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Tonight we have with us Jonathan Cohn who will speak about his book Sick. But before Jonathan speaks we have with us Larry Levitt an Economist with the Kaiser Foundation who will talk to us a little bit about healthcare in America. Thank you. It is always nice to introduce the introducer. As said, I am Larry Levitt from the Kaiser Family Foundation. For those of you who aren't familiar with us, we are a health policy institute based out in Menlo Park and probably most important is what we are not. We are not affiliated with Kaiser Permanente, the Health Plan or Kaiser Aluminum or Kaiser Wilhelm or the Kaiser Chiefs or whatever Kaiser you can possibly think of. And I am very pleased to introduce Jonathan Cohn, Senior Editor of the new republic and author of Sick a book we help support through our year long media fellowship. Or at least hope Jonathan will agree that we help support him. And you know, they say in real estate, that the key is location, location, location. Well in politics and policy the key is timing, timing, timing and Jonathan's book could not be timed any better. It's clearly a crisis in healthcare which I think has probably not surprised anyone here over the last six years. Health insurance premiums have risen 87 percent, far faster than people's ability to afford them. And as a result the number of uninsured in the United States is now at 45 million and growing by at least a million a year in recent years but until recently politicians have not recovered from the failure of President Clinton's health plan over 10 years ago. I mean, I have been willing to step up and tackle the issue once again. But that that seems recently to be changing in fact quite recently to be changing in fact quite recently. Any every democrat on the campaign trail running for President is now supportive of universal coverage in comprehensive health care reform. Even a few Republicans are supportive. Now as well, Governor Romney is running for President, former Governor Romney of Massachusetts enacted and signed a Bill in Massachusetts to provide universal health coverage which is now being implemented. Governor Schwarzenegger, I am not sure if there are any Governor Schwarzenegger voters in the room. But Governor Schwarzenegger put out a I think what many would consider a surprising plan a few months ago in January to provide universal coverage. I don't agree with all of the you know, but Jonathan with agrees with all of it either. But for someone like the Governor to come forward and feel the need to offer a plan which, I think, has a decent chance of passing this year is assigned that the issue has a great deal of momentum and Jonathan's book is timed perfectly to tap into that momentum. And I should say I have been doing this for a lot of years. Pretty much had a career of failing at health care reform. So I am sitting out this debate. So maybe it has a chance, a chance of succeeding but I have to admit that you know, I have written a lot of, lot of drawing and boring studies and reports over the years. I mean, I was in a lot of bad legislation. But no, no driver report that I can write can do with Jonathan's book can and has done which is to tell the story of the healthcare crisis not only in political and economic terms but also through the lives of people who experience it. And for those of you who have not read it yet, I would certainly encourage you to do so. It's an extremely powerful book and I hope, hope Jonathan is not quite as jet lagged as I am because we both were in Washington this week where we hosted a debate between Jonathan and a somewhat more conservative commentator at the free market oriented Cato institute. And I would say frankly Jonathan won hands down. He is appearing alone here tonight so I think, he has the upper hand tonight as well but in all seriousness he is someone who can absolutely hold his own against anyone and I am pleased to introduce friend and colleague Jonathan Cohn. Yes sure I did. I debated somebody at the Cato Institute earlier this week and if you want to talk about jetlag and whiplash. It's quite an experience, I have done this is my third reading on the so-called book tour. I have so far, I have given readings in Ann Arbor Michigan where I live, Greenwich Village, Home of the Strand Bookstore and now here and to have sort of the Cato Institute debates sandwiched in between there it's a very interesting perspective. I actually expect, I see Don McCanne in the audience so I am looking forward to getting a lively debate going from the other side from where I was earlier this week and you know, but then again like I said living in Ann Arbor and coming to Berkeley I look forward to those opportunities. I want to thank Cody's, I want to thank the Kaiser Foundation. The Kaiser Foundation, for those of you not familiar with them, they inform the health policy debate in this country. Most of the information you see frankly use by both sides, I would argue some what more disingenuously, disingenuously by the other side comes from the Kaiser Foundation. They do enormously significant work, and they also do support the work of journalists and one of the great thing about their fellowship is that their fellowship, they offer to journalists really is a very hands-off fellowship, pick out people who they think are doing good projects. I see one of my fellows, former Mark Schiffer here in the audience and then they let you do you are thing. And that's a good thing, because the timing that Larry mentioned is entirely accidental. This book was actually supposed to be done two years ago. And unfortunately for me I was not very good at meeting that deadline. It turned out to have been good bit of timing, proves for that sometimes procrastination does payoff. I am going to start, take all these readings, so I am actually going to read from my book. I am going to actually start with the very beginning of the book which is it takes place in my adopted hometown in Boston. It was 4:43 on a clear November afternoon when the paramedics found Cynthia Kline, pale and short of breath, slumped against a bedpost in her double-decker Cambridge home. Although Kline was in obvious pain, she seemed keenly aware of what was happening inside her 55-year-old body. One of her blood vessels had closed off, blocking the flow of blood to her heart. Minutes before, she had phoned 911, taken the nitroglycerin tablets prescribed for such an emergency, then waited for help to arrive-an ordeal that stretched out an agonizing extra few seconds while the rescue workers, having found the front door locked, scampered in through an open second-story window. Now, while the paramedics worked busily over her, noting vital signs consistent with cardiac distress, Kline turned to one of them with an anxious plea: "Take me to Mount Auburn Hospital." Kline, a teacher who worked with special- needs children, had no formal medical training. Yet her instinct about where to go was as sound as a seasoned cardiologist's. Nearby Mount Auburn Hospital, a private teaching facility affiliated with Harvard Medical School, had some of the city's finest doctors and nurses. More important, it had an intensive cardiac care unit that specialized in cases like hers. A few days earlier, staff at Mount Auburn had treated Kline's advanced coronary disease by inserting a balloon into her circulatory system and then expanding it, in order to open up a partially blocked blood vessel. A variant on the very same procedure, "cardiac catheterization," could be used in an emergency like this one, when the flow of blood through a vessel was almost completely cut off. Cardiac catheterization had saved literally thousands of lives across the country. And it had the potential to save Kline's life, too, just as soon as she could get to the hospital and receive it. But getting there was precisely the problem. On the way to Kline's home, the ambulance driver had checked with a dispatcher about hospital availability. Mount Auburn was no- go. The emergency room there was overflowing, with no space to handle new patients. So as the paramedics wheeled Kline into the ambulance, one of them told her they would have to deny her request: "Ma'am, we're going to Cambridge Hospital instead." Kline accepted the news, and maybe for a moment she thought it would be for the best. Although Mount Auburn was less than two miles away, Cambridge Hospital was even closer-just a short trip through the crooked, disjointed streets that surround Harvard Square. It was also a highly regarded medical facility in its own right, with a top- notch medical staff and a recently renovated emergency capable of handling the majority of trauma cases that came its way. Had Kline's condition remained as it was, it probably could have handled her case, too. But just four blocks into the journey, Kline's condition suddenly deteriorated. The instruments tethered to her arm could no longer detect a blood pressure; her heart rate, seventy beats per minute just moments before, was down to thirty-eight. Kline, strapped into a stretcher, was conscious through all of this-and increasingly agitated. At her side one of the paramedics, a kind-looking thirty- year-old, tried to calm her, explaining that the hospital was just seconds away. But as the ambulance made a right turn around one final corner, bringing the tall redbrick facade of Cambridge Hospital into view, Kline began to cry out: "I'm going to die. I'm going to die." It was 5:04 p.m., just twenty-nine minutes after Kline had first called 911 and about an hour into the heart attack, when the green-and-white ambulance pulled up to the emergency bay. Informed of the patient's newly worsened state, attendants hustled the gurney into the hospital as the medical team began administering intravenous medication to increase Kline's heart rate. For a while it looked like she might pull through. Her pulse went back up to forty- five beats per minute-a far cry from normal but at least not "very low," as it had been in the back of the rig. Her breathing was more regular, too. Soon, however, a cardiology exam confirmed that Kline needed catheterization, something the Cambridge Hospital staff could not do. A nurse began inquiring about available hospitals, but now it was two hours since the chest pains had first begun-and time, finally, was running out. At 6 p.m. Kline's heart stopped altogether. The doctors began performing the familiar ritual of cardiopulmonary resuscitation (CPR), pumping her chest and using electrified paddles to shock the heart back into a regular rhythm. It made no difference. At 7:03 p.m., the trauma team relented and Cynthia Kline was dead. Fifty-five- year-old women, particularly those who have a family history of coronary disease, die from heart attacks all the time. So as a forensic matter, at least, Kline's death was unremarkable. But the technology that might have kept her alive existed-and it existed at a hospital that was less than five minutes away from her home. There was no guarantee that Mount Auburn could have saved her. Still, as one source familiar with the case told the Boston Globe, whose story on the matter sparked a state investigation, "Within an hour and a half they would have started to open her artery with a catheter. If you get the artery open there's a 50-50 chance." None of which would be so troubling if the overcrowding at Mount Auburn on that day in November 2000 were an isolated incident. It wasn't. During a one-week period shortly after Kline's death, a survey of seventy- six Massachusetts hospitals found that sixty- seven of them had used emergency crowding procedures or had diverted ambulance traffic. Massachusetts General Hospital, Boston's largest medical facility, was closing its emergency room to patients forty-five hours per week. On the day of Kline's heart attack, MGH was the next closest hospital with a cardiac cath unit-just three miles away. But it wasn't taking emergency patients that day, either. And even if Kline's wasn't the only known fatality from ambulance diversion, there was plenty of reason to think that the overcrowding epidemic was routinely jeopardizing the well-being of patients. In 2000, when the Massachusetts College of Emergency Physicians surveyed the directors of more than sixty emergency room facilities, four out of five said they'd diverted traffic at some point-and nearly 40 percent said overcrowding had led to "adverse health outcomes." Sometimes it was a matter of forcing ambulances to drive longer distances in order to find available hospital beds, sometimes, as in Cynthia Kline's case, of shunting, you know, the case for shunting people to hospitals less able to provide accelerated treatment. And sometimes it meant that patients who got to the right emergency rooms had to wait for many hours before receiving treatment. In some cases, patients actually waited inside the ambulances. Boston in other words had an emerging public health crisis on its hands and it wasn't alarming. In Atlanta an ambulance crew carrying a patient for respiratory distress had to pull over and wait on the side of a highway for 18 minutes because the nearest hospital was full and the paramedics were busy trying to find an alternative. When the mother of 40 year old Cleveland male with liver failure called a local community hospital, staff there referred him to Metro Health Medical Center which had more advanced facilities. So when the ambulance arrived, Metro Health was on diversion. The man ended up back at the Community Hospital where 15 hours later he died. In suburban Houston where a 21 year old man was hit by a car the local trauma centers turned him away because they had no room. He ended on a helicopter ride to the next closest trauma hospital in Austin more than 150 miles away and died shortly after arrival. Fed up with incidence like that a Texas neurosurgeon named Guy Clifton started an advocacy organization called Save Our ERs. The group's first order of business was to compile data on Houston's emergency services and have produced some sobering results. The cities two level one trauma centers the hospitals that are capable of dealing with the dire emergencies were simultaneously on diversion for extended periods of once every two days. I have been in the business, for 25 years Clifton said and I have never seen anything like this. It has been more than 10 years since the United States last had a great national conversation about health care. But the conditions in our emergency rooms are a reminder that another conversation like it is long over due. If you talk to the experts they will tell you that ER over crowding is actually a symptom of broader deeper elements reflecting American healthcare like the rising number of peoples without insurance, to fill ERs to capacity or the downsizing of unprofitable services like psychiatry which causes backups, that hospital staffs search desperately for empty beds into which they can put their most dire patients. And while all trends may seem unrelated at first they are all consequences of the unique way we pay, America pays for its medical care. A system that is now crumbling before our every eyes. Many people have heard the statistics 43 million, the number of people at anyone time who don't have health insurance. 16 percent, the percent of our national income that we spend on health care more than any other country in the developed world. $12000 is the average price of the family insurance policy which you needless to say, is more than lot of families can afford. But if everybody has heard these statistics, I don't think everybody really understands what they mean. After all the majority of Americans still do have health insurance. They like it and they can get affordable health care when they need it. They may know that millions of other Americans aren't so lucky, but they have a hard time imagining themselves in those shoes. They may grasp that the uninsured sometimes don't get quite the same treatment as the insured. But they believe that alternatively somehow, someway, everybody really gets the medical care that they need. This ambivalence, I think, goes a long way to explaining why our healthcare system looks the way it does. You know, lot of people look back on the debate over the Clinton health care plan in 1993 and 1994. They think ruefully of the opportunity missed and they focus blame on the Clinton administration for the mistakes they have allegedly made. Or on the special interests for piling on all the misinformation that scared so many people and spread so many lies about what was actually in Clinton Healthcare plan. Now I actually think there is some credence to both of these theories. But at the end of the day I think neither of them fully explained why we didn't get Universal Healthcare in 1994. I think the biggest problem in 1994 was the fact that the public honestly didn't feel that insecure. The possibility of losing access to medical care didn't seem real enough. The potential consequences that might result didn't seem awful enough to warrant a wholesale change in the system. And when presented with the possibility of creating a Universal Health Insurance system a possibility that inevitably even in the Clinton plan meant asking the government to do something that in this country we were offering the lot on the private sector to do, a majority of the public looked and said no thanks A few Americans realized just how vulnerable they were, or how that vulnerability was about to grow. And that is really what this book is about. Another train noise is going by. This book is about how our decaying healthcare system has put ordinary hardworking Americans at risk of financial and medical catastrophe and it's a story I tell them, not just through statistics although there are statistics in there for those of who like to read numbers. It's a story I primarily tell from the story of eight individuals from around the country. Eight people I selected from hundreds of people I interviewed over the years. Eight people who all found themselves in the medical crisis that quickly became a financial crisis. One of them is Gary Rotzler, we care up we catch up with Gary in the early 1990s when he and his wife, his high school sweetheart have set only to a tiny idyllic village located in the foothills of the Catskill Mountains in upstate New York. They have three young children. He has a good paying job as an engineer and a defense contractor. They are really living the American dream. And then one day he gets outsourced. He loses his job. And he is able to make up the income partly with part time job and temporary work and eventually he gets his old job back at the defense contractor with one small wrinkle. Now have is a temporary employee and he doesn't get health insurance. As a result his wife decides to put off some routine medical care. She decides not to get few ailments checked out, some back aches, some fatigue that is a decision that will come to haunt them and resulted in a medical and financial catastrophe. Sick also introduces readers to Janice Ramsey. A spark plug of a real-estate consultant in Central Florida, who, happens to have diabetes. She worked hard her whole life and she is making good money but because she is self employed she has to buy insurance on her own and once insurers hear that she has diabetes, they don't really want any part of her. Eventually in her struggle to find a affordable insurance, leads her through ordeal that sounds almost too good to be true and then it turns out to be too good to be true. And somebody who had never paid a bill late in her life, who had built herself up her own business on her own hard work suddenly, finds herself in a mountain of medical debt. We meet Elizabeth Hilsabeck resident of an upscale suburb west of Austin, Texas and a mother of twins born several weeks premature. Her son develops cerebral palsy and needs physical therapy to walk some day the doctors say, but her insurance, her excellent insurance provided by her husband's very well paying job at a bank will uncover it. She is determined to get her son, the treatment he needs and I will tell you right now, that she does but the question is not whether she gets the treatment but what she has to sacrifice along the way and then there is Lester Sampson a veteran of the US navy and a 30-year employee of the Morrell meat packing company in Sioux Falls South Dakota where he started as an 18-year-old scooping the brains of pig carcasses. He retires with the premise of a lifetime health benefits. A precious bit of financial security upon which he and his wife will plan the retirements and then one day he will open his newspaper and he will find out that that company changed its mind and then he is not offering retiring benefits any more. And the lives will be changed forever. I chose these four people and the others in the book because they represent the vast diversity of American life economically, geographically, racially, education but when people read these stories, I think, they'll find a little bit of themselves in everyone of them. None of these people are so different that not for a change in lack or circumstances they couldn't be you. And that really is take home message of this book. This is not somebody else's problem. Maybe you are healthy and maybe your financial situation is secure, but don't for a second think that with the right or wrong combination in circumstance you couldn't end up like one of the people in this book and what makes this also incredible is that it doesn't have to be this way. It doesn't have to be this way because the American healthcare system didn't come by - come to be this way by accident. It is the result of choices made and choices not made. America's historic faith in individualism and antipathy for the state that strange brew of optimism and skepticism that makes us unique in the developed world. This is the other story I tell in Sick, the one I hope that will move us from anger and sympathy maybe finally to action. The origins of the American health insurance system date back to a late 1920s and 1930s which is really the first time that American healthcare became sophisticated enough that it was worth charging money for and that was a great thing. We developed cures, hospitals began to learn to do operations and surgeries. For the first time you could go to the doctor and actually get better but of course, there was one downside to all these medical advances, they cost money. And then in late 1920s and early 1930s I found a group of foundations established what was called the committee on the cost of medical care to take what was really the first national survey of medical spending in this country and it quickly became, apparent two things. The first was that lots of people were suffering. That people suddenly, they couldn't pay literally afford to be sick. A week in the hospital was worth a month's salary to the average American. But there was a bright side to all of this. That only a few people at any one time suffered these where in this situation. Medical expenses were concentrated among a very small group of people. If you could just find a way to get everybody to pay into a pool to get healthy people to contribute with the knowledge that maybe someday they might be the ones who would be, needed the financial assistance you could create an insurance system and take care of everybody. Well that was great, but of course, that raises another question, what kind of insurance system to have? Now in the 1930s we had a new president, we had a new political spirit, and we know from the history books that Franklin Roosevelt fought hard about adding National Health Insurance to the Social Security Act but he was worried. He was a politician and he really cared about getting the Social Security Act passed. And his advisors told him that if he included Health Insurance as part of social security, state medical societies would rise up against him and then only when they had bought National Health Insurance they might derail the entire Social Security Act. So FDR ditched National Health Insurance and now it's a fateful decision because it turned out patients weren't the only people stepping with medical bills, hospitals were too. In the 20s they had expanded, they had built all these new facilities, taking advantage of all this new technology and now the wards with former patients who couldn't pay their bills. And if the patients couldn't pay the bills well eventually neither could the hospitals. So they needed a way to come up to pay with their bills. They needed a way to stay financially afloat and they were the ones who invented modern health insurance. They started in Dallas Texas at the Baylor hospital when the new superintendent there who had worked at the Dallas schools approached the Dallas schools and said, went to the teachers and said if each of you contribute a small amount every week or every month we will provide 14 days of medical coverage. And now is the first health insurance plan as we know it today. These plans proliferated and eventually the proprietor of a plan in Minnesota thought it would be a neat idea on his advertising poster to illustrate his new insurance plan with a Blue Cross and that's how we got the blue cross system. The Blue Cross system actually operated a little bit like what you would call a social insurance system. After all it was designed for the benefit of the hospitals. They wanted as many paying patients as possible. So it started by approaching large businesses. That way they knew that if you got a large group of people and healthy people there will be enough healthy people paying into the pool to cover the cost of these few that were sick but they also had a pretty open door policy to individuals. If you came to Blue Cross and you had the money to pay for one of their plans they would give it to you and they didn't ask whether you had recently had cancer or whether you had risk for a heart attack. Again their goal was to insure as many people as possible and so overtime this system evolved. There were a few tax breaks that helped it along the way. Wage and price controls in World War II and before you knew, we had what we have today and the system of private health insurance based on employment. It was assumed that the majority of working Americans would get their health insurance from their jobs and from the 1920s up through the 1970s this system worked well. Or as I like to say, they worked well enough for enough people. That effort to dismantle it failed and at a time when medical care was relatively cheap employers liked this arrangement because it was a nice easy way to buy worker loyalty. And unions and workers liked this arrangement because at a time when you stayed in the same job for your whole life was it a liable way to get health benefits and even people who weren't employed were okay with the system. Because as I said the early insurance plans had a pretty much an open door policy. Of course, they were always those left out of the system, the poor, the elderly who even managed to fix those problems. Sort of in the 1960s when we created Medicare and Medicaid and so you ended up in a situation by the 1970s where 90 percent of the population had health insurance. It wasn't perfect but had gotten a lot better than where it started. And it wasn't perhaps unreasonable to think that it would keep getting better. Only then the economy changed. Unions became weaker, employers suddenly felt squeezed, by competition abroad and competition at home. And this all happened at the same time that Medical care suddenly got a lot more expensive and if up through the 1970s all the incentives weren't placed to load up, and to give employees, good generous health benefits. Starting in the 1970s incentives reversed. And I think the best illustration of this is you think of the model corporation of the 1950s is General Motors which eagerly loaded up its employees with very generous health benefits. Well what's the model employer today? Its Wal-Mart, it strives very hard not to give it's employees good health insurance and of course when you have Wal-Mart driving, not giving its employees' good health insurance, well, then all the other companies feel pressured to do the same thing. And that is the big reason why employers suddenly find themselves or under all this pressure and you see employers, slowly getting out of the business of providing health insurance. Now n the 1990s we had managed care and managed care was supposed to save all of us. It was going to give us good high quality care, it was going to save money and the Clintons actually had the idea that you could actually use that savings to deliver insurance to everybody. Of course the Clinton plan didn't pass but we still got managed care any way, despite what Louis said and in the end the only difference was the money didn't go into providing health security, instead it went to profits and it went into employee wages. And that wasn't entirely a bad thing. Higher wages was good, and more security insurance was good but there were no rules about managed care had to behave and often when they squeezed heath cost to save money they squeezed it in ways that hurt people that needed the insurance the most. All of which pretty much brings us to where we are today. Managed care doesn't save money any more, at least not like it used to and players are getting out of the business in health insurance. The safety net, it is expanding, but not fast enough to keep up with the greater demand for it. So what's going to happen next? I actually wish I knew. I do know this much, we do have a conversation starting about health care and we do have a conversation in which we have at least one presidential candidate, John Edwards who has come out and offered a detailed plan for universal healthcare. Now some of his competitors have said, they were going to do healthcare too, although it was not clear whether they will have detailed plans or, even a set of principles but whether perhaps they will just campaign on the slogan and hope that's enough to get by. But there are other signs positive signs that something could happen. One of them is the change in the business community. You have the CEOs now starting to embrace Universal coverage and not just support it, but actually advocate on behalf on it. One particularly striking example is Steve Bird the CEO of Safeway. Now anyone who is familiar with Steve Bird will know that he would be never be confused of having a bleeding heart. This is the man who helped to lead the California grocers into a strike with their unions a few years ago because the unions wouldn't accept skincare health benefits. Well if talk to Steve Bird today you will find out he has become a passionate advocate of universal health care. Now he is not doing this out of any sense of social solidarity, he is doing it out of a sense of business. His company is being squeezed by Wal-Mart too. And he thinks this is hurting American competitiveness. Now I will be the first to admit or maybe the second, because I think he would be the first to admit, that he and I don't exactly agree on what Universal Health Care should look like or why you should do it? But the fact is that when you have Steve Bird getting up there, sending along side a union leader, or next to a Democratic Senator saying yes we need Universal Health Care that gives the idea of political respectability. And I think that political respectability is important because even with Steve Bird endorsing Universal Healthcare, it's hard to know whether we will get it right this time. For every Steve Bird and every Safeway and you still have Wal Mart. For every lobbying group that is slowly turning around the way the doctors have, I think, because they've realized that managed care can be just as frustrating as a government bureaucracy, you have other interest groups that remain just as opposed to universal health care as before. You may hear that business roundtable making nice noises about universal healthcare but I guarantee you you won't hear it from the National Federation of Independent Business, which is one of the most hard - hard core opponents of universal health care in 1993 and is emerging as one of the most hardcore opponents today. And one sobering lesson of the Clinton healthcare fight is that it takes just a few very committed lobbyists to help bring down the plan. You think back to the Clinton healthcare plan and I am not going to put Larry Levitt on the spot here to talk about this, although we could. It was actually a great deal for the big insurance companies. It was basically a guarantee of business for life and I liked the plan but they didn't lift a finger to fight for it. Meanwhile the small insurance companies, the ones you really leave off screening their customers and keeping out the patients for the pre-existing conditions. They hated it. They are the ones who gave us hearing in Louise. And I can guarantee you that inversely any kind of Universal Health Care system they would fight again. So what do you do about that kind of opposition, well one school of thought holds that the best thing you can do it is to be very clever. To come up with a plan that will navigate these shawls better than the Clinton healthcare plan might have. To come up with just the right combination of gimmicks and whistles and bells and gadgets, to make the plan more acceptable to the lobbying groups. Also you will find I am not against any plan that would get us to Universal Healthcare, I think any serious plan for Universal Healthcare deserves a fair hearing. By I am also worried of promises that with just the right amount of policy tinkering, you can get this right. Because I think the way you get to universal health care is that you build momentum for it now. Not in January of 2009 but before the next presidential election. You need to build a mandate. If not around a specific plan, then around a specific set of principles. Still when the fight does come back, when you are elected president in the next election and the lobbyists fight you can play that card and say, I was elected to do this. And you can say to members of Congress, you were elected to do this. And if you are afraid of being attacked by the lobbyists because you won't - if you are afraid of losing your contributions, just remember that you will face a voter backlash if you don't do this. And the way it is, I think, involves a lot of education. And I think that means in the next years you have to do a couple of things. I think it needs to start by getting rid of some of the myths about Universal healthcare, you need to tell people that the stories they have heard about England and Canada are a) wildly exaggerated. b) Not indicative of what Universal Healthcare has to look like. I happen to refer to talk about other countries. You will hear me talking a lot about France or Germany or Japan and Switzerland. Four very different systems for Universal Healthcare, with systems that I think Americans in general would be pretty comfortable with. They have a large degree of freedom, they don't have waiting lines. It's not the waiting line that we have heard about. We actually have around the United States, that's the other part, you know, they had, they have very high quality healthcare. They managed to cover every body and yet they managed to spend less than we did. Fancy that. You remind people of what they have right here what is the most popular insurance program in the United States. It's Medicare, a big bad government run single payer healthcare system and the beneficiaries love it. Poll after poll shows it is more popular than private insurance policies in this country and you should remind people, they seem skeptical about Universal Health Care that every time this subject has come up, the opponents of Universal Health Care said that the private sector can do it better. That the private sector can solve it on their own and then you turn to them and ask them, the private sector has done such a great job of solving this problem, why do we keep having this debate, every 10 to 15 years. And then last of all, if you do, if you do read this book remind them of the people you met in them. In these pages, remind them about Garry Roxboro, the engineer from upstate New York. And how quickly he went from living the American dream to the brink of financial and emotional reeling. Remind them about Elizabeth Hilsabeck when the HMO decision to deny treatment was able to break the shield of financial and vulnerability, she once thought her husband's job guaranteed, remind her about Lester Samson how he spent a lot of time hacking away at pig guts and how he did it for a promise of life time health benefits that evaporated just because the company decided it didn't make profit, it wasn't profitable any more. And remind him of Cynthia Kline, the Boston school teacher who might have survived a heart attack only if the local ER wasn't overwhelmed with so many patients. You remind them in other words that this will be their problem sooner or later. If not today, then maybe tomorrow and maybe it won't be then, maybe it will be a friend or a loved one, it will be somebody they know. Ask them about that, ask them if they want to live in a society that takes those chances, that makes life in effect a big role of the dice particularly when it doesn't have to be that way. Thank you.