Policy Analysis

Lessons from Brexit Friday

By Maureen Wolsborn

A month ago, the average American knowledge of the United Kingdom and European Union spanned littler further than the royal family, soccer, and Eurovision. But last Thursday, the US and the world watched as UK citizens voted in their third ever referendum to leave the EU. And on Friday, or Brexit Friday as it may now be known, we continued to watch in somewhat disbelief as the news came in that Brexit or British Exit, was actually happening.Cameron and brexit

While the U.S. will undoubtedly be impacted by this vote, we aren’t British, or European, and understanding how the EU membership impacts a country, not only economically, but politically and socially, is complex. Yet the UK asked its electorate to make this big choice, one which could (and now seemingly will) impact their lives dramatically. And on Friday, as it became increasingly clear that a majority of UK voters had decided that life outside the EU was worth the gamble, many felt confused. Wondering ‘how did this happen?’ and some, even regretting their vote for Brexit, as the reality of their new future set in.

So how did this happen? How can the majority of a nation pass a referendum, yet leave so many people upset, confused and regretful about their vote?

First, there was a stark generational divide between Remain and Leave supporters. With roughly 75% of individuals between ages 18-24 wanting to stay in the EU and close to two thirds of people over 65 wanting to leave. Conversation between generations seemed stilted and unable to find common ground on what they want as a nation, and a member of the EU.  The U.S. is no stranger to this generational divide. There seems to be very little ideological middle ground between millennials and baby boomers, even if their desires and goals for their own lives are parallel. Joining these two groups in conversation is difficult, it seems that in the UK there was little dialogue across Brexit lines. Leaving undecided voters confused of where to cast their vote.

Brexit age graph Leading us to Friday, where the news coverage overwhelmingly focused on voter regret.  Most notably, a man who had cast a vote for leave stating “I didn’t think this was going to happen. I didn’t think my vote would matter too much…” This, unfortunately, isn’t an uncommon sentiment among voters. In the U.S. presidential election, voters are frustrated about candidates after a long nomination process, feeling that their participation in a primary vote or caucus really had no consequence. While in reality, and in a fair election system, a vote does count, I think many Brexit voters wondered if their vote truly mattered if they didn’t understand or really like either of the options. Brexit guy And as the Brexit Friday haze lifted, many voters asked themselves ‘what does this all really mean’. Common search terms on Friday in the UK were: ‘what happens if we leave the EU?” and ‘What is Brexit?’ While the Leave campaign made claims of saving 350 million pounds a week, and using that money to fund the NHS (pictured, notoriously, on a Leave campaign bus), Stay was equally vague in not only explaining the benefit of staying in the EU, but also negating the arguments of their opponents. Which leads us to the question of whether the campaigns (at least one) failed to explain the real impacts of Brexit, or if voters didn’t take the necessary time to truly learn about the consequences of the vote.  Educating voters is difficult, especially when voting on issues, EU membership being an extremely complicated one. Brexit bus Some are questioning if Brexit was a failure of direct-democracy. Perhaps everyday day citizens are ill equipped to cast a vote on such a complicated issue. And as an outside observer and non-UK resident, it’s unclear if voters had access to enough outside, unbiased information before going to the polls. What is clear is that Brits are coming to terms with their uncertain future. And for now, Brexit can be seen as a lesson for us all. Not in its outcomes but in how we treat elections and voters. Without conversation and dialogue, accessible and reliable information, and empowered voters, who know their vote has meaning and consequence, there may be many more Brexit Friday’s to come.

28 Jun 2016

Engaged Benefit Design Conference Recap: Two Exciting New Concepts in Health Care Come Together


In April, we at Engaged Public hosted a first-of-its-kind conference intended to help bridge the divide between two of the most innovative concepts in health care reform today: shared decision-making, which aims to get patients more involved in their treatment decisions, and value-based insurance design, which aligns consumers’ out-of-pocket costs with the clinical value of services. The result was a full day’s worth of in-depth discussion and forward-thinking deliberation that has the potential to transform health care as we know it.

We call this novel approach EBD: Engaged Benefit Design. But rather than a jargon-filled abbreviation, EBD is at its core highly intuitive. So much so that it is surprising – almost shocking – how most of its concepts have barely been integrated into U.S. health care delivery in spite of their promise.

Our goal is to change this. We recently led a pilot of the program at San Luis Valley Health (SLVH) in Alamosa, CO., and just launched a subsequent program at Hilltop Health in Grand Junction, CO whose goal is to demonstrate scalability and integration.

San Luis Valley Health EBD Pilot


For example, Russ Johnson, senior vice president at Centura Health, noted that the response from both the employee users of the health plan at SLVH as well as providers has been encouraging. Employees appreciated the information they received, the fact that they were more involved with their own health care, and the monetary rewards for choosing the higher-value treatment. Providers remarked that implementing EBD was easier than they thought. In addition, they were happy that their patients were better informed as a result, and in fact wanted to put in place EBD for all their patients (and not simply SLVH employees).


SLVH’s Occupational Medicine Program Manager Tiffanie Hoover gave a ground floor-level overview of EBD’s operation, acknowledging that some patients initially were upset at the increased prices for certain treatments they were used to, but after watching the decision aids , many changed their minds on high-cost and low-value MRIs and surgery (the $50 inducement to complete the decision aids also helped). This was seconded by Amy Downs, senior director for policy and analysis at the Colorado Health Institute who is the official evaluator for the SLVH pilot. She highlighted that SLVH’s pre- and post-project employee surveys indicated that overall satisfaction with their health plans was relatively stable, but at the same time they became a lot more cost-conscious. Additionally, the percentage of employee respondents who reported receiving all the health care they thought they needed remained constant.

Hilltop Pilot

Later speakers spoke positively of the prospects for the second pilot.


Hilltop CEO Mike Stahl went over the basic design of the second pilot: reduced co-payments for mental health services and high-value specialist care (only with physician referral); zero co-pays for common medications, prenatal services, and maternity care; fully-covered wellness checks; and a $500 increase to patients’ cost-sharing if they chose one of 11 identified low-value treatments ($250 waived if patient completed a decision aid, and another $250 also waived if the decision was made with the doctor). In Hilltop’s early implementation (without the technology to be implemented later in 2015) over the last two years preventative and routine medical care has increased by 12%, inpatient hospitalization has decreased by 123%, and per-employee health care expenditures have dropped significantly. Jim Swayze, CEO of CNIC Health Solutions, the administrator of Hilltop’s employee health plan, emphasized the importance of DAs being nuanced and driven by the needs of a particular community, while imploring more employers to sign up and help move EBD to scale.

Trend updates from the experts

The conference culminated with a couple speakers who are at the very forefront of the two concepts that Engaged Benefit Design is attempting to merge and publicize: on the shared decision-making side, Michael Barry, chief science officer of Healthwise and president of the Informed Medical Decisions Foundation, and on the value-based insurance side, our keynote, Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan.


Barry presented a wealth of statistics confirming low patient knowledge about medical procedures and a low percentage of clinicians discussing such procedures and their alternatives. This is evidence that, unfortunately, informed consent may be broken. He stressed the importance of decision aids, but noted that they were only a tool to make shared decision-making practical in a busy clinical world. Still, Barry pointed out that 130 trials in the updated 2014 Cochrane Review were about decision aids, and by now the clinical evidence is clear: decision aids have been shown to increase patient knowledge, make risk perceptions more accurate, lower decision conflict, ensure fewer patients are passive in decision making, lead to 21% fewer patients choosing low-value surgeries, and result in increasing treatment rates among underserved communities.


Finally, Fendrick emphasized the importance of shifting the national health care debate from how much we spend to how well we spend. He criticized the one-size-fits-all benefit design of most Americans, which fails to acknowledge that studies have revealed beyond a doubt that some medical services fail to do more for our health than others, not to mention that as cost-sharing goes up, people stop using essential services (which, in some cases, leads to an increase in health care costs) and health disparities worsen. With value-based insurance design, consumer cost-sharing is based on clinical benefit and not the acquisition price of the service. However, Fendrick cautioned the audience to keep in mind that clinical reality is often complex: for instance, colonoscopies, coronary stints, and back surgeries can both be low-value and high-value, and ambulatory centers can both be low-cost for certain treatments and high-cost for others. He underlined recent legislative successes that have seen a number of state employee health plans as well as Michigan’s Medicaid plan embrace aspects of value-based insurance design. Fendrick closed by urging the audience to combine the clinical nuance of value-based insurance design and the consumer engagement of shared decision-making by means of a unique (and tasty) peanut butter and jelly analogy in order to improve the quality of care and reduce medical waste.

Click here to read the more detailed conference proceedings.


21 Jul 2015