there was after 9/11 when there was a considerable amount of talks with iran. so the potential's there. so the bottom line is i think we can manage the crisis. but the crisis or the problem will be there. i don't see that going away anytime soon because i think we have very different views of the future of the middle east. >> host: i am with you there, and i want to thank you for this conversation and for best of luck with the book. >> guest: thank you very much. appreciate it. ..

its recent passage and the fiscal effect on insurance providers and the federal government. this is just over an hour. >> [inaudible] principal author called the battle over health care what obama's reform means for america's future. it's a nonpartisan analysis of health care reform and where we

are headed. i approached writing that book with a question how did it happen. since the time of franklin roosevelt america has tried to have universal health insurance coverage in this country and for decades people have tried but it failed. what went on behind the scenes and the deals that were done and the important players in that, the health care industry, the insurance industry, the drug companies. what went on? what made it happen? what were the special ingredients and did america get a good deal? our finally we going to see costs control in health care? we will talk about that today. will health care be safer? will there be less over treatment? for u.s. future physicians there are many residents in this room today. what will health care look like

for you as a future physicians? really important question. finally, did we build it in health care reform a sustainable system? we build a house what would be one that generations will be able to live in? let's get started. why health care reform? just a reminder of why it's so important. you hear at st. peter's see it every day last night at dinner we were talking about the uninsured and you see patients coming in with heart disease, and managed diabetes, people with cancer that has spread to read why? because they've lacked health insurance because it's too expensive and the enormous suffering that takes place because they don't have access to health care this is a photograph to provide all for the uninsured this is america's

safety net and yet another picture. if you're uninsured and can't afford medical care this is where people will drive hundreds of miles to receive needed care. where there's a pair of eyeglasses, a sore tooth that needs to be pulled or you have cancer treatment but can't afford the follow-up care. this is where you go. this has been health care in america for millions of people. and so the decisions about what to do about it and then went here. this is a picture of blair house in washington, d.c.. the white house summit in early 2010. democrats and republicans together debating, quarreling over what it should look like if it should even have been at all. and the battle for health care will continue to the health care is reform of the land that is designed for the president to pass both houses of congress for

the constitutionality of the individual mandate last month last month the battle will continue. republicans vowed to repeal at and is a valid to prevent it from being funded and there are many substantive issues that remain to be addressed. we still have a shortage of primary-care physicians, the imbalance between primary care and specialty care remains a dillinger there enough physicians and nurses to take care of the 32 million people as the boomers turn on medicare 30 million people over age 65 will be on medicare in the next 35 years, additional people. we have enough doctors and nurses to take care of them? health care reform couldn't fix everything but there's still a lot to be done and the battle will continue. so this presentation is a non-partisan look at health care reform. the focus will be on two main

areas colin coverage and cost we can't cover the waterfront just because it is a huge bill if you want to build a health care reform to provide a good foundation will that be around and what support people with good care for generations to come so the residents who are here now 40 years from now look back on it did we do health care reform right? that's the question. there will be four parts to the presentation this morning. did health care reform diagnose the right problem? u.s. physicians know how important getting an accurate diagnosis is. did we do that as a matter of public policy? the second question is what will be covered and what will it cost? third, we will focus on what this health care reform mean for you as future physicians and for those of you that are currently practicing. finally where are we headed from an economic point of view and fiscally can we sustain financially the systems that we are creating and if we can't

what can we do about it and what should we start doing now to fix it. the reform will diagnose the problem is lack of health insurance and it's true there are up to 50 million people estimates suggest people don't have insurance and so the solution that has been prescribed, the treatment order is let's have more insurance. and so now of to 60 million people will have access to private health insurance coverage many of them with subsidies to talk about an imminent and up to 16 million people could have medicaid coverage. one of the reasons people cannot afford insurance is because he can't afford it because it's too expensive and that's because health care costs are too high. we are going to drill down on that for the next few minutes. there's a study published in the archives of internal medicine earlier this year that looked at

the cost data for uncomplicated appendicitis in the state of california. the researchers had access to all the hospitals in the state and the median cost of the hospital bill to treat appendicitis was $300,011. that is a percent of the per capita income which is $44,481 in 2011. what is a special interest in mr. range of how much the hospital bills were. of the local county hospital, it was only $1,500. other hospitals it went up to $183,000. some of the higher cost hospitals according to the study were for-profit institutions. how do we sustain this? is it sustainable? i am writing a book on medicare presently and i have the privilege of interviewing a 65

year old gentleman from kentucky who went into the hospital for a procedure which he wanted to keep private but he said he needed an operating room and chances are he might have had a pacemaker and he got a hospital bill for to under $44,000 for that one night in the hospital and that's about the cost to buy a house in his community. in fact you can buy houses cheaper than that in his community. he was on medicare and medicaid pays only $18,000. he was floored by the bill that he called the hospital and said what happens if i didn't have insurance? he said well, we will still make you pay. i recently did a radio interview in washington, d.c. and a woman called in and she said that her husband had gone in for treatment for kidney stones. he had two of them and they each, the building got was $52,000 for each one. this is the reality of how much

health care is costing, and this is why we have health insurance premiums that keep spiking. in 2011 a drug company gained rights to produce a a shot used to prevent premature births. used to be able to buy it for $10 an injection. when the end of the exclusive right to the increased the price to $1,500 in injections for a total cost of $30,000 per pregnancy. is that sustainable? and this happens in the united states because there's nothing to stop it. there's nothing to stop the price increases. in this case the american college of structure x and gynecology pushed back. the issued a statement setting for the u.s. health care system simply cannot be expected to observe the cost of its current prohibitive price without significant negative repercussions. in this case the company backed down because the exception rather than the rule an

individual patient study of the power to pressure to reduce their hospital bills. so we have a problem of gun control prices and american health care at a time when 32 million people will be getting coverage. we have an interesting situation in the country with volume a recent study in the archives of internal medicine was a survey of physicians primary-care physicians 42% of them believe their patients receive too much medical care. 25% of them believe they themselves provide too much medical care. the good news is about 75% of those surveyed said they are interested in learning how the practice compares to other practices so they can curb unnecessary medical treatment. and as young residents you have the opportunity to do that. i'm sure with dr. qatari's leadership you will learn how to do that and you should.

you will be where the american board of internal medicine foundations choosing wisely campaign to encourage doctors to provide the care people need not the carried out the issue top five list is coming out for 27 different specialties within medicine of things we can do less of and have really good care for patients. here are the top five in internal medicine. you might know them from previous presentations but i will run through them very quickly. imaging for low back pain often overused. let's do waiting for the next four to six weeks and there's no red flags. don't do the blood chemistry paddles healthy adults. don't do the annual electrocardiograms. again and a symptomatic low risk to patients. news on the generic status and don't do the bone screening for osteoporosis for women age 65 these are recommendations coming from the evidence in primary care physicians. we will talk more about this

leader about what we can do to try to curb the rise in health care spending so we can have health care reform that lasts for generations to come. this is a medical index of the annual cost for a family of four for medical care. and note in 2012, $20,728. it's been rising a thousand dollars a year if you can see that. that's where we are on health care today and there is nothing to stop that trajectory. meanwhile the median family income in the u.s. in 2011 was $50,000. so how in a family of four the average annual spending is $20,000. how do you do that? are there even enough federal subsidies? is there enough money in the federal government to keep subsidizing that? while i was writing the battle

over health care i listened to an interview on the abc nightly news. the secretary of health and human services kathleen sebelius was being interviewed in the context of stories the were being reported about tremendous increases in health insurance premiums but individuals are having to pay like 20, 30, 40%. and i found the question and answer really quite remarkable. the question that was asked by the interviewers what should people do if they get an increase in their premiums of 20, 30 or 40% and they can't afford it? and this was after health care reform and the most remarkable answer which i frankly was not aware of until it was said so starkly her reply was they should contact the governor of their state and state legislatures demanding that deval will be changed referring to the law pretending to the health insurance review. and what that told me was that there's nothing in the health care reform law to stop the increase in the cost of private

health insurance or medicaid. there's nothing. so we define health care reform the problem as a lack of insurance. is that the real problem? is the real problem affordability? for the subsidies on exploding cost cox also while i was writing the battle over health care you will remember the oil spill in the gulf of mexico and pictures like this were seen around the world of the oil coming out of the earth and there was no way to stop a. day-by-day people watched around the world and there was no way to find it. finally the engineers rate to cap and i couldn't resist making a comparison with care. there's nothing to stop it. it keeps coming and there is nothing to stop it. just a word about medicare. the one part of health care reform that has brakes on it pertains to medicare.

there are a number of other provisions adding preventive benefits for annual mammograms and colonoscopy is that of co-payment closing the doughnut hole for prescription drugs, all good things and here's where we're headed in medicare. this is a -- from the medicare trustees' report reports on the state financial state of medicare it starts in 1967. this is data for how much the average person is over 65 and collecting social security let's take someone who's earned $50,000 a year the average over the course of their working life. today retire and when you retire you have to pay for medicare. it's not free you have to pay premiums and co-payments. you pay for part b which is doctors' charges and part b is prescription drugs. in 19672 years after medicare was started, the average person

on social security paid 6% of their social security checks just for physician visits. there wasn't part d a times a 6% of the social security checks. in 2010, its 27%. in 2035, it's going up to 40%. 25 when the young people in this room and you are in your eighties you'll be spending 46% of your social security checks just for physician visits and prescription drugs. it does not include the cost of hospital care the deductible or the co-payments that you have to pay. again these are projections that this is very sobering. in the health care reform law there is a recognition that medicare we need to find a way to address the cost trajectory. there's a provision for an independent payment advisory board to be set up 15 mayors appointed by the president and confirmed by the senate and they

would recommend ways that medicare can keep spending and check. now there's one thing that believe it or not president obama and rush limbaugh agree on. they agree that medicare is unsustainable as it is now. so if they agree on something that must be true. here is what president obama said. the u.s. government is not going to be able to afford medicare on its current trajectory the notion we can keep on doing what we are doing and that's okay is not true and of rush limbaugh's that i don't like the idea of letting medicare collapse. it's not sustainable. as of the independent payment advisory board was included in the health reform legislation it cannot change eligibility or ration care increase premiums. if congress doesn't like the recommendations it doesn't have to implement them but congress does have to find an equivalent amount of savings to pare back medicare spending.

but the independent panel advisory board has been targeted for repeal buy very powerful forces and this is a pattern and health care reform and all the deals are done that any curve on any revenue any effort to curb that revenue they want to stop. so just as 32 million people will have engines the industry will be getting 32 million customers but it's lots of revenue and they don't want any impediment of getting that revenue. it's interesting the year the health care reform law was signed, "the wall street journal" reported its annual ceo compensation survey they reported the highest median compensation of any sector in the u.s. economy that year was healthcare. it wasn't the banking industry, it wasn't the oil industry. its health care.

i am also mindful of during the financial crisis charles princeton was head of citigroup said when the music stops things will get complicated but as long as it's playing we have to get up and dance and we are still dancing by for a rebuttal to we have these trajectories and where are we headed? the question remains is the healthcare bill to last? what do you think? let's talk about the cost and coverage provisions under health care reform who will be covered under the patient protection affordable care act and would cost. the good news is up to 16 million covered under medicaid the joint federal program there's a number of state governors who are not inclined to expand medicaid. i think it's more for political reasons they also have serious budget situations. i suspect there will be a lot of pressure from hospitals in the state that will wear down at the

positions of it's not clear all 16 million projected people will be on medicaid. new jersey is a state of foreign debt thousand four to 50,000 people some of the people who come to your clinic or are uninsured now will have insurance. that will be a good thing. so what is this individual mandate. it requires almost everyone under age 65 to have an jergens either from their employer or from medicaid or private insurance. and if they don't have this they will have to buy at and that is employer coverage on medicaid and that will effectively estimate up to 60 million people and they have to start getting insurance starting at 18 months in january 2014. there's been a lot of talk about subsidies but how much will it really cost? so the kaiser family foundation has a wonderful subsidy

calculator where again the year just estimates and projections based on data from the congressional budget office. the report to the 45-year-old head of household with an income of about $46,000 a year will pay $2,600 a year for insurance in 2014 and puts subsidized and have maximum out-of-pocket costs of more than $4,000. the with the subsidies are structured the benefits are different a 60 year old person earning $48,000 a year will pay $10,000 for insurance in 2014. and plus out-of-pocket costs of to $6,000. i was surprised at how much. that's enormous. what is an exchange and how will it work? people will be able to get their private insurance on an on-line exchange. they will also be built access

it by telephone and provide information to help consumers shop for health insurance plans and apply for subsidies and tax credits. so when a travel website plight expedia.com it will all be there. you can select your choices from that. make it a lot easier than it is now. you might have heard about the penalty. do i have to pay a penalty if i don't buy insurance? in 2016 the panel to be $695,000 a year or 2.5% of income what ever is greater that there will be extensions. the will be exempt if you have financial hardship for religious reasons and others who won't have to pay the penalty. so as health care reform moves from the supreme court to the court of public opinion, will people buy insurance? wealthy be able to afford it? even with subsidies? are the penalties strong enough to encourage people to buy insurance? you can imagine people with a

serious illness who haven't been able to buy insurance because they've been excluded the will be delighted the prospect so relieved they will sleep better at night and they will be happy to buy it. others may feel differently. if healthy people don't enroll and only the sick people in all, what's going to happen to those premiums? if you have only sick people they are going to go up even higher. there's no enforcement of the penalty. there is no lien on your property or garnishing of wages. so even though we've come this far, still many unanswered questions and uncertainties. what about employer provided insurance that will affect most of you in this room who are fortunate to have it. how many of you have insurance? so what will an employer provided insurance cost. what benefits would offer? will employers continue to provide insurance? most employers will continue to provide insurance as they are

now, but it's changing. i'm sure you have seen the changes yourself. you are paying more of your income for health insurance. people are getting fewer benefits. the deductibles are higher. i call it the swiss cheese. health care insurance has become like swiss cheese, has more holes come unless she's. here is the the from the kaiser family foundation. on the bottom line you see the growth in employees and come from 1999 to 2011. so people's incomes have been growing over that time period by about 60%. the cumulative increases. but then look at the top line. that's how much people are paying more for health insurance. the increase in their health insurance out of pocket for employees was 169%.

so you have a huge gap. what it means is incomes are not rising anywhere near as fast as the cost of health care. and to see that trajectory is going up and up and up. if you look in the top right corner, right here, while the cost for insurance is going up, and we use are being asked to pay a higher share of it and that is reflected here in this slide. if you work in a company with two injured 99 workers, that's the top line here you'll see 29% of employees are paying to hundred thousand dollar deductibles before their insurance kicks in and look at the growth trajectory from 2006 at 6%. and much higher in 2011. so there will be insurance but i will have a lot of holes. there's a penalty for employers

if they don't provide insurance depending upon how large the employers are. employers with more than for the employees that don't provide insurance and have at least one full-time employee who receives subsidies from the insurance exchange will pay a penalty. will be to hundred thousand per employee excluding the first 30 employees. but the businesses have already calculated it's cheaper for them to pay the penalty than it is to pay insurance. so what's going to happen? this is the trajectory of all firms offering health benefits from 1999 to 2001. the researchers can't -- i'm not sure what causes the public that you see here but you see the overall trajectory is moving downward and i predict that there will continue particularly among small employers. what they may do is offer just like we've done with retiree benefits we've moved from a defined benefit defined contribution to get a set amount of money and then you can go get

your insurance. i predicted that is what would happen. what about states and medicaid? that expansion and the federal government will pay 100% of the cost of medicaid expansion from 2014 to 2019. but beginning in 2020 that will change and states will have to pay 10% of the cost. if you have been reading the news if you have time, you will see that california and new york both headed by democratic governors have had to slash medicaid budgets because overall state budgets are under tremendous pressure to read a former state medicaid director in california governor arnold schwarzenegger said medicaid provides care that's invaluable but it is under its own weight states are now being asked to implement the largest social prison since medicare and medicaid began. matteo is falling apart as the states could benefits as enrollment increases because of

the recession and we are still seeing the after effect of the recession a recent report cannot about the state of state finances two weeks ago and it's a very challenging environment still. what this health care reform mean for u.s. physicians? what will be different? what will life be like? the good news is more of your patients will have health insurance. when we were having dinner last night the doctor was mentioning how when he was a grunt 1965 and medicare got started, basically it was the clinic because older people for longer needed a free clinic for the uninsured because they had medicare. here there will still be uninsured americans but they will be far fewer of them and that is a good thing to read what about primary-care? access to primary care will be more challenging than ever.

the way i talk about is health care reform is like building a house without a first door. there are provisions in the health care law, terms you may have heard called patient centered medical homes which are wonderful things the they are not enough of them and there are not enough primary-care physicians for nurse practitioners to be able to handle the number of people. and that many hospitals around the country today if you call to get a visit with a primary-care physician you cannot and we are going to be heading 32 million more people come onto the system. for people on medicare, while we close the doughnut hole for prescription drugs, the number of geriatricians is actually shrinking. so who's going to take care of those 35 million more people who will be on medicare in the coming decades as the boomers retire? who is going to take care of them? who will coordinate their care?

s future physicians who will be practicing in a professional team based care that will be an expected competency for you. practices 18 high functioning teams and physicians advanced practice nurses, clinical pharmacists and others and future physicians will be expected to demonstrate competency and working in a professional team. this will be part of your maintenance of certification assessments. this will be unexpected confidence because we have to work in teams to manage all the care. the other thing that you will be seeing is downward pressure on physician payment. as all those cost pressures keep escalating, there's only a few ways to cut that and that is to keep payments low. we are already seeing that and as a consequence demands for increased productivity. we see more patients in a

shorter period of time. that's very dissatisfying as physicians. on the flip side would agree to happen is increasing volume working even faster and faster. so the question we have for the day is how do we ensure health care and reform is built to last? how are we going to ensure that the house that we've built is going to be around for generations to come? if current trends continue, the data are clear that we just can't continue and this would have happened whether or not there was healthcare. if anything health care reform may accelerate because we have more people using more care but this is going to happen even without health care reform and this is not a democratic republican issue everyone bares responsibility for a.

so what happens if we don't act? putting on an economic stat for just a few minutes you may have heard about the national debt. the national debt is how much the federal government owes the people who have lent money. in 1985 the united states was a net creditor to the world. we used to loan money to countries. and here we are in 2012. the u.s. has gone from the net creditor to the net debtor. we don't loan people money anymore. we have to borrow from them to pay the bills. so when you see medicare patients and those bills going to medicare the federal government doesn't have enough money to cover all of its bills so it has to borrow money from countries like china to pay the doctor bills and hospital bills. how much debt does the u.s. have? presently the total debt is

$16 trillion. it's hard to get your hand around what is $16 trillion. so here is what $1 trillion is. sidey dr. qatari a million dollars a day since year one, since the year jesus christ was born that wouldn't total a trillion dollars and we have 16 of those that is how much debt the u.s. has so when you the debates in congress which will come up again about raising the debt ceiling that is what this is about to read are we going to allow the country to keep borrowing more and more and more. a summary of the we put in the battle for health care which i hope never happens but if we don't act and do something now at some point we are looking at what is going on in the bureau's own countries places like to greece and spain that cannot

repay their debt they are having to ask for a bailout money from the countries and from the international monetary fund. heaven forbid the united states ever gets in that position. the international monetary fund is already monitoring health care reform because the united states is a member of the international monetary fund. so that is the debt situation that we're looking at as a country. where do we begin to change course? that is where all of you come in especially those of you that our future physicians who will be taking care of patients. what can you do it? the institute of medicine estimates that about 30% of all the money spent on health care in the united states is wasted meaning it does not add value to the care of patients. it does not improve their health. so what is included in that? it includes over use, it

includes an efficiency and fraud we will talk about all of these and how much as 716 billion as close to that trillion dollars? and we waste that every single year. if we can take that out of the system we will be in really good shape and we will have built a house with health care reform that will be around for generations to come but will depend in part on you. what to do to reduce over treatment. your pen and that keystroke which you use every day to order tests and prescription drugs it's a very, very powerful tool if you have in your hand. as mentioned earlier with the choosing wisely campaign this 27 medical societies that have developed these top five lists or are developing them of things that we can do a lot less of or

maybe stop doing at all. in addition, there are other procedures and surgery's that have been well documented in the medical literature is being overused. heart bypass surgery, angioplasty come back surgery, prostatectomy come antibiotic use all over used. in september of this year the joint commission credits the nation's hospitals or many of them will be hosting its first meeting on over treatment and they will be looking at a number of these topics trying to come to consensus on what it can do as a creditor of hospitals to encourage hospitals to reduce unnecessary treatment. i think we have a moment in time now with health care reform that if we have unnecessary procedures let's stop doing them on people who don't need them and use the talent and skill and resources on people who really do need them. if we can make that switch now,

everybody will be kept intact. maintenance of board certification. if you will be seeking board certification in the future i see your heads come up. in 2015 appropriate use will be part of maintenance of certification. to knowing when is it appropriate to do imaging for low back pain. screening for osteoporosis. when is it appropriate if you do one ecology for that third round of chemotherapy? and when is there no evidence it will actually and if the patient? lummis angioplasty appropriate and not? this is what you have the opportunity and it's a good thing. so we can keep the system whole for everybody that needs it. what is overuse as defined by the institute of medicine as a potential for harm exceeds the possible benefits.

so this is not about rationing. this is not about cost control. this is in fact about a good care with the patient. i've been continuing to work on over treatment. i was here two years ago to talk about the book i wrote called the treatment traffic coming and i am happy to say now that there is a lot more momentum to address this issue of over treatment. here's what some patients are saying about their experience. a colleague i used to work with said i'd been getting an ekg since i was 27. i am 41 now. i don't know why i've been getting it. i have no heart disease. my husband gets one, too. i spoke with this person recently and she said you know, i went and i talked to my doctor and i don't get those anymore and the same with my husband because they are not medically necessary. here is another one.

i get a chest x-ray every three months from my doctor. i don't have any underlying medical conditions. next time i'm going to ask him why. this came from a state legislator i gave a talk at the council of state government recently the east coast regional conference, and was how we really have to address this issue of overuse if we are going to have system in the house everyone can live and brought this of and said he was going to go back to his doctor and say why am i getting this and think of the radiation in this book who's counting that? do you even know how much it is? we are not tracking and we probably should. here's another one. my knees were hurting and i went to an orthopedic surgeon. he said he could do surgery. he didn't talk about me or my situation. i left and found a personal trainer that helped me strength and my muscles. i am much better now.

so we are seeing in from the educated people make a good informed decisions about the use of health care. it's not anybody by any stretch at least we are beginning to see it and we are seeing good doctors have good conversations with their patients about the appropriate use of resources that is what the choosing wisely campaign is about and why am delighted the residence will be learning choosing wisely as a part of your curriculum. finally my 83 year old mother-in-law was having problems with her shoulder she went to a doctor that said he could operate. i went with her to get a second opinion with physical therapy and time for healing she was fined. better outcomes, better care and by the way, it costs less. there's abundant opportunities in the health care system to do this. you know the way i think about health care it's how we deal with suit. on the one hand, we have an obesity epidemic sets off the

charts. people eating too much food, the wrong kind of food at the same time we have pockets of communities where people are malnourished. we have an extraordinary imbalance and the same is true in health care. we have people getting too much medical care and yet we have people who can't get what they need. if we can reduce the overuse and put to good use for people who really need it we will have enough to take care of everyone. we have that opportunity to do it now and we have to get started because we don't have much time or money to waste and the was a topic of the book the treatment trapp overuse how do we curvets? finally here is a fact i found interesting. the fbi has done an estimate of how much fraud there is an healthcare. i began to look at this and give a talk of the anti-fraud association.

it turns out about 10% of health care spending the fbi estimates is lost to fraud and the extent and the sophistication of it is enormous. so if we take just 10% of health care spending if we spent $2.6 trillion a year that's 2.6 billion were tendered 60 billion that we spend that's lost to fraud. that amount of money will cover every single uninsured person in america just reducing that to read the health care reform law includes provisions to curb it, but it's their modest steps, very important steps it's a far cry from what we could do to to get out of the system and use that money for people who need it. the people who come to your clinic at st. peter's or on insured who will be able to get better care.

so what can you do? we have to preserve and sustain the good the medicine does and they do have a value to life. what can you do? u.s. physicians and nurses? you can ask yourself of the test that you are contemplating will it really do that person any good? will they be better off by it? what is the evidence objectively? what do your peers say? do they agree? the good news is we are seeing more and more consensus although there is a lot of different points of view. but i will leave you with this quote. he says we call the face of the poorest of the weakest man whom you may have seen and ask yourself if the steps to contemplate is going to be of use to him.

will he be better off because of its? then your doubts and yourself will melt away. that's how we can make health care sustainable. it's how we can make health care reform which for generations to come to serve everybody so they get the care that the need. the care that will sustain them and bring them whole figure and happier lives. thank you for all you do and i would be happy to have some questions. [applause] >> you have to go to the microphone so everybody can hear because we are on tape. hello, good morning.

>> the starting point might be collapsing under its own weight the health care system might collapse as you say that there will be a lot of pain and various other avenues that might materialize in this global world where health care might be exported and people might even seek health care elsewhere. knowing that we are seeing the globalization on lots of industry's growing abroad, so a lot of people are not missing out on employment and likewise health care for the good, and it

seems there is a lot of pain. it is this particular part that is going to be so troubling on the unregulated unsavory practices might prop up along the way and we have to build with all of those. one of the other things that comes to mind is the way we are taught at medish school we learn indication of this an indication of this operation and that operation or the street under that treatment. then when it comes to take care of a patient you tend to think the same way by the way i'm a surgeon. i have an operation to offer. nothing else was talked about.

you might say what has to be changed with every single patient what is the treatment along the way not particularly for the most expensive treatment for most rewarding treatment yourself i don't think that is taking care of the patient's welfare. the medical schools to test to at the med school level yes we are teaching you this way in fact thought myself at medical school of this notion indication of this an indication of that and such. >> you mentioned the word description. because of a federal law, federal officials are required to report at a certain point

when the medicare program reaches a certain fiscal situation i won't go into all of the details, but since the administration of george bush and more recently the obama administration federal officials have issued funding about medicare financial state and the use the term the destructive consequences to society if we don't fix this long term trajectory. so you are right about that. let me also say something about globalization. i had the privilege of speaking of the british medical journal for health care improvement conference in april on the evidence of overuse translating it into improvement. and i asked this audience of people from around the world 70 countries represented. i'm not sure if they were all there at that particular session i asked if you or someone you never had medical care that they thought was unnecessary and all fees hands went up.

i asked how many of you reside outside of the united states and all of these hands went up. i was surprised when people came out afterwards khan to say from finland, germany, the u.k., new zealand we're seeing in the emerging markets in brazil and india evidence of overuse. so this is a global phenomena that we will have to tackle. in provinces in canada 41 and 42% in some provinces of the state's budget spent for health care. if you are doing that you are not spending money on education and infrastructure on investments of science and technology. it's an enormous issue. thank you for your question and comment. >> climate >> guest: they're always is to have spent time in primary care as well and i could spend an hour just counterpointing and raising so many issues that its internet, but i wanted to make a

couple of points and that is the first thing is the issue of primary care. the primary care physician is being asked to be the foundation. the primary care physician has the most responsibility of any other physician. they have to know everything. they have show with the right and left hand is doing. they are responsible for everything that fay refer people to come they have the least amount of time. they are the ones that have to talk to that patient who went to the orthopedic surgeon and could have been talking about going somewhere else for care. they can't do that because they have to go faster because they have to see more patients and its crushing and for people to become primary care physicians they get the least amount of

money they have the least amount of responsibility the of the biggest burden for lawsuits and that brings me to the fact that there is an imbalance because this in balance that we have come and i really don't know who was behind closed doors when the whole obamacare of 50 billion pages was implemented, but i've got to believe as a physician in the trenches there were not enough of us in their helping to formulate a plan, and i feel just from my gut because all the people that implement the plan all the congressman just happened to be lawyers and because of the fact we can't control health care costs, part of the overuse of health care has to do with the fact that we are shaking in our boots have

the time about being sued for things that we shouldn't have to be sued for because using clinical judgment and standard of care just isn't good enough sometimes because when the lawyers are breathing down our throats we still have to worry about the time that we have to spend in a courtroom for a frivolous lawsuit this going to take us away from our patience and even if we are found to be non-guilty spent time, we lose money, our patients suffered and the lawyers are laughing to the bank. the same thing happens with -- and then i will close because i know i'm going on and on like a mad person. but the other thing is as long as you have political action committees that are powerful and the political action committees of the insurance companies are powerful so what did we do? we said everybody has to have health insurance.

okay, so the ceos who are making all the money that you talked about are laughing to the bank because now everybody has to have health insurance but there is no competition across the state lines. we've lost the sense of competition to make a product that gives good care that is going to provide people with the care that they need. instead, we have people having $2,000 of deductibles so they never get any health care insurance at all. premiums going up, no competition among state lines. if you can pick and go online and pick any health care insurance product in the country may be we would have competition and needy people would care about providing a good product maybe there would be good insurance and maybe those ceos would have to take less of a bonus so we are talking about fraud of such a huge magnitude that has to be routed out and we just have a lot of work to do a

lot of it is to do with government. >> think it reflects the views of a lot of the physicians. [applause] if they cannot and supported the health care reform law to the opposition for many physicians so the community was really decided when it came to whether or not to support it and that division continues. i think you make a good point and i would takeout from the patient perspective did health care reform design a system the was going to be good for patients? reticulate the price doubles, drugs that go on the market and then go off because they're found to be helpful. we have a lot of financial interests at stake that make it difficult to change and i think that relationship between

patient and the physician and not so sure health care reform was built around that and that isn't good for doctors and it's not good for patience. so think you. yes, sir. >> can you comment in also address this issue of the dartmouth that was recently published that about 50% of health care costs, and the last two years of life and guess which state leads the way and that at last report. new jersey. so, can you comment on care at the end of life, the cost at the end of life and how the new health care reform would address that? >> as you know, there was an attempt to put a provision in bill walz that would allow medicare to pay for a conversation between a doctor and a patient about serious

issues about a life on it singleness and suddenly we have this term called death panels that cropped up that to cut profession out. it the intention of that provision was to recognize when patients are seriously ill and was commented earlier seven minutes isn't enough time to talk to your physician when you're facing this illness when you have a bad diagnosis. the intent was to create a space in time what i called a secret conversation about what people's choices are, what's important to them. so we tried it but was for political reasons i believe. i spent 12 years of the robert wood johnson foundation trying to bring care into the mainstream of the u.s. health care system. it started when a major study cannot was published showing how

poorly we care for people at the end of life and so we launched a major initiative and we started to help hospitals and physicians and nurses established these programs and their hospitals which is a good thing where people can get the care that they want to read it serve the early form of shared decision making. so while that has taken off and we have a specialty called medicine that they put together the question remains how come they keep going up and up and up? on the other side of the equation are the families that are deeply, deeply troubled about what many of them not all but many are deeply troubled about what they see their loved ones going through. it's a manifestation that we don't know what to stop and we don't have a mechanism to stop and that will rely on physicians, future generations and i would love to hear your thoughts on we can do to insure

people get the care they need that will benefit them we have public expectations that's why we have an overuse problem we think there's a cure for everything if you turn on gray's anatomy or those television shows on almost every night you think that we can work miracles so we said the public a steady diet that more is better that there is a cure for everything. the television show house every test known to mankind can be done and should be done is we've created this infrared for the public to believe more is better and how we begin to reverse that and that is the choose leah why is campinas for and we should stop drinking a therapy under certain conditions we tried the third round there's no evidence why are you doing that? so, i can't agree with you more. it's very tough publicly to do but a love -- the first time i heard him patience and families describe what they see their

loved ones going through and very, very terrible terms it's almost like post-traumatic stress the experience because of the intensity, and yet its medicines desire to want to do good. but also the need of wisdom to know when to stop. ..

you you you you you you you you you you were back home hospital and he asked the financial people to go through the inventory within minutes operating room to find out how much all those things cost. he had no idea. it turns out there were things with $700,000 at the supplies and equipment in that inventory. 10% of that was expired. and he whittled it down saying i really only need $295,000 worth of enormous savings. dashes when operating. so then he went to the ceo did she imagine if they did this systemwide in a calculated, they could save billions of dollars. just by asking a simple question when prescribed a drug for your patience, when you do a test you

don't want to be done on the basis of price, but just being aware of how much these things cost. was just do it. we all need to be good stewards of resource. simply asking the question. i now see more of price transparency in the health care bluebook. for patients going to have no idea. they think they can pay $1500 for a colonoscopy. sewer beginning to see more price transparency. that's no guarantee that we'll see prices come down. i think it's asking questions, simple questions. how much does that cost is the place to start. >> i am a fourth-year medical student from tracker university. matt has to do with medical education the cost of it. i'd go to one of those expensive medical schools in the country

and that goes with what dr. goldstein earlier. when were coming out of medical school was such a high amount of data, that kind of changes the opinions of what field should i go into? how i sustain myself in the future and pay off my debt and have a good living? and already they changed the way we get along with the subsidies. they're taking some of it away this year. what is being done about that? also 32 million people. more and more medical schools are opening up, but are we able to provide and sustain the cost of education in producing one physician more and more i feel it requires a lot from society of college medical school in training. so your thoughts on that. >> thank you of support your school asking that question.

why does it cost that much? on what basis do we decide that issue cost as much? i think what we have with medical education is the cost of college guys going out in a perfect storm of health care and education coming together and you thought right then about that story. you another medical students. and i don't think there is any answer for that. the health care reform law has similar provisions that people want to go to primary care and work in underserved communities, but that's not an answer. thank you. we have one final comment. >> ima urologist and i sympathize with the medical students at the current education system and the debt

burden that they have. doesn't lead them into primary care at all and this is what they need is to the system has to be steered in such a way that should be incentive enough for some sort of relief from the cost of education. and the system otherwise lined up importing.there is specifically geared to primary care. i think that's the avenue that the countries that to take. >> i think that's what's happened to geriatrics. it's the lowest paid of all the specialties within medicine and 40% of fellowships are and how this i understand. so symptomatic of a set. many foreign medical graduates come in and do a fellowship. they may not have the same that we have within the u.s. so health care reform on the fixed part of it and there's many, many other things than

each be done and that needs to be put on the agenda. thank you for all you do in the care you provide to your patience. [applause] >> louisville has contributed many cultural icons directv from the kentucky derby future children to the louisville slugger baseball bat. louisville hopes that their louisville affiliate to have a live rich literary historical culture. >> my name is karol bassi. i am co-owner with my has-been of carmichael's bookstore in louisville, kentucky. we just celebrated her 34th anniversary and eight rule.

we sell a little bit of everything. we do for space reasons exclude some categories, technical books we don't get into very much. a lot of literature, history, and lot of children's books come is certainly a lot of local lan trace, but we are a general bookstore, so we have just about anything people are looking for. i think that a small story is the right size store and it took a while for that -- people to figure that out. but i think that is the direction. it's the whole shop local, supporting the businesses who are in your community because that keeps money in your community. people are starting to understand that message. also the personal service you can get in a small store rather than wandering around a bit like store looking for somebody to help you. so i think our side has really been an asset to us over the

years. >> how many books are there going to be? we are living in chicago in the 60s then she got just a clerking job in the bookstore called barbara's in chicago than i was doing something else and after a little while she said he should come -- this is really a pretty nice life being a bookseller. we did that for about five, six years and kind of tired of the city a little bit and decided to try this ourselves. we at kentucky connections, so louisville was a good place to start and we started small and kind of stayed small, but we do not affirm his 35 years. certainly in the 70s the

competition in chicago was enormous because there were lots of old bookstores like crack summertime is that it bednar for 60 and 70 years and some of the first discounters crown books, which some people may remember her one of the first big discount bookstores, a lot of stores in chicago. so that was a little tougher i think you have an independent that when i first came to louisville. and it was before the superstores and everything. and all people worried about where walden in the mall. it was the day at the mall in the 70s. now that's changed. it's crazy. so there was no bit box store competition until much later. it was a struggle. it was really tough because, you know, books aren't food.

everybody eats, but you know, buying books in the bookstore is a really small percentage of the population, so it was kind of a struggle. but that's true of every small business i think. you know, it takes a little while to build up critical mass and repeat customers and you make somebody happy one time and then they come back and you make them happy again and they tell three friends. it takes a while to build a small business. a lot of the stories that i've seen thao are stores that were open by people who were interested in having a business, not the fever had an attachment to books or love of books. they were business people and i saw an opportunity and books to have a business. i think you really have to have kind of a got attachment to

books to care enough about them because your customers are like that. i mean, they come because they really care about books. so you have to have that kind of same wavelength they think to be successful, to him somebody about to say i loved this book and have them come back to you and say i'm so happy zometa or as i love it, too. you really have to care about it. it's not potato chips or bradbury product. it really is -- you feel like you're doing something important with your book. >> i think the role role in the communities as a bookkeeper will keep independent bookstores alive because people want to place were you contacted talk to people that has come in no company still has that human interaction rather than just sitting in a computer clicking.

there is discovery that only can happen in a physical bookstore and i'm optimistic that is going to keep us another independent bookstores helped it along when. >> for information on this and other cities is today by c-span local content vehicles, visit c-span.org/local content. >> what are you reading this summer? booktv wants to know. >> i'm chuck todd with nbc news. i read about 60% of the time on my ipod and 40% of the time hard copy. let me start with my nonfiction this summer. during the last break i read a book on fdr, the election in 1844 by david jordan.

another one came up a family weintraub, the same campaign. i'm obsessed with this for a number of reasons, but why it may be interesting to political junkies in today's time. comedy read about thomas dewey and you see a lot of mitt romney. the good, bad, all the issues that we're talking the gc being talked about mitt romney, you see pop-up when you read these books about thomas dewey, particularly the campaign of 44. forget the campaign of 48. so that no one am working on. i'm also finally gaining to a nonfiction book i've been meaning to read for some time. it's about a friend of mine named john pack. he wrote a book called pinched and it was about the great recession and it is chronicling sort of how is culturally changing us. it's not just in the pop in books, the sort of a kind of

long-term changes taking place in many places around the country, talking about a white male underclass is one of his thesis is there. but it's a good way and think about making it required reading frankly for a lot of my folks internally. but i think every politician that you read this and understand because it really explains as well as anybody that chronic pessimism out there. we see it in all the polls, but that's something that's way that we are so pessimistic about the future? we don't have this optimism anymore. there is just a pall of pessimism. it's not necessarily translating them the benefit frankly one party or the other. it's been sitting there and sitting on s&s great recession. look, we've gone through this before as a country. it takes time to get out of these things and that's why you