be not that they have certain policy preferences. that is not at all. that they have reason terry of rights and respect for the framework of the constitution which is separation of powers, a federalism, individual liberty, and limited government enumerated in the vermont government. they believe in those four things there is the kind of justice i would like to see on the supreme court ..

school choice and free speech. robert levy, is senior fellow at the cato institute. for more information visit cato.org and ij.org. >> this summer "booktv" is asking, what are you reading? >> hi, i'm governor ed rendell. don't get a chance to read many books. this summer i try to leave the life story of lex ander hamilton. i love history and love reading about leaders of the past. i always get good insights. >> to see morer reading lists and other information, visit our web site, booktv.org >> ezekiel emanuel, chair of

the of bio ethics at the clinical center of national institutes of health, presents his plan to reimagine the nation's health care system. according to dr. emanuel, the united states spent $2.1 trillion on health care in 2007, 47 million americans were uninsured. his proposal includes eliminating employer health care and creating an independent program, that grades insurance companies and health care plans. he's the brother of rahm emanuel, president obama's chief of staff. the event, hosted by the commonwealth club of california in san francisco, is an hour. >> good evening and welcome to night's meeting of commonwealth club of california. you can the club on the internet at commonwealt commonwealthclub.org. i'm mark smith, chief

executive officer of the california health care organization which is the underwriter for tonight's program. now it is my pleasure to introduce our distinguished speaker, dr. ezekiel manuel, chair of department of bioethics chair of at national institutes of health and author of a book called, "health care guaranteed." i will not labor my introduction of dr. emanuel. he is known by you in many ways. i can't let opportunity unnoticed he wrote what in my view is one of the most insightful articles written in the last several years he had out today's generation of physicians in the 21st century, rather than being required to take psychology, is required to take physics. rather than taking organizational behavior, is taking organic chemistry. rather than taking communications is taking calculus. it is one example of extraordinarily insightful contributions that dr. emanuel has made.

making it as he does from the pinnacle what is arguably the world's most prestigious and influential biomedical research enprize, makes him all the more remarkable. please join me in welcoming dr. ezekiel emanuel [applause] >> well, for anyone who tries to educate the public it is tremendous pleasure to be here at the commonwealth club. it is one of those pinnacle places that you dream about, being able to speak at and it's really my privilege and i am amazed, i was told i'm not a football fan, there is a big football game tonight. i'm amazed so many peopled out despite missing the football game tonight. one of the things mark smith didn't say about is that i do a lot of surveying. i do a lot of surveying of doctors, a lot of surveying from the patients and public about various medical issues and i want to start to's

talk by a little bit of a survey. i will begin with to questions. the first question is, overall, how well do you think the health care system is functioning today? how many people think it is functioning very well? hold up your hands. there is one person i see. moderately well? a few more. fairly well? that seems to be the majority of people. not well at all? there is a sizeable number there too. so my second question for you is, overall, how happy are you personally with the health care services that you personally get? very happy? about half the audience. moderately happy. another good chunk. fairly happy? not happy at all? that shift, the fact that a large number of you find the system operating very well, but a large number of you

also are personally very happy is one of the big barriers to health care reform. we're going to come back to that -- american politics note that there are four things that have to coalesce and come together if we're going to get big change in american society. first, you have to have widespread recognition that there's a problem with the american health care, or the american system, whatever that problem is. second, you need an agreed-upon solution by the major actors. third, you need a champion or a set of champions who are going to push that through thick and thin, the ups and downs of the system. and last, you need a transforming political event that will open the policy window which you can pass legislation. so it's useful to ask about those four questions how they relate to the health care system that we have and our moment today in 2009.

first, the problem. i do think overall we could say that the problems of the american health care system are pretty well-recognized. we could go down a laundry and i could spend all night and tomorrow morning, we could adjourn just talking about the problems but let's talk about three in particular, big three. the coverage problem all of us have been beaten over and over about 47 million people uninsured. you can bet with the recession and depression that we are about to continue to endure it is going to go up. what you probably know less well is the fact that between 2/3 and 75% of those uninsured, are either full-time working people in the households of full-time working people. that is very un-american. they work hard, and yet they're not getting the benefits of american society. more heartbreaking is the fact that nine million of

the uninsured are children. we can't possibly expect them to pay for their own health care coverage. then there's the cost problem. we spend $2.2 trillion on health care each year. now you are a very smart audience. and i've been to a lot of smart places, harvard, washington university, university of michigan medical school. university of virginia law school, lots of places and what i learn is that, very few americans have a good sense for trillion. so i'm going to give you a sense how big a trillion is. how long ago was a million seconds? anyone know? it was week. it is about 11 days ago. a billion seconds ago? round-about when richard nixon resigned the white house.

a trillion seconds ago? 30,000 bc. that's 15,000 years before any human being stepped foot in the north american continent, we're spending two of those each year. just an astounding number. you can't even get your head around it. we're truck and worried about china and chinese economy and fact they might overtake the united states as next superpower. we spend on health care almost entrier chinese gdp. we spend it on health care alone. their gdp is 2.5 drl trillion. we're spending 2.5 trillion on health care. it is not how much we're spending. it is how much it is growing year to year. since 2000, health care premiums on insurance have gone up 75%, double inflation. as a matter of fact, if you graph out, where health care spending is going, i call it the tsunami graph if you look at it, because it goes

up and by 2082 we're either all patients or all doctors, that's it. the entire economy is health care. we have to get that under control. it is taking money away from everything else we care about, whether it is education, or it is travel or, infrastructure. and then there's the quality of the care we're actually buying. yes, we have peaks of tremendous quality in this country. whether it's right here in san francisco at uc-sf. stanford, yo clinic, harvard we also know the quality is uneven, unpredictable. studies show your chance of getting right medicine is roughly a of the coin. not very good. we have 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 doctors in a year including five specialists. they're unconnected. they're not related clinically, adminively, no shared electronic records. this is no way to run a system. most americans even if they don't know the details i mentioned understand the system is broken. the way you voted suggested that the system isn't working. so we understand that we have a problem in this country. i think it is very widespread. prior to the economy cratering, health care was either the top or the second top issue in the presidential election. the second thing we need is, shared agreement on reforms. now, there are lots of proposals for reforming the health care system in this country. lots and lots of proposals. maybe hundreds of them. but they can all be boiled

down to one of four flavors. you either are an incrementalist, we'll make some changes. we're not going to try to get, achieve any of the big items all at once. we'll not try to get universal coverage and cost control and quality. we're going to have electronic medical records or expand s chip or we'll do a few things around the edges. personally i'm not sure why this is very persuasive to people. if i think the system is broken, doing a few around the edges is not fundamentally fixing what we need fixed. you do that only if you can't get big reform that is compromise position. that is not the position you go in at start that is not the end state. most people advocate incremental reform, advocate it as politically feasible. not the best policy option. we should be thinking about the best policy option not because we can do because we're often wrong what we can actually achieve.

the second possible reform are mandates. now you in california have been very experienced with this your debate in the last year was about having an individual mandate and employer mandates to try to get to 100% could have. try to facilitate people buying insurance by establishing insurance exchanges so that they can get the product cheaper. and then subsidizing people who are poor to buy those products. massachusetts has tried that and it has had some very important successes. just talking to the guy who runs their connector, their insurance exchange. their rate of uninsurance 2 1/2 years after implementation is down to 2.6 or 2.7% from 10%. that is a big improvement. that is a very big improvement. satisfaction with the system is very high and political support is very high. they haven't done anything about cost control and there are a lot of people and commentators who are worried

that rising costs will undermine the system. then there is single-payer. a lot of people have proposed that we have medicare for all or canadian style single payer system. i myself do not think that's the best system. it is very hard to provide a single-payer system for 300 million americans. there never has been one organizational structure provided any service to 300 million people anywhere in the world. there are other difficulties in my opinion. i'll mention two of them. one of the problems of most single payer proposals they lock in fee-for-service delivery system where they pay doctors to do more and more. that is a, not a very good system for improving the quality of care, for creating more, organized and coordinated care. and second, as we've seen with medicare it is very difficult to have effective cost control under these

systems, because of political pressure. the last set of prodoesn't have a very elegant name. i've now begunning it social insurance. that's unrelated or delinked from the employment system. it's actually the proposal i want to elaborate for you. the proposal that victor fuchs, a professor of health economics at stanford, i like to refer to him as one of the three horsemen. one. three original economists to look at the health care system in the '50s and '60s. he and i have been worked for five years what we call the guaranteed health care access plan. it has gotten elements to it. i'll just go through the 10 elements for you. first, people get a voucher to buy a standard benefits package which is modeled on what congressman and senators get, the federal employee health benefit plan. insurance companies have to

guaranty issue. so if you come with a certificate they have to give you insurance. they have to renew insurance and no preexisting disease exclusions. in exchange everyone is in the system. everyone gets in the system. individual americans have a choice between 5:00 and 8:00 plans and they can choose which one fits with them better. which combination and doctors and hospitals 89. which set of cocase is for them. it is funded by value-added tax dedicated to health care. the tax only goes to health and we don't add any other money and it doesn't get diverted to social security, wars in iraq or whatever. fourth, americans have the option of additional services, supplementary insurance. they want a wider selection of doctors and hospitals, you want concierge medicine, you can buy it in addition. five, the private sector continues to organize and deliver care. creates the networks. provides the services.

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 who get insurance through your employer, you don't pay income tax and you don't pay payroll tax on that. that is the single biggest tax deduction in the united states income tax code. it is worth more than $220 billion. twice as much as the mortgage deduction. and it is incredibly regressive. rich get more because they have typically better health insurance and are in a higher tax bracket. and, if you have to pay for insurance out of your own pocket you get none of that benefit. so our proposal to get rid of it and decrease incentive for employment-based coverage. seven, phase out medicare and medicaid. that doesn't mean anyone would be thrown off. just no new enrollees.

if people turn 65, they stay with the guaranteed health care access plan. eight, administration of the system, these insurance exchanges, deciding what's in the benefits package, assessing quality of plans, done by an independent, health board, modeled on the federal reserve system. so people are appointed for long time. they have separate funding mechanism through the value-added tax. th, there would be institute for technology and outcomes assetment. what that would do take new technologies and evaluate them. whether existing data on research or conduct and undertake new studies to compare existing technologieses to new technologies. it would also do what is called outcome assessments. which is to evaluate, processes of care, combinations of care, because, not everyone gets an individual technology. you often have people getting multiple

technologies and there's other things that aren't just technologies that need to be evaluated. how often should we have you see the doctor? how often do these follow-on tests matter? finally, you have malpractice reform and patient safety through centers of patient safety and dispute resolution. patients who think they have been injured would file with these centers, and those who have been determined to be injured would be compensated. but more importantly you would have a organization responsible for patient safety with the responsibility of, accountability, and resources to actually implement proven patient safety measures. right now we have such organization. i think this plan is where we want to end up. we are not going to get there by flipping a tomorrow and being there. but i think it's where he want to end up. it is the best policy option. many people who looked at it, including those who don't

advocate it think it is the best policy option. they don't advocate it not because it is right but because they think it is too hard to get to. those are four alternatives. let me recap them. incremental reform, mandates what they're doing in massachusetts. single-payer, and then something like our guaranteed health care access plan. the third element you need, you need recognition of a problem. you need agreed-upon solution, is you need a champion or a set of champ who are going to champion a proposal through thick and thin. we have a lot of champions but i think that there are some key groups who have not weighed in the current situation. let me mention a few of them. one of them subpoena businesses. not a lot of businesses and chief executive officers have complained about the health care system complained about the cost of the health care system and said we have to change. what you haven't heard

enough of it seems to me, what are they for? we know that they don't like the current system but if we're going to get out of here, out of the problem we need them to say what will they accept? what is acceptable to them? and they have to lead and not just wait. a second group are governors. i've not quite understood why governors are not more active in this. medicaid, increasing cost of providing coverage, certainly recession we're in with more people that are going to be uninsured and unemployed, medicaid is simply handcuffing governors from doing new things. right now in most states, medicaid, schip and insurance for state workers consumes a third of the state budget. health care is the number one item on state budgets. and because it goes up faster than tax receipts it's consuming more and more money from state budgets. initiatives governors would like to undertake and state legislators would like to

undertake whether it is in education or environment or infrastructure, very hard. finally our patient advocates. the current system, is getting very difficult for many patients. if you have a disease, some of the drugs necessary are enormously expensive and copays and coinsurance are very high. i know that i as an oncologist begun talking to a lot of oncology groups and they are very concerned because many of their members, they know what the right treatment is but it's very difficult and the costs are high and they're also beginning to worry and begin to be clued into the issue, maybe they're not getting great quality for their illnesses. last, i would suggest, there's a very important group that has to recognize the link with health care. and that are the budget hawks. people who are worried about the deficit's impact on our

children and our grandchildren. what's driving these deficits in state government and federal government? health care. and they, i think have to recognize that health care reform is critical to ending the budget deficits. the last item, if we really want reform, is a transforming political event. you can have all all three. you can have recognition of a problem. you can have agreed-upon solution. you can have champions. but, that won't go anywhere until something big happens that changes the landscape and allows reform to happen. well, i think, we've had a transforming political event. we've actually had two transforming political events that make reform more likely now than it has been in a long while. maybe than ever. one is the election of barack obama, a black president.

143 years after the end of the civil war who won two confederate states. where many americans, tune into him and listen to him in a way that i haven't seen for a long time. people stop, and listen to what he has to say, and he has an amazing ability to articulate what the country feels and to explain himself in a way that people i think really believe, and you can see the very positive feelings. the american people want him to succeed. he's also done something pretty remarkable which i think with his appointments made an amazing team and i'm going to get back to that in a second. a potential transforming event is this fiscal sis we're in, clearly the worst since the great depression. and i think it has changed the landscape in several ways. we are now talking about spending hundreds of

billions of dollars, maybe even a trillion dollars for recovery. health care reform fits into that. second, with potential rise in unemployment, the financial insecurity, american population is going to want security, and one key element of that financial security is secure health care. they want to know, if god forbid they become unemployed or their employer hits financial turmoil and cuts health insurance, they're still covered. i think they will really push for health care garrity now. second -- guaranty. second there are employers. won't want this weighing on their books now. it could be difference between staying afloat or not. then i suggest there is also going to be these budget hawk who is have understood, we need, we need to have health care reform to actually reduce the budget deficit. if we're going to spend a

lot of money in stimulus, we actually have to spend more prudently in other areas. now i shouldn't end, i'm going to, end with two more comments. the first is, we should be sober there are, despite these transforming events, lots and lots of barriers to reform. we have failed for over 90 years in health care reform. well, as i started at the start, the vote we here or the poll i took here on those two questions suggested one barrier. most of us are happy with our own personal circumstance, even if we think the system is broken. and so the attitude, even if we don't articulate it is, oh, yes, keep change the health care system, but keep mind the way it is. very hard to do that. second, we have a political

system which is, given to gridlock and given not to passing major reforms. when james madison wrote the constitution, right, what was he worried about? tyranny what did he want? checks and balances so no one could actually usurp the reins of government too much. he succeeded. he would be very proud of the gridlock. makes it hard to change though. then there's what i like to machiavelli rule of reform. machiavelli, grit political scientist and advising the prince, and he says, beware of initiating anything new, because those people who have investment in the old will oppose you vigorously, whereas those people who might benefit from new system, only lukewarm supporters. why? those who lose know what they're going to lose, those who support you, it is hypothetical, it is abstract,

maybe it won't pass. then there's finally what i think many of you in california have experienced, the rule of second best. some of you may be incrementallists. some of you may be more mandates. some of you may be die-hard single-payer advocates. some of you i might have convinced to my program. all of us have a second best, do nothing. i suggest to you it is not a second best in the current system. it is a prescription for failure but it is hard for us to know. why am i optic, nonetheless, despite all these things and let me conclude on that? i do think we have a unique moment in our history, a unique recognition of the problems, a growing consensus about some of the key elements to change even if we can't agree on the final outcome. i also think we have a unique set of characters in washington that make this more possible. first the president has assembled an amazing team

beginning with senator tom daschle and his assistant, to head health care reform. his director of office and management and budget, peter orszag, has studied health care and at the congressional budget office issued report after report. really understands the economic problems related to that. larry summers, the national economic coordinator, also understands health care. it is his most important academic paper probably is on health care. finally there will is my brother who actually understands how to get things through. i didn't say that about him though. in the congress, senator baucus and senator kennedy are committed. senator baucus, cheryl. finance committee. senator kennedy chairman of the health committee. the two key committees. they really want to get something done and we haven't had that combination in a while. on the house side there are many powerful and smart people committed to health care reform.

henry waxman among the leaders. . .

asking you to elaborate on the, in your book assessing the lapeyre will quote on quote to break the bank and also i would add you did say one of your concerns is this difficult to impose cost control single payer. how many asked blacks. >> how difficult? >> how did break the bank? >> so let me say a few words about single payer. the fundamental structure of single payer is that we will have one national plan for everyone that is going to cover a fairly robust set of services and get rid of the insurance companies and save money on the administrative cost, going to have a national drug formularies and save money by driving prices

down, and continue with the fee-for-service reimbursement system that we have now. so i have a number -- the way i like to think of single payer is the most radical reform on the financing of it health care well keeping the 19th century horse and buggy delivery system that we have now and that is not a tenable long-term strategy. so let me say a few things about that. i think one of the fundamental things we need to do in american health care and one of the litmus tests you can do to evaluate health care reform proposals is how they perform the financing system to get everyone in but how they perform the delivery system to make sure we control costs and improve the quality of care and one of my major problems with single payer systems is they keep the old payment system a fee-for-service and they do not therefore encourage quality of care. fee-for-service encourages doctors to do more things, more

tests, more a procedures, not necessarily paying better for quality. if you want quality, i think if you study ever on the road and started the best systems in the u.s. whether male or the cleveland clinic, which you see is that the have coordinated care. the court made the doctors with the hospitals and the home health care agencies and the pharmacies in the nursing home's. that can be done on a fee-for-service basis and, as a matter of fact, it militates exactly against that. and so it seems to me one of the fundamental things you need is payment performance and the major proposals on the single payer don't go there. in fact, i would say that the political structure of just having one pair makes it very hard to change the payments system. second, i don't know the best way to pay a doctor and hospitals. i don't think anyone in the

world knows. we know the verse, that is what we're doing. [laughter] but we don't know the best and therefore we need a lot of innovation and experiments. we just haven't had that. finally on the cost control issue, single payer proposals man is a just as they are going to have cost control. cost savings immediately by reducing the administrative cost. they're going to have cost control over time. change how much we are spending. they have one mechanism and that is reduced the price they pay the doctors, reduce to the pharmaceuticals and price to hospitals and all the other providers. well, you don't have to be a ph.d. in economics to know that that is generally a failed cost-control mechanism. setting prices has lots of ways of getting around us. one way is you can increase the number of things you do and so you just collect the same amount of money or more.

another is to invest something new that doesn't have a price yet and have a higher price for it and that happens with a lot of technological innovation in madison. it's not an effective way of setting and try to control cost. the final thing i would say is one i mentioned before in passing which is the issue of scale. it is very hard to imagine running a health care system 300 million people. we don't run any thing -- there is no organization that big in the world. i would challenge you to suggest that is going to be inefficient system if you run for 300 million people in one organization. if we think we've got bureaucracy when we've got some system that run for 30 million or 49 people, 10 times the size. you can point to canada. canada is one-tenth the size of the united states -- excuse me, no where near the complexity.

i just think scaling it up is going to be not just difficult, and possible. >> we are going at it again. i can say. [laughter] >> you didn't think you'd get away with one question about single payer, did you? >> i will run out the clock. >> are a number about single payer particularly on this aspect and i will pick the one on one side of encarta and that is, why would we even include the insurance industry in a national health care plan when there are no fundamental role to avoid the sick, denied claims, and pass costs on to others? >> let's agree with the second half of that -- that is what they have been doing and that is how they make money. absolutely. and here's a question for you. do you think every year those insurance companies go to the best business schools in the country whether stanford r. m.r. t.? it is your nastiest, manus graduates so we can make them insurance executives? [laughter]

or do think it is a different situation? which is they are in a very bad situation where the incentive structure that they are given by the way restructure the health care system is to do exactly that. i suggest to you it is the second. we have created an environment and a structure where that is the response so that they can make money with what they have to do. we have created the behavior we don't want. so you can either say get rid of them and i will tell you what i don't think that such a hot idea, or you can say we will have to change the incentive structure here and do something different. why don't we want to get rid of them? they have behaved badly, we all agree to that. believe me, when i have to fight about my claims i am absolutely sure that. but we need an organization which is going to provide

information systems, is going to provide an infrastructure to bring doctors and hospitals and home health care agencies and other providers together, and provide incentives for them to work together. you can call it whatever you want. coordinator coming into greater here is going to look a lot like an insurance company in the end. because you have to have an organization that does that kind of stuff. the question is, can we changed incentive structure for them so that they do the right thing? so let me give you some suggestions about that. one is a standard benefits package so that they're not competing and taking services out. two, risk adjusted payments, that's a fancy word but here's what it means: if you pay them more for taking care of sick people with diabetes or heart failure or emphysema or asthma and less to take care of health teetwenty roles. right now and have a big incentive to get the hell the 20

year olds. the get the premium and a lot of payments. change that, pay them more to take care of sick patients and then you'll see a different kind of behavior. also have a situation where they keep you for a long time. you have an incentive to stay with them for a long time. suddenly they're behavioral change because if you -- if they let you get sick, if they let you -- don't venture ellises it is on their tab. well, that changes their incentive structure tremendously. right now things change. your employer decides he wants a cheaper deal, switches insurance companies. not a very good incentive for them to do the right thing. so i could be wrong. [laughter] but i think psychology has this concept of the fundamental transaction error which means we attribute people bad behavior's and is really the environment

that almost all the set in that environment that behave badly. it seems to me that's what we've got and what we really need to do is to look into the structure of the system. it is too easy for us to point fingers and say, bad boy, we have is a bad system and we've created the behavior we don't want. >> in the interests of full disclosure of the receive any private insurance finding? >> [laughter] i am a government official. [laughter] no campaign contributions, you can do that. >> in other words, it is the environment. you're listening to commonwealth public radio program and we're talking with ezekiel emanuel about his vision for a complete overhaul of our health care system. let's go to another on his question. you're plan could set up a two-tier system, those who can afford will have a gold standard and those who can't will be without. how you prevent this? >> i'm not sure you want -- i'm sure you want to prevent the

without. let me just say i think hearing or the rich being able to buy more. chris wallace recognize it is inherent. in canada they have one system. the rich still buy more and i come to the united states, they go to harley street in britain. from a practical standpoint the rich will always buy more and buyout. they don't buy it here they will buy in the cayman islands, go to britain, switzerland, wherever it is being offered several a practical standpoint you will have a two-tiered system. let's be realistic. second of all, the question should be can the rich buy more? the real question we want to ask is for the vast majority of people who aren't rich, what are we giving them? and is what we are giving them good? and that seems to me to be the question we want. how they spend their money -- that's their business. what we want to know is if we

are in the system do we get the services that are proven effective and that seems to me is the key question. i have a brother who is a hollywood agent and has way too much money for his own good. he is mr. hypochondriac. [laughter] something happens he wants the mri scan, he wants this and that. i want to deny him that. if that is how he wants to waste his money, god blessed he has the money to waste. what i want to know is when i get sick to have good enough care? that's a very different question, we should not be envious of them who want to get another mri scan or too many of these things. we should want to know, is the care we are getting good body for money. and is seems to me that is the key question and the structure i have outlined for the vast majority of americans who are rich is going to be very good care a very good services.

>> what is the government's role of federal and state it any in your proposed framework for guaranteed health coverage? >> there is extensive role for government. for one thing you need oversight. you need funding. you need someone to organize the insurance exchanges to collect data and processes the data and analyze the data, to oversee the various health plans and ensure they're actually doing what they claim to be doing purell there is still a whole panoply of things. we do need a loss of government oversight. this isn't a this regulated and ragged market. that would be terrible. you just can't have that. this is way too complicated. >> how you propose lowering interest company's overhead blacks? >> again, this is another case that seems to me where we are aiming at the wrong target. i don't like fancy swedes. i don't like million-plus dollar

bonuses and set truck. but it seems to me what do we want to focus on? we want to focus on with regard to pay you and assess your quality of care. how they achieve that, that is when to take experimentation and a lot of different kinds of initiatives and i am less worried about that. as a matter of fact, if we pay them and demand high quality care i don't think that those perks, there will be a lot of money left over for that. so it seems to me what we've got to do is focus on what we want out of the system instead of trying to find evil people everywhere and say that as the problem. chief executives of pharmaceutical companies to rich, chief executive of insurance companies, too rich, party of thoracic -- there are more than enough people people in that arrangement. it seems to me we want to focus more on how to create a structure where people are

trying to provide a lot right health care and get good outcomes at a fair and reasonable price to all americans. and when we try to find the evil devil here, we are really missing in the bigger problem with a system which is the we restructured its. i think 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 company's annual not fundamentally a universal coverage in this country, have a reasonable cost control, and improve substantially the quality of care in america. you just won't and so that his party of the wrong tree. >> what is your definition of basic health care and why should people need to pay more for services? >> so i think this is a fantastic question. let me tell you where i began

when. i began and i think most people would begin with the public at the employee federal health benefit, the plan that federal employees get in senators and congressman get. it's not the rich is package in america but it is pretty good. it is very good and that is -- as people like to say if it is enough for congressman would ever in this is probably good enough for most americans and i think that is where we should begin the debate. we can discuss whether we should i let down, something we might want to include hospital care, primary care prevention, referrals, mental health benefits. it is a fairly rigid package and i think most of us would be very happy with it. i know, it is better than 85 percent of americans have it -- that's the kind of package i have in mind. >> a number of questions about bioethics. >> [laughter] >> i work in a large hospital i

see you. when you talk about failures to reform, what about the patients and families wanting quote on quote everything done for their loved one with the best medical advice agrees efforts of utile? >> is a fantastic question typically but not always that is a result of failure of communication through the system. but let us get to i think the underlying point of that question which is what we demand services. it's easy to point to some family and say they're demanding millions of dollars being paid. you would not have a healthcare crisis if or when to families and of and how these costs out of control. it is always too easy to point to someone else. let us ask ourselves and i just got a question about can we have a really rich benefit package to cover everything we want. is sort of ghost in the opposite direction. part of what we need to do it

seems to me is two have a situation where what is called the value based insurance where things which are proven effective, proven to improve health you don't have to pay co-parented things which are discretionary, the extra hour -- the extra mri test of an extra chemotherapy. there's no evidence it is really going to work. i have to pay more. maybe even a lot more. than me get you one of my examples as you heard i am an oncologist and happen to be a breast on colleges so i'll pick on the prostate cancer doctors. [laughter] this year there will be a more than 200,000 american men diagnosed with prostate cancer, most of them early stage prostate cancer and there's a lot of different ways we can treat that. one way is watch awaiting. for many men it will not be a threat and they will die with the disease and out of the disease. another way is surgery, remove the process.

another way is radiation therapy and inside of radiation therapy there are a least four different flavors of radiation therapy you can have -- there is 3-d conformal radiation, the traditional style use an mri to focus the been. costs about $11,000. there is pretty fair before you take radiation seeds and implanted in the prostate costs about 15 for $16,000 and then there is i am are taken intensity modulated radiation therapy. focus the been even more, $42,000. then some of you know there is proton beam their pay, you don't even seven electrons could send protons. the machines cost hundred, $200 million and have to be house and in football size building and that costs $80,000 so you might ask yourself, when is the difference? well, i can tell you for early stage prostate cancer, zero difference in terms of survival.

i also can tell you we really don't know very much about the comparison because there's never been a head to head seven of these were different treatments. at best we think from single institution studies my experience that there might be a decline in sight? from about 14 percent of men having sex in the 3-d conformal radiation to 4% and the proton beam. so you might ask yourself is that worth $70,000? for the ladies in the audience, look at the man next to you and asked to pay $70,000? [laughter] so that is a case where you might say, a good insurance system would say, look, we will pay 11,000 are 15,000 for the basic radiation. you want a proton beam, god bless, you pay the remaining 55,000 or $65,000. so that is a situation where we

provide everyone very good care in this country. and he wanted the deluxe model you can pay for the deluxe model pickup now, that goes to the tiering system. you bet it is tearing. is it bad during? i don't think so. we all get a very good care. let me give another story if i might. i had to get a crown in my mouth. since i'm not so careful. the dentists recommend it this titanium whatever. and the insurance company sent back to me and said we only cover gold and if you want the titanium it is $500 more. i was outraged but then i sat back and said, that is very reasonable. if gold is a good care but i want the super deluxe titanium, i should pay that extra $500. it seems to me that is very rare. it makes me think, how much is

that worth it to me? and that is what we have to get more of, not just in them and us to. we have to experience that and make those choices for ourselves. wish to stop pointing fingers at everyone else and that may i suggest to you is requiring restructuring the health care market. most of us don't see that now. we need to restructure the system so we are paying for value and if we want more value, if we want the deluxe we pay the difference rather than asking our neighbor to pay for us. >> a reminder that you are listening to the commonwealth public radio program, talking with ezekiel emanuel about his vision for a complete overhaul of our health care system in the audience tonight obviously has a number of it kaiser patients because they've asked, what to think of kaiser model of health care? >> look, kaiser is a classic model of integrated care under

one system with a have an incentive to have the doctors work with hospitals and the other health care providers. i think it's a very good model of care and most people that have studied it think that is provided excellent care comparable to any thing in the country. i should have a confession to make. something about it senior executives at kaiser are good friends of mine. [laughter] they haven't bought me any dinners, but i do think it is a wonderful model and is a good for everyone? will everyone wanted? probably not. are there lots of people who have experienced it and really like it? the answer is, yes. >> our elected officials are struggling mightily to find ways to increase unemployment, the economy needs. [laughter] providian slip. health care reform will inevitably reduce employment.

how you reconcile these two? >> you're made. that is very limited. i don't agree with that promise at all. so the first thing to say is that no one is talking about taking money out of a health care system. no one cared for one thing if you want to cover 47 million americans released to have to keep the system as it is two not only expanded initially. what we want to do is change to the rate of growth from year to year. so from an employment standpoint you're not going to get rid of and that total number of people. you might not have people doing insurance billing and you might have some people instead looking at quality of outcomes are providing more services so the job descriptions by the difference but i think the total employment is not going to decline and all. second, if we can actually get costs under control, if we can

actually restrain increases from year to year in madison. what is going to happen? more of your money is going to say in your pocket. states are going to have more money which to invest. your action going to have a better economic times so let me just give you some history. between 1993 and 1998, roughly 1999 health care inflation actually moderated in this country. stayed relatively flat. that after the to be the time of managed care which most americans hated but one of the most important side effects was relatively slow health care inflation. well, what was in the economy doing during those years? it was employment rising, quite the contrary -- some of the best economic years america has had since the 1960's. those for the clinton boom years. there are many things that

contributed to that time, but all the economists agree that one of the key things was a moderation of health care inflation that allowed increase in wages and allow people to spend their money more and stimulated the economy so i do not accept the premise that if we have health care reform we will decrease employment and create more economic problems. quite the contrary. moderating health care inflation, giving everyone into the health care system i think will have just the opposite affected actually be good in the long term for even in the short term for the american economy. >> how does your plan deal with a lack of primary care doctors in this country? >> that's a fantastic question. we have a serious problem. ask yourselves again, why do have a serious problem, is a because doctors are nasty people and they don't like to talk to patients or is it again the structural problem? we pay people to do things. procedures, do that operation.

well, you don't have to be an economic genius, nobel prize winner to figure out, well, if i do a lot of specialty that is a lot of procedures i can make a lot of money and, on the other hand, if i talk to patients and that doesn't get paid is going to be hard to pay the bills. even as much as i like it. so you have to have a major change in how we pay doctors and we have to compensate more for talking to patients, managing their problems rather than doing things to them whether it is tests or another treatment. so that is the key question. and my system, you got the insurance companies that are going to be required to report that comes, they will be within a fixed budget. they will have a real incentive to change who does a lot of money. not to use more taxes, but to

add to have more communication, or caring, and so that i think is a fundamental issue. there are other things we need to do. i think we need to change medical education that encourages people who are interested in primary care going in. we need to decrease that of dr. so there are lots of things we could do but i think the fundamental thing we could do is change what we pay for and how we pay it. >> what you say that medicare and medicaid need to be phased out? is this really necessary? >> well, they are -- let's take medicare, it's a very good program. people are very satisfied with it, but it is unsustainable from a physical standpoint. and i believe there are good reasons to phase them out and put everyone in one program. when i go to the mat for this if we were keeping it, that would

be ok for me, but let me say one problem here. why should we segregate out the 65 year-old? think of the incentive structure that freeze for insurance companies or everyone else. you don't do a very good job, someone turned 65, there is someone else's financial problem. one of the things you want to do is two have people responsible fiscally for their issues and not taking good care of people. and so that is one of the reasons. the medicaid side, you know, it is just i think for some people it does a great job but overall it doesn't pan out. 2% of doctors don't take medicaid patients, they have a difficult time getting primary-care. i think it is widely perceived to be a second-class program. you want to fold them in with us in the system or there with everyone else rather than segregate them out. ..