Bill Moyers Journal (2007-2010); 1345; Wendell Potter; Marcia Angell

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BMJ 1345

March 5, 2010

BILL MOYERS: Welcome to the Journal.

Ever since last week's White House summit, it's been like one big game of political ping pong, with the president and Democratic and Republican leaders paddling health care talking points back and forth so fast, the rest of us can hardly keep up. So for the moment, we're going to step away from that game, remove ourselves from the roar of partisan rhetoric and remind ourselves of why this country needs health care reform in the first place.

One day before that big summit last week, there was a hearing in Congress to find out why Anthem Blue Cross of California is raising premiums by as much as 39 percent -- 15 times the rate of inflation.

REP. BART STUPAK: Do you swear or affirm the testimony you're about to give to be the truth, the whole truth, and nothing but the truth in the matter pending before this committee?

CYNTHIA MILLER: Yes.

ANGELA BRALY: I do.

BILL MOYERS: Angela Braly, the CEO of WellPoint, the parent company of Anthem Blue Cross and Blue Shield, was called before a House subcommittee to explain the increase.

REP. MICHAEL BURGESS: You know, you had to know this was going to be trouble. I mean, a 39 percent rate increase in this climate. You know what we've been doing up here the last year?

ANGELA BRALY: Yes.

REP. MICHAEL BURGESS: You know what's happening down at the White House tomorrow?

ANGELA BRALY: Yes, yes.

REP. MICHAEL BURGESS: You knew this was going to be trouble.

ANGELA BRALY: Yes.

REP. MICHAEL BURGESS: So you knew the landscape into which you were entering, correct?

ANGELA BRALY: Correct.

REP. MICHAEL BURGESS: Did you make a judgment as to whether or not this was the best time to do this?

ANGELA BRALY: It's a difficult situation and even to break even the rates would have been in the 20s in terms of overall average, the overall average. And we were concerned which is why we also capped the rates at the top end of 39 percent because we did not want rates for individuals to go in excess of that cap.

BILL MOYERS: News of the increase was brazen and shocking enough on its own. But it turns out that in 2008 WellPoint paid 39 of its executives a million dollars or more. And that over two years alone, the company spent more than 27 million dollars for executive retreats at luxury resorts. Fresh ammunition for those who argue that health care costs wouldn't be skyrocketing if the insurance industry didn't put profit ahead of patients.

REP. BART STUPAK: It'd be great if we could guarantee every business to have 2.5 to five percent profit, and heck, you're at 7 percent or more.

ANGELA BRALY: You know, actually over the five-year period our profit margin has declined. We continue to get more efficient as a company and as a business, and we are working hard to reduce health care costs and improve access to high quality affordable health care. So it is important, to be a business that sustains, that we have an appropriate profit. And we think a 4.8 percent margin on a relative basis is very efficient.

BILL MOYERS: That's 4.8 percent of the 60-plus dollar billion in earnings WellPoint reported last year. In other words, nearly three billion dollars of profit after taxes.

REP. BART STUPAK: I don't mind you making a profit but at the end of the year 2009, a horrible year, you still made two-point-something billion dollars. And that's not enough?

ANGELA BRALY: And we serve 34 million Americans across the country and we feel that it is appropriate for our business to be sustained so that we can be there for those members when they incur those health care costs.

BILL MOYERS: Anthem Blue Cross policy holders testified that with the big jump in premiums, their only options are to pay through the nose, switch to a cheaper policy with less protection or drop their insurance completely.

JEREMY ARNOLD: I will have to hope that I don't get sick or injured. Hope is not an effective health care policy and hope is not what Anthem is supposed to be selling. I eat right, I exercise, I take care of myself, I am generally a healthy person and I resent being squeezed in this way.

JULIE HENRIKSEN: In this economically depressed environment, I find the act of Anthem Blue Cross raising premium costs to individual policy holders for such high amounts truly unconscionable. My current policy states that I must meet an annual one thousand dollar deductible for each two members of my family, which totals 3 thousand dollars and an annual out-of-pocket expense of 4,500 dollars for each two members of my family which totals nine thousand dollars, in addition to the yearly premium of 12 thousand dollars that I pay already.

REP. BETTY SUTTON: Do you believe a company that can afford to pay a single executive nearly 10 million dollars in one year has the right to demand higher premiums from you so that it can, quote, "keep up with the market?"

JULIE HENRIKSEN: It makes me sick to think that all of this money is going to executives in this economy when so many people are struggling.

JEREMY ARNOLD: I, of course, too think it's unconscionable and I believe the number I read was that in the last quarter WellPoint had a profit of over 4 billion dollars. Even if you cut that in half, it's still an incredibly healthy profit. So it just speaks to, as I said in my testimony, profiteering versus profit-making. There is a difference. And profit-making is fine. It drives our economy. It's the foundation of American business. But profiteering, when it affects people like us in the way that it has, is just wrong. It speaks to a lack of decency. And lack of decency may not be illegal but it's wrong. And that's why I think it requires government intervention and regulation.

BILL MOYERS: WellPoint's Angela Braly stayed on message. She was unapologetic about her company's profits. But what she heard back from the subcommittee was, "Shame on you."

REP. JAN SCHAKOWSKY: I think that a 39 percent rate increase at a time when people, Americans, are losing their jobs, losing their health care, is so incredibly audacious, so irresponsible. How much money do you make?

ANGELA BRALY: My salary is 1.1 million dollars. I receive stock compensation with a value of 8.5 million dollars and last year an annual incentive payment of 73 thousand dollars.

REP. JAN SCHAKOWSKY: Well, of course, it makes sense then that you would need a big rate increase.

REP. BART STUPAK: Do you think you're finally going to get to the point where basically you're killing the goose that laid the gold egg; no one's going to be able to afford you?

ANGELA BRALY: You know, it is really an issue that we have got to get to the underlying cost of care because we want access to health care. It is-- there are wonderful advances, wonderful technologies and we want to make sure that we continue to have access

REP. BART STUPAK: Correct.

ANGELA BRALY: And that our customers continue to have access. And it needs to be affordable. And so we have to think about how--

REP. BART STUPAK: But do you believe there's going to be a point when we can no longer afford it, individuals?

ANGELA BRALY: I think we as human beings greatly value our access to health care, which is why we continue--

REP. BART STUPAK: I agree and every family has to make a value judgment; can I afford it today or not. So when my rates go up 39 percent as these, our first panelist said, we look at it, and pretty soon it's going to be can I afford it any more or do I just drop it and hope I don't get sick?

ANGELA BRALY: Which is why we are in the market saying we have to get to reducing health care costs, making sure that people aren't getting unnecessary procedures or redundant procedures. We play that important role in health care. To eliminate us from the process eliminates the opportunity to get to that value equation.

REP. BART STUPAK: And you're getting to the point where no one can afford it.

ANGELA BRALY: And we are serving 34 million Americans across the country and our goal and desire is to try to get for them affordable health benefits that they can continue to access the quality care, the drugs that they need and want--

REP. BART STUPAK: And it's not working. When I came to Congress, like our first panel, small business people, 64 percent, and the people had health insurance. We'd buy it. Now, we're down to about 34 percent. That's why we have to do something on health care in this country because the cost is killing us.

BILL MOYERS: Sure enough, last year, with millions of people out of work and our economy in a tailspin, the country's five largest health insurers increased their profits by 56 percent, to over 12 billion dollars.

So if President Obama and Congress finally agree on health care reform, does it get us any closer to solving problems like this? Who really wins -- the health insurance industry or the rest of us? That's one reason why I invited Wendell Potter back to the Journal.

Our conversation with him last summer resonated far and wide because he had just gone public--

WENDELL POTTER: What we have today, Mr. Chairman, is Wall Street-run health care.

BILL MOYERS: --testifying before Congress about an industry in which he once had thrived, as head of corporate communications for Cigna, the country's fourth largest health insurance company. Wendell Potter was an insider, an industry executive who had fought long and hard against health reform, until one day in 2007 when he came upon a rural free clinic in West Virginia.

WENDELL POTTER: What I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents, to care for people. I mean, there was no privacy. In some cases -- and I've got some pictures of people being treated on gurneys, on rain-soaked pavement. And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. It was absolutely stunning. It was like being hit by lightning. It was almost like -- what country am I in? It just didn't seem to be a possibility that I was in the United States.

BILL MOYERS: Wendell Potter returned from that experience a changed man. He quit his job at Cigna, became a Senior Fellow at the Center for Media and Democracy and ever since has been one of the country's leading champions of health care reform.

Wendell Potter, welcome back.

WENDELL POTTER: Thank you for the opportunity, Bill.

BILL MOYERS: You have as much knowledge as anybody I know about how these insurance companies work. So tell me, what on earth was WellPoint thinking when it jacked up its premiums by nearly 40 percent just as this health care debate was coming to a head?

WENDELL POTTER: Well, these companies are for-profit companies, and they think first and foremost about their shareholders. That's the first stakeholder that they consider. And they know that they have to meet those expectations or their stock prices will suffer. She, Angela Braly, mentioned that she has stock options, so she has the incentive for that stock price to keep going up, because the more it goes up, the more she makes. So that's number one. They're looking after the best interests of the shareholders first, not the best interests of their customers.

BILL MOYERS: But to increase premiums by double digits in 11 states seems to me a pretty stupid thing to do, if you're trying to win friends and influence members of Congress.

WENDELL POTTER: You'd think so, but they spend so much money on lobbyists, on other ways to influence votes in Congress, they've invested many millions of dollars -- all these companies have, over the course of many months and many years to influence their votes--

BILL MOYERS: They just-- the Chamber of Commerce and others says they're going to spend a lot more money in the next month before all of this comes to a head.

WENDELL POTTER: They will. And a lot of that money will come from the insurance companies, from your premiums and mine, that will go into the insurance companies, and they in turn will funnel money into the US Chamber of Commerce and some of their other allies, and also into front groups, to try to kill this bill before it ever reaches the president.

BILL MOYERS: So are you suggesting that they could go ahead and do this really startling increase in premiums, because they know they've got a grip on Congress, through their contributions?

WENDELL POTTER: They do this because they know they can. And they're willing to sacrifice or they're willing to take whatever lumps they might take in the public and before Congress. And you can rest assured that she was well prepared before she went before Congress.

BILL MOYERS: She's not alone, by the way. Look at this list of the total compensation for the top ten healthcare CEOs in 2008. Aetna, 24 million. CIGNA, your old company, 12 million. WellPoint, nine million. That's her. Coventry Health, nine million. Centene, eight million. Amerigroup, five million. Humana, four million. Health Net, four million. Universal American, three million. UnitedHealth Group, compensation, three million. Their profits come from the difference between-- what we pay in premiums and what they pay for our health care, right?

WENDELL POTTER: That's right.

BILL MOYERS: So they have this incentive you talk about to deny health care as often as possible.

WENDELL POTTER: Oh, absolutely. And they deny health care. And the reason why we have so many people who are uninsured and a growing number of people who are underinsured is precisely because of that. They are actually running business away-- they want to get rid of unprofitable customers. They've been doing that for a long time, and Congress is just now catching onto that. Yeah, one of the reasons why they've had to jack up the rates so much in the individual market to make money, is that they have put more people into that market by running off small businesses, for example. They're purging small businesses.

BILL MOYERS: Yeah, I noticed in the story just at the middle of this week that these rate increases are aimed at individuals who can't get coverage through the workplace. They have to buy this on their own, as individuals, and at small businesses. Up to 50 employees. I mean, they have to know, as the Congressman said, that a lot of people cannot afford health insurance. So, what do they expect to happen?

WENDELL POTTER: Well, they don't care, number one, that a lot of people don't-- can't afford insurance. It's highly unlikely that those CEOs that you mentioned have spent much time talking to people who really are in dire straits, who have lost their insurance or have been denied coverage. I was in that boat. It was a revelation to me to come face to face with a lot of those people, and most of those CEOs take great care to be able to make sure that they're not in that kind of a position.

BILL MOYERS: Excuse my growing cynicism at this age and stage, but could this be the briar patch strategy? In other words, they want to get people angry enough to-- for Congress to pass that health care reform with the mandate that delivers millions of new customers to them under penalty of law.

WENDELL POTTER: Well, the way the legislation is structured, this will give them a lot of new business. And millions and millions, billions of dollars in new revenue, and much of it coming from taxpayers in the form of subsidies over ten years-- about half a trillion dollars will come from the US government to help cover the premiums, for people who otherwise couldn't afford to pay those premiums. So yeah, they will win. There's no doubt. They don't like a lot of this legislation. There's much they're trying to kill. And they could live without this bill being passed.

BILL MOYERS: Well, they're doing pretty well as it is.

WENDELL POTTER: Oh, absolutely.

BILL MOYERS: Personally and individually.

WENDELL POTTER: And yeah, exactly, and this system can be sustained quite a long time. And they can get richer and richer as we get more and more underinsured and uninsured.

BILL MOYERS: But let me show you something the president said in his speech on Wednesday. I want to know what you think about it, so let's look at this video.

PRESIDENT BARACK OBAMA: "...many, probably most, Republicans in Congress just have a fundamental disagreement over whether we should have more or less oversight of insurance companies. And if they truly believe that less regulation would lead to higher quality, more affordable health insurance, then they should vote against the proposal I've put forward."

BILL MOYERS: Is the president essentially saying that the gist of this bill is oversight of the insurance industry?

WENDELL POTTER: Much of it is. There is a lot of new oversight of the insurance industry that this legislation would bring at the federal level. There's-- there has not been anywhere close to adequate oversight of the insurance industry at either the federal or state level, and most of the regulation occurs at the state level, and it varies from state to state.

What we're seeing is regulation can work, but it can only work if the insurance departments have adequate resources and if they understand the importance of regulation. And there needs to be a federal component, because a lot of states don't do it adequately. It has been deregulated, or there has been deregulation a lot of states. And we have seen these price increases go up, and in a lot of states, the insurance coverage is woefully inadequate because there aren't many customer protections in the new states.

BILL MOYERS: No one knows right now what the compromise, final legislation will look like-- the Senate bill, the House bill, President Obama's own version that is now in play. But of all that's being discussed and of the likely compromise, what do you like about it? What's good about the most promising compromise?

WENDELL POTTER: Well, first of all, going forward, insurance companies cannot deny us coverage. They will have to insure us. So many of us are born with preexisting conditions, born with preexisting conditions, and are not able to buy insurance at any price. That will end. And that automatically will make sure that a lot of people who are uninsured can get coverage. It will end some of these egregious practices like rescissions, which is a practice of companies going back and canceling your insurance when you start-- when you get sick or injured. That happens all the time. That will become unlawful. A lot of these practices of these insurance companies will be made illegal as they should have been a long time ago.

BILL MOYERS: Do you see anything in this debate, and the provisions that are being debated in Congress right now that would cut one dollar of corporate profits?

WENDELL POTTER: I do. I think that first of all, if you can end the practice of their using preexisting conditions to deny coverage. That's a big, big thing.

BILL MOYERS: Why?

WENDELL POTTER: It's a big thing because that is one of the ways that they cut people out of being covered. If they're forced to take all comers, even people who really need insurance, which is what we're really hoping to accomplish with this legislation, that means that they'll have to spend money covering the care that they need. And that's another reason why you have this mandate of trying to make sure that everyone does get in the system, because you have to have everyone in the system before that works.

BILL MOYERS: But at the same time, they're getting, as you say, this mandate which delivers them millions of new customers. So in effect, is it a wash? I mean, they have to spend more money if this legislation passes, but they get more income from the mandated coverage.

WENDELL POTTER: They do. They do that. But I think we need to look at this as a win for consumers as well. Yes, it'll be a win for the insurance companies, but I don't think we're going to wind up with the insurance companies walking away, winning the whole ball game. If we don't do anything right now, that's what they'll-- that's what will happen. They'll win everything.

BILL MOYERS: So preexisting condition is one reason that you like this? You think that might be something good coming out of that?

WENDELL POTTER: Oh, absolutely.

BILL MOYERS: What's another one?

WENDELL POTTER: Increased regulation, as we talked about. And also, this will, if the president's proposals go through, there will be more regulation at the federal level. There will be more effective review of these rates, and the Secretary of HHS will be able to determine if those rate increases are appropriate or not--

BILL MOYERS: Before they're made?

WENDELL POTTER: Before they're made--

BILL MOYERS: Not after the fact. Now, many states has the review after the fact.

WENDELL POTTER: Yeah.

BILL MOYERS: So, what else?

WENDELL POTTER: Well and it will also limit the amount of money that people pay out of their own pockets for care. And this is extremely important because one of the ways that these companies are continuing to make more and more money every year is shifting the cost of care from them and from employers to us. One of the women before Congress was talking about her out-of-pocket expenses being in the thousands, maybe nine thousand dollars. Well, Anthem in Ohio got approval to offer a product, a health plan, with a 20 thousand dollar deductible. That's the future. If we don't have reform that makes stuff like that illegal, we're all going to be in the ranks of the under-insured pretty soon.

BILL MOYERS: So I hear Wendell Potter saying that if he were in the Senate or the House, he would vote for this reform?

WENDELL POTTER: I would vote for it. I was distraught when I saw what happened, what I saw the Senate voting on. But then I realized, you know, I studied a lot of these efforts over the past many years to get reform. And often we've come short because we've tried to get the perfect, and we've never been able to get anything as a consequence. So I fear that we may be--

BILL MOYERS: Not since Medicare, right?

WENDELL POTTER: Not since Medicare.

BILL MOYERS: But I remember, Wendell, I remember President Johnson saying, "Well, let's get this bill. It's a flawed bill, 1965, passed. And other Congresses and presidents will come along and improve it over the next several years." That never happened.

WENDELL POTTER: But there have been some improvements. People who are on dialysis, for example, they can you know, they now are qualified for the Medicare program. That's an improvement. And people with disabilities are eligible for Medicare. So, it can change. And who knows? Maybe in the years to come, there can be other substantial changes to Medicare and Medicaid, that will be beneficial to all of us. But yes, this is important. We need to have a foundation. And this may seem to be not an adequate foundation for a lot of people, but there are more than 50 million people in this country who don't have insurance. I don't want to go back and tell them, "I'm sorry. We just couldn't get a good enough bill. So you're going to have to wait to who knows when. Maybe you won't live long enough." 45 thousand people, Bill, die every year because they don't have health insurance coverage. And that's recent. In years to come, that will increase. People can't wait any longer.

BILL MOYERS: Do you see any of the proposals being debated on the Hill reversing the perverse incentives that lead doctors to overtreat the well insured?

WENDELL POTTER: There are not as many controls in this legislation as I think that there could be, but I think that there are some.

And doctors do have an incentive, in many cases, to over prescribe and overtreat. And there are provisions in this bill that address that.

BILL MOYERS: Do you think there are enough provisions that will contain the soaring cost?

WENDELL POTTER: I think it's a beginning. I think you will see that. The private market has lost its ability to control these costs, so the federal government has to step in and play some role. And I think that we'll begin to see that with this legislation.

BILL MOYERS: So you're saying what others have been saying, that doing nothing is not an option?

WENDELL POTTER: It's not an option. The free market does not work in health care like it does in other sectors of the economy. In fact, it works just the opposite. And what's happening is that competition is driving up cost. It's not controlling cost. It's driving them up. It doesn't work like other sectors of the economy. The hospitals and the doctors, now that they are bigger and more powerful and have more bargaining clout, can get more at the bargaining table, in terms of increases in what the insurance companies pay them. So that's why costs keep going up. The insurance companies have lost the ability to control costs. And the way they're continuing to make money is to shift more and more of the cost to us, through these high deductible plans that they're marketing.

BILL MOYERS: So Senator Potter votes for it. It passes. The president signs it. Now you're facing an opponent in this upcoming November election. Your opponent runs ads saying, "Senator Potter voted for a massive government takeover of health care. Senator Potter voted to put bureaucrats in between you and your doctor." So you get-- you're getting bombarded with all of these ads. How do you respond?

WENDELL POTTER: Well, I would-- by facts, for number one. But also by-- one of the things that I think advocates of reform have not done is to understand how the opponents play the political game. And they've been talking about this being a government takeover of the health care system for a long time. They've been engaging in fear mongering even before the first bill was introduced in either the House or the Senate. They knew what was coming, and then their strategy was to try to manipulate public opinion. So the incumbents, the Democrats, are going to have to go back to the reasons why we're having this debate in the first place, and to say, "Look, what would happen if we didn't do anything? Here's what would have happened to you. You cannot rest assured that you're going to be able to keep your insurance, if you lose your job. You probably already know somebody who's lost their job and their coverage. It might be someone in your own family. Think about your own children. Think about what could happen if we didn't-- could have happened if we didn't act." This might be the most important thing that any member of Congress right now will vote on. And I would certainly want to make sure that I voted the right way.

BILL MOYERS: So let's go back to your unrepentant days, when you were in the war room of the health insurance industry and you were trying to figure out PR strategies to advance the interests of your company and the industry. What would you be advising right now?

WENDELL POTTER: I'd be advising that a lot of the money that they have available to them for PR and advertising be funneled into organizations like the US Chamber of Commerce, the National Federation of Independent Business, and other groups that are their natural allies and have been for many years, to advertise all across the country. And in particular, in states and districts where there might be some vulnerable members of Congress, to call this a government takeover. To try to continue to scare people. We'll see that, to scare people away from this. And at the same time, try to say that we are in favor of reform. We just need to have a bipartisan approach to reform. Those are words that sound good, so--

BILL MOYERS: Why?

WENDELL POTTER: --so continue with its duplicitous campaign. Why? Because people like--

BILL MOYERS: Why do they put-- why do they put bipartisan on it, when the Republicans haven't yielded an inch?

WENDELL POTTER: Because they know that the public likes the idea of bipartisanship. And the public doesn't realize that the realities in Washington are making bipartisanship virtually impossible, at least on this issue and on many other issues. It's not achievable.

BILL MOYERS: So Wendell, you reluctantly are going to support this bill?

WENDELL POTTER: I would.

BILL MOYERS: What don't you like about it?

WENDELL POTTER: I don't like the fact that it doesn't include the public option. That was so much a part of the House bill, even though it was watered down. It was a good thing to have included, and I regret that. And I hope that maybe in future years, Congress can revisit that. And I think they will, if they're seeing that the reform doesn't work as envisioned.

BILL MOYERS: So you would say yes, and then fight again for another day to make it better.

WENDELL POTTER: I would vote for it. Is it the be all and end all? No, it's not. There are other things that I think will have to come back in years to come. But wouldn't you rather, and I think wouldn't most Americans rather that we have something to start from rather than starting from scratch the next time? It's very hard to build up to doing this in the first place. And keep in mind that the special interests have almost an unlimited amount of money to spend to influence the results. I'm frankly pretty amazed that we're getting this close to passing something.

BILL MOYERS: Wendell Potter, it's been good to see you again.

WENDELL POTTER: Thank you very much, Bill.

BILL MOYERS: We'll be back in just a couple of minutes with my next guest, Dr. Marcia Angell, and more on the health care reform fight. Please take this opportunity, in the mean time to pick up your phone or go to your computer and make a pledge to this public station. In these difficult times, we need analysis of the news and issues that affect each of us more than ever. Your pledge keeps the candle in the window of this local station. Thank you.

BILL MOYERS: We like to hear what you think of our reporting on the Journal. So right now we'll share some of your comments. Kevin Drum and David Corn of "Mother Jones" magazine joined us recently to talk about why we can't get serious financial regulation reform.

KEVIN DRUM: The financial industry has convinced us, you know, in the '50s what was good for General Motors was good for America. Now it's what's good for Wall Street is good for America. And they've somehow convinced us that we shouldn't ask about what's right or what works or what's good for America. We should ask what's productive, what's efficient, what helps grow the economy.

BILL MOYERS: Here's what some of you had to say:

VOICE 1: Tonight's topic stirred my anger up again to the boiling point. The Democrats and Mr. Obama have made me despondent because the system has been broken by both parties and given up to the moneyed interests in this country. We knew almost immediately because the clowns who helped create this mess were immediately appointed to the cabinet. We, the people, are nothing but pawns who get trampled on by the bankers, corporate America and the military industrial complex. I despair for my country. Elizabeth Williams

VOICE 2: It's the big, moneyed bankers verses us little guys...I have written my Congressional representatives and even participated in phone banks. What difference does it make? It's extremely frustrating...Maybe we should all cut up our credit cards and mail them to Congress. I'm tired of expressing opinions to people who don't pay attention! Susan Caba

VOICE 3: You didn't ask some important questions; like, what would the consequences be of tough regulation of the banks? Would the banks migrate to some other country? John Vrugtman

BILL MOYERS: The historian Thomas Frank, author of "What's the Matter with Kansas" and "The Wrecking Crew" discussed his view of how conservatives approach government.

THOMAS FRANK: The conservatives have for decades now made their- the whole point of their party is to attack government, attack the state, encourage cynicism about government. And then wreck it when they're in charge, right? Democrats never defend the state. They never come out and say, "No, no. It's important to have, you know, government. It's important to have a Department of Labor. These are, you know, having government actually- a good government increases your freedom. It doesn't ruin it." They never fight back.

VOICE 4: I always commend PBS for its intelligent content, which is why I donate to my local station. However in this segment, the guest categorically demonizes all conservatives as bumpkin government haters or greedy soul suckers...As a limited government conservative, I think the guest brought up some really interesting ideas, but I did not appreciate being marginalized. Just because a person is not an Obama superfan doesn't make conservatives the disease that's killing America. Brasky

VOICE 5: The elephant in the room during this discussion was the bare and ugly fact that the administrative "judgments" of the past criminal decade have been continued by Mr. Obama even as he mouths platitudes about turning over a new leaf. Juliania

BILL MOYERS: And finally, Greg Mortenson, the humanitarian and co-author of the bestseller "Three Cups of Tea," shared with us his mission to bring peace to Afghanistan, one school at a time.

GREG MORTENSON: As a child in Africa, I learned a proverb. And it says, "If we educate a boy, we educate an individual. But if we can educate a girl, we educate a community." And what that means is when girls grow up, become a mother, they are the ones who promote the value of education in the community. The education of girls has very powerful impacts in a society. From my own observation, when girls learn how to read and write, they often teach their mother how to read and write. Boys, we don't seem to do that as much.

VOICE 6: What Greg Mortenson is doing seems to make so much sense it begs the question...why isn't our foreign policy based on the model he uses? One million dollars to build 30 to 40 schools as opposed to one million dollars to keep one pair of boots on the ground sounds like a no brainer. Troy

VOICE 7: Mr. Mortenson is a great spokesperson for the US war machine. He makes the white-male christian look and sound like the great educator and white hope for Iraq, Afghanistan, and soon Iran, all while carrying out the endless crusade. Good thing the generals are listening to him - a man with Jesus on his side just can't be wrong - can he? Jon

VOICE 8: I have, until your program last night, been assuming that the Taliban had probably been destroying the schools that have been built. I was so pleased to learn that the Afghan schools have not been destroyed; instead more have been built! I was hopeful when you and Greg Mortenson talked about the military leaders who know about his work and the schools. Jane Weil

BILL MOYERS: Keep your comments coming -- by mail, e-mail, or on the blog at pbs.org, and we'll keep reading.

BILL MOYERS: Welcome back. You just heard one advocate of health care reform say that what's happening in Washington is not to his liking. But the cost of doing nothing is unacceptable and yes, he would vote for the compromise that seems to be emerging. But there are passionate advocates of reform who believe that such compromise itself would be worse than nothing.

So I'm curious to know what my next guest thinks. Dr. Marcia Angell has been one of the foremost champions of a "single payer" nationalized health system, a kind of Medicare for everyone that was a plan favored by Barack Obama before he was president. But he backed off in the health care debate, saying it's just not viable in the current climate.

You've seen Marcia Angell at this table before. A physician trained in both internal medicine and pathology, she was the first woman editor-in-chief of "The New England Journal of Medicine." She's now senior lecturer in the Department of Social Medicine at Harvard University Medical School and writes extensively and often about health care. On her previous visit to the Journal last July, she had this to say:

MARCIA ANGELL: I would rather see Obama go down fighting for something coherent and practical that the public could mobilize behind, than go down fighting for this amorphous plan that tries to keep the private insurance industry in place.

BILL MOYERS: Since then, health care reform has gone through more twists and turns than a mountain road. And Dr. Marcia Angell is back to tell us what she thinks now. Welcome to the Journal.

MARCIA ANGELL: Thank you very much. Good to be here.

BILL MOYERS: So, has President Obama been fighting as hard as you wished?

MARCIA ANGELL: Fighting for the wrong things and too little, too late. He gave away the store at the very beginning by compromising. Not just compromising, but caving in to the commercial insurance industry and the pharmaceutical industry. And then he stood back for months while the thing just fell apart. Now he's fighting, but he's fighting for something that shouldn't pass. Won't pass and shouldn't pass.

What this bill does is not only permit the commercial insurance industry to remain in place, but it actually expands and cements their position as the lynchpin of health care reform. And these companies they profit by denying health care, not providing health care. And they will be able to charge whatever they like. So if they're regulated in some way and it cuts into their profits, all they have to do is just raise their premiums. And they'll do that.

Not only does it keep them in place, but it pours about 500 billion dollars of public money into these companies over 10 years. And it mandates that people buy these companies' products for whatever they charge. Now that's a recipe for the growth in health care costs, not only to continue, but to skyrocket, to grow even faster.

BILL MOYERS: But given that, why have the insurance companies, health insurance companies been fighting reform so hard?

MARCIA ANGELL: Oh, they haven't fought it very hard, Bill. They really haven't fought it very hard. What they're fighting for is the individual mandate. And if they get that mandate, if everyone does have to buy their commercial products, then they're going to be extremely happy with it.

BILL MOYERS: But this is all about politics now. It's not about pure health care reform. So given that reality, what would you have the President do?

MARCIA ANGELL: Well, I think you really do have to separate the policy analysis from the political analysis and I'm looking at it as policy. And it fails as policy. Moreover, a lot of people say, "Let's hold our nose and pass it, because it's a step in the right direction." And I say it's a step in the wrong direction.

You're right. Politics is different and there are a lot of people who say, "Look, it's a terrible bill. Even a step in the wrong direction as policy goes. But we need to get Obama elected again and we need to continue with the Democratic majority in Congress. And so we need to give Obama and the Democrats a win. If we don't, the Republicans will come in and take over Congress in the fall, and then the White House in 2012. But the problem with a political analysis is sometimes you're right and sometimes you're wrong. And Democrats and particularly liberals have a history of outsmarting themselves.

And I'm not so sure that if this bill goes down, it's going to make it any harder for them politically. So I think it's difficult times for the President and for the Democrats. But if you look at it as a matter of policy, the President's absolutely right that the status quo is awful. If we do nothing, costs will continue to go up. People will continue to lose their coverage. Employers are dropping health benefits. Things will get very bad. The issue is will this bill make them better or worse? And I believe it will make it worse.

BILL MOYERS: The President, with all due respect, would disagree with you. Let me show you something he said--

MARCIA ANGELL: Yes.

BILL MOYERS: --in his speech on Wednesday.

MARCIA ANGELL: Yes.

PRESIDENT BARACK OBAMA: My proposal would bring down the cost of health care for millions, families, businesses, and the federal government. Our cost-cutting measures mirror most of the proposals in the current Senate bill, which reduces most people's premiums and brings down our deficit by up to one trillion dollars over the next two decades. Brings down our deficit. Those aren't my numbers. Those are the savings determined by the Congressional Budget Office, which is the Washington acronym for the nonpartisan, independent referee of Congress.

BILL MOYERS: Not good enough for you?

MARCIA ANGELL: Well, first of all, you have to look at what the CBO is looking at.

BILL MOYERS: Congressional Budget Office.

MARCIA ANGELL: Yes. They're not looking at the cost to the system as a whole, to the larger system. They're not looking at the private system. They're simply looking at the federal budget as a budgetary item.

BILL MOYERS: Right. They look at the government--

MARCIA ANGELL: The government part of that. So if they can save money in Medicare, then they come out ahead, no matter what happens out in the private sector. And so that's what he's talking about. It will take money out of Medicare and put it into the private sector. Medicare is the source for a lot of the funds that are going to go to subsidize the private health insurance industry. So that's the first thing. The second thing is the CBO has to build in assumptions. And those assumptions are arguable, to put it mildly.

And as far as cost-cutting, there are sort of promissory notes. ‘We'll get a committee to look at the cost of effectiveness, of various medical procedures.'

BILL MOYERS: Well, you remind me 45 thousand people, as Wendell Potter said earlier, die every year for lack of health insurance. That should be-- they're--

MARCIA ANGELL: It's not lack of health insurance. It's lack of health care. There is a difference between health insurance and health care. You can have insurance offered that is too expensive to buy or too expensive to use. What good does it do? And what happens when this occurs, is that what you see is instead of improvements, look at my state of Massachusetts.

Instead of seeing improvements, you see it shredded even further. You see more people denied access anyway. Now they're about, I think over 60 thousand people in my state who are exempted from the plan for financial hardship and this is also in the Obama plan. If you're really poor, you don't have to participate, and these are the very people who should be in a plan to cover them.

BILL MOYERS: But, the very poor do get Medicaid.

MARCIA ANGELL: Yes, yes. And one of the things about the Obama plan that I do like is that it expands Medicaid up to 133 percent of the federal poverty level and that's fine. The problem is that could have been a stand alone measure. You didn't need to have it incorporated in this massive Rube Goldberg apparatus.

BILL MOYERS: Is there anything else in there you like, in the Obama plan?

MARCIA ANGELL: Oh yeah. I mean--

BILL MOYERS: What?

MARCIA ANGELL: First of all, the intention is very good. The expansion of Medicaid is very good. Raising the age of dependents to 26, and saying that they have to be covered under parents' plans. I think that's very good. Looking at the cost-effectiveness of various procedures is a good thing to do in its own right.

So yes, there are things in it. But the bill as a whole, the more I look at it, the worse it gets. It's going to increase costs, not decrease them. And it's going to increase the rate of growth. It's not going to bend the curve, except in Medicare.

I think in order to look at a reform and to measure a reform, you have to look at the problem it's designed to answer. You have to look at what's wrong with our system, in order to evaluate a reform. You have to ask yourself, "Why is it that we spent over twice as much per person on health care and yet don't manage to cover everyone?"

BILL MOYERS: Why is that?

MARCIA ANGELL: And the reason is that we have chosen, alone among all advanced countries, to leave health care to for-profit industries, to leave health care to businesses that then distribute health care as a market commodity according to the ability to pay and not according to medical need.

So if you look at what's causing the problem, the causes are not being targeted in this plan. They're not being addressed. Maybe some of the symptoms of the causes are being addressed like let's stop excluding people from pre-existing conditions. But it doesn't stop the insurance industry from raising its premiums.

BILL MOYERS: So how can you be sure, just as you say politics often goes off-track. We don't get the politics or the policy we want. How can you be sure that these terrible things are going to happen?

MARCIA ANGELL: Well, if you get-- I think it was Senator Rockefeller who said, I mean, that was a wonderful comment he made in the summit last week. Senator Rockefeller referred to the private insurance companies as rapacious, rapacious, and said, "Like sharks, they swim under the water, and you don't know they're there until you feel their teeth." Now there are not many people in America who would disagree with that description and so what this plan does is says, "This is a terrible industry, so let's force people to buy their commercial products. And let's subsidize it and put a lot of money into it."

And what do you think they're going to do? If you were an insurance company, you would say, "Well, thank you, Santa Claus. I've got all of these captive customers. Young ones are healthy. They probably won't even use the insurance. There's nothing to stop me from raising my premiums. I have all of these subsidies coming in." Don't you think that the prices would go up? I think it would be remarkable if they didn't.

When I look at the Senate bill and the President's suggestions, almost every paragraph, there is a poison pill for someone. I think sometimes they're unintended. Let me give you one example. They allow for insurance companies to charge three times as much for older people as for younger people.

So from the point of view of the insurance industry, this is a god-send because either way, they win. Either the 55-year-olds cough up three times the premiums, and that's good. Or else they can't, and that's probably the more likely situation. They can't, and then they're fined. And the insurance companies don't have to take care of people who might actually get sick. They're left with all of the thirty-year-olds, who are less likely to get sick, but who are required to buy their products.

So this sets up a situation which probably all plans, for 55-year-olds, are high priced. So they can't afford to buy it, or if they do buy it, they have to pay an excise tax on it. This is a real poison pill for these older people. It's a gift for the insurance industry.

BILL MOYERS: But the President is pushing ahead; he wants Congress to act in the next month. What would you have us do?

MARCIA ANGELL: I think the problem is this, Bill. If this plan is passed, and I think there's real doubt as to whether it will be, and there's even more doubt as to whether it would ever be fully implemented, but let's say that it's passed. It will begin to unravel almost immediately. And then what will people do? Well, they'll say, "We tried health reform, and it didn't work. Better not try that anymore."

It'll be like what happened after the Clinton plan failed. There'll be another 16 years before anybody comes up with the courage to try that again. People say, "Too expensive. Just can't have universal care. Tried that, did that, didn't work, good-bye." Whereas if the bill dies now, people can say, "This bill died because it was a bad bill." And the problem is still on the front burner. And then one can hope that we get some version of Medicare for all. And that we don't have to wait 16 years.

BILL MOYERS: What makes you think it would come back in 16 years or more? What makes you think it will ever be back on the table?

MARCIA ANGELL: Oh, I think it has to be. I mean, I think that this system is unraveling so fast, doing nothing or doing the Obama plan, so fast, that something will have to be done. Unless we want to, you know, explicitly be a third world country. So I don't think it's going to wait. But if we pass this plan, it's going to delay.

BILL MOYERS: Are there any, you know, three or four things that could be changed in the next month that would make you change your mind and vote for this if you were in the Senate?

MARCIA ANGELL: No, I don't think so.

BILL MOYERS: Not one?

MARCIA ANGELL: That could be--

BILL MOYERS: If they took out the mandate--

MARCIA ANGELL: --that realistically--

BILL MOYERS: Yeah, realistic.

MARCIA ANGELL: No, no. If you take out the mandate, then the private insurance industry says, "No, we're out of here." This Congress will do what the private insurance industry wants it to do. If you look at the money that has flowed into Congress over the last year, and particular to people who were crafting this bill, you can see that the pay masters get what they want.

BILL MOYERS: Marcia Angell, thank you very much for returning to the Journal.

MARCIA ANGELL: Well thank you.

BILL MOYERS: Listening to Wendell Potter and Marcia Angell I kept thinking of the late Fred Friendly, a pioneer in broadcast journalism and my friend and mentor. Fred used to talk about how argument and discussion should make the agony of decision making so intense you can only escape by thinking.

So what do you think? Should the President, as Wendell Potter says, go ahead with the best bill he can get from this bad process or as Marcia Angell says, should he declare it a bad bill, pull it, and come right back at us with a plan for universal coverage -- Medicare for all.

Let us hear from you at our website on PBS.org and I look forward to reading your comments this weekend. That's it for the Journal, I'm Bill Moyers. See you next time.