about single payer. the fundamental structure is that we have one national plan for everyone a fairly robust set of services and get rid of the insurance companies and save money on the administrative cost and have eight national drug formulary and drive prices down and continue with a fee-for-service reimbursement system that we have now. the way i like to think of single payer is the most radical reform on the financing of health care while keeping the 19th century horse and buggy delivery system that riyal that is not a tenable long term strategy. one of the fundamental things we need to do with american healthcare and litmus test

rican news how do they reform the financing system but also how did they reform the delivery system to make sure we control costs and improve the quality of care? one of the major problems is they keep the old payment system fee-for-service and do not encourage quality of care. fee-for-service encourages doctors to do more things, more test, more procedures, and not necessarily paid them better for quality. if you want quality and steady around the world whether the mayo clinic or cleveland clinic you will see they have coordinated care. they coordinate the doctors with the hospitals with the home health-care agencies, first pharmacies center signals that cannot be done on a fee-for-service basis that facilitates exactly

against that bird but it seems to be one of the fundamental things you need is payment reform and a major proposal of single payer, i don't go there and i would say the political structure of just having one pager makes it very hard to change the payment system. second, i don't know the best way to pay doctors or hospitals. i don't think anyone in the world does. we know the worst. that is what we're doing. [laughter] but we don't know the best therefore be need innovation and experiments that we just have not have that. finally on cost control the singled fare proposals mainly suggest they have cost control but have cost savings and mr. -- immediately buy reducing administrative costs. but change how much free-spending but they have one mechanism which is reduced

the price they paid to doctors and the pharmaceutical industry, to hospitals and other providers. you do not have to be a ph.d. in economics to know that is genuinely a failed cost-control mechanism. setting prices has lots of ways of getting around it. one way is increase the number of things that you do purview just collect the same amount of money or more. another is you invest something new that does not have a price and that happens with technological innovation. it is not an effective way of trying to control costs. the final thing is it is very hard to imagine running a health care system of 300 million people. there is no organization that

big in the world and i would challenge you to suggest that would be an e efficient system if you run it for 300 million people in one organization. if we think we have bureaucracy with base system that runs 30 or 40 million, 10 times the size you can point* to give up. candidate is one-tenth the size of the united states. excuse me know appeared near the complexity. i just think scaling it up is not just a difficult but impossible. we are going at it again. i can see. [laughter] >> you just did not think you're going to get away with one question? >> i will run out the clock. >> there is also a number of questions on this aspect why would we even include the insurance industry in a national health-care plan with

the fundamental role has been denied claims and pass cost on to others? >> let's agree with the second half that is what they have been doing and that is how they make money. absolutely. here is the question, do think every year those insurance companies go to the best business schools and the country rather harvard or stanford give us your nastiest meanness graduates we can make them insurance executives? [laughter] or do you think it is a different situation which is they are in a very bad the situation where the incentive structure they are given by the way restructure the health care system is to do exactly that? i suggested is the second we have created an environment and structure where that is their response so they can make money. we have created the behavior we don't want.

so you can either say get rid of them and i will tell you why i don't think that is such a hot idea or you can say we have to change the incentive structure to do something different. why don't we want to get rid of them? the behave badly and we all agree. when i have to fight with my claims and i sure that. but we need an organization which will provide information systems, and infrastructure to bring doctors and hospitals and home health-care agencies and providers together and provide incentives for them to work together. you can call it what everyone to a court nader, integrator it will book a lot like an insurance company in the end because you have to have the organization that does that kind of stuff. the question is can we change the incentive structure so

they do the right thing? let me give you suggestions about up. one is a standard benefits package so they're not competing on taking services out. number two, the risk adjusted payment we fancy word that means you paid them more for taking care of sick people with diabetes, heart failure and the seamen, asthma and less to take care of healthy 20 year-old's per write now they have a big incentive to get the help the 20 year-old's because they have the premium without a lot of payments but change that and take, pay them to take care of the sick patients and you will see a different behavior but also have a situation where they keep you for a long time if you have the incentive to stay but suddenly the behavior will change because of they let you get sick to my if they don't prevent your illnesses it is on their tab the. that changes their incentive structure tremendously.

right now things change the employer decides he wants a cheaper deal so the switches insurance companies that is not a good incentive for them to do the right thing. i could be wrong. [laughter] psychology has a concept called the fundamental attribution air we attribute to people bad behavior that is really the environment that all of us in this environment would be paid badly it seems that is what we have got and what we really need to do is look into the structure of the system. it is too easy to point* fingers and is a bad boy but what we have is a bad system and we have created the behavior we don't want. >> in interest of full disclosure do you receive any private insurance money? >> i am a government official.

[laughter] no cotte -- no campaign contributions you cannot do that. >> it is the environment. >> we're talking to ekekiel emanuel for his vision of a complete overhaul of the health-care system per your plan could set up a two-tiered system for those who cannot afford have a gold system and those who can will be without. >> i am not sure you want whenever sure you want to prevent the without the love me say i think the rich being able to buy more, a first of all, recognize it is inherent. right? in canada they have one system the rich still buy more. they come to the united states they go to harley street in britain but from a practical standpoint the rich will always buy more and buy out. if they don't buy it here mob the cayman islands, switzerland, britain and so from a practical standpoint you will have a

two-tier system. be realistic second it the question should not we can the rich by more? the real question is for the vast majority of people who are not rich, what are we giving them? what we're giving them is a good? that seems to me to be the question that we want. how they spend their money is their business. what we want to know is if we're in the system do we get good services that are proven effective? and that it seems as the key question. i have a brother who is a hollywood agent who has way too much money for his own good and is mr. hypochondriac of something happens he once the mri scan i do not want to deny him that if that is how he wants to waste his money he has the money to waste. but i want to know when i get sick, do i have good enough

care? that is a very different question. we should not be envious of those who want to get another scam but we should want to know is the care we are getting good value for our money and it seems to me that is the key question and the structure i have outlined for the vast majority of americans who are not rich will be very good care and very good services. >> what is the government's role of federal and state if any in your proposed framework for guaranteed health coverage? >> there's an extensive role for one thing you need oversight, funding, someone to organize the insurance exchanges, collected and process the data and analyze it and oversee the various health plans and make sure they are doing what they claim to be doing. ferris is still a whole panoply of things. we need a lot of government

oversight. this is not a unregulated market that is terrible. it is way too complicated. >> how you propose flooring insurance companies over had? >> again, i think this is another case of where we are aiming at the wrong target. i don't like fancy suites and million plus a dollar bonuses, etc. but it seems to be what do we want to focus on? we pay you and assess you're quality of care. how you achieve that, that will take experimentation and a lot of different kinds of initiative and i am less worried about that. as a matter of fact if we paid them and demand high quality care i don't think those perks will have a lot of money left over for that. it seems to me what we have

got to do is focus what we want out of the system instead of trying to find evil people everywhere and say that is the problem. chief executives and pharmaceutical companies, too rich chief executive hospital too much money coming there are more than enough evil people in that arrangement. seems to me we want to focus more on how to create a structure where people are trying to provide the right health care and have good outcome had a fair and reasonable price to all americans. and when we try to find it that evil double, we are really missing the bigger problem with the system which is the way we have structured it. if i can send any message to someone here tonight, that is the issue. you can find and get rid of all of the rich corporate executives at the insurance companies did you will not

fundamentally debt universal coverage, have reasonable cost control, and improve substantially the quality of care in america. you just wall. that is barking up the wrong three. >> what is your definition of basic health care and why should people need to pay more for more services? vivica this is a fantastic question. let me tell you where i began. i think most people who have looked at the problem look at the federal plan that is a plan of federal employees the senators and congressmen debt, not the riches package but pretty good it is very good. as people like to say if it is good enough for congressman it is probably good enough for most americans and that is where we should begin the debate. we can discuss whether we should dial the down or there

is something to include that includes hospital care, primary-care prevention, referrals, mental health benefits, it is a fairly rich package and i think most of us would be very happy with it. it is better than what 85 percent of americans have. that is the kind of package i have in mind. >> there are a number of questions about bioethics. i work in a large hospice i see you and when you talk about barriers to reform what about the patient and family is one thing quote-unquote everything done for the loved one when the best medical advice agrees efforts are futile? >> a fantastic question and typically but not always that is the result of a failure of communication through the system but lets us get to the underlying point* of that question which is when we demand services, it is easy to

point* to a family and say they are demanding billions of dollars be paid berkeley would not have the health-care crisis if it were one or two families. but it is always too easy to point* to someone else. let us ask ourselves, just a question can we have a really rich benefits package to cover everything we want calexico's of the opposite direction. part of what we need you do is have a situation is to have value based insurance where things which are proven effective and improve health you don't have to pay a call by eight -- okay. the extra chemotherapy there is no evidence it will work you may have to pay more. me give you a favorite example i am an oncologist i happen to

be a breast on colleges so i will pick on the breast oncologist. [laughter] this year there will be more than 200,000 diagnosed with prostate cancer early stage. one way to watch that is what to call waiting and for many men it will not be a threat and they will die with the disease and not of the disease. you can remove the prostate or the third way is radiation therapy and inside of that there are at least four different flavors you can have. 3d conformal radiation, a traditional sound that you use the mri to focus the beam that cost $11,000. and then take little radiation the seats and implant them back costs 5,416,000 common then there is the intensity modulated regulation therapy to focus the be, $42,000 than

some of you know, there is the proton beams that you do nine been sent and electrons but protons the machines cost $200 million and have to be housed in april ball sized building that cost $80,000. you may ask what is the difference? for early stage prostate cancer there is o difference in terms of survival. can also tell you we do not know very much about the comparison because there has not been a head to head steady of these treatments. at best we think from single institution study is my experience there may be a decline in side-effects with 14% of men having side effects and second formal radiation of four or 5% with the proton beam. you may ask yourself is that worth $70,000?

for the ladies in the audience ask your man would you pay $70,000. [laughter] that is a case where you may say a good insurance system will say we will pay the 11 or 15,000 for the basic radiation if you want a proton beam, a god bless. you pay the remaining $65,000. that is a situation we provide everyone very good care in this country. if you want the deluxe model, you can pay for it. that goes to the tier system. you bet it is a tear. is a bad? i don't think so. we all get very good care. another story, i had to get a crown in my mouth because i am not so careful. and lead dentist recommended

eight titanium whenever and the insurance company said we only cover gold and if you want to the titanium it is 500 more dollars and i was outraged. but then i sat back and said that is very reasonable. if gold is good care but i wanted the super deluxe i should pay the extra $500. and it seems to me that is very fair. it makes me think how much of that is worth it? and that is what we have to get more of common not just of them but us as well. we have to experience that and make those traces for ourselves. we should stop pointing fingers that everyone else and that's why i suggest requires restructuring the health care market. most people do not see that we need to restructure the system so we pay for value and if we want more value we want the

deluxe rather than asking our neighbor to pay it for us. >> just a reminder you're listening to the commonwealth club of california we're talking to ekekiel emanuel for a complete overhaul of our health-care system the audience includes a number of kaiser patients, what do think of the kaiser model of health care? >> kaiser is a classic model of integrated care of under one system where they have an incentive to have the doctors work with hospitals or other providers it is a very good model of care and most people that have studied it think it has provided excellent care comparable to anything in the country and here i should have a confession to make, some of the senior executives are good friends of mine. [laughter] they have not bought be any

dinners but i do think it is a wonderful model and is it good for everyone? will everyone wants it? probably not but there are a lot of people who experience it and like it, and the answer is yes temecula act officials are struggling to find ways to increase employment which this economy needs. health care reform will inevitably reduce unemployment how do reconcile the two? >> dear me, that is very limited i do not agree with that promise at all. the first thing to say is no one is talking about taking money out of the health-care system. no one. for one thing if you want to cover 47 million americans you have to keep the system as it is if not expand initially but we want to expand a growing

your two years from the employment still employed not getting rid of a total number of people you may have people not doing insurance billing and some people man's the book that quality of outcomes or providing more services. so the job descriptions may be different but total employment will not decline at albreck a second if we could get costs under control, if we could actually restrain increases year-to-year in medicine what will happen? more of your money will stay in your pocket. the state will have more money. to invest you actually have better economic times. let me give you some history between 93 and 1998/99 health-care inflation

moderated and stayed relatively flat that was during the time of managed care what most americans hated but the important side effect is a relatively low health-care inflation. what was the economy doing it during those years was implemented rising? on the contrary some of the best economic years america has had since the 1960's those were in the clinton boom years. many things contributed to that time but all economists agree one of the key things was a moderation of health-care inflation that allowed people to spend their money blower that stimulated the economy. i do not accept the premise if we have health care reform we will decrease in employment and create more economic problems. quite the contrary moderate health-care inflation and getting everyone into the system will have just the opposite effect and it will be good in the long term or in

the short term for the american e economy. >> how does your plan deal with the lack of primary-care doctors? >> fantastic question we have a serious problem brass again why do have a serious problem because doctors are nasty people? or is it a structural problem? we pay people to do things, procedures, do that operation, you don't have to me and economic genius a nobel prize winner to figure out if i go into a specialty i can make a lot of money but if i talk to patients and that does not get paid it is hard to pay the bills even as much as i'd like it. so you have to have a major change in how we pay doctors. we have to compensate more for

talking to patients and managing their problems rather than doing things to them whether a test or another treatment. that is the key question. my system you have the insurance companies that will be required to report out gums come would be within a fixed budget and have a real incentive to change who gets paid a lot of money. not to use more test but actually have more communication, a more caring. that i think is the fundamental issue. there are other things we need to do like change medical education, that encourages people going in and decrease the dead of doctors of their a lot of things but the fundamental thing is change what we pay for and how we pay. >> why you save medicare and medicaid indeed to be phased

out? is this really necessary? >> it is a very good program people are satisfied but it is unsustainable fiscally and i believe there are good reasons to phase them out and put everyone and one program. if we have health care reform keeping medicare, that would be okay with me but let me say one problem, why should we segregate out 65 year-old? just think of the incentive structure for insurance companies if you don't do a great job and somebody turns 65, they are somebody else's financial problem. one of the things you want to do is have people responsible fiscally for their issues if they do not take good care of people. that is one of the reasons. of the medicaid side, it is

just come i think for some people it does a great job but overall it does not pay enough 50% of doctors do not take medicaid patients they have a difficult time getting primary-care it is a second class program you want to fold them into the system where they are with everyone else rather than a segregate them out plus there is a huge turnover that makes it difficult to get good continuity of care. the average time in new york medicaid is nine months but it is very hard to take care of people when they are in and out of the system. >> unfortunately we have time for one more question. it is easy. where is the patient responsibility and all of this? [laughter] that is a tremendously good question because about 35 or

40 or 50% of health is related to what we eat, our exercise and smoking. those three things we control a lot of our destiny. not everything but a big portion of it. we don't control that a loan. as you know, fast through did not just grow up and we go to mcdonald's zero social infrastructure is related to that and a social network related to smoking so it requires concerted action but we do have to take our responsibility. flip it around. how might that happen under a new system or the system i describe? again commit think what happens if you are an insurance company and you now have the same people year after year? suddenly began to think if i get too many kids who are obese this will be dangerous for