New England Journal of Medicine; WGBH Forum Network; Health of the Nation: Coverage for All Americans

The consequence of uninsured affects those who are uninsured and those who are insured who live in that community. All of us are in the boat together 18000 people die every year because they're uninsured. A country should be judged by how it treats its less fortunate in that respect unashamed of our time. We can make a body feel good. But if the internal calls are still given up three times faster than wages simply cannot be sustained. All of these plans have a substantial element of unreality to the health of the nation. Coverage for all of us is a project of the New England Journal of Medicine. It's a production of the Fred Friendly seminar at the Columbia University Graduate School of Journalism. Panel let's let's start. With the proposition that it is spring time 2000 and now we're in the city of Metropolis in the facilities of. A

suburban doctor. How are you old man. He's got to get to Washington for some professional thing and he's got a few patients this morning. Who want to get through and get to the airport. He's seen Robert Roberts about 50. He's in for a sinus condition. The real problem with Robert. Is that. He's 80 pounds overweight. And he smokes like crazy. Steve in the couple of minutes you've got. What do you say to polo you've been smoking. Twenty five twenty six years. Do you know what it does to you. Yeah I know it's bad for me but it makes me feel good I like it. Ever try to stop. Five six times. OK. Would you like some help in trying to start this morning. Yeah. I thought you were going to have to watch me at the house today and I'll stay around to help you. This is the most important thing that I could do for you. I could add 10 12 years to your life.

Give you the opportunity to watch your grandchildren get get married have you and your wife have a have a good time after you stop working. Very very important for you to read a few will read Dr. Oldman. What's going through your mind. I think what's first going through my mind is how tough this is going to be because you've heard the message a whole bunch of times. So what am I going to be able to offer that's different and unique What kind of resources are available in the community. What kind of partners I can get together and I'm also think about your family because I know I got to get to your wife I got to get to your kids I'm going to put together a combination of punches to knock this problem out. REED You're making this sound like a full time job. I'm only one of your patients. Well that's why I say that as a doc thinking about this for the five minutes that I've got I've got to be worried about you as a person. I also now I'm starting to think what are the combinations of things that can come together to not only help you. I got a bunch of other people I got to be a part of. All right.

The good doctor heads off to the airport. He's on his way to D.C. Actually we're in D.C. and we're walking on the mall and you're talking about health care and reform and you're saying to yourself what is it we want. For Americans. In terms of their health status. Well for a while Robert back I'd say. We're going to work on you come with me to Washington. I'm a heart lung transplant surgeon. Do that have done that for 20 years. Every day. And in truth I don't determine health. For people listing the terms of health how you define it how long you live there determines genetics. Pretty good impact. Socio economic status how rich how wealthy somebody is not that important it ends up being in terms of environment some impact but not that great. The big one is going back to Robert behavior behave it how long you're live this is one measure of health. It probably has a 40 almost 50 percent

impact on how long you live. One thing I haven't mentioned in what I spent most of my life doing. It all off my mind when politics in medicine and the impact of hospital doctors health insurance is time. Only about completion. I have a bit of a contrarian view. I really reject the notion that health care doesn't make any difference in that in the nomination scimitar service compared to behavior not least we call culture. Well it's not the smoking diet and exercise matter but if you look at the mortality that's related to medical care the US has nineteen thousand one hundred countries. The Institute of Medicine said 18000 people die every year because they're uninsured. They can't afford medications. People report that they go without needed care. So Intel we as a nation deal with the problem 47 million uninsured 16 20 million people with inadequate insurance. We're going to

be the only country where significant numbers are not getting the care that could be beneficial and helping them relieve healthy productive lives. All right as we walk down the Mall we see a group of people in white coats carrying something. It's a fee for service is fairness capitation will decapitate. Health care in America. Who are those people. Well as the editor of dismal medical economics magazine I'm heard from these folks for quite a long time. And they are essentially see this through the lens as most normal American capitalists would of income it's protecting their incomes. And so I take it you're telling me their doctors will or beautician certain group of doctors. But you see them is just one of the many competing interests.

I'm trying still to get my mind off of that first patient Robert because as a general internist I'm wondering about the sinuses. I'm just one of them. My experience was the better deal with the problem but they came in with and then get into the weight of the smoking so I'm hoping the sinuses are OK but look Susan I don't think you're wrong and I think the way you framed it is one way to look at it. I also think you look at a group of dedicated physicians who kind of are watching the world change and they don't get paid for talking about smoking and they don't get paid for helping with obesity instead of talking in the third person. Let's get close to that little group and lo and behold. Who's there. It's our friend Harry Oldman. Art you're Harry. Tell us why you're here. Cherry blossoms. I'm here because I went to medical school. I'm loaded with debt that I still haven't quite paid off. I got an office full of

people pushing paperwork every day. I don't have time to talk to anybody listening to this conversation I heard about in the abstract about smoking in wait I don't have that five minutes. To do that. I'm irritated that no one in Washington seems to care what I think about as a doc so I came down here to try and bring some real world perspective to the fact that you're crushing my practice. I can't function this way I don't get reimbursed enough. I'm swamped by paperwork and enough time for anything. And I answered a bunch of non EMT folks who told me what to do half the time. And on top on top of that on July. 1st of this year I'm going to cut you 10 percent. I mean right now you're dependent about 50 percent of your practice on average maybe more on Medicare and I the government is going to cut you 10 percent then and that the legislation passes that these congressional leaders here in Washington want to pass. I'm going to cut you 20 percent a year and a

half from now. And this reminds me that I think a lot of this reminds me I mean anybody go talk to in Washington since Frist left. Right. And. It's funny everybody's in Washington today. Well there's an explanation. When the 0 8 campaign was running. The person elected president did so on a platform of coverage for all Americans. Indeed every candidate. Was pushing that idea. Well the new president has appointed an incredibly high level commission. The hearings are scheduled. On Access sure but hearings are also scheduled on payment. For doctors costs. The mode of medical practice range of subjects. I think you two are linked. All these things are tied together no question about it. OK. Well

this morning's hearing was about pain. And Tom you testified to the question. And there was a direct question to you. What is the future of fee for service. What do you say. How about those Red Sox and make it happen. No I think I think it's gotta change and we all know it. And the question is how can we change without causing tremendous disruption to the providers and to the patients they take care of. Go where are you feeding us. A euphemism when you say it's got to change do you really mean it's got to go away. I think that over the next several years it will not be viable for folks who are just taking fee for service without any kind of incentive for. Things other than you know volume. You know Charles would you have to as well. I think what I would have said is the fee for service is probably not going to go away

because we model in the healthcare space when it comes to reimbursement because we don't know what else to do. I actually hope that what Harry says is that primary care needs to be treated with a lot more. Respect by the payor community generally and by Medicare in particular because Medicare is for all intents and purposes the payer who sets the rules of the game for everybody else. And Medicaid Medicare is procedure driven. It's technology driven and it doesn't pay for time. It pays for transactions. Arnie what would you have said. You know I would have said we're going to learn the lessons from the early 90s. And if there was a lesson from the failed Clinton health reform there were a couple. It was let's not try to radically force a completely new system down America's mouth because they will not take it. We had alliances and we had hit picks and we had a thirteen hundred pages of change that we were going to put forth and it was almost dead on arrival. All right let me give you some texture. About. Harry

Oldman he practices with two other physicians it's a three physician family practice. He's got the typical clowder facility lots of file cabinet. Karen you tell me what the optimum. Compensation Scheme. Well Farai. I think what we need to move to is give him the option of being a patient centered medical home. What do I mean by that. That practice should be rewarded for taking accountability for making sure those patients are getting appropriate counseling. They're up to date with their preventive care. If they're overdue for a diabetes checkup that they've been told to come in the doctor wants to see you. And that means in addition to fee for service a monthly panel food for being a medical home. So it's moving to what I think of as a blended system a payment which has worked very well in Denmark where people have well-established relationships with primary

care and poor compensation for primary care is on a par or even higher than compensation for specialty Tom and now you tell me is he ready to be a center. No I think Harry Harry needs help taking care of those folks and I don't think Harry can do it by himself no matter how hard he tries. And. I think here you know the theme is Team care these days and it's not in we always need teams for like the really sick people but for the not sick people the people who need help with their weight in their blood pressure and smoking cessation. It shouldn't be Harry who's sort of following up to see if they stop smoking and Herries all practice has to get paid in a way that it can support a team around them so I think this medical home concept is critical. You know we need physicians to trust non physicians to do things that they don't have to see every single thing and how is not set up to be seen. Harry it's Harry's practice needs help evolving in that way.

And. I think what I would do for Harry's practice in particular is I would add a fee for consultation and advice. I think there is absolutely an opportunity for us to pay physicians for their cognitive advice and counsel to their patients which would be different from I think you're helping your patients to your circle one so that's one thing that Medicare can do that is sort of could do that if it if it wanted to thank a being that I would do it. I would absolutely not go the route of a primary care case if the Medicaid programs have tried that for years and it does that affectively change their clinical outcomes of the physician engagement. If on the other hand. If you were to give the physician a budget that the physician he or she can use to direct to outside support of agencies whether that social work or counseling or dieticians etc. Now you have the physicians with a pool of resources to assemble a team a team of individuals who can support patient care. But I think that the the crux of making the difference here is not to destroy the fee for service system but to add to it to make it a valuable use of the physicians time

to have a conversation an intimate relevant purposeful directed conversation with his or her patients on a regular basis. In fact speaking for Harry I have to say I don't care all that much about how I get paid I'm very interesting getting paid I want to get paid but I won't take my time. But you keep taking away from me not you but the system. I don't have time I spend doing everything but medical care it comes out of what I can do with my patients. I want my professionalism back and I want some relief from constantly being tortured by third parties like. Lawyers. And also Harry Harry is telling his. Harry is telling his 25 year old daughter don't go to medical school. Don't be a doctor. And the why. What is Harry thinking is exactly that. It's more red tape. It's more paperwork and all I want to do is heal. But we have a cost but cannot but because it was a better idea to let let's get to it then real quick.

That's what happened in the elections last year where in 2009 was it the uninsured which is a huge issue. Forty seven million people uncovered they die sooner they get care later it is a terrible problem if the cost is too high. It drives up the ranks of the uninsured. And then you get back to the causes of cost and that's where we're at this hearing today with fee for service because I do believe that if you're incentivizing the system by the number of procedures done heart transplants heart surgery numbers of patients and that's away your pain so therefore you have to see 25 patients instead of 15 a day. You can't talk to them about their smoking. We got a problem. So the incentive system today for physicians is to do more cases more procedures for service however you don't have to blow it up. Because I agree it's part of our American system. But you do have to change what the service is. Right now we pay on volume and what we need to be doing is paying on value

outcomes. How good a job and rewarding that outcome. OK one thing is clear. Has got to change. The way you raise an interesting point Art. He sits there with his. Paper records filling out forms. What are we going to do about that. It's a big problem and I don't think Harry can fix that. I think that it would help if the insurance companies could get together on the simplification thing but for them to do it they need the business is to get behind it. It's a collective problem. We do seeing that reducing the bureaucracy. This one thing I don't understand is as I wander around I see people with computers. When I go to my doctor. He's constantly shuffling paper. What is that. There are so many health care technology options out there. And the reality is any physician from a sole practitioner to a large medical group can outsource all of that paperwork to any one of a number of companies who will take

care of that for them. Why doesn't my doctor do start them through the doctors in the room to give you credible answers but what one reason is that it is change and they would rather not deal with it one way that it's not affordable. One reason is that you could outsource all the things and still have all this left over paper. And I think part of it is that you know there's a there's a I believe a focus on the medical professional on practicing medicine not. Technology and business. And so if you ask a physician where am I going to spend my time researching how to out source all of my technology for reading a journal is going to let me practice better medicine or touching a patient I would rather do one of the other two than figure out what company to hire to manage my own information technology. And this is why I'm optimistic generally about the transformation of health care if we use information technology right which health care has not invested in as a sector ever compared to every other industry out there. We have the opportunity to transform medicine

today evidence based medicine transparency smart consumers where they can shop and know how good a doctor is or how good a hospital is or a plan is none of what you can do today. But information technology if appropriate applied will allow that. What is the bottleneck. It's not the private sector. It goes back to the physician. And it goes back to these 20 patients the physician is saying at 45 minutes just to just to get compensated adequately today. And you put that computer in their office instead of seeing 20 patients a day because your productivity follows for at least six months. That computer is slowing you down. It is hurting you. It benefits society. It benefits the health care system but it hurts the keyhole through which all this has to flow. And that's the position they are and what they said about it we're going to say how close we can center buys it but basically tie in a little bit a reimbursement. So your productivity may befall but you'll get paid a little bit more if you use health information technology or the electronic health record and that will change

because we send out a describes this is a short term long term almost cultural phenomenon. Again. Let's hang the doctors out I think the technology companies no offense men have over committed and over promised with regard to how easy and seamless the pursuit of an electronic office will actually be. And most of them. Not one or two of them but most of them didn't pan out. I mean I spent a day. Following one of the docs in our network around his office they were going through the process of implementing a electronic medical record system and the complexity associated with having your scheduling in one system your billing in another system your referral activity in another system and your electronic medical record in another system is real. And meanwhile the whole time he's worrying about all that the phone's ringing and it's his patients call and saying you know what about this what about that you know so-and-so is on the phone I need some help. And I came away thinking.

The technology companies have not done a good job of walking around in the dock shoes and understanding what the true issues associated with trying to make this transaction are. Karen is this important. It's absolutely important. And physician practices around the world have many of the problems that Charlie's talking about but we are way behind. One fourth of American primary care physicians have electronic systems in all the countries they are already fair. The Netherlands New Zealand Denmark UK 90 percent of physicians have totally electronic offices and they have all of those problems you're talking about. What's different. The government was willing to set standards an acceptable system. They had many software vendors help there but they know if they buy one it's going to meet the standards and that this information can be pulled together in the health information exchange of the government set up in

other places they help pay for these systems so I think we need to build it into payment or assess insurers Charlie including yours. But in Denmark they found once they cough this up and yes there was a front productivity loss. But once they got it running they were saving 15 minutes a day because it was so much easier to get the information they needed to order a prescription or authorize a refill of their prescription. It really pays off and and not that long and it needs leadership national leadership caring as a patient can understand this is easier to build. And to do a lot of. Sort of semi Mundine as. Is your real. Value to this. Absolutely the first thing that happens when I go in to see my doctor is the receptionists head foreman said. Fill out your medical history. So that's the first opportunity for a medical layer that I don't remember all the medications I'm on that I don't remember but it was the last time I had

that test. Why doesn't my doctor's office have that sometimes my internist sends me to him when I go back to her she said why did they tell you. And so I tell her the advice I got. But does she have an integrated electronic medical record that not only has her information tracking my cholesterol over time but has the medications that my ophthalmologist has. Has the medications that other doctors might have me on. No we've got a fragmented health system and until we really get with it on comprehensive information but have lots of medical errors lots of duplication lots of waste. You look very troubled. I want to ground this in a little bit of reality. These challenges are clear they're they've let that they have set down the rhythm track of the problems. Let's look though that we've got a relationship with 550000 physicians the number of them that are connected with a company like ours

doing interactive work electronically is on the rise. It is fairly very significant. Secondly we know now that there is an organization that is actually creating the national standards so that they will be in a wrapper ability. And lastly from your point of view as a patient you know that for example with our company 20 million people have personal health records those personal health records accessible through a swipe card every time they go to their doctor's office very very easy to get. So the important things that Cameron mentions are available today in real time. We're not moving fast enough but we are moving. I think there's an elephant in the living room. We're not talking about all these comments presume it's persistence of a vibrant primary care system. But. If. Harry is telling his sons and his daughters and his nephews not to go into medicine those that go into medicine know for sure they don't want to go into primary care and they want to go on what they call now the road to happiness. So this means they want to go into radiology athame ology anesthesia

dermatology or emergency medicine it's an old fashioned road. They want to do that they will do that because they're coming out with huge debts because unless we fix the payment system they're not going to get the kind of income that they'd like that they're more attracted to shift work. So they don't have to worry about patients after they leave they want that 8 to 5 job. And then finally they don't like all the hassles that we've been hearing about that the art has just talked about so the electronic medical record by itself isn't going to fix that. And unless we do more fundamental surgery on making primary care a more compelling field I think we're going to worry about and maybe this isn't bad that medicine in the future and primary care will be practiced by others than doctors. You got a quick fix. Fix the reimbursement system. Increase the prestige within medicine and within the medical schools and try to get some technological help to the practices that isn't going to go away. Thank you. Thank you. Thank you.

Ladies this is still going to talk about Robert for a second. Robert the patient and Robert's pretty pissed off. Pardon my French. He makes an average of what maybe maybe he makes 40 grand and all his hearing is that doctors want to make more money. It's important that people in this table here that you do have a large consuming public. That doesn't much care how doctors get paid but they clearly want the physicians to get paid adequately and they want to visit and to be there when they need them and they want the hospital to be there. But the more they hear about how little they make and how much more we have to pay doctors and hospitals the angrier they get. And we can't right Robin out of this conversation and so far I'm afraid we have nor can we right now. Roberts distant relatives Mabel down at Appalachian obese hypertensive uninsured unemployed disabled and nothing that anybody has talked about for the last 10 minutes. Electronic medical records.

Physicians fulfilling their life's dreams of being wealthy is going to matter one iota I just totally disagree I think if we're tying it back together. But to me the conversation is very much a part we started in these campaigns talk about the uninsured that's the the big problem that's out there but it very quickly gets translated down to cost the cost that Robert sees the average plan today is fourteen thousand five hundred dollars for a family of four. So poor Robert Wise the cost so high but you got to go back to the health care system which is a two point two trillion dollar system out there. And how do you lower that cost curve over time and you do it by technology. You do it by by information technology and electronic health records. You do it by having positions which are incented on service on outcomes and not just on volumes themselves so they do tie together we're not forgetting about Robert when we go back and address the cost of our health care say art has been sitting here listening to this conversation I think you've been listening.

I have. Actually had a recent. Occurrence. Related to costs. A physician friend non-college. Reported that a patient of his has. Had colon cancer. We want to tell the rest of the story. Well my oncologist friend said you know there's a new drug out and this guy's got disseminated colon cancer. So it's bad. But I think this new drug would help this guy probably prolong his life two months maybe 30 percent chance. Of two months two months not trees coming out of the hospital. Still may not feel well. It's going to cost about $200000. And my question to you Art knowing. That you are a thoughtful

advisor on ethics is whether it's worth it. And should I offer this. Bring it up. And should I even bring up the cost for them. And your answer oh great one. I said I'd consult with a pinhole. I. I said Look. It two months $200000 I'm not going to forego presenting things to people. They have a right to know their options. But you better be ready to come in there with a recommendation about what you think he ought to do relative this drug because when I see doctors talking about new technologies new drugs new devices even new vaccines that might be very expensive they tend to come in and say you know. It's it's a very expensive thing. Not sure how much is covered. But I'll tell you what Mrs. X if you want

to kill your husband don't use it. I think that kind of dilemma is eclipsed by the much bigger dilemmas that. In fact physicians have to confront every day. When you have patients with very garden variety conditions that require certain kinds of garden variety interventions and the patients can't afford them. That the dilemma for a physician is. Do I even start to counsel patients on the kinds of treatments that I would recommend or the kinds of treatment options I would recommend. Because this patient really doesn't have any of these choices. Well that's going to be hard to learn. But now you're patient. Mortgage of the house. Take available liquid assets can cover the

200000. It's not insured. Does that color what you say to the patient. It would and I think a lot of doctors may not yet but soon will be confronted with increasingly expensive targeted drugs for individuals are going to cost a lot more money. And I have to start to say to them at the bedside. Cost is going to factor into our decision about where we're going here. This particular situation. Is simply a microcosm of this. World we live in new drugs new devices new diagnostics Americans who believe we should expand everything we can even at end of life and the right thing to do is to do all you can for your loved one right. Now. Tom do we just. Accept this is America. This is the way Americans think.

Well you know this I think it is the way we think and I think that this question you bring up you know you know the joke about three boxen you're best in out too hard. You know this is this is the two hard one and we're going to have to face it. But I think we should we have to do everything we can to dodge the question by doing everything else we can to improve how and make here more fish and where we actually know what to do. You know following guidelines we actually have evidence and there's a lot we can do. I don't really think it's going to help us completely dodge that question of of the very high cost drugs and other forms of progress. But we can do a lot to mitigate the need we have to face it. This is a big problem the numbers I've seen on this put it something like a hundred and thirty billion dollars a year. And the quip is that the U.S. is the one country in the world where they think death is optional. And we act that way. And I think as difficult it is I take it out of the too hard box and to force it on. We have to start to deal with this box and the time to deal with it is not at the bedside.

It's with a broader groups trying to think about standards and trying to think about piecemeal efforts so we can put things out of bounds so to speak. And I don't know if that means we say that people don't get dial eyes when they're 97 or bring it back to 95 or 92 or that certain medications in the cost per life year adjusted is $500000 per year. We say that we're really not going to cover them. And we try and change the culture but I think we have to do right by the way. I have not seen one insurance company ready to take on the issue of what you're going to do at the end of life. Well I would say to you that consequence. Well not I. I would say this that first of all it is. It would be ridiculous to think any one sector trying to make these decisions you joked about it but your joke was I actually had the glimmer of truth in it when you said I would consult a panel that you have got to have the physicians involved in this. Now it is very clear that the variance in pay or at the end of life even at our best scientific centers when you

compare them head on is so extraordinarily virginal and divergent and inconsistent as to be of major concern and we are trying to get the profession to create guidance. Before you get to the bedside about what's important. The problem is failure of leadership right now we've got to find ways of doing it I'm going to jump in with one other ethics thing in the know. Let my people members know me through this dilemma but. If it's $200000 for my MO. Versus your lady who needs prenatal care for your diabetic hypertensive in my choice by a lot of Americans are going to say yeah but now we're going to pollute twice what every other country spends So my first question is What does this drug cost in France. And I bet you it costs 50 to 70 percent less. In France than it costs here. So the first thing. I want our physician leaders with their white coats marching down the Mall in Washington to do is to not just say

we can't stand it that you're cutting our fees by 10 percent. I want him to say we can't stand it that there are 47 million uninsured. We can't stand it that our patients can't afford medications and we as a nation need to do what every other nation has done and that's not just universal coverage it's being willing to negotiate pharmaceutical prices to get better deals. The U.S. is subsidizing prescription drugs in other countries because we accept whatever pharmaceutical companies charge rather than having a system of assessing the cost effectiveness of drugs devices and procedures and negotiating part of the entire population to get decent prices. Maybe we should stop them breaking. The. Law. Thank you for that. Right now we're putting our research dollars in the wrong place. But that wasn't me. Karen a saying is the false dichotomy I mean you don't have

to do that from an ethics point of view. You can't show that. Faucet off the public doesn't want it. They want to see advances so does the medical profession I think if you went to patients and said We get it in one cost just not going to have much in the way of new stuff for the next couple of decades. It's not a tradeoff they'll take. OK now. Let's get back to Sarah. Sarah's been worrying about access. As we've gone through this discussion. We have. AS. The senator said 47 million uncovered. Is this an ethical issue in your mind. Oh I think it's the most basic ethical issue of Allah but it is a national decision on our part it's not the federal decision. It's not the state decision. It is a national social decision and we've been very doubt about this. Steve do you think it's an ethical human rights issue. I think that a country should be judged by how it treats its less fortunate

in that respect I'm ashamed of our country. Thank you. Thank you for talking to contributors question I think me the ethical issue is. Because it's a failure on the part of America to provide for the adequate health care for all of its citizens. Now that has become a debate over insurance. Insurance is one way to finance health care for us and for its population. It is not the only way. And so all Americans or all in America whether you are an American or not should be able to access health care services. But I think that insurance is one model. Block granting another model directly subsidizing the provider is another model. So I don't think the issue is insurance or not is whether we are financing adequate health care for our population or not. But OK John I said that but let me ask you. We hear it's

an ethical issue. We hear it's a human rights issue is that a winner. If you take it to the public on that basis you know I think if there's one lesson we've learned about health reform the last few decades it's that being right doesn't count for very much. We can come up with lots of stories to evoke moral outrage and by the way it's not just about the uninsured. There are many Americans with insurance who have inadequate protection and who file for bankruptcy every year because they're under insured. But if we're going to fight this battle for health reform on moral grounds we're going to lose this one patient. Oh good old Harry. Left it's me. I'm already. And I've heard this discussion about 47 million. Fine. But look. I've got a job. It's a stable job. And I've got a health plan. If you tell me

that these 47 million. Are going to increase my taxes or will increase my co-pays which I'm frankly real sick of I'm not with you. Unless you can tell me that there's something in it for me. I eat there. Is there something you know you are but yeah I heard Look I don't want to. Be. The doormen. Thank you so much. We heard about the Iowa study on the consequence of the uninsured I was on that committee and what we documented clearly were that the consequences when you live in a community with people who are uninsured you are being affected through the inadequacy of the public health system. The diversion of resources you're being compromised because of the effects on your hospitals and your physicians in your community. At the end of the day we could go through a laundry list of those things but the consequences of an insurance affect those who are uninsured and those who are insured who live in that

community. All of us are in the boat together and I want to help. I would also add on the cost if you wrote real quick. It's going back to talking to you the patient. And I would start off saying yes it's a moral issue and yes it's going to be expensive and yes your taxes may go up a little bit. But I'd also say that recognize it for these 47 million people. 12 million. We already have a program for you either Medicaid or the children's health care plan. So that takes it down to what 47 down to thirty five 10 million are non-U.S. citizens still have to deal with it whether it's community health center how we deal it still have to deal with what are probably and probably 8 million make more than $50000 a year. So the uninsured is not really the 47 million it is but in terms of what you have to worry about in terms of finances is this hard core probably 20 25 million people. Secondly I would say you're paying it right now you're paying a premium of two hundred thirty five dollars every month for your

private health insurance. Seventy dollars of that goes directly to the uninsured. Right now. And then thirdly I would say you're already paying the American taxpayer fifty billion dollars for the uninsured for those 47 million. Fifty billion dollars is already going to the uninsured. Why because we have legislation that if uninsured come to the emergency room you're taken care of. So I would begin that explanation because we're already paying for a lot of care for the uninsured in a very indirect and transparent inefficient way that morning 5 billion of that cost comes from. The cost of taking care of an insured people are inadequately insured people who are working but their employer does not provide health insurance coverage health insurance coverage. So unless this is a shared responsibility for all employers to either. Cover their workers or contribute to a fine we're not going to have the resources that takes to do this right.

This is a winning. Set of arguments. I didn't hear anybody say that my monthly payment which he understate it will go down. Can we win with this. If you promise everybody coverage we can put the plan together. But it goes back to where we started. They had it every health insurance is still going to go up three times as much as wages every year as it's done on average the last 40 years. No because we can make a body feel good. But if the internal costs are still driven up three times faster than wages it simply cannot be sustained. Thank you John I think you asshole let's be honest about the price tag for universal coverage the price tag really is not that much. If you talk about adding the uninsured to the existing system you're talking about roughly 100 billion dollars a year. We already spend over two trillion dollars so that's a markup but not much. When we cut taxes in 2001 in 2003 we found the money to do

that. When we passed the Medicare prescription drug benefit in 2003 we found the money to do that. When we went to war in Iraq we found the money to do that so this is a question of priorities. And the uninsured are not a political priority and it's not that they are unaffordable it's that we haven't chosen to pay that money in terms of a winning argument I think the senator was was on to something there which is one of the untold stories is that health care costs are crowding out the wages of American workers. If you look at American workers and the growth in wages since the 1980s it's essentially even up by inflation. So where's that money going. Well a lot of that money that should be going to higher wages and salaries is going to pay their healthcare bill. And so we've got to make that economic case that this is good for American workers. But we also we need allies. OK. He was overpowered there for through the magic of a hypothetical. Whereas we've spent the day in 2000 and. We're

going back to 2000 in eight. And I suppose now that I'm a comfort I am delighted that both political parties in this year of a presidential election are talking health care so one this beautiful spring day. I've taken my nephew Sam who's 25. He works at make up marked. Which doesn't provide health care. And we've gone to Fenway Park. We're there to see the Sox play. Make Tom Lee happy. And we're talking about the fact that Sam doesn't have health care and I guess we're as we're sitting there in a very slow pitchers do. We want to review. First the Republican platform. Senator what is the Republican platform manifested by

Senator McCain. Is number one no mandates no employer mandate no individual mandate. Number two it is a $5000 tax refund double tax credits what has meaning to people who are very low income. For a family of four or $2500 a refundable tax credit for the individual. Thirdly. John McCain's plan eliminates the employer sponsored deduction which has really been the backbone of the bottle bolster our employer sponsored system which insures about one hundred sixty two million people today. And the fourth for the people who cannot get an insurance plan it's out of their reach. He wants to give direct plea to the States grants. Through which they could get coverage. So how is going to affect same 25 year old without employer basically gets a check two thousand five hundred

dollars. What's it going to do for me. Already where I've got health coverage for my employer. You do first thing your employer may or may not do is all of a sudden to your employer was put about $6000 in to subsidize your health care plan or $3000 and the federal go or the American people were subsidizing your health care plan. Because you can attack I LOVE YOU AND I LOVE That's right. So your employer may say well the government's not helping me. The American taxpayer no longer is subsidizing your plan $3000 therefore I'm going to stop offering health care. And you figure it out. You get your 2500 to $5000 look they're going to buy it with $2500. Well it's going to be what are insurance. Friends here can offer a plan today for a family of four calls twelve thousand five hundred dollars in front. Are the insane at Fenway. There are two of the fans. There's Karen. And the center. So what do you say to Artie

incentive about this Republican platform. Well I think you've got to look at that as he said many employers may they drop us and leave us on our own in charge. But trying to find health insurance in an insurance market that's going to be deregulated. And what that means is they may not take any kind of health problem in the past. Sara what do you say. Well the Republican flag I've been listening to this and I just got finished telling my friend Karen that my daughter who lives in New York City who's about to be independently employed theater director went on line last week to find an individual policy. And the best we could do for an individual high deductible plan a New York. Dad gave or even remotely reasonable coverage was about eleven hundred dollars a month. She's going to be making probably in a good months couple of thousand dollars as a young theater director.

She's got 80 friends probably in the same boat. I just don't see that this is real. Read Do you have any reaction to the Republican plan. The You'll think I'm avoiding the question. The issue is if you want to create the political equation to actually get something done in Congress what it's going to require are multiple different stakeholders who are all prepared to go for their second choice. What is frustrating is once you get beyond the moral outrage what happens is that every sector the private insurers the manufacturers small business the advocates for for individuals everybody has got their own eighteen point plan. And what we have learned over and over again is that when people get wed into those fundamentals it can only be employer mandate it will be individual mandate. If you don't believe that if you expand Medicaid and S-CHIP if it is only if it is only what happens is you never get to the calculus of actual legislation it can get passed so what I'm sort of saying to you ultimately is it is inappropriate for people to

start laying down what camp they are in at this moment what is important is what people to make a public commitment to be part of the coalitions to actually get something done and stop arguing about all these ideological must haves. OK so you've successfully evaded the question. The ball game's over in deference to Sox win five for. Now. Artie and Sam have left and waive their right outside the stadium they're having a brought worse and B Now Susan you were sitting in the row behind one of the democratic form. Yes because a small medical economics we actually did a side by side looking at the plans and attempting to take what is real in those plans and what is fantasy. Our ratings show that all of these plans have a substantial element of unreality to them. Part of it is either

Democratic or Republican holy writ that is being recycled from past debates. Part of it is fantasy based on a lack of understanding about how things really work now. And that's why we came out our editorial page the dismal medical economics said much the same thing we just said which is that we will have to wait until after the election. See how things settle out between who has the presidency and who has the Congress and then engage in a realistic you're not talking about how hard it is to him as they munch down that brought worse because in reality they're trying to figure out who to vote for. Well I'm telling already and say that all this is a put down there. But this is going to be a long process and as important as it is that who is the president. It's also going to be important who's in the Congress who takes Senator Frist place. What are people what is the sentiment that

people walk away with a feeling of what the American public would really want here. And also importantly some kind of mechanism to get people closer together on the same page because as a nation we're not there now. Let me can I can I jump in just a moment. On the Democratic plan right now. The universal it is the goal. There are mandates of the employer mandate. The second big issue is the promise. And for the uninsured that equals that of a United States congressman or Medicare that that's promised to everybody. And the third component is is the increased involvement of government expansion of Medicaid expansion of S-CHIP does overall increase government. And. Those sort of. Three components there I think of the gist of the plan that they have to be thinking about and they power them what I'd be thinking about the universal makes sense but have it has that plan addressed what I mentioned earlier that you promise everything

but you still have costs going up three times wages which hits the consumer the individual is or anything in that. Plan that does that. But you know employer employer reaction I think business has is as willing to get out of what it's doing now as it's been. Then I remember even more so than probably the early nineties just simply because the costs continue to compound. And so I think I might call it let's make a deal. But the deal has to be what's on the other side and that's why I think I'm really really in agreement with Senator Frist that in less the Congress can work together on access and cost at the same time. It's going to be difficult to sway the business community into believing that what's on the other side of what is in today is going to not be worse than today. Now let me quickly stratified to say you

got it when you talk about the business community. You've got a divide right away between those that offer coverage who are in a very different situation that those who don't offer coverage and it's really a large middle large versus a small employer so I'm speaking really now on behalf of those that offer coverage. Charles reaction to the proposals. I think the I think they're both. Political bromide from both parties. Put out there so that if somebody says do you have a position on health care coverage the answer can be yes. I am completely in agreement with Reid that the whole debate about health care for us for the past 20 or 30 years with the possible exception of the Medicare Modernization Act where you know. Whether you like it or not the president basically said I'm going to stake my presidency on this and it will happen. And as a result it did. That's what you need a president to do if you're going to get the coverage question resolved until that happens and it can

happen. Health of the nation. Coverage for all Americans. It's a project of the New England Journal of Medicine. It's a production of the Fred Friendly seminars at the Columbia University Graduate School of Journalism.