All Is Not Well:

Citizens Speak Out About Health Care in Daviess County

A report on 52 community health forums

September 2002

Table of Contents Introduction Summary of findings Citizens' concerns, solutions Cost is the top concern Everyone needs a doctor Let's fill the gaps The system could be more consumer-friendly Respect is important Exhibits Survey results Table 1: Ranking of issues' importance Table 2: Ranking of strategies The voices: who participated Chart 1: Geography Chart 2: Education Chart 3: Ethnicity Acknowledgements Letter of thanks How the project came about Progress in health care access Forum moderators and recorders Advisory committee List and map of forums

Introduction

The People's Health Project involved the citizens of Owensboro-Daviess County, Kentucky, in discussions of health care access at 52 moderated forums in 2001-02. The forums were structured to cover seven issues that were among the greatest concerns local citizens expressed in a University of Kentucky Health Needs Assessment released in August 2000:

Forum moderators introduced participants to the findings from the health needs assessment and other relevant data. Through two-hour discussions and follow-up questionnaires, they were asked to share impressions and personal experiences, and to select or provide their own ideas for community strategies.

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Summary of findings

The dominant theme of the forum discussions was this: Many Daviess Countians, particularly those with low incomes, have a hard time coping with medical conditions and bills, and many have significant difficulties getting and affording the health care they need. Here is what forum participants said regarding the seven access issues targeted by the People's Health Project:

1. Health care costs, including prescription drug costs, are too high.
High costs were the overarching concern of forum participants. Cost affects everyone, but women more directly than men, according to UK's analysis of surveys filled out by forum participants. Citizens believe costs are unjustly high, and that the reasons include:

2. Everyone needs a doctor.
Citizens agreed that primary care is critical for everyone. This is important for prevention and early diagnosis, which also keeps health costs low. Many people are frustrated in finding a doctor, they said — particularly those who may be unable to pay. Citizens are also concerned that there is a shortage of primary care doctors, which means that even those with a regular doctor don't get to spend enough time with him or her. Citizens supported a systematic effort to connect patients with doctors, but when that falls short, they supported more effective recruitment, expanded clinics and services.

3. Let's fill the gaps.
Many stories were shared about people falling through the cracks of our local health care delivery system. These people included the insured, uninsured, underinsured, people with chronic problems and those who need help navigating the system. Citizens support a better way — be it a clearinghouse, hotline or ombudsman.

4. The health care system could be more consumer-friendly.
Participants said obtaining proper health care is often complicated by transportation problems, work schedules and paperwork. They supported steps to help people overcome these barriers.

5. Respect is important.
Many citizens described feeling embarrassed, ashamed and mistreated when accessing the health care system. Yet they said they know that respect works both ways and that patients can be rude, unfair and cavalier about appointments. They said they want everyone — those who can pay and those who cannot — to be treated with care and consideration.

6. Funds are already available to fix many problems.
Citizens were more likely to support steps that will not increase taxes or fees. With the huge sums spent on health care, and with the local hospital sustaining a substantial surplus, they said a better system should be possible with funds that are available already. They said they prefer that their local health care providers focus more on collaboration and access issues.

Other themes

Participants felt so strongly about some issues that they often brought them up even though the issues were not included in the discussion booklets used at the forums. These included:

1. Lack of competition
A theme expressed in nearly every forum was that our community has only one hospital, few insurance choices and not enough providers. Citizens expressed these concerns over and over.

2. Abuse of the emergency room
Citizens expressed frustration about the inappropriate use of the Owensboro Mercy Health System (OMHS) Emergency Department (ER). They were concerned that the poor and uninsured have nowhere else to go, but also that people abuse the free services there, resulting in higher costs for everyone. (OMHS recently funded a full-time physician for the McAuley Clinic, which serves the uninsured.)

3. Poor health habits
Citizens said they are frustrated with those who are not conscientious about their health and behavior. They are increasingly aware that health care costs and insurance premiums are influenced by behavior choices that include smoking, substance abuse, poor nutrition, lack of exercise and lack of preventive care. They feel that more effective health education is key.

4. Information dissemination
Citizens said they are confused by and largely unaware of community resources — where to go for health services, how to get transportation, the hours and services at local clinics, which doctors accept Medicaid and uninsured patients, how to take advantage of prevention and early detection screenings, classes and support groups, etc. (The Public Life Foundation of Owensboro has already responded by publishing directories of primary care services and community health centers.)

5. Funding and staff
With the amount of money that is spent on health care, citizens expect a higher level of services and staffing. They feel more funds could be redirected to provide more physicians, nurses, nurse practitioners, physician assistants and office staff.

6. Paperwork
Citizens — as well as health care professionals — are overwhelmed and frustrated by the growing burden of filling out forms.

7. Appreciation of services
Despite anecdotes about the shortcomings, frustrations and challenges of Owensboro's health care system, citizens also gave examples of the generosity of many health care providers in our community. Free and reduced-price care and medications are provided routinely by caring professionals, organizations and institutions.

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Citizens' concerns, solutions

Cost is the top concern Citizens ranked high medical costs and the cost of prescription drugs as their top two priorities among the seven access issues that were identified by the People's Health Project. Many participants told stories about the problems they have had paying for or getting the care they need — nine of 15 participants at one forum, for instance, said they had not been able to fill prescriptions because of the cost. Citizens said repeatedly that it is unacceptable that someone must take half of their prescribed dose of medicine or forego it entirely to pay food or utility bills. People are "forced (to choose between) paying gas bills or medicine," said one. Another said a social services agency intervenened in the case of one woman who spent her money on medication: The gas company "was going to shut her gas off."

Among forum participants in general:

• ninety percent ranked high costs and prescription drug costs as very important (see Table 1).
• high costs were important to people regardless of race, age, education level or where they lived; however, high costs were significantly more important to women than men.
• nearly a third of participants considered high costs the most important issue; another 10 percent ranked prescription drug costs as most important.

  "I have no insurance. My husband has insurance on himself only. So I don't go to the doctor unless it is an emergency. Two years ago, I broke my ankle and had to go to the emergency room and that cost us over $3,000. And that threw us in a pinch."
  — Eastview Elementary forum participant

  "Less people are able to have (health care) because of the cost."
  — Kentucky Wesleyan College forum participant

  "I can't go to the doctor because I can't pay. It is $249 per visit at the specialist and medications' cost ... is $1,200 a month. I can't pay for it. I wish there was some way I can get some help. Please."
  — Boulware Center Mission participant who has a chronic condition

Citizens believe that costs are unjustly high because:

• Hospitals, doctors, insurers and drug makers charge too much for some of the services they provide. Many participants gave examples, either from their own experience or the experiences of others.

  "When a doctor treats you in the hospital, you end up getting three bills from three doctors."
  — Dugan Best Neighborhood Association forum participant

• Health insurance is too expensive for many people and is not offered to others who work part-time. Also, insurance often doesn't cover the services or drugs that people need or doctors order.

  "I'm married and a mother of three and I've had a nephew for eight years. We can't afford to pay for insurance, but yet we make too much to qualify for assistance."
  — Dugan Best Neighborhood Association forum participant

  "Health care is a crap shoot unless you have money and insurance."
  — Fourth Street Baptist Church forum participant, relaying a favorite saying

  "My insurance company will not pay for mammograms ... but they pay for Viagra!"
  — Health Department Clinic forum participant

  "Employers should offer insurance to those that work only part-time. Therefore, I think more people would work."
  — St. Joseph Fire Department forum participant

• The system of care for the poor and uninsured is not efficient. As an example, many people mentioned the use of the OMHS emergency room for routine medical care by people who cannot afford to pay for care at the hospital's convenient care center and do not have a regular "medical home" with a primary-care physician. This means they don't get the preventive or early care they need that can reduce health problems and costs. Some also expressed concern that some people with unhealthy lifestyles do not take responsibility for their own health and may abuse free services in the ER.

  "If I had the money to go to (OMHS) Convenient Care, it wouldn't cost me as much. But because (a new medical problem) is something that is unexpected, I have already spent all my money on bills and groceries. I have no money to go to Convenient Care, so therefore I am forced to go to the ER."
  — Eastview Elementary School forum participant

  "With costs so high, people overlook their health to avoid the cost. The system is there to help, but people don't know how to use it."
  — Free Clinic forum participant

  "Some people wouldn't go to the doctor even if free and others would go all the time and demand the free service and the real troubled people would be left out."
  — Longfellow Adult Learning Center forum participant

Other major factors are:

• exploitation of the system by providers (doctors, hospitals, insurance companies, drug makers) who are mainly concerned about making money. Citizens understand that drug makers should recover their investment in research, for instance, but said they sense that advertising and business interests are driving costs.

  "If doctors would go back to taking a real concern for patients, only prescribe what is needed, give old-fashioned advice ... instead of prescribing a med the drug rep just came by with."
  — Chamber of Commerce Young Professionals forum participant

• inefficiencies in the system which make it less responsive to the poor and uninsured. Some pointed out that the ER is attractive to the poor because they don't have to pay, don't have to miss work to go, and can be seen immediately. At the same time, though, there is not enough follow-up care provided to make sure their medical problem gets solved.

  "The Health Park was supposed to be for preventive health. But it's not affordable. Lots of people need to go there and can't afford it. It looks nice, but only serves a certain type of clientele. It doesn't serve the uninsured so it defeats the purpose."
  — Local labor representatives forum participant

  "Physicians accept more burden of uninsured patients than most people know. Imagine being on call and up 24-plus hours caring for someone who does not care for him- or herself and how frustrating that can be. ... (After paying back $100,000 of medical school loans) caring for a non-paying, irresponsible individual is hard to swallow. Yes, doctors went into this field to help and heal, but they cannot do so without continued financial means. It is a community health education problem."
  — Daviess County Medical Society forum participant

Other reasons cited for high costs were: lack of early detection of medical problems (the problems become serious and more expensive to treat). lack of preventive care. "Preventive care needs to be a primary focus." — Kentucky Wesleyan College forum participant consumer demand for the latest technological advances in medicine (medical equipment, drugs, etc.). "To some degree we can get by on some of the less expensive medication in some circumstances. But patients want what is new, what costs more." — Chamber of Commerce forum participant

• unhealthy lifestyles of people in general.

  "We need education in healthy lifestyles. Most of our health issues involve diet (poor diet, dental disease, heart disease, obesity, high blood pressure, etc.)."
  — Seventh Day Adventist Church forum participant

• a lack of understanding by the public of the actual cost of care.

  "People who are not satisfied with their doctors ... wait until after office hours and go to the emergency room. We tie up a multi-million-dollar facility because we don't like someone."
  — Daviess County Farm Bureau forum participant

• spending by health providers on nonessential items such as buildings (in particular, the Owensboro Mercy Health System Health Park and office buildings).

Citizens believe making the system more efficient, primarily for the poor, is the only justification for paying higher taxes or fees for health care.

• Since the current system falls short when costs are so high, citizens do not feel that spending more money on health care is the answer.

"Health care issues of cost, access and quality are inherently complex. Tradeoffs and choices must be made."
— Participant in forum for human resources managers

• Nearly half favored paying more to help fund an organization to match health care needs with available doctors, clinics, hospital services, etc.

  "I believe that everyone deserves some sort of health care whether they can pay or not. Human life is too valuable to put a dollar sign on it!"
  — Owensboro Community College nursing class forum participant

• Nearly half favored paying more to fund a full-time regular doctor at existing clinics. (There is now a regular doctor at the McAuley Clinic, funded by OMHS.)
• More than 40 percent favored paying more to expand transportation services to medical care for the poor, and/or to provide mobile health units for underserved neighborhoods.

  "Traveling clinics in rural areas and low-income areas of town might be a big help."
  —River Park Center volunteers forum participant

There were many different points of view expressed at the forums, including these opinions on the availability of health care: "For the most part I think affordable health care is available in some form and that programs that assist individuals exist. Many who do not have health care do not want it or do not take advantage of the system." — Physicians forum participant "National health insurance is a basic need and solution of many of the issues." — Habitat for Humanity forum participant

More than 90 percent of participants also favored

• a watchdog effort to make sure doctors, clinics, hospitals and contract health services do not overcharge (only a third were willing to pay more taxes or fees for this).
• making it easier for doctors to distribute free prescriptions by reducing paperwork, for example (only a third were willing to pay more taxes or fees for this).

  "We need more ... ways to obtain medications. Medicare needs to help pay."
  — Precious Blood Church forum participant

Participants also suggested

• encouraging employers to provide better benefits and the lowest possible premiums so more people can afford the company-sponsored health insurance plans.
• expanding screenings or developing a community-screening center that would push prevention, catch more problems early and reduce costs.
• expanding efforts of agencies, such as Green River Area Development District (GRADD), that train volunteers to help people qualify for prescription drug assistance programs.
• using drug samples more efficiently. Many samples are disposed of when not distributed by an authorized date.
• pooling agency resources and learning of one another's services. For example, many may not be aware that Audubon Area Community Services (AACS) pays for medications if patients qualify and physicians authorize it.
• purchasing medications in bulk for free clinics and distributing them based on a formula. Use generic medications to reduce costs.

The forum's discussion "promotes an environment of blame for problems in the health care system - doctors, hospitals, insurance companies and drug companies. The discussion does not focus on the individual's responsibility and the discussion that needs to take place at a societal level." —OMHS staff forum participant "I feel that our American culture has influenced how we "care"for poor people. We are too greedy, too individualistic, and too competitive." — Central Latino Center forum participant

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Everyone needs a doctor After the high cost of health care and prescription drugs, citizens are most concerned about the number of people without primary care and prevention services, and they connect this to the local shortage of doctors, another of the access issues identified by the People's Health Project. 72 percent of forum participants ranked the lack of a regular doctor for many citizens as very important; 61 percent ranked a shortage of doctors as very important. 14 percent of participants ranked the need for regular doctors as the most important issue; another 10 percent ranked the shortage of doctors as the most important issue. Significantly more women than men ranked both issues as very important. "We need more doctors and assistance to help provide for everyone, especially those that have kids and work." — St. Joseph Fire Department forum participant

Citizens believe some people don't have (or want) a regular doctor because of:

• cost, particularly if they are uninsured or underinsured with high deductibles.
• frustration with the system, including the hassle of getting in to see a doctor.
• the unavailability of doctors, especially to those without insurance.
• lack of trust in doctor-patient relationships.

Citizens described the implications of not having regular doctors as:

• less preventive care.
• lack of trust in doctor-patient relationships.
• increased use of emergency and urgent care centers.
• higher costs.

Citizens believe there is a shortage of doctors which they attribute to:

• the economics and appeal of practicing in a small town, with fewer amenities or options for a spouse.

  "If the doctor is used to living in New York and comes here to Kentucky, they soon leave because it isn't the same lifestyle they've been used to."
  — Dugan Best Neighborhood Association forum participant

• rivalry among providers which prevents existing doctors or the hospital from aggressively recruiting or welcoming new doctors.

  "We need a medical community that recruits more of its own — not a closed competitive system."
  — Estes Elementary forum participant

  Despite data to the contrary, some local health care professionals disagree that there is a shortage of doctors. They claim that many teaching physicians and residents at state medical schools skew the data in other communities. Citizens overwhelmingly disagree. And physician spouses emphasized the workload of local doctors: "Some doctors have not had a vacation in years." — Small Business Owners forum participant

Citizens said the shortage results in:

• dissatisfaction among patients who feel their doctors don't have enough time for them.
• an imbalance in the system, with too few primary care doctors compared to specialists — but also too few specialists to see patients in a timely way.

  "There are perhaps too many chiefs and not enough Indians in the medical field - that is, too many specialists and not enough doctors who act as primary care physicians."
  — Dugan Best Neighborhood Association forum participant

  "A shortage of psychiatrists and nurses must be considered in Daviess County."
  — Owensboro Christian Church forum participant

  "In our area we have a large number of specialists. I personally go to a urologist, a cardiologist, or an ear, nose and throat doctor instead of my internist for those specific problems. So, the lower number of general practitioners is probably a result rather than a cause."
  — Henry Wilson Discussion Group forum participant

• overuse of urgent care centers and the emergency room. While many people expressed satisfaction with urgent care centers, they considered them inadequate substitutes for a regular doctor. In addition, they only serve paying patients; others are referred to the emergency room.

As solutions, more than 90 percent participants favored:

• helping patients find a regular doctor or medical home (most favored this only if it did not require a tax or fee increase).

  "It is important for more people to see a physician on a somewhat regular schedule."
  — Chamber of Commerce Young Professionals forum participant

• recruiting more doctors to Daviess County (most favored this only if it did not require a tax or fee increase).

More than 80 percent supported trying to convince doctors to accept more nonpaying patients and providing a tax deduction for doctors for this service (most favored these only if they did not require a tax or fee increase).

Participants also suggested:

in regard to making sure everyone has a regular doctor:

• promoting community-wide the importance of having a primary care physician.
• encouraging employers to promote and endorse the importance of establishing a medical home with employees at annual benefits meetings. Remind employers that healthy employees are more productive workers.
• encouraging employers to identify employees with/without primary care physicians and to track them through an in-house database.
• encouraging workplace health fairs during work hours. Encourage and assist employees in finding a primary care physician. Offer to pay for an introductory physical examination.
• expanding the number and role of nurse practitioners and physician assistants, who have more time to spend with patients. (However, if a patient makes an appointment with a doctor and expects to see a doctor, they should not be referred to a nurse or physician's assistant.)
• developing a health resource directory to let people know where to go for services.

in regards to addressing the physician shortage:

• developing a mobile health unit to serve rural areas and target neighborhoods.
• approaching retired physicians to help alleviate shortages.
• providing incentives for physicians to establish practices in our community: tax breaks for charity cases, assistance with medical school loans or other financial incentives.
• promoting the Health Kentucky program; few people know about it.
• developing a physician hotline.
• developing a better physician (and dentist) rotating system to care for the poor fairly.
• promoting the alternatives available, such as nurse practitioners and physician's assistants, to people looking for a doctor

Let's fill the gaps Citizens are deeply concerned about the many people who fall through the cracks of our health care delivery system. Many shared stories of family or friends who were denied coverage by a health plan, whose condition deteriorated while waiting for approval for treatment (from an insurance company or the federal government disability agency) or who are not taking their medications because of cost. 70 percent of forum participants ranked this issue as very important. 8 percent of participants ranked it as the most important issue. Significantly more women than men ranked this issue very important. "I have known people who really need health care but do not qualify under existing systems and therefore receive little to no care." — Precious Blood Church forum participant

Citizens were most concerned about:

• the lack of insurance coverage for medicine for the elderly under Medicare.

  "Everyone needs access to affordable care - not to have to beg or put food or drugs, one in front of the other."
  — Elizabeth Mundy Center forum participant

• the inability of the working poor to pay for insurance or get other low-cost services.

  "Single parents with fairly good income that do not receive child support make too much money to qualify for assistance, but on the other hand, struggle to provide medical and dental care for their family."
  — Dugan Best Neighborhood Association forum participant

Citizens described other gaps that included:

• loss of insurance coverage when changing jobs.
• lack of insurance for some members in a family.
• lack of mental health coverage for both adults and children.

  "The lack of mental health care for children is a real challenge. Insurance does not cover much. Therein lies the problem — finding a provider willing to work for nothing."
  — Owensboro Mercy Health System board forum participant

• lack of coverage and translation services for the growing Hispanic population, particularly children.

As solutions, more than 90 percent of participants also favored:

• using more physician's assistants, nurses, nurse practitioners and midwives to fill gaps (more than 40 percent would pay more taxes or fees for this).
• helping the poor and uninsured fill out paperwork to get approval to see a doctor (only a third would pay more taxes or fees for this).
• promoting and supporting more and better health insurance plans offered by employers (only a third would pay more taxes or fees for this). Participants also suggested: 8 establishing a health care clearinghouse or ombudsman to help patients with difficulties, inconveniences, paperwork, directions, information, transportation and linkages to primary care.
• providing translation services or on-line resources to serve those not fluent in English.

  "Doctors can't continue to increase the charity care they give as more employers drop insurance coverage."
  — Health Insurance Professionals forum participant

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The system could be more consumer-friendly Fewer citizens rank inconvenience and intimidation as a critical issue, but transportation problems were discussed frequently during the forums. Participants were more willing to pay higher taxes or fees to address transportation problems than they were to spend money on some other proposed solutions to health care access problems. 47 percent of forum participants ranked this issue as very important. Significantly more women than men ranked this issue as very important. (Women, more frequent health care system users, are more likely to experience the inconveniences.)

Citizens said the major inconvenience in the health care system is transportation.

• The elderly, in particular, have problems with transportation.
• Citizens acknowledged the value of the GRITS (Green River Intra-county Transit System) minibus program, but also pointed out that one must call ahead, wait several hours and risk being late for appointments.

  Diabetics have trouble using GRITS because "if you have to wait too long without eating, there is a problem."
  — Daviess County Farm Bureau forum participant

  Many elderly riders need assistance from their front door, and GRITS vehicles pull up in the street.

Citizens said they are frustrated by filling out forms, approval processes, being shuffled from one doctor's office to another and long waits.

"Even though you have a doctor, they tell you to go to a convenient care place. ... When you go to convenient care, people get frustrated waiting for 2-3 hours."
— Dugan Best Neighborhood Association forum participant

• Some participants said large hospitals are intimidating.
• Many people said they do not understand medical explanations or instructions related to medications.

As solutions, nearly half of participants said they would be willing to pay higher taxes or fees for:

• mobile health units for underserved neighborhoods and remote areas.
• expanded transportation services to and from the doctor's office or hospital.

Participants also suggested:

• issuing public transportation vouchers for the poor and elderly who need health care.
• developing health care partnerships with neighborhood associations for information, screenings, etc.

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Respect is important Citizens acknowledge that far too many people — providers and support staff as well as patients and families — do not always treat others with respect and courtesy. While participants rated it last in importance among the seven access issues, they shared many personal experiences where they felt they were not treated well by the medical system. Forty-five percent of forum participants ranked this as very important. Significantly more women than men ranked this issue as very important.

Participants had complaints about:

• treatment of poor patients. The most common complaint is that patients are asked first if they have insurance when they call a doctor's office.

  "I haven't established a family physician yet. I moved here four years ago and the ones I do call, the first question they ask is, 'Do you have insurance?' which I do. It just rubs me wrong that that is their first concern. Not 'What do you need today?' The main concern is that you have insurance so that they can be sure that they are going to get their money. That's the feeling I get."
  — Eastview Elementary School forum participant

  "I wanted to pay $10 per week on my bill but the doctor wouldn't work with me and told me that wasn't enough."
  — Estes Elementary School forum participant

  "When you go to the doctor, be sure to be well dressed. It makes a difference in how they treat you. If you look like a slob, they treat you like a slob."
  — Precious Blood Church forum participant

• rude and inconsiderate patients. But physicians and office staff complained about rude, demanding patients as well and about the large number of patients who miss appointments.

• the lack of time spent by doctors with their patients. People felt that doctors "rush in and out."Others said that physicians are often arrogant and sometimes unwilling to compromise.

  "Biggest problem that I see and hear from my friends —-doctors just don't listen!"
  — Hospice forum participant

About 61 percent of participants said they favored taking steps to ensuring courtesy, respect and equal treatment for all if there were no costs associated with this.

Some people claimed that physicians and office staff treat uninsured and Medicaid patients with less respect than those who are insured: "...the funds take awhile to come in to pay the physicians, so doctors' offices don't treat the Medicaid or Medicare patient special." — Dugan Best Neighborhood Association forum participant On the other side, a physician said: "Medicaid patients are more demanding, more abrupt, more likely to sue." Because of low reimbursements, "I lose money each time I see one." — Physician forum participant Another physician acknowledged that it is harder for Medicaid and uninsured patients to get in to see a doctor. He does not accept them. "The uninsured have a hard time. There are other factors involved. That is a reality." — Physician forum participant Still other forum participants complained about the "freeloaders" (AARP forum participant) whose care is paid for by "the rest of us who are willing to purchase insurance" (Small business owner forum participant). "Sometimes those without insurance get in before the rest of the people waiting. Why? ...Because the uninsured do not have to complete all the forms that the insured are required to." — Dugan Best Neighborhood Association forum

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Exhibits

Survey Results

Table 1

Forum Participants' Ranking of the Most Important Health Care Access Issues Facing Daviess County
(The issues were identified by an August 2000 Survey by the University of Kentucky)

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Table 2

Forum Participants' Assessment of 16 Possible Strategies To Address Health Care Access Issues
(The issues were identified by an August 2000 Survey by the University of Kentucky)

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The voices: who participated

Widespread participation. Fifty-two forums were held from March 2001 to February 2002; 1,147 people were personally invited to a forum, 578 participated, and 491 completed questionnaires.

Urban and rural representation. Of those who completed the questionnaires, nearly two-thirds of the participants (64 percent) lived in the city of Owensboro, 29 percent lived outside the city limits in Daviess County and 6 percent were from other areas.

Age and gender participation. Forum participants ranged in age from younger than 18 years of age to older than 65. Women made up 65 percent of participants; 35 percent were men. (Coincidentally, these are the same percentages that responded to the Health 2000 survey conducted by the University of Kentucky).

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Letter of thanks A project and report of this breadth requires the diligent work of many people. The Public Life Foundation of Owensboro is fortunate to have been able to put together an outstanding project. In particular I'd like to thank the following: Public opinion consultant John Doble, for wise and valuable counsel and guidance throughout the project. Carol Ireson and her assistant, Jennifer Galland, of the University of Kentucky for their comprehensive and meticulous analysis of data from the forums. Beverly Mills of PLFO, for the organizational skills she brought to gathering and assembling the data from the forums. Writer/editor Fran Ellers, for her efforts to make the report not only thorough but readable.

All these people contributed significantly to this project, but it succeeded in large part because of the leadership of Rodney Berry, PLFO president. Rodney attended virtually all the forums and moderated many of them. He helped design the study, collect the data, and write the report. Most importantly, Rodney has been tireless advocate for giving the people of Daviess County a voice in local health care decisions and debates. I offer my thanks to Rodney, the forums' participants and volunteers, and the team members who helped make this project and report possible.

John S. Hager Founder,
Public Life Foundation of Owensboro

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How the People's Health Project came about

Why health care access? In August 2000, the Public Life Foundation of Owensboro and more than 20 other sponsors released a comprehensive health needs assessment for Owensboro-Daviess County and the seven counties of the Green River Area Development District. The study, conducted by the University of Kentucky Center for Health Services Management and Research, included surveys, focus groups and telephone surveys of 1,800 citizens, each of whom was asked more than 90 questions about health and health care. Two major issues emerged as barriers to healthy citizens: access to health care and unhealthy lifestyles. Since several community organizations were already focusing on lifestyle issues, the Foundation targeted health care access.

From information to deliberation. The Foundation embraces a three-pronged process for community problem solving: information, deliberation, action. With new information from the UK study, the Foundation brought citizens together to deliberate in People's Health Project forums so they will be empowered to take action.

Easy-to-understand information. The UK study identified seven health care access issues. The Foundation presented these issues, themes and supporting data in easy-to-understand discussion guides for community forums.

Connecting with citizens. The Foundation developed an ambitious forum plan to attract citizens from all walks of life. Civic and service clubs, church groups, neighborhood associations, parent-teacher organizations, trade and professional associations and other groups hosted forums throughout Owensboro and Daviess County. Any group was welcome to participate, and all forums were open to the public.

Trained citizen leaders. The Foundation formed a citizens advisory committee which helped recruit moderators to lead the forums and recorders to take notes.

A chance to be heard. In each forum, participants were introduced to the latest information related to health access issues. They were asked to share personal or family experiences and circumstances. They told their stories.

Issues, options and strategies. Participants were then asked to discuss and rank the importance of various issues. They learned about opposing points of view. They shared ideas and explored possible community strategies.

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Progress in health care access Key Initiatives in Owensboro-Daviess County Through August 2002 Clinics and charity care (1970s - present) For many years, Daviess County's poor and uninsured turned to physicians and dentists who would provide charity care, the hospital emergency rooms, the Free Clinic (one night per week, working poor only), or the McAuley Clinic (one day/night per week). Public opinion research (1998-99) Preston-Osborne and Doble public opinion studies documented local citizen concerns about health are (cost of care, insurance premiums, medications, distrust of system, etc.).

Health needs assessment (2000) Comprehensive University of Kentucky study stressed issues of unhealthy lifestyles and health care access.

Citizen voices (2001 -02) Public Life Foundation shared UK findings and facilitated citizen dialogue in 52 health care forums.

Attention to lifestyles (1990s - present) Healthy Horizons, OMHS HealthPark, Corporate Challenge, health fairs, screenings, school nurse program, Fit for Life school programs, and a planned Community Summit on Healthy Lifestyles point to a growing acknowledgement of the importance of behavior and personal responsibility in health care.

County government resolution (2001) A bold community goal is proclaimed by county leaders: 100% access and zero health disparities.

Examining models (2001) County judge-executive convened health care and community leaders to learn how other communities have improved access to quality care for all. A North Carolina model was introduced.

Federal grant, county tax for expanded public health facilities (2001) County government secured $2 million federal grant and the county health tax was increased to finance expanded public health facilities. Facilities will include space for a primary care clinic.

Prescription drug report (2001) Reacting to this citizen priority, the Public Life Foundation commissioned a prescription drug study, identifying resources and models from other communities.

McAuley Clinic partnership-pilot project (2001) Daviess County Fiscal Court, Green River Health, and OMHS formed a partnership to manage and monitor a free clinic staffed by a full-time physician, nurse practitioner, and caseworker.

Directories (2002) Responding to another need, the Public Life Foundation published directories to inform citizens of primary care and community health center resources.

Prescription drug and medical transportation task Forces (2002) The Public Life Foundation convened interested citizens, health care providers, and agency representatives to explore ways to work together to help more people with medications and transportation. Both groups are developing exciting collaborative models.

Citizens Health Care Advocates (2002) Concerned citizens who participated in Public Life Foundation forums have established an organization to work on behalf of the public interest in health care.

Robert Wood Johnson foundation grant A major grant proposal has been submitted by the Citizens Health Care Advocates to fund a four-year citizen-driven health access program.

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Forum Locations
Audubon Area Community Services Moonlite Bar-B-Q Restaurant Wesleyan Heights Methodist Church Kentucky Wesleyan College First Baptist Church East View Elementary School Third Baptist Church Daviess County Public Library Centro Latino Center Utica Elementary School St. Stephens Catholic Church Campbell Club Elizabeth Mundy Center Apollo Heights Baptist Church St. Joseph Fire Department Dugan Best Recreational Park Daviess County Farm Bureau Roosevelt House Owensboro Community College Seventh Day Adventist Church Foust Elementary School	RiverPark Center YMCA Owensboro Christian Church Colby's Restaurant Precious Blood Catholic Church Green River District Health Department Boulware Center Mission Zion United Church of Christ Owensboro High School Longfellow Learning Center Friendship House Counseling Associates Kentucky State Building RiverValley Behavioral Health Estes Elementary School Brescia University Fourth Street Baptist Church Owensboro-Daviess County Chamber of Commerce Settle Memorial Church Owensboro Mercy Health System

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