Audio Roundtable: Health Care Reform: Clinton's Defeat, Obama's Hope



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This interview was conducted on March 12, 2009.

Joanne Silberner: Welcome to POV's special series of Web conversations surrounding the film Critical Condition. Critical Condition explores the nation's health care crisis through the stories of four families who discover that being uninsured can cost them their jobs, health, home, savings and even their lives.

I'm Joanne Silberner, and I'm a health policy correspondent for NPR in Washington, D.C. I'm going to be playing devil's advocate today, challenging the two folks here with me about their ideas about health care reform. And they are Ron Pollack, the executive director of Families USA, which is a national nonprofit organization that works for health care reform. Ron has been lobbying for health care reform since well before the last effort. Ezekiel Emanuel is with the Obama administration. He's special advisor for health policy at the Office of Management and Budget. By training, he's an oncologist and an ethicist. And he's author of a book I have right here, Healthcare, Guaranteed.

All right, let's start. Question one, everybody thought it was going to happen last time in the early '90s. Is it going to happen this time? Ron, do you want to start?

Ron Pollack: I think it will happen this year. I'm more optimistic than I've ever been. I think the stars are lining up: You've got a president who is deeply committed to achieving health care reform. There are five committees with jurisdiction over health care; each of the chairmen really care deeply about getting to health care reform. The various interest groups that span the ideological and interest-group spectrum are searching for common ground and are saying that we cannot allow the status quo to be the second favorite choice. So I think that we have a better chance than ever, and remember, there are so many people in this country who are hurting because we don't have health care reform. Businesses can't afford to provide health care coverage, even though they want to. More and more families that used to take health coverage for granted are joining the ranks of the uninsured and underinsured, and that's exacerbated by the economy. So yes, I think this is going to be the time and I think we will accomplish it in 2009.

Ezekiel Emanuel: I would have to agree. I am also more optimistic, having participated in the '93 effort on the Clinton health care taskforce for a short time. I do think this is different. First, the problem is more widely recognized and it's not just the problem, as it was in '93, of the uninsured. It's now widely recognized that it's a problem of cost threatening the fiscal stability of the whole country and the whole federal budget; the cost is also really weighing down on businesses, weighing down on individual families with the increases in premiums, deductibles and copays. So I think there is this sense that the problem is much bigger. It's not just about the uninsured: It's about the cost of health care in this country. And there's also this worry about quality. I think people have heard that, despite the fact that we have islands of just tremendous, outstanding greatness in medicine -- I've been privileged to work at many of them -- we also have inconsistent quality. We can't always be sure when we go to the doctor that we are getting the best care and we are getting the appropriate care. I think the recognition of the problem is much more widespread, and people also recognize that it's about more than just the uninsured.

The second thing, as Ron alluded to, is the alignment of people who in '93 actively campaigned to kill this. There is no one better to embody that than Chip Kahn, who is the guy who developed the Harry and Louise ads.

Silberner: Remind us about the Harry and Louise ads.

Emanuel: The Harry and Louise ads were ads showing a husband and wife sitting around talking about the Clinton health care reform. The couple indicated that the reform would adversely affect their situation: It would eliminate their ability to choose their doctor: it would force them into a managed care organization they didn't want. They were incredibly successful ads, as anyone who lived through that period can tell you.

If the ads weren't the only thing that torpedoed the reform effort, they certainly drove a stake into the heart of it and were very successful at turning the tide of public opinion. Now Chip Kahn is a very active campaigner in support of comprehensive reform and recognizes that we need to have it. He's not the only one, but I think it's very symbolic that he is on the other side.

The final thing, I would say, is that we have a president who has made quite clear that this is one of his absolute top priorities, because it's absolutely essential for the long-term viability of the country. If we don't solve this problem, it really does threaten the foundations of what make this country great. And I think that passion on his part is going to be extremely important. And the fact that President Obama is a great communicator and a great persuader, I think, is going to go a long distance to making this a reality.

Pollack: I want to add one thing to what Zeke just said. In 1993, President Clinton actually did care about health care reform, but there were three things that came before health care reform: You had the debate about the North American Free Trade Agreement (NAFTA). You had a debate about balancing the budget. You had a debate about gays in the military. And it wasn't until September of '93 that the president gave his speech on health care reform, and it wasn't until November of '93 that he introduced his proposal. President Obama is doing this differently. You need a president who's got a great deal of political capital to lead this effort, and President Obama does have that. He has not expended his political capital and so I think we've got a real chance with the leadership that the president is offering, because it's being done in a timely manner.

Emanuel: Let's say one other thing about that. And sorry to keep adding to this list. As I mentioned, I was part of the '93 effort and worked on various aspects of the reform, including some of the ethical issues that arose, but also some of the support for academic medical centers and training of doctors and nurses, and doing research to get data that would inform decisions. But that was an effort that sort of took place behind closed doors: there wasn't a lot of media contact permitted. The health community wanted to support it -- Joanne, you remember that you and I had contact to try to explain this, despite the fact that the Clinton administration did not want a lot of information leaked out.

That sort of hidden-bunker mentality is obviously 180-degrees different than the way the Obama administration has gone about this. We just had a health care forum [earlier this month], and not only was it broadcast, it was streamed on the Web. Anyone who wanted to see any one of the five breakout sessions could break into a session and see it. And I think you're going to see this whole process run much more openly and inclusively, and we definitely want all groups that have opinions on this to express their opinions, because in the end it is going to be something that is important to everybody and we do need to make sure we understand everyone's perspective.

I think the other thing that was said about '93 is that there were no doctors involved, and I'm here, as it were, as living proof that at least in this effort there are a couple of doctors very much involved, and the opinions of people who care for patients and really care about making sure we get high-quality care to people is integral to the whole process.

Silberner: Well, what's the first step going to be? What's got to happen?

Pollack: The first step, and it may be the most important step, is the development of the budget by Congress, and that sets the parameters for everything that Congress does. The president offered a very significant investment -- it was a down payment, as he called it, of $634 billion over ten years, but you need a larger investment to achieve the objectives that the president has set out. Now, that investment is important, because in the long run it is going to bring the cost growth curve down, and it's going to create enormous savings for businesses and for families, and ultimately for the government as well. So the first step is what will be in the budget resolution: Will it contain a sufficient investment so that we can get health care reform done? I would say that with the president's first investment of about $634 billion, fully paid for, Congress is now going to have to meet that and approve that and build on that and work together with the president.

That's going to be the debate that's going to occur in the latter part of March and in April, and the outcome of that is going to determine whether we truly can deliver high-quality affordable health care for everyone, because it's going to require, as the president's framework proposal outlined during the campaign, some subsidies for people who currently can't afford health care coverage so that we get everyone covered. Without that, we're not going to come close to getting everyone covered, and we're not even going to be able to reform the insurance market to make sure that insurance companies stop cherry picking by denying coverage to people with preexisting conditions or charging them discriminatory premiums. So this budget fight is essential and, thank goodness, the president has led with a very, very helpful initial investment.

Silberner: Let me push back a little bit on that. Of that initial investment, $177 billion comes from the Medicare Advantage program. That's where people on Medicare can join a managed-care plan and maybe get more benefits, and it costs the government more, and the president has said, "Let's put that out and make the insurers bid for that business. Let's not necessarily pay them more. Let's see them bid." The insurers have been right upfront, saying, "We are here. We want to be part of the discussion. We want to be at the table." My favorite expression going around Washington is "If you're not at the table, you're on the menu." And I think they've taken that to heart. They want to be there, but they don't want to give up that money, either.

Emanuel: Yes, of course. Look, no one wants to give up what's essentially free money, but what is being proposed is that the government not set prices, which is what's happened up till now, but that we allow the market to play out, and market prices to determine the price that is paid to the managed-care companies for offering this product. Almost all of us say we're for the market, we're for competition, we think this will deliver a better product at a cheaper price. And what this budget does is essentially say, "All right, let's put that ideological claim into practice in this area."

Silberner: So you guys think they're going to go for it?

Emanuel: It shouldn't be one where we say, "Oh, in this particular area the government is better at setting prices," because we know in fact it's not better at setting prices, that competition in this case is likely to bring the price down.

We've spent 16 percent of the gross domestic product, the GDP, on health care. Everyone who's involved in health care, and there are more than 13 million people who provide health care in one way or another related to the industry in this country, has a financial/economic stake. If we're going to make changes, some people feel like they're going to be hurt more than they're helped. The whole point of doing this right is to make sure that everyone is better off in the end. Will that require some pain? Yes. I was trained as a chemist, and I like to say that the big issue here is not whether at the end of the day we are all going to be better. I think that's undeniably true. No one who looks at the current system thinks it works well -- no one. Not even people who are doing pretty well in the system. The issue is to get over a potential energy barrier, where some people for a short period of time are going to have some pain, and I think that is what we have to convey to everyone. We have to try to structure a package where people are giving up something, but also gaining something.

So, to take the example that you brought up, of the insurance industry, yes, they're going to have to give up guaranteed profits in this one segment of Medicare, but the question is at the end of the day in health care reform can they gain something? Well, if we insure 50 million people, then we put those people -- or at least a big portion of them -- into the private health insurance market, then the insurers should be able to gain something out of that. They'll have more people.

Second, as Ron has mentioned, they will be able to get out of a business model that I think even they don't like. Their business model now is "Can we pick the healthiest people to insure, and therefore make profits, because if we get too many sick people it's going to kill our bottom line." Well, if we have everyone in America in the insurance market, then the chances of the insurance companies getting too many sick people are lower, and so they can behave differently. They can do what is called "giving community rating," so they can say, "All right, we're not going to determine what someone's health status is, whether they have diabetes or heart disease. We're going to get a wide spectrum, and so we can actually not worry about the risks and be comfortable that if we actually do a good job in terms of getting people the right care, getting it to them appropriately, we can still make a profit. Our profits will not be dependent upon cherry picking."

So, I think from their perspective, if in fact we get coverage for all Americans, if in fact they get a wide spectrum of people, they'll actually have a way of running their business that they really want to use, but we just haven't allowed them to because of the the way we've had the insurance market structured.

Can the insurers find a win-win here? Yes. Is it going to mean taking away some of their business in one area but expanding their business in another area? That's my hope, and I think if you look through all the actors, whether it's hospitals or doctors or long-term health care facilities or the pharmaceutical industry, I think by having a better health care market all of them can, in fact, win, even if they have to give up something as well.

Pollack: I'd like to add two things to Zeke's thoughtful comments. First, when we're talking about this so-called Medicare Advantage program, everyone recognizes that the insurance companies have gotten a huge windfall. They get paid 13 percent more than traditional Medicare, and mind you, the Medicare Advantage program that's run by the private insurance companies actually has less risky people in the pools because when they market they try to get the healthiest and youngest people. When this program was started, the insurance companies got 95 percent of what Medicare paid for, and they still were making a profit on it because of their selection of who they were enrolling. So for them to be getting 113 percent -- there simply is no justification for that. For one of their products that doesn't do anything in terms of managing care, they're getting 118 percent. So I think there's clear recognition, and the president has said it time and time again, that this is something that's wasteful and that we should change.

The second thing I would say is that of course the insurance industry is not going to bid against itself and it's not going to say, "Hey, take my Medicare Advantage overpayments away." I've spent a lot of time with numerous strange bedfellow organizations, including members of the insurance industry, and I think they've got a clear recognition that they're not going to hold onto what right now is an incredible windfall, and they're not going to put it on the table, and they will probably make the arguments about what they're doing and how helpful it is. But at the end of the day I think there's recognition that this is an overpayment, that we need to protect the taxpayer and save those funds so that we can actually achieve the reform that Zeke was talking about.

Silberner: Interesting. But there are some problems on the horizon. I mean in one of these organizations, which has an incredible breadth of interest groups including businesses, insurers and consumer groups, already the two big union groups have dropped out. Is that a signal that it's going to be hard holding these coalitions together?

Pollack: I really don't want to comment on that specifically. I will say that our friends in the labor movement are going to be at the table throughout this process. We are working very closely with the very unions that you're referring to, and they are going to be pushing throughout the process for meaningful health care reform. I don't think this is a rupture of any sort. So I'm not going to speak specifically to this particular transaction, but I will say that the labor unions will be at the table. We're working right now, for example, with SEIU on a robust effort to try to mobilize people in key states in support of the president's proposal, and SEIU has performed remarkably in this respect. So, no, I don't think this is going to be a problem.

Silberner: What are the hurdles to getting something done? Last time around the hurdle was that nobody wanted to get hurt. The insurers said, "Let everybody else get hurt." The drug companies said, "Let everybody else get hurt, not us." They all tried to protect themselves. Now, you're saying this time everybody knows they're going to have to give something up. What are the hurdles? The economy is terrible. Is there money there for this?

Emanuel: There are three points to make. The first is that we do have a terrible economy, and we have to do this for the sake of the economy, and for the sake of the long-term fiscal stability of the country. We cannot continue to have health care consuming evermore of the country's money, because it's taking money away from other things that we need to be doing, whether it's investing in new products at companies, whether it's investing in education in the country, whether it's investing in infrastructure. Health care has just been consuming more and more money and taking funds from other areas. Let me just give you a little fact: About four or five months ago I was in Minnesota talking to some of their state legislators at a meeting, and the head of their House Committee on Health told me that in 1985 the University of Minnesota got 30 percent more money than all the health care programs in the state. Today the health care programs in the state of Minnesota have 300 percent more--

Silberner: What do you mean by health care programs?

Emanuel: Medicaid and insurance for state workers consume 300 percent more than the University of Minnesota. That's one way of looking at it, and it does seem to be the case that Medicaid and insurance for state workers is taking money away from higher education and the universities, and those are essential to train our workforce, to train future generations that are going to keep the economy going. We can't continue to have that.

So, you asked whether we have the finances to do that. The real question, and I think the president put this out at the health care forum, is we don't have the finances not to reform health care. If we keep going this way, we are going to be bankrupt as a country.

Silberner: So, you're talking about insuring more people, getting more people taken care of and spending less money.

Emanuel: That's right. And it won't happen immediately that we're going to be able to save money. We are going first to have to put everyone in the system. It used to be, certainly when we were debating this in '92/'93, that people said out of covering everyone, controlling costs and improving quality, you could have two out of three, but you couldn't have all three at the same time. And today we've recognized you have to have all three at the same time or you won't get one of them. So if you don't cover everyone it's going to be impossible to control costs.

Silberner: That's a very important point -- that if you don't have all three your pyramid falls.

Emanuel: Absolutely. First of all, if we don't have cost control you can't get everyone into the system, because you might get them in for a minute, but then we're just not going to have the money. You can't get cost control without improving the quality of care. We have to change how doctors deliver care so we're not doing unnecessary things, we're not doing more expensive things when cheaper things will be just as good and improve people's health just as much. And further, you can't get cost control without getting everyone in the system. To get a very well-functioning insurance market and not to have people show up sicker than they would otherwise be, we need to have everyone into the system.

So, this is a situation where we are going to have to reform the whole system to make it function right, and make it sustainable over the long term. And if I'm not mistaken, the president emphasized -- and I think he was absolutely right to emphasize this at the forum -- the importance of sustainability, of having a reform that can last a long time, because it can pay for itself and it will be self-reinforcing in a positive way.

Pollack: I would say, again, two things. The president cited some numbers actually from a report we released a couple of years ago. If we don't extend coverage it has a profound impact on those people who actually do have coverage. A few years ago we showed that out of the total premiums that are paid for family health coverage, the portion just devoted to paying for the uncompensated care costs of the uninsured cost more than $900 to $922. And so people who have insurance actually have a stake in making sure they don't get the cost shift from people who are uninsured and underinsured.

Your opening question asked about the various groups, and I'd like to cite something that Stuart Altman, a professor from Brandeis who has been involved in health care for eons, says. Stuart says, I think quite correctly, that "every group, conservative, liberal, Republican, Democrat, has come into the process and said, 'Here's my top priority proposal.' And when it appeared that their top priority proposal would not be adopted they either walked away from the table or opposed what was left on the table." Another way of saying that was everyone's second favorite choice was the status quo. Well, I will tell you there isn't a single organization in this town or around the country that's saying its second favorite choice would be the status quo anymore, and that's enormous progress. And it does mean everyone is going to have to contribute in some way for the greater good, and hopefully with the president's leadership we will actually see that through to the finish line.

Silberner: Let me get the public involved here. I'm going to pull out a number I saved. Drew Altman had a column where he was talking about what this means to people. When people were asked "Do you think you'd be better off with health reform," 38 percent think that they'll be better off, and last time around, in '93, that number was smaller. Drew says that's the number to watch. But I still think that number could go and swing. People are in such desperate straits.

In Critical Condition we had a guy who had his foot amputated because his insurance was running out and he was worried about keeping his job and getting insurance. Another guy died because he had been uninsured and couldn't get the medication he needed. There are stories like that. But I think that in an uncertain environment people are afraid of change.

Pollack: In 1993/1994, as Zeke said before, the debate appeared to be about the uninsured. And while there are a good number of Americans who have empathy for people who are uninsured, they often don't necessarily project themselves into the same shoes. What has happened, however, is that people now know that their premiums are going up, their deductibles are going up, they're paying more in co-payments. As the president cites, over the last years, premiums have risen four to five times faster than wages. Everyone feels that. Everyone feels that they are in jeopardy of losing something they used to take for granted. When you transform this debate from one of altruism for somebody else to self-interest because I fear I may lose the coverage that my family needs, that's a totally different political dynamic.

We released a report just a week ago that showed in the last two years there were 86.7 million people who were uninsured at some point during that time. Three out of four of these people were uninsured for at least six months. That's one-third, by the way, of the people under 65 years of age. That means essentially everybody knows somebody in their family, a neighbor, a friend who lost health coverage or didn't have it. And so I think this is now a self-interest issue, not simply an issue of altruism, and that's a very powerful impulse.

Emanuel: I would absolutely agree with that. I think with the unemployment rate rising, with people seeing that in fact their companies might have to cut back or even eliminate health insurance because of the worry about the economy and worrying about staying profitable; seeing their kids come out of college, losing the college coverage but not having a job that pays benefits; seeing their premiums go up. I think it is the case that everyone now can see that this is a very uncertain, unstable situation.

So what can health care reform do for people? The first thing it can do is provide them security, to give them the sense that no matter what their employment status, no matter what their health status, their age, they will have coverage and they will have a good, solid insurance package. Second, if we do in fact rearrange the health care system, we are going to be able to save money. In fact, people won't see these premiums inexorably rising much faster than their incomes. Third, people are going to get better health care and have better choices. They'll have computerized health care records, so when they go to other doctors or facilities those records will follow them.

I think that combination of lower cost, guaranteed coverage, security for them and their kids and their parents, the fact that they have the sense that they are going to get the best coverage, that there's going to be information about what works and what doesn't, that they don't have to take the more expensive drug but that the cheaper drug will work -- I think that is going to be very powerful for people. Again, the fact that the economy's getting worse and not better makes the reform all the more important, both to give people security that if in fact they are one of the very unfortunate people who lose their job or their kids can't get jobs there will be coverage. and the security that if in fact, their company, God forbid, has to cut health insurance, they'll still be able to have insurance, and they won't face increasing costs. I think that is going to be a very powerful motivator in this debate.

I do think people have to look on this as something where they're going to win. Remember, whatever we do now is going to last generations. I think people don't fully appreciate the fact that it was more than 45 years ago now that we passed Medicare, in 1965. It's stayed with us. It's been a very important program. Whatever we do today, it's going to be around for 40, 50 years and it's going to impacts us, our kids, our grandchildren.

Silberner: I'm going to give each of you a present, a big one: this $634 billion that the president wants for health reform. Zeke, in your book you suggested a voucher program, where we would have a special VAT tax that would pay for people to have vouchers. There'd be quality controls and all the rest, but people would buy their own insurance. You've got the $634 billion. What are you going to do with it?

Emanuel: We're going to need more money at the start for this, and I think the president's--

Silberner: You want more already? [laughs]

Emanuel: The president's been quite clear: The $634 billion is a down payment. I think there are certain things everyone recognizes we have to do. We have to rearrange the insurance market in this country, create exchanges, or what in Massachusetts they're calling "connectors," where the insurance companies provide a standardized product, and people can go in there and shop. Then you have a large number of people so that the risk is standardized, and the insurance companies aren't cherry picking people. That has to be put in place. I think everyone agrees to it.

In his stimulus bill, the president enacted two other critical elements of health care reform: computerization and health information technology. In the next few years, we get all the medical records on a computerized system, and we have interconnectivity, so we can actually begin to have hospitals talk to each other, hospitals talk to doctors, pharmacies talk to doctor and then also collect the information so that, in fact, we can analyze what's happening, have early warnings about adverse drug events and know if too many people are taking a drug and there seems to be something going wrong with it. We can actually see very clearly patterns of care that are working and patterns of care that aren't working. So that was enacted in the stimulus package. Then there's this comparative effectiveness research to test and look at new technologies, and even existing technologies, to see which ones work better, so doctors and patients have information -- not just which works better or worse, but also what are the side effects in large populations, what are the tradeoffs that people have to make.

Those are very important elements, and then we have to have a proposal to get everyone into the system--

Silberner: You're not going to make your proposal?

Emanuel: My voucher plan? Look, I'm all for my voucher plan, but I don't think it's on the table now. It might come back if you have a deadlock, but I don't think it's there, and I'm a very practical guy. I'm working for the president. Unless it becomes his plan, that's not what I'm pushing at the moment.

I do think that health care reform is going to require an agreement. It's going to require compromise. And I do think that is going to be very, very important. From my perspective, my job is to prevent things that don't work, that are unsustainable from getting enacted, because I think that actually could be the most dangerous thing for us. You get only one shot at this now, at health care reform. It's been 15 years since our last effort. And I am very conscious that we could do this wrong in many, many ways, and I think, again, the word sustainability is important. The kind of reform we put into place has to be sustainable over the long term, and I'm very conscious that we need to structure it in a way that provides the right incentives to doctors and hospitals, to patients, to insurers, to the pharmaceutical industry, so that we really are getting high-quality care that's affordable to people.

Silberner: Ron, I'm giving you $634 billion.

Pollack: Well, I appreciate your generosity. [laughter] But, you know, the issue is not how I want to spend the money, or how Families USA wants to spend the money. We have got to find a way that makes good policy sense and that is politically practical. I'm not going to say, "Here's the Families USA proposal." We're going to support what the president puts on the table.

The thing I really want to underscore is something that Zeke has mentioned a few times, and that is if we use this investment wisely in order to try to bring down the cost growth curve, the real savings to the American public, in terms of what we're spending through government, what we're spending through businesses and what families are spending, is enormous. Zeke's colleague Peter Orszag, who is the head of the Office of Management and Budget--

Emanuel: He's my boss, not just my colleague. [laughter] And one of the smartest guys I've ever worked with.

Pollack: He said very thoughtfully something that I actually heard as a little boy. When I was a little boy, one of the heroes in investment was Bernard Baruch, and Bernard Baruch said, "The eighth wonder of the world is compound interest." [laughter]

Silberner: Andrew Carnegie said something about dividends from stocks, so there you go.

Pollack: Well, Peter Orszag's taken this to new heights. He said, "Look, if we bend the curve 1 percent, or 1.5 percent from what's projected, we are talking in the out years of saving trillions of dollars." Now, that is important for business, that's important for families, that's important for government, and so I want to take this investment to make sure we get everybody covered. We create greater efficiencies in the system so that we can have this downward glide from our current projections of what we're going to cost, because, while I want to see everyone covered and we'll work our heart out to achieve that, I want it to be sustainable. I don't want a Pyrrhic victory. And the only way we're going to win that victory is if we get the cost growth curve down, and that's ultimately what I want to see achieved.

Emanuel: I'd like emphasize again, playing off something Ron mentioned, that no one is talking about taking two, three, four hundred million dollars out of the health care system. What we need is to rearrange what we're spending. We know we're not spending it in the most efficient manner, and so the real issue is to take the money that we're spending and spend it much more efficiently. That will allow us to get everyone in. It'll allow us to change the delivery system to get better care at a lower price.

Let me give you a very concrete example that is in the president's budget that we proposed, which I think is a very important innovation. One of the things the president has proposed is what's called bundling of payments, to give hospitals a payment not just for when the patient is in the hospital, but also for 30 days after a patient gets discharged, so that the hospital has an incentive to think through not just the four or five days that the patient's there, but to think about how they are going to take care of the patient. And this is important for two reasons. First, it's important for better quality care. We know, for example, that if a patient discharged from the hospital with certain conditions sees a doctor within the first five days after discharge he or she is much less likely to go off the rails and to be readmitted to the hospital. That is not a trivial problem, because we also know that 18 percent of hospital admissions are readmissions within 30 days of a discharge from a previous hospitalization. When I was working in the emergency rooms, we used to have a very not-nice name for these people. They were called "frequent fliers." You saw them one day. You came back and worked six days later, and guess who was in your emergency room again? Someone you had just admitted and discharged from the hospital. That's not good care.

So, here is a situation where we can provide the hospitals with an incentive for managing the whole process, not just the hospitalization, but making sure that the patient gets good-quality care afterwards, whether it's a nurse visiting the house, a nurse calling on them, arranging for the doctor's appointment right after, making sure they go home with the medicine and are taking it properly. Those things are good for quality of care. They reduce cost by reducing hospital readmissions. Everyone is a winner there. That's part of the president's budget. We have lots and lots of those kinds of cases in the health care system, and, again, at the moment, the way we're paying doctors and the way we're paying hospitals don't provide incentives to take that more global approach to making sure patients stay well. We need more of that.

I would say another thing that we need more of is prevention. People talk about it. Prevention is not free. Of course there's prevention in the sense of better screening, better cancer screening tests, better vaccines. But there's also prevention outside of the medical field: better nutrition, better exercise. We need a bigger investment in that, and the president's stimulus package contained a billion dollars for that because of the recognition that if we continue on our current path, not just in terms of spending but also in terms of obesity, we are going to have a big, big problem in the future because obesity is associated with many, many illnesses, including diabetes, heart disease, cancer. That would be a deadly combination, if more people are getting very expensive chronic conditions.

We need to focus our health care thinking globally. If we do it, as Ron has pointed out, we can actually do what's called "bend the curve" -- reduce the rate of inflation from what it has been, which is 2 or 3 percent over underlying inflation in the medical field, so that instead of medicine taking more and more money every year, we'll have people taken care of, getting very good quality care in this country, but money left over to do other things in our country that we really value. And that, I think, is the place we have to aim toward.

Now, is it going to be easy? No. But is it doable? This is a great country, and I do think we can fashion a compromise where everyone gives up a little but everyone gains a lot through the reform of the system.

Silberner: I hope you're right, and I think that's a good point to end on. So let me tell you that that was Zeke Emanuel of the Office of Management and Budget and Ron Pollack of Families USA.

I'm Joanne Silberner, and I hope you enjoyed this conversation as much as I did. Thank you all.