Different deliberative techniques or tools can be used to explore how groups make decisions when faced with various options. CHD’s approaches vary depending on the topic of the deliberation, the types and number of individuals that will participate, and the time and resources available. CHD uses a variety of approaches including:

As public input has gained credibility as a relevant contribution to healthcare reform, healthcare leaders have shown interest in developing and instituting deliberative processes with their constituents. CHPR works with the Center for Health Decisions (CHD) to provide nonpartisan work with the public and has brought insights into individual and societal values that are particularly relevant to healthcare reform.

With so few nonprofit, nonpartisan organizations focusing on the “citizen” perspective, CHD’s knowledge can benefit state and national groups that are working to improve healthcare quality, coverage and affordability. Consequently, CHD staff is often recruited as members of boards and advisory committees.

We work with policymakers, healthcare providers, government agencies, professional associations, community organizations and researchers to understand the views and priorities of the public. Whether you are considering changes within your company or local community or are facing a state or national policy dilemma, we can help you engage your constituents.

CHAT® (Choosing All Together) is a computerized process for individual and group decisions. Licensed through the University of Michigan, CHAT is an effective tool for establishing coverage priorities and for other types of priority-setting when multiple options are available. Since 2002, CHD has designed more than a dozen versions of CHAT for use in California and other states, facilitating more than 300 sessions with various demographic populations.

CHAT® is a simulation exercise, allowing participants to use their own experiences, beliefs and values to create the best possible coverage for themselves and others.

CHAT was created by bioethicists at the University of Michigan and the National Institutes of Health who understood that the public needed more information and opportunities to participate in policy discussions that impact them and their communities. CHD has customized the CHAT process and utilized it with four unique projects in California. CHD has also worked with four other states to help them design their own CHAT board and engage their state residents in this social decision-making exercise. CHAT comprises both a qualitative and quantitative process. The goal is to better understand what participants most value and why. Data from all sessions are collected and analyzed, along with answers to pre- and post-session survey questions.


How CHAT Works

  • On individual computers, participants consider 12-15 categories of coverage displayed on a pie chart. Each category offers one or more benefit levels.
  • Participants have more coverage options than they have resources to spend.
  • Participants make coverage decisions for a whole population, not just themselves, moving from “What do I want?” to “What makes sense for all of us?”
  • A skilled facilitator encourages participants to explore their views and values in an engaging, interactive environment.


Completed CHAT Projects include:

Just Coverage: Citizen define the limits of ‘basic’ healthcare (PDF)

REPORT BREIF: Designing Coverage: Uninsured Californians Weigh the Options (PDF)

Responding to growing interest in universal health care (pre-ACA), more than 900 insured and uninsured Californians defined the core components of an essential health plan. Project results showed:

  • What healthcare needs should be met by insurance coverage and why
  • How essential coverage was distinguished from non-essential
  • How groups balanced cost-sharing, provider restrictions and coverage limitations
  • That an informed public could develop an acceptable basic plan

Project Publications:

Making Tough Choices: Adults with Disabilities Prioritize Their Medi-Cal Options (PDF)  

In response to anticipated cuts in the state’s Medi-Cal budget, adults with disabilities identified the most acceptable trade-offs if funding was to be reduced by 15%. The California Foundation for Independent Living Centers recruited 131 non-institutionalized adults with disabilities to participate in 12 discussion groups statewide. Results were shared with leaders at the CA Department of Health Care Services.

Project Publications:


When Options Exceed Resources: Making Trade Offs in Healthcare Benefits (PDF)  

Facing increased coverage costs, employers sought guidance in addressing the tensions between what consumers want and what companies are able to purchase. We worked with seventy-one public and private sector companies in the Sacramento region and learned the coverage priorities of their 750 employees.





Many of the challenging issues affecting healthcare policy or practice relate to healthcare quality, cost containment, physician or patient authority, and the results and use of medical research. Both the lay public and healthcare professionals can best respond to complex trade-offs when those trade-offs are described to them using scenarios that illustrate the issue through a common medical situation. Case scenarios are used as examples of the issue at stake; from these examples – and by introducing variations in the scenarios – facilitators draw out the underlying principles that are foundational for individual/group choices.


Completed Scenario Projects include:

Sharing in the Cost of Care: Perspectives from Potential Health Plan Users of the California Health Benefit Exchange (PDF)


During its planning phase, Covered California (the state’s health benefit exchange) asked CHD to find out how future beneficiaries would structure healthplan cost-sharing in the fairest way possible to meet the needs of new enrollees. CHD held deliberative sessions with ten discussion groups throughout the state, meeting with a total of 113 uninsured Californians. Participants reviewed and prioritized multiple case studies that illustrated how different cost-sharing models would affect patients with different needs: chronic illness, episodic care, catastrophic care and preventive care.

What Matters Most: Californians' Priorities for Healthcare Coverage (PDF)


What Matters Most tackled a key aspect of healthcare reform efforts: at a time of rising healthcare costs, what medical situations are most essential for coverage and which are less essential? The project included a telephone survey of 1019 randomly sampled Californians. Each ranked 10 (of 80) short medical vignettes on a scale of coverage importance. This was followed by 15 group discussions with 176 community members who reviewed the results of the phone survey and provided their reasoning for differentiating higher and lower priorities. Findings were reported in the Congressional Quarterly, on Talk of the Nation and through other national media outlets.

Probing the public’ views on V-BID (PDF)


In June 2012, CHD completed a pilot project, Probing the public's views on V-BID, with partners in Michigan that was designed to determine how average employees consider the pros and cons of using value-based insurance design as a tool for encouraging high-value healthcare and discouraging low-value healthcare.

Hospital Quality: How and why the public cares about certain quality domains (PDF)


In an effort to help leaders of the California Hospital Assessment and Reporting Taskforce (CHART) evaluate how useful consumers find its work, CHD asked diverse groups of consumers throughout California to consider four quality domains: clinical effectiveness, patient safety, responsiveness to patients, and efficiency. Using an Audience Response System (keypad voting) and a series of case scenarios, project participants were asked to prioritize the relative importance of these domains and discuss the rationale for their decisions. This CHD report has been distributed nationally to organizations sponsoring hospital public-reporting websites.

Phone or internet surveys are not considered deliberative, but CHD has occasionally used surveys to lay a foundation for a deliberative process. For example, identifying the public response to an uncomplicated healthcare policy issue through use of a survey could form the basis for a more detailed deliberative exploration that involves trade-offs. In other instances, a survey can be used to validate qualitative conclusions drawn using other approaches.


Completed Survey Projects include:

What Matters Most: Californians’ Priorities for Healthcare Coverage (PDF)

What Matters Most tackled a key aspect of healthcare reform efforts: at a time of rising healthcare costs, what medical situations are most essential for coverage and which are less essential? The project included a telephone survey of 1019 ramdomly sampled Californians. Each ranked 10 (of 80) short medical vignettes on a scale of coverage importance. 15 group discussions were then conducted with 176 community members who reviewed the results of the phone survey and provided their reasoning for differentiating higher and lower priorities. Findings were reported in Congressional Quarterly, Talk of the Nation and other national media outlets.


Visible Fairness: Cost-Effectiveness as a Criterion for Medical and Coverage Decisions (PDF)

This regional project was a community-wide dialogue on the role that cost plays in healthcare treatments and coverage decisions. Designed to gauge the public’s notion of cost-effectiveness as a component of medically necessary care, this was an extension of Stanford University’s earlier report on Defining Medical Necessity. Consumers weighed in on one of society's most difficult dilemmas: how to balance the medical needs of individuals with those of the larger community. CHD conducted a written survey of 500+ physicians, held 25 discussion groups with 263 consumers and commissioned a 500-person randomly sampled phone survey of the general public. Results were presented in CA and nationally. To see an example of how average consumers debate a controversial health policy issue, view this 8½ minute video.


Additional Publications for which CHD used the Survey Approach:

While our work is primarily meant to inform healthcare policy and practice, deliberative discussions are also educational for participants. Regardless of the healthcare topic, the process itself exposes individuals to insights about themselves and others and fosters understanding of “social decision-making” – when the needs of many people are taken into account. This is especially important in healthcare, for which the structure of the system, financing and care delivery are based on models that must serve diverse populations.

Lectures about health insurance are exceedingly complicated and inherently boring. But when you ask groups of people to negotiate and collaborate on policy decisions, this activity improves their understanding of healthcare and appreciation for the collective wisdom that emerges and that is not boring. In fact, it is stimulating in ways that surprise people and helps to connect them to real world situations.

CHD has been using CHAT for interactive group discussions since 2002. While most of this work has been project-specific – to help address healthcare policy dilemmas about what health plans should cover – we learned quickly that this process does more than answer research questions. It helps individuals think about healthcare policy from a different perspective – the perspective of citizens grappling with competing priorities and disparate values.

For that reason, we have been using CHAT for three distinct purposes:

  1. Educating healthcare and community leaders.
    In academic settings, CHAT can be used as an effective process for understanding the dilemmas of allocating communal resources; learning the relative costs of coverage components; and appreciating how societal values influence individuals’ judgments of what is essential and what is not.
  2. Creating “next generation” health plans.
    Businesses, public sector entities and communities may be seeking new models of healthcare coverage in an environment of diminishing resources in which value-based, high-quality care is what must be delivered. Leaders can learn from their constituents. CHD can create customized versions of CHAT, in response to the interests and circumstances of sponsoring organizations.
  3. Team building.
    Organizers of leadership trainings, conferences, and board retreats seek activities that are engaging, highly interactive and educational. For health and non-health organizations alike, a two-hour group CHAT session can have participants responding as one member of the Society of Actuaries did, "Easily the best session I have ever attended at an SOA meeting."Click here to see the types of groups that have benefited from using CHAT as a team-building exercise.

To learn more about how CHD can assist in your company’s education programs, please contact Patricia Powers at pepowers@ucdavis.edu.