other health Opinion is split over the desirability of a trigger care industries (56%) (Table 6). Just 25 percent of mechanism for creating a public health insurance respondents favor restricting the exchange to the oper- plan. Given the controversy surrounding the creation ation of a clearinghouse Web site where people could of a public health insurance plan option, as well as choose plans and investing state insurance commis- recent voluntary commitments made by the private sioners or other regulators with the authority to review insurance industry to control cost growth, several or set standards for participating insurance plans. H ealth C are O pinion L eaders ’ Views on H ealth R eform 5 Figure 6. National Insurance Exchange Model package less generous than the FEHBP standard BCBS “A national insurance exchange might include strong oversight—including option, including half (53%) of those in business, standards for participation—or operate largely as a Web-based clearinghouse insurance, and other health care industries. for insurance plans that meet minimum benefit standards. Which model do you favor?” Not sure Most favor increasing the federal excise tax on 5% alcohol, cigarettes, and sugar-sweetened drinks Limit the exchange to Give the governing the operation of a body of the exchange and requiring employers to offer coverage or pay clearinghouse Web the authority to enforce site for people to a percentage of payroll to finance coverage. Opinion standards of choose plans. State participation by leaders were asked to indicate their level of support for insurance commis- carriers, standardize sioners would have benefits, set rating a variety of approaches to finance coverage expansion. the authority to review rules, and review or or set standards for Seventy-nine percent of respondents indicated they negotiate premiums participating 70% support or strongly support increasing federal excise insurance plans 25% taxes on alcohol, cigarettes, and sugar-sweetened drinks and allocating the revenues to a health insur- Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. ance trust fund (Figure 8). Meanwhile, 77 percent of A majority of opinion leaders favors the establish- ment of a minimum basic benefit package similar Figure 8. New Revenue Sources and Cost-Saving Strategies “Financing coverage will require new revenue sources or significant cost to the standard plan for federal employees. Fifty-six savings within the system. Please indicate your level of support for each of the percent of survey respondents favor the establishment following approaches to financing expanded coverage.” of a minimum basic benefit package similar to the Strongly support Support Increase the federal excise tax on standard Blue Cross Blue Shield (BCBS) option alcohol, cigarettes, and 54% 25% 79% sugar-sweetened drinks, and allocate offered by the Federal Employees Health Benefits revenues to health insurance trust fund Require employers to either offer coverage 40% 37% 77% Program (FEHBP) (Figure 7). Support is highest or pay percent of payroll among those in health care delivery (61%) and in aca- Cap amount of employer-financed premiums that are exempt from federal 33% 26% 58% income taxes for employees demic and research institutions (60%), and lowest Increase federal marginal income tax rate among those in business, insurance, and other health or institute a new higher bracket for 27% 19% 46% high-income households care industries (42%) (Table 7). It is noteworthy, how- Institute a “luxury” sales tax dedicated 17% 21% 38% to health insurance trust fund ever, that one-third (35%) of opinion leaders favor a Assess an income tax surcharge that would be earmarked for 12% 18% 30% health insurance trust fund Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. Figure 7. Approach to Benefit Standards “There are different suggestions for a standard benefit package that would be required of individuals. Please indicate your favored leaders support or strongly support requiring employ- approach to benefit standards.” ers to either offer coverage or pay a percentage of pay- The standard required There shouldn’t be a benefit package should be roll to help finance expanded coverage. Three-quarters standard benefit package 6% more generous than FEHBP of respondents in business, insurance, and other health 3% care industries are in favor of the pay-or-play require- ment (Table 8). A majority (58%) of health care opin- The standard required benefit ion leaders supports or strongly supports capping the The standard required package should be benefit package similar to that of the amount of employer-financed premiums that are should be less FEHBP Standard exempt from federal income taxes for employees. generous than FEHBP BCBS option Standard BCBS 56% Increasing taxes on high-income households is sup- 35% ported by about half of opinion leaders, while about a third support a luxury sales tax (36%) or an income Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. tax surcharge (30%). 6T he  C ommonwealth F und There is substantial support for new insurance respondents. About half (48%) favor limiting inflation reporting requirements, joint negotiation of phar- updates for providers in high-cost geographic areas. maceutical prices and provider payment rates, lim- While fundamental payment reform has sub- its to high-cost providers and overvalued services, stantial support, very strong measures are less popular, and global fees. Opinion leaders were asked to indi- including total elimination of fee-for-service payments cate the extent to which they support or oppose several (42%), setting expenditure targets on total outlays strategies to reduce health care costs. Nearly eight of (29%), and setting expenditure targets on Medicare 10 (78%) respondents support or strongly support a outlays (29%). requirement that all private insurers report revenues, profits before taxes, administrative expenses, and Seventy-two percent of leaders support ending the claims expenses, using a common form (Figure 9). two-year Medicare waiting period for the disabled. More than seven of 10 support or strongly support Disabled adults must wait five months to begin receiv- allowing public and private payers to negotiate pre- ing cash benefits from the Social Security Disability scription drug prices jointly with pharmaceutical com- Insurance program and then an additional two years to panies (72%) and setting limits on payments to high- begin receiving Medicare benefits. An estimated 1.8 cost providers and/or overvalued services (71%). million disabled people enroll in Medicaid while wait- Allowing public and private payers to negotiate pro- ing for Medicare eligibility to begin, at significant cost 8 vider payment rates jointly (61%) and offering global to states. Seventy-two percent of health care opinion fees to accountable care organizations (59%) also leaders support or strongly support ending the two- enjoy support from a strong majority of survey year waiting period for Medicare coverage (Figure 10). Support is highest among those in academic and research institutions (75%) and lowest among those in Figure 9. Health Care Cost-Reduction Options business, insurance, and other health care industries “Coverage expansions and insurance market reforms can be designed to slow the growth in health care costs. Please indicate the extent to which you support (65%) (Table 10). or oppose each of the following strategies to reduce health care costs.” Strongly support Support Require all private insurers to report revenues, profits before taxes, and administrative expenses and the amount 50% 28% 78% Figure 10. Two-year Waiting Period for Medicare paid out in claims, using a common format Coverage for Disabled Adults Allow public and private payers to jointly negotiate prescription drug prices with 40% 33% 72% “Disabled adults who begin receiving cash benefits from the Social Security pharmaceutical companies Disability Insurance program must wait two years before receiving Medicare benefits. Please indicate the extent to which you support or oppose ending this Set limits on payments to high-cost two-year waiting period for Medicare coverage.” providers and/or overvalued services 36% 36% 71% Allow public and private payers to jointly negotiate provider payment rates Strongly support 46% Strongly support/ with full public disclosure of 24% 37% 61% price and payment methods Support 72% Offer capitation or global fees Support 26% to accountable care organizations and limit inflation updates for providers 26% 33% 58% not part of such organizations Somewhat support 11% Limit inflation updates for providers in high-cost 18% 30% 48% geographic areas Oppose 8% Strongly oppose/ Require all payers to eliminate any form Oppose of fee-for-service payment to health 12% care providers by 2020, substituting 19% 23% 42% Strongly oppose 3% capitation, global fees, or ... Set an expenditure target on growth in Not sure 6% Medicare outlays, enforced by adjusting 9% 20% 29% fees to all providers Set an expenditure target on growth in Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. public and private health care outlays, 11% 18% 29% enforced by adjusting fees to all providers Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. H ealth C are O pinion L eaders ’ Views on H ealth R eform 7 Figure 11. The Urgency of Action on Health Care Reform exchange, which would offer a choice of private and public health plans, sliding-scale premium subsidies, “What is your view regarding the urgency of action on health reform?” regulations against underwriting on the basis of The dire economic and Other health status, a minimum standard benefit package, fiscal situation requires 4% Medicaid expansion, and an employer requirement to that health reform be postponed 9 6% offer coverage. It is urgent to enact To ensure that families and individuals have The Administration comprehensive and Congress should health reform access to needed care and financial protection and to this year make a down payment 68% provide a foundation for ongoing improvement in on health reform this year, covering the health care quality and efficiency, the Commonwealth most vulnerable uninsured Fund Commission on a High Performance Health 21% System has put forward an integrated set of insurance, payment, and delivery system reform options with the Source: Commonwealth Fund Health Care Opinion Leaders Survey, June 2009. potential to extend affordable health insurance to all and slow the growth of health spending by $3 trillion 10 Over two-thirds of survey respondents believe it is by 2020. The number of uninsured—projected to urgent to enact comprehensive health reform legis- rise to 61 million by 2020 absent significant reform— lation this year. A large majority of opinion leaders would instead fall to an estimated 1 percent of the feels it is urgent to enact comprehensive health care U.S. population. reform this year (Figure 11). Support for comprehen- Many of the Commission’s health reform strat- sive reform is high across all fields, including 60 per- egies are endorsed by survey respondents. Offering a cent of respondents in business, insurance, and other public health insurance option alongside private plans health care industries (Table 11). Just 6 percent of within a national health insurance exchange; moving opinion leaders feel that the dire economic and fiscal toward innovative payment methods that reward value, situation requires that health reform be postponed. In not volume, of services; requiring employers to cover part because of the nation’s economic crisis, President or contribute to coverage for employees—all are seen Obama has called on Congress to deliver comprehen- as effective strategies for ensuring affordable coverage sive health reform legislation that extends affordable for all Americans. Increasing federal excise taxes on health insurance coverage to all Americans this year. If alcohol, cigarettes, and sugar-sweetened drinks and appropriately designed, it could relieve financial pres- having employers share in financial responsibility for sures on households struggling to pay mortgages and coverage are both seen as legitimate sources of financ- medical bills as well as businesses fighting to survive ing for health reform. Comprehensive and innovative while paying health insurance premiums for employ- changes such as these have the potential not only to ees. Over the last decade, premiums have gone up make affordable coverage available to the millions of three times as fast as wages—creating pressure on people who do not have any, but they can also put us households and firms alike. on the path to a high performance health system that works for all Americans. The Path to a High Performance Health System Health care opinion leaders agree that enacting health reform this year is urgent. Major reform proposals being considered in the House of Representatives and Senate include provisions for a new national insurance 8T he  C ommonwealth F und 5 N otes Commonwealth Fund Commission on a High Performance Health System, The Path to a High 1 C. DeNavas-Walt, B. D. Proctor, J. C. Smith et al., Performance U.S. Health System: A 2020 Vision Income, Poverty, and Health Insurance Coverage in and the Policies to Pave the Way (New York: The the United States: 2007 (Washington, D.C.: U.S. Commonwealth Fund, Feb. 2009). Census Bureau, Aug. 2008); C. Schoen, S. R. 6 Collins, J. L. Kriss, and M. M. Doty, “How Many Schoen et al., Fork in the Road, 2009. Are Underinsured? Trends Among U.S. Adults, 7 A. Wayne, “Blue Dogs Demand Tight Constraints 2003 and 2007,” Health Affairs Web Exclusive, on Any Public Health Plan Option,” CQ HealthBeat, June 10, 2008:w298–w309. June 4, 2009. 2 C. Schoen, K. Davis, S. Guterman, and K. 8 S. Guterman and H. Drake, The Long Wait: The Stremikis, Fork in the Road: Alternative Paths to a Impact of Delaying Medicare Coverage for People High Performance Health System (New York: The with Disabilities (New York: The Commonwealth Commonwealth Fund, June 2009). Fund, May 2009). 3 S. R. Collins, J. L. Nicholson, S. D. Rustgi, and K. 9 H.R. 3200, America’s Affordable Health Choices Davis, The 2008 Presidential Candidates’ Health Act of 2009, July 14, 2009, 111th Congress, 1st ses- Reform Proposals: Choices for America (New sion; “An American Solution: Quality Affordable York: The Commonwealth Fund, Oct. 2008). Health Care,” House Tri-Committee Health Reform 4 H.R. 3200, America’s Affordable Health Choices Discussion Draft Summary, Committees on Ways Act of 2009, July 14, 2009, 111th Congress, 1st ses- and Means, Energy and Commerce, and Education sion; “An American Solution: Quality Affordable and Labor, July 14, 2009, available at http://energy- Health Care,” House Tri-Committee Health Reform commerce.house.gov/Press_111/20090714/hr3200_ Discussion Draft Summary, Committees on Ways summary.pdf; Affordable Health Choices Act, and Means, Energy and Commerce, and Education Senate Committee on Health, Education, Labor and and Labor, July 14, 2009, available at http://energy- Pensions, July 15, 2009, 111th Congress, 1st ses- commerce.house.gov/Press_111/20090714/hr3200_ sion; “In Historic Vote, HELP Committee Approves summary.pdf; Affordable Health Choices Act, the Affordable Health Choices Act,” Senate Health, Senate Committee on Health, Education, Labor and Education, Labor, and Pensions Committee Press Pensions, July 15, 2009, 111th Congress, 1st ses- Release and Summary, July 15, 2009, available at sion; “In Historic Vote, HELP Committee Approves http://help.senate.gov/Maj_press/2009_07_15_b. the Affordable Health Choices Act,” Senate Health, pdf; and “Expanding Health Care Coverage: Education, Labor, and Pensions Committee Press Proposals to Provide Affordable Coverage to All Release and Summary, July 15, 2009, available at Americans,” Senate Finance Committee, May 14, http://help.senate.gov/Maj_press/2009_07_15_b. 2009, available at http://finance.senate.gov/ pdf; and “Expanding Health Care Coverage: Roundtable/complete%20text%20of%20cover- Proposals to Provide Affordable Coverage to All age%20policy%20options.pdf. Americans,” Senate Finance Committee, May 14, 10 Commonwealth Fund Commission, Path to High 2009, available at http://finance.senate.gov/ Performance, 2009. Roundtable/complete%20text%20of%20cover- age%20policy%20options.pdf. H ealth C are O pinion L eaders ’ Views on H ealth R eform 9 A ppendix A. M ethodology This survey was conducted online by Harris Interactive on behalf of The Commonwealth Fund among 208 opin- ion leaders in health policy and innovators in health care delivery and finance within the United States between June 8, 2009, and July 8, 2009. Harris Interactive sent out individual e-mail invitations to the entire panel con- taining a password-protected link, and a total of four reminder e-mails were sent to those that had not responded. No weighting was applied to these results.  The initial sample for this survey was developed using a two-step process. The Commonwealth Fund and Harris Interactive jointly identified a number of experts across different professional sectors with a range of perspectives, based on their affiliations and involvement in various organizations. Harris Interactive then con- ducted an online survey with these experts asking them to nominate others within and outside their own fields whom they consider to be leaders and innovators in health care. Based on the result of the survey and after care- ful review by Harris Interactive, The Commonwealth Fund, and a selected group of health care experts, the sample for this poll was created. The final list included 1,246 individuals. In 2006, The Commonwealth Fund and Harris Interactive joined forces with Modern Healthcare to add new members to the panel. The Commonwealth Fund and Harris Interactive were able to gain access to Modern Healthcare’s database of readers. The Commonwealth Fund, Harris Interactive, and Modern Healthcare identi- fied readers in the database that were considered to be opinion leaders and invited them to participate in the survey. This list included 1,467 people. At the end of 2006, The Commonwealth Fund and Harris Interactive removed those panelists who did not respond to any previous surveys. In 2007, recruitment for the panel contin- ued with Modern Healthcare recruiting individuals through their Daily Dose newsletter. In addition, Harris Interactive continued to recruit leaders by asking current panelists to nominate other leaders. The final panel size for the this survey included 1,353 leaders. Only those who have responded to one or more of the Commonwealth Fund Opinion Leaders surveys over the last 16 months, October 2007 to January 2009, were included, totaling 565 active panelists. One hundred eighty-eight of these panelists completed the survey, and 20 additional inter- views from opinion leaders who responded to the survey but who had not participated in any of the other recent surveys were added, for a total of 208 respondents. The response rate was 36 percent. With a pure probability sample of 208 adults, one could say with a 95 percent probability that the over- all results have a sampling error of +/– 6.8 percentage points. However, that does not take other sources of error into account. This online survey is not based on a probability sample and therefore no theoretical sampling error can be calculated. The data in this brief are descriptive in nature. They represent the opinions of the health care opinion leaders interviewed and are not projectable to the universe of health care opinion leaders. 10T he  C ommonwealth F und A bout the A uthors Kristof Stremikis, M.P.P., is research associate for the president of The Commonwealth Fund. Previously, he was a graduate student researcher in the School of Public Health at the University of California, Berkeley, where he evaluated various state, federal, and global health initiatives while providing economic and statistical support to faculty and postdoctoral fellows. He has also served as consultant in the director’s office of the California Department of Healthcare Services, where he worked on recommendations for a pay-for-performance system in the Medi-Cal program. Mr. Stremikis holds three undergraduate degrees in economics, political science, and history from the University of Wisconsin at Madison. In May 2008, he received a Master of Public Policy degree from the Goldman School at the University of California, Berkeley. He can be e-mailed at ks@cmwf.org. Karen Davis, Ph.D., is president of The Commonwealth Fund. She is a nationally recognized economist with a distinguished career in public policy and research. In recognition of her work, Ms. Davis received the 2006 AcademyHealth Distinguished Investigator Award. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. A native of Oklahoma, she received her doctoral degree in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment; Medicare Policy; National Health Insurance: Benefits, Costs, and Consequences; and Health and the War on Poverty. She can be e-mailed at kd@cmwf.org. Sara R. Collins, Ph.D., is vice president at The Commonwealth Fund. An economist, she is responsible for survey development, research, and policy analysis, as well as program development and management of the Fund’s Affordable Health Insurance program. Prior to joining the Fund, Dr. Collins was associate director/senior research associate at the New York Academy of Medicine, Division of Health and Science Policy. Earlier in her career, she was an associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Office of the Public Advocate. She holds an A.B. in economics from Washington University and a Ph.D. in economics from George Washington University. She can be e-mailed at src@cmwf.org. Cathy Schoen, M.S., is senior vice president for research and evaluation at The Commonwealth Fund and research director for the Commonwealth Fund Commission on a High Performance Health System, overseeing the Commission’s Scorecard project and surveys. From 1998 through 2005, she directed the Fund’s Task Force on the Future of Health Insurance. She has authored numerous publications on policy issues, insurance, and health system performance (national and international), and coauthored the book Health and the War on Poverty. She has also served on many federal and state advisory and Institute of Medicine committees. Ms. Schoen holds an undergraduate degree in economics from Smith College and a graduate degree in economics from Boston College. She can be e-mailed at cs@cmwf.org. Editorial support was provided by Christopher Hollander.