him, you know, he comes into the office maybe a couple times a week to check mail and whatnot. but he's busy painting. he's still writing. he's kind of pursuing his own stuff. when i first started at city lights, he would come into the office everyday. so that was -- i'm glad to have had that privilege to see him and work with him. >> stacy lewis, thanks. marketing director of city lights bookstore. >> thank you. ..

>> good evening and welcome days welcome to the commonwealth california you can find us on the internet and i am the president and chief executive officer of the california healthcare foundation which is the underwriter for tonight's program. now it is my pleasure to introduce our distinguished professor dr. ezekiel emanuel from the national institute of health and author of the new book health-care guaranteed. i will not be labor my introduction of dr. emanuel the is known to many of you but i cannot let the opportunity go unnoticed that he wrote what is in my view one of the most insightful

articles written in the last several years that he pointed out today's generation of physicians in the 21st century rather than being taken at psychology or physics or organizational behavior is organic chemistry is one example of the extraordinarily inside the contributions that dr. emanuel has made and as he does in the pinnacle what is arguably the mother days the world's most prestigious and implement so biomedical research and surprise makes him all the more remarkable please help me at to join dr. ekekiel emanuel [applause] for anyone who tries to educate the public and is a tremendous pleasure it is one of the places you do about to speak at the commonwealth club

and it is my privilege and i am amazed, i was told by and not a big football fan and i am a me summit people turned out despite missing the ball game tonight. one of the things lark it did not say about me is i do a lot of surveying of doctors, patients and various medical issues and i want to start by talking about all little survey. i will begin with two questions. the first is overall how well do think the health care system is functioning today? how many people think it is functioning very well? hold up your hands. 1%. [laughter] moderately well? a few more. fairly well? that seems to be the majority.

not well at all? there is a sizable number there. the next question overall how happy are you personally with the health-care services that you get? very happy? about half of the audience, a moderately happy? another good joke. fairly happy? not happy at all? that shift, that all large number of you find of the system not operating very well but you also are personally very happy is one of the big barriers to healthcare reform. we will come back to that at the end of the talk. political scientist notes that there are four things back coalesce come together if we are to get big change in american society. first they have to have widespread recognition there is a problem with the american

system, and you need an agreed upon solution by the actors. third, a champion that will push that through thick and thin come to the ups and downs of the system and last days transforming political event that will open the policy window through which you can pass legislation. it is useful to ask about those four questions how they relate to the health-care system and our moment today in 2009. first, i think we could say the problem of the american health-care system are pretty well recognized. i could spend all night and tomorrow morning we could turn talking about the problems but let's talk about the big three. the coverage problem. all of us have been beaten over the head over and over 47 million uninsured and you

can that with job losses and the depression it will go up. you know, less well that between 2/3 and 75% of those uninsured are either full-time working people or in the households of full-time working people. that is very an american. they work hard but don't get the benefits of america and society. more heartbreaking is the fact that 9 billion our children and we cannot possibly expect them to pay for their own health care coverage. then there is the cost problem. we spend 2. $2 trillion on health care each year. now you are a very smart audience and i have been too smart places a harvard, who own washington university, university of

michigan medical school, a virginia law school and what i learned is very few americans have been very good sense 4 trillion. also i would give you a sense of how big 1 trillion is. how long ago was 1 million seconds? last week. 11 days ago. 1 billion seconds roundabout when richard nixon resigned the white house by bob 1,000,000,000,002nd? 30,000 b.c.. bad is 50,000 years before any human being is the but on the continent and we're spending two of those each year. that is an astounding number you cannot even get your head around it weird about china and the chinese economy and the fact they may overtake the united states as the next superpower we spend almost the entire chinese gdp on health care loan.

theirs is 2.5 trillion dollars and reese spent 2. 2 trillion on health care is not just how much we're spending but how much it is growing year to europe days year-to-year since 2000 premiums have gone up 75%, double inflation as a matter of fact if you grab about where spending is going i call it the tsunami graph because it goes up and buy 2082 we are either all patients were all doctors and that is it the entire economy is health care of. [laughter] we have to get that under control progress takes money away from everything else we have whether education or travel or infrastructure and then there's the quality of care yes we have some peaks of the tremendous quality whether

it is right here in the san francisco, a stanford, mayo clinic, harvard, but we also know the quality is uneven, unpredictable and lots of studies have shown your chance of getting the right medicine is roughly the flip of a point*. not a very good. have a high use of unproven treatments that cost a lot of money and don't add a lot. and we have a very fragmented system. the average medicare beneficiary sees seven different doctors per year and five specialists that are not related clinically, administratively, and no shared electronic records this is no way to run is is down. even if the americans don't know the details that understand the system is broken and brad w. botha is suggested that you understand the system is not working. we understand we have a

problem with the economy cratering health care was the top or the second issue in the presidential election. the second thing we need is shared agreement on reforms. there are lots of proposals for reforming the health-care system in this country. lots of proposals. maybe hundreds. but they can all be boiled down 21 of four flavors. you either are a incremental was, changes, weevil not try to achieve any of the big items all at wants we will not do universal coverage but we will have electronic medical records or expand or do a few things around the edges. personally i am not sure why this is persuasive if you think this system is broken because going around the edges

will not fix what we need to fix. you do that only if you can't get big reform it is a compromise position that that is not the us position from the start it is not the end state. most people abdicate its as politically feasible not as the best policy option. but we should be thinking about the best policy option not what we can do. because we're often wrong for what we can actually achieve. of the second reform is mandates. ewing california have been very experienced in california at it was about individual or employer mandates to get 100% coverage, to facilitate people buying insurance to establish insurance exchanges so they can get the product cheaper. then the subsidizing people who were poor to buy the products. massachusetts has tried that ended has had some very

important successes of assessed talking to a guy who runs the and exchange and their cost two 1/2 years later is down at 2. six or 2. 7%. that was from 10% and is a big improvement and satisfaction with the system is very high and support is i have not done anything with cost control and there are a lot of commentators who are worried that rising cost will undermine the system. then there is a single para britcom lot of people have proposed that we have medicare for all or canadian-style single payer system. i myself do not think that is the best system. it is very hard to provide a single payer system for 300 million americans there has not been one organizational structure that 300 million people anywhere in

the world there are other difficulties and i will mention two of them one of the problems is they'll lock him of the four service delivery system where they pay doctors to do more and more. that is not a very good system for improving the quality of care or organizing more coordinated care. second, as we have seen with medicare it is very difficult to have the effective cost control under the system because of political pressure. fell last seven proposals does not have a very elegant name. i have now becoming to call the social insurance that is unrelated from the employment system market is actually the proposal i want to elaborate. the proposal that the professor from health economics at stanford and i like to refer as the original three horsemen one of the three economists to look at

the system in the '50s and '60s we have been working on the guaranteed health care access plan. it has 10 elements. i will just go through the 10 elements for you. first, people get a voucher to buy a standard benefits package which is modeled on what congressmen and senators get. insurance companies have to guarantee issue they have to issue and three new and no disease exclusions and in exchange for that everybody is in the system. individual americans have a choice between five or eight plants and they can choose which one fits better, which combination of doctors, hospitals, which sets of cool paper:third, the plan is funded by a bout you added tax dedicated to health care

that means the tax only goes to health care and we do not add any other money it is not diverted to social security or wars in iraq. fourth of americans have the option of buying additional services of supplementary insurance of their one day wider selection, a concierge medicine, that is in addition. five, the private sector continues to organize and deliver care, it creates a network, provides the services and figures out how to pay doctors and hospitals. six, the tax exclusion for employment based coverage is phased out. what does that mean? those of you to get insurance through your employer, you do not pay income tax or payroll tax on that. that is the single biggest tax deduction in the united states income tax code worth more than $220 billion, twice as

much as the mortgage deduction. and it is incredibly regressive the rich get more because they typically have better health insurance and in a higher tax bracket and did you have to pay for it out of your own pocket you get none of the benefits of our proposal is to get rid of it and decrease employer base coverage we would phase out medicare and medicaid. that does not mean anybody would be thrown off but they just take no new enrollees. number eight the administration, the insurance exchanges deciding the benefits package, done by the independent health board modeled on the federal reserve system's of people are appointed for a long time, they have separate funding mechanism through the value added tax. nine, there'll be an institute for technology and outcomes

assessment for about that first takes new technology and evaluates them whether existing data on research or conduct and undertake new studies to compare existing technologies and also to outcome assessment which is to evaluate the process these of care, combinations of care because not everybody gets individual technology. you often have people getting multiple technologies and there are other things how often should we have you see the doctor? how often do these tests matter? finally we have malpractice reform and patient safety through centers of dispute resolution preparations to think they have been injured while with the center and those who have been determined to be injured will be

compensated by you have an organization responsible for patient safety with the responsibility and accountability and resources for safety measures and right now there is no such organization. i think this plan is where we want to end up. we will not get there tomorrow by slipping a switch but i think that is where we want to end up. it is the best policy option many people who look at it think it is the best option but they do not advocate it not because it is not right but too hard to get to. those are the four alternatives. it's incremental reform, the mandates like massachusetts, a single player and then something like our guaranteed health care access plan. the third element that you need is recognition of a problem, and agreed upon

solution from it a champion or a set of champions to a chance and a proposal through thick and thin. we have a lot of champions and i think there are some key groups who have not always been in the current situation. let me mention a few of them. businesses and the ceos have complained about the health care system and the cost of the health-care system and said we have to change but what are they four? we know they don't like the current system but if we're going to get out of here we need them to say what will they except? what is acceptable to them? they have to me and not just way. the second group are governors i have not understood by governors are not more active. medicaid and that increasing cost of providing coverage and certainly in the recession with more people who will be

uninsured and unemployed, and medicaid is simply handcuffing governors from doing new things are right now in most states medicaid come s-chip in -- consumes one-third of the budget health care is the number one item. because it goes up faster than tax receipts it consumes more and more money from state budget so initiatives the governor's role like to undertake whether education or the environment or infrastructure comment is very hard. finally, patient advocates. the current system is getting very difficult for many patients. if you have a disease the drugs that are necessary are expensive and copays and insurance are very high. i as an colleges have begun talking to oncology groups and they are very concerned because many members, and they

know the right treatment but it is very difficult and the costs are high and also beginning to worry and to be clued in to the issue maybe they are not getting great quality for their illnesses. last, i would suggest as a very important group that has to recognize the link with health care and those are the budget hawks those who are worried about the deficit impact on our children and grandchildren. what is driving these deficits with the state and federal government? and healthcare. they have to recognize that health care reform is critical to ending the budget deficit. the last item if we really want reform is a transforming political event. you can have all three, recognition, and agreed upon a

solution, champions, but that won't go anywhere until something big happens that changes the landscape and allows reform to happen. i think we have had a transforming political event, we have actually had two that make reform likely now than at has been in in a long while, then maybe ever. one is the election of barack obama, 143 years after the end of the civil war who want to confederate states where many americans to into him and listen in a way i have not seen for a long time. people stop and listen to what he has to say. he has an amazing ability to articulate what the country feels and to explain himself in a way that i think people really believe prepare you can see the very positive

feelings. the american people want him to succeed. he has also done something pretty remarkable with his appointments has made an amazing team and i would get back to that in a second. the second transforming event is the fiscal crisis we are in. although clearly the worst since the great depression, and i think it has changed the landscape in several ways. we're not talking of spending hundreds of billions or even $1 trillion for recovery, a health-care reform fits into that. second, with the potential price of unemployment the financial insecurity the american population will want security add one key element is a secure healthcare. they want to know if god forbid they become unemployed or their employer has financial turmoil they are still covered. i think they will really push

for health care guaranteed. second coming employers, they do not want this on their books anymore. it weighs them down it could be the difference between staying afloat and not. and then i suggest there are also the budget talks to have understood that we need to have healthcare reform to reduce the budget deficit. and that if we spend a lot of money on the stimulus come a we have to spend more prudently and other areas. now i should not end, i will end with two more comments, the first, we should be sober. despite these transforming events, lots and lots of barriers to reform, we have failed for over 90 years with health-care reform.

as i said at the start the poll but i took year on these two questions suggest one a barrier, most of us are happy with our own personal circumstance even if we think the system is broken purpose of the attitude is yes, change the health care system but have my just as it is. very hard to do that. said kent, we have a political system that is given to gridlock and not passing major reform when james madison wrote the constitution and what was the word about? tyranny. he wanted checks and balances so nobody could usurp the reins of government to match. he succeeded and would be very proud of the gridlock. [laughter] it makes it hard to change.

then there is a machiavelli rule of reform. machiavelli is a great political scientist and he said be aware of initiating anything new because those people who have an investment in the old system will oppose you baker's the rouse those people who may benefit by the new system are only lukewarm supporters. why? because those who lose know what they will lose than those of say it is a hypothetical and maybe it will not pass. then there is finally with many of you and california have experienced the rule of sec and best. some of you may be incremental west carnegie die-hard single pager advocates i may have convinced you to my program and it is do nothing. [laughter] i suggest it is not a second bus but a prescription for failure but it is hard for us to know.

why am i optimistic nonetheless despite all of these things and let me conclude on that. i do think we have a unique moment in our history a unique recognition of the problem a growing consensus of the key elements even if we can agree on the final outcome. iso think we have a unique set of characters in washington that make it is more possible. the president has assembled an amazing team beginning with senator tom daschle and his assistant gt lambrew to have health care reform this and peter orszag has studied health care at the cbo issued report after report and understands the problems that larry summers the national economic coordinator also understand his most important academic paper is on health care and finally my brother

who understands how to get things through. [laughter] but i did not say that about him. and but congress senator baucus and senator kennedy our committee chairman of the finance and house committee really want to get something done and we have had not have that combination and on the house side there are many powerful and smart people committed to healthcare reform henry waxman is among one of the leaders that is a unique combination of talent that want to get something done and they understand the problems and what is doable and i think we have a chance to really have a difference and put ourselves on the right course to changing our system so we can get full coverage of americans at a reasonable cost and with high quality for the first time. thank you very much [applause]

>> thank you very much ekekiel emanuel for your comments this evening i am the editorial page editor from the san princess go conoco will not only have a full house but an active house with quite a few questions so let's get right to them. first of all, probably have the questions we receive are in one way or another related to the criticism of the single payer system. so let's start with one asking you to elaborate on the comment in your book that single payer will break the bank quota of quotes you deserve one of your concerns it is very difficult to have cost controls. how? how difficult? how would a break the bank?