emergency medical chairman and the director of respiratory care at the hospital. we'll also talk to the chief nursing officer. "washington journal" start now. .

caller: good morning. i feel like the stimulus package is helping our economy. from the beginning there were threats of this recession being a depression. many people i know did not reveal the head of this recession. they have the opportunity to do the head of it, but the decisions the president made were very good -- maybe not the best, but they worked. -- they have the opportunity to feel the hit of this recession but did not really feel the hit of it. caller: good morning, i think

the stimulus package may be happening a little bit, but i cannot tell. i just want to ask a question early on here. it really does not pertain to that, but since senator kennedy 's death and all the accolades -- he was a good man and everything like that, but we have another democratic senator you don't hear much about who is in bad health, senator robert byrd, the longest ever serving senator and i would think he would get a little -- the reason i mention him, me being a republican, is because i'm concerned about the czars in this government. i do think that senator robert byrd is a wise person. he wrote a letter to the president on february 25 and talked about the dangers, the

usurpation of the power from the congress about all these czars. with all the stuff up in the media about all of them i'm very concerned about this. i would be concerned if senator robert byrd -- ex-kkk or whatever, but i do respect the man for his audacity to question the government, the president. host: yes, springfield, ohio. caller: yes, i took a driving trip to florida on interstate 85 and i saw construction in ohio and tennessee. the road work there, kentucky, georgia, and florida. i think the stimulus plan has put people back to work. i saw it for myself. host: all right, baltimore, md., timothy. caller: i'm glad you brought up

this topic this morning because i don't think this administration is getting its due. my wife and i have received two stem as packages -- the first was the homeowner-supported refinance. we went from 7% down to 4.5%, going from 30-years down to 15- years. we took advantage for cash for clunkers and got rid of a big ford f150 and got a nice show the car. we're looking into the process of looking for my daughter who is in college, looking at the volunteer to get a $4,000 cash credit. it is helping out and we have been doing many more things like we have lowered our thermostat -- actually put it up for the

summertime. we use energy bu-uselbs throughout the house and we're cutting every way we can. we see roadwork done here throughout baltimore in maryland. reelected this president for four years. this report card that people like to put out what he has done from the time he got elected to where he is now -- we elected him for four years. i'm hoping it will work. i have seen great signs. my 401k which to go hit -- i lost about $10,000, and by what lost about $8,000. host: what do you do? caller: i'm a power plant engineer and worked for one of the city government's share. my wife works for the state of maryland. she has been laid off for nine days because they took a furlough there. we are in it for the long haul.

host: the color reference cash for clunkers and in the paper today, on the front page this article -- auto sales are up things to clunkers. -- thanks to clunkers. the next call comes from illinois, william. caller: yes, i think this is just propaganda to boost confidence so that people will go out and spend when they should not. we have -- digit unemployment -- double-digit unemployment and

we're handing out welfare with cash for clunkers, people who may not be able to afford payments. i foresee the u.s. to be in an inflationary period at the end of the year that will be the highest ever. host: all right, mount rainier, on the independent line. caller: i'm calling in regarding the stimulus and if it is improving the economy. i want to say that it most definitely is. there are over 1.5 million people currently unemployed. they're still being paid through the estimates. people can question whether or not it may cause inflation -- they're still being paid through the stimulus. but it is securing people's homes, taking care of their families.

the stimulus is creating jobs even though some of them for the infrastructure is going slow. the percentage is probably too low. and should have been geared to around 40% for more infrastructure. it was made out to much for taxes, but nevertheless, it went out and some businesses and other industries had a tax decrease. it has really helped out the economy. many people who are very criticized -- who are criticizing these federal programs are making a big mistake. host: mich., independent line. caller: yes, i agree 100% with the last caller who thinks more of it should have gone to infrastructure. the people who know the least

seem to be the loudest. i think that obama is doing a bang up job. all these republicans are just being loud. host: from page, atlanta a journal-constitution. the economy shows new signs of life. the hopes for a sustained recovery are clouded by concern. they write that americans are hamstrung by flat wages and job losses. the next call comes from wichita falls, texas on the democratic line. caller: yes, the speaker before this last man does not want to give anyone credit for anything. i do not know where he lives or what he does, but he has got to come to reality that the stimulus package is working.

we're going to have to give obama a chance. he and his administration are doing a great job. host: all right, in other news on the opinion page following up on a tuesday editorial in which it called for the u.s. to pull out of afghanistan, this column says where the previous reporter got wrong. next call, ohio, nancy.

caller: good morning. how are you? my concern is these people calling about the stimulus package. we just had a food line in lima, ohio. so, if the people think that the stimulus is helping, they should look at the facts. adjusted an article with quite a few people from the government, the car dealers -- they still have money they have not received because the government is so slow. caller: my think with the stimulus package's most of the money has not gone in yet. you have people employed by the

government getting jobs. we the people are the government, so that is more money for us. here in florida the highways have been under construction for over three years. that was before obama came along. we have been slow. it has nothing to do with stimulus money. i think it is a fallacy that people think that is causing growth. host: little rock. caller: yes, the lady who just call from florida -- the reason it was slow is probably because bush did not give any money to help get it along. these people need to quit lying. i think we're living in the last days. they need to straighten their lives out and be more like god.

host: all right. on health care, democrats tried tougher tone on health plan. they write that the democrats are shaping the strategy in response to the public pounding they took over the summer. next call, or again. -- oregon. caller: i definitely see the stimulus package having its effects, but they're very slow. as the lady earlier mentioned, and has not all been spent yet. people who expect an overnight change, or the economy to switch

from recession back to growth mode overnight -- that is not going to happen. what i am frustrated about and want to mention is that in my view the republicans and they're talking heads are doing their best to not president obama off his pedestal -- or what they think is a pedestal -- i think it is called the presidency and he should use it for all it's worth. the republicans are demonizing it in hopes of winning more seats in congress in the 2010 election. most people are not even considering that. if you look at the motives behind the republicans, that is what it is. you just read a piece saying democrats are trying to convince the country saying that the

republicans are not cooperating -- all you have to do is open your eyes to see that the republicans are not cooperating. caller: i would like to say obama is doing all he can possible to bring back this economy. the people on the other side, the republicans, are holding him back. they are trying to hold him up because they want to now now, they don't want another four years. republicans are the ones who put this economy in the shape it is a in. bush and everything. how are you going to keep a solid ground when you are digging the dirt from underneath? host: hi. the other washington.

caller: i can say that the industries are alive and well. we have seen our inventory go down from 40,000 vehicles here to 20,000 vehicles. it is directly related to the cash for clunkers thing. host: do you work in the car industry? do you think there will be a bust after the program? caller: yes, i do. there might be a lull, but i think it really helped. i am a driver for a temporary agency here. host: so, you support the cash for clunkers program? caller: yes, i do. host: alexandria, va.. caller: i say the stimulus package is working. we should make a wish list for

things we would like that we can use the stimulus money for. people need to have patience. there is a hierarchy of problems going on. which do you solve first? host: maryland. caller: first-time caller. i think the stimulus package is working. i wonder how it could not. when you pump money into the economy it will have to work long term. it will eventually fall apart, but how could it not work? host: all right, thank you. next call, frederick, md., robert. caller: good morning, i have a few things to say. first of all just as far as the stimulus goes, you cannot see it

yet, but this is the same type of economy that bush propped up. it is called demand-side economics, putting money into the hands of people so they. can spend it that always fall short because once the money runs out the economy falters. the way to sustain the economy is to prop up businesses. make it attractive for global businesses to come in. you match what china is doing, which is to abolish the capital gains tax. you do what ireland is doing and lower the corporate tax to 12%. do those two things and businesses will flood into the country.

we will have so many well-paying manufacturing jobs that it would be. be that is first. that is how you get an economy booming. -- you'd have so many manufacturing jobs that it would be ridiculous. secondly, the reason people are upset with obama it is because he is a closet socialist. he is stalking his administration with people who call themselves socialists. it is not even have been any more. if you look beyond the surface you will see that he really is a closet socialist. it is the antithesis to our constitution. host: ok, missouri, joyce. caller: i think it is one of the biggest farces and one of the

most telling points about waste, fraud, and abuse. we're talking about nearly $1 trillion being frittered away. they have had a stimulus for building three buses at 4 $4 million, putting four people to work. they gave it the canadian border $40 million for crossing -- for a crossing between canada and the u.s. they showed a lonely road it was maybe three people crossing id per day. yet on the texas border where 145,000 crossed per day they gave them $2 party. -- per day.

the cash for clunkers program is ridiculous. as soon as that money is lost or frittered away, we will be back in the same situation. we need a sustained jobs for manufacturing. from that would come many other types of jobs. i want to know how many of these billions are spent on those 33 czars that he uses to supersede the congress and senate? host: grand junction? caller: i have not heard this for many people, but how much money would we save a in healthcare concerning illegal immigrants? if we had this health plan and all the americans would have universal, who will cover the

health plans for immigrants who do not have it? host: in other news in "usa today" -- aarp raises a voice in clash over health. host: the next call is from michigan, which caller: town maybe, michigan. -- which town is it?

caller: maybe, michigan. it really is. i would like to respond to people who wonder where this came from -- this will not work because most of this was pork. obama's promised during the campaign was that no piece of pork would cross his desk. the cash for clunkers was a failure. after one week they needed another $2 billion. i know dealers who are $300,000 in the hole waiting for the government check that was supposed to come 10 days after signing off on the deals.

when republicans are seen as trying to do obama in, he is really doing it to himself. he is the one who is promising and cannot deliver. host: indiana. caller: good morning. i am baffled by some of this talk. i have just listened to all that has been going on in the last few months and them totally appalled. first off, my husband works in the steel industry. as everybody knows, that industry took a big hit during this recession. his over time was cut, there was no profit-sharing. but now he got his over-time back, got a raise that win to affect this week. -- a raise that went into

effect this week. now people are coming into our area and using these catch phrases like czar and socialist -- well, my son does not have health care because my healthcare company does not consider him of full-time student which she is but he does not go to a public or private college because it cannot afford. so, all these catch-phrases in the impatience of people -- it took a long time that bush and the mighty powerful money- grubbing people who got us into this mess -- obama has been president for only months. ok? sit back, take a breath, and let's get off these catch- phrases like czar and socialist.

host: tom, long island, new york. caller: i don't think the stimulus package is working right now. i don't see it happening. you have to get manufacturing back in this country and that will not happen. host: pensacola, fla.. caller: yes, i would like to piggyback on an earlier caller. people seem to forget that eight years before obama took office republicans ran the country. he had only been in office less than one year. he is fighting not only the republicans the republicansrich people. -- his fighting not only the republicans, but rich people.

people who have power are killintelling those with no money that obama is the problem. it is a problem of ignorance. people are more concerned with catch-phrases like the earlier caller said, then with reality. you cannot talk to a car dealer who says that the cash for clunkers program is not working. most of the car dealers were republicans. talk to them privately and they always say that there coffers are being enriched. host: next we will talk about the war in afghanistan with a fellow from the brookings institute. ♪

>> later this week, a review of the highlights of health care in congress. on sunday, a comparison of health care systems from around the world with his former reporter from "the washington journal." >> this national book award winner has analyzed and critiqued the u.s. education system.

>> as the debate over health care continues, c-span healthcare hub is a great resource. you can watch the latest events and share your thoughts online. you can include any video from town halls to have gone to. >> supreme court week begins october 4 with the debut of hour documentary. here is the producer. >> today this is one of the final days of shooting documentary of the supreme court. we have been in there for about two months. we have talked with nine of the justices about their job. the give us insight as to how it operates. we're getting a couple of final shots today. >> supreme court week, starting

october 4. "washington journal" continues. host: this is jeremy shapiro joining us today. is a former adviser to general mcchrystal. president obama says he will take the report to camp david. what will he read in this report? guest: he will read at a lot about the shift of how america and nato will fight in afghanistan. it will be a strategy focused on the population rather than the enemy. it is not sufficient to hunt down the enemy through mountain valleys, but rather to concentrate on protecting the population. he will hear that it will require a certain cultural

change in the u.s. military. it will be a greater willingness to except risk. host: the assessment was grim. do you agree? guest: the report opens with the word "serious." everyone in afghanistan is quite worried. i recognize the trends are not good. the first question the general asked advisers who came to him was "can this mission be accomplished surcease the general consensus was that under the right circumstances it is. -- "can this mission be accomplished?" host: does the report addresses many troops need to be on the

ground? guest: no. host: what is the process and who has the say, and how does it get to the president? guest: that belongs to the general who was cast by the secretary of defense to do a 60- day assessment. he was free to set up the process as he desired. he brought in about nine or 10 civilian experts from various think tanks in the u.s. and europe to help. we advise, but are not responsible and do not necessarily agree with all that is in there. host: do others have a part of it? guest: yes, but the bulk was

done by his staff. host: what is the general protocol with the president? guest: the report is given to the secretary of defense and the secretary-general of nato. he will eventually get it as president. he can do whatever he wants with it then. the report is intended to give awareness of how the general sees the problem and whether he thinks the mission is achievable. it will also provide some outline of what he thinks he needs to accomplish the mission, and the risks otherwise. host: how often are these reports produced? guest: i do not know. in the past years there have been huge numbers of reviews. things have not been going well. there is not an official of rhythm. it has to do with the situation.

people are concerned in washington and in allied capitals that there is not a clear strategy or goal in afghanistan. that we are just trading water. there is a real perceived need for clear statement. host: jeremy is a research director at the brookings institution. if you have a question, please call in. let's take our first call takehuntsville, alabama. caller: how are you all doing? -- let's take the first call from huntsville.

caller: yes, the first concern of be how many they actually need over there to get the job done successfully, and then how many lives might be at stake to increase the percentage in the bank account. could you tell me where you think might be next? guest: i'm not sure i fully understood the question. if you are asking how many lives are stake, afghanistan is a serious issue. there are 30 million living in the country. there has been casualties in the last year of about 2000 civilians and several hundred military. no matter what the report says or what the u.s. or nato does, there will be several years of fighting along those lines.

host: how many u.s. troops are currently there? guest: there are about 64,000. the target by the end of the year is about 68,000. there are approximately 42,000 troops from 41 different nations. close to 110,000 total by the end of the year. host: the next call comes from fullerton, california. caller: as a devout republican i voted for obama because he promised to get us out of these wars. i see some parallels between our intervention in afghanistan and when russia intervened in the late 1970's. their country then like ours is now was internally crumbling

from economic -- bad planning. i see that happening now with our own country. how successful will we be in afghanistan? it has been and unconquerable country that has only held at the demise of superpowers. here we are repeating the same events. we are spending all this money on this war that seems not to be accomplishing much except in casualties. i will wait for your answer. guest: that is a great question. it is very important to understand afghanistan's history, including the russian intervention. that is relevant.

afghanistan is an incredibly difficult country to deal with. the russians found that. you have to be a little careful drawn parallels between the russian intervention and the nato one right now. the russians were trying to conquer afghanistan against the will of the afghan people and international committee. they never succeeded in pacifying the country. the situation there is very different now. although the population are slowly losing faith in their capacity to gain against insurgents, they still support the goals of the international

community. the operation is popular. the taliban is very unpopular. what is interesting about problems in recent years is while the international committee has lost popularity, the taliban have not gained it. they regularly only get about 11% of an approval rating. they are quite bloodthirsty. people know what the taliban role is like -- awful. they were not allowed to listen to music or have basic freedoms. they do not want it back. that creates a different dynamic. host: i want to follow up with the front page here this morning, and a headline the taliban is surprising u.s. forces with new tactics.

host: how is the taliban improving their strength? guest: they are an effective enemy. we're really talking about a fair number of groups who are more or less. less they had similar goals -- they are more less unified. nonetheless, there are specific groups among them that are very effective learning organizations. one of the things that have particularly learned in the last few years is that makes little sense to attack nato or u.s. forces in large units had on. you see their tax moving more

towards asymmetric tactics -- you see there attacks moving that way. they attack the army post and then leave before anyone can respond. they no longer gather in large groups. they do not a technical forces directly except by roadside bombs which have become the most effective means to target western soldiers. that is a big tactical problem for nato. host: mississippi. caller: hello, your last caller made my point about the russian history in afghanistan. then you elaborated on the part about the geography. considering that most of the country is isolated and most of these tribes are isolated, is a possible that the afghani people

themselves are not standing up to the taliban as they should? if they are not fighting for themselves they will prolong our stay there. they seem to enjoy the changes occurring with the music and so forth. but unless they're willing to fight, unless they're willing to stand up to the taliban for themselves, we will be there forever. at what time does congress -- and i will not say president obama because he did not have much to do with this except when he was in congress -- when do we pull out and tell them to stand up for themselves? guest: that is a good point.

it is clearly the exit strategy of the international community. to get the afghans to stand up, build a government and security forces capable of fighting the war without direct assistance. that is the long-term plan. if the afghans are not responding over a duration, then clearly the plan will not work and we do not have another one. afghanistan has been noat war continually for the last 30 years. it's society has been destroyed several times over. it is the fourth poorest country in the world. i see a lot of will to stand up and fight the taliban. there are any number of individual stores you can tell

about brave, determined afghans working toward that and -- any number of individual stories. but it will be a long-term effort to build up the shattered, illiterate society. there is progress, but it is frustratingly slow. one afghan expert told me that it would be a success iif in 20 years afghanistan could reach the level of pakistan right now. that is hardly satisfying. host: lancaster, pennsylvania. caller: good morning. and a lot of people are wondering about priorities. how are these wars being of any assistance to american people? guest: i will not speak for any

of the wars, because not all of them have been essential in my view. i think that afghanistan is. returning to history, there are few stylized? it is important to understand. -- there are few stylized facts it is important to understand. in the 1980's we participated in the war against russians and sent a lot russiansarms to create an insurgency -- which sent a lot insurgencyarof arms. it had a vicious civil war. that played host to al qaeda.

the use afghanistan to train and plan and launch terrorist attacks against the u.s., specifically in 9/11. the idea to go into afghanistan and overthrow the government, to set up a new government to ensure the country will never be a platform for terrorism is to prevent that from happening again. i think we would take a risk if we abandoned afghanistan to its fate. we have run the experiment and it did not work. host: this is a message from twitter. guest: yes, i think it has. it has not lowered the chance to

zero. for the u.s. invasion in 2001, afghanistan was the perfect platform. there was a huge network of terrorist training camps. they came from all over the world to train. there were listed into al qaeda. al qaeda has been dislocated to afghanistan. it has moved to pakistan. pakistan is much less congenial for al qaeda. host: why? guest: it is not a state they control. they have to worry about the government periodically turning on them. many cuckoo operatives have been

killed, captured, and arrested in pakistan. host: ohio, neva. caller: good morning. host: if your television is on c-span, can you change it? just take it off the channel because it is creating too much feedback. caller: oh, ok. yes. host: will go to the next call. peach tree city. caller: i have a quick statement and question. personally, from things i have seen it seems the whole

terrorist thing has not turned one way. our economy is going down. the thing is draining us. frankly, i think bush had no idea how bad it would be. dick cheney is the devil. obama is doing the best he can -- god only knows what that is all about. if you kill the american dollar if you kill our country. we will look like afghanistan. i want to know where our cheap gas is if we have to be out here and dined with this war. we need to get our people back over here. -- we are dying with this war. every great nation in the

world's history has fallen when we have had civil war. think about it. we are not together. if we are divided, we will fall. guest: yes, the question of how these wars affect our economy is very important. the caller is right that if we do not have a strong economy at home, a strong society, then the results of the wars will not matter. i'm a little less sure about the direct link between these wars and would ever economic problems we might have at home. i am not an economic expert, so i will not comment there. but these wars are small potatoes from the standpoint of the economy -- i know it is hard to imagine that. i'm not sure the spending in

afghanistan or even iraq really has a direct effect on the economy. for better or worse these are efforts we can, if we choose, if we are willing to spend the blood and treasure, these are efforts we can sustain from an economic standpoint. i worry about other things sapping our economic strength. host: there is the contested election there, and a report concerning the opium cultivation being down sharply -- how did these affect progress there? guest: the election is important for understanding progress because it is a milestone set.

was the election free of fraud and violence? the success has been mixed. in terms of violence it was probably better than expected, but the word on fraud is not fully in, but it does not look very good. if you think about the need to create an afghan government which is legitimate as an exit strategy -- the government would be an important indicator, a source of legitimacy. it will be a setback if it does not bestow a certain amount of legitimacy. the poppy cultivation is an even more difficult problem. afghanistan is a very poor, agricultural, has bad infrastructure for marketing.

in such a society opm presents a real opportunity -- opium presents a real opportunity for the poorest in society. at the same time, it is clear that a lot of the money generated by the opium trade helps to fund the insurgency. we have to be very careful in the way we try to deal with that. they are trying to introduce alternative livelihoods' whereby they encourage farmers to grow alternative crops. these have had mixed success. it is probably a mistake to look at the year-to-year fluctuation

in crops that has more to do with market condition then with our success in eradicating it. if opium were eliminated we would have a huge problem in terms of poverty. it is both a something that helps to fund the insurgency, but also helps to sustain the afghan economy. host: indiana. caller: i think it is rude to let people go on and on with their answers and let the callers hang on. i want everyone to good to with the pds and type in charles nesbit wilson. this representative in congress secretly gave $70 billion to israel to buy weapons to give to

israel to feed the russians. this guy has not mentioned it. seven cia people did this to get the russians out of afghanistan. this guy has not said one word about it. the u.s. was behind. this guy wanted to give just a few dollars at the and to set up schools to help with democracy. republicans voted it down. guest: learned the truth i am sorry to run on. i guess i have a lot to say. the u.s. was very active in afghanistan in the 1980's in funding the insurgency against. against as a technical point, it was not the taliban we were fighting -- there were not formed until 1994.

that was after the russians left afghanistan. you're right, the u.s. sent a lot of money and arms there, partly through mr. wilson, but i think it was a broader policy to help give the russians. this policy started under jimmy carter right after the russian invasion in 1979. ronald reagan continued it. in my view this creates a certain responsibility in the u.s. to not abandon the country as we did in the 1990's. caller: you can look up what motivated the 9/11 hijackers. we are there because of 9/11. it happened because of u.s. support of israel's oppression. that is another war that is all

because of israel. you can go to several websites to look it up. guest: when you look at the motivations for 9/11, it is complex. if you go back to read the al qaeda statements you see very little attention to israel. you see more attention to saudi arabia and u.s. support for a legitimate arab regimes throughout the world. you also see a diffuse anger at the modernization and globalization of the world and its threat to traditional values. and of you that america is the harbinger of these bodies. -- and that view of america.

maybe there is a more hidden plot there, but i think al qaeda has been upfront about what they dislike about the u.s., which is virtually everything. . . republicans, 202-737-0001

>> homeland security secretary janet the pelotonnapalatino saye should expect a big influx of h1n1. she said many cases are likely to surface before a vaccine for h1n1 is available. supreme court justice john paul stevens has caused some to speculate that he may retire next year, according to the associated press, because he has hired fewer law clerks than usual. if he does step down, it would give president obama his second high court opening in two years. in one hour, the american constitution society will host a discussion on next week's supreme court oral argument. it will be life on c-span radio and c-span2 television.

the man charged with killing a security guard at the u.s. holocaust museum in washington will appear in federal court. if the victim has recovered enough to appear, it will be the first time he has been seen publicly. >> next tuesday president obama delivers a nationwide address to public-school students. this morning, the aspen institute on no child left behind looks at ways to improve underperforming public schools. we will have that discussion right after "washington journal" at 10:00 a.m. eastern. one week from today, the supreme court will hear oral arguments, looking at the constitutionality of campaign finance law. this morning, a discussion about the case. live coverage from the american constitution society beginning at 9:00 a.m. eastern on c-span2.

>> later this week, a review of the health-care debate in congress with highlights from house and senate committees, and analysis from capitol hill reporters. and on q&a sunday, a comparison of healthcare systems from around the world with a former "washington post close court reporter. >> kozol analyzed and critique the american public school system. >> "washington journal" continues. host: we are now discussing the u.s. response to the h1n1 swine flu virus. joining us now is dr. georges benjamin, apha executive director. thank you for joining us. president obama is strongly advising americans to take the swine flu vaccine when it comes available. guest: in the spring, we did not

have a vaccine. we had a non vaccine strategy. a lot more people got sick then we had hoped. hopefully we will have a vaccine this fall. >> when will it become available? sometime guest: mid october. there's a possibility of a movement earlier. host: how many doses of the vaccine will be produced for the u.s. population? guest: it depends. somewhere around 150 million doses. we have never really gotten much more than 100 million doses to anybody at one point in time. this will be a real challenge this fall. host: is this in conjunction with recommendations for the regular seasonal flu vaccine? guest: that is correct. there are several challenges.

the first challenge is we are preparing for two flu seasons. the seasonal flu, and this new strain. that will result in two to three shots for influenza. the other challenge is the actual outbreak maker before the vaccine is ready. we may be giving the vaccine at the beginning of the outbreak. the third is the difference in the at risk population. normally the seasonal vaccine, we give to the very young and the very old. this one we are emphasizing kids basically. and high-risk individuals, which includes from the women and people with chronic diseases. host: why haven't the elderly been affected by swine flu? guest: they are not very clear about that.

there may be some evidence that people who were around the last time we had an outbreak of the h1n1, which was called swine flu at that time, may have some degree of protection. it is not enough protection for this particular strain. there's also the fact that people who are older have been around longer and have been exposed to lots of viruses. there may be some minor cross protection. host: we are discussing h1n1 swine flu virus with dr. georges benjamin. if you would like to call in, republicans, 202-737-0001. democrats, 202-737-0002. independents, 202-628-0205. in the medical community, what is the expectation for how many could be affected by swine flu?

guest: it could be several hundred thousand people infected. the real problem is how many people might die. there's an estimate that up to 50% of the population may get the disease. the good news is, for most people, this is not a very severe disease at all. it may be a cold like event to something very severe. for most people, this will not be a big deal. for a small percent of the population, it could be very serious. host: are there any symptoms or distinctive factors that someone would know they would have swine flu versus some other illness? influence the presents fever, chills, muscle aches, and classic symptoms. there's one thing that makes this more likely because there are some gastrointestinal

systesymptoms. these are not diagnostic symptoms at all. you can get the other normal seasonal flu, and a small percentage have gi symptoms from those as well. host: let's take the first call from pittsburgh, pa. on the democratic line. caller: i'm a big admirer. i worked in the motion picture industry. many of the major houses on future architectures -- i do not think that the world community understands the magnitude of what will take place with the forces, especially the h1n1. the confluence of the possibility of these viruses being combined, especially with the possibility of bio terrorism.

i think the government is absolutely unprepared. i love president obama. i think he is a marvelous president. i think they need to step up and get a more comprehensive approach toward multiple scenarios with this situation. guest: let me agree with a couple of things. first, we have demonstrated some competency to deal with this outbreak based on the experience in the spring and the fact that influenza comes every year. we really do not do this very well. we know that 36,000 people die every year from this disease. we know that we do not vaccinate a enough of the eligible population. and we play yo-yo funding with the money. we do not put all the money that we need into the public health system to keep its robust. then you add someone who wants to do something intentional, as

we saw with the anthrax attacks in 2001, you can see what happens when an intentional person can do to our system. i have always argued that we need to build this system in a holistic way, regardless of the threat, whether it is an outbreak of the injury, we ought to build a conference of public health system to address all these things. we have not yet done that in the united states. host: john on the republican line from pennsylvania. caller: i read somewhere that 60% of the health care providers have been surveyed about the swine flu virus and they felt it would rushewas ruso judgment.

guest: i believe the study was not done in the united states. that doesn't really matter. one of the things that you always have to do is convince the health care practitioners themselves to give the shots. we do have a large percentage of health care providers who routinely do not get the flu shots. i encourage them to do so. it is not just a matter of putting themselves at risk, but they also put their patients at risk. if you were getting nursing home, for example, you need to get your influenza shots for the seasonal flu. if you work around kids, then you absolutely need to get the h1n1 vaccine to protect those children so you do not make them sick while you are taking care of them. i understand that there's always hesitancy on taking any kind of new medication. we have been producing seasonal flu vaccine for quite some time. we understand the risk quite well.

understand the efficacy for effectiveness and the safety studies on this new vaccine are just being done right now. they will be done very shortly. we'll have an idea about the effectiveness and safety of the vaccine. host: cambridge, minn., amy. guest: good morning. caller: i want to make a comment. about a week and a half prior to the h1n1 virus breaking out, there were vials -- nobody knew what it was, but it was from a laboratory. is it possible that this h1n1 was star by ted by a terrorist attack? is it possible for someone to run a investigation into that?

guest: i am not familiar with the story. let me tell you what i do know about the people who have gone back and looked at this outbreak and the genetic structure of this virus. this organism absolutely looks as though it is naturally occurring. it does not look like it is man- made. people have done that investigation. we're pretty comfortable, based on those studies and those reports that this is mother nature, father nature that created this fivervirus. host: houston, texas. caller: that in the 1970's, i have the swine flu and gave it to my mom. we live in tennessee in a small town.

[inaudible] my father took care of us. we would have died. we did not get better for weeks. we were not able to do anything. it weakened us so bad. i do not know of anybody that died back in the 1970's, but i know that we came very close. host: do you have a question?

caller: is this the same, or do you believe it is going to be the same type of flu that came back in the 1970's? guest: i think the caller is talking about the h1n1 outbreak that occurred in the 1976 or so. that certainly was an outbreak. many people did get sick from that. people who got the disease this year and got very sick, those people talk about how sick they got from this. again, everybody did not get that sick. a vast majority of people did not get the sick, but we did have some deaths. the recommendations are still that even if you had the flu

back in the 1970's, you should still get vaccinated. i always say to guess someone's age, but the fact that she was a round in 1976, she may or may not be someone who is in the highest priority group, but if she has any chronic diseases, heart disease, lung disease, or diabetes, she should really talk to her doctor to see if she is one of those folks eligible for the vaccine in the highest priority this year. host: next call from new york. caller: good morning. i would like to ask dr. benjamin about the testing for the vaccine. i have heard that it has not been thoroughly tested and that the government says just get out there and get a shot anyway.

i am very skeptical of this. back in the late 1950's and early 1960's when the fda -- a woman named kelsey stopped it from coming to the country and stop a lot of problems with a birth defects because of that. i'm concerned with why at this time, and coincidentally when obama is trying to rush toward government health care, i'm just wondering if this is not a political ploy by the obama administration to take the focus of the health care plan to nationalize health care. guest: that is a fair question. let me point out the fact that this has been a bipartisan effort. many of the plans were crafted

under the bush administration. this is absolutely a bipartisan effort to protect the american people. this is one of the things that many of us were supportive of, and worked with the bush administration i am trying to put together a national pandemic plan. yes, the obama administration has refined it some people we have a difficult communications challenge. we want to make sure it will be available at some point. we want to encourage people -- we have 300 million people in this country. getting to everyone of them is very difficult. we want to make sure we get to everyone and make sure they understand who the highest priority clients are in terms of getting the vaccine. the caveat they have always said is, right now the vaccine is

going through testing for efficacy and safety. once the results come out, they will look at those, and it will go to the committee process. the committee will make a recommendation to the center for disease control, will then make a recommendation to health and human services. and then they will decide whether to formally release the vaccine for utilization in the united states. it will still need to be licensed by the food and drug administration. we have a long history of creating flu vaccines. quite frankly, had this outbreak at a different time, in my in the formulation of the seasonal vexing -- it might be in the formulation of the seasonal vexinvaccine. it may get put into the seasonal vaccine. it remains to be seen. people are doing what they should be doing it in terms of trying to make sure that only

offer a product that is as safe as it can be for the american people. host: i have a clip. the cdc director was discussing swine flu last sunday. >> everything we have seen in the u.s. and everything we have seen around the world suggest we will not see that kind of number, if the virus does not change. the presidential commission did a terrific job of giving an overview of what are the challenges in addressing h1n1 and what are some of the things that we need to do. many of those things are under way now. many of them are difficult. addressing influenza is hard. influenza is one of the least predictable of all infectious diseases. we need to do a lot to get ready. to get ready in terms of our health-care system -- what would we do if we needed more people in intensive care units?

those plans are underway. what can we do to vaccinate people as quickly as possible when the vaccine becomes available? how can we make sure the people who have underlying health conditions like asthma and diabetes, and who may get very sick, get rapidly treated if they get sick. guest: yes, i think he was commenting on a report that came out by the president's science advisers. it looked at what we might expect. they said, if it is 1918, the worst influenza we had, and something in 1976 -- as they looked up the numbers, the good thing to do would the to split the difference. i think he said that is good. that may be the worst case scenario. but what we need to do is recognize that we have not seen it that bad yet based on the

experience we have had around the world. nevertheless, i am an er doctor. i've always plan for the worst and hope for the best. his job is to calm and make sure that people do not panic. you can be darn sure that he is planning for the worst behind the scene. i think you heard him say that. he said that hospitals should prepare. people should better understand this. this to talk to their doctors about the risk. and they need to make their own personal decisions to take the vaccine, which we encourage, and the need to decide what they would do in terms of making plans to stay home if their kids are sick. host: how many cases of swine flu have been reported in the u.s.? guest: i do not know the exact number. we count in portable diseases of people who are sick or die who have been cultured or who have

had a test to document the swine flu. we stopped counting as the epidemic waned. it is still going along at the very low level. we really do not know. we have heard numbers in the millions, but we really do not know. also, for seasonal flu, we really never account. host: why not? guest: most people who get the flu do not go to the doctor. there's no good way to get a count. we do have a surveillance system. we have several doctors around the country and clinics that to test on a routine basis on people that come in with what we call an influenza-like illness. they report into a computer system. we look at that account and we make an extrapolation based on the population, and they do the

best guess. host: next call from tennessee, kathleen. caller: i am a 45-year-old woman. i use my own remedies. i have been healthy for the last 10 years. not needing any cough medicine, nothing. i have not had to put any of my money into that big money pit. what i'm hearing and what i am very concerned about -- is a possible that what i'm hearing is true, that the government could make this vaccine mandatory and forced people into taking this? a person like me, who has been healthy for years, i have never wanted to be part of that. once you put a needle into someone's skin, you are inviting to pathogens into somebody's body. i do not want any part of that. guest: the good news is that this vaccine is voluntarily.

we do encourage it. it is voluntary. i'm glad you're healthy. i hope it is because you are eating better than i do and exercising more than i do. host: next call, alabama, john. caller: yes, i took the swine flu vaccine in 1976. i am wondering if that has any protection against a new strain. also, people should not take aspirin with the flu. guest: they are still recommending that you get the new vaccine. they believe this strain is substantially enough different from the one back then. the second thing is that the aspirin recommendation is primarily for children.

there are lots of other things that one can take for pain and fever. you do not have to take aspirin, even as an adult. you can take advil or other things. as long as you are not allergic. host: from new orleans, jerry. caller: doctor, let's talk about the fact that glaxo pharmaceutical was caught red handed trying to distribute millions of flu vaccines to 14 different foreign european countries that were tainted with the avian flu. this is impossible to happen by accident. isn't it great that baxter pharmaceutical is the same company that has a hand in

making our flu vaccine? this is a eugenicist program. these vaccine pop up at military bases because we use our troops as guinea pigs. this is the perfect vehicle to have this country be thrown into martial law with the coming economic collapse. there's no reason for a healthy person to put pathogens -- this flu has been shown to have 1/8 of avian flu, one swine flu, and two human flus. i wanted to cite the study that this happened in nature. please cite those studies. i'm looking at studies that show the difference. this is completely made up by

the government and the pharmaceutical monster companies to put us into martial law. guest: thank you for your comments. i do not know anything about the study that you're talking about. the reference of the pharmaceutical company. let me tell you what i do know. i know this is a rna virus. they're very good at changing their genetic structures. they do that all the time. every good scientist who does agrology is very aware of this. the people who are experts in this -- i am not an expert, i admit. i am looking and reading what they have written, i trust there wer -- i trust their work. the vaccine is voluntarily.

host: who is producing the vaccine? guest: several companies. i'm not sure who they all are. host: if people get these at the doctor, is there a fee? is it covered by health insurance? guest: good question. let's talk about both of them. the seasonal flu vaccine will go through the normal distribution system. you will get it the way you normally get it. you can get it at your local quick clinic, or from your doctor, or at work. it is either reimbursed by your insurance company, or in my case, at my job, we pay for it. there is the h1n1 virus vaccine. once it is approved and made available, it will come to the state health departments. they will decide who exactly

will have access to that vaccine. in some states, it may very well be to a range of providers who have already been preselected to do that. some of the clinics will have access to it. or like in new york city, they're going to vaccinate kids through the school health program. they have a very robust series of school health programs. the vaccine is free. if you go to your doctor and your daughter has access to the vaccine, the doctor will bill the insurance company -- if you go to your doctor and your doctor has access to the vaccine, the doctor will bill the insurance company. this should be free to relatively very inexpensive. host: next call from maryland.

caller: good morning. in the health care professional. i will probably be receiving both vaccines. i am also a nursing mother. i know that the vaccine is recommended for pregnant women, infants, and toddlers. as someone who is taking both vaccines, shouldn't be concerned with the mercury -- should i be concerned with the mercury being transmitted to my child? guest: if you have any concerns, get the vaccine that is free of that. it will be available.

host: sacramento, calif., john. caller: with all due respect to you, kind of commenting on the cynicism of previous callers as to the real concern of the pharmaceutical companies as it relates to sincerity in administering good health, or concerning themselves with the bottom line. i am part of that cynicism also. the numbers from epidemiologist s, as it relates to the health care providers with this a western model, leaves a lot to be desired. i do say all due respect to you.

to personalize it, i have been able to combat the flu for the last 15 years. i have not had a cold or the flu using something like goldenseal. you never hear about these things being non marketed, but highlighted with this western model of medicine as it is administered in this country. i do not necessarily trust the pharmaceutical companies i am looking now for my best interest. i do not know how you can recommend a flu shot when you do not know the consequences of taking that particular shot. i wish i was a little bit more

articulate. i'm not used to talking on tv. it is just going into studies now. as the previous caller said, how do i know how this is going to affect my unborn child at this time. of course the only response you have is check with your doctor. your numbers are really not that good when you compare it to other industrialized countries in the world. why should i trust you guys? thank you. guest: you should be a cynic. i do not disagree with your cynicism atoll. i do think that i asked questions all the time of my doctor. i do my own research. and i try to better understand my doctor's opinion. and i add that opinion to my own.

i know that we have been reducing flu vaccine for some time. these safety and efficacy studies we do -- we do them all the time. i do need to point out that there's no question that there is no therapeutic that is 100% safe. anyone who will tell you that is true is just not telling you the truth. we are trying to make them as safely as we can. and then we do a risk-benefit assessment. and we say, would you much rather get sick from this, and will this medicine help you with a minimum side effects, if any, protect you from the disease? we try to balance this. the truth of the matter is, if we could get people to do prevention and eat better and exercise more -- things i know i need to do more of.

we would go a long way to making people healthier. i'm a big advocate for alternative and complementary medicine says. and trying to find alternative ways to ensure we are healthy. that requires a great deal of research. we do have people were doing that kind of work, but they are underfunded. we need to put more money into that kind of research to answer the very questions that you asked. i'm a champion for that. i really applaud you for being a champion for that also. host: i want to ask you about the timing of the vaccine. this morning, the homeland security secretary said people should expect a big influx of swine flu cases this fall and prepare as best they should. she says the best thing people can do are the simple things, like washing hands, and coughing into sleepves.

guest: it is kind of funny. kids thinare tragically little incubators. when people play and work closely together, you have an outbreak. the fact that this virus is circulating and is still circulating, and kids are now going back to school, the assumption is that it may get into the school population, and we may see an outbreak. that's why they're talking about vaccinating kids as early as they can. the data shows they are at greater risk. what they're saying is do the simple things. cover your nose and mouth when you cough or sneeze. wash your hands as frequently as reasonably possible. wipe down doorknobs.

clean your keyboard. if you cannot get to good soap and water, then use and sanitizer. these are the simple things we can do. if you're sick, do not go to work and do not go to school. have plans so there's not a family crisis when someone gets sick at home. those of the things we can do to plan for this. vaccine and then when becomes available, we add that to our strategy. host: is hand sanitizer as good as washing your hands? guest: it is acceptable. it is pretty good. you have to use it. the real challenge is that it has alcohol in it. a lot of people have the irritation of the skin. sometimes people do not tolerate frequent hand washing, so they need to use a soap with the moisturizer.

caller: the vaccine that is being developed, is it a live vaccine vaccine or vaccine -- or killed vaccine? is there a dna vaccine? guest: they dare doing both, and i do not know the dna answer. caller: ran across a video on youtube. it was a 1979 episode of "60 minutes" on swine flu. over 40 million people were inoculated with the vaccine. the government was using the same scare tactics. more people died from the vaccine then from the swine flu itself. my son took a vaccine about six

years ago. he is a diabetic and he gets his blood checked regularly. after taking the vaccine, and is split levels dropped below 10,000. i would urge anyone to really do some research before taking the vaccine. guest: vaccine i support vaccin. i also encourage people to talk to their physicians and to their own research. host: this is the last call. lake jackson, texas, carol. caller: why are these drug companies getting immunity for these vaccines? guest: there is an ongoing immunity program that was put in place after the 1976 event.

obviously, one of the big issues is to try to encourage vaccine manufacturers to make vaccines. there are some trade-offs. i'm not sure they got a more specific community for this vaccine. that is one of the questions i ought to go back and find the answer to. we used to have vaccine a lot have manufacturers in this country. the kind of went out of business because it was not profitable to do and there were high risks. not just in terms of making a safe vaccine, but high risk in angeles starting the process and getting a reasonable product at the other end -- but high risk in actually starting the process and getting a reasonable product at the end. the government has done some things to try to encourage more companies to come into the vaccine manufacturing business. i think that trying to get more people in and getting more competition is a good thing.

host: dr. georges benjamin, thank you. guest: thank you. host: next will be the final part in our series from the virginia hospital. >> the labor department says worker productivity grew at the fastest pace in nearly six years in the spring. labor costs fell by the most in nine years. as companies reduced costs in response to the recession. economists expected an increase. more on the swine flu from the education secretary. he said federal officials want to make sure that every young person between five and 24 gets the vaccine free of charge. he praised efforts by states and localities to get ready for new infections. he said that what you see around the country is an outbreak of common sense. firefighters are making gains on a wild fire north of los angeles, aided by lower temperatures and higher

humidity. the spokesman says there's little active flame and that this is a good day. admiral timothy keating says he does not expect major changes to the u.s. defense relationship with japan despite the election of a new government that has vowed to reevaluate its ties with washington. he said the u.s. had resumed talks with china's military for the first time in 10 months. he said that washington is concerned about some of the weapons systems beijing is developing. those are some of the latest headlines on c-span radio. host: this is day three on our series on hospitals and health reform. today from the virginia hospital center in arlington, va., about 10 miles to the west of the u.s. capitol. we will caltalk with three

guests about what is going on in dc and around the country. here on our set is the director of the program, dr. john sverha. how many people come through the virginia hospital system every year? guest: every year we see about 55,000 patients. that equates to 150 per day. host: what is the peak time? guest: we track that. it ramps up by about 11:00 a.m. in the afternoon. about 10 people per hour were coming in our doors until about 10:00 p.m. it never stops. we see people through the night. host: have you been able to track why it rahm. at certain times? guest: i think that is when the need arises. there's some components to people being awake and needing

care and realizing that. there's also a component or other access to health care closing at 5:00 p.m. or 6:00 p.m. that's probably why are volumes continue into the evening and into the night. host: into the evening and on the weekend, do you see an increase in using the emergency room as a primary care unit? guest: there may be some component of that. truthfully, there's a spectrum of emergencies that, and every hour of the day. it is hard to generalize. host: is there a doctor on duty in the emergency room 24/7? guest: yes. in this department, during peak hours, we have four emergency physicians and two physician assistants. host: do you have to treat everyone who comes in by law? guest: yes. host: does everybody have the

opportunity to see a physician? guest: that is correct. access to a physician is irregardless of your ability to pay. it was established over 20 years ago by federal law. it is something that really defines what the emergency department is. we do not ask you any question related to insurance status until we see the reason why you're here and we initiate treatment. it is something that defines the emergency room and makes this a great. host: place: -- and makes this a great place to work. host: of those 55,000 people, how many get sent on their way? guest: about 20% of patients. it just represents the illnesses in the community here. if you have a high gear pediatric population -- if you

have a high your pediatric population, the rate is a lot lower. we are about 20%. that is pretty constant month to month throughout the year. host: there's a large hispanic population in arlington, va. do you have people who speak spanish on staff? guest: if a staff member is bilingual, that's a great asset. we are more likely to hire them. we have volunteer interpreters here through the week. during off hours, we use a language line. host: dr. john sverha is the chairman of emergency medicine at the virginia hospital center. we will put the numbers on the screen. we will be talking with him and we will be talking to the head of the icu and the director of

nursing in the next hour and 15 minutes in day three on our series on hospitals and health care reform. host: when the emergency medicine become a specialty? guest: over 30 years ago. it is an often misconception. i'm often asked where's my office and when do i plan to stop doing this. honestly, it is a career that i chose. every physician in this department really chose this. host: you are an employee of the hospital? guest: it is slightly different than that. there are some models were the physician is an employee of the hospital. or a physicians group a can

contract with the hospital. host: you work with a group of physicians? guest: that is right. i'm part of a group of emergency physicians that basically has a contract with the hospital to provide services. host: at the same time, you're the chairman of the emergency medicine department. guest: i worked closely with the hospital. they're my partner here. some days i feel like a hospital employee. i am certainly very active in the hospital here. i know all the medical staff on various committees. who writes my paycheck -- that is someone different from the hospital. host: why is that the arrangement that's best for you? guest: that is a good question. there are groups that have done it both ways. there's a lot of work that goes into managing a physicians group a and motivating a group of physicians.

that is something the hospital has traditionally left to the physician group. host: you volunteered here when you were 15. guest: that is how i got my start. i had trouble getting my life guard license in time. that is the short answer. i still remember some of the things i saw in my first days as a volunteer. it happened to be in this hospital, believe it or not. many years later, i came back looking for a job. host: did you know you wanted to be a doctor at 15? guest: i was not for sure. my father was a hospital administrator. my mother was a nurse. host: you're a graduate of stanford, yale university medical school. and then you came back to arlington, virginia. our first call for dr. sverha is from michigan on the injsured line. caller: good morning.

i do not understand why we have such a healthcare crisis situation when anybody has access to go to a hospital to see a doctor. as you mentioned earlier, whether it be a head cold or someone who needs to be admitted to a emergency surgery -- i had a similar situation happen to me. they saved my life. that was the bottom line. they treated me just as good as if i had insurance at that time. even during that time, all i needed to do was go to the urgent care clinic. but there's still little pay as you go. if theyou need a little help, ty will give you a sample, or a prescription for $10 at the drugstore. dental insurance needs more

work. i have a big medical problem now. host: let's leave it there. let's go to the emergency room as primary-care facility. what would you respond to that? guest: yes, we are kind of a safety net for folks who do not have medical insurance. there will always be a role for the emergency department in that spirit as to whether the system is working well, i think it could work better. we can all give you antidotes on a daily basis whereby it would have been better if the patient would have had insurance. people sometimes delayed coming to the emergency department even with a serious problem because they're concerned about the bill. there are circumstances where we may diagnose your problem in the emergency department, but treating that problem is not something we can always accomplish in the emergency

department. sometimes getting the next part of your care is difficult if you are not insured. host: do you encourage people to use the emergency room as primary care? sometimes if you call your doctor's office, you'll hear the message that if you're very sick, please go to the emergency room. guest: i never encourage people to use it as their primary care. that is typically not the best setting for continuity of care. i'm also very understanding of the people who come in. every once circumstances are different. if you probe underneath, sometimes because they work 12 hour shifts and it off at 9:00 p.m., no one can see them, or if they're out of town. there's always something behind this. there is some misuse. there's often a decent reason. that's my experience. host: next call for dr. sverha. caller: good morning. i have an issue with the hospital itself, where it is

located. i do not see many poor people living in that area. it is an empty hospital. i have been looking at it for three days. the emergency room is empty. how can you have uninsured people coming to the hospital when they do not live in that area? host: thank you. guest: i think we are empty because the tv cameras are here this morning. if you came back a few hours later, i think you'd find this to be full. as far as our location, yes, we are in a more affluent area than some hospitals. we see a significant number of people without insurance. we see about 20% people who come into our doors to do not have health care insurance. host: dr. sverha, does your group lose money when people are uninsured? guest: yes and no. if you provide services and you

do not receive compensation, you are not making any amount of money and you cannot sustain the operation here. it is variable. some folks come in without insurance and receive a bill and they work hard to pay off the entire bill. we're very thankful for those people. host: next call, fresno, calif. you are on with dr. sverha. caller: i would like to ask the doctor's opinion. i read an article that the medical industry as a whole has been -- they more or less treat the symptoms of the patient rather than preventive care or trying to find exactly what the disease actually is. the medical industry as a whole is set up that way. it's not really set up to cure a patient. i just want his opinion on that

. guest: it's an interesting point be made that perception if you have a disjointed interaction with the medical system. it points to the value of having a primary-care physician, someone who knows you. you could get that impression if you had different interactions with a variety of different doctors. i could see how you could have that impression. it is my first time meeting you and i may not know you well enough to give you the best judgment or address all of your concerns. host: is it fair to compare what you do to triage? guest: to some extent. it comes from the words to sort. we try to see everyone in this hospital within 30 minutes of arrival whether it is a sprained ankle a heart attack. there will always be some sorting process in the front end

to identify the sickest folks. host: how many hours do you work? guest: about 20 to 25 in the clinic and about 20 administratively. host: so you do have a life outside the hospital? guest: yes. host: are you satisfied with your salary? guest: yes, i enjoy what i do. it is a meaningful job. i feel lucky to have this job. i feel like i am fairly compensated. i enjoy the job. host: is there high tech to emergency medicine? guest: there is high-tech. there's a lot of low-tech. what we are trying to get better at is patient flow.

we do see waiting times. there's a lot of tech to that. it may not be the radio device we are operating, but there is technology in running a successful operation such as this. people really need to go into the system, and go through it, and got out of it quickly. host: next call is a medical professional. you are on with dr. sverha. caller: good morning. guest: good morning. caller: i was calling to ask the doctor if it is true in that area that you have what is called a golden hour, when people come into the emergency room with a gunshot or knife wounds, that you have what you consider a golden hour? host: why did you ask that?

what kind of medical professional are you? caller: in a visiting nurse. i'm sort of continuing my great uncle's work. he was a doctor in the early 1900's in arkansas. he used to go out into the mountains on horseback and treat people. that is why i am a visiting nurse. host: bgolden hour? guest: it is typically used in the context of trauma and the injuries from trauma need to be identified as quickly as possible in the patient needs to be resuscitated as quickly as possible. it pertains to other medical concerns. time is of the essence for part attacks, strokes -- time is of

the essence for heart attacks and strokes. the patients we try to identify early on is those related to strokes. . guest: not too many but we do see them here. they come not through e.m.s. we have the front door, we arrive. and there's a backdoor, all the paramedics come.

we see 30 paramedics a day, 120 walk-in patients a day. we might get a gunshot victim every month or two, maybe every three months, perhaps. but if that was the case, they would come through our front door which creates a scene. host: flu season is coming up. we've heard a lot of talk about h1n1. a, are you worried about it? b, what's the prep that's been done for it? guest: i'm concerned. i don't know if i'm worried, per se. it's a focus in the hospital. the good news is we're able to build on our emergency planning that's been done over the last seven or eight years here. there's been a big focus. think it's part of our mission to be a very well prepared -- in regard to a lot of different scenarios. we've had a pandemic flu pan for years here. we're not process of tweaking that plan, working with local

hospitals. all the hospitals in northern virginia to heap sift in planning -- help assist in planning. we try to get a consistency on what the hospitals are doing. it's a complicated problem, the issues of getting the staff immunized, anticipate staffing shortages that may occur if our staff gets sick during this. where you would surge patients into if our volumes went from 150 a day to 250 a day. a lot to talk about but a lot to be done. host: do medical staff tend to get more sick since they're exposed to the different viruses? guest: my own personal experience is i think i've been exposed to just about everything under the sun. but as emergency physicians. but, yes, they do get sick. i think the concern is to get as few of them as sick as possible. and if they do get sick, they can't come in and work. they'll only add to the problem. so it's a two-part message. to make sure that you don't get

sick and use all the appropriate means to prevent it. and then if you do get sick, you have to own up to that and not come into work when you're sick. host: what was 9/11 like? you are six miles from the pentagon. guest: right. i was on duty that day. it was an interesting day. it was a challenging day. a sad day, obviously. when i was working in the emergency department, i guess we received a phone call through the radio that a plane had gone down somewhere near crystal city. we didn't know what it had hit. host: which is in arlington. guest: that was the last communication we received until we started receiving patients from the pentagon itself. they had come by vehicle and eventually by e.m.s. we saw about 40 patients or so in the hour or two after the attack on the pentagon. the hospital responded wonderfully. i had a lot of support. host: and like you said, did that change your emergency procedures here at the hospital?

guest: yes, it did. i think it woke us up to the different things at the hospital, in the emergency department, to be prepared for. i think that was the introduction to that thought and that conversation. certainly there's a great focus on that. host: chris in new york city. uninsured. please go ahead. caller: thank you for taking my call. many years ago i worked for the new york city emergency medical. the amount of care, prehospital, just to anybody that gets hit by a car or anybody that dials 911 is quite extraordinary. better than anyplace else. really in the world. america does a great job at that. and, also, when we look at public hospitals versus private hospitals, the caller earlier made the comment, public hospitals are not well run.

i don't think that we want to use them as a model for how to go forward. think if we really want to understand how to -- there is no crisis, really. but delivery of quality medical care is terrific. i think the real issue is, how do we manage that properly? i think the private hospital systems is a good example of what the public should model themselves after. thank you very much, doctor, for taking my call. host: what do you think of his comment? guest: can i only say good things about the paramedics and the e.m.s. service here. we're blessed with a very professional e.m.s. service here in arlington. host: is that a public service, funded by arlington county? guest: it is. we're the only hospital in arlington county, however. so we are where they go when they transport patients essentially here. but we work hand in hand with them. one of our emergency physicians here actually serves as the medical director for the

arlington county e.m.s. service. i see these guys every day at work so they're really like colleagues to me. host: that caller also brought up health care reform, you know, some aspects. when you watch and listen to the health care reform debates currently going on in d.c. and around the country, what are your thoughts? what are your fears? guest: well, i guess i'm with most people in that i think things can be better. in the emergency department, i have a little skewed view of the world in that i see a safety net. work in the safety net every day. although, as i mentioned before, it's not an ideal system that we have set up right now. i think most emergency physicians would like to live in a world where everyone had insurance, basically who came in. the people weren't really worried about a large bill. i think we'd all love to work in a world where it was easy to refer someone for ongoing care. that's not the situation we're in right now.

host: what scares about health care reform? guest: i guess that it could be done wrong. i think that's everyone's concern here. from your emergency department standpoint, i don't really ever see a changing that we are not going to be the safety net here. i don't think -- i haven't looked at all the proposals on capitol hill, but i'm sure none of them say we're going to collect payment up front before you see a doctor in the emergency department. i don't think any of that will change. so i think my role in the emergency department will stay intact. host: do you set the cost? does your group set the cost for the emergency medicine? guest: not from the hospital side of it. from the emergency physician side of it obviously we have some controls as to what our charges are. if you come into the emergency department, you'll typically get a bill from the hospital and then from the physician group. and obviously the bill is related to the intensity of the service you required when you were here. host: what's the minimum? if somebody walks in and sees somebody from your group, what's the minimum they will pay?

guest: good question. i think it's about $20 or $30. that's for the simplest complaint. as the conversations previously revealed, it gets complicated. just like the hospital, we have contracts with insurers and payers and so forth as well. we negotiate rates with payers just like the hospital does. for the lowest level of service, that's the ballpark we're talking about. host: that includes you negotiate with medicare also as a private group? guest: i don't think medicare negotiates too well with us. i think they set our rates. but with some of the other insurance companies we do. host: next call from cliffside park, new jersey on our insured line. go ahead, joe. caller: i -- i'm a marine vet. i've got the v.a. to fall back on. but i found in the state of new jersey that because of the

different programs, the care, the way the hospitals operate with each other and state, not everybody can get health care because they may not have insurance. but god forbid they have a really big problem, they'll pick them up off the street, take them in the hospital. they don't ask them how much money they have. they just fix them. this may be an inefficient way to do it, but we've been doing it this way for 30, 40 years. something along that lines has to be fixed but i don't think a whole revamping of health care will do it. host: an interesting comment. i agree it's not going to change. we're not going to start scooping people off the street or bringing them in the emergency department. we have people who fly into reagan national airport with

their sick relative overseas and will come directly to the emergency department and we will start treating them. that's not going to change. i don't foresee that ever changing. i think there are problems on the other end of it. how does the hospital and the physicians get paid for that service? and how do we keep that person from getting a tremendous bill that they work years to pay off? those aspects i think still need to be fixed. host: do you know overall the cost of your education? guest: i was lucky enough some of it was paid for by my parents. host: we've talked a little bit about a physician shortage. do you see that at all? guest: i guess i can see that coming to some extent. if we expand coverage, i'm sure to all the folks that don't and

there's a demand in other services as a consequence of that, can i see that the number of physicians, nurses and everyone would increase. there would be a greater need for that. host: in our conversation with the chairman of the board here, the cardiac surgeon, he and his wife, who is a pediatrician, pay vast index malpractice insurance rates. what's the rate for an e.r. physician? guest: it varies state to state. can i tell you in our circumstances, i think i pay probably $7 or $8 per patient i see. goes to covering the malpractice for that patient. host: per patient? guest: yes. host: two more questions. what is facep on your jacket? guest: fellow of the american college of emergency physicians. host: is that a good thing? guest: it's a good thing, yes. it means that you've done a little bit above and beyond the call of duty besides simply becoming a member of this professional society. host: we were talking earlier

about your mission trips to honduras. tell us a little bit about this. guest: it's something to get involved in in the hospital. there's a group of about 75 physicians and nurses. all sorts of folks that come down -- go down once a year for the week-long trip. we see several thousand people from a primary care standpoint. we do about 100 surgeries, give out eyeglasses, physical therapy services. then we come back. it's a great thing. host: who pays for it? guest: we pay for it ourselves. we get some donations, but all of us take a week of our own vacation time, pay for our own flights, food. host: when you compare the two systems, u.s. and honduras, maybe not a fair comparison but what do you see? guest: they're very different here. there's such a great need, obviously, where we go. we go outside of the major cities to some of the smaller towns. their access is very limited to medical care. they have some clinics that are very poorly stocked. they're always very happy to see

the american doctors roll into town. it's something we enjoy doing. host: the doctor runs the medical emergency department here. thank you. coming up next, we're going to talk with dr. zimet, head of the i.c.u. here at the virginia hospital center. first, we talked to a couple of doctors here and we asked them whether or not health care was a moral right. guest: currently there's an enormous cost shifting going on. ok? if you're a medicare patient and you're in the hospital. your care is being subsidized by patients who were on commercial insurances. and that's not right. if you come in without any insurance at all, all of the costs of your care are being

subsidized by commercial insurance companies. so as a hospital, it's critical since medicare you have no negotiating power. so it's left to the commercial insurance companies to essentially make up the difference because medicare is not going to cover your charges and your expenses. so you have to make it up from the commercial. so i think the immorality is sort of that equilibrium between the amount paid and the amount received. host: in my opinion, everybody, anybody that lives in this country, americans should have a right to health care. the question gets very, very murky when you say, who's going to pay for this? the answer in my simple way of looking, we're all going to pay for this. this is not something -- it's certainly not going to work by cutting what hospitals get paid

what insurance -- what physicians get paid. that will not solve the problem. having said that, as mike is saying, it is a very complicated equation. but the question is a very basic question. do we have a right as citizens of this country to receive health care? my very straight answer would be, yes. how are we going to pay for it and how are we going to allocate care and are we going to restrict or limit what patients can receive because of issues of funds and money? the example throughout the world is most likely we cannot offer 100% all the time. we're not going to be able to have a liver transplant placed on every person because there's no country in the world where that is possible. and the second message is that every system of health care, it doesn't matter where you look -- england, canada, whichever ones we talk about recently are flawed. there's not one that works perfectly. do we have it right as citizens

of this country to receive health care? in my mind, in my opinion, the answer is yes. host: the virginia hospital center in arlington, virginia. our set is in the emergency room. we've taken up a bit of the emergency room here at the hospital. we've left plenty for patients. we appreciate their allowing us in here. now we're joined by dr. steven zimet. doctor, why does the i.c.u. have a doctor who is in charge of the i.c.u.? guest: , well, i think i.c.u.'s around the country have medical directors. and our jobs in general are the to set poll i is is and make sure -- policies and make sure protocols are followed. hopefully provide effective uses of resources. guest: are you employee of the hospital or private? guest: i'm private practice.

i have a contract with the hospital. so i am reimbursed for those hours that i spend as medical director. host: so i would guess that most patients that go into the i.c.u. have their own primary care physician who's work with them. correct? guest: that is correct. host: so how do you interact in that situation? guest: well, i work with the nursing staff primarily in terms of making sure protocols are followed. and that people are having appropriate scultdions -- consultations with specialists in the intensive care unit. host: how big is the i.c.u.? how many people do you see there a year? guest: well, we have 24-bed unit at our hospital. we have four sort of emergency beds that we could use in an extreme emergency, thinking about the flu season coming up. it makes you think about those things. we see about 1,100 patients a year in our i.c.u. host: and what are the reasons they're in the i.c.u.?

guest: we have what's called a medical surgical i.c.u. so we see patients with medical problems, heart attacks, surgery problems, trauma. and people just overwhelmingly sick from infections, things like that. host: what's the minimum cost of staying in i.c.u. overnight? guest: one day in our i.c.u. costs $3,500. host: why? guest: well, mostly what makes it an intensive care unit is not the geography but the service that are provided to the patient. and we have primarily nurse that's are there. there's a concept in health care called nurse-patient ratio. we operate pretty much on a one-to-one or one-to-two ratio with our nurses. then we also have the monitoring that goes on. and that cost includes test and

other things that are done. so it's not strictly just the i.c.u. cost. that's sort of the hospital-wide cost. those patients usually demand the need of lots of services, blood tests, images, things like that. host: is it difficult -- what's it like to deal with the insurance company and with medicare and convince them that patients need i.c.u.? guest: great question. medicare is actually our easiest insurer to deal with because they just pay in an arbitrary way whatever they want and don't bother us in terms of what we do. the other insurance companies we have actually have case manager that have to call the insurance companies and justify the admissions, continued admissions, of those patients there. host: on a case-by-case basis? guest: on a case-by-case basis. and some insurers on a

day-by-day basis. host: of that $3,500, how much is medicare going to pay? guest: well, i can't really give you a direct answer on that. in general, we get about 80% or 80 cents on the collar costs -- dollar costs hospital wide. i would presume it's pretty close to that in the i.c.u. host: we've got the numbers on the screen. if you would like to talk to the director of i.c.u., also the respiratory care director. dr. steven zimmet, trained at georgetown, also a professor of medicine at some of the universities. we'll ask him about that in a second. the numbers are on the screen. besides being the i.c.u. director here what else do do you? guest: well, let's start with my day job which is i'm in private practice. i have a group of nine providers. we do pulmonary critical care, internal medicine, and some sleep work in our practice.

host: sleep work? guest: one of my partners is director of our sleep center here. guest: so there's your day job. guest: then i do the i.c.u. job. that's also part of my day job. i also have the honor of serving on the board of directors of the hospital. host: you're also a professor at georgetown and g.w., george washington? guest: i'm a professor of georgetown. i have a associate professor at g.w. host: how often are you at georgetown or george washington university? guest: we actually teach their students and house staff when they're here at our hospital. host: so this is a teaching hospital. guest: this is a teaching hospital. we rotate -- georgetown rotates interns, residents, sometimes fellows come here to our facility. that's where we do our primary teaching. host: how many hours a week do you work on the average? guest: not counting call, about 65. host: and counting call? guest: well, in the last year or two i've not been taking calls. so that's made life a little bit

easier for me. my partners that do take call work in excess of 80, 85 hours a week. host: why did you stop taking them? guest: they said i was mature enough to deserve that. host: do you work too much? guest: well, i enjoy what i do. my wife might tell you she thinks i work too much. but as i said, i don't think so. i enjoy what i do. host: first call up comes from gaston, north carolina. bernard, on our insured line. please go ahead. caller: how are you doing, doc? i make about $60,000 a year. i don't have any children. basically i pay about 30% in taxes every year, pretty high taxes. i'm thinking that y'all guys with this whole insurance debate, i'm a single payer advocate myself even though it will probably never go through. we can resolve this problem if people would just stop being cheap and pay a little more in their taxes, 1% 2% and we could

cover these uninsured people. your hospital, that's not a good example because american medicine is good, but only if you can afford it. if you can't afford it, it's no good. and the people with money or got a little bit of money like myself, i'm ok, kick in a little bit more and then we could help alleviate the cost for the uninsured coming through. you know what i mean. host: thank you, bernard. let's get a response. dr. zimmet? guest: i think universal coverage is a clear goal that we as a nation need to move to so that people do have access to care. and i agree with you, how it's financed, you know, obviously it's a very complicated question. we don't discriminate in our hospital whether patients have insurance or not. they get the same care. but it's a difficult situation in hospitals, in communities that don't have as many insured

patients or suffer even more than we do. host: i just wanted to follow up on his call. he is an advocate of the single payer plan. what do you think of that overall, what you think about it? guest: part of the problem with these buzz words is your definition of single payer may be different than mine. i think competition in the insurance plans is a good thing. i think people giving people choices would be a good thing. but i do think we need to cover everybody. host: if you had your druthers, would you like the government completely out of health care? guest: well, from what i read about what happened with medicare, before medicare came online, when senior citizens didn't have coverage, that was pretty sad. and i don't know that it would be nice not to have the government involved. but i think there is a role for government in providing a safety net for everybody and providing coverage for people who can't afford it.

host: as somebody on the board of correctors, in charge of i.c.u. and in private practice, this might be delicate. but does the i.c.u. make money for the hospital? guest: i don't think it's a delicate question at all. i'm sure we don't. host: at $3,500 a day? guest: well, first off, that's our cost. we don't get that money paid in. reimbursement is not that high. i think that's the first issue. secondly, i'm not sure that very much in-patient business makes money for hospitals these days. i think most of hospital income comes from some of the ancillary and outpatient service that they provide. but i.c.u.'s are necessary parts of hospitals. so what we try to do is be cost effective as well as obviously provide high-quality care. host: our next call comes from kansas. ryan on our uninsured line. guest: yeah, hi. as you said, i am uninsured.

i am 25 years old, single. i'm self-employed. so obviously by definition i am a capitalist. i'm all for making a profit on things. i do believe that certain things should not be for profit. i've only heard this opinion from one person, which is howard dean, who has talked about treating the insurance companies as public utilities and basically making them not for profit, which is what the netherlands has done, for example. what i wanted to ask the doctor is what his opinion would be as to dealing with an insurance company that is technically a not-for-profit public utility that is just regulated by the government and not, you know, making any kind of a profit whatsoever.

guest: if i didn't have to deal with insurance companies every day, that would make my life terrific. certainly in the outpatient setting, virtually every patient, every test, the concept of preauthorization for testing, the concept of having to get medication as proved, particularly newer medication that come out that might benefit the patients. we have people on my office staff at 1-800 numbers calling, trying to get patients authorized. insurance companies have a large margin. i think they make about 15% of all the premium dollars. they only pay out about 80%, 85%. so i'm not a big fan of insurance companies. i think they need to be more competitive. how that's done i'll leave to other people to decide. but is it a problem to deal with now? yes. host: in your private practice do you employ people simply to deal with insurance and medicare

and the paperwork? guest: yes. host: is that a pretty big expense? guest: oh, it's a substantial expense. yes. i mean, we have -- we take up a lot of staff time doing that. host: next call comes from culpeper, virginia. kirk on our medical professionals line. please go ahead. caller: good morning. good morning, doctor. i'm a health care professional of 25 years, working in radiology. also an advocate of single payer, another of the millions of people out here who are advocating for national health care. you can call it whatever you want and whatever anybody else thinks is appropriate, but it's essentially expanding medicare for all that would be very simple act for the government to take. i just wanted to ask you, doctor. there have been questions related to single payer.

even your interviewer has asked that question. and you made a response. you responded to his question regarding simplifying what is the easiest entity to deal with as far as reimbursement. and you said, medicare. the question is, isn't it obvious -- there are many cases to be made for national health insurance, especially the morale imperative. but wouldn't you say that simplifying -- getting rid of the private insurers ultimately would simplify and save so much administrative costs and that your job would be much easier and we could lower that $3,500 a day i.c.u. cost by just cutting out all of these insurance and reimbursement challenges that we deal with every day and extracting the profit? wouldn't you be a single payer advocate, sir? thank you. guest: , well, a couple of things. i said that administratively medicare was easiest to deal

with. they only provide about 80 cents of the dollar of our costs. so if we have a hospital that has 100% medicare, we would probably be out of business in a relatively short amount of time. so medicare administrative easy to deal with. medicare reimbursing not adequate. so that's the problem there. if everybody had medicare and medicare provided coverage, and that would include a margin -- i think mr. cole and dr. garrett talked about it yesterday. to allow capital reinvestment for equipment and things that we need, maintaining buildings and things like that, that has to be added in. i think in fairness, though, even if they provided enough, we have to change the fundamentals of how people are reimburse sod that incentives are appropriate both -- reimbursed so that incentives are appropriate for lifestyle and effective care on the physician and providers side. host: how quickly does the technology in an i.c.u. change?

guest: often very rapidly. it's a very dynamic sort of thing. i think in the last maybe five years we've had some dramatically improved ability to monitor patients in real-time, to keep tabs of data and things like that. and that has really provided a more effective and i think more cost effective care. the technology costs money, but i think at the end of the day it does help. host: when we started this conversation, you mentioned you work with the nurses or are responsible for the nirses as head of the i -- nurses as head of the i.c.u. what's their relationship and what's their role in the i.c.u.? how specialized are they? guest: well, my concept of the nurses in the i.c.u. is that the i.c.u. is a nursing unit. they are the people who run the unit. the doctors make cameo

appearances there. provide services that we provide. the nurses do the hard work. host: and do they become, in a sense, the patient advocate also? guest: they become the patient advocate, the bridge between the patient, families and the physician. they are the glue that keeps the i.c.u. together. host: so are your duties up there administrative more than patient, one-on-one? guest: well, i have two roles. as a practicing physician, we have patient care responsibilities for the patients, particularly ones seen by my group. and then also as the i.c.u. director. so the nurses will come to me with issues that need to be resolved in terms of how the patients are being cared for, even with those that i'm not directly involved with. we also have a policy here where we can intervene if it looks like there's an emergency and things need to happen quickly,

where we can be more direct in the intervention. host: what's the importance of family members? guest: family members -- family and friends are vital parts of the patient's universe and needs to be parted of their care and recovery. host: are there instances when the squeaky wheel gets the grease? guest: i think the squeaky wheel always gets the grease. that just happens. but i think part of the issue -- part of the job with the nurses and the doctors is to manage expectations in the i.c.u. "think we watch a lot of television, see a lot of people have major surgery at 10:00 and eating lunch at 12:00, and people think that's going to happen. and i think -- particularly as we get into discussion of end of life issues -- i know dr. garrett discussed it the other day -- appropriate expect

it's as. and the nurses are often very, very useful, very, very helpful and effective in that regard. host: last call for dr. zimmet from providence, rhode island. cindy, please go ahead. caller: yes, hi, doctor. the reason i'm calling is it sounds so easy on the tv when your doctor gets on tv and explains all of these things. but there is people that really do suffer. like i have a husband, had an operation. another time he had a blockage. then an imagery on his brain. and i brought him to the hospital, 5:00 in the morning. and the doctor came in the i.c.u., intensive care, whatever they call it the emergency room. and until 9:00 at night they didn't see him. the reason why i'm calling is because everything is so easy for you doctors to say that this is going to happen, we're going

to do this, do that. but once you get in the hospital, no matter if you're covered, not covered, they push you on the side and they take their time to sigh if you're die organize not dying. in italy, my country, my husband went in on vacation. he got sick, was having chest pains, was having a heart attack. he went to the hospital. he didn't belong over there. he was an american citizen. they took care of him for three days. they did everything for him. and when he asked to pay for a bill, they said, no. when you go back to the united states, you tell your president this is what italy does. it doesn't abandon people no matter if they're italian, american citizens, any kind of citizen. we do not charge. let them know what they do. but the other doctor before you said that it cost him about $100,000 to become a doctor. a doctor could make in a couple of days his $100,000. they make a lot of money to take

care of people. but they make it sound like they're not making nothing. that's why they own villa, yachts, all of these things because they overcharge everything. blue cross doesn't want to know nothing. host: all right. let's get a response to your comments. guest: well, i think the example of italy is an interesting one. we'll talk about that first. i think there's a lot we can learn from our allies in europe and canada in terms of providing health care. whether that model would be useful in this country or not, i don't know. i can tell you that most doctors today graduating from medical school have debts closer t to $200,000. the doctor was lucky, as he said, that his personal debt was a lot lower. but i think in today's world. and i don't think physicians and physicians salaries are as

abundant as the caller might think. particularly in the specialties of primary care and the pediatricians and psychiatrists and people who really spend their days taking care of people one-on-one. host: dr. zimmet is in charge of the i.c.u. here at the virginia hospital center. thank you for spending time with us. guest: thank you. host: up next, the director of nursing. but first we talk to a surgeon about getting reimbursed for an operation. >> i don't. i know what our charges are. i know that i am not paid what our charges are because i have contracts with insurance companies, as do most physicians. but i don't know specifically what that will translate to patients in terms of what their co-pay is, the 80/20, 90/10. so for each patient i really don't know what that will translate to. and the patients don't know either. host: if you're doing a radical

mastectomy what does that cost? what's the total cost of that? guest: the cost and the charge are different. >> what's the difference? >> so the charge is anywhere from $1,800 to $2,000. the payment is usually a medicare reimbursement for a mastectomy is usually between $650 and $750. >> is that your -- that money comes to you, the doctor? >> that money comes to me to help pay my salary, my overhead. i have five employees working in my office. i will have two associates. i currently have one. i have another one who's starting next week. that covers rent, malpractice insurance, supplies to the office. so one of the miss nomers for physician reimbursement is that money goes right to my house to my bank. that's not what happens. as most small businesses or big businesses have overhead to cover so do physicians. and so that payment helps defray all of those costs.

>> so it's $600 and something from the medicare if you're paid for by the insurance company, do they give you the full -- >> no. typically the insurance company rates are maybe the same or slightly more than what medicare will reimburse. and so if i am seeing patients and i'm a participating provider, i have agreed to accept what the insurance company contract payment is. if the patient is seeing me and i am not a participating provider, i have the ability to bill for the difference between what the insurance company will pay and what my charges are. but typically we don't do that. host: as the debate over health care continues, c-span's health care hub is a key resource. go online. follow the latest tweets, video ads and links. watch the latest events including town hall meetings and share your thoughts on the issue with your own citizen video, including video from any town halls you've gone to. and there's more. at c-span.org/healthcare.

host: back live at the virginia hospital center in arlington, virginia. we continue day three here of our series on hospitals, health care, and health care reform. in our set in the emergency room here at the hospital we are joined by the vice president and chief nursing officer. how many nurses work at the virginia hospital center? guest: we have over 500 nurses here at the time. that is not -- that is have you had individuals, full-time, part-time we have a robust staff. host: how specialized as nursing gotten over the years? as doctors specialize, nurse is the same. correct? guest: absolutely. nursing has evolved into medical different specialties. i think it's been a real benefit for both nurse and patients it gives the nurses an opportunity to find their specialty niche and really become specialists in the event that patients need

that kind of care. and nurses are attracted to be specialists and that kind of level of care to patients. host: i just want to mention that we have set up our third line for this segment, for nurses only if you're a nurse, the number to call is 202-628-0205. again, nurses only on that line so we have a chance to hear your story. tell bus some of the specializations. guest: right now in the virginia hospital center we've been spending these last few days in the emergency room. obviously we have emergency room nurses here. a very important group in our nursing department as they often see our first line of patients here. throughout the hospital we also have cardiovascular specialty nurses, cardiovascular intensive care and stepdown unit, critical care nurses. dr. zimmet talked about their role. we also have a robust women's and infants program here. we deliver 3,700 babies a year

so those nurses are very specialized in labor and delivery, postpartum care. we have a 16-bed nicu care here. neo-natallal intensive care unit. our departments are strong. we have a center of excellence for stroke. we have a center of excellence for hip and knee. a center of excellence for breast care. along with each of those centers of excellence we have nurse that are qualified to work there with their education and their focus on those specialty population patients. host: back in the day you could become an r.n. with a three-year diploma program. correct? guest: yes. host: what did today? guest: today, someone who wants to sit for the licensure has to be a graduate of one of three different state approved schools. there is still the three-year diploma school of nursing usually associated with hospitals. but those only make up about 4% of the schools that are out there today. there are also with it-year a.d.

graduate programs. and there are the four year bsm programs. all of those programs qualify for the examination which our state government boards of nursing licensure examination. host: is that an l.p.n.? guest: it is not. there are several practical nurse programs that range in the time frame of about 18 months. and nursing has always been looking at itself carefully to identify what level of nursing really makes up the professional nurse. there is more and more conversation on a professional level and movement towards the b.s.n. that's actually observed and recognized the professional nurse. can i tell you -- i can tell that you in this organization we have all of the nurses here practicing. we have all the nurses of all of the schools of nurse who's are absolutely excellent. we do encourage our staff nurse at every level to seek and pursue the b.s.m. level. host: what are the duty

differences between an l.p.n. and a general r.n.? guest: a general staff r.n. is the r.n. who actually manages the patient in the patient care setting. we partner with l.p.n.'s. we also partner with patient care systems who in the past used to be called nurses aides. they make up teams of nursing. there is a different level of responsibility that is placed upon the registered nurse in relationship to creating the plan of care, executing physician orders. they have higher level of responsibility for medication administration. especially when it comes to advanced protocols. so we work in tandem and teams up to the level of competency of each individual to provide that best care for patients. host: dr. zimmet called the i.c.u. a nursing center where doctors make cameo appearances. guest: i heard him say that. i think he's being very gracious. i like to see the i.c.u. and almost any unit within the hospital as a real orchestra. yes, the physicians are in and out. and the nurses are there 24/7

with our patients. our physician colleagues set the roadmap. and together they partner with us and we set the care plan together and really provide the best care for patients. that's the real combination of efforts of the whole team in a hospital. the physicians are obviously at the front end of that, with nurses partnering. host: has the relationship between doctors and nurses changed over the years? guest: i believe that relationship has improved. and improved for the patient. i believe that nurses have always had a great respect for physicians. and as the education for nurses has been -- has actually grown and responsibility has grown along with that, physicians have always respected nurses. that's been my experience. but the level of education now is equalizing to some degree in that the level of conversation, the planning, the complexity now that is involved in taking care of our patients, that has changed greatly. so the dependence on each other, i think, has increased.

and relationships and communication is always where that health care can improve and where the best outcomes are achieved. host: what's the starting base salary for a nurse here? guest: the starting base salary for an entry level graduate nurse is somewhere around $53,000 plus. host: that's pretty good. guest: yes, it is good. it is very good. i think it's a reasonable -- particularly in the economic downturn that we see people who are really taking a second look at all health care professions. we have a clinical track nurse, track here for those people who progress through the hospital and their experience. and the salary gets graduated with experience and performance outcomes against that clinical track. a nurse who's been long in the field and is very specialized in their field can move upwards from that quite significantly, up to $80,000, $90,000, plus.

so people are paying attention to this field more in these times. host: and salarie salaries for s has improved over the years. correct? guest: yes, it has. and, again, i think it has tracked along with the education, the responsibility that we have to manage. host: let's take some calls. darlene is the chief nursing office and vice president of the virginia hospital center. our first call up subpoena is a nurse in kansas. -- call up for her is a nurse in kansas. caller: hello. i have been a nurse for 34 years. i graduated from one of the old diploma schools of nursing where we were hospital based, three-year program. i actually made that decision because i was so unimpressioned with the bachelors degree program coming out of k.u. med center nurses because i was working as an aide and i was unimpressioned with their clinical ability once they got

to the floor in pediatrics. so i went into this school of nursing and was immediately into i.c.u. right after graduation. i have had a career in emergency rooms, i.c.u., transport team, pediatric i.c.u. and i've been in the caj lab now for seven -- cath lab now for seven years. my question to you is, do you find there are any possibility for us to finally go to universal health care for the american public? and how can we nurses facilitate that happening? i have witnessed too many uninsured people coming in to the emergency room. i know that we will bill them later, after we take care of them. but i know that they will probably be unable to meet that obligation which puts a lot of financial drain on the hospital.

we serve a huge community, outlying community. i'd like to see this hospital survive. but they seem more interested, and i see other hospitals also in the country, in building. building new buildings. building new facilities, new equipment. kind of the bricks-and-mortar instead of actually hiring better nurses, more nurses. and i would like to see how we can get away from the money-making aspect of hospitals and get back into just providing care for all of the american public. thank you. host: patricia, two questions. do you enjoy your work? and could you give us an idea of how much money you make? caller: i enjoy my work.

very much in the cath lab. i think it's a great combination of i.c.u. and e.r. it's exciting. the patients are basically conscious. so we get acquainted with each of them. we get to actually fix a lot of what their problem has been, kind of immediately and see the end result of that. so that's exciting kind of medicine for me. and it also is challenging. and it's the best patient carry can give because i have three staff members to one patient. and when you go home at the end of the day, you never feel like you have given poor patient care. but my cohorts in nursing, i would say, by and large, are not happy people. they are not in the cath lab. they work on the floor. they're under staffed, over

worked. and their management is unsympathetic to that. in fact, management changes so rapidly often times managers of particular units stay only a year or two and then they are replaced. so there's no consistency there. and it's a very frustrating situation for nurses. host: are you satisfied with your salary? guest: no. as your guest said, the starting nurses at $53,000. and i'm making that at 34 years of nursing. host: thank you very much. a lot to work with there. guest: you bring up many, many key points in your relationship to your experience as a nurse and where we are with health care today. i, too, first started out with a three-year dloam i can't school and then went on to get my degree and masters. so we have about the same amount of tenure in the field. and you're saying that you've

seen an awful lot of change. and you've had the opportunity to try a lot of different things in nursing and in the health care arena which you found your niche and where you're able to make the most difference. and i'm always one that supports nursing, finding that opportunity. that doorway to the patient care, to the arena which they love and have a palings for. you ask a question to how nurses can impact health care reform. my response to that, patricia, is that we're over three million strong in this country. nursing, as you know, makes up a vast majority of caregivers at the bedside and caregivers in the health care industry. so we need to be well versussed on what the issues are related to health care reform. we have a lot of professional organizations. i'm sure that you've participated in and your colleagues have participated in. and you're probably following, as i am, and as we are here, what those reforms are looking like, what kind of impact it's going to have on nursing. as i was preparing this week and

thinking about what message for virginia hospital center nurgses might be most appropriate for me to convey with an opportunity like today, and nurses throughout the organization here at virginia hospital sent rer concerned as you are. what is it going to look like in the future? how is it going to impact the number of nurses we're able to provide the resource that we have to deliver the high-quality care at the end of the day that we're satisfied with? this is on everybody's minds. and to that i would encourage us, as some of the nurses have said here in this hospital, as an industry to take stock of where we are to appreciate the gains technically that you have seen and i have seen so that we do have people surviving through the cardiac caj rizzations and outcomes. take a pause. look at what our achievements have been and don't lose that ground. build on top of that ground that we've work sod hard for, doctor -- worked so hard for. people attached to the health care for these many years have

driven our outcomes to places that other countries in relationship to what we're able to achieve with our interventions and our treatments that are still out of reach for them but comes at a cost. and it is a large dilemma. but stay tuned to what's going on. be a part of the voice in relationship to making decisions. the other message i heard from the nursing staff here at virginia hospital center is to urge our legislative people to not rush to an end too soon, to be thoughtful to take their time, to think about what needs to happen next with the sense of urgency. but not to rush people to a place where they're fearful of what's coming next down the line with health care reform. that some of what we're seeing in the public might be because it's so personalized in relationship to the outcome of where this health care reform is going to land. but, again, nursing is going to be a big component. we've been a big component of health care in the past.

we will be in the future. and actually, it's an exciting time. if you are energized around providing patient care to have your voice heard and be part of where we're going as a nation. host: nurses are first-team medical care. do they know whether a patient is medicare, blue cross-blue shield, united, uninsured? guest: no. i would say we have an awareness of it in relationship that we're part of the team that's also helping manage what is in the best patient care interests related to the length of stay. there are teams in the hospital responsible for that and working with the physicians and the nursing staff together to coordinate that activity. when we're in front of patients, we don't have that awareness. nurses in general, and i believe physicians as well, that's not what we're here for. we're here for meeting the patient, where they are, what their needs are. the ability to pay or not pay is not something that is ever in the forefront of our minds. host: how did you decide to become a nurse?

guest: i had the advantage of growing up around mentors who were very influential. my mother, my father were people of father, of compassion, and of great service. my father is a world war ii veteran who came back, had a job. but also served in our community of the town council, as fire chief, as a county official. i had the advantage of seeing my mother and my father extend their hand to people throughout my growing years. i also volunteered in the hospital. as many of you heard, physician colleagues of mine. i volunteered. i saw this as an opportunity. i enjoyed the sciences and just wanted to be with people and it grew from there. i had a mentor, an aunt as well. there's many nurses in my family as well as physicians. host: jack, savannah, georgia, insured line. guest: my daughter is a registered nurse in the state of michigan. she works in delivery, neo-natallal and i.c.u. for babies.

she's been there 18 years. i support single payer, universal health coverage for all. i'm a big-time supporter of that. but i also support tort reform. and not only limit the amount of damages for some of these that people have, bunt i think that a panel should sit down and work out loss of foot, loss of hand, loss of whatever and say this is the maximum that the courts can allow to be paid out. i also believe that the lawyers should get their hands out of the pot. that should be included in it. we have all of these allies around the world who have already went through this whole thing, canada included back in the 1950's. we don't have to pick a

particular one. we can pick and choose the best of all of these plans and come up with a uniquely american plan. host: thank you, jack. two issues. single payer and tort reform. guest: first of all, jack, you mentioned that your daughter is a nurse in nicu, neo-natallal intensive care. i believe that nursing has a feel for excess throughout the nation because so many people do know nurses. therthis is a really good examp. i'm sure a lot of jack's opinion is based on what he hears his daughter come home and say. in the nicu we've seen great advances in the last 10, 20 years. we're seeing baby that are -- even 15 years ago were unthinkable of being able to survive at the age and gestation that they have, how early they're born and the weight that they are. but also an arena where legal issues are a concern. it's a fine balance between what parents expect or patients might

expect coming in the door for care, what we're able to actually do. every person who arrives in the hospital setting or is working with the physician is expecting usually the very best of outcomes. those expectationses when they're not met, whether they're realistic or not, can turn into legal issues. tort reform is something that i'm not an expert in, but certainly health care industry and physician practices have been greatly impacted in how they make decisions, how we operate in this very litigious society. tort reform has taken hold in different states across the nation. i believe there is still a lot more work to be done there. host: darlene vrotsos, do nurses carry medical malpractice insurance like doctors do? guest: nurses should. i do. i certainly do. in hospitals there is an insurance coverage for all practitioners, all clinicians within the hospital. but beyond that, in this society, i encourage every nurse to carry their ownnd