Center for Health Decisions | Center for Healthcare Policy and Research

Center for Health Decisions

Founded in 1994, the Center for Health Decisions was a non-partisan, non-profit organization that merged with CHPR in 2017.

Man talks to doctor on his computer from a living room.

The Center for Health Decisions’ (CHD) mission was to advance health and healthcare that reflects the values of an informed public.

While active, staff members collaborated with UC Davis researchers and others to promote civic engagement and capture public views on contemporary, controversial, and value-laden health issues. Target audiences for study findings included local, state, and national policymakers, community members, and other stakeholders, such as purchasers and practitioners. Active projects concluded in 2022. 

CHD and CHPR worked together to:

  • Identify challenging health policy issues for which informed public input plays a role.
  • Help other health stakeholders identify the health issues that are most relevant to their constituents.
  • Assist researchers with obtaining IRB exceptions to informed consent through facilitating community consultations.
  • Produce, implement, and evaluate customized non-partisan deliberative processes that meet the needs of our partners and clients; our methods are engaging and include the use of games, scenarios, and surveys.
  • Communicate relevant project findings to inform the work of policymakers and health leaders through presentations, professional publications, and social media.
  • Educate diverse professional and lay groups on the concept of social decision-making in the health and healthcare arenas through the use of interactive discussion groups.

Since its creation in 1994, the Center for Health Decisions:

  • Played a leadership role in local and statewide work to improve care at the end of life.
  • Brought Public Deliberation projects to organizations throughout California.
  • Had a significant role in national projects and agencies bringing the citizen voice to healthcare reform.
  • Presented project findings at state and national leadership symposia.
  • Published multiple articles in peer-rereviewed journals. 

CHD received funding from philanthropic grants, contracts with other organizations, donations, honoraria and in-kind contributions.

Grants and contributions

  • California Healthcare Foundation
  • Dignity Health
  • Kaiser Permanente
  • Blue Shield of California
  • LeadingAge Ca
  • Sutter Health
  • Sierra Health Foundation


  • UC Davis Health
  • American Institutes for Research
  • Covered California
  • Coalition for Compassionate Care of California

CHD staff served in roles on committees and boards with a wide range of organizations.

  • National Quality Forum, Board of Directors, 2013–2016 
  • California Medi-Cal Performance Advisory Committee, 2012–2015 
  • Institute of Medicine, Committee member, Determining the Essential Health Care Benefits, 2011
  • Cal e-Connect, (California’s HIE), Board Member, 2010–2011
  • Integrated Healthcare Association, Board Member, 2007–2016
  • NCQA, Committee on Performance Measures, 2007–2015
  • California Technology Assessment Forum (CTAF), Panel Member, 2007–2016
  • California’s Pay for Performance, Steering Committee, 2007–2012
  • California Hospital Assessment and Reporting Task Force, Board Member, 2005–2016
  • Blue Shield of California, Quality Advisory Board, 2003–2007
  • California Coalition for Compassionate Care, Co-Chair, 1999–2006
  • National Advisory Committee, RWJF initiative, Community-State Partnerships to Improve End-of-Life Care, 1998–1999
  • Health Data and Public Information Committee, Office of Statewide Health Planning and Development, 1998–2005

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 worked with the Center for Health Decisions (CHD) to provide non-partisan work with the public and brought insights into individual and societal values that are particularly relevant to healthcare reform.

With so few non-profit, non-partisan organizations focusing on the “citizen” perspective, CHD’s knowledge benefited state and national groups working to improve healthcare quality, coverage and affordability. Consequently, CHD staff was often recruited as members of boards and advisory committees. Staff worked with policymakers, healthcare providers, government agencies, professional associations, community organizations and researchers to understand the views and priorities of the public. 

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. Starting in 2002, CHD 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 customized the CHAT process and utilized it with four unique projects in California. CHD 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.

CHAT Projects

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

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. Publications include:

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.

Scenario projects:

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. The CHD report was distributed nationally to organizations sponsoring hospital public-reporting websites.

Phone or internet surveys are not considered deliberative, but CHD 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.

Survey Projects:

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 1,019 randomly 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 video.

 Additional Publications:

While our work was primarily meant to inform healthcare policy and practice, deliberative discussions were 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 started using CHAT for interactive group discussions in 2002. While most of this work was 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 used 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.


Key Findings from Public Deliberation with Community Members about Police Reforms

Community members who typically do not participate in local police reform discussions acted as community representatives for this public deliberation process about police reforms.


Doing What Works: The Public's Perspectives on Reducing The Use of Unnecessary, Harmful Or Wasteful Healthcare Services

Working with the Statewide Workgroup on Reducing Overuse, this project involved 117 Medi-Cal, Covered California, and CalPERS members in discussions on strategies for reducing overuse.


Common Cents: The Public’s Views on If and How To Reduce The Use of Low-value Medical Care

This report summarizes pilot project findings on the views of the public regarding various actions to reduce the overuse of ineffective or unnecessary medical interventions.

Re-Designing Medicare: Findings from the California Medicare CHAT Collaborative

810 current and future Medicare beneficiaries, healthcare professionals and community leaders in California offered their insights which comprise this report on how Medicare can best meet the needs of future generations. A 4-page Executive Summary is also available.


As a sub-contractor to AIR, CHCD worked on this national 3-year AHRQ-funded grant to learn how the general public responds to the use of evidence in healthcare decision-making. 


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

For this project, uninsured Californians considered the fairest way to structure health plan cost-sharing when trying to meet the needs of many Californians.

Value-Based Insurance Design: Probing the Public's Views on V-BID?

In this report, employees discuss V-BID options for encouraging high-value healthcare and discouraging low-value care.


Hospital Quality: How and Why the Public Cares About Certain Quality Domains

Californians prioritized four IOM hospital quality domains during this project to help guide corrective actions by California hospitals.


What Matters Most: Californians' Priorities for Healthcare Coverage?

In this project, 1200 Californians identified the medical situations they felt were most essential for healthcare coverage and those that are not.


Designing Coverage: Uninsured Californians Weigh the Options

Developing health coverage with a limited budget, uninsured Californians conveyed their coverage priorities and trade-offs.


Just Coverage: Citizens Define The Limits of "Basic" Coverage

Northern Californians constructed a lower-cost health plan for the uninsured by identifying key aspects of minimum coverage for this study.

Getting Good Value: Consumers Debate Costly Treatments - Is the Gain Worth the Expense?

For this project, consumers debated when it is appropriate to deny coverage if the expense of treatment greatly exceeds the benefit.


Making Tough Choices: Adults with Disabilities Prioritize Their Medi-Cal Coverage Options

Medi-Cal beneficiaries conveyed their views and priorities about Medi-Cal coverage in the face of budget cuts for this study.


When Options Exceed Resources: Making Trade-offs in Healthcare Benefits

Public and private sector employees weighed in on their healthcare coverage -- and found ways to compromise.


Visible Fairness: Cost-effectiveness as a Criterion for Medical and Coverage Decisions?

In this study, physicians and consumers had different views on medical treatment that offers small benefits at high costs.


ECHO Community Recommendations for Appropriate, Humane Medical Care for Dying or Irreversibly Ill Patients

Sacramento Area consumers and health professionals collaborated in this study on how to improve care at the end of life.

CHD was often invited to state and national meetings and conferences to present and discuss its work related to healthcare reform or improving end-of-life care. Select presentations on issues related to healthcare reform:

  • CalPERS Board of Directors. The public’s views on policies for reducing low-value care. Monterey, CA. July 2017. 
  • Executive Fellows, California State University Sacramento: CHAT, Sacramento, October 2016.
  • California Health Care Foundation Fall Alumni Meeting: The Public as Policy Makers in Overuse, September 2016.
  • Choosing Wisely® Summit, Results from engaging the public in policies for reducing overuse. Washington DC, May 2016.
  • Integrated HealthCare Association, Webinar, The Role of the Citizen Voice in Reducing Overuse, May 2016.
  • American Enterprise Institute/ Brookings Institution joint conference. Reforming Medicare: What Does the Public Think?  Washington DC. Sept 2014. 
  • American Society on Aging annual conference: Identifying the public’s coverage priorities for re-designing Medicare. San Diego, March 2014.
  • Agency for Healthcare Research and Quality webinar: Facilitating Deliberative Discussion Groups. June 2013.
  • Institute of Medicine: Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement, Washington D.C., February 2013.
  • California Health Benefit Exchange Board of Directors Meeting, Sharing the Cost of Care, Sacramento, June 2012.
  • California Department of Health Care Services Quality Symposium. Sacramento, March 2012. 
  • Insuring the Uninsured Conference: Institute of Medicine’s Committee on the Essential Health Benefits. Sacramento, February 2012.
  • Agency for Healthcare Research and Quality webinar Using Public Deliberation. December 2011
  • Calif. Program on Access to Care Conference: Value Assessment, Consumer Choice and Health Care Cost Containment. November 2011.
  • Association of Physicians Groups Conference: ACOs: but how will they play in Peoria? Palm Springs, May 2011.
  • Information Briefing sponsored by The California Endowment and the Senate and Assembly Health Committees: Wellness Incentives: Mixed Messages. Sacramento, March 2011.
  • Health Affairs Issue Briefing: Designing Insurance To Improve Value In Health Care. Washington, D.C., November 2010.
  • Roundtable discussion with MedPAC staff re: consumer views on high- and low-value medical care. Washington, D.C., September 2010.
  • International Society for Priorities in Health Care Conference: What Matters Most: Identifying Medical Problems As Priorities For Healthcare Coverage. Boston, April 2010. 
  • Center for Health Improvement’s Health Policy Forum: Leveraging Public Reports of Health Care Provider Performance to Improve Quality. Sacramento, November 2009.
  • UC Irvine Center for Health Care Management and Policy Conference: Comparative Effectiveness: Implications for the Public. Irvine, CA, October 2009. 
  • AcademyHealth Annual Research Meeting: Citizens' Priorities for Healthcare Coverage. Chicago, June 2009.
  • Association of Health Care Journalists Annual Meeting: Explaining Costs in Health Stories. Seattle, April 2009.
  • AARP/Consumers Union, Solutions Forum: What Do Consumers Have To Gain From Comparative Effectiveness Information? Panel on Patient and Consumer Perspectives. Washington, D.C., October 2008.
  • Intermountain Medical Ethics Conference on Setting Priorities for Healthcare in Utah.  If We Can’t Have It All: Seeking Public Input on “Basic’ Coverage. Salt Lake City, October 2008. 
  • State Coverage Initiatives, Summer Workshop for State Officials: Using CHAT to identify citizens’ coverage priorities. San Francisco, August 2008.
  • AcademyHealth, Annual Research Meeting, Panel on comparative effectiveness: What does this mean to citizens? Washington, D.C., June 2008.
  • National Governors Association, Center for Best Practices, Conference on Defining Benefit Packages in Health Reform, Lunch speaker: How Consumers View Benefit Design. Philadelphia, March 2008.
  • New America Foundation, Capitol Briefing, Health Insurance: What Should Everyone Be Covered For? Washington, DC, November 2007.
  • American Society of Bioethics and Humanities Annual Conference, Panelist: Priority Setting in Four Countries, Washington, DC, October 2007. 
  • California Health Care Foundation, Capitol Briefing, Designing Coverage: Uninsured Californians Weigh the Options, Sacramento, July 2007.
  • California Health Care Leaders Network, Spring Meeting. Panelist: Health Insurance for California: What is Basic for All, Los Angeles, April 2007. 
  • Kaiser Permanente 16th Annual Regional Ethics Symposium, Bringing the Public’s Voice to Health Care Policy, San Ramon, March 2007. 
  • International Conference on Priorities in Health Care, Just Coverage: Defining Basic Healthcare When Resources Are Limited and Cost-Effectiveness as a Coverage Criterion: Assessing American’s Views, Toronto, September 2006.
  • National Association of Insurance Commissioners, B Committee (Health Insurance), Results of the Just Coverage Project, Washington, DC, June 2006.
  • Agency for Healthcare Research and Quality, expert panel on cost-effectiveness, Getting Good Value: Assessing Consumers’ Views about Cost-Effectiveness as a Coverage Criterion, Maryland, May 2006. 
  • Washington State, Insurance Commissioner’s Hearings on Health Care, When Options Exceed Resources: How Consumers Make Decisions, November 2005. 

Select presentations on end-of-life care:

  • Swedish Hospital Palliative Care Conference: Community Process to Improve Care at the End of Life, 2010.
  • National Hospice and Palliative Care Organization: End-of-life Issues in the Workplace, audio web seminar, 2008.
  • Final Journeys conference panel: Death and Dying – Is It a Personal Journey, 2007.
  • American Society on Aging/National Council on Aging workshop: The Clinical Realities and Advance Care Conversations That Count, 2006.
  • National Rallying Points conference: Working with Faith Communities on End-of-Life Issues, 2003.
  • Rallying Points Leadership Development Workshop: Leadership Update from the Front Lines—Engaging Leaders from California’s Latino and Chinese Communities, 2003.
  • National Health Ministries Association Annual Meeting: Helping People Prepare, 2002.
  • California Hospice Foundation Annual Meeting: Taking Care of our Communities: Working with Moyers’On Our Own Terms, 2001.
  • KQED San Francisco, Panelist: Difficult Decisions, 2000.