came from mexicans. from a historical standpoint, it has to be looked at with the circumspect from. circumspect from. ther there is abundant evidence that the virus evolves from pre- existing viruses of the chimpanzees, cats, guerrillas, that had been living in africa. that seems to be the most overwhelming evidence. i am not sure the origin matters. as for the aspect of homosexuality, it is important to note that the aids virus has nothing to do with homosexuality. its job, if you will, is to move from person to person so it can keep on producing more of viruses. host: our guest is the author of

"dread." we are taking calls on u.s. policy for disease control and learning more about the history of disease control. when it did it disease control actually become a reality, and effective thing? what part of history and how did it evolved in the early days? . . d that occurred during the black death. at the same time, people were launching quite cogent disease control measures. quarantine, for instance, was essentially invented or at least begin policy very early on in begin policy very early on in the plague years, in the 14th century, and became

institutionalized soon thereafter. that was quite a long time ago. the idea of what is called the sanitary cordon, wally off your town, not allowing visitors in. but also began early on -- that also began early on. of course, disease control has evolved and changed with the advent of germ theory, modern technology, vaccination, antibiotics administration. but the basics of disease control, isolating the contagious, is quite old. host: there's a photo in "the washington times" of children getting hand sanitizer. the point of the whole story is that schools are preparing for swine flu. kids will be first in line for vaccinations.

how does it work today? how well does disease control work, beginning here in the united states? guest: disease control can be extremely effective, especially in the developed world where there's money to put into it. and the u.s. response to swine flu seems to me to be both circumspect, but evidence based, straightforward. i think there was a little bit of panic at times. schools will probably kohl'wered that did not need to be closed. i really have to credit the cdc for keeping people informed in the wake that seemed to be designed to naught fomenting hysteria.

in developing countries, disease control can be very carefully administered. again, in developed countries, we put a fair amount of funding into disease control. some people will say not enough, but much more than poor countries. there's a big problem there. you are probably aware that with the likelihood that there will be a vaccine available against swine flu sometime this fall, the question arises -- what countries should have access? should the united states and europe be able to buy up the vaccine because we can't afford it? what about the poor countries? host: in the financial times -- more

thank you for waiting. >> i am really happy that you have this man on here. it is so nice to see someone intelligent on c-span talking about something intelligent. of what the sec first that i have a couple of questions. my favorite book of all time is "a short history of nearly everything." there is so much interesting stuff in there about science, where they talk about diseases and things. people need educate themselves and read more. my question is, when i was in elementary school, which was 35 years ago, i remember people came around and gave us some kind of vaccine, maybe flu or smallpox. i don't know what anybody does that anymore and i wonder why. and the next question is, why

don't we quarantined groups of people when we think that they have something that can spread to the rest of everyone? guest: i think the caller -- i thank the caller. i want to talk about the vaccine question. question. but the last question is compelling. why don't we shut the border when there was the swine flu? the chinese quarantine. you might remember the saar's epidemic in 2003. the shutdown university for three weeks. most recently, china quarantined or put a court on a round of village -- cordon

around a village where had that bennett -- were there had been a small outbreak of plague. that possibility does not seem to work very well except if you know exactly who needs to be quarantined and you can be really good at it. to our credit, we try to develop ways to recognize individual freedom and what people up when there are inter -- when there are alternatives. swine flu quarantines would not be very effective. it can be transmitted before people get sick. it is too hard to know who has been infected. would be hard to know who should be quarantined. the question about vaccination in schools -- i am not sure that the vaccine was actually given out in schools.

that is not the practice now in most parts of the country. you have to show that you have been vaccinatioed in order to register for school to the decision has to do with policy. i am not a policymaker. i believe that has to do with policies about the relationship between the disease control authorities and the education authorities. it would be a question better put to the education people themselves. host: a message via twitter. guest: that is the $64,000 question these days. everybody should have access to health care. can it fuel an epidemic?

could be considered not to? as i said, an epidemic is a story. i guess you could tell the story that way. i try not to say that this is an epidemic and that is not. if obesity and crystal meth addiction can be epidemics, maybe a lack of health care could be called an epidemic. is a little the semantic. does lack of health care fuel epidemics? i think it is fair to say that in historical experience, when people are unhealthy, they are more susceptible to disease. it is certainly true that the spread of disease is often faster among the poor because of crowding and the inability to afford preventive measures.

in that sense, it is related. host: chuck is on the line in chattanooga, tenn. on the democrats' line. caller: i want to ask a question about what you believe is the most expensive and the most overblown epidemic of the 21st century. you talked about obesity and other kinds of the epidemics. what has caused america more than anything else so far this century? guest: it sounds like she has an answer in mind. i do not have a good answer to the question. i cannot tell you exactly in dollar amounts where we have put

the most money. certainly, lots of fundy was tracked into aids -- lots of funding was put into aids. we spent a lot of money on diseases that do not often register as epidemics. i think we probably should. as you know, heart disease is the leading cause of death in america. we spend money on that. most people probably believe we should. i would not want to say we are wasting money on a and b, and not spending enough on c and d. i am more interested in the way we talk about epidemics. the question of expense is not one that i have dealt with. the question of what we talk about most, i think, until swine flu came a few months ago, we probably would have said bird flu, obesity, drugs, alcohol,

and cigarette smoking. it could take your pick depending on how you listen to the public dialogue. should we? that is the problem. that is a policy problem. how do we decide what is the most important thing? how do we decide what is the real threat? host: the role of the media in all of this. good job? bad job? what do you think? guest: i am often asked this question. i will tell you. there is the paradox of getting past about the role of the media as i am talking to the media. without pulling punches, i think the media, in general, do what the media are supposed to do. that is, delivers information in a way that tells a story. sometimes the media highlights stories that are inflammatory.

we talk about shark attacks probably much more than we need to since not the medieval diane shark attacks -- seen as how not that many people die in shark attacks. people like them. society tells stories to ourselves. it does not seem to me that by and large media creates a mysteriouhysteria. host: joann on the republican line. caller: good morning. i was watching the science channel years ago. they have a program on about how they collected all these health

records that went back generations. they were discussing obesity of the time in the families. they traced it back to a famine that have occurred generations before. are you familiar with this study? guest: it rings a bell, but i could not cite you chapter and verse. caller: i was 1wondering. we have all these fake sugars today. and they have this outbreak of diabetes. i was just wondering if any of this could be tied into our genes and illevolution. guest: she brings up the

question of obesity and genetics and evolution. other than swine flu, obesity seems to be on our public health mind the most. i talk about this in the book. there is a lot of inquiry about obesity and/á everyone seems to have a different take on what is causing the problem. it seems to me that the problem of obesity, based on current data, is overblown -- that the mortality associated with obesity really is not that great and that safe levels of weight are often miss estimated. it seems from the data that the

extremely obese with an increased risk of mortality, so if you just go by data, it is not clear that this is such a big public health problem. and yet it is a big public health problem because we talk about it in that way. a lot of money and programs and research goes into obesity. as to the genetic hypothesis, there seems to be genetic components to obesity. they're sometimes seems to be dietary components. it is very hard to say this is the cause of obesity. it is very hard to say that obesity is a problem. it seems to be a problem for some people. some people who are obese develop diabetes or heart

disease. many do not. many experienced a long and relatively healthy life. it is hard to say. you cannot say that if you become obese, you will die from it. it is a complex problem. there are lots of pieces to this. it all has to do with the way we live our lives today. the public health conversation about obesity and besides conversation -- and the science conversation, it is over layered with all sorts of questions about what is wrong with the way we live today? host: another passage from the book. host: here's another look at the

book. our guest is philip alcabes, author of "dread" in new york. sheila on the democrats' line. caller: every day we hear about so many people losing their jobs. a lot of people cannot afford cobra and they lose health insurance. now we have the swine flu fall season coming up. what would happen if many, many people came down with the swine flu and they could not afford to get health care? guest: it sounds like there are two parts to her question. there is one part about health care, which is on everybody's mind these days. the other part is positively about swine flu.

let me answer the swine flu part. i do not have a crystal ball. i do not know if swine flu is coming back. nobody knows that. some people think it will. others think there's good reason to believe that it will not. there's a very persuasive paper by some people who are very good scientists and historians of influenza. it appeared in the journal of the ama this week. it is about the history of the h1n1 flu. it says it is likely there will not be what some people have called a second wave of small inflow. -- second wave of swine flu. we do not know if it will come back. preparations are being made in case there is more swine flu this fall. what would happen to people who do not have health insurance?

that seems to be a central policy question. that is part of why the health care debate seem so pressing right now. for many years, we have had a health care system that is content to leave tens of millions of americans without health insurance. what happens to people like that if there is some really bad 7 health problem. maybe it will be flu. maybe it will be something else in the future. i do not have a good answer. i think it is a policy answer that remains to be developed. host: another question from twitter. guest: as the immune status of adults in the u.s. declined?

i do not know if that is true. it is very common for people to think that modern times has done something bad to us. on the face, it would seem that we are doing better than ever. not everybody. americans live longer now than they ever have before. the percentages of people who die in disease outbreaks is smaller than before. as i mentioned earlier, people -- the leading cause of death in america is hard disease. -- heart disease. is hard to say that we're doing something right because it is easy to see what we're doing wrong in our society, but we are doing better than our grandparents did. empirically, it does not seem like we have made ourselves more susceptible to disease.

host: orlando, fla. on the independent line. you are on with philip alcabes. caller: good morning. you made a comment a few minutes ago that prompts me to ask you two questions. why is it so difficult? they are talking about not having enough vaccines. i have heard because it is not enough profit and the pharmaceutical companies do not want to make it. why is it so difficult to make the vaccines? you said that you did not know if there was going to be another wave of h1n1. it has not gone away. in orlando, just last week, we

had another person died from the flu. it is just continuing. host: two questions. why don't you take the first one first. vaccines and profit and making an offer everyone who needs it. guest: you want to the vaccine production to go slowly. we have a very good example of what happens when flu vaccine production went too fast. that was in 1976 in what is sometimes called the swine flu fiasco. there had been a small outbreak in new jersey. a few recruits died. i think the number was 13. there were about 300 cases altogether. because of alarm that this was the beginning of a reprises of the terrible 1918 flu, u.s. authorities launched a nationwide vaccination program.

vaccine production was hurried so the vaccine would be ready in the fall. i think about 40 million doses were administered. then it turned out that people were getting a syndrome, a bad neurological syndrome. some people died from it. that was a lesson about hurrying vaccine production. i hope we have learned it. there are questions on whether there will be vaccines available soon enough. with a vaccine production, you what to make sure it is safe before you offer it to anybody. let me say that vaccine production is done by forms of new companies. it is not by thdone by the govet in this country. it is a profit making enterprise. in some cases, it is a cutthroat

one. some people have said blood thirsty. the pharmaceutical companies want to be able to make their profit when they are producing a vaccine or other products. that is what for-profit companies do. the caller also mentioned h1n1 has not gone away. that is true. when people talk about a second wave, they're talking about the possibility that there will be a lot of new cases in the fall. that remains a possibility. host: 1 other viewer via tw itter. what can we look forward in terms of organization, money, that kind of thing? guest: because i do not have a crystal ball, i will not attempt to read the future. i will tell you what i copal

happens and hope that will be a sufficient response to the streetweet. -- i will tell you what i hope happens. i hope that we do it in a smarter way. to use an old-fashioned term, more holistic, more and related to the complex relationships between the environment, environmental change, commerce, transportation, human migration, the food supply, and human susceptibilities. i think we're trying to do that now. i am impressed with the movement that is called one world one health. it wants to redirect our attention in a more complex and

holistic way. if you really want to control viruses, and others that come from animals, we have to stop thinking about locking the doors to the human population, which is what we attempt to do with the flu vaccine. and really think in a much more complex way about the entire ecosystem that we live in. hope that is the future. host: this is in open called the baltimore sun -- this is in "the baltimore sun" this morning.

host: do you ever see something like that happening? guest: alas, i am sure the research will go on. this is the elusive but beguiling silver bullet. everybody wants the one shot that will fix everything. i am old enough to remember the space program of the 1960's and the food that the astronauts had to eat.

you want to put everything into one box and injected into people and they will be magically immune. that would be great. that would be a terrific efficiency. i. -- that would be a terrific efficiency i suppose. that gets into germ theory. it goes away from my vision of what really sound public health in the future has to look like, which is we stop thinking about viruses as a problem of humans and start realizing that the march fro an environment that we share with animals and all the determinants and that the way that the animals live and the way that we have directed them and the food that we eat. host: here is that you were

questioned by e-mail. -- eight you were questioned by e-mail -- a viewer questioned by e-mail. guest: will stay away from that. there are many cancer deaths every year. it is much more of a problem than a century ago. partly because we live longer and we are actually good at controlling the killers of a century ago like tuberculosis and pneumonia. do we want to call it an epidemic? that is up to the viewer or the eye of the beholder. host: let's go to florida, william on the line for republicans. caller: i'm a first-time caller. i have a question for fellow. host: go right ahead.

caller: thank you for the opportunity. i would like to talk about my experiences and then my question. the reason for it in first and second grade, i was given a vaccine. by that time i got the third grade, to% of our class -- 10% of our class suffered from the disease. it was very scary. this leads me to my question. what is an acceptable rate of incidence of the disease caused by the vaccine itself? host: mr. alcabes. guest: you touch on a terrible problem. one of the reason why the vaccine cannot be the whole answer to bar a diseases -- to buy role diseases.

in the early vaccine of the polio, the first one was contaminated with one of the viruses. kids who got the vaccine actually got polio because of the vaccine. many of them would not have had polio had they not been vaccinated. it was a terrible thing. it qualifies as tragedy. vaccines are by and large safer now. it is a reminder. but along with the experience in 1976 -- it is a reminder about the problem with vaccination. there is likely to be some adverse consequences of vaccination. it may be an answer, but it can also harm some people. william house to what is the

acceptable level of harm. -- william ask what is the acceptable level of harm. i would not be able to say that. of course you want to minimize harm. the decision about a vaccination strategy means you have to decide whether you are really to take the chance that some people will be harmed by the vaccine. host: tell us more about why y wrote about autism. here's what you wrote. guest: yes, autism is not nothing itself, of course true that is a real way of behaving in the world. a lot of people have the way of behaving in the world. if we say that we are ready to accommodate people who have autistic styles, than in what

sense is this an abnormality? the rhetoric about the autism epidemic seems to be about a certain set of fears about modern life. in particular, there have been concerns about vaccination and concerns that vaccinations causes autism. and also about environmental influences. perhaps changes in diet and so forth. in a way, talking about autism as if it was an epidemic is a way of talking about the things about our modern life that makes us uneasy. as we learn increasingly that we can deal with kids to have autistic styles, if we think about good ways to do it.

host: one last call on the democrats' line. good morning. caller: good morning. i get up at all different hours. i am retired. in a tv switcher. in may, there were talking about the swine flu. it had dna from swine, flu, and humans. there was a scientist on the re that said that this flu was man-made or it was an accident. i did not see it again. i called congressmaen.

nobody knew what i was talking about. it was never on the news again. why? guest: that turned out to not be true. early on in the swine flu outbreak, because the h1n1 strain was unusual -- tan lee, is -- technically is rna not dna. it is from pig viruses. some people speculated it was made in a laboratory that turned out to not be the case. host: host: our guest has been philip alcabes. he is the author of this book, "dread: how fear and fantasy

have fueled epidemics from the black death to avian flu." thank you for being with us. >> white house senior adviser bowery jarrett talk to online activist about the health care debate comic a marriage, and the military's don't ask don't tell policy. see her comments from hernetroots nation conference here on c-span. president barack obama says that no one is talking about taking away medical benefits for veterans. he told a convention of veterans of foreign wars in phoenix the proposed health-care overhaul is not going to change how veterans get their medical services. you can see his entire speech tonight at 9:10 p.m. eastern. >> lobbying, influence, and money. ellen miller of the sunshine foundation on how to use the

internet. tonight on c-span2. dollars this month, the booktv weekend's continue all week in prime-time with more books on the economy, current events, and politics. tonight these authors. >> how is c-span funded? >> the u.s. government. >> i do not know. i think the biggest government rates. >> it is not a public thing. >> probably the nation's. >> i would say from my tax dollars. >> how is c-span funded? 30 years ago cable companies created c-span, a private business initiatives -- no government mandate, no government money. >> of the rand corp. issued a report today on the status of the health care system in

massachusetts. under a program established in 2006, it requires all residents to have health insurance. the report looks at the outcomes of the program so far. this is about 40 minutes. >> i like to welcome you here today. the briefing is being recorded as part of our multimedia's series and you can access it on our website. you can also listen to today's discussion by tuning in to congressional weekly series. rand is a nonprofit research organization that does research across a variety of areas, but our single largest area being health. in 2006, massachusetts passed an initiative for universal health care but the challenge of making a sustainable is a problem because of how to pay for it. today, dr. christine eibner, the

co-author of the study, will discuss the projections of massachusetts health-care costs and options for policy makers about how it can be paid for. her current research is extensive, posing on trends and the availability and affordability of health insurance, socio-economic disparities, and the effect of changes on costs, health care coverage, and other items. dr. eibner also played a key role and compare, the new transparent evidence that's -- evidence-based approach to help evacuation. you can access that on our web site. today's briefing is the first of several briefings on health care costs. the next one is next monday at the same time, 1:00, in the same room. it will address health-care growth and its relationship to the u.s. industries. i hope to see you all there next week.

in addition, rand is participating in what we're calling a critical conversation on august 29, focusing on the third rail of health reform costs. i like to turn this over to dr. eibner. >> thank you, shirley. today i am going to be talking about options for health care containment in the state of massachusetts. all of the options i will discuss today can be modeled specifically to address the needs of state of massachusetts. but we think this exercise is important from a national perspective as well, because most of the policy options to be considered are currently discussed in a national health care reform debate. in addition to the fact that the policy options for cost containment are being discussed in a national debate, there is also the issue that

massachusetts has been one of the first states to enact health care reform. 2006 massachusetts enacted landmark legislation to end chirred nearly universal coverage to the population. the three major components of the legislation included a mandate requiring all individuals to obtain health insurance or pay a fine, a separate mandate for implores requiring get them to offer help in current -- health insurance coverage or pay a fine, and also state regulated options became available that would make it easier for people to purchase insurance coverage even if they did not have access to an employer sponsored policy. the insurance rate fell to 2.6%. this is a big achievement. it is worth noting that going into health care reform, massachusetts had favorable demography for reform.

it was 8% compared to 50% nationally. the median income in massachusetts is higher than the national median income. the poverty rate in massachusetts is lower than national. and the unemployment rate in massachusetts has been lower than the national average. so what the reform has been successful at achieving close to universal coverage. but there is a question about whether or not the reform will be sustainable. the key issue relates to the cost of health care in the state of massachusetts. we have projected trends in massachusetts starting in 2010 and moving to 2020. in 2010, we've projected health spending will be $43 billion. this will grow to almost doubled to reach $82 billion by 2020. we know that all sectors of the economy are growing over time. or at least that is the general pattern. there is a question of how this

compares to a typical inflation or another sectors of the economy. it turns out that we were able to constrain growth of health care costs in massachusetts to match the rate of gdp, and an expansion treasures -- and expenditures could rise at a lower rate. this is a substantial difference, 7.7% difference achaemenid heavily over these 11 years. -- a cumulatively over the least 11 years. we would not see health care consuming a larger share of gdp over time if this was true. the question is, do we want to see it even larger? probably not. these are one of the rationales of constraining growth to national gdp growth. in order to address this

question, we act t rand were asked by massachusetts to compare cost containment objectives. we had a select the options that we would consider for analysis. then for each of the options, we had a conduct a literature review to understand the background, the evidence, and that there is supporting the gatt pact. and finally for options that showed promise and for which there was sufficient evidence and that, we did modeling and analysis to actually estimate numerically what with the likely effect of those options on health care spending in the state would be. the first was selecting the options for analysis. we came up with a list of about 75 different cost containment option. that was too many prostitutes in the context of a single study so we never did. in the first group -- we grip the reforms in the five

different categories. reform payment, redesign health care delivery, reduce the waste, encourage healthy behavior, and then reform medical malpractice law. wheat group them by category, and then with the client we selected options -- a total of 21 options that reflected all five of those categories to do more in-depth analysis. they were selected to reflect the ones that seem to have the most momentum within the state at the time. one of the challenges we encountered in conducting this analysis is that you have an option if you make will have a very promising option for reducing health-care costs, if you want have two criteria. you like have strong theory and logic suggesting that it is likely to work. and in addition to the theory and logic, we would like have implementation and experience to suggest that it actually has worked in practice. adly speaking, the kinds of reforms that we considered grouped into two

different categories. the first is regulatory reforms. and for regulatory reforms we have a lot of theory and logic about why they might work. we also have a strong history about implementing them in the u.s. in the 1970s and '80s. we can draw on that experience to determine how likely these options are to work currently. the other set is market based reforms. we have a lot of theory and logic, but we have less experience with these kinds of reforms. a challenge with the regulatory reforms that were implemented in the test, it didn't necessarily show in implementation a very strong effect on health care spending. we want to think about considering these reforms again we have to think about reasons why they might work better this time. and then for the market-based reforms, there's a lot of logic to support the idea that they

might work but we don't have as much implementation. this has been a challenge, and it's not really a fair fight. one we have experience to draw on and we can sort of draw conclusions based on that experience and the other is relying more on logic. okay with that i want to go through the different reforms that we did select to consider. and out of the 21 options that we did the in depth review, we ended up with 12 for which we created model estimates. so the first four we considered grouped into the general category of reforming payment system. so i've listed them here. the first two reforms are more market-based orientated reforms. and the second two are more regulatory. and the very first is bundle payment. and i'm going to through what bundle payment is and give an example later on in the talk.

the second two policies relate to pricing for academic medical centers in the state of massachusetts. so this is actually, these two policies are very specific to the state of massachusetts. massachusetts has a lot of academic medical centers and they tend higher prices than community hospitals. these policies would be trying to reduce spending at academic medical centers that are not necessarily relevant for the u.s. overall. the fourth one is hospital all payer rate setting. that's a regulatory, and one of the reforms that was adopted in the '70s and '80s, and has been abandoned by all states except maryland. the second group of reformed that we considered fell into the category of redesigning the system. the first three are all about expanding primary care and increasing the efficiency of primary care. and the last is disease management which is obviously about better managing chronic

illness. the third group of options that we considered had to do with reducing waste in the health care system. we hear a lot about reducing waste as a potential policy for -- for health care savings. so the challenge here was articulating which policies used to reduce waste. we came up with three that might be promising, eliminating payment for some events. and finally accelerating the option of health information technology. and then finally we evaluated one reform that was in the area of encouraging consumers to maintain health. and that reform is called value-based insurance design. i think that bared a little more explanation. value-based is setting propayments for medical services so they reflect the value that a patient receives for that kind of care. so they are frequently discussed in the context of pharmaceuticals, and so the idea would be for the someone with a

serious illness who has a need, they would get a lower copayment than someone using for a less serious condition or something. and then before the modeling, i would say there were originally five categories that we considered. when we narrowed it down to select options for modeling, they fell into four categories. the categories that was left off was medical malpractice. we developed health care spending projections for the state of massachusetts from 2010 to 2020. and these projections adjusted for population change. and they also allowed for health care cost inflation. and we projected that over this time period massachusetts would spent $670 billion on health care. an then we model what would be the likely effect of implementing policies on the

health care spending. and for each model -- when we model these policy options we created an upper and lower bound estimate. upper bound lower bound takes a more pessimistic view. i want to talk about medicare before i move on to the results. so medicare spending was included in the $670 billion of total health spending projected cumulatively of 2010 and 2020. however, it was kind of challenging to determine how we incorporated medicare into our estimates. the reason that our charge was to think about policies that could be speed limited by stakeholders within massachusetts. and medicare is of course outside of the massachusetts in general. and so for many options we assumed that there would be no

medicare policy changes. and if that was the case it would not -- medicare would be unaffected. however, there were a few exceptions. the first exception was that we thought the waiver could be obtained and a particular type of policy. this really applies to hospital rate regulation. the evidence from past experience has just that medicare has been willing to participant -- participate in those options. we had medicare within the rate regulations. we also allowed medicare to be included either medicare enrollees or providers to make sure of the system changed. so an example of this is health information technology. we think the providers adopted health information technology, they would use it for all regardless of who was paying for that care, and so that case medicare was included in our estimates. okay.

so now i'm going to move to the results. and first just to orient you to how i'm presenting this, the red star here on the graph representing the 7.7% that we'd like to see deline between 2010 and 2020 in order to achieve a production that would match the rate of growth in gdp. the difference was 7.7% this is the target we're trying to achieve. the option that turned out to be the most promising for reducing spending at least in upper bound estimate was a policy balled bundle payment. as a payment we project would lead to 5.7 reduction in accumulative spending. so before i was -- before i go with the rest of the policy options i'm going to go through what we did for bundle payment

in a little detail. just to tell you what it is, and how we conducted these only analysis. with these service, providers are reimbursed to the service they provide. that could lead to the overuse of care. the total cost of caring for a condition and providing a particular procedure would be calculated and that bundle payment would be given as opposed to fee for service payment. the idea would be that all cares of the patients condition would come out of the bundle. the bundle amount is usually reduction for the condition or procedure. it would be applied across multiple providers and care settings. and well this is one of the market-based reforms for which there is not tons of evidence.

the limited evidence suggests that it would save money. okay. so we considered bundle payment for ten different conditions and four procedures. they are listed here. the conditions are chronic conditions such as diabetes and high blood pressure, colts procedures like hip replacement. there's a payment reform system called the promethus system. we were able to draw from that data in order to figure out how much it would save the state of massachusetts. so walk through the example of how it works, for a typical patient with diabetes, the average spending for that parable is about $6,000 per year. but promethus has gone back and looked at evident-based

guidelines. and they determined that 39% of payment for care is for evidence-based guideline recommended care. and the other 61% is for care that was potentially avoidable. and by potentially avoidable, i mean it could have been a test that was ordered twice so you got the same test results back for the same situation. or it would be something that became a -- became necessary but could have been avoided. an example of that would be an emergency visit for hypoglioseem ya. >> and in this situation we've said that the reduction on potentially avoidment payment would be 50% sop this causes the payment for diabetes to fall from an average of $6,000 to $4200 per patient per year.

now the reason that this is attractive is that it gives providers a little bit of a cushion in case of the some of the care was actually in evidentable. but it also gives an incentive to participant. because if you're a provider and you think you can get your care levels to provide only recommendations care, you stand to make money o this policy. we multiplied the difference out between the $6,000 and $4200 and we came up with an estimate of savings. but there's a question about how this would work in practice. i mentioned before that there is some evidence that bundle payment has worked. but the evidence comes mainly from hospital-based conditions and it's mostly for coronary-artery bypass conference. the lower bound estimate included only hospital-based conditions. and you can see from the side

that there was a specially a 0 effect, so this was marginal reduction when you include only the hospital-based conditions. so chronic illness is really the biggest cost saver, and we don't have enough evidence at this point. who owns the bundle and allocates the payment? in an integrated delivery system, it might work well. but in a more traditional system, where the doctor may not communicate with a hospital, it might be hard to see how that bundle gets allocated across different providers. they are also to develop -- difficult to develop at a price. we're using a bundle developed by prometheus, which took them about three years to develop prices for those bundles that i showed earlier. and then there are unknown

effects on quality of care. by capping the amount that you pay for a particular service, providers could pull back not only on providing unnecessary care but also one cared that could have been necessary. this goes back to the slide in shows the average no estimate for bundled payment. it turns out that four awp -- options that work in most promising were those related to panic reforms in massachusetts. the opposition of the most promise of our options that in -- that aims at how -- get changing how health care is paid for. ben ben who felt the affirmation technology as one of the three options but they two that are listed are options that are aimed at improving efficiency and expanding capacity of primary care. and then there were three options group at the bottom of our analysis. they are creating medical owns,

using bayou based insurance the nine, and encourage disease management. -- medical homes, using the value-based insurance, and encourage disease management. for all of these three options, they are better management of illness for patients. . a wide group of patient. and then the savings come down the road. hopefully some people end up using less hospital and emergency care because they managed it better in the first case when something started to develop. so the reason these might provide uncertain savings is because the spending that you have to give in order to better manage care is a certainly and a manage care is a certainly and a savings that come are very uncertain. okay. to summarize. we have limited experience with most policy options. the policy that seem to be the most promising at least in the upper bound are all used on

reforming payment system. and the policy that were aimed at better managing chronic illness, they require investment that may or may not generate savings. weaver looking specificically at health care spending. we're not thinking about the value that's added in terms of quality of life that would come about. the we don't mean to suggest they are not good ideas, but from a spending prospective, they are not necessarily going to save money. the final conclusion that no single policy a magic bullet. bundle payment was the most promising option in the upper bound would leave to 5.7% reduction in the 11 year period. the target is 7.7% reduction in spending. so we're not getting all the way to the target with any one of these policy implemented alone.

and obvious next step would be to think about combining options. it turns out it's more challenging that you might imagine. we don't think in terms of projecting the likely effect. we don't think these effects are likely to additive. for most of the policy options they are addressing the same sources. many of the policy options that we consided are about reducing spending that occurs within hospitals for conditions that might have been avoided. and so you can obviously only save that money once regardless of the specific policy that you'd use. we can't necessary add these together. we think it would be possible to come up with an estimate of how combined package of different reforms would effect health care spending but we haven't done that at this point, and it would be another project. so in terms of the next step we delivered to the client earlier this month. the findings were released.

about three weeks before we delivered our reports, they recommended global payment as a strategy to reduce health care. global payment is extreme form of bundle payment where all care for a particular patient would be bundled as a specific price and the provider would receive one payment per patient per year. it was provided by the payment reform commission is that bundle payment could be the first step on the road to global payment. i should mention that bundle payment at this point is not a lot of implementation. we are currently evaluating in four different sights. hopefully with that evidence we will have something to say about the bundled payments. okay. so that concludes the reported portion of this believing. -- briefing. at this point i'd be happy to take questions from the

audience. yes? [hushed conversation] >> how reliable would it be if you were to have a disease and you were to get a price on how much to pay for that disease, what would happen if other diseases came about as as -- because of the former disease you have. how would bundling be able to excel sate, and how would you compensate with the cause of different health care :

>> the bundled amount could differ for different patients. yes, tony. >> can you explain the bundle payment? >> a bundle pimm is the payment for particular episode of care. capitation is a broader concept that would apply to all care for a particular patient across a given amount of time. beyond that, we also think of global payment as been coupled with a different performance incentives to make sure the quality of care does not offer -- does not suffer. yes? >> it seems like it is a lot of emphasis on the bundle payments. for chronic care patients may be reducing the use of the e r.

most of the bundling that i have seen is demonstration are in post acute-care. is anyone evaluating a pre- acute-care bundling tight program that will keep them at a hospital in the first place? first place? >> i'm not aware of whether not that is underway. peter, do you know? this is my co-author. he may be able to answer that. [inaudible] >> in the back. >> could you describe how the bundled payments is evaluated with different. [inaudible] >> so the bundles are based on those 10 conditions that i

presented earlier so they were payments, they were intended to be payment for chronic conditions that would be an annualized payment per patient per year. for each payment with that condition. and then there were also four different bundles that related to sort of acute episodes of care like a geriatric surgery. it would cover all of the care that went along with a geriatric surgery, whether it occurred before, or after that was related to that episode. [inaudible] >> with bundled payment we would assume it would take three to five years to get fully operationalize and then after that we would see the savings accruing overtime for the period between 2010, 2020. [inaudible]

>> no, we only look at the original case, the state regulatory board. yes, was there another question over here? >> is increasing prices charged such as pharmaceutical questions or manufacturers of medical technology, increase their pricing play in projected costs of spending in massachusetts? and our price controls off the table? >> we didn't evaluate either of those off options. i can't speak to that. >> why didn't you? >> we had the school to evaluate about, we started with about 75 different options and we narrowed down to 21 based on what stakeholders and what our

client our most important to consider. that's how we narrowed it to 21. the ones we left off the list weren't promising, they were just options we didn't have the scope and resources to evaluate. >> the bundled payments that they have come up with, taken into account geographic area asian? >> that is a good question. i will ask peter. is bent and baltimore with the prometheus analysis. >> where they analyze what the prices in a particular market, but also potentially avoid the use. so they are tailored for the program.

[inaudible] >> they are in now. [inaudible] who does the bundled payments go to? is that the hospitals or providers? how does that work? >> that's a good question, so if it were -- i think the model would be typically two integrated so that the primary care provider for the patient was holding a bundle but how that would work in practice is difficult to say. we could see it working well in integrated delivery system but mormore challenging temperamentf there wasn't a link across different providers. [inaudible]

>> okay. so accountable care organizations was actually not one of the things we consider. it turns out that the three options that grouped sort of in the middle, two of those three were delivery system reforms. so focused on approving the efficiency of primary care physician so substituting lower cost primary care providers like nurse practitioners and physician assistant for indecent. mds. yes? [inaudible] >> so as we modeled it for that option we really only considered it fairly narrowly to focus on substituting for primary care dividers to see more nurse practitioners and physician assistants as opposed people with mds. we discussed that could be implement more broadly to encourage the greater use of primary care physicians over specialist and there will be

other examples of how that might work as well. additional questions? follow-up? [inaudible] >> and now safety net providers are able to adopt if it isn't? >> so i'm not sure that the analysis that we did spoke to either of those specific questions that you raise. the way we talk about health i.t. is having savings across a number of different dimensions, including sort of reduced paperwork, reduced or better drug prescribing so there is less redundancy and unnecessary drug prescriptions. i'm trying to think about the other areas. nursing time, so that would be a savings to nursing time from having a health information technology of a low. we had several categories of savings that we consider that went into the health information technology kind of pricing.

yes. >> so notwithstanding the estimates that you got from the changes to the health care delivery system, given that bundled payments scenes, upper bound at least, estimates seem to work in the case of integrated delivery system, at that point in argue for the medical home concept or some other concept that does integrate the >> we discussed that a little bit that in order to implement the reform, you might have to have structure underlying it. in the report for the state of massachusetts they discuss it in the context of accountable care organizations and holding them accountable for the quality of care delivered. >> [inaudible] >> i think the idea would be to

implement them in tandem. >> for consumers and patience, what are some of the possible down sides? >> i think the biggest downside would be if quality of care could be affected negatively. the way that that would be dealt with would be by implementing performance incentives alongside bundled payments to ensure the quality of care being delivered appropriately it is a little that unknown at this point and something we need to study further. >> [inaudible] if they started 20 or 30 years ago with managed care was first introduced in california, did you get a concrete example of at that outcome for a patient because of its bundled payment? >> i cannot give a bad example, no.

other questions? yes. >> [inaudible] doesn't massachusetts choose of nurse practitioners are a lot of care are ready? >> that is a good question. we have doing -- we have been doing estimates at the national level. i think the biggest difference is that the national level we can envision medicare playing along. that would mean the savings potential for many of the different reforms is bigger because medicare consumes such a big portion of total spending. >> in your modeling, how did you assign a role for medicaid? because at the state level, that's the big consumer of state budgets. >> right. we use data from the medical expenditure panel survey and we used the dissolution of the

medicaid spending that was in an altered that spending basically in the same way we altered spending for other payers. okay. are there other questions? all right. thank you very much, everyone, for your time and i would be happy to take questions afterwards if you would just like to contact me personally. thanks again. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009]

>> valerie jarrett talk to online after this last week about the health-care debate, detainee irrigation -- interrogation policy. hear her comments at 8:00 eastern on c-span. barack obama said no one is talking about taking away medical benefits for veterans. he told a convention in phoenix that is proposed health-care overhaul is not going to change of veterans get their medical service. if you can see his entire speech tonight at 9:00 eastern. -- you can see his entire speech tonight at 9:10 eastern. an>> this month, "book tv" weekd

continues all week. tonight,gillian teet, chris andersen, and harry reid. >> how is c-span funded? to coach the u.s. government. >> i do not know. i think some of it is government raised. >> it is not public funding. >> probably donations. >> my tax dollars. >> how is c-span funded? america's cable companies created c-span as a public service. a private mandate. no government money. >> an overview on the massachusetts health care program. we will hear from the state health and human services director. this is a conference on primary health care hosted by the

federal health and human services department. it is about 40 minutes. >> good afternoon. >> i am very pleased to introduce our next speaker. she will talk to us about the work that she has been doing around massachusetts. we have been watching with great interest in taking counsel from the experiment. the budget reflects our recognition of the need to invest and primary care. we are thrilled that you can join us today secretary of health and human services director oversee 17 state agencies and she serves as -- serves on the cabinet of the

governor. herb broad range of experience as a primary care physician, prof., researcher, and health policy effort -- expert gives her a unique insight into how the people -- the state can best serve the people. her top priority is insuring that the state has high-quality in excess of services to massachusetts residents. some of the program. she oversees includes air -- include the state's medicaid program, child welfare, public health, disabilities, veterans affairs and other affairs. since her appointment, the secretary has successfully implemented many aspects of the highly successful health care reform law. the state has adopted the first plan to address the long-term needs of the elders and persons with disabilities and she championed the creation of the office of the child advocate to approve the state's walt --

welfare system. she was the medical director of community health care programs. she was also associate professor of medicine at harvard medical and director of the schools excellence in womne'en's health. she served on the white minority women's health services. she was president of the society of general internal metaland = medicine. and her medical doctorate is from harvard medical school. please join me in welcoming her. [applause]

>> good afternoon, everyone. i want to thank you for the introduction. i am going to tell you all that i have a cold. i am not shaking hands. i am not hugging. please bear with me as i go through my presentation because of that. this is a wonderful opportunity to be here. obviously everyone knows that health care reform is on everyone's lips these day. in ways that are surprising to some, but it is a wonderful opportunity to tell you something about what we have done in massachusetts and to talk about the challenge its and successes that we have had. i am just going to go through and tell you what we have actually tried in massachusetts and show you a little bit of the results that we have seen, both

from increasing the number of insured and also trying to get you an idea of the impact it has had on the people. we are more than just counting the number of people with insurance. just to summarize the health care in massachusetts it includes several initiatives. government support for low- income individuals i would say is one of the most important aspects of health reform in massachusetts. the way that massachusetts did this was to expand eligibility for the medicaid program. the state also developed a new subsidized insurance plan for low-income individuals were not that -- who were not eligible for medicaid. people are eligible if they do not have access to affordable employee--- employee year-

sponsored insurance. -- employer-sponsored insurance. i think what we have seen is that individuals have benefited from this more than small groups. there also are expanded options for young adults who are healthier, but this expanded options include some allowing people to staying on their parents' insurance policy if they were living at home and up to age 26 and some other options. there is also employer contribution which recall the fair share. -- which we call the fiar share. -- fair share.

if they did not participate at a level that we define as fair share, they are assessed a 295 ss that for each full-time employee. individuals and massachusetts are required to purchase, if they cannot afford it. i will talk about our experience to finding affordability. when of the other elements of reform in massachusetts is what we call a connector authority, which is commonly referred to as the exchange in the national debate. the connector has several functions. number one it sets the floor for coverage. it is very important to define what minimal coverage is, given that we have an individual mandate. i

we do not want people to buy insurance that does not cover very much they all will -- it also have established a seal of approval for health care plans. the connector sets the standard for affordability. remember i said people have to have insurance if they have access to affordable coverage. the connector authority, which is a board made up of serious stakeholders set the floor for affordability. the state subsidized product is administered in the connector at the ready, but it is not one of the products available of the exchange. the connector also maintains a website and information about various products for individuals have been small groups so they can compare the packages and costs of these products.

i will show you a little bit about what that looks like in a few slides. here we are in massachusetts in terms of uninsured adults. you can see that one of the advantages that massachusetts have that we started out with a relatively low percentage of uninsured individuals. there are some that suggests that these big years actually underestimated the percentage of uninsured in massachusetts, and we did redesigned the survey tool after we came into office, but this gives you an idea of how brevan -- how we have been able to decrease the number of injuruninsuraed. this represents 260,000 people

in massachusetts. this shows you where these people are now insured. this is basically, if you look at health care reform, the bill was passed in april 2006, so this tracks the number of newly insured individuals in massachusetts starting in july of 2006. this goes through the summer of 2008. as of december 2008, the estimated -- we estimated that there are 428,000 people who are now insured. the yellow bar represents the people that are represented and the state program. and this is 163,000 people. the dark blue bar is 149,000 people who are in private

employer-sponsored insurance. the 76,000 are the new people who are enrolled in massachusetts health. the last far, 41,000, or represents individuals who purchase insurance on their own. you can see that a very substantial percent of the newly insured individuals are an employer-sponsored insurance. this shows you of the type of insurance that people had in 2008, 60% were in employer- sponsored insurance. this is the entire population of massachusetts. so even though we estimated in 2008, the last time we did

survey on insurance coverage, that 2.6% of the total massachusetts population was uninsured, we know that we still have some challenges in terms of seeing higher rates insurance among certain populations. what you see here is about 5.4% of the individuals who have 150% or less of federal party of income -- income at the federal poverty level. you can see that as people get into the 300 to 500 range, their rates on insurance is much lower. so low-income individuals are much more likely to be uninsured than high-in termcome people.

as you can see, among the total population this is comparing 2007 with 2008, what we see is for the total population and estimate of 5.7% compared to 2.6% sen. if you look at whites, at the entrance warate dropped. -- the uninsured rate dropped. and for agents it went from 4.521 paris -- for asians and it went from 4.5% to 2.1% sen. well we still see there are differences by race and ethnicity, these are by far the lowest rates upon insurance among these populations that we

see in the united states. we are looking at things other than people that are insured. this is a very complicated slide. i want to point out a few things about what this represents. one of the issues of the health care reform in massachusetts has been the issue of affordability. and whether people really have access to affordable coverage. what this slide represents, you see three lines going across, and they represent various levels of the affordability standards set by the connector for people at various income levels. if you look at the bottom line, which has $165 next to it, that is the level of maximum

affordability for individual with an income of about $37,000, i believe. when hundred $65 per month. with the various cars represent is the actual cost -- what the various spars s bars represent t they actually pay. the next represents an average employer-sponsored insurance out of pocket costs for individuals and that is about $114. then you see in the light blue bars, those of the subsidized insurance products that we have in massachusetts for individuals up to 300% of federal poverty

level. as incomes goes up within the range of $100 to 300 -- 100% to 300% their share goes up. the last set of bars represent what the individual expenditures are for people who choose to buy individual policies, ranging from what we call the bronze package to the gold package. you can see that their costs are within the affordability standard set by the connector. this gives you a sense of how this actually played out in terms of trying to figure out what is affordable for people. the reason this is important is

because when people file their income tax returns in massachusetts, they have to document that the help health insurance. if they do not have health insurance, they have to show they are not able to afford what is accessible to them. yet this is the standard they choose to measure of portability. > what you are seeing is data from 2006 before health care reform was implemented. in 2007 and 2008, for which is

the most it the -- for which it is the most recent year in which we have data. this is a percentage of people who in a survey said they did not get health care for any reason, whether it was because they did not have a doctor, it cannot afford it, or whatever reason. but for health-care reform it was 25%. in 2007 it was 21% sen. this has gone down somewhat. the next line shows the percentage of individuals who indicated that they had a usual source of care. this increase from 86% in 2006 to 91% in 2008. this is a very important number for this audience because this conference is all about primary- care and the role it should play. we know that we have a challenge of primary-care providers in massachusetts, but in spite of that we still saw the percent who were able to

report that they had a usual source of care, other than the emergency department. we also are seeing the people reporting that they are seeing doctors for preventive care and also we have seen the percentage who say that they have made a dental visit go up. the reason i am showing this is because one of the things that health care reform actually mandated is that the medicaid program cover dental benefits for adults. we think that that policy is actually mostly responsible for this increase in dental visits. this next live looks at what people are saying -- this next slide looks at what people are saying about the affordability. in the first line you see people reporting that they have an unmet need due to costs. that decrease from 17% in 2006

to 11% in 2008. yet the percent to said they had problems paying their medical bills decreased from 32% before health care reform and went down to 24% in 2007, but went up again in 2008. this is obviously something that we are concerned about. also, the percent who said they have to pay their medical bills overtime increased -- decrease from 27% to 23%, but then in 2008 went up a little bit. this is something that we are tracking. it may represent the fact that people who do not have access to health care initially found that they had access but as they continue to gain access, a crude out of pocket expenses that were not measured in 2007.

who do we think the uninsured are in massachusetts that are remaining? this slide shows you to the uninsured are by various characteristics. you can see that by age, the least likely to be in this group of uninsured are the ages of 50 and 64. whites are overwhelmingly represented among the uninsured. 6% for blacks is represented and 6% for hispanics. you can also see in the side looking at educational repayment that those without a high- school diploma are least likely to be in this pool of uninsured.

again, i think that represents the fact that we have state subsidized plan for low-income people who are likely to be authenticated. did you can see that those with a high-school diploma but not a college degree -- you can see that those with a high-school diploma but not a college degree are disproportionately represented. we still see there are workers represent and among the uninsured and the highest percent are workers in firms with more than 50 employees. i want to move on now to talk a little bit about what we have seen in terms of some of the issues related to primary care. when i showed a slight two people, if they do not believe me. -- when i showed at this light to people -- when i showed this

to people, they did not believe me. these are people who do not actually practice medicine or who are still in training. the yellow car represents all doctors. you can see it is almost 394 compared to the u.s. average of 249. this is reflected in the number of primary care physicians that we have at 125 per hundred thousand compared to 88 for the u.s. average. when we talk about a primary care shortage, i am sure there are some states that would love to report figures like these.

in spite of those big years, various analysis that have been done at the department of public health, by the massachusetts medical society, suggest that we do have health professional shortages that include primary care physicians and nurse practitioners, dentists, mental health professionals, -- psychiatrist, and ob/gyn. this slide shows what our community health care centers have seen since the implementation of health care reform, which i think is a very important analysis for this audience. as you can see here, in 2005 there was an estimated 431,000 patients to use community health centers in massachusetts. we have a very strong network of community health centers in

massachusetts all across the state. you can see that among the 431,000, about 36% were uninsured individuals and about 30% were covered by medicaid -- 38 percent and were covered by medicaid. in 2006, which is the year in which health care reform was just beginning to be implemented, you see there were 436,000 visits to community health centers where patients using community health care centers. the percentage of uninsured had already started to decline. we implemented the first phase of health care reform in october of 2006. the percentage of uninsured went from 36 to 33% sen. and-- went from 33% t6% to 33%.

in 2007, there were 432 patients using community centers. the amount that were uninjured decrease to 26%. remember in 2005, it was 32% sen. the percentage who had medicaid was 42% sen. the percent who had private insurance did not change. what you see there in that white bar,5%, is the percentage that are in the common care program, the state subsidized program. with the expansion of medicaid and the creation of a new state subsidized program, we were able to get real insurance to individuals that had previously been uninjured.

one of the things i will note about massachusetts is that we have what has long been called a free care pull that pays for services that uninsured individuals access act community health centers and acute-care hospitals. the pool was used to fund health care reform in massachusetts. half of the money was used to pay for commonwealth care initially. there is 300 million remaining in that pool. that is what pace for the 26 -- that is what pays for the uninsured. one of the things about health

reform and health centers is that as i have said, the patient traffic increases between 2005 and 2007. i would suspect that if we had data from 2008 that those numbers would have to continue to go up. health centers required additional staffing to meet the demands. many of the newly in shirt were previously uninsured there obviously was a new population that had not previously access services there. >there are many reports that previous individuals came to a significant health care problems, what people call pent- up demand for chronic conditions that they had not had care for. we are beginning to see that

phenomenon level of somewhat, that you can imagine that this presents a very significant challenge as people who are newly insured come into any system. in an effort to address the primary care shortage problem in massachusetts, we have a few initiatives going on. i will talk more about this at a workshop later this afternoon but in august of last year, the legislators passed and the governor signed a bill known as chapter 305. in that bill was a creation of the workforce center that has a 16-member advisory council. this works -- work for center will be accounted for it for tracking primary data and monitoring trancprimary-care soe

have a better idea of what the needs are. they will review regulation and calls for understanding the impact of those things on recruitment and retention. this includes whether or not the medicaid program allows nurse practitioners and physician assistants to be paid as primary care providers. this work for center also is responsible for creating and implementing a program that tries to fill in the gaps that other loan prepayment programs which exist in the state do not cover. for example, if people are not eligible for national health service because it is not designated as a hypsia or do not qualify for one of the other programs we have, this will try to fill in gaps there.

we are also in the process of developing a state-wide plan for insuring that by the year 2016 every primary-care practice will be designated as a patient practice medical home. the state has been a patient center medical home coordinating council. all those that participate in paying for health care in massachusetts are at the table in this group. we are developing a consensus on what the definition of a medical home is. we are determining what the payment methodology should be. excuse me. and also provide the type of resources that will be necessary for practice transformation. as part of the evaluation of this program, we will be

tracking a unified set of clinical outcomes, practice outcomes, -- and provider in patient satisfaction. we are working with 14 community health centers in massachusetts to get a jumpstart on this initiative, and we are looking forward to the roles that community health care centers will play. i just put this live up to give you a sense -- i just put this light appear to give you a sense of how we are looking at health care reform in massachusetts. i think part of the difficulty with the national debate on health care reform is we do not all speak the same language about reform means. when we talk about reform in

massachusetts, we recognize that we have multiple segments of the health-care system, the health-care regulatory system, the payment system, that we have to coordinate our efforts if we are going to see true reform and -- lasting effects. -- -- lasting effects. -- long-lasting effects. the department of public health, through our determination of need process, has the responsibility for trying to promote right care in the right place. and also planning around work force. we're looking at whether or not we should be more proa-acted about what we're doing with -- wheeler also looking at whether we should be more pro-active

about what we're doing. we also have a health insisted that is responsible for developing a state-wide plan for implementation of electronic medical records and they help information exchange. this was part of -- this was created as part of chapter 305. we do have resources to implement this and are building on the federal stimulus to a lot less to do this in the most efficient way. there is a statewide council looking at disparities that will make recommendations about how do we make continued progress on eliminating disparities. the health-care quality and cost council is something that was created with the original health

care reform bill, chapter 58. it has created a consumer friendly web-based site where individuals in massachusetts or anybody can go and look at what are the different rates that insurers pay? acute hospitals for different medical procedures and diagnosis, and they will look at all the performance measures that right now individual players are providing of providers. we are looking at how do we oversee the governments of all of this various initiatives that are going on. we just had a special commission on payment in the health-care system. we released a report that suggested that we should move away from a fee-for-service model to one that represents

more copayments. medical malpractice continues to come up as initiative that needs reform. we do not have the answer for that yet. we're looking at ways we can keep consumers engaged in this process. overall, we also recognize that what we are looking for is helped wildness in the commonwealth. we do have a state-wide program to promote that. and this gives you a sense of all of the activities that are going on massachusetts. it is not lamented to health insurance reform. we're looking at what we need to do across various systems and figure out ways to coordinate them and be very clear about the results that we want to give it and how we will get there. -- the results that we want to get and how we will get there.

we have a lot of stuff going on. i think that is minee -- that is my. i would be happy to take questions. [applause] >> we have time for about two questions. we have time for a couple of questions now and she will be available later on this afternoon. >> i am wondering how you are dealing with the issue of foreign nationals, in particular, undocumented foreign nationals in the program. >> none of the programs that were implemented in

massachusetts cover undocumented individuals. it is why the free care " would probably never go away. historically individuals to get care and health centers have been paid for it out of that pool. >> yes. >> judy from n.y. -- you -- judy from nyu medical school. i eat appreciate your comments about the dental program. this is a wonderful en route with appropriate clinical education and appropriate clinical group to give patients into primary care to would not otherwise do that. great job. >> thank you. >> one more.

>> [inaudible] >> it was a backup slide in case someone asked about cost. basically what this shows you is pre-reform. the state was paying about $1.4 billion and a three-caracul -- in the free-care pool to pay for the care of individuals who did not have insurance. as you can see, the total cost was about 1.3 billion, still less than what the down payment was. in 2008 it was about 1.7 billion. about 300 million more.

the 2009 numbers are in red because they are not final yet. it is a notion that this is costing the state much more than they anticipated and much more than was budgeted for is simply not true. >> why was the public option not put in the exchange? >> so quite frankly we do not believe that either chip program or any program that looks like medicaid should be in the exchange. by having the public option at the exchange, it allows us to better manage the administration of that program. what we have seen over the last couple of years is that

individuals actually move from the state subsidized program to the medicaid program based on what their job situation is or what their income levels are, and administratively we manage the eligibility determination and that sort of thing through our medicaid program. that is one reason why it would be administratively a nightmare if we separated them. . .

>> valerie jarrett talked two on-line activists about many issues. see her comments at 8:00 eastern here on c-span. president barack obama says that no one is talking about taking away medical benefits for veterans. the president told a convention of the barons of foreign wars in phoenix at a proposed overhaul would not change how medical -- how veterans get their medical services. you will see his entire speech at 9 attend p.m. tonight eastern. >> lobbying, influence, and money. ellen miller of the sunshine foundation on how to use the internet to provide transparency to government. >> how is c-span funded?

>> the u.s. government. >> i do not know. i think some of it is a government raised. >> it is not public. >> probably donations. >> i would say for me, from my tax dollars. >> america's cable companies created c-span as a public service -- a private business initiative, no government mandate, no government money. >> more about health policy now from this morning's "washington journal." alcabes talks about disease control. from new york city, philip alcabes, author of "dread." let's get right to it. early in the book, you write that epidemics fascinate us.

te that epidemics fascinate us. host: give it your best shot. describing an epidemic for us. what is it? how should we look at? guest: bitan epidemic is always a story that a society tells itself about a disease outbreak or the threat of a disease outbreak. sometimes we talk about epidemics that do not qualify as diseases in the classical sense. for instance, we talk about an epidemic of obesity nowadays. 10 years ago, we were talking about an epidemic of road rage. those do not seem like diseases in the classical sense, if you think about the plague or colorists. it is a story we tell about a social crisis. maybe that is the best way to put its.

host: you also say that epidemics create opportunities to convey messages. host: this is right at the front of the book. explain more. guest: it often seems to be true that when we face a social problem, when we do not know how to deal with it, we do not know what the best way is to make it go away. we handed over to the public health industry. the way we do that is by calling it an epidemic. i gave an example a minute ago about rage. when people in the 1980's were concerned about what was happening with children in day care centers. you might remember the hysteria about the satanic ritual abuse. more seriously, there has been a continuing problem about domestic violence.

that was considered a police problem for a long time. later, it became a public health problem. i think that we sometimes call things epidemics because we want to hand them over to the public health apparatus. on the other hand, there are real disease outbreaks, like swine flu. host: the author is philip alcabes. u.s. policy for disease control, the main topic here, and we have separate lines for democrats, republicans, and independents. fear and fantasy, you spent a long period of time. it is quite a span of history.

what is most common in all of that history about epidemics? tell us more about the reaction to them. guest: the most common thing is dread. we bring our fears to the way we look at the world around us. those fears are complex. there are lots of pieces to them. the innate dread of death, destruction, and social disintegration is part of it. there's more. there are anxieties that we have about the world. we see an epidemic coming, or someone tells us that one is coming, and we often imagine that this disease outbreak is telling us that we were right to be afraid. in the 19th century, cholera was

the emergencing infectious disease of the day. it had never been seen in western europe or the united states. in the second quarter of the 19th century, in 1831-1832, it caused a terrible outbreak. it came back a few times. the discussion about cholera was always a layered with the social issues of the day. part eagerly toward the irish, who were both in england and ireland. if you read what people were writing about cholera in those days, it was often about the habits of the irish, or about immigration. cholera has nothing to do with speed irish or immigration. it is a waterborne disease caused by bacteria.

but in all the discussion, there was a reflection of the social anxieties' of that day. host: more of the words of our author. the first call for philip alcabes, author of "dread" is from the list, minn.. caller: good morning. this is a great guest. this ties in with the previous guest and the callers, but also in swine flu. in the top people were having about blaming the mexicans yes,

all the fear in people. just afraid of didying. guest: and afraid of plenty of other things. we have our worries about modern life. swine flu is a great example. i wish i could have written this book a few months later. i could have included a lot more interesting information about how we have responded to an incipient epidemic. as the caller mentioned, at the beginning, there were lots of concerns about mexicans. i heard in late april, a reporter from chicago told me that there have been soccer games between the mexican team and another team. people were boycotting the games because they did not want to go near mexicans.

a typical response, alas, that some foreigner has done this to us. it is not mexicans that bros one flew to america. -- it is not that mexicans brought swine flu to america. as the caller suggested, those kind of anxiety ies come out. host: middletown, new york, republican caller. caller: they have proven that this swine flu outbreak was developed -- it does not have the pedigree. it has traces of human, swine flu, and bird flu. they tested it on the ferrets and the ferrets died. they called back and said they never radiated it.

they said they gave homeless people in poland the test vaccine and people died. i was in the army in 1976 in the first outbreak at a military base. it always happens in military bases. like the doctor that says they're going to reduce the world population by 80% and we need another type of 1918 pandemic. they want to reduce the world population. it is all out there if anybody wants to read. thank you. host: thank you. philip alcabes, any reaction? guest: i have heard some, but not all of those rumors about swine flu and its origin. the investigation was done on where the strain of h1n1 came

from. it was conclusively determined that it did not come out of a laboratory. there's an article that was published about six weeks ago with the pedigree of the virus. i can neither recalled to the pedigree or the name exactly when the article came out, but it showed pretty clearly, as the caller suggested, this h1n1 virus has genetic pieces that come from viruses that have infected different species, including pigs and birds. we do not have to imagine some malevolent laboratory worker putting this together. this is what happens in nature. genes of flu viruses recombined. sometimes come across species.

this seems to have evolved in a complicated way, but not a naturunnatural. the caller brought up the 1976 outbreak. that is important and relevant. in 19676, there was concern based on a few cases of h1n1 that seemed to come from a pig virus that was isolated from recruits at fort dix in, new jersey. it became the basis for a nationwide vaccination campaign. in the end, there was no widespread outbreak. there were about 230 cases among recruits. there were 300 cases in greater new jersey. there was no big help break of swine flu. -- there was no big outbreak of swine flu. there was a nationwide vaccination campaign, which

seems to have caused some cases of a syndrome. 1976 is probably relevant to our experience now, although, we are not sure exactly how. the caller mentioned an allegation that eugenicists want to reduce the world's population. if so, a flu virus would not be a good way to do that. the very worst flu outbreak of all time was in 1918, sometimes erroneously called the spanish flu. that killed maybe 600,000 people that killed maybe 600,000 people in the u -- that means 99% in the american population survived it. that was the worst pandemic of all time. it is something to keep in mind.

even what seems like a terrible outbreaks do not diminish the population by that much. host: our guest was educated at union college and columbia, at johns hopkins. philip alcabes is also a director at school of health sciences up in new york city. he is the author of this book, ""dread: how fear and fantasy have fueled epidemics from the black death to avian flu." as we look back in history and pick it up with the black death itself, how did that dread antianxiety manifest itself in those days and how did it change, if that has changed over the years? guest: we're talking about black death, which was the middle of the 14th century. it becomes plate and comes to

europe and the 1340 -- in the 1340's. it may have killed a quarter of the european population. plague was not brand-new. but it was well out of memory of anyone who was alive at that point. the previous outbreak was over 600 years before. it had circulated in the area of which would be central area -- asia now but at that -- but had not come to your for all of that time. -- to europe for all of that time. was terrifying. there's a really classic example of the way that a coming of a disease outbreak galvanized

fears that people had about society at the time. one of the horrible things that happened -- the countries that we know of them now did not exist. it would be the western part of germany and parts of france in part of belgium and the netherlands. the massacre of jews. it was a very christian time. christianity itself was changing. people had their anxieties about that. when the plague can, townspeople in dozens of towns massacred jews. they said it was a way of warding off the plague. for that time, the massacres stopped. every law the fears and -- there were a lot of fears and unrest

about the way society was changing. the end of feudalism, the growth of towns, and the changes in the church came out of this very dark picture. host: lexington, ky on the democrats' line. your honor with philip alcabes. good morning. caller: good morning. i'll understand that fleas from rats cause black dust. what do we have to fear about fleas from domestic animals? guest: yes, the caller is correct that plague can be spread by fleas. it is normally a disease of small mammals.

often prrodents. nowadays, it can be found in a wild rodents. that is the most common reservoir in the western hemisphere. the radical, a flea that has been jumping from rodent to rodent that happens to land on the human could transmit the plague to a human. very few cases of plague in the u.s. every year. a handful. it is a bacterial infection. it is treatable with antibiotics. i do know that it is not a big public health worry. that is partly because it is treatable. we do not have the same ecological arrangements that erupted in the -- that europe

did in 1340's. rat species is different. the entire is logical system is different now. i am not sure if i have answered the question about fleas in particular. if you what can be in a place where there was wild rodents known to harbor the plague, your physician might advise you to come in for care if you have symptoms. it is rare. host: the next call is from mark on the independent line from california. caller: and was concerned about the origins of some of these diseases and whether or not a biological researcher may be involved in this.

for instance, most people may recall the panic that occurred when aids was right been the nation. two people initially came forward and said they knew what the disease was. the french person wrote a book about aids. in the book, he said that he believed that aids as it is in africa was likely brought to africa by u.s. homosexuals who contracted the disease here from research that was going on in new york and places like that, and then took the disease to africa. this is one of the discoverers of the disease who said this. this is not some sort of crackpot. when he said that jews were often executed when diseases started to spread.

this was also true in germany. most people might be surprised to learn that -- hitler talks quite a lot about disease. and makes the connection between jews and syphilis and homosexuals. guest: let me try to break this down. there have been a number of allegations that the aids virus may have come from a laboratory. that is almost certainly not the case for the main reason that the state of knowledge about molecular biology in the late 1970's when the aids virus started to produce the disease that we now call aids was not sufficiently advanced to create a virus that is at dispatthis

sophisticated. the allegation that americans brought aids to africa -- american and european scientists believe that the virus that causes aids originated in africa. africans believed it originated in the u.s. for quite some time. this is a fairly common phenomenon. everybody thinks the terrible epidemic came from someone else. it is so ancient a phenomenon that the ancient greek historian wrote that when the plague of athens cam around 430bc, the people said they came from africa bill that goes on today. -- came from africa. that goes on today. like an earlier caller said, people like to believe swine flu

came from mexicans. from a historical standpoint, it has to be looked at with the circumspect from. there's abundant evidence that the aids viruses -- there are several different related types -- evolved from pre-existing viruses of chimpanzees that had been living in africa. that seems to be the most overwhelming evidence. i'm not sure the georgian matters. -- i am not sure the origin matters. as for the aspect of homosexual lobby, it is important to remember that the aids virus has nothing to do with homosexuality. its job is to move from person to person so that it can keep on producing more jr. aids viruses. host: our guest is philip

alcabes, author of "dread." we are taking calls on u.s. policy for disease control, and also learning more about the history of disease control. when did disease control become a reality? what part of history? how did it work in the early days? guest: i imagine the horrord that occurred during the black death. at the same time, people were launching quite cogent disease control measures. quarantine, for instance, was essentially invented or at least begin policy very early on in the plague years, in the 14th century, and became

institutionalized soon thereafter. that was quite a long time ago. the idea of what is called the sanitary cordon, wally off your town, not allowing visitors in. but also began early on -- that also began early on. of course, disease control has evolved and changed with the advent of germ theory, modern technology, vaccination, antibiotics administration. but the basics of disease control, isolating the contagious, is quite old. host: there's a photo in "the washington times" of children getting hand sanitizer. the point of the whole story is that schools are preparing for swine flu. kids will be first in line for vaccinations.

how does it work today? how well does disease control work, beginning here in the united states? guest: disease control can be extremely effective, especially in the developed world where there's money to put into it. and the u.s. response to swine flu seems to me to be both circumspect, but evidence based, straightforward. i think there was a little bit of panic at times. schools will probably kohl'wered that did not need to be closed. i really have to credit the cdc for keeping people informed in the wake that seemed to be designed to naught fomenting hysteria.

in developing countries, disease control can be very carefully administered. again, in developed countries, we put a fair amount of funding into disease control. some people will say not enough, but much more than poor countries. there's a big problem there. you are probably aware that with the likelihood that there will be a vaccine available against swine flu sometime this fall, the question arises -- what countries should have access? should the united states and europe be able to buy up the vaccine because we can't afford it? what about the poor countries? host: in the financial times -- more calls for our guests.

republican line, john. gcaller: i am really happy that you have this man on here. it is so nice to see somebody intelligent on c-span talking about something intelligent. i have a couple questions. my favorite book of all times is a book called "a short history of nearly everything." it has so much interest in step about science. people should just educate themselves and read more. when i was an elementary school, people came around and gave us some type of vaccine, maybe flu or smallpox. i don't know what anybody does that anymore. and the next question is, why

don't we quarantine groups of people when we think that they have something that can spread to the rest of everyone? guest: i thank the caller for the compliment. i wanna talk about the vaccine question. the last question is telling -- why don't we quarantine people? a lot of people left last as why don't we shut the borders when there was swine flu? the chinese are big quarantine rs these days. you're right -- you might remember the sars outbreak where they thought and universities for three weeks. people had to bring flu -- food to the students. most recently, china quarantined a village in the western part of the country

where there had been a small outbreak of the plague. that is still a possibility. it does not really seem to work very well except if you know exactly who needs to be quarantined and you can be really good at it. can be a really good at it. to our credit, we try to develop disease control systems in this country that recognize individual freedom. mostly, there are alternatives. for something like swine flu, quarantine would not be very effective. can be transmitted before people get sick. it is too hard to know who has been infected. would be hard to know who should be quarantined. the question about vaccination in schools -- i am not sure that the vaccine was actually given

out in schools. that is not the practice now in most parts of the country. you have to show that you have been vaccinatioed in order to register for school to the decision has to do with policy. i am not a policymaker. i believe that has to do with policies about the relationship between the disease control authorities and the education authorities. it would be a question better put to the education people themselves. host: a message via twitter. guest: that is the $64,000 question these days. everybody should have access to health care. can it fuel an epidemic?

could be considered not to? as i said, an epidemic is a story. i guess you could tell the story that way. i try not to say that this is an epidemic and that is not. if obesity and crystal meth addiction can be epidemics, maybe a lack of health care could be called an epidemic. is a little the semantic. does lack of health care fuel epidemics? i think it is fair to say that in historical experience, when people are unhealthy, they are more susceptible to disease. it is certainly true that the spread of disease is often faster among the poor because of crowding and the inability to afford preventive measures.

in that sense, it is related. host: chuck is on the line in chattanooga, tenn. on the democrats' line. caller: i want to ask a question about what you believe is the most expensive and the most overblown epidemic of the 21st century. you talked about obesity and other kinds of the epidemics. what has caused america more than anything else so far this century? guest: it sounds like she has an answer in mind. i do not have a good answer to the question. i cannot tell you exactly in dollar amounts where we have put

the most money. certainly, lots of fundy was tracked into aids -- lots of funding was put into aids. we spent a lot of money on diseases that do not often register as epidemics. i think we probably should. as you know, heart disease is the leading cause of death in america. we spend money on that. most people probably believe we should. i would not want to say we are wasting money on a and b, and not spending enough on c and d. i am more interested in the way we talk about epidemics. the question of expense is not one that i have dealt with. the question of what we talk about most, i think, until swine flu came a few months ago, we probably would have said bird flu, obesity, drugs, alcohol,

and cigarette smoking. it could take your pick depending on how you listen to the public dialogue. should we? that is the problem. that is a policy problem. how do we decide what is the most important thing? how do we decide what is the real threat? host: the role of the media in all of this. good job? bad job? what do you think? guest: i am often asked this question. i will tell you. there is the paradox of getting past about the role of the media as i am talking to the media. without pulling punches, i think the media, in general, do what the media are supposed to do. that is, delivers information in a way that tells a story. sometimes the media highlights stories that are inflammatory.

we talk about shark attacks probably much more than we need to since not the medieval diane shark attacks -- seen as how not that many people die in shark attacks. people like them. society tells stories to ourselves. it does not seem to me that by and large media creates a mysteriouhysteria. host: joann on the republican line. caller: good morning. i was watching the science channel years ago. they have a program on about how they collected all these health

records that went back generations. they were discussing obesity of the time in the families. they traced it back to a famine that have occurred generations before. are you familiar with this study? guest: it rings a bell, but i could not cite you chapter and verse. caller: i was 1wondering. we have all these fake sugars today. and they have this outbreak of diabetes. i was just wondering if any of this could be tied into our genes and illevolution. guest: she brings up the

question of obesity and genetics and evolution. other than swine flu, obesity seems to be on our public health mind the most. i talk about this in the book. there is a lot of inquiry about obesity and a lot of rhetoric about obesity. it seems that everybody has a different take about what is causing this problem. it is worth pointing out that it seems to me that the problem of obesity, based on current data, is overblown. the mortality associated with obesity is normally that rate. the safe levels of weight are often missestimated.

from the data, it is the extremely obese who have been increased risk of mortality. if you just go by the day the, it is not clear that this is such a big public health problem. and yet it is a big public health problem because we talk about it in that way. a lot of money and programs and research goes into obesity. as to the genetic hypothesis, there seems to be genetic components to obesity. they're sometimes seems to be dietary components. it is very hard to say this is the cause of obesity. it is very hard to say that obesity is a problem. it seems to be a problem for some people. some people who are obese develop diabetes or heart

disease. many do not. many experienced a long and relatively healthy life. it is hard to say. you cannot say that if you become obese, you will die from it. it is a complex problem. there are lots of pieces to this. it all has to do with the way we live our lives today. the public health conversation about obesity and besides conversation -- and the science conversation, it is over layered with all sorts of questions about what is wrong with the way we live today? host: another passage from the book. host: here's another look at the

book. our guest is philip alcabes, author of "dread" in new york. sheila on the democrats' line. caller: every day we hear about so many people losing their jobs. a lot of people cannot afford cobra and they lose health insurance. now we have the swine flu fall season coming up. what would happen if many, many people came down with the swine flu and they could not afford to get health care? guest: it sounds like there are two parts to her question. there is one part about health care, which is on everybody's mind these days. the other part is positively about swine flu.

let me answer the swine flu part. i do not have a crystal ball. i do not know if swine flu is coming back. nobody knows that. some people think it will. others think there's good reason to believe that it will not. there's a very persuasive paper by some people who are very good scientists and historians of influenza. it appeared in the journal of the ama this week. it is about the history of the h1n1 flu. it says it is likely there will not be what some people have called a second wave of small inflow. -- second wave of swine flu. we do not know if it will come back. preparations are being made in case there is more swine flu this fall. what would happen to people who do not have health insurance?

that seems to be a central policy question. that is part of why the health care debate seem so pressing right now. for many years, we have had a health care system that is content to leave tens of millions of americans without health insurance. what happens to people like that if there is some really bad 7 health problem. maybe it will be flu. maybe it will be something else in the future. i do not have a good answer. i think it is a policy answer that remains to be developed. host: another question from twitter. guest: guest: i do not know what that

is true. this question -- it is very common for people that think that modern times have done something bad to us. on the face of it, it would seem that we are doing better than ever. not everybody, but americans live longer than ever before. the percentages of people who die in disease outbreaks are smaller than before. as i mentioned before, the leading cause of death in america right now is heart disease. so while it is hard but we're doing something right, it is very easy to see what is wrong, but we're doing better than our grandparents. whether our t cell counts are as high as bears work, i do not know that data. but empirically it does not seem that we have made our saved --

made ourselves across the board more susceptible to disease. host: let's hear from florida right now. line. you are on with philip alcabes. caller: good morning. you made a comment a few minutes ago that prompts me to ask you two questions. why is it so difficult? they are talking about not having enough vaccines. i have heard because it is not enough profit and the pharmaceutical companies do not want to make it. why is it so difficult to make the vaccines? you said that you did not know if there was going to be another wave of h1n1. it has not gone away. in orlando, just last week, we

had another person died from the flu. it is just continuing. host: two questions. why don't you take the first one first. vaccines and profit and making an offer everyone who needs it. guest: you want to the vaccine production to go slowly. we have a very good example of what happens when flu vaccine production went too fast. that was in 1976 in what is sometimes called the swine flu fiasco. there had been a small outbreak in new jersey. a few recruits died. i think the number was 13. there were about 300 cases altogether. because of alarm that this was the beginning of a reprises of the terrible 1918 flu, u.s. authorities launched a nationwide vaccination program.

vaccine production was hurried so the vaccine would be ready in the fall. i think about 40 million doses were administered. then it turned out that people were getting a syndrome, a bad neurological syndrome. some people died from it. that was a lesson about hurrying vaccine production. i hope we have learned it. there are questions on whether there will be vaccines available soon enough. with a vaccine production, you what to make sure it is safe before you offer it to anybody. let me say that vaccine production is done by forms of new companies. it is not by thdone by the govet in this country. it is a profit making enterprise. in some cases, it is a cutthroat

one. some people have said blood thirsty. the pharmaceutical companies want to be able to make their profit when they are producing a vaccine or other products. that is what for-profit companies do. the caller also mentioned h1n1 has not gone away. that is true. when people talk about a second wave, they're talking about the possibility that there will be a lot of new cases in the fall. that remains a possibility. host: 1 other viewer via tw itter. what can we look forward in terms of organization, money, that kind of thing? guest: because i do not have a crystal ball, i will not attempt to read the future. i will tell you what i copal

happens and hope that will be a sufficient response to the streetweet. -- i will tell you what i hope happens. i hope that we do it in a smarter way. to use an old-fashioned term, more holistic, more and related to the complex relationships between the environment, environmental change, commerce, transportation, human migration, the food supply, and human susceptibilities. i think we're trying to do that now. i am impressed with the movement that is called one world one health. it wants to redirect our attention in a more complex and

holistic way. if you really want to control viruses, and others that come from animals, we have to stop thinking about locking the doors to the human population, which is what we attempt to do with the flu vaccine. and really think in a much more complex way about the entire ecosystem that we live in. hope that is the future. host: this is in open called the baltimore sun -- this is in "the baltimore sun" this morning.

officials had been left scrambling. host: do you ever see something like that happening? guest: alas, i am se the research will go on. this is the elusive but beguiling silver bullet. everybody wants the one shot that will fix everything. i am old enough to remember the space program of the 1960's and the food that the astronauts had to eat.

you want to put everything into one box and injected into people and they will be magically immune. that would be great. that would be a terrific efficiency. i. -- that would be a terrific efficiency i suppose. that gets into germ theory. it goes away from my vision of what really sound public health in the future has to look like, which is we stop thinking about viruses as a problem of humans and start realizing that the march froy emerge from complex interactions that we share with animals and all of the determinants of the way that animals live in the way we interact with them. host: here is what viewers question via e-mail.

is cancer an epidemic? if not, why not? guest: i will stay away from stating if this is an epidemic and that is not treated cancer kills a lot of people in america. i think there are 600,000 cancer deaths every year. that is much bigger of the problem than one century ago. that is partly because we live longer because we are good at controlling the killers of a century ago like tuberculosis or pneumonia. do we want to call an epidemic? that is in the eyes of the beholder. host: william is on the line for republicans. good morning. caller: good morning. first-time caller. thank you for the opportunity,

c-span. first, by to talk about my experiences and then i will ask a question. i dread vaccines. the reason is that in the first grade and the second grade, i was given a vaccine. by the time i got to the third grade, 10% of our class suffers from the disease. it was a scary experience. what is an acceptable rate of instance of a disease caused by the vaccine itself? guest: william debts at a terrible problem. it is one of the reasons why vaccines cannot be the whole public health answer. in the 1950's, early in the

polio vaccine era, in the first vaccine, it was contaminated with what is called wild type of virus. kids who got the vaccine came down with polio because of the vaccine. many of them would not have had polio had they not been vaccinated. it is a terrible thing. it qualifies as tragedy. vaccines are by and large safer now. it is a reminder. but along with the experience in 1976 -- it is a reminder about the problem with vaccination. there is likely to be some adverse consequences of vaccination. it may be an answer, but it can also harm some people. william house to what is the

acceptable level of harm. -- william ask what is the acceptable level of harm. i would not be able to say that. of course you want to minimize harm. the decision about a vaccination strategy means you have to decide whether you are really to take the chance that some people will be harmed by the vaccine. host: tell us more about why you wrote about autism. here's what you wrote. guest: yes, autism is not nothing itself, of course true that is a real way of behaving in the world. a lot of people have the way of behaving in the world. if we say that we are ready to accommodate people who have autistic styles, than in what

sense is this an abnormality? the rhetoric about the autism epidemic seems to be about a certain set of fears about modern life. in particular, there have been concerns about vaccination and concerns that vaccinations causes autism. and also about environmental influences. perhaps changes in diet and so forth. in a way, talking about autism as if it was an epidemic is a way of talking about the things about our modern life that makes us uneasy. as we learn increasingly that we can deal with kids to have autistic styles, if we think about good ways to do it.

host: host: time for one last call. caller: i get up at all different hours. i retired and i am a tv switcher. in may they were talking about the swine flu. it had dna from swine, dna from flu, and dna from humans. three different dnas. there are scientists that said that this flu, it was manmade or it was an accident. and i did not see it again. i have