New England Journal of Medicine; WGBH Forum Network; Election 2008: Health Care in the Next Administration

But what I want to do is set the set the tone for this. Say a little bit about the context and try and get us all on the same page to start. I'm going to start from probably many you might expect with that triad of issues that so important in defining the challenges in health policy access to care quality of care and cost of care. I'm going to start with access because in some ways that's where it starts getting people in the system. Access can be really multi-factorial in many many things but in our country it has a special association with insurance status in part because of the developed countries we really lag way at the rear. We've got 45 million Americans who are uninsured. Eight million children uninsured. And I can tell you that that's not cosmetic characterisation. Right. If you're uninsured you are less likely to go see the doctor when you see the doctor the doctor is less likely to be a regular doctor. You're likely to get less preventive care you're likely to get really less routine care. And I think maybe most startling of all if you're sick and you see the doctor

whether it's in his or her office or in the hospital or in the intensive care unit you still get less. You still get less. And that shows up in increased morbidity and higher mortality. And it's going in the wrong direction. The turn of the decade we've got roughly a million persons more each year who are uninsured. But insurance status is not the be all and the end all and there are many issues in the health care system. And for those who are comforted because you've got insurance it's not at all clear you'll get all the things that are indicated for you. We've become increasingly knowledgeable in recent years that quality of care in America which we consume is the best in the world has got real problems with it. The landmark study I'm proud to say published in The Journal was Beth McLuhan's work with her colleagues at Rand and their number was 55 percent. Some 6000 patients and they found 55 percent of the time patients got was indicated for their high quality care. Well I can tell you it's not just a number like that

I've studied this literature closely. And you can choose the condition hypertension or congestive heart failure or asthma chronic obstructive pulmonary disease colorectal cancer breast whatever it is breast cancer that the chances are 30 40 50 percent of the time you won't get the high quality services even if you're in the care system. And it's not just under use as Barry said. We've had professors here Lucian Leape in Troy Brennan early on who exposed us to the knowledge that the way care is delivered also can have dilatoriness consequences. And patient safety we now know is a major problem. And it's not clearly getting better. The third part of this and this is going to seem almost like Woody Allen. You know I've already told you that access is bed and quality is bed. Now men tell you the portions are small. Well ball costs are really just raining out of control. We not only have a lot of care but that isn't doing us well but it's costing us a huge amount of

money in the last four years. Premiums have gone up roughly 35 percent 8.5 percent annually. The CPI at the same time has gone up 3 percent. An individual insurance policy costs forty four hundred dollars a family policy cost more than $12000. Let me put that in context. If you were the leader of the median American household you'd be looking at a pretax income of just over $50000. Imagine what it's like to have a pretax income of $50000 and you potentially have to give this might be you especially if you're self-employed have to give more than 12000 that way up front to cover health insurance. Not to mention co-insurance not to mention deductibles not to mention the things that aren't covered. And again there are no signs that this is changing. How do we move ahead. I think we come to Convergence in part by pursuing an honest straightforward

forthright dialogue like we're about to have this afternoon. What's going to happen come the new year. I don't know for sure but I can tell you one thing I can tell you that what the president does what he puts on the table and the strength and resolve that he brings to moving it forward is going to have a huge effect on what Congress may or may not pass. I would like to to follow up Arnie's comments and start off by laying the foundations of what Senator Obama said he wants to do in health care. And there are really three things and they match up extremely well with the things that already told you where the fundamental problems of health care. The first thing the first point is that all Americans should have access to quality affordable health care. This statistics that Arny told you about the uninsured are real the estimates are that about 20000 Americans die every year because they don't have health insurance. It's a moral issue it's also an economic issue.

Whatever your view is about social and technical change in the economy you've got to have everyone having health insurance or else our ability to undertake anything else that we want to do socially or economically is going to be diminished. So everyone has to have access to quality affordable health care that is Tenet number one. Tenet Number two is we need to modernize the health care system so that it improves health it lowers spending and makes medical practice more rewarding. We cannot continue to have a system that costs 40 percent more than other countries do. That way somewhere between 40 and 50 percent of all medical dollars on services that are not improving patients health. That in many cases harms people. And that turns off doctors left and right gets them not to go into primary care makes them be embittered about the profession tell their children they do not want to become doctors and runs itself over and over again. We need a modern healthcare system that is in sync with where we are which is to do what we what it does well to do it at the lowest cost that it can and to get the services to people when they really need it. So that is the second test. The third tenet is that we need a public health system that works with the medical care system to prevent disease and

improve population health. We have major issues ranging from continued need to to promote continued reductions in smoking to an obesity epidemic. Two questions about food and water safety and imported goods and global catastrophes. And we need a public health system that is up to the challenge of doing that. That is not separate and that has not turned into a politicized public health system. Those are the three fundamental parts of what Senator Obama believes and the way that he judges health care reform is by how they reach these three goals the way that he deals with political. Issues is by how well they work with him and with each other towards realizing those goals. So let me just start off with coverage. How is it that you get coverage. It's actually not very hard if you ask people who are uninsured why they don't have coverage they say because they can't afford it and they don't know where to get it. So what you need to do if you want to get people coverage is you have to make it affordable and you have to make it accessible. OK. And once you do that then the then the vast vast bulk of people

will will buy coverage. How do you make it affordable one thing that you do is you reduce the cost of medical care by getting rid of all the fluff all the stuff that we don't need all the duplicative tests all the waste all the redundancies everything that fills the pages of the medical journals that's been the subject of Iowan reports for at least the past decade that says that we can do better we have to do better. Second we need to provide help to low and middle income people so that they can afford coverage. Senator Obama has proposed a very very generous set of tax credits for people who are low and middle income so that they can afford to have health insurance that doesn't leave them $7000 in the hole for health insurance that's expensive in the short run it's going to cost money. OK. And one of the big differences between the candidates is are they willing in the short term to spend the money that it will take to reform the health care system. Senator Obama has said yes and he's identified the source of money that he would use for this. The source of money is the tax cuts that President Bush an active for people earning over $250000 a year. Senator McCain has said no. Finally you need to set up a mechanism where where people can get insurance the biggest problems in the market now are for individuals and small firms they face insurance premiums that are 20 to 40 percent higher than what

people in large firms get. We know from the experience of Massachusetts that when you group individuals and small firms together you can get greater choice lower cost incredible satisfaction with the system Senator Obama wants to replicate the experience of what we've seen in Massachusetts and other places Massachusetts individual premiums have fallen in half by grouping the individuals in the small firms together and creating a place where they can buy. We know how to get people coverage. The issue is two things. One is you have the political will to do it. And second is are you willing to say that this is a more important priority than other priorities are. And Senator Obama is willing to say says yes to that. The second part modernising the health system means focusing on good care. And what does that mean. What we need what we all know that we need is a is a is a radical transformation of the medical system and in several dimensions. One is the medical care system needs to stress prevention not just treatment when people get sick. The despite the fact that about 75 percent of medical care is associated with conditions that could be prevented. We spend less than one in every $25 on preventing

things. Health plans cover it very poorly when you stick people in individual markets will cover it even poorer. We need to have a commitment to STATE OF THE ART preventive services that will keep people healthy as long as as we can and that will save money in many cases down the road and Senator Obama has said that that's what that that's one of the things he's committed to. Second we need to we need to know more and we need to pay smarter. We need to have comparative effectiveness analysis that tells us what works and what doesn't work. We need to invest in health information technology. We need to move medical care from in 1903 industry into a 21st century industry where we know what is happening and we know what people need and we know what works and what doesn't work and how it should be done. We need to measure quality give that information out to individuals get the information to providers so that they can learn about it. And we need to pay for good quality care not just more care. And then finally we need malpractise reform. And what we know from the literature is that the most important practice reform is going to be reforms that reduce errors just like preventive care is the best care preventing errors in the first place is the best way to reform the practice. The health information technology will be extremely

important there in addition to innovative ways to settle disputes that don't involve going to court telling doctors that if they do the right thing they can't get sued for doing the right thing the way that it's defined. We can make enormous progress in terms of making medical practice cheaper making it work for doctors making it work for patients as well. We know that these things work we strip. There are a variety of initiatives to stress prevention at least 18 states have initiatives ongoing that stress prevention and chronic care management instead of just acute treatment. Comparative effectiveness analysis Well it's not done in a major way in the U.S. it is done in other countries and also various areas in the U.S. have stressed gotten doctors involved in stressing what works and trying to care for patients in the way that the doctors guidelines say works and it's having very good effect. We know it's possible to share health information in places like Indianapolis they are doing that. We know that you can have payment reform. Detroit is is is a leader there. We know that we can reduce errors for many of the studies that were mentioned earlier studies of computerization in hospitals studies of reducing. Puff spittle

caused infections hospital acquired infections in Pittsburgh. We know this can be done. What we need is the leadership that will get us there. Finally we need to politicize the public health system and make it work better. I was stunned when five former CDC directors complained about the politicization of science in the Bush administration. We need to end the war on science. We also need to deal with with pressing public health priorities. What would be the impact of doing this let me give you a few dimensions of it. One is that we estimate that 98 to 99 percent of all Americans would have coverage by making health insurance be affordable and accessible and reducing the cost of that coverage. Second costs would fall. Our estimates are that the cost of health care would fall by about twenty five hundred dollars for the typical failed 10 million more people would have employer based coverage because of the cost of employer based insurance would fall more rewarding practice environment physicians will actually be freed up from spending their time dealing with unnecessary administrative expenses and actually taking care of patients.

The two candidates agree on many things they disagree on many others. One is what should be done with health care savings. Senator Obama said that money that we save in the health care system should be used to expand coverage. He wants to take that money make sure we can use it to help low and middle income people afford health insurance. Senator McCain has proposed extending the Bush high income tax cuts and doubling them again. And also balancing the budget in four years. The only way to do that mathematically the only way to do that is huge cuts in health care programs. Should we encourage employer based health insurance. Senator Obama says let's build on what works that is the part of the private health insurance system that works most functionally now. Let's not tear it down. Senator McCain proposes to tax people's health benefits at work that will inevitably encourage employers to drop coverage individuals not to be able to afford it. Twenty million people. The best estimates are we'll lose health insurance through employment as a result of the McCain plan. My sense is we shouldn't tear down something before we know what's going to replace it. Should preexisting condition exclusions be

eliminated Senator Obama says yes and no insurance company should never deny someone coverage because they're sick. Senator McCain says no insurance company should be allowed to deny people coverage because they're sick. Basic difference between the candidates. If you look at the last two very big health care issues that have come up in public policy you can see where the candidates stand. Should we expand the S-CHIP program. Senator Obama said yes. Senator McCain said no it was too expensive. It's too expensive if you're doing it in the context of we need to keep the Bush tax cuts and we don't have any money left. By the way this was actually paid for by a tobacco tax increase. Just a few weeks ago there was a question about should we go ahead with a Medicare cut in physicians income of 11 percent. Should we protect that Senator Obama said yes. Senator McCain didn't vote but he indicated he was opposed to it the way that was paid for was by reducing the overpayment to private health insurance plans that participate in Medicare. Senator McCain didn't feel like reducing that overpayment. I come back to those principles that I want to start off with. We need to make sure that everybody has access to quality affordable health insurance coverage. We

need to modernize the medical care system. We need to have a public health system that works that is going to take a lot of effort bringing people together. It is going to take money in the short term. It's going to take intense goodwill and it's going to take someone who's willing to see the longer term gain and place health care high enough on the priority scale that we actually get it done. Thank you very very much. Let me talk a little bit about the issues as the McCain campaign has seen them. We do agree in describing what the problems are that this country faces and sustainable health care spending quality problems and patient safety issues and way too many people without insurance coverage. And the question is how is it that we get our arms wrapped around these issues. Not surprisingly. We have some differences in terms of where we think we

need to start and how we need to roll out changes. There are some tough issues that any health care reform plan needs to resolve. But there are no easy wins without downsides. Each of the solutions has positives and negatives. And one of the issues that the country and ultimately the Congress will have to decide is on balance which of these strategies works best. Let me give you some examples of what I mean. If you tie insurance to employers in a mobile labor economy and there is nothing more mobile than the American labor economy you are ensuring disruption. Because when people change jobs they will change the insurance they have and usually therefore the network of physicians that they have a nurses that they have available to them. It also tends to hide the cost of insurance. The single most unknown piece of information is how much has your employer contributed to your insurance

people don't know and it's frequently not what they would have chosen. Even in terms of just the benefits. Second problem is some people are predictably high spenders. How you need to deal with that or how you choose to deal with that can differ. You need to compensate at some point for people who are predictably high spenders whether you force insurance companies to pretend they can tell that some people are predictably high spenders and try to fix so that they don't have windfall gains and losses is one strategy. Or you can try to compensate individuals or make other means of adjusting for these predictably high spenders. The problem is they are the strategies are varied as to how to try to respond. If insurance is not compulsory you run the risk of high free riders. If you have more support and more access you will have some people who will be free riders from what you choose to be bothered by that is an issue. If insurance is required in

Senator Obama's case the mandate the only mandate that exists is for children. It's not clear what it is they're mandated to have or how it would be enforced. But once you have a mandate you have to define what it is that people have to have. That raises a whole series of other issues and be prepared to enforce them somehow. To me the most critical of the issues we have to solve is finding ways to moderate spending. We are absolutely in a path of unsustainable spending increases. And because health insurance spending increases is the single biggest predictor of increased numbers of people without insurance coverage it exacerbates the problems that we've been facing in this country. What Senator McCain has done is to focus and make insurance more affordable by trying to look at some of the underlying drivers of health care spending and recognizing that when people change jobs

frequently having insurance portable for many will become an important part of going forward. So what the McCain proposal has focused on is that the current tax exclusion where you don't have to count what your employer pays as part of your taxable income is extremely inefficient and extremely unfair. And the reason that's inefficient is because it distorts the choice between wages and in insurance coverage because you get to use pretax dollars for one and not for the other. It's unfair because the higher your income the more value it is to us. It's therefore why the notion of changing the tax code and in its place having a refundable tax credit is so important. It puts the money to the individual and it makes it in to a much fairer way in terms of how it is being distributed. $5000 for couples. Twenty five hundred dollars for individuals these are not small amounts of money. Most middle class people get actually far less from the current subsidy now that we have

in terms of how health insurances is being subsidized by employers. Why is this important. Well it will help make insurance clearer what it is you're buying what it is it cost. And if you change jobs whether or not you want to keep your insurance or whether or not you want to have the insurance that your employer offers elsewhere. And as I've indicated it makes it more equitable and portable. If you want it. He has also proposed having access to an open insurance market where people can buy insurance in other states. Now why is this been an issue. There are a lot of places where the insurance market is effectively dominated by a blues plan 70 percent 80 percent of the market. You know get a lot of competition or pressure. You frequently don't get variation in terms of what benefits are offered sometimes because of what the state has required and sometimes because of what the

plans make available this is to put pressure on companies and plans to offer the kind of insurance benefits that people want and to reduce their overhead expenditures because people can go elsewhere in order to reduce their. Of course if states want to continue trying to make pooling arrangements available. McCain's plan encourages both in terms of Medicaid and in terms of this state flexibility so there's no reason that insurance that states can't continue to experiment in ways with making insurance more available to the population. But it is really to allow people to access markets that have been closed to them. One of the issues that has been raised is what do you do about predictably high spenders high cost individuals. Well there are some provisions that are already in place and that would continue in terms of state law. That is we have a hippo law

and people who have employer sponsored insurance and our presumption is that right now 98 99 percent of large employers are providing insurance and our presumption going forward is that almost all large employers will continue to provide insurance for people who have insurance coverage and continue in a group coverage which is basically two and more hipper rules provide a lot of protection with regard to preexisting conditions. It is less true for people who start out in the individual coverage or who never had any coverage and who have some preexisting conditions and making sure there's a way. To help people who are predictably high spenders and who won't have access to group insurance is an important issue and what the senator is proposed is having subsidised state high risk pools. Now high risk pools at the state level have gotten a bad rap and usually for one good reason nobody's been willing to put the money up. And Senator McCain has indicated this requires new money he is going to be

willing to put new money on the line. He would like to encourage. Flexibility in terms of how states would do this it is said he will get the governors together to talk about various strategies that they have found at work. It is not a problem that can be ignored and it isn't ignored in the plan. There are various other strategies that have been proposed in order to try to moderate spending. David's talked about some of them. Spending more money in terms of federal research for chronic disease and more of a prevention focus promoting information technology there's been an interesting way that was included in the bill passed in July that had the first couple of years with a small incentive for e-prescribing followed by a penalty in years four and five. I think this is an interesting model we'll see how it works in terms of how you might go forward without having a large new

cost involved emphasis on price and quality transparency and an understanding of the need to reform payment for the entitlements Medicare and Medicaid not just not paying for the never invents that certainly that but also rewarding the kind of behavior and response that we want from physicians and institutions. Want to talk a little bit about what's likely to happen when you go through a campaign and you hear the issues that the candidates raise and have a chance to hear how the philosophical differences between the candidates affect issues of concern as in this case in terms of health care. You understand that kind of directional guidance that presidents are able to provide how much regulation and who does the regulation how much reliance on incentives and who receives those incentives

how much a plan might cost. But it's important to remember that in our system the president proposes and the Congress disposes each of these proposals the Obama proposal and the McCain proposal are going to face serious challenges as I see them when it comes to working with the Congress for Obama. Where does the money come from. I know that David has said he's going to let the Bush tax cuts expire. Fine that's nice that pays for a portion in my view of the cost of the plan but there been many other proposals that have been raised as well. They even mention the twenty five hundred dollars of savings that each family will be able to achieve. Now I certainly think that there are many ways we can find to spend smarter in this country changing the reimbursement and the incentives that occur as a result of having more and better information comparative clinical

effect innocent and other ways. But the likelihood that we will be able to achieve. Significant savings within a first presidential term to me just belies credibility. Now again as I've said it doesn't really matter what I believe it will matter what the aggression the budget office believes. Because when it scores the proposal that's what it is anyone who's part of the Clinton administration knows this well. That was if not the seal of doom to the Health Security Act it was a major nail in the coffin for Senator McCain. The real challenge is going to be how to get what is assuredly going to be a Democratic Congress to seriously consider the tax code changes that he is proposing. I'm assuming that there is not going to be 60 sure votes in the Senate going in one direction. And the point of saying that is it means that if we are going to have any health care reform in this next session of Congress it's going to require crafting

a bill that can have a bipartisan majority support working with the administration. I think we could have had significant health care reform in 1993 and 1994 and we let that opportunity slip through our fingers because there wasn't a willingness to have all of that happen. I hope that we will not do that again and want to indicate the importance of as we go into this next period of understanding that when we end this campaign that is what it will take to have health care reform. And of course I will resist saying one of Senator McCain's great strengths has been his ability to reach out to find people on the other side of the aisle in the other party that he can forge alliances with occasionally to the consternation of his own party in order to take positions that resolves issues that he thinks needs to be resolved. It will be a critical element

and whether we get health care reform in 2009 or 2010 I think. Thanks very much to both you and I share your optimism that we can do better we have to do better. I'm nervous that some of the potential solutions that we're tossing around could be at least partially mess. And to you three of the potential Missa make me most nervous and you hear people say that better quality can save money and we can pay for health care that way. Another potential solution that individual behaving as consumers can make the health care system work and then the potential solution that i t can solve all of our problems and save money and lead to major reductions and costs. Do you think these potential solutions if any of them might be overrated and if they are what are the implications for the two candidates positions. There are about six or seven ways people have thought of

that would rationalize modernize health care and we don't have great evidence on which of them will work. In fact. I think thinking of them individually is the wrong way to do it. That is you could pay for a computer for every doctor and you'd have a very heavy paperweight. You could give a doctor performance incentive and if she has no information she can't do any better. So you're going to have to come. It's going to have to be the whole of the whole system together. What Senator Obama said is the cost problem is so severe that we'd better try everything we can think of and some will some will work to save money and some will not work to save money but we have to try everything we can think of the only thing he's not in favor of. That's an idea that a lot of people are in favor of is making individuals pay a lot of the cost on their own. And it's exactly because of the issue you raised about are consumers being are individuals really ready to be good consumers but everything else he said we need to try and we need to try it as much as we can as rapidly as we can. Now to me this is

the right analogy is not the kind of big bang saving but it's what's gone on in manufacturing in the U.S. for the past 30 years or so every single year. Manufacturing productivity increases by about two percent or so then you're factoring output per worker increase by about two percent that's a source of real gains in living standards over time that's why prices of manufactured goods go down. And the reason is not because. Firms do any single thing not because they bought a computer not because but because that's what the focus is the focus is on how do you deliver a better product cheaper. And that involves getting the right information getting the right incentives and getting the right framework in which that happens. And so I see this as creating the framework in which all of this can happen get investing in the information getting the incentives right getting the goals right so that that's what we're focused on is delivering a better product. Whether that turns out to be myth if it turns out to be a myth the only

thing we have left in our tool bag is to ration access to care. If we really care that much about cost everything else is in this set of proposals. And it may be that will fail and that what will come to is an explicit set of rationing of care. But what Senator Obama wanted to do is try every single thing short of that quality. Can Save money. But quality in itself doesn't necessarily save money it depends a lot on the structure and the incentives that go on with it. Health I.T. is a means. I agree with the notion you have a heavy paperweight. Interesting CBO report that recently came out indicating that people are way too optimistic in terms of looking at. Health I.T.. It will take a while to be implemented and introduced and implemented in Access it's one of the reasons I think we need to be to temper the notion of how quickly we're likely to actually achieve

some of these savings. I think individuals can participate in some of this decision making if they need to have information about prices and quality they heart. They certainly can't do anything if they also don't know something about comparative clinical effectiveness the quality of the institutions and the physicians they see that. The prices that they are going to face. Senator McCain is now trying to push everybody into high deductible plans most high deductible plans do exempt prevention or at least those areas of prevention that appeared to be cost effective. But for people who don't want to do that that's that's certainly not end an issue. So I think we need to be realistic not about the importance of trying to improve the delivery system but to recognize that this is going to require some time to happen and some time to see the effects of that either in terms of improved

quality and outcomes and to slow down spending and to not have. Expectations that to me are simply unreasonable and unrealistic. We can't do everything at once but we have to pick and choose the areas that we think are going to be most important and start there and put a lot of effort in then sequence. The other changes as quickly as we can. The good news is that the. There is a lot of agreement even during campaign season about the kind of delivery changes that need to occur in our system. Both of you stress the urgency of the problem. David said the cost problem is severe Kail I think in your earlier remarks he said it's the most critical issue is to slow growth. So we're at 2 trillion in health spending now by 20 17 will be over 4 trillion under your candidate's administration. How much would they bend the curve. How would

they do that. And most importantly how would they deal with the interest that would lose money since someone spending is someone else's income. So I can't answer specifically that the estimate of over the course of the decade how much they will be able to bend the curve. So let me try to indicate more. More generally how it is viewed that these changes will occur. You definitely have. Correctly assessed that slowing down spending. By the variety of mechanisms of emphasizing chronic disease and Prevention changing how we pay for chronic disease and Prevention specifically going after smoking cessation by same obesity but I there's been more emphasis and at least in print in terms of of smoking cessation trying to have this is at a more much. Smaller level increase the use of generics in terms of

drugs looking at re-importation if that can be done safely. So there are big items there are little items making better information available. It is the real question is how do you try to put enough in place early the first two or three years that over the course of a decade you really can bend the curve. And part of this is to be able to bring. Patients as consumers and families as potential patients into the mix rather than only looking at the delivery system and I think that's probably one of the biggest differences. Let me just start up with where the I think the academic landscape is which is that about 40 to 50 percent of medical spending is not doing any good. Relative to that what we have said is we believe our plan can save 80 percent of medical spending.

And people say that's overly optimistic. And you just sort of look at the at the disconnect between how much is there. You take all the ideas that are on the table and you do them and. You say 8 percent if you're willing to use the Bush tax cuts as one source of revenue when you're willing to take a lot of the savings that you'd be able to get from covering people you need 4 percent of savings to be able to afford to cover everybody. Yes it's a hard process but relative to the scale of what people believe it is manageable. I just don't accept that number because I don't think we understand now how much is waste. Now I will say I have a bias. Somebody says waste it means zero value or harm. So with zero in negative if you mean things that we do in the United States said we have a lot of uncertainty have a low probability of success. I don't give much clinical value relative to the cost. I don't believe 40 or 50 percent I mean by the

30 percent number to tell you the truth. But I don't believe we know. I think there clearly are things we do that have zero value. We need a lot more effort to figure out where they are and for whom and what to do about it. But this notion of do we think and and can we likely know before the fact about whether there's zero value or we do only know it after they're done and they don't have zero value. We're not we're not going to the two of us certainly aren't going to resolve this. I think. It's not all care that's received but the whip but how much it cost to provide. Let me just give you one example. I was talking with the CEO of a big integrated group staff model plane a couple weeks ago. And I was asking him how his various I.T. investments were doing and so he said let me give you an example of how they work for us. He used to take 43 minutes for one nurse at the end of a shift to explain to him to the next nurse all about the patients and what specific things they needed new medications and so on. And because we

put in a better I.T. system it now takes 12 minutes which means that we now have 31 more minutes of nursing time pers shift than we had before. And so that's 31 more minutes of patients to be saved or 31 fewer minutes that they have to pay for the same thing. And so that's the kind of stuff I think that's in there not just who is getting an operation that doesn't need to get it but how efficiently is it delivered and the efficiency with which it's delivered is so poor that you kind of have this sense that doing anything to save those 30 minutes those 30 minutes add up very quickly. David you said you covered the Obama plan we cover 98 99 percent which means taking 16 percent of uninsured down to 1 or 2. That's quite ambitious. So my question to you is without mandates on adults it's easy relatively to mandate kids or other me is what you're thinking about. How to get those free riders I'm thinking about myself when I was 22 and hitchhiking around the country and I can tell you that health

insurance at two bucks a month was not cheap enough to get my interest and then the question I had for Gayle is actually is universal coverage. Your candidate's objective for essentially everyone out of the immortal range. You know the people who know they're immortal and don't want to hear otherwise when you ask them why they're uninsured they will tell you it's not because they don't want it but because they can't afford it and they don't buy into the festival so that the vast bulk of the uninsured you pick up by that way by making affordable accessible In addition there to other parts of what Senator Obama has said that I think are very important here actually and have really not been stressed enough. One is that Senator Obama has proposed that children up to age 25 be covered under their parents policies regardless of whether they're in school or not. Those 22 year olds are very very cheap. Many most of their parents will have insurance so actually adding them to their parents policy does not cost very much and will cover quite a lot of them. That's one thing. The second

is. The thing we know about a lot of people is that they do whatever the kind of default option is. And let me give you an example from pensions. If a firm goes to work we've seen this you know a big firm goes to work and says we have a plan. Here's a form fill out this form give it to us and you'll be enrolled in the 4 0 and k plan about 40 percent of people enroll. The rest say yes I want to enroll but have to go study the choices and I'll do it tomorrow night and I'm busy this week and I'll do it next week. If instead the firm does exactly the same thing but it goes to the worker and says we have a nice for a 1 k plan we know that most employees want to be enrolled in the four and k plan we put you into the for 1 k plan but if you want to be out just sign this form check this box it will take you out to 90 percent of people stay in world. So the very act of whether you check a box to be in or check a box to be out has an enormous impact. And the way that you can deal with a lot of people Senator

Obama's proposed this on pensions and he also believes it on health care is you make it easy you make being in the default not being out the default. And you say look we believe this is important to you you're going to get a tax credit for this when you're 22 you don't have that much income. We're going to send it to this insurance company it's there for you. But if you really really don't want to be in it and you don't have to. What is also said is by the way if it turns out there are pockets of people who still won't be in and know that it's affordable and we know that it's accessible then he's open to a mandate. But the first thing you have to do is make it be affordable and make it be accessible to get as many people as you can enroll and then come back. The objective is to provide a financial means for people to buy insurance and to give them ways to access what will be lower cost insurance and it is very much to make sure that people are able to have. Access to a more affordable insurance plan than has been. Possible in the

past and to try to help those who are high class to be able to be responsive to that. With regard to the Immortal's and we know that there's a disproportionate number of people. Who are in the 18 to 26 category who go without insurance coverage as David said Senator Obama lets them be on their. Parents plan. Senator McCain would give them as individuals a tax credit which clearly for this group would make it you know $2 a day insurance would easily come in You're a refundable credit whether or not some of your other Massachusetts colleagues are correct who were estimating that without a mandate. Now you could have as many as 5 percent without insurance coverage will have to wait and see. It's because of all of the problems that arise with regard to mandates. It seems to me that whatever your strategy and whatever your political party.

Making a significant effort to make more affordable insurance available is a perfectly appropriate first step. And. If it doesn't solve all of the problem we can see how big the remaining problem is in deciding what we want to do about it. What do you think will happen with Medicare under two potential different administrations particularly with Medicare Advantage. You know the structure of payment the overall crisis of physician payment they the focus thus far. Not surprisingly have been on the more global issues with regard to expanding coverage and trying to find ways to slow spending and the level of discourse as best I can tell in both campaigns has been laying out the notion that we need to change reimbursement so that we reward the kind of behavior that we want to see. Senator McCain has indicated in terms of a coverage issue that just as Part B now.

Is has smaller subsidies for high income seniors that he thinks that's an appropriate consideration. For others but this is not a part of that direct campaign. The issue about the delivery change is one that it particularly with a physicians really has to be taken up and the pressure is probably going to be first and foremost on the Congress because they for better or the worse have been whens digging themselves into a hole that has grown completely out of any kind of proportion and have done so in a way. That. Has incentives that are somewhere between unhelpful and perverse. Senator McCain is talking about encouraging coordinated care trying to either through Medicare Advantage or through other mechanisms be able to have care coordination is something that is very important. I don't know that anything would say that would be against the. Medical

home model that has been raised. It is the one part of Medicare that is going to force itself on the system because as any physician who has paid attention knows. We fall off the proverbial cliff January 1st 2010 when the last patch wears off and instead of having a 4 percent decline or a 10 percent decline now facing a 20 percent decline the first baby boomers will retire in the next president's first term in 2010. Medicare will be spending more money each year than it takes in and by 2019 the Medicare hospital insurance trust fund will be exhausted so what will your candidate do to ensure that Medicare is solvent when the people in this room need it. Let me give a couple of answers to it. One is the current standard that we use for thinking about Medicare 75 year actuarial projections. Nobody has a plan for 75 year actuarial balance in Medicare the way that the program

looks now. What we need to do I think is to to take the steps that put us on the best path. To being able to realize. Financial solvency for Medicare. And there are a couple of parts to that. One is the kinds of things that we were both talking about in terms of reforming the delivery system inside and outside Medicare. Second there are issues about trying to allow and create incentives for people to work at older ages when they're very productive for that they can be contributing in terms of Medicare taxes coming in each of those are solutions. And finally I do want to come back to this because you know the public finance person in me really cringes I think it's just completely irresponsible to promise the Bush tax cuts two times over when

you know you don't know how to afford Medicare and that's the only source of money. So one of the things that's honorable has been very clear about is not using whatever money we may save in those programs to fund high income tax cuts. One of the issues that. Actually has some agreement on analysts in both parties is that the best way to help Medicare is to slow down health care spending. Many of us have seen the reports that indicate aging per se is not really what is going to do us in. It is the spending gap the two and a half percentage point growth faster in the rest than the rest of the economy that we have in health care have had for the last 45 years combined with. The aging maybe rumors that we can't sustain.

So it really indicates that the importance of finding strategies that will slow down spending is not just that it will help us extend coverage to the 45 million people that health insurance coverage but it will also be an important part of helping us with Medicare. Karen had raised an issue that's important that I forgot to respond to which is if we are going to slow down spending the people who have been used to having the two and a half percentage point excess growth the institutions and the physicians in the industry sector are probably not going to be happy about this. And how will we or will we be able to respond to the pressures they'll bring to the system. My belief as an analyst and policy person is that only with good credible information through comparative effectiveness or other information of quality and value and outcomes if we can show in convincing ways that what is being reduced has little value.

We have a chance otherwise we know what the are you will be some payer private government whatever is trying to keep some physician or other health practitioner from doing what he or she thinks best for that person. And that's why we're not doing something. I don't know whether good credible data will be enough. I am absolutely positive that in the absence of good credible data that certain procedures we've been doing interventions we've been doing for some subsets of the population have very little value maybe primarily harm. We have no chance without that. I'm impressed as a historian but also as a businessman formally that we've been at 60 years of failure to enact that all the charts. And I wonder since you're a longtime observers and very familiar with some of the workings of government if either of you has some observations or suggestions about what to do differently.

At various moments in time there are pieces of legislation that can be passed. And the real issue is whether there is an ability. Typically by the White House to recognize that the best package that is likely to be able to be passed at a moment in time and decide after whatever first efforts are made to get what the administration really wants. Whether they will embrace and try to drive forward with the best they can go that they can get or not. We could have in my opinion had in 1903 in 94 a federally funded health care benefit for everyone who was poor in some parts of the low income in a variety of insurance changes as well at the very minimum maybe a little more than that. But definitely not universal coverage. And because it was not that it really was not allowed to push together a coalition of Republicans and Democrats that could have passed legislation in 2003. And

I I don't want to pretend like I am in a hammered with the Medicare Modernization Act because I am not. There are more warts on that bill than most pieces of legislation have. But there was recognition that that was the best bill or the only bill that was likely to be able to get through the Congress at that point in time and a majority although just barely a majority and with a lot of last minute pushing decided that rather than wait till 2009 or 10 which is when the next opportunity would have been to go forward and try to deal with various problems after the fact. We are not going to have that neater looking version of national health insurance in this country in any time. In my vision going forward I think we can have all or most people with insurance coverage. And the question is whether we will aggressively move forward in the pieces that we can do when the opportunity presents itself. I see several reasons to be optimistic. One is.

One is of course the the problem is worse now than it was 15 years ago and that makes more people be ready to do something so the more hopeful and there's a lot of bipartisan interesting remarked on this there's a lot of bipartisan interest in getting things done so you have Senators Wyden in Bennett with a bill that would essentially cover everybody. You have about I don't know 10 or 15 bills on health information technology and changing payment system and delivery system reform. You've really got a lot of activity going on. In addition you've got people being involved in politics for in many cases the first times in their lives and that the message that we're trying to send that Senator Obama is trying to send to everyone is We need citizens to be involved in government. We need everyone to be involved in government. And if you want to be part of the solution then you are welcome to join the discussion. He wants a table that is open where people discuss it where we go forward trying to find what is

the consensus. And I think that is a very hopeful way to proceed and that makes me more optimistic than we've been in some time. I feel enormously enriched by this a symposium today and I'm enormously grateful both to the speaker sent to the expert panel here who helped us move ahead. Thank you.