we scale back some of the taxes and taken back to the rates in reagan years. .

medicare is basically a subsidy of private insurance companies because folks are able to buy medicare advantage. it seems to me we would be able to take the scenario and increase it for the entire country, and that is why i still support single payer, and i know at one point you did, and i table for consideration, and thank you so much for your time. >> let me just talk about some of the different options better out there, because sometimes there has been confusion in the press and the public, and people use politics in talking about the issue. there are some folks who say socialized medicine.

socialized medicine would mean the government would basically run all of health care. they would hire the doctors, run by hospitals. they would run the whole thing. great britain has a system of socialized medicine. when you hear people say socialized medicine, understand i do not know anybody in washington proposing it. certainly not me. socialized medicine is different from a single payer. away a single payer plan works is that you still have a private doctors and 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 or services -- the services provided to senior citizens on medicare. there have been proposals to have medicare for all -- a single payer plan for all americans, and that person likes it. 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. we are not starting from scratch. we have already gone -- because of all sorts of historical reasons, we have primarily an employer-based system that uses private insurers alongside a medicare plan for people above a certain age, and you have medicaid for people who are very

poor, so we have a patchwork system. it was my belief and continues to be my belief that whatever we might do if we were starting from scratch, that 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 trying to 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, and you are self-employed, so this is a different category, but the majority of people still get their health insurance through their employer. rather than disrupt things for them, let them keep the health insurance they have got -- the doctors they have. there is still a role for private insurance, but let's have insurance reform so you cannot eliminate people for pre- existing conditions, so that --

there is none of the cherry picking that is going on to get the healthiest people insured and get rid of the sick people, so you have got to set up some rules for how insurance companies operate. number two, four people who are self-employed, for small businesses, for others, they should have an option they can go to if they cannot get insurance through the private marketplace. that is why have said i think a public auction would make sense. what that does is give people a choice. if they are happy with what they have got, if they are employed by somebody that provides them with good health care, you can keep it, and you do not have to do anything, but if you do not have health insurance, you have an option available to you. how this debate is evolving in washington unfortunately falls into the usual politics, so what

you have heard is some folks on the other side say i am opposed to a public auction because that is going to lead to government running your health care system. i do not know how clearly i can say this, but let me try to repeat it. if you have got health insurance you are happy with, we are not going to force you to do anything. .

>> how this die bait is going to evolve over the next eight weeks, i'm very open minded. and if people can show me here's a good idea and here's how we can get it done and it's not something i've thought of, i'm happy to field people's ideas. you know, i'm not ideologically driven one way or another about it. so the one thing that i do think is critically important, though, is for self-employed people -- because there are a lot of self-employed people here. and a lot of small business people. they don't have the ability to pool their health insurance risk. and what that means is, part of the reason that typically if you

work for a big company you get a better deal on health insurance than if you're just working for a small company is because there's a bigger pool and that means that each of us have a certain risk of getting sick. but if that's spread around, everybody's premiums can be lowered because the total risk for everybody is somewhat lower. if you're self-employed you don't have access to that same pool. and part of what we have to do -- and that's where a public plan potentially comes in or at least some mechanism to allow you to join a big pool. that will help drive down your costs immediately. your out of pocket costs for premiums, lower your deductibles, and what i'd like to see as i said is that every plan includes not only prohibitions against discriminating against people with pre-existing conditions but also every plan should have incentives for people to use, preventative services and wellness programs so that they

can stay healthier. you're somebody who i think can be directly impacted and directly helped if congress gets this thing done and hope, by sometime in october of this year. all right? ok. the guys' turn. it's the guys' turn. this gentleman in the suit. [applause] >> welcome again, mr. president. it's a honor to have you here. >> thank you sir. >> my name is john corbiss. i'm fortunate enough to be here with my 10-year-old daughter whose missing her last day of school for this. i hope she doesn't get in trouble. >> oh, no! do you need me to write a not? [laughter] >> i'll take you up on that actually mr. president. [laughter] [applause] >> go ahead. i'll start writing it now. what's your name? >> john corbiss. >> no, her. [laughter] >> well, considering i have some people here from work that are

very interested in -- no, i'm serious. what's your daughter's name? >> her name is kennedy. >> kennedy. all right. that's a cool name. >> that's a very cool name. thank you. >> all right. i'm going to write to conedy's teacher. go ahead. i'm listening to your question. >> thank you, sir. i work in the health system. and we work with employers, we work with payers, brokers, everybody to try to lower costs for employers. we have retail health clinics, walk in clinics, regular primary clinics and emergency departments. and everybody's trying to do something now, but all i'm hearing is about what's going to happen long-term. and my question is, what is a timeline that we have set up for this? what do you see happening especially in the area of working with employers to either offer more insurance or the uninsured being able to get them something now? >> well, look. we're not going to be able to --

whatever reforms we set up, it will probably take a couple of years to get it in place. here you go, kennedy. [cheers and applause] >> there you go. you've got it. all right. [applause] >> so whatever -- whatever reforms we pass, we're not -- it's going to take a couple of years to get all the reforms and all the systems in place. there are some things that i think we should be able to do fairly quickly. for example, the pre-existing condition issue. some of the insurance reform issues i think we should be able to get in place more rapidly. the thing that i think we're going to have to spend the most time thinking about, and really get right -- and you probably know more about this than i do because you're working with a lot of these employers and insurers and so forth -- is how

do 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's 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. and they start off asking themselves, how can we provide the best possible care for this patient? and because they're coordinating they don't order a bunch of duplicate tests. and the primary care physician who initially sees the patient is in contact with all the specialists so that in one meeting they can consult with each other and make a series of

decisions. and then they don't overprescribe. and they make decisions about how quickly you can get somebody out of the hospital because oftentimes being in the hospital actually increases the incidence of infection, for example. so there are a whole series of decisions that can be made that improve quality, increase coordination, but actually lower costs. now, the problem is more and more what our healthcare system is doing is it's incentivizing each doctor individually to say "how many tests can i perform? because the more tests i perform the more i get paid." and it may not even be a conscious decision on the part of the doctor. it's just that the medical system starts getting in bad habits. and it's driven from a business mentality instead of a mentality of how do we make patients better. and so what you've got it --

[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 costs. people are healthier coming out of there, they do great. and then you've got places -- there's a counsel in mccal up, texas, where costs are actually a third higher than they are at mayo but the outcomes are worse. so the key for us is to figure out how do we take all the good ideas in a mayo clinic and spread them all across the country so that that becomes the dominant culture for providing healthcare? that's going to take some time. it involves changing how we

reimburse doctors, it involves doctors forming teams and then working in a more cooperative way. and that's kind of a slow lay boreious process. so here's the bottom line. if we pass healthcare reform this year, my expectation would be that immediately some relief on some -- families are going to see some relief on some issues but we will not have the whole system set up until probably say four or five years from now. and i think that's a realistic time frame. but if we wait, if we say, well, you know, since we're not going to get it right right away let's put this off until two or four or five years from now, it's never going to happen. that's what's been going on for the last 50 years now. people have said, "we can't do it right now." and as a consequence it never gets done. now's the time to do it.

all right? [applause] >> ok. it's the girls' turn. lady right there. >> thank you. thank you, mr. president. you've talked a little bit about the government plan and the competition with other insurance companies. and we all know that in the insurance business everything is about managing risk. and i guess i'd 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's your philosophy about primary care and the role of primary care? do you subscribe to the medical home theory? how do you engage patients in this model so that that risk can be better managed and we can ultimately result in a population that has better health at a lower cost? >> you sound really knowledgeable. are you in the healthcare system? >> yes, i am.

my name is chris wileski and i'm with bellen health. >> well, in some ways you answered your own question. because i think that the more we are incentivizing high-quality primary care, prevention, wellness, management of chronic illnesses. and one of the things that it turns out is that about 20% of the patients account for 80% of the care and the costs of the healthcare system. and if we can get somebody first of all who its overweight to lose weight so that they don't become diabetic we save tons of money. even after they've 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

prorate the costs for a counselor to call the diabetic on a regular basis to make sure they're taking their meds. and as a consequence, we don't pay $30,000 for a foot amputation. all right? so there are all sorts of -- [applause] >> -- all sorts of ways that i think that we want to improve care. and that helps us manage risk. now, people are still going to get sick. and going to still be really catastrophic costs. and there have been a lot of ideas floated around in congress or the ways that we can help to underwrite some of the catastrophic care that takes place. so that would help lower premiums. i'm open to a whole range of these ideas. and one of the things -- one of the approaches that i've tried to take is to not just put down

my plan and say it's my way or the highway. first of all, one of the things it turns out is congress doesn't really like you to just tell them exactly what to do. [laughter] >> i think keegan can testify to. that so it's always better to be in a collaborative mode. and to listen. but the part of the reason it's not just the politics of it, it's also because these are genuinely complicated issues. and nobody has all the right answer so what we have to do is to find the 80% of stuff that everybody agrees on. things like electronic medical record that can eliminate errors in hospitals because right now nurses can't read the doctor's handwriting. but if it comes out on a p.d.a. that reading, then they're more likely to be accurate. and reducing paperwork.

everybody agrees there's no reason why you should have to fill out five, six, eight forms every time you go to see a doctor. everybody knows that. [cheers and applause] >> huge amounts of wasted money. >> electronic billing. and billing that you can understand. everybody knows that's something that needs to be done. so there are things that can be done that republican, democrat, liberal, conservative, we all know need to happen. the challenge is going to revolve around how do we deal with the 20% of the stuff where people disagree? this whole issue of the public plan is a good example, by the way. i mean, right now a number of my republican friends have said, "we can't support anything with a public option." it's not clear that it's based on any evidence as much as it is their thinking, their fear, that

somehow once you have a public plan that government will take over the entire healthcare system. now, i'm trying to be fair in presenting what their basic concern is. and that's going to be a significant debate. and what we're trying to explain is that all we're trying to make sure of is that there is an option out there for people where the public -- where the free market fails. and we've got to admit that free market has not worked perfectly when it comes to healthcare. [applause] >> because you've got a lot of people who are really getting hurt, 46 million uninsured, a whole bunch of more people who are underinsured who are seeing their premiums and deductibles rise. so i think a lot of the questions you're asking, those details are exactly what trying to work out. this next eight weeks is going to be critical, though. and you need to be really paying attention and putting pressure on your members of congress to

say, "there's no excuses. if we don't get it done this year, we're probably not going to get it done." and understand, even if you're happy with your healthcare right now, if you look at the trends, remember what i said. your premiums are going up three times faster than your wages and your incomes. so just kind of ex trap plate late. -- extrapolate. think about what that means for you five or 10 years from now. if nothing changes then you essentially are going to be going more deeper and deeper into your pockets to keep the healthcare that you've got. and at some point your employers may decide, "we just can't afford it." and there are a lot of people where that's happened, where their employers suddenly say, "either you can't afford it or you've got to pay a much bigger share of your healthcare." so don't think that somehow just by standing still just because you're doing ok now that you're going to be doing good five

years from now. we've got to catch the problem now before it overwhelms our entire economy. [applause] >> all right. the guys' turn. the guys' turn. >> this gentleman right here. right there in the blue shirt. there you go. >> oh. you got a good voice but we still want to give you a microphone. hold on a second. where's my m irk c people? here we go -- mic people? here we go. >> my name is matt stein. i'm a teacher. i've been in education for almost 20 years. [cheers and applause] >> thank you, matt. what do you teach? what do you teach? >> i teach at north central area schools in the upper peninsula of michigan. >> outstanding. >> u.p. power.

upers. >> is that what you call yourselves? youpers? >> yeah. >> that's cool. [applause] >> proudly we call ourselves youpers. [laughter] >> one of the things that i've learned in education in the last 20 years is that the system is now broken. and it bauers me when i -- boars me when i here politicians and our educators say our education system is broken. not to insult you. >> i don't feel insulted. >> good. the system works in cases. there are great things happening in green bay in appleton and all over the u. p. and there are things that can be reproduced. my question is, when will the focus be on reproducing those things, smaller classrooms, creating communities in your classrooms, and moving the focus away from single-day testing and

test-driven outcomes? [cheers and applause] >> all right. i first of all, thank you for teaching. my sister's a teacher. i think there's no more noble a profession than helping to train the next generation of americans. [applause] >> you know, i completely agree with you that there's a lot of good stuff going on in american education. the problem is that it's uneven. and well, let me put it this way. there are actually two problems. in some places it is completely broken. in some urban communities where you've got 50% of the kids dropping out, you only have one out of every 10 children who are graduating atde