i haven't pre-selected anybody. i'm going to go girl-boy, girl-boy. so that i'm not accused of bias in any way. all right. and i won't be able to get to every single question, but i will try to get to as many as possible. so there are microphones in the audience. if you can wait until the microphone comes to you, that way everybody will be able to hear your questions. stand up and introduce yourself as well. that will be helpful. this young lady right here. >> good afternoon, mr. president. i am paul eth gear and. as a seff employed individual, i spend approximately $8,000 annually on my health insurance premium. and it's a $2,000 deductible, no dental, no vision coverple. as my business is declining because of the economy we have, i'm now in a situation where

i'm taking savings to pay for food and housing because i don't want to lose my health insurance. and i am a supporter of a single payor system over any other smts because i do -- thank you. i do believe that it will meet your three criteria and be the most economically feesible plan that we have. . . that is why i support single payer. i ask that is still be on the table for consideration. thank you for your time. >> thank you for your question.

[applause] let me just talk about some of the different options that are out there because sometimes there has been confusion with the press and the public and people use politics in talking about this issue. there are some folks to say socialized medicine would mean that the government would basically run all of the health care. they would hire the doctors, run the hospitals, they would run the whole thing. great britain has a system of socialized medicine. nobody is talking about during that period will hear people talking about socialized medicine, i do not know anyone in washington that is proposing that, certainly not me.

socialized medicine is different than a single player pan -- single payer plan. you still have private doctors, hospitals, providers, etc., but everything is reimbursed through a single payer. that is usually the government. 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 the 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. we are not starting from scratch. we have already got, because of all kinds of historical reasons, we have primarily an employer base system that uses private insurers alongside a medicare plan for people above a certain age. then you have medicaid for people who are very poor and do not have access to health care. we have a patchwork system. it was my belief, and it continues to be my belief, that whenever we might do if we were to start from scratch then it was important in order to get it done politically but also to minimize disruptions to families, we need to start with what we have as opposed to trying to completely scrap the system and start all over again. when my attitude was, if you have an employer based system, and a lot of people still get their health insurance through their jobs, self-employed people

are a different category, the majority people still get theirs through their employer. rather than completely disrupt things for them, my attitude is let them keep the health insurance that they have, the doctors that they have, there is still a role for private insurance, but number one, let's have insurance reform so you cannot eliminate people for pre- existing conditions. [applause] there is none of the cherry picking that is going on to get the healthiest people and get rid of the sick people. we need to have some rules for how insurance companies operate. number two, four people who are self-employed, small businesses, for 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. what then then does is it gives people a choice. if they are happy with what they have, if they are employed by someone who polite -- and provides them with good benefits, you do not have to do anything. if you do not have health insurance, they have an option available steve. -- they have an option available to you. how this is evolving in washington, it unfortunately 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 is going to lead to the 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 health insurance that 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 do 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 preventive services, you put off going to a doctor until you are really sick because of the out of pocket expenses. let's change some of those incentives so you get more people getting prevention. more people will get help staying healthy in opposed -- 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 and still has room for insurance companies in 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 a good

idea, here is how we can get it done, and is not something i thought of, i am happy to steal your ideas. i am not ideologically driven one way or another about this. [applause] the one thing i do think is critically important is for self-employed people, because there are a lot of you here in a lot of small business people, they do not have the ability to pool their risks. what that means is typically if you work for a big company, you get a better deal for health insurance than if you are just working for a small company because there is a bigger pool and that means that each of us has a certain risk of getting sick, but that is spread around aaron's premiums can be lower because the total risk for everyone is somewhat lower. if you're self-employed, you do

not have access to that same poll. -- same pool. this is where some mechanism would allow you to join a topool and will drive down your costs immediately. lower your premiums, deductibles, and what i would like to see is that every plan includes not only prohibitions against preexisting conditions but also every plan to have incentives for people to use preventative services and well as programs so they can stay healthy. you are someone who i think can be directly impacted and directly helped if congress gets this thing done and gets it on my desk, i hope, by sometime in october of this year. [applause] it is a guy's turn. it is a guy's turn. this gentleman in the suit.

>> welcome to green bay, mr. president. i am here with my 10-year-old daughter who is missing her last day of school for this. >> oh, no. do you need me to write a note? [laughter] >> i will take you on that, mr. president. [applause] >> i will start writing your note now. what is your name? [laughter] >> i have some people here from work and. >> and no, i am serious. what is your daughter's name? that is a cool name. i am writing to kennedy's teacher. >> i work in a health system and we were prepared, brokers,

everyone trying to lower costs for employers. we have a retail health clinics, will get health clinics, primary clinics -- retail health clinics, primary clinics, and all i'm hearing about is long term. i question is what is its timing had set up for this? what you see happening especially in the area of working with employers to either offer more insurance or to be able to get them something now? >> 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. [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 we should be able to do very quickly. for example, the pre-existing conditions issue. some of the insurance reform issues 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 it right, you probably know more about this than i do because you're working with a lot of these employers, insurers, and so forth, is how do we change the medical delivery systems that can either drive costs went up decree's quality or drive prices down and increase quality. and describe to what is happening. part of the reason is -- border

the reason my green bay's doing a better part than some other places in the country is that there are places where doctors to the work together as teams and they start asking themselves, how can we provide the best possible care for this patient? because they're coordinating, they do not order a bunch of duplicative tests. the primary care physician who had initially seen the patient is in contact with all the specialists so that in one meeting they can consult and make a series of decisions. then they do not over prescribed and make decisions about how quickly you can get someone out of the hospital because oftentimes being in a hospital actually increases the incidence of infections. the whole series of decisions that can be made to improve

quality, increase coordination, but actually lower costs. more and more what arse -- what our system is doing is incentivizing each doctor individually to see how many tests they can perform because the more tests they perform, the more they get paid. it may not even be a conscious decision on the part of the doctor. it is just that the system gets into bad habits and it is driven from a business mentality instead of a mentality of making patients better. so, what we have have [applause] we have a situation where the clinic in rochester, minn., it is famous for some of the best quality and lowest costs. people are healthier coming out of there and do great. then there is a town in mcallen,

texas, where costs are 1/3 higher but the outcomes are worse. the key for us is to figure out how do we take all the good ideas from this one clinic and spread them all across the country so that it becomes the dominant culture for providing health care. that is going to take some time. it involves changing how we reimburses doctors, doctors forming teams and working in more cooperative way, and that is a slow, laborious project. here is the bottom line. if we pass reform this year, my expectation would be then immediately families are going to see some relief on some

issues, but we will not have the whole system perfectly set up probably until four-five years from now. i think it is a realistic time frame. if we wait and we say since we're not going to get it right away, let's put this off for another two, four, five years, it will never happen. that is what has been going on for the last 50 years. people have been saying they cannot do it right now and as a consequence it is never gets done. and now is the time to do it. [applause] ok. it is a girl's journey. -- girl's turn. >> think you, mr. president. you have talked about the

government plan and competition with other insurance companies. in the insurance business, everything is about managing risk. i'd like to know what your vision is and 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? you subscribe to the medical home theory? how you engage patients in this model so that the risk can be better managed and we can alter the results in the population that has better health and lower-cost? >> you sound very knowledgeable. are you in the health-care system? >> yes, i am. >> in some ways to answer your own question because i think the more we are incentivizing high- quality primary-care, prevention, wellness, management of chronic illnesses.

as it turns out, one of the things is about 20% of the patients account for 80% of the care and the cost in the health- care system. if we can get someone, first of all, who is overweight to lose weight said they did not become diabetic, we save tons of money. even after they become diabetic, if we're working with them to manage their regimen of treatments in a steady way, it might cost us $150 when you provide the costs for a counselor to call the diabetic on a regular basis to make sure they're taking their medicines. as a consequence, we do not pay $30,000 for a foot amputation. there are all sorts of ways that i think we want to improve care

and that helps us manage risk. now, people are still going to get sick and there are still going to be really catastrophic costs. there have been a lot of ideas floating around in congress on the ways that we can help to underwrite some of the catastrophic care that takes place so it would help lower premiums. i am open to a whole range of these ideas. one of the approaches that 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 congress really doesn't like for you to tell them that. steve can testify to that. it is always better to be in a collaborative mode and to listen. it is not just the politics of

it, it is also because these are genuine the complicated issues. nobody has all the right answers. will we have to do is find the 8% of stuff that everyone agrees on like electronic medical records that can eliminate errors in hospital because right now nurses cannot read handwriting, but if it comes outonto a pda, they're more likely to be accurate. reducing paperwork, everyone agrees there is no reason why should have to fill out five, six, eight forms every time you see a doctor. everyone knows that. [applause] huge amounts of wasted money there. electronic billing and billing that you can understand. everyone understands that is something that needs to be done. there are things that can be

done the republican, democrat, liberal cannot -- liberal, conservative everyone can agree. how can we deal with the 20 percent of the stuff where people disagree? the whole issue with the public plan is a good example. a number of my republican friends have said we cannot support anything with a public auction. it is not clear that it is based on any evidence as much as it is their thinking, their fear that somehow would 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're trying to explain is all we're trying to make sure is that there is an option out there for people with the free

market fails us. we need to admit that the free market has not worked perfectly when it comes to health care. [applause] we have a lot of people who are really getting hurt 3 46 million uninsured, a whole bunch for people who are underinsured or seeing their premiums and deductibles rise. i think a lot of the questions you're asking, the details are exactly what we're trying to work out. the next eight weeks are going to be critical and you need to be really 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're probably not going to get it done. understand even if you're happy with your health care right now, if you look at the trends cover remember what i said. unions are going up three times faster than your wages and your income. --premiums are going up three

times faster. what does that mean for you three years from now, 10 years from now? if nothing changes then you essentially going deeper and deeper into your pocket to keep the health care that you have. at some point of your employers may decide they cannot afford it. there are a lot of people that is happening. their employers set in say, either we can afford it, or you have to pay a bigger share of your health care. just by standing still, just because you're doing ok now you're going to be doing good five years from now. we need to catch the problem now before it overwhelms our entire economy. [applause] it is a guy stern. it is a guy stern. -- guy's turn. this judgment in the blue shirt. -- this gentleman in the blue shirt.

you have a good voice, but you still need a microphone. where are my microphone people? the yugo. -- there you go. >> imf -- i am a teacher. i have been education for 20 years. >> what do you teach? >> u.p. power. >> is that you call yourself, uppers? that's cool. [applause] >> prodi. -- proudly. one of the things i learned in education in the last 20 years, the system is not broken. it bothers me when i hear

politicians and even my president say that our education system is broken. , not to insult you, -- >> i do not feel insulted. >> the system works in cases. there are great things happening in green bay and oliver the u.p., and there are things that can be reproduced. when will the focus beyond reproducing those things, smaller classrooms, creating communities in your classrooms, and moving the focus away from test driven out comes? [applause] >> all right. first of all, thank you for teaching. my sister is a teacher and i think there is no more noble profession than helping to train the next generation of americans. [applause]

you know, 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. 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 have a 50% of the kids dropping out, you only have one out of every 10 children graduating at grade level, the system is broken for them. i'm going to get to that. we cannot have too big of a debate here. you got your question. i'm going to answer your question. there are some places where it 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 their there are schools that work. the question is why are some schools working and some are not? why do we not duplicate what works in those schools? so then, all kids would have a chance. now, in other places, green bay, appleton, 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're falling behind when it comes to mass -- comes to math, science. we have kind of settled into

mediocrity when we compare ourselves to other advanced countries and both countries. that is a problem because the reason that america over the last 100 years has consistently been the wealthiest nation is because we have also been the most educated nation. it used to be by a pretty sizable factor that we had the highest high school graduation rates, the highest college graduation rates, the highest number of the doctorates, the highest number of engineers and scientists. we used to be headed shoulders above other countries when it came to education. we are not any more. we are in the middle of the pact now -- pack now amongst industrialized countries. even with good schools, we have to pick up the pace because the world has gotten competitive.

the chinese, indians, there coming at us and they're coming at us hard. they are hungry. there really bothering down. -- they are realy buckering down. they place your video games and are in the class from a lot longer. -- they played fewer do games and are in the classroom longer. we have to step up our game. which brings us to your next question, how do we do that? i agree with you that what -- that if all we're doing is spreading around standardized tests and teaching the test, that is not improving our education system. [applause] so, there is a saying in illinois that i learned when i was down in rural