 I just came from speaking to the California Medical Association. They were down at Disneyland. And we walked around Disneyland a little bit. I can tell you that talking about health system reform, it's not a small world. This is a very contentious, very conflict-ridden issue. It's divided the country in very many ways. And I'll talk a little bit about that in terms of our values. But this is from the AMA's perspective. This is the perspective of the American Medical Association. We think that we need to have access and coverage for all Americans. We think we do need to control costs. We need to improve quality. Absolutely no question about it. We want to seek medical care that's patient-centered, safe, effective, efficient, equitable, and timely. But when you look at American values, you look at the values of freedom, autonomy, choice, competition, and we're a capitalistic society. We do things on the market. And if you delve a little further, we also have the value about fairness and justice. And a lot of the debate is about how much do we give to the individual and how much do we divide up among the community? If we had a lot more time and perhaps we can discuss this on the panel, this is part of what the debate is all about. Well, the AMA took a position a couple of years ago, recognizing that we had, at that time, I think it was 42 million uninsured. Now it's up to 46 plus million uninsured. We consider this a national tragedy. People were living sicker and dying younger. Thousands are dying every year solely because they do not have health insurance coverage. We developed this program, The Voice for the Uninsured. We did it during the presidential primaries. We brought it out to all the primaries. We wanted to make sure that whoever was elected president that this would be the top domestic priority and we're pleased that it has been. So we have invested greatly in making sure that we would get this issue in the minds of the public. Now what are the AMA's criteria for health system reform? What are the things that are most important? This is based on a lot of policy that we have at the AMA, but they are simply that we want to make sure that we protect the patient-physician relationship, that decisions are made between the patient and their physician and not interfered with by the government or by health insurers. We want to make sure that everyone has affordable health care coverage. We want to make sure that there is promotion of quality prevention and wellness in this legislation. We want to repeal the Medicare payment system. Dr. Altman mentioned that a little bit. I'll talk about it a little bit more. This is a very flawed system. Each year we have to go back to Congress to make sure that physicians aren't cut in their payments. We're concerned that that will limit seniors' access to care and indeed a lot of primary care physicians are dropping or not taking new Medicare patients because they're concerns about the payment system. We want to make sure that medical liability concerns, defensive medicine is dealt with in some way in the legislation and that the administrative burdens that we as physicians go through every day in terms of trying to seek approval to get care for people and then trying to make sure that we actually get paid for it that that is eased in the legislation. So that at a very high level is what we're looking for. Now here's the curve. There's not much that's going down nowadays except the economy, but when you look at the curve you see that it's going up in terms of healthcare costs. We're at about $2 trillion a year. And what Dr. Altman mentioned about bending the curve, let me just mention that the president called some of the biggest healthcare sectors into the administration this year and said how can we get that increased rate of inflation down? How can we find some $2 trillion in savings? He did get assurances from all the parts of the healthcare sector to make that happen. Now that's not written into the legislation. We'll see if that actually occurs. We're gonna be meeting again with the president in May. But he has basically gotten a pledge from the big parts of the healthcare industry to try to get that inflation rate down, to try to bend that curve. And that's what Dr. Altman was talking about. Again, we spend a lot more money than other developed countries. There's no question about it. And there are concerns that in some areas we're doing a lot better than some other countries, but in a lot of other countries they're doing better than we are. No question that we have many very good things about our healthcare system, but there's also no question that we can do better. Now a little bit about the Medicare dilemma that I mentioned. If you look at the bottom curve, if Congress doesn't fix the Medicare payment formula every year, then that's where the physician payments are down on that bottom curve. And physician practice costs are in the top curve. So most physicians are in small practices. Even though there are some large group practices, about two thirds of physicians are in small practices, they're trying to run a business and keep a practice going, pay their staff. And if the money they're getting from Medicare is going down like that and their practice costs are going up, that's why we have this dilemma with Medicare payment. Everyone in Congress agrees with that. And then if you look at the total Medicare spending, if things keep going the way they are, it's just gonna go off the chart. Medicare is gonna go bankrupt. So clearly it's an unsustainable situation. And so we agree with Congress, we agree with the President, that the status quo in terms of the cost and what we're doing is really unacceptable. We do need to make things different. Now one interesting recent survey that was done by the Sherlock Company, they were trying to compare administrative costs in Medicare and the private plans. And there's been a great deal of discussion about how perhaps Medicare has less administrative costs. So this is a study that was done of about 36 Blue Cross and Blue Shield plans. And what they're thinking was that a lot of the data that had been comparing administrative costs before was from very old data. And if you look at the costs here, it looks like the Medicare costs are about 13 plus percent and the private plan costs are about 12 and a half percent. So I think we need to dig a little bit deeper into this to see whether this goes across states and across different health plans. But it is an issue of debate about on the Medicare side, whether the administrative costs are really significantly less or actually they're more than the private plans. Now what about the public plan? Now nobody knows what the public plan is or what the public option is. And the AMA doesn't have any policy on public option because we don't know what it is. But what we do think is if there is gonna be a public option and we are open to listening about what a public option will be. We haven't signed on to it but we are open to listening about it. We think if there is one that physicians should be able to participate in a voluntary way. We think that patients should have a choice, not be forced into one particular plan. We think that the public plan should be subject to the same set of regulations that private plans are. So we think there should be competition in the market if they're in the market. And we think that the public plan ought to be self-sustaining. It shouldn't be a constant drain on the treasury so that if it gets up and running it should keep going. And we think that the premium should be set by the market and that they should not be linked to Medicare rates. Now again, we don't know what the public option is gonna be. And early in the summer, the AMA did support and issued it support for House Bill 3200 which included a public option but we were pretty sure that it was gonna change and we weren't sure how it was gonna come out. We have gotten support for taking that position. We've also gotten castigated for that position. So we've gotten it from all sides from our physician community and there is division among the physician community. But we wanted to make sure that we would keep that process going. We wanted to make sure that something would go through the house because we wanna make sure that health reform legislation gets passed this year. On the other side of this, the other side of the public plan and the whole issue of competition, this chart basically, the bluer it is means that that's how concentrated that particular state is in terms of the health plans in that state. So if it's really dark blue, that means that there are only a couple of insurers in the states that are dark blue. So what we've seen over the course of the last couple of decades is that every state has two or three insurers which basically dominate the market. And from our point of view, that also reduces competition. And from the physician point of view, since we're unable to join together because of antitrust laws that puts physicians in a very difficult position in terms of trying to negotiate with the insurers. Okay, so what are the AMAs goals for legislation? What will we like to see out of the legislation? We wanna make sure again that Americans are provided with high quality, affordable health insurance. We wanna make sure that they reflect the needs of America's patients and physicians. We wanna have a permanent fix to the Medicare payment formula. We want there to be a push for liability reform. We want it to support primary care, prevention, wellness and health IT. And we wanna make sure it's financially sound so that whatever is passed, we wanna make sure that there's not an expectation for the American public that something's gonna be delivered but there's not enough money in the system to actually make it occur. Well, the president came, he was the second president, the address, the House of Delegates, the AMA, he came in June, it was a wonderful experience. He told us that he recognized that liability issues and the cost of defensive medicine was a significant concern and needed to be addressed. He also told us he was not in favor of caps on non-economic damages, but he did say that he would help us in terms of trying to move the issue of liability reform defensive medicine forward. So what he did was he authorized HHS to provide $25 million in grants to states to do pilot projects on health courts, early offers, other things basically on the lines of trying to improve patient safety because I think what we're all about, what we've seen is that the medical liability system doesn't improve patient safety one bit, doesn't do anything for it. So we think we are committed to trying to have patient safety. He's providing these grants to try to make patient safety a priority and we thank the president for doing that. Okay, Dr. Altman talked a little bit about where things are at in Congress right now. You've got the bill that came out of the Senate Finance Committee this last week. It creates a national insurance exchange. It has an individual mandate to buy insurance, subsidies for low-income people, no denials for pre-existing conditions, in caps on payment for conditions. It does not repeal the Medicare physician payment formula that I talked with you about and it only fixes it for one year. I'll talk a little bit more about that later. We are working with the senators to try to fix the Medicare payment system. The House bill, there was the tri-committee version, that was HR3200, which we supported. They're still in front of the Energy and Commerce Committee, 50 or 60 amendments and I have no idea what they are, but there's lots of amendments. They are pending, they may go as a separate bill. The leadership of the House, the Rules Committee are all gonna negotiate to bring a bill to the full House for debate. It will probably occur after the Senate finishes its work. I think they'll wait later in the month. And there will be a separate vote on a single payer system in the House. And then after the House finishes its work, it'll go to Conference Committee with the Senate. On the Senate side, the Help Committee in the Senate has already finished its work. It also has 180 amendments. I certainly don't know what those are, but we'll see what happens with those. The Finance Committee has acted on its bill. They'll meld those two bills in some way and get that then to the Senate floor for a vote. And then go to Conference Committee. Well, breaking news is that Senator Debbie Stabenow this last week announced the introduction of Senate Bill 1776. This is a bill to fix the Medicare payment formula that I told you about. It would wipe out all the previous debt, get us back to ground zero, get rid of that, that terrific grill on our back in terms of the Medicare payment formula. And there are actually gonna be, I know this is a scholarly panel here, but I've gotta tell you, if you wanna do something that's gonna help physicians and help seniors, get on the phone and call your senators, tell them to support 1776. I don't think either of your senators currently is on board with this. This would repeal the Medicare payment formula. It would get this off the table and let us have a reasonable payment to physicians so that we don't have to worry every year about seniors' access to care. So there's lots of ways to call your senators. There's actually gonna be a vote probably tomorrow. It takes 60 votes to get this through the Senate. There'll be a couple of more votes. On the House side, they've already, in the House bill, it already repeals that Medicare formula. So if we got it out of the Senate and we got it out of the House, we are hopefully gonna be successful with that. Okay, so it's a very complicated, it's very complicated to get a bill to the president. You've got the three committees in the House. They've gotta go to the House floor. You've got the committees in the Senate, the Senate floor, Conference Committee, and then finally to the president. So it is a very difficult and convoluted process. Certainly not pure by any means and it is sausage-making at its best, but it is moving along at this time. Okay, so what do I think is gonna happen? The Congress is gonna shift the dials on how many they wanna cover. And as Dr. Altman mentioned, it's not covering everyone, so they're gonna dial that. How much is it gonna cost? How much is the individual mandate gonna be? All those dials will be adjusted. And to try to get to something that will actually pass both the House and the Senate. The key insurance reforms require universal coverage. And you saw this last week, there was pushback from the health plans because their original idea was that everyone would be in the risk pool and now it's not gonna be everyone, so they're saying it's gonna be more costly. We'll see what happens with that. There might be adjustments there also. Perhaps there'll be some different kind of a phase in approach than what they have now. But all those dials will be adjusted as things go forward in the Congress. Now, a couple of big gorillas in the room that I really, we're not talking about, but if, oh, I've got one minute. Okay, then I can talk really quick. 50%, about 50% of our healthcare expenditures of the $2 trillion are in health behaviors that are preventable. Obesity, tobacco, alcohol, sexually transmitted diseases, violence, and so on. So we have to make sure that when you talk about healthcare costs, we've gotta take care of that. I think everyone agrees with that. That's something we need to work on. The other thing about primary care physicians and the house bill, there are incentives for primary care physicians, that's good. We've got a lot more specialists in primary care physicians. Clearly, we have to do more for primary care. Different ways of paying, as Dr. Altman mentioned, we're looking at accountable care organizations. We have to pay physicians and health systems in a different way. We absolutely agree about comparative effectiveness. We are supportive of comparative effectiveness. Final thoughts, we think the bill's gonna get written. We think it's gonna be signed by the president. We are supportive of a bill getting written this year. We want health system reform to get passed this year. There have been health system reform efforts over the last 70 years, all of which have been virtually unsuccessful. So we wanna get things done this year. We don't think it's time to wait for a perfect bill. This is not a perfect bill. It's not gonna satisfy everyone, but we wanna make sure that health system reform gets passed this year. Thank you very much.