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Topic. And I think that what I am exited about is that we have three experts here not only they have deep insight, but I think have somewhat different points of view on this issue which should make for a very interesting dialogue. Let let me begin by introducing them. Ezekiel Emanuel is the author of many books and articles including the book, "No Margin, No Mission", which addresses ethical challenges in healthcare delivery. Another of his books is "The Oxford Textbook on Research Ethics". He is the Chair of the Department of Clinical Bioethics at the Warren G. Magnuson Clinical Center at the National Institutes of Health. He has served on President Clinton's HealthCare Task Force, the National Bioethics Advisory Commission, and Pan American Health Organization. Chris Jennings is the President of Jennings Policy Strategies, a health policy and advocacy consulting firm in Washington DC. He is the former Senior HealthCare Advisor for President Bill Clinton at eh Domestic Policy and National Economic Councils He contributed to the development of a number of very important pieces of health legislation including the enactment of Children's Health Insurance Program. And finally to my right is Ron Wyden, Senator from Oregon. He is a very respected voice on healthcare and has developed a position on healthcare reform that he will be telling us about. He serves on a number of committees including Finance, select Intelligence Budget, Aging, Energy and Natural Resources. And prior to being a Senator, he served for 15 years in the House of Representatives. Let me check off the discussion with just a few comments. Healthcare in the U.S is the most rapidly growing business segment $2 trillion a year 16 percent of the GDP with scaling up very quickly to take even more of a share in the future. The amount is growing but at the same time there are number of issues that people are concerned about quality being one and access the subject of this conversation being another. 46 million people in the United States lack health insurance and the number of those are children. So, the need for health reform I think is accepted by many. But the means where by to achieve that reform is not agreed to. And I think we can start the dialogue with Chris if you would like to share a few comments. Okay well. Good afternoon everyone, it's a pleasure to be here. I am know in Washington as a has been used to be, which means that I used to be relevant and these two are still relevant. I in November of 2004, that day of the election I became a could be again. And then I was a will be and then sooner after I was a could have been. And now I have more in fact into a used to be. After 24 years of doing this, I certainly do have some scares to talk about healthcare and I could standup here and tell you why all the reasons why nothing can happen and on other days in Washington DC that what lobby get paid for it. Now they are very their view is brilliant when the said nothing would happen and they turned out to be right, - I was really brilliant. But actually I am quite optimistic. And I want to lay out a couple of reasons why and lay out a couple of issue that I think need to be addressed effectively to make real progress which is what I think this conference is all about. Its if you go to what has changed, I want to I won't talk about what has changed that is even more substantial in terms of positive trend lines in 1993 when we had our last debate. First, the healthcare crisis is absolutely seen as an undermine, as as a complete threat to our ability to compete nationally and internationally. There is broader pool of businesses even more in 1993 than there was than there is and there is now four major reforms including retailers, which in small businesses in retails who really weren't there before. There is a strange [0:05:01] ____ of plans and manufactures and providers who are all now calling for in developing universal covering plan, something that we hadn't seen before. We have a religious community including the fundamentalist who are now calling for major changes in our healthcare system. We have a greater variedness within dissatisfaction with incrementalism in this county. And of and a really frustration with this status for far beyond what I saw in 1993. And we have some thing new that's happened, which is a broader acceptance of the need for value purchasing to help deal with the driver of the healthcare reform debate which is always costing affordability. All these things are important but they they also have reflected changes politically too. And I want to talk just a moment about those. The Governors are attempting and implementing substantial reforms throughout the country. Republican Governors are actually proposing and implementing universal coverage within their states. Both Governor Schwarzenegger and [0:06:09] ____. There is a a huge acceptance support for and commitment too by all the democratic country just running for President. The universal coverage has to be a part of their platform. And you may think all that happens every time that was in the case of 1996 was not the case of 2000, was not the case in 2004. And also, all the candidates have the benefit of learning from the past including my former boss, Senator Clinton. And lastly, we have some real innovations in the Healthcare debate that are occurring and I want to hear about that today with Senator Wyden and Ezekiel. Now, I want to talk a little bit about just a moment about the importance of languages we discuss healthcare. And I had a you can talk a little about this by introducing some of the questions that you know, often times we have this discussions about Public versus Private or Individual versus Government or versus Government. You know, it's going to be all it's going to Private, it's going to be Public, it's going to be Government, it's going to be business, it's going to be individual. We often hear the debate of bare-bones versus cardiac coverage. It's just going to be neither. It's not going to be bare-bones, and it's not going to be comprehensive coverage. And we often hear this, My Plan versus Your Plan. It's not going to be either. It's going to become Our Plan if this is going to work. And lastly, we hear this debate of Consumer Directed Care versus anyone stupid enough to say they are against Consumer Care. Consumer Develop Delivered Care Directed Care, who can be opposed to what did the hell that means. So, let's go to one more a couple quicker other things and I am I will turn it over. First, thought we need to understand that 90 percent to 95 percent of the Public votes has health insurance. And, they care a lot about healthcare, they care about its cost, they care about its and affordable, they care about its quality, they care some about coverage for all that primarily because they are afraid loosing it themselves. And we have to play to that. Those real fears and those real concerns of what is going to be very effective in this area. So, if I had a advice to be given to any candidate, who will be the focus on the drivers of those concerns of costs, affordability quality, which I think if we could address three issues, it would be these three issues. One would be preventing, imaging chronic disease. The second would be a really addressing administrative cost we spend 20 percent or 30 percent of our overhead on healthcare is just administrative. And thirdly, we need to empower purchases whether they are Public or Private to make informed clinically based decisions about what works and what doesn't and pay for it accordingly. If we did those three things and those three things alone, we would constrain cost substantially achieving enough savings nationally to be out the reinvest to cover everyone. That doesn't mean that we want me to have the a Federal Investment of fund but it does mean that we will be providing confidence to the Public in large that we get it, that we are addressing the issues that they care about and we do in the context of improving quality and constraining cost to enable us to provide coverage for all. So with that I will conclude. Great. Thank you very much. Ezekiel, go next. Yes. I would like to say that we should analyze the topic in four questions. The first question is what do we want? And you just heard from Chris a very aliquant reason why we want universal coverage, we need cost control, and we need to improve quality? That's because the insured people need parts of that and the uninsured need parts of it. I want to give you another reason which does tells exactly with what Chris said, which is if you want sustainable universal coverage, that can go on for years and years and decades and decades, you have the constrained cost, and the constrained you have to improve quality, it's the only way to get sustainable universal coverage, have cost control, so that business won't get out of what they want and governments won't go abroad providing health care and the only way to get cost control is to improve quality in the way that Chris just mentioned, better care for chronic diseases, better care of knowing what works and not paying for things that don't work, so that's the first question, what do we want, we need all the three things, the second question is, do we want incremental reform, Expand Medicare a little down to 55 year old expand ship to kids whose parents make 350 percent of poverty, or do want comprehensive reform. Now I would submit to you, we had incremental reform, and the system is ever more broke, to really get cost savings, and to constrain cost of improved quality, we need comprehensive reform, we cannot get a good system giving the current way we pay, because you don't set up the right incentives either for the providers, the doctors or for patients, you don't set up a way to be efficient, you can't get any administrative efficiency out of the current system, you need to change the system, comprehensively, and there are incremental things you can do to get to the comprehensive change, but I think you need comprehensive change, and I think if you hear candidates talk about incrementalism you should be very worried, that they are going to get any savings, control cost or improved quality, the third question is what are the alternatives in terms of comprehensive reform, and I think to give you a frame work, in my view there are three flavors and every thing is a variation of these three flavors, flavor one some kind of mandate, the sort of plan of the day is the Massachusetts style individual mandate Chris know that. You know I remember, 15 years ago it was employer mandates, it's some kind of mandate, the individual mandate has some subsidies to poor people to buy coverage, the second flavor is some single pay of plan [0:12:17] ____ and the third flavor is one that we advocate which is voucher plan, that you give every one a voucher to buy a standard benefit package model, and what congress man and I get to the federal employee plan, you want to buy more, you pay more with after tax dollars and the people who provide the services are health plans, insurance companies and they have to organize all your service, and you collect data from them to make sure that they are doing a good job. Those are the three flavors, I advocate the last one, I can give reasons why I think the first two are not viable in the long term, but we can talk about that in the questions. The last thing is when and how, it's a sort of political question, but it is little more than a political question, and I am both a cautionary and optimistic like Chris, even though both of us have lots of scars and Ron and certainly has a lots of scars to show for this, I am cautionary that I don't think which you get our hopes up too high, for the next president, I think there are lots of reasons, the first one is we don't have a national consensus, we are just beginning the national debate, we don't have a consensus around one plan and secondly business while they are talking a good story are not yet, coalescing around one plan, and as I would like to say, they like the wine, but they are not yet at the lobbing stage, as you saw the big three, you know they have lots of other issues that they have the debate with congress cafe standards, fuel efficiency, health care, well it's important to them always drops down the list, because there are other things of mission standards and I think that's true of lots of business. The third thing I would say picking up on what my brother said yesterday, some of you heard him, that other things the president in the first term, is going to be focused on, so I am optimistic for 2013 for several reasons the crisis is going to get worst because we are not constraining cost business will be actually screaming and in the bargain, governors will be governing under the weight of Medicare and the American public I think will increasingly have participated in the debate, got clear about the kind of reform, and I think in the first year of the second term of the president who gets elected in 2008, is when we can probably get health care reform, as Chris says we can all think of a thousand reasons that will never happen, and there are lots of interest groups, but my belief it - for many of the reasons Chris mentioned is we are likely to have the crisis increase and we are likely to be able to finally get the stars correctly aligned, and so I am very optimistic. Thank you, Senator. Well wonderful ideas for aspen institute to keep the United States senator to four minutes speaking, I am not going to mention any names but, I don't think I can sell this to the entire coke and Chris and Ezekiel have said it very well, let me just kind of pick up one few points and then and then we are anxious hear from you, the first is I would suggested we are spending enough money today on American health care, we are not spending it in the right places, you all having your packets, we are going to spent $2.3 trillion this year the 300 million to others you divide the 300 million into 2.3 trillion and you could go out and hire a doctor for every seven families in America, pay the doctor $200,000 a year and say doctor that's your job this year, whenever I bring it up with the physicians group they say Ron, where do I go to get my seven family because you would like to go back to be in doctors again. Second, there is an ideological truth blowing a very powerful one on this issue, the peaceful legislation then I am going to talk about the bill I have introduced is S334, the healthy Americans act, my lead sponsor is a fellow named Robert Bennett from [0:16:24] ____ a republican, a member of the republican leadership Mitch McConnell's chief lieutenant is my lead cosponsor and the reason I think we have got this ideological truths blowing is that republicans have moved a long way around the preposition that to fix health care you have got to cover every body, because if you don't cover every body, people who are un insured shift their bills to the insured. So republicans have moved a long way in last few years democrats in my view are also moving, more and more democrats were saying you cannot have government control health care it's not going to you know work, so I think that then takes you to the third point which Chris highlighted and that is how do you persuade people most of whom have coverage to be part of any of this, and I am just going to wrap up by telling you how I spent the last three and a half years and it has been going out to my constituents I have town meetings in every county in my state and bringing this up with the idea of trying to prepare for this legislation, and if you come to a town meeting in Oregon I think this is true a lot of places, most of the energy is on some kind of single pair system, a Medicare for all government plans some thing like that and so the discussion starts that way I point out well, in Oregon, people actually pull on the ballot and got voted down like three to one, and then a bunch of people say you know we don't want all that government, we want some thing else with less government you know they wait in line in Canada, we don't want that, so there is then a draw between these two groups, the people want government and the people who don't want much government and at the beginning a couple of times that happened right at this point some one would stand up and say you know what we want Ron? We want what you people in congress have and then every body starts cheering like crazy, people really aren't sure what we have, but if we have it they want it, so I went back to Washington and I would say how in the world I am going to do this? And of course we have private coverage, private policies I had a blue cross card in my pocket and I spent three and a half years breaking down how you could get a guarantee that all Americans could have choices like members of congress have, coverage like members of congress have and benefits like members of congress have and that's the basis of my legislation seen on the website and a group called Leeuwen and associates they are kind of the gold standard of this health policy, kind of business probably say the word health actuarial analysis they said that under my legislation, we will be able to expand coverage for no more money at the out set, and we will actually be able to slow the rate of growth over the next ten years and haven't seen a proposal, I share the view of Chris and Ezekiel that all of this is a work in progress, we had a hearing in the senate budget committee last week, senator Bennett and I came in and virtually every member of the budget committee, democrats and republicans said, you know the structure of this is pretty sound, so I think we are getting there, we have obviously got a tremendous amount of educating to do. The big idea in my legislation is to redirect the money we are spending in the federal tax code. Today under the federal tax code if you are a high flying CEO you can go out and get a designer smile plastered on your face and right of the cost that on your taxes but if you are a hard working women at the corner furnisher store you may get nothing. So I want to change the federal tax code redirect those expenditures so gets to people in the middle class essentially the working class. That's one of the big ideas. The other big idea that I personally think after three and a half years the country is ready for is we are to cut the link between employment and health insurance. We did this, we did this folks spite accident in the 40s we are waging price control and all our wonderful troops were coming on we said lets slap it on the employer. We probably could get away with in the 40s we can't in 2007. So when I introduced my legislation and these turn the head of the surface employees stood on siding Steve Bird, the CEO of Safe Ways stood on the other side and both of them said we are for cutting the link between employment and health insurance. So we have got a lot of energy and a lot of talent in this in this audience, I want to say because I agree overwhelmingly with what Chris and Cisco have said. I think this can be done by the next president, I think that there is going to be a bipartisan consensus built to bit on some of these principles that I am touching on a widely shared built around the education kind of issue and Ezekiel touched on that and all acknowledge there is a huge amount of education, I will wrap-up with just one challenge I had. The other day in Central Oregon it's some little bit more beautiful than aspen, you get the drift, so wonderful wonderful place and a young guy heard my proposal listened to and came up to me afterwards and said Ron I really like you I am always going to vote for you, you are for the environment you know, this and that. I don't want to have to buy health care I don't want to have to do you heard Ezekiel and Chris talk about it, and I could just see this is a guy with a golden can nobody fat I could just tell what I was dealing with he said I am taking care of myself why should I have to buy it. So I pointed at the mountain we got all these beautiful mountains in Central Oregon and I said hope it never happens to you but what if you get in a big skiing accident this week end and you are hospitalized, he said Ron I have been thinking about that if I get in a really huge skiing accident I will buy health insurance there. Well the United States senator has always got to be very respectful of their constituents. So I said I said as just this way I said gosh, health insurance doesn't kind this sort work like that what you got to do is buy at a headed time and if we all buy at a headed time we can spread the cost and the risk and that kind of sort holds the cost down for everybody else and his eyes got very wide he said cool and he didn't say he was going to be for the healthy Americans, he will be for what Ezekiel is talking about and Chris talking about. So it is going to be a huge education you know, effort but folks we cannot sustain what we are doing. Our employers cannot sustain it, you open a business today and you spot your employer 15-20 points the day the door is open. That's why Andy turns to next to Steve Bird when I introduced S-334 not principles and actual piece of legislation, we cannot sustain what we are doing I think the country is ready for it you look forward during thanks Great well thanks very much. We I will not - I have several questions that I want to ask to the panel but before I do that any of you want to comment on anything that your fellow panelist said. They were brilliant Real political remark, okay. I want to get back Chris to to a comment you made about language, it seems to me that everyone is quick to say that this is a vitally important issue, but there is a lot of rederick and a lot of abstractions in the conversation. And I am wondering what can we do to get down a pragmatic dialogue that the people of United States can participate in and understand. Well start but, I think that we need a focus on to the patient, and what they get what they care about, we frequently in Washington have these labels that are really more indent to quick descriptions that lead to divisions not unity, and you know, the best examples are the private, public debates you know, there is a famous line about the I think it was John Abraham use about the constituent he talk to, he said I want you to tell those people in congress to keep the government of my Medicare, and keep them away from my Medicare don't let them touch it and you know we have those educational issues and there are people who you know we get to this this question of you know Medicare. I mean, Medicare if I tried to tell single pair advocates, who say you know, who want to batch the private sector and and the private sector wants to batch the public sector, it's a waste of time we are going to have both you are going to utilize both, they both have strengths they both have weaknesses and if we engage in one thing better than the other then we are really just prolonging an argument that's unconstructive and let me give you example on Medicare, Medicare yes is a government program. But Medicare also is a private program Medicare contracts help with HMOs, BPLs private people service and traditional people service, all of which administered by private insurance. You ask most people about that and you said I want a Medicare for all in that single pair, well you define what single pair is. So terminology that is a relevant to people and what they receive I think is kind of productive and we as policy makers or people who advocating for improvement just need to be careful about playing in to those divisive comments And I actually think you hear a lot know you know, x1 socialized medicine and the boogieman of socialized medicine is coming back I thought it was crazy before and very now, because we are not going to have doctors employed by the government in this country, we are simply not. And I think part of what we need to do is to educate the public about the difference between financing how it gets paid and delivery? How you how the doctor who you see how the doctor gets paid and how the care is organized and I do think this is actually kind of be a big education challenge this is the most complicate part I think of American society that people engage in and there are very few people who understand the whole system including doctors I mean I am always surprised how little doctors actually understand the system they might understand their part of actually delivering care but how it is finance and all of that. So that's a big problem and I think one of our problems for the forum is the complexity of the system you know, because Americans the moment they hear lots of stuff, they sort of face out and they say well that's really complicated I am not sure how I am going to fear out of this, lets keep to the what we got and you know Chris mentioned you got to explain to the 90 percent of Americans who have insurance who vote you know, why they are going to better under a chain system, and I think Ron pointed out you know one of those things to get the employers out, you can move in you don't have the change of insurance, you can lose your job god for bit and you don't loose your insurance you kid graduates college and goes to work and the company doesn't provide insurance but your kids still has coverage. That is a big huge plus for a lot of Americans it might actually cost you less over the last five years the amount of you paying paying is going to five hundred percent. You know what happens if we actually control cross the way Ron's program does and our program does. You might actually not see those dollars go up year in and year out. So I think that's going to be the big big challenge just kind of break down the complexity of the system so people can digest it and fell comfortable with what's coming even if they don't understand all moving parts. One of things that I do like about Ron's plan I think it is very similar to ours he got up a few limit the number of moving parts, too many complications make it hard to understand, and it also completely breaks down the incentive structure for tax and for health plans and for insures, that's to what they are supposed to do how they can make the most money and how they can provide good quality care. So I get rid of socialized medicine that we are not going to have that in America and none of the plans being proposed with that so it is a ridiculous red hearing. And its again one thing which makes me worry that people are running away from the issue and the republican side and trying to black mail any one thinking about compressive effort. Uh-huh do you have any comment? Okay actually I had a question for you. Given the computing priorities in congress right now public attention on other issues, what is possible in terms of health care reform in the next four years? I think the two big issues in the country and again I use this kind of town meeting test is in the war in Iraq and fix American healthcare. I think those are the two things you know people want and on the healthcare front the big issue of course right now is going to be the children's health initiative program what's called Chip, we very much need it's a moral block on our country to not be covering all children we got to do that I think that the debate will also highlight how broken the system is overall and I hope that would give senator Bennett benign opportunity on in this session to advance our proposal you know the popular wisdom of course is that there is no way anything can happen, the congress is so divided, Washington can organize it to corporate little long fix American healthcare but I still happen to believe that democrats and republicans in the United States senate were have to go to voters in the fall of 2008, that is before our presidential election and I am still hopeful that we can get a big breakthrough on this issue. I would also like to subway if I could for just one other point that is the role of the states on the question of what is going to happen If you can see the pent up desire for a form on healthcare is clearly galvanizing the state because they like everybody else have to respond to their constituents and I think the story should be that the states are doing unbelievably good work with virtually no bandwidth in which to operate. The reason I say that is the States cannot touch any of the big drivers in American healthcare. They can't touch the federal tax code that is more than 200 billion dollars out the door, they can't touch Medicare much bigger than the federal tax code and as you saw on the Wall street journal this morning they can't touch something called ERISA, the employee retirement in common security act except under unbelievably complicated circumstances. So my sense is we ought to encourage the states, all three of us have been long advocates of giving the states a wide birth. But I am very hopeful that in this session we can end the moral outrage of leaving so many kids without these healthcares and actually move further other than with the kind of effort that you are hearing from all of us. Can I say one more incremental thing? There is a bill which you probably be able to say better, thinking about a setting up an institute or a center for technology assessment, it actually look at the technologies we have, the drugs we have and evaluate them and asses whether they are worth it whether they are good or not. That I think is a very important piece of legislation personally because it is very critical, no matter what healthcare reform you have to have better evaluation of our technologies now. As many of you know you know a drug gets evaluated in clinical trials in this few thousand people then goes on sales we have a half pass way of assessing it afterwards both for its affectedness and cause, we need a much better way to access not just drugs but devices as well as complicated interventions that doctors develop surgeries and others that don't go through the FDA and I think what ever healthcare plan we have, evaluating technologies is going to be critical to it and that's a piece of incremental reform that I think all of us should be for and I am hopeful that congress will pass it this law because its critical to ensuring good quality medicine and reducing cost, because I think it will sent a message to all the people who develop technology you know you are going to be under some scrutiny as to whether what you got is really affective actually improving life and is cost- effective, is in fact going to save us some money or not be more expensive than what we are doing today. So that is a piece of incremental legislation which I think is vital.