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Tom Atlee Writes About Use of Hi-Tech Games to Help Citizens Deliberate

In a February 6, 2004 message to his email list, Tom Atlee of the Co-Intelligence Institute wrote about how citizens can use games – computer simulations and other scenario-based games – to learn about the trade-offs involved in making decisions about public issues. When combined with deliberation, he says, this can greatly improve the sophistication of citizen recommendations and the level of public buy-in for whatever fair policies are approved.

Tom’s message continues:

Dear friends,

Frances Moore Lappe sent the intriguing article below about a new form of citizen deliberation — a game about health benefits. The game is described on the CHAT Project link at www.sachealthdecisions.org as follows:
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“CHAT is a computer simulation game developed by physician ethicists at the National Institutes of Health and the University of Michigan, whereby participants are faced with making decisions about health plan benefits packages when there are more choices than resources to pay for them.

“This stimulating and educational process takes place in a 2 1/2 hour discussion group where 10-12 participants design a healthcare benefits package for themselves, their company and their state.

“The CHAT game is conducted using individual laptop computers combined with group discussion that involves negotiation, compromise and consensus-building.”
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This makes me wonder how many other games could be developed to explore trade-offs in other issues — war and peace, educational choices, what is national security, global trade policy…. In particular, citizens should be able to work over city, county, state, and national budgets like this. It would be very interesting to see what different decisions — and similar decisions — were made by different groups. Results could be combined in various ways to constitute policy recommendations.

It is interesting to note that in high quality deliberation — which scenario games could stimulate or augment — citizens come to understand more about how the money they pay in taxes or premiums is (or could be) connected to services they and their community receive. They usually become more willing to pay more taxes AND more selective about how those taxes are used AND more tolerant of belt-tightening measures when they’re really necessary. It only makes sense.

If I let my imagination be brave, I can see a society where every issue has its game(s) and every coffee shop, church and library has people playing them, talking animatedly, and, at the press of a button, sending their conclusions off to be integrated into policy recommendations.

Along these lines, subscriber Cynthia Cutting wrote me: “As I ponder the implications of this global warming situation I am thinking that it’s time for some conversation about how to address this matter. One thing that came to me is rather fun, actually – maybe a board game could be developed to help people get the hang of what the challenges will be. I’m not sure there is any way of avoiding this phenomenon at this point. Might as well face it head on and be creative about it.”

Perhaps it is an idea whose time has come. Perhaps a whole new profession will be born to create these games. People might start to feel involved in the decisions, aware of what trade-offs were made and why….

Public policy might start to make sense…

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Health Benefits Game Yields Surprising Results
by Kathy Robertson

November 24, 2003

Getting people to agree about group health insurance has never been
an easy task. And these days, it seems the only point not in dispute
is that the economics of providing coverage are becoming more and
more painful. Weary employers find themselves facing another year of
rate hikes; anxious workers are preparing to shoulder a bigger share
of the cost. Neither side is happy.

Traditionally, the process of calculating who gets what goes
something like this: Businesses settle for the best deal they can
afford, which is often much less than employees want or expect.
Managers are then faced with the prospect of selling the new plan to
skeptical unions and wary workers, many of whom have no idea what
their health care benefits really cost.

So what happens when employees are asked to design a benefit plan for
themselves? Turns out, they do a pretty good job.

Over the past year, nearly 750 people from more than 40 private
business, public agencies, and other organizations in the Sacramento
area have learned how and why some of their health care benefits are
determined by participating in a computer game called Choosing
Healthplans All Together, or CHAT. The game, available through
Sacramento Healthcare Decisions, shows players how different
combinations of health care benefits might work in the real world-and
at what cost.

There were some surprising results. According to a final report
released last month, almost three-quarters of those who played agreed
that it’s reasonable to have limits on health care coverage. Most
changed their minds about what types of coverage their employer
should offer after talking to others in their group. And a whopping
85 percent said they were willing to accept the benefits package they
had a role in creating.

“The fact so many people said they would abide by the decision of the
group speaks volumes about having a role and acceptance of group
process,” said Marge Ginsburg, executive director of Sacramento
Healthcare Decisions. “Particularly at this time, when there’s so
much tension, so much anger, and so much lack of understanding about
why people have to pay so much when they hardly use anything at all.”

Make It a Game

The object of CHAT is to develop a hypothetical group health plan by
confronting players with real-world trade-offs. Each player is issued
50 markers to “spend” on a menu of 99 health care services
distributed among 16 categories ranging from primary care to “last
chance” treatments such as organ transplants. This approach forces
participants to make tough choices, balancing the needs of
individuals against those of the group. They then test the resulting
plan against a series of random health events representing a wide
variety of potential illnesses and accidents; some grave, others

A board game adapted for easy use on laptop computers, CHAT is played
in three or four rounds that last a total of about two hours. First,
players pick a benefit plan for their own family, then one for their
business or organization. As a final exercise, players are asked to
decide what elements should go into a model universal coverage plan
that would provide health insurance to everyone in the state. Some
groups then go back and revise their own health plan.

The game has no right or wrong answers, but choices have some
unexpected consequences. Suppose you pick the most basic pharmacy
benefit, and then develop severe allergy problems that require an
expensive drug? How about if you bypassed dental care, only to come
home and find that your child’s tooth had been knocked out at school?
Or what if a family member is diagnosed with breast cancer and your
benefits won’t pay for the genetic test that would indicate whether
you yourself are likely to get the disease?

The game was developed by two physician ethicists: Dr. Marion Danis
at the National Institutes of Health and Dr. Susan Goold at the
University of Michigan Medical School. The goal is to make health
insurance more “patient-centered,” help consumers understand how
group coverage works, and give health policymakers a better idea of
what people want in their health plans. “It’s based on the idea that
people should have some voice in what’s happening to them,” said
Goold. “Problem is, it’s really complicated.”

CHAT was adapted for use in California by Sacramento Healthcare
Decisions, a nonprofit, nonpartisan organization that seeks to
involve the public in health care policy issues. The project was
funded by a $250,000 grant from the California HealthCare Foundation.
Other versions have been distributed in North Carolina and Minnesota.
A test version of an online product is in the works.

Get as Much as You Can

Overall, those who played the game in Sacramento opted for a
statewide plan that offered the widest possible range of benefit
categories. They sacrificed provider choice in order to include
“something for everyone.” Most players expressed the belief that the
average person shouldn’t have to pay out-of-pocket for routine health
care services unless the insurance picked up a good portion of the

The typical plan designed by participants included primary, hospital,
and specialty care, along with pharmacy benefits, scans and x-rays,
lab tests, mental health services, dental care, rehabilitation
services, vision care, and “last chance” treatments. Quality-of-life
services such as weight-loss remedies and hair-growth products were
quickly dropped, along with complementary services such as
acupuncture and chiropractic. There was more discussion of
infertility treatment and support for the uninsured, but in the end
both of these categories generally fell by the wayside, as well.

A survey tool included in the game revealed that only 45 percent of
participants knew the total cost of their own monthly insurance
premium, and most regarded health insurance as guaranteed services
rather than pooled resources that have to serve a diverse group of

Topping the list of the three most important factors in considering
health care coverage-a question asked before and after the game-was
the ability to get a doctor’s appointment quickly. Sixty-four percent
of the players picked this at the outset and the percentage dropped
only six points, to 58 percent, by the end of the game.

Benefits selection in three categories increased substantially as the
game progressed. The proportion of people who chose to include mental
health services jumped to 61 percent, although this category was
initially picked by just 39 percent of the participants. The number
who picked “last chance” treatments grew to 60 percent from 38
percent, while rehab climbed to 68 percent from 46 percent.

“People were so surprised when they had to make choices for everybody
in the state,” Ginsburg said. “For folks who’ve only looked at this
personally before, this was revolutionary.”

Taking the Guesswork out of Contract Negotiations

Faced with a $6 million increase in health care benefit costs for its
5,000 eligible employees, the Elk Grove Unified School District
invited a cross section of all employee groups to participate in one
of four CHAT sessions.

“We knew we were looking at tough bargaining this year and that
health benefits would be a major issue,” said Jeffrey Markov, manager
of compensation and benefits for the district. “We thought, ‘Hey,
this might be a good way to educate employees.’ ”

It worked. Employees learned about rising costs and possible
trade-offs. Their choices helped management decide what to keep in
and what to throw out when they headed for the bargaining table.

Take vision care for example. The benefit costs the district $1
million per year. Management figured not everybody needed it, so why
not make it optional? “Oh man, they protected vision,” Markov said.
“We figured we’d better not bring that up in negotiations.”

On the flip side, management expected mental health services to be
important to workers, but discovered many bypassed this benefit in
initial rounds of the game. They changed their minds, however, when a
peer pointed out that it could help a teenager with a drug problem or
provide valuable counseling following a death in the family.

“CHAT was a really valuable tool,” Markov said. “The entire team went
through the process. It’s usually just people in administration. They
now understood how health insurance is purchased and what decisions
have to be made. The bargaining process was much easier.”

Teichert Inc. is just starting a second round with the game, this
time for real. Five groups of employees at the Sacramento-based
construction company have already played. Now, a new version is being
designed specifically for the firm.

“It was a good eye-opener for people who don’t pay attention to the
rising costs of benefits,” said employee benefits manager Kelly
Cleveland. “They got an idea of the trade-offs.” Teichert plans to
hold additional sessions in December, and use the information to make
appropriate changes in benefits when renewal time comes up in April,
she said.

Staff at Golden State Donor Services, an organ procurement and
transplant company in Sacramento, can’t really do much to change
their health care benefits at the local level. They’re owned by a big
corporate office in Nashville. Still, the CHAT game helped local
employees understand how difficult it is to make choices about what
to offer, said Janet Kappes, executive director. Asked to
participate, workers were initially skeptical but ended up having a
good time.

“Our staff constantly complains about bad benefits,” Kappes said.
“After CHAT, they realized they are not that bad-and could be worse.”

A Tool for Brokers, Policymakers

CHAT offers a valuable tool for insurance brokers who want to educate
supervisors, managers, or all employees about the compromises
inherent in health insurance, said Sacramento broker Linda Hunter.
“It’s a valuable eye-opener, probably one of the best educational
tools out in the field of employee benefits,” she said.

Looking ahead, CHAT proponents see several ways to make more use of
the game. There’s talk of a Medi-Cal CHAT to learn which benefits
low-income people value most. The prototype could also be used to
design a basic benefits package for workers who will get covered by a
statewide pool under the California Health Insurance Act of 2003 (SB
2), a new law that requires businesses to provide health insurance
for their workers or pay a fee so that the state can cover them.

A version of the game could help policymakers find out which pharmacy
services seniors want if Congress decides to fund a Medicare
prescription benefit. CHAT could also be adapted for use in poor
countries, Goold suggests.

“It’s a universal problem: Our expectation of what we can get from
health care is costlier than we are willing to afford,” said
co-author Danis. “We designed this game with the specific intent of
getting the public to participate in priority-setting efforts.”

More on the Web

Get information about Sacramento Healthcare Decisions and the CHAT
report, or sign up to play the game at www.sachealthdecisions.org.

The Department of Clinical Bioethics at National Institutes of Health
will be placing material related to CHAT on its website (www.bioethics.nih.gov/chat/index.html).

Additional information about the CHAT project will be available at
the University of Michigan website (www.med.umich.edu/bioethics/chatpics.htm).

The program can also be contacted at chatinfo@umich.edu.

Email Tom Atlee at cii@igc.org to join his email list.

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Sandy Heierbacher
Sandy Heierbacher co-founded the National Coalition for Dialogue & Deliberation (NCDD) with Andy Fluke in 2002, with the 60 volunteers and 50 organizations who worked together to plan NCDD’s first national conference. She served as NCDD's Executive Director between 2002 and 2018. Click here for a list of articles and resources authored by Sandy.

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