healthcare than on housing or on food? what we tell those businesses that are choosing between closing their doors and letting their workers go? what we say to americans like laura, a woman who has walked all -- who has worked all her life, whose husband has worked, whose family has done everything right. a brave and proud woman whose child school recently took up a penny try to help pay her medical bills. what do we tell them? [applause] here is what i am going to tell them. after decades of inaction, we have finally decided to fix what is broken about healthcare in america. we have finally decided it is time to give every american quality health care at affordable cost. we have decided to invest in reforms that will bring costs down variate [applause] -- that will bring costs down.

we have decided to bring costs down now and in the future. we have decided to change the system. so that our doctors and health care providers are free to do what they studied and worked so hard to do, to make people well again. that is what we can do right now at this moment. i will not accept no for an answer. we need to get this done, but i need your help. that is why i welcome your thoughts and questions on this and any other issue. thank you very much, green bay. [applause] ok, here is what we will do. i have 15 or 20 minutes. everybody, sit down. here is how we are going to work

it. there are no pre-arranged questions. just raise your hand. i have not preselected anybody. i will wrotgirl, boy, girl, boyo i am not accused of bias. i will not get to every single question, but i will try to get to as many as possible. there are microphones in the audience. if you can wait until the microphone comes to you, and that way everybody will be able to hear your question. stand up and introduce yourself as well. this the young lady right here. >> that afternoon, mr. president. as a self-employed individual, i spent approximately $8,000 annually on my health insurance premium. it is a $2,000 deductible, no dental, vision, or prescription

is -- coverage. i am now in a situation where i am taking the savings to pay for food and housing because i do not want to lose my health insurance. i am a supporter of a single payer system over any other system, because i do and believe it will meet your three criteria and be the most economically feasible plan that we have. and you were speaking, you mentioned that if we go with the public and private option, the public auction will keep the private insurers honest. my concern is that we will end up in a situation like we had with medicare, where medicare is basically a subsidy of private insurance companies because folks are able to buy medicare advantage. it seems to me we would take that same scenario an increase in our for the entire country. that is why i still support single payer, and i know that one point you did. i would ask that it still be on the table for consideration.

>> thank you for the great question. let me just talk about some of the different options that are out there, because sometimes there has been confusion in the press and public. people use politics in talking about the issue. there are some folks who say socialized medicine. you hear that all the time. socialized medicine would mean that the government would basically run all healthcare. they would hire the doctors, run hospitals, they would just run the whole thing. great britain has a system of socialized medicine. nobody is talking about doing that. when you hear people say is socialized medicine, understand, i do not know anybody in washington who is proposing

that, certainly not me. socialized medicine is different from a single payer plan. the way a single payer plan works is that you still have private doctors, private hospitals, providers, etc., but everything is reimbursed through a single payer, usually the government. so medicare would be an example of a single payer plan. doctors do not work for medicare, but medicare reimburses for services that are provided to seniors who are on medicare. there have been proposals to have essentially medicare for all, a single payer plan for all americans. that person likes it. [laughter] there are some appealing things

to a single payer plan, and there are some countries where that has worked very well. here is the thing. scratch. we have already gone, because of historical reasons, we have primarily an employer based system that uses private insurers, long sought a medicare plan for people above a certain age. then you have medicate for folks who are very poor and not have access to health care. so we have a patchwork system. it was my belief, and continues to be my belief, that whatever we might do if we were just pouring from scratch, it was important in order to get it done politically, but also to minimize disruptions to families, that we start with what we have as opposed to try to completely scrap the system and start all over again. my attitude was, if you have an employer based system, and a lot

of people still get their health insurance through their jobs -- obviously you are self-employed, so it is a different category. rather than completely disrupt things for them, i attitude is, let them keep the health insurance that they have got, the doctors they have, there is still role for private insurance, but let's have insurance reform so that you cannot eliminate people for pre- existing editions, -- pre- existing conditions. there is none of the cherry picking to try to just get the help these people in short and get rid of the sick people. you have to set up some rules for how insurance companies operate. no. 2, for people who are self- employed, small businesses, and others, they should have an option that they can go to if they cannot get insurance

through the private marketplace. that is why i have said that i think a public auction would make sense. but that does is give people a choice. they are happy with what they've got, if they are employed by somebody who provides them with good health care, you can keep it. you have to do anything. if you don't have health insurance, then you have an option available to you. how this debate is evolving in washington, unfortunately, sometimes falls into the usual politics. what you have heard is some folks on the other side saying i am opposed to a public auction because that will lead to government running your healthcare system. i do not know how clearly i can say this, but let me try to repeated. if you have health insurance you are happy with through the private sector, then we are not going to force you to do

anything. all we are saying is, for the 46 million people who did not have health insurance, or for people who have health insurance like you who are self-employed, but the premiums and deductibles are so high that you almost never get prevention services, it put off going to a doctor until you are billy sick because of the out-of-pocket expenses, let's change some of those incentives so you get more people being prevention, more people getting healthcare to keep them healthy as opposed to just treating them when they get sick. i think we can come up with a sensible, common-sense way that is not disruptive, that still has room for insurance companies and the private sector, but that does not put people in a position where they are potentially bankrupt every time they get sick. how this debate is going to evolve over the next eight weeks, i am very open-minded.

if people can show me here is a good idea and here's how we can get it done, and it is not something i have thought of, i am happy to steal people's ideas. i am not ideologically driven one way or another about it. [applause] the one thing i do think it's critically important is for self-employed people and small business people who do not have the best ability to pool their health insurance risks -- part of the reason that typically, if you work for a big company, get a better deal on health insurance than if you work for small company. there's a bigger pool, and that means each of us have a certain risk of getting sick, but if that is spread around, everybody's premiums can be lower because the total risk for

everybody is somewhat lower. if you are self-employed, you do not have access to that same pool. part of what we have to do, and that is where a public plan potentially comes in, or some mechanism to allow you to join a big pool -- that will help drive down their costs immediately, your out-of-pocket costs for premiums, lower your deductibles, and i would like to see that every plan includes not only prohibitions against discriminating against pre- existing conditions, but also every plan should have incentives for people to use preventive services and wellness programs so they can stay healthier. you are somebody who i think can be directly impacted and directly helped if congress gets this thing done and gets it on my desk, i hope i sometime in october of this year. it is a guy's turn.

this gentleman in the suit. >> it is an honor to have you here. i am fortunate enough to be here with my 10-year-old daughter who is missing her last day of school for this. what do you need me to write a note? [laughter] >> i will take you up on that, mr. president. >> what is her name? >> i have some people here from work -- >> no, i am serious, what is surname. >> her name is kennedy. >> that is a cool name. i am going to write to kennedy's teacher. what is your question? >> i work and help system, and

we work with employers, payers, and brokers, everybody, to try to lower costs for hurt -- for employers. we have clinics and emergency department. everybody's trying to do something now, but all i am hearing is what is want to have a long term. i question is, what is a timeline we have set up for this? what do you see happening in the area of working with employers to offer more insurance or getting the uninsured something now? >> whatever reforms we set up, it will probably take a couple of years to get it in place. here you go, kennedy. [applause]

whatever reforms we pass, it is going to take a couple of years to get all the reforms and all the systems in place. there are some things i think we should be able to do fairly quickly. for example, the pre-existing condition issue. some of the insurance reform issues we should be able to get in place more rapidly. the thing that think we will have to spend most time thinking about, and really get right, and you probably know more about this than i do because you work with these employers and so forth, is how we change the medical delivery systems that can either drive costs way up and decrease quality, or drive costs down and improve quality. let me describe to you what is

happening. part of the reason that green bay is doing a better job than some other parts of the country. there are places where doctors typically work together as teams. they start off asking themselves, how can we provide the best possible care for this patient? because they are coordinating, they did not order a bunch of duplicate tests. the primary care physician who initially seized the patients is in contact with all the specialists so that in one meeting, they can consult with each other and make a series of decisions. they do not over prescribe. they make decisions about how quickly you can get somebody out of a hospital, because often being in a hospital actually increases the incidence of infection, for example.

there are a whole series of decisions that can be made and improve quality, increase coordination, but actually lower costs. the problem is, more and more what our healthcare system is doing is incentivizing each doctor individually to say how many tests cannot perform? the more tests are performed, the more i get paid. it may not even be a conscious decision on the part of the doctor. it is just that the medical system starts getting in bad habits. it is driven from a business mentality instead of a mentality of how to make patients better. [applause] what you've got is a situation where, for example, the mayo clinic in rochester, minnesota is famous for some of the best quality and some of the lowest cost. people are healthier coming out of there. they do great.

then you have places -- there is a town in mcallen, texas, where costs are a third higher than they are at mayo, but the outcomes are worse. the key for us is to figure out how do we take all the good ideas in the mayo clinic and spread them all across the country, so that becomes the dominant culture for providing health care. that will take some time. it involves changing how we reimburse doctors. it involves doctors forming teams and working in a more cooperative way. that is a slow, laborious process. here is the bottom line. if we pass health care reform this year, my expectation would be that immediately, families

will see some relief on some issues, but we will not have the whole system perfectly set up probably until four or five years from now. i think it is a realistic time frame. but if we wait, if we say we are not going to get it right away so why not put it off for four or five years, is never going to happen. that is what -- that is what has gone on for the last 50 years. people said we cannot do it right now, and as a consequence, and never gets done. now is the time to do it. [applause] it is a girl stern. -- is a girl's turn. >> thank you, mr. president.

you talked a little bit about the government plan and the competition with other insurance companies. we all know that in the insurance business, everything is about managing risk. i would like to know what your vision is for how we would better manage the risk, especially if there is going to be a government program. what is your philosophy about primary-care and the role of primary care? do you subscribe to the medical home theory? how did you engage patients in this model so the risk can be better managed and ultimately result in a population that has better health at a lower cost? >> you sound very knowledgeable. are you in the health-care system? >> yes, i am. >> in some ways, you answered your own question. i think that the more we are incentivizing high-quality primary care, prevention,

wellness, management of chronic illnesses -- it turns out that about 20% of the patients account for 80% of the care and cost of the health-care system. if we can get somebody, first of all, who is overweight to lose weight so they do not become diabetic, we save tons of money. even after they have become diabetic, if we are working with them to manage their regimen of treatments in a steady way, then it might cost us $150 when you break the costs for a counselor to call the diabetic on a regular basis to make sure they are taking their methods. as a consequence, we do not pay $30,000 for a foot invitation. so there are all sorts of ways

-- for a foot amputation. there are all sorts of ways to improve footca health care, andt helps us manage risk. people will still get sick, and there will still be catastrophic costs. there have been a lot of ideas floating around in congress for ways that we can help to underwrite some of the catastrophic care that takes place that would help lower premiums. i am open to a whole range of these ideas. one of the approaches i have tried to take is to not just put down my plan and say it is my way or the highway. first of all, one of the things it turns out is that congress does not like for you to just tell them exactly what to do. steve kagan can testify to that. it is always better to be in a

collaborative mode and to listen. part of the reason, it is not just the politics of it. these are genuinely complicated issues. nobody has all the right answers. what we have to do is find the 80% step that everybody agrees on, things like electronic medical records that can eliminate errors and hospitals. right now, nurses cannot read the doctor's handwriting, but if it comes out on a pda they are reading, they are more likely to be accurate. everybody agrees there is no reason you should have to fill out five or six or eight forms every time you go to see a doctor. huge amounts of wasted money. electronic billing and billing that you can understand.

everybody knows that is something that needs to be done. there are things that can be done that republican, democrat, liberal, conservative, we all know we need to have. the challenge will revolve around how we deal with the 20% of the stuff for people disagree. this whole issue of the public plan is a a good example. a number of my republican friends have said we cannot support anything with a public auction. it is not clear -- a public auction. it is not clear that is based on evidence as much as they are thinking, their fear that somehow once you have a public plan, that government will take over the entire health-care system. i am trying to be fair in presenting what their basic concern is. that is going to be a significant debate. what we are trying to explain is, all we are trying to make

sure of is that there is an option out there were the free market fails. we have to get that the free market has not work perfectly when it comes to health care. you have a lot of people who are really getting hurt. 46 million uninsured, and more who are underinsured, who are seen premiums and deductibles rise. i think a lot of the questions you are asking, those details are exactly what we are trying to work out. this next eight weeks is going to be critical. you need to be paying attention and putting pressure on your members of congress to say there is no excuse. if we do not get it done this year, we will probably not get it done. understand, even if you are happy with your health care right now, if you look at the trends -- remember what i said. your premiums are going up three times faster than wages and

income. just extrapolate and think about what that means for you five years from now. if nothing changes, then you essentially are going to be going deeper and deeper into your pocket to keep the health care that you have got. at some point, your employers may decide they cannot afford it. employers suddenly say they cannot afford it, or you have to pay a much larger share. do not think that just by standing still because you are doing ok now, that you will be doing good five years from now. we have to catch the problem now before it overwhelms our entire economy. it is the guy's turn. this gentleman right here in the blue shirt.

you have a good voice, but we still want to get you a microphone. >> i am a teacher. i have been education for almost 20 years. [applause] >> what do you teach? >> i teach in the upper peninsula of michigan. >> outstanding. you yourselvesyooperxs -- you call yourselves yoopers?

>> proudly. one thing i have learned is that the system is not broken. it bothers me when i hear politicians say our educational system is broken. not to insult you, but the system works. there are great things happening in green bay. there are things that can be reproduced. i question is, when will the focus be on reproducing those things, smaller classrooms, creating communities in classrooms, and moving the focus away from single day testing and test driven outcomes? [applause] >> first of all, thank you for teaching. my sister is a teacher, and there is no more noble and profession and helping to train

the next generation of americans. [applause] i completely agree with you that there is a lot of good stuff going on in american education. the problem is that it is uneven. that we put it this way. there are actually two problems. in some places, it is completely broken. in some urban communities, you have 50% of the kids dropping out. one out of every 10 children graduates at grade level. the system is broken for them. we cannot have too big of a debate here. don't worry, i am going to answer your question.

so there are some places where really is completely broken. there, yes, a lot of it has to do with poverty and families that are in bad shape. there are all kinds of reasons, and yet, even there, there are schools that work. so the question is, why is it that some schools are working in some aren't, even in the worst circumstances, and what we duplicate what works in those schools? so that all kids have a chance. in other places, green bay, appleton, and many communities throughout wisconsin and michigan, the average public- school is actually doing a reasonably good job, but can i still say that even if you factor out the urban schools, we are falling behind when it comes to masth,