 Good afternoon. We'd like to get started. I'm Jim House. I'm a faculty member here in the Ford School and in the Department of Sociology and a member of the research faculty and the Survey Research Center at the Institute for Social Research and the Department of Epidemiology in the School of Public Health. On behalf of the Ford School and our co-sponsors of this event, the School of Public Health and the U of M Systems Forum on Health Policy, it's my pleasure to welcome you to this panel on health care reform, which is made possible by support from the Martha A. Darling and Gilbert S. Oman Health Policy Fund here at the Ford School. I'm delighted to have Martha and Gil here with us. As I really don't have to tell you, this panel could not be more timely and we certainly didn't know that at the time that we planned it as the Congress has now passed out of committee, as you know, five health care reform bills and are poised to begin debating and reconciling these bills into one that may emerge for signing by President Obama within the end of the year timeframe that he has urged. On the other hand, as he said the other day, a great deal remains to happen if that's to be the case. We're extremely fortunate and indebted to have with us today five experts in the area of health care and health insurance reform who span the fields of public policy, medicine, sociology, political science, economics and public health. First, Matthew Davis is another faculty member in the Ford School here and also on the faculty of the U of M Medical School is gonna provide a brief introduction to the history of health care reform over the last century and over the last year. Then we've asked each of our invited panelists to speak for up to 10 minutes focusing in a manner that capitalizes on their own unique perspectives and expertise on two issues. What are the most important things that we need in health care reform and why getting to any kind of health care reform has been and continues to be so difficult in this country and what they see as the prospects for this round of reform efforts. Your program describes the exceptional qualifications and accomplishments of the individuals and in the interest of time I'm not going to reiterate those but I would like to close with just a personal observation on I think some of the special attributes that each of them brings to the conversation today and to the our understanding of the challenges and promise both of health care reform. Matthew Davis is one of the few, relatively few individuals who has trained both in medicine and in public policy and has especially informed both professional and public policy making regarding children's health and health care. David Mechanic is for me and my sociological colleagues. The really thought of as the dean of the sociology of health and health care having over half a century authored the books and the articles that have largely defined the field and mentored most of its leading members. John Kingdon who's a former faculty member in the Department of Political Science here is the author of a landmark volume on how major policy reforms come to pass. One that has been very compelling to me as I know too many others in understanding public policy regarding health and health care. Katherine McLaughlin has been a national leader in understanding health insurance reform. Uniquely and courageously from my perspective illuminating what such reform can and cannot do in terms of improving both health and health care. And finally, Marian Udo brings the unique perspective of having helped top leadership positions in both the private and public insurance, health insurance systems and an ability to communicate compellingly with policy makers, students and lay people on these issues as I've observed personally when she visited my class in public policy last year. So without further ado, I'm gonna turn things over to Matt and then ask each of the panelists to follow him in the order of Dr. Mechanic, Dr. Kingdon, Dr. McLaughlin and Dr. Udo. Thank you, Jim. It's a pleasure to see all of you here today. Thanks for making it through the drizzle. And it's a great pleasure to see so many friends, colleagues of current and former and future students hopefully as well. It is a great pleasure for me today to be the setup man or as we say in academics to contextualize the discussion. It is because of the ambitious agenda of this gentleman, our president, Barack Obama, that we are having this discussion today. Although there's obviously been a lot of momentum building towards health care reform in the US over the last several years, nothing this major as what we are contemplating today has been contemplated until he set out to really push the debate as did his primary opponent, Hillary Rodham Clinton during the Democratic presidential primaries. He has continued that campaign promise during his initial year here in office and we are witnessing what is going to be a tremendous debate in Congress about the shape of health care reform. But I wanna emphasize that all that you're seeing in the newspapers now is not actually all that new. It has a tremendously strong system of roots in health care reform efforts in the US over the last 100 years or so and perhaps on even a broader stage than that. As President Obama thinks about health care reform, we can often think about his priorities focusing on coverage and costs. And when people have been talking about health care reform in the US and its history, a lot of folks over the past few weeks and months have taken us back to the time of Teddy Roosevelt who rightly deserves credit as being the first sitting president to talk about and even utter the words socialized medicine. In fact, what Teddy was thinking about here is that universal health care will cost this much. When President Obama holds out, actually President Obama never holds out his hands knowing how much it will cost, so that's fine. But I think actually the origins of the health care debate in the US go back before Teddy Roosevelt. In fact, two different shores to Europe. And these two thinkers, activists in their own way, of course on the left, Karl Marx and on the right, Otto von Bismarck. Why Karl Marx? Because like Barack Obama, Karl Marx was interested in coverage for workers, right? Coverage was his main interest. Now, not just health coverage, we're talking about protection in general for workers about a lot of things, but health care was one of them. Von Bismarck said, I don't think so. I don't think you're gonna be able to have worker protection just around health care. I want that for me, for my government. I want the citizens of our nation to have alliance with me because I provide their health care. So he was thinking, this would be a tremendous political win for him if he offered the first universal government-sponsored health insurance. The issue here was, would it be the only one? And in fact, we know now it was not the only one. It wasn't even close to the only one. It was followed again and again and again and again by countries that saw the benefit of covering their workers' health care costs. It became a European thing, even then a hundred years ago, even more than a hundred years ago. The question for America was, was it actually an un-American thing? And back in the 1910s, we were already arguing about socialized medicine in the US and how we weren't gonna have it here. Flash forward now. I'm skipping a bit of the story, forgive me because we're short on time. Up to Terry Truman after World War II, who uttered the words, we can afford to spend more on health. And in fact, he talked then about universal health care as well. But for reasons of politics, chiefly, failed to achieve his goal. 20 years later, we saw here a signing ceremony in Independence, Missouri. Why Independence, Missouri? Because there on your right is Terry Truman and Bess Truman. And on the left, obviously, is Lennon Baines Johnson and Lady Bird Johnson. And here, President Johnson was saying, well, we are gonna spend more on health. We're just authorizing Medicare and Medicaid. That was 1965. A time when a little boy was just three and a half years old. Not thinking so much about his health care or about his presidential goals, but about where he was gonna hit the ball next. Flash forward to the 1990s, the time of the last major effort to reform health care. We know what happened here. President Clinton, candidate Clinton, saw the opportunity to expand health care coverage. And Hillary Rodham Clinton put in charge of the health care commission, talked about how we could call this invention the health security card, an obvious echo of the positive sense of security with social security. But this didn't work either. Many authors have written about the failures of the Clinton health care reform. So that brings us to the question of, well, can something major, something as major as Medicare and Medicaid actually come to be in the U.S.? Ever the pragmatist, President Obama, told us, this isn't gonna be pre. It's gonna be difficult. He was right. Maybe even he didn't know how difficult. This is an extraordinary battle, not only in the halls of Congress, but as we saw down here, this is actually a photo from Canton, Michigan, from a health care town hall held by Representative John Dingle, where tempers have raised, flown. What is the metaphor? Things were flying, thank you. And what we've seen is a Congress that has many different ideas about how to pass health reform. And not one of them is exactly what President Barack Obama would like to see passed. Meanwhile, as we see on the far right at the bottom, we have an increasing number of uninsured Americans over the past 10 to 15 years. Even though there might be a little bit up and down, the general trend is in the wrong direction. And we have major interest groups, politicians who are playing roles, we didn't necessarily expect them to play. And we're about to hear from our illustrious panel what they might make of all this opportunity and challenge. So with that introduction, I'll move things on now to Professor David McCannick. It's a great pleasure to be back in Michigan and see so many old friends. I used to come around a lot when I was Wisconsin for those 19 years, but I haven't been around much lately, but I see you're prospering in many ways. I'm gonna go fast and cover a lot of things you probably know, but perhaps say some things you don't know. Now, unlike Europe, I've been involved in policy discussions in Europe on many occasions. Our culture isn't very strong on social solidarity. You can't engage in a discussion in Europe before people are talking quite explicitly about the need to maintain social solidarity, get old people involved, and so on. We don't usually talk that way. And any acquaintances just been pointed out with the history of health reform efforts over the past 50, 100 years would make clear that significant health reform would be difficult and contentious, and given our culture and politics, it's clearly so. It might surprise some to know that the proposals we're discussing now are not very leftish. In fact, they're very much like the proposals of President Nixon in the early 1970s that with some degree defeated by the liberal left who felt it was not enough and we should wait for something better. Our system, as I think you all know, provides poor value for expenditure. It's very wasteful, and in many ways dysfunctional. And we provide incentives for doing more rather than doing well. There are many features that need correction. I can go through these. You can see these. You can probably know about most of them. There are many features that need correction and access and quality and delivery and regulatory systems that affect healthcare and certainly in controlling costs. Now if we were starting from the very beginning, we might adopt a national health insurance system like Germany or France or a single payer system like Canada or a modernized form of Medicare. And indeed, as you know, President Obama said as much that he's a long supporter for a single payer and he said if we were starting in you, that's the way we'd go, but he didn't see it as viable under current circumstances. But with healthcare now approaching 18% of our economy, there are too many powerful interests that have a large stake in the outcomes. I think most insiders that I wouldn't talk to are pretty convinced that we're going to pass something. But there are clearly going to be many compromises and we're going to get a lot less than we I think hope for. Healthcare reform typically doesn't occur anywhere without paying off the powerful interests that have a great ability to stop things. And indeed, we are seeing some of that which may indeed be necessary, but perhaps not desirable. If you remember when the National Health Service in England began in 1948, when they were fighting over the political, when the political battle was taking place, the doctors were posing it vigorously. And then Bevin, who was the Minister of Health made a deal and he later said, I stuffed their mouths with gold. And that was his explanation of how he got the consultants in England to go along with health reform at the time. Much of medical care in the US is driven by monetary incentives and profit. Much of what pays well has uncertain or little value, but it does pay well. And when people are paid well, they do what they're paid well to do. And there's a great deal of value that is not executed because financial incentives are weak and there's little incentive for individuals to engage in those behaviors. But as you all know, the politics of payment are extremely difficult. And you also know from the quality studies by Rand and others that approximately 50% of effective care is never delivered and much of that care is on the left side of this chart that is cost-effective, it's worthwhile and yet it's not delivered, particularly things like immunization because there's very little incentive for providers to do that. On the other hand, total body scans are very immunative or CAT scans for cancer screening, which things that have no known value, they may possibly have value sometime in the future, but at this time there's no evidence to support their use. And yet they're done because they're highly immunative to the organizations and practitioners who do that. Now we've known for more than 30 years about vast differences in expenditures in small geographic areas and comparable systems of care. We now know that high spending areas do not provide higher quality care and indeed there may be somewhat higher mortality in some of the higher spending areas. Some health systems we all know perform admirably. And the usual examples, Mayo, Cleveland Clinic, Kaiser Permanente, Geissinger Clinic, their Marshfield Clinic, but there is a lot of very simplistic thinking that we can have huge savings simply by getting everybody else to behave the way these clinics behave and bringing the rest of the system down to the level of expenditures of these outstanding systems, which tend to be relatively low expenditure systems. But it's important to also understand that that's wishful thinking in that these systems developed over long periods of time, in some cases 40, 50 years. They've had long histories of development and high quality leadership. And in order to achieve the kinds of things these systems have achieved requires rebuilding culture and developing new professional norms and changing many people's behavior. And that is a very long-term and difficult task in some areas of this country, probably an impossible task in any kind of foreseeable future. So while it is true that you can provide the highest quality of care at much lower cost, it is not necessarily true that you can bring the systems that are high-cost, down to low-cost without destroying the quality that they are providing. And you can see here the tremendous disparities in expenditures among systems of comparably high quality, Mayo and Cleveland Clinic on the one hand and places like Hopkins and UCLA Medical Center on the other hand, all very, very high-quality places with fantastically different rates of use of resources and expenditures. Now on an abstract level, there's considerable agreement about the need for greater access and insurance coverage, elimination of exclusions of preexisting conditions, reducing cherry picking and risk selection on the part of health plans, and protecting people as they move from one job to another or lose their employment so that they don't lose their health insurance. So while there's a lot of agreement at the abstract level the devil is in the details and who's paying and who's losing. The evidence from many, many surveys is the majority of the public strongly support health reform and continue to support health reform according to the later polls. A majority of the public support the public option, but there's also evidence that a growing number of the public as they listen to the debate are becoming increasingly uncertain about how they're gonna do as a consequence, whether they're gonna be better off. And more and more people are reporting that they think they're not gonna be better off. And as we know from past experience, when anxieties rise, support tends to revert to the status quo. Everyone wants change, but if they're gonna be hurt, they would rather just leave things as they are. And that's one of the challenges we face as this debate goes forward. Now, as you know, we have two Senate bills and three House bills, and they have many common features. But as you also know, in the background is the whole issue of our federal deficit and the concern about reducing the growth of healthcare costs. And that is a very big set of issues. As you can see, there's a lot of agreement in these bills on the individual mandate, on premium subsidies, and extension of Medicaid, and so on, but how that all works out as the debate goes forward really depends on the specifics and the interests of the people who are involved. As you know, the health insurance industry, which was very supportive of health reform, is now backing off and advertising against health reform. So the interests are really gonna be very active in the next couple of months. Now, as we go forward in the next couple of months, there are gonna be many contested areas. As you can see, I'm sorry that I missed that one. No, but that's not the one I wanted. There are many contested areas. Four of the bills have an employer mandate. One has a little employer responsibility if their employers are getting subsidized. Everyone wants to eliminate risk rating and pre-existing conditions, but the insurance company says that unless we insure more people, it's not viable for them and they're opposing it because of the weakening in the backest bill of what they see as the personal mandate. They're tremendous support for expansions of Medicaid, but the governors of the states are upset because of the financial burden that puts on them and dealing with their difficult budgets. There's a lot of opposition from the interests about payment constraints. The private plans are very unhappy about having the public plan competing, and it looks like it's unlikely we're going to have a strong public plan. Everyone believes in cost-effectiveness research as long as it doesn't have any cloud, as long as it doesn't affect decisions about benefit design and what will be available. And obviously, if they're gonna be serious, we have to use that information reductively in deciding about benefit format and what things are covered and so on. You all know about the fight over the reimbursement for the end of life counseling under Medicare. That original idea came from Republican, and then when it was adopted, it became a source of great acrimony as it got misrepresented for the public. Abortion is still an issue that hasn't gone away. It will continue to plague us in this debate, and of course, illegal immigrants seem to be completely out. Let me just go back. I would say that there are many elements that are now being talked about as being important elements in terms of bending the curve or cost constraints, including the implementation of IT, using the insurance exchange to reduce administrative costs and proof of disease management, medical homes, and so on. Unfortunately, the evidence for all of these things is relatively weak, and it's quite unlikely that these things by themselves without much tougher constraints coming through regulation are going to really seriously bring down the growth of course of medical care. Now we're going to face some very difficult choices on financing and cost control, and one of the problems is that no one is willing to openly discuss the more foolproof ways of bending the curve. A lot of these things that I talked about, people are saying, well, bend the curve, but the evidence, as I said, is very weak. One way of clearly bending the curve is to have a national limit on annual expenditure growth. It's difficult administratively to implement, but it can be done. It's been done. Another way to bend the curve is seriously using cost-effectiveness analysis for benefit design and payment through a super med pack or another agency which we've developed, which would be something like Nice in England. But in fact, it's unlikely that we're going to get these very strong kinds of controls initially. Now, as I said, Democrats have no real alternative to passing the health reform bill, however compromised it's going to be. I'm most insiders, and I'm not a political scientist, but I'm most insiders who are close to the Congress tell me that the Obama administration to really survive has to pass something, has to fulfill it to some degree on its promise, and so the prediction is that Democrats will come together and pass something. But in all likelihood, the extension of insurance will be the basis of further extensions in facing the really tougher issues when there's no other alternative but to face them. So in my view, this is only the first iteration of a very long process. I can't believe that Obama was serious when he said a couple of weeks ago that he would be the last president who would have to deal with health reform. It's going to be choked throughout our lives. Thank you. I guess I want to spend just a couple of minutes on this issue about why is it so difficult to get fundamental health care reform and then I want to talk about why I think something's going to happen this year. I have thought so for a year or so now. Why is it so difficult to get fundamental health care reform? And I think there are four things that I want to mention. One is it's a very complicated issue. It's complexity. This healthcare system has a lot of moving parts and you're trying to reform a sixth of the American economy. And so it's just inherently difficult just from the point of view of complexity. The second reason is the way that we set up our institutions. Our constitution set up a governmental system that is designed to gridlock. It's designed not to work. That's the whole idea. That's what separation of powers and checks and balances and federal system. That's what it's all about. And so it's hard to move these institutions around. They were set up in order so that you couldn't mobilize them. That was the whole idea. There's no better example of that than the United States Senate. Here you have equal representation of states with regard to the population. You have the filibuster and holds set up to make it possible for 100 egomaniacs to get gridlocked. Someone did a calculation of what percentage of the population was represented by the gang of six on the finance committee. It's 2.77% of the population represented by those states. And so the Senate in particular is really hard to deal with. The third thing is that you have a fierce interest group environment. There are insurance companies. There's pharma. There's docs. There's the hospitals. Consumers, labor unions, small businessmen. There are lots of veto points. There are lots of people who have an interest in not wanting to do something. And the fourth thing is what I might call the American political culture. Some of you may know I've written, my last book was called America the Unusual. Why the US is different from other industrialized countries? And one of the answers is that compared to other industrialized countries, Americans just have a different political culture. We trust government less. We want limited government more. We prefer lower taxes. It's no wonder we don't have national health insurance when that's the way that a lot of Americans think. I don't mean that as an absolute statement about American political culture. I just mean that as a statement of America compared to other industrialized countries. So in the face of all of that, why have I thought for more than a year that there's something major going to happen? And I think an answer to that comes in comparing this iteration to the last big push during the Clinton administration. And some of you may know that in the second edition of my book on agendas, I wrote a little case study of the Clinton experience. And so it's instructive for us to think about how things are different now from the way they were then. The first major thing is the problems were bad then, but they're much worse now. And particularly with regard to healthcare costs. The federal government's long-term fiscal picture is really bleak. And most of it is driven by entitlements. And most of that is driven by healthcare, particularly Medicare and Medicaid. And now the social security part of the entitlement thing is pretty easy to solve actually. Alice Rivlin and I just wrote a little piece that argues that a little tinkering here and there can do it. And we should just get it done and get it out of the way. Medicare and Medicaid are really a lot more formidable. And so budgeteers, I don't mean necessarily health policy people, budgeteers are desperate to reduce costs. And I think that's one of the major things that's driving the federal government's interest in healthcare reform right now. For instance, I've heard Peter Orszag and Kent Conrad both talk about the Dartmouth studies. That talked about inefficiencies in the healthcare system. They're profoundly affected by them. They know studies like that. They cite them. They illustrate it with this comparison between the Mayo Clinic and the UCLA Medical Center. And the idea is that if we could just bring $700 billion of inefficiency out of the system each year, we would go a long way to solving our cost problem. That would save a lot of money. And that's one of the major things that's driving the interests of people like Orszag and Conrad. Not so much health policy people, but budgeteers. Still sticking with costs. The recession I think has highlighted problems with the employer-based system. Now if you are laid off, as a lot of people have been, you lose your insurance. And the other things happen even if you're keeping your insurance, your premiums and your deductibles and your copays are going up. So the cost to individuals are going up and the cost to companies are going up. Particularly, a lot of large companies who are exporters have gotten to be quite interested in health care reform because they're carrying the cost of health insurance for their employees and their retirees and their competitors in a global marketplace are not. So labor unions have always carried the water for national health insurance, but now the companies are interested in it too. So the major interests, and this is quite different from the Clinton experience, they're all at the table. Now part of it, part of the reason for that is that the Obama administration is set about to buy them all off. That's the idea is that in return for more customers, which an individual mandate gives you, we're gonna take, you're gonna get more money by that. So we want to have you make a contribution in cost, but the current system is pinching them all. And that was not true before. It used to be somebody would prefer the status quo to change. And I think in general that is not true now. The second major difference between now and the Clinton administration experience is that I think there's more consensus than there was then on the major policy approaches. In 1993, there was no consensus in the policy community and the proposals for change were all over the place. There was Single Pair, there was the Jackson Hole Group, there was the Hillary Clinton Task Force and so on. This year, the major advocates have coalesced ahead of time, ahead of time, around some basic principles. An individual mandate with subsidies for low income people, that was not much discussed in 1993 and now it's a keystone of all of these and we have the Massachusetts experience as well. There's agreement on creating these exchanges and a reliance on competition among insurers and third, there's an agreement on trying to bring inefficiencies out of the system through electronic medical records, best practices compared to effectiveness, coordination of care and so on. We don't know how to do all of these things, particularly how to go from where we are to where we will be or we want to be. In particular, we know how to change the incentives for providers. If providers were on salaries or if they were being reimbursed by capitation, then we wouldn't have nearly the cost problem that we have with fee for service, but we don't know how to get from one to the other. Now there are a lot of remaining disagreements. One of them is over the public option. I think one plausible scenario is that the Senate is gonna pass roughly the campaign, the finance committee bill, the House will pass a bill that includes a public option and the conference bill will agree on Olympia Snow's trigger and that would be kind of a compromise. There's also a compromise about the tax on Cadillac plans which is perfectly, that's perfectly bargainable. The Senate can give up doing so much with Cadillac plans. The House can give up doing so much with the search tax on rich people and so on. The third thing that's really different is that the Obama strategy is very different from the Clinton strategy. The Obama relies on Congress for the drafting and they have a stake in the outcome because they're drafting it. The Hillary Clinton task force was then in secret. It took more than a year. The window was closing before it ever was unveiled and then when it was unveiled it was an approach that had not been softened up ahead of time like the individual mandate thing has. It was complicated, untried, unfamiliar. As far as I can tell it kind of sprang from the brain of Iver magazineer. And so it was dead on arrival. George Mitchell and Jay Rockefeller tried to pick up the pieces but it was too late. Now Obama has made it possible for senators and representatives to have a stake. They have a stake in getting it done. And the fourth thing is I must say a rebound from the Bush years. There's a lot of pent-up demand in a lot of areas. It's not just health insurance school but climate change in a lot of places. Someone said, I didn't know they gave a Nobel Peace Prize for not being George W. Bush. But I think there's a lot to the notion that there's kind of a rebound from the Bush years and that's working in favor of reform. So I think all of these things are making it more possible. Now if I can just say one more thing. If you look over the long term, I'm talking about several years out now, not just what's gonna happen this year. I think something major is gonna happen this year along the lines that I've described. The federal budget will still be have a very frightening problem with long-term debt. It's really in frightening shape and most of it, as I said, is due to healthcare in one way or another. We can try to bring inefficiencies out of the healthcare system through a lot of the things I've described but as David McCann had just said, it's unlikely that that's gonna produce a lot. It'll be useful but it won't produce a lot. But there's still gonna be a lot of national debt there and it's gonna be due to health and it's gonna be unsustainable. So I think that as much as we wanna reduce costs through all of the things that everyone's talking about, we're still gonna need revenue. And that has led me for some couple years now to say, I think we're gonna need a new taxation. And I think that the way to do this is for the Congress, it's gonna take a leadership, it's not gonna be politically easy to do, but I think the thing to do is to establish a new healthcare trust fund that would fold Medicare, Medicaid and whatever new we do into it. Finance it through a nationwide value added tax. And I think effective leaders could sell that. The question is whether politicians will step up to the plate. But that's quite a few years off. That's the last slide. Boy, what a retrospective. Amazing. Well, David, thank you very much for providing such a big overview of all the different pieces. And so I will try to reduce redundancy as much as possible in what I talk about. Given that for at least the last decade or more I've been studying the uninsured, it shouldn't come as a surprise that that's gonna be my focus is to look at that. As has been pointed out, the number of uninsured and underinsured, it's very high in rising. And it's in part because of this that I agree with you that something will happen. Not only is the number of uninsured rising the composition of the uninsured is changing. It's very different now than it was 20 years ago. As we know here in Michigan, the unemployment rate is rising and rising and rising. And it has been estimated that for every one percentage point increased in the unemployed, about 400,000 adults become uninsured. And about 600,000 children become uninsured. The thing that most people don't think about however is not only has the number of unemployed been rising but the spell, the average spell of being unemployed has increased. And the longest spell of being unemployed is for men between 45 and 64. And do I need to say more? I'm an economist, not a political scientist, but let's face it, that group is gonna be more vocal and say, we need to have some coverage and we need to have some change. So the type of people who are becoming unemployed and uninsured, the length of time that they're unemployed uninsured is increasing. 45 to 64 year old men, very high risk time for a lot of medical care problems, they wanna have insurance. And I think that is gonna make a change. In addition, we have an increase in the number of people underinsured. We have increases, not only in the percent of the premium that people are paying directly, but we have increases in the size of the deductibles, the size of the co-payments and co-insurance rates. So many people are facing like a $5,000 deductible. If you're a family earning $35,000 a year, that quickly becomes an issue for you and a concern. And so again, we have more pressure points, more people are included. I think President Obama was very clever in his address to Congress when he recast this as stability and security. He said, this is stability and security and you may feel very secure right now in your health insurance coverage, but we are seeing day by day by day, more and more people losing their job, losing their health insurance coverage or suffering decreases in the richness of their coverage. Another thing that we know painfully well here in Michigan is more and more large firms are dropping retiree health benefits. So you have another constituency who's saying, we need help, we need to have some kind of help, we need some kind of reform. And I think that will put on much pressure. Just a brief comment that I think a lot of people feel as though the uninsured tend to be low income people who are sick. And so if we give them coverage, it's gonna cost us a fortune. However, there are a lot of people who are not low income and there are a lot of people who are very sick, including many of the people in this room who are known in the insurance industry as the young invincibles. There are a lot of people between 18 and 19 and 24 years old who are uninsured and feel no need to get insurance because they never get sick. Now that's part of where the individual mandate comes in. If we force them to contribute a modest amount towards health insurance, even though they don't see a need for it now, that will lower the cost by spreading it over more people. And that's one of the reasons why the insurance industry and others are fighting so hard this time to have an individual mandate. When in 1993 it was the M word, mandate. Oh, that's not American. We don't force people to do something. I think people understanding now more about the realities of spreading risk and spreading burden, that's become something that many more people are in support of and they are coalescing around. The other thing that's important though when you're talking about a mandate is coverage for what. And it would be very easy. I heard someone say recently, oh well, you can mandate that everyone get insurance with a $10,000 deductible that only covers outpatient care and we could claim universal coverage. But I don't think any of us would be really happy with that solution. And one of the things that is different this time as well is that they're not going into the nitty gritty details in these bills that they did in the Clinton administration of defining this service is in, that service is out. This will be included, this one won't. They're trying to get agreement about the principle of individual mandate and coverage and making sure that it doesn't go beyond a certain percent of a person's income. And then leaving the details really to the bureaucrats, the administrators to figure out what precisely would these packages look like. So, I'm an economist, I have to do this. We look at, I'm not a sociologist or political scientist, we've heard from them, classic economic tools, what should reform do? Well, the classic change, the supply of health insurance, change of the demand for health insurance. And then the policy approaches incentivize, my mother used to be an English teacher shutters whenever she hears that, incentivize the market or government regulation. And obviously there are political concerns on both of those. So on the supply side, and what's interesting is these slides that I'm showing you are just a modest modification of slides that I use teaching health economics and school public health over 10 years ago. And so, you're gonna be really amazed when you see how closely these fit into the bills that are being discussed. And it was the issue that David and John Boas said, these aren't new ideas, it's the same old ideas we've always had, they're being cast differently and it's a different situation. So allow small businesses to form large pools, expand high risk, offer health insurance independent of employment. And a public option is one way to do this, expanding Medicare and Medicaid, or letting people buy into what our members of Congress get this and so we all should do. There are a lot of ways to change the situation so that it doesn't matter if you work for a small business or a large business, it doesn't matter if you're an entrepreneur and self-employed, that you should be able to get affordable health insurance. And then changing what the health industry does, get rid of the underwriting, the pre-existing condition exclusions, non-insuring certain people and put in premium caps. On the demand side, there's a series of voluntary efforts. They fall into two broad categories. One is to reduce the premium by reducing healthcare costs and that would reduce the premium for everybody. The other is to directly reduce the premium by providing subsidies or tax credits. Just a little bit more about this one. I had animation, if you missed that look up, animation. Change provider behavior, all right? So if we change reimbursement incentives, and as John said, we really don't know too much about pay for performance. We don't know how effective it's going to be putting people in capitation that works so well and the HMOs and the managed care backlash. People also are now saying, oh, HIT and I was part of a working group a number of years ago where Brent James from Utah would tell everybody who listened to him if we adopted HIT, we reduced costs by a third. There's really no good evidence to suggest that that's true outside of the system, the Intermountain Health System in Utah. A lot of people want to cap medical liability. President Obama is going to do a national demonstration on this. The Republicans love this one and they say, well, the Democrats don't like it because they're all lawyers. But if we cap medical liability and detort reform, they'd say, you got it, a 30% of our costs. The economists who have studied this say maybe 1%, 2%, but President Obama was clever and said, let's do a demonstration and find out. And so I'm saying, I'll do that, I'll evaluate it. I'll do that one. A third, reduced waste, raw and abuse. The CMS has been doing this for Medicare and Medicaid for a number of years. There are a lot of people who think there's a lot of waste in the system and if we could just force those providers to be more efficient and also voice some of those fraudulent claims we would save, you got 30% of costs. We started thinking on a working group, boy, pretty soon physicians are gonna pay us for getting medical care. This is a pretty good system. Change consumer behavior. Have consumers get more skin in the game. A couple years ago, that was the big thing during the Bush administration in Washington. Consumers get skin in the game. They face these high deductibles and face high co-pays. They're gonna be prudent shoppers and they're really gonna do a good job. And I heard her new Gingrich talk about this many times for elderly people. Let's tell them, let's give them quality measures, performance measures of all their options and have skin in the game and then they're gonna be wise shoppers. And my mother turns 90 in two weeks. If you don't tell her, I told you she'd be really embarrassed. She doesn't even own a computer. Much less the ability to go on internet and then shop for the best value so again, there's been very little evidence that that can do a lot of good although certainly having consumers bear some responsibility as it becomes, I have to believe would be helpful. Then the third is just to directly reduce the premiums and that subsidies or tax credits. Obviously, if you are low income and somebody subsidizing the premium for you or giving your tax credit, you're gonna be more likely to take it up. One of the problems is if you only give it to the uninsured, there's a worry that this would decrease employer sponsored insurance because they would say, I don't have to offer you insurance. If you're not insured, you'll get that subsidy and you actually better off. But as John Gruber at MIT, who's one of the architects of the Massachusetts plan has pointed out, if you give a subsidy to everybody, over 80% of working American adults already pay for health insurance or trade wages. Then if you give them all $5,000 and that gets to be pretty expensive per newly insured person. So that's something that has to be struggled with. And then finally, the mandate either individual or for the employer and a pay or play. Here are the three bills that are really being discussed because the house, they did in fact merge their three bills into what's known as the tri-committee bill and you'll see all of them are doing something to try to pool the different insurance and so have some kind of state based plan. They all as was said are expanding Medicaid although at different levels. The big thing is that all of them are saying kids, adults without kids who are poor are now qualified for Medicaid, which is not true at present. Public option, two of them are saying yes. The Senate Finance Committee instead has the consumer operated and oriented plan. Most of you know that as co-op. Change underwriting, they're all going to regulate the insurance industry and try to make some changes in what they're allowed to do. On the provider side, most of them are trying to do something. HIT, they have a center that's working on it. The insurance cap, the liability cap is a demonstration. They all believe in waste fraud and abuse. They all want to change Medicare a little bit to reduce federal spending. But you'll notice this empty line consumer behavior. It's not on any of the bills. None of the bills. And I'm personally not sure if they're afraid of doing it or they just aren't sure how to do it. And then finally, subsidies and mandates. They all have some form of subsidy. They have some form of mandate. They're just minor differences. The Finance Committee, the employer mandate is the weakest of the three, but they all have some kind of participation by individuals and firms to try to finance it and try to get everybody into the pool. Jim told me that I was gonna go last because I am the in the trenches person and all of the academics were gonna go first and then I could do the cleanup piece. So I'm delighted to have that opportunity, but I really wish I'd heard John's talk before I agreed to run the Department of Human Services for the state. And I know Joe Schwartz is here in the audience, so it wasn't from your time, Joe, but if I had known the system was so rigged to produce absolute stalemate, it would have saved me a lot of heartache at the time. So thank you for that insight. Absolutely true. So we have just a very little bit of time and I really wanna stay fairly global and I don't wanna repeat what everyone said, though I do agree with really everyone who's gone before me and talked about the major issues and the major barriers to getting change done when we talk about healthcare reform. But I am gonna bring it from my perspective of having done this work for many years, having worked with Jack Wenberg to try and get practice variation changes in Michigan, having worked with many colleagues in actually trying to expand coverage, et cetera. So I wanna bring it back to some of the things we've tried to do and from that perspective, talk about the things that, first of all, that I think really are most important in healthcare reform and second, why it is so tough to get this done in this country. And I would agree with my colleagues who said that we will have health reform this year and it will be meaningful and it will be good. And you saw what Catherine showed in terms of the comparison of the different bills. At a very fundamental level, those are all important issues, but they're really detailed issues. And there is, as I think John talked about, much more consensus than we sometimes think there is when we hear all of the heat, not always the light, that we hear about the debate about healthcare reform. There really is fundamental agreement on some very important points. And so what happens in the future, President Obama will not be the last to deal with healthcare issues, but I think he could be the last who at least starts us on the path of having a national health policy that gives us the platform to deal with healthcare issues. And I think that's very important. So three things that I think are extremely important to have in any healthcare reform bill and any significant policy change on healthcare reform. First is clearly the issue of health insurance coverage. And Catherine talked about that quite eloquently. I'm not gonna go back over that. What I will say is that having health insurance coverage is the starting point for discussion. Everybody's talked about why that's important. The Baucus bill, the projections would achieve 94% of coverage for the country. That's probably good enough for this starting point. Coverage is important. Catherine really gave you the fundamentals of why it's important and why the need for it is growing. And I put in the coverage bucket of the issue of rating reform, insurance reform, the whole issue of preexisting conditions, medical underwriting, all of those things need to be whatever happens and I believe will be. Every bill deals with it one way or the other. I think those things will pass. Second, everybody talked about the importance of getting better value in the healthcare system. And here we talk about the money we spend for what we get back. And I think this audience well knows that as a country we spend the most per capita of any country in the world on healthcare. And if you look at a variety of healthcare measures, population health measures, we don't necessarily get the value for that spending. And so figuring out how to improve that value equation is very important in any bill. I agree with David. He talked about all of these different issues. As did Catherine, and I think there is no magic bullet in healthcare to really change that picture. And I heard Catherine in another talk she's given where she talks about the fact that every developed country is seeing the same rate of growth that we're seeing on a different base, a much lower base. But the rate of growth is still an issue around the world. So there is no magic about healthcare reform. All of the, on the cost side, all of the things that Catherine talked about, all of those ideas that are out there are actually all pretty good. Well, maybe not all of them. But most of them are really pretty good and most of them will do something. So it's not a matter of choosing one or the other. It's choosing to do all of those things because we've got to come at this problem for many different angles. But I do want to highlight two that I think are particularly important and very significant and could make a very significant change. One is the issue of how we pay providers of care. In our current system of payment for healthcare for the vast majority of people, I'm not talking about health maintenance organizations, we pay on a piecework basis. The more you do, the more you get. And it's a system that is very biased to interventional specialty care that is very different from how payment of providers works in other countries where there is much more value placed on how primary care physicians deliver care. So it is actually no surprise we're spending as much as we are because all of the incentives in the system are there to do more and to do more high priced things. That's how you get an income in the system. Changing that picture, very complex. I don't have time to talk about why and how you would do it. But you can do it. And it's very important. You've got to change how providers are compensated in our current system of healthcare. Second on the cost value quality picture is this issue of comparative effectiveness research. We have to do a better job at determining both what works and helping practitioners implement that evidence based information through the right incentives, through the right education, through involving patients in their own decision making about medical care. Those things are important. I think it was in David's slides that he talked about the fact that the current proposals, at least many of them, for comparative effectiveness research, specifically state that that research cannot be used to make payment decisions. That is ridiculous. And it's ridiculous on two fronts. First of all, you want to use this information because it is evidence based. We should be making payment decisions based on the evidence, not based on how we do it today. And second, we're already doing it. We're just not doing it with the evidence. So any of you here in this room who have private health coverage are already getting your care rationed in one way or the other. And the way that it's done in the insurance industry, you read your policy, every policy you have has a provision in there that says the insurance company will pay for medically necessary care. I can tell you, having done this work for many years, that definition of medically necessary is pretty vague and entirely up to the discretion of the insurance company. So I love these debates about, oh, the private option, they're gonna be killing off our senior citizens because they're gonna ration care. Well, believe me, private insurance has many more tools in its armament today to ration care and uses those tools every single day than does the public sector. We have no evidence the public sector will use this tool in a more draconian way than is already being done. But what is not happening today is that those decisions are being made based on good evidence. And that's what we need. This whole debate about rationing care is a red herring. We do make choices. We are by no means paying for everything that could benefit someone. We make choices every day and we need to do it with evidence. So that is a very important part of the healthcare cost and quality perspective. Third major element that needs to be in these bills and is much less discussed than the other two is the issue actually of access to care. We've mostly spent our time talking about access to insurance and about the cost quality issue. We spend very little time talking about actual access to care. The bills have a little bit in there about encouraging more primary care physicians about supporting nurses, which is gonna be fundamental to deal with a primary care shortage. But no one is talking about another issue that's very important, completely overlooked because it's too difficult to solve right now. And that is the issue of the Medicaid program. Medicaid is a disaster. I will tell you that flat out. I wish it would collapse. I wish it would get totally included in the Medicare program. It was a flawed concept from the start and it has only become more difficult over time. It is a fragile program. We provide inconsistent care for poor people all over the country. And it is totally subject to the challenges of state budgets as anybody who lives in Michigan should be aware today. These bills almost all expand coverage to the low income in the Evoca's bill up to 133% of poverty by expanding coverage in Medicaid. And even though actually most of them provide at least for some period of time full federal funding of Medicaid for that expansion, even Baucuswood in Michigan, not all states, even though that does provide full federal funding, they provide that full federal funding with the current payment system in place for Medicaid. Increasingly physicians, dentists and others are not accepting Medicaid patients because Medicaid pays so little. And so as we expand Medicaid and don't deal with this underlying payment issue, we are in fact providing coverage with no access to healthcare. One only has to look at what has happened in Massachusetts, not so much for Medicaid, but because they have a shortage of primary care physicians. They have many more people with coverage, but many people are having a hard time really getting access to that medical care. That is a fundamental issue that has got to be dealt with in these bills. So those are the three major things that I think need to be in any healthcare reform. Some of them are there, some are not quite there yet. So let me turn to the second question just very, very quickly in terms of why is it so difficult in this country to make change? And that's really my favorite question. I'm like, John, I just love this issue because it just is so fun to understand what drives Americans and why we are so different. Why is it, as Matt said, is this really an un-American idea? Well, I'll tell you three things very quickly as to why I think this is so hard in this country and I'm not gonna go into any detail because we don't have time on them. I number one, and John really did talk about it, it's one sixth of the economy. You know, the reason the insurance companies are out there now really fighting healthcare reform is because they don't like the details. They really liked healthcare reform when it was just about them getting more paying patients. They're not so happy now because there are a lot of technical things in there that they're really not so happy about including the taxation of high-cost benefits which reduces their income. So it's a lot about interest group politics, one sixth of the economy. Second is the issue that is very much tied to how these kinds of things get sold. It is, as John said, very complicated. We are a single payer model, very easy to understand. You could get a group marching on Washington in support of single payer. We are not gonna get single payer for the reason John talked about and so what we have is complicated. It's hard to understand. But I'll tell you, people are much more prone to being afraid of change than they are to embracing change. And so it's a lot easier politically to get people out there fighting death panels than it is to get a march on Washington in support of accountable care organizations. I mean really, this is a hard thing to get passion in favor of change. And so that's very important. And last, and it really is the issue, I think John hit it well. It's about who we are as Americans and I'll just conclude with one of my favorite quotes when I look at the issue about the difference between us and Europeans and in Canada. We are a country that is built on the principle of life, liberty, and the pursuit of happiness. And I say this in lots of sessions so I apologize if some of you have heard before but I just love it. In Canada, their equivalent to life, liberty, and the pursuit of happiness is peace, order, and good government. The rest of the world sees things so differently than we do and it makes this kind of change so hard. Thank you very much. I'll come together up at the table and I think there was not as much disagreement among them as one might have anticipated so I think we're gonna pass over and giving them a chance to say, respond back to work for each other and open it up to questions. And I am going to repeat your question, not because you haven't said it clearly but because that way it gets into the videotaping system. I'm not sure to whom I should address this but the question has to do with an evaluation of how Medicaid fair on the Bush administration let me contextualize that. It is altogether conceivable. Let me just ask that you try to keep the questions short otherwise I won't be able to repeat them. It's also conceivable that a foreseeable future of administration that is opposed to government insurance without the responsible money and I wanted to what extent Bush administration's administration of Medicaid is an example of what we're likely to get under those circumstances. So the question is basically the executive branch has to administer the program of the legislation that's passed and the Bush administration demonstrated what one can do in that regard with respect to the Medicaid program. What can we expect down the road? Yeah, so just quickly in terms of the Bush administration of Medicaid actually the Bush administration did not cut Medicaid in any fundamental ways. It didn't focus on any expansions. There were some waivers approved that allowed some states to do some creative things but what the Bush administration did do in the Medicaid program was to restrict it in ways that required and it came out of the 9-11 tax and ways that really were more broadly applied across the country and our policies to require documentation of citizenship and made it much more administratively difficult for people to get coverage. So there weren't specific policy limits on Medicaid per se but again, it's much more of a state issue. It's a very difficult state system to keep running at any sustainable level with the financial issues that we see at the states. I guess I would like to disagree with the notion that Medicaid is not a really good program. Obviously there are real problems with under financing and certainly it varies a great deal from state to state. Some states have a very limited Medicaid program but in many states the Medicaid program really is in many ways better than general insurance particularly for people who are very disabled and chronically ill because the benefit package is much broader for people with serious mental illness with people with serious disabilities of other kinds and in many ways the work on chronic disease, serious chronic disease and multiple morbidities is done better within the Medicaid program than the system as a whole in many places. Now there is a problem in that the payment to providers is very poor and lots of providers don't wanna participate in many states and there is an issue to be remedied but I don't think Medicaid really deserves the bad name it gets in many quarters. If I could just quickly add in response to your point maybe what you're referring to is that the Bush administration proposed as some other administrations have that Medicaid be converted into a block grant program. So from an entitlement where anybody who qualifies gets assistance to a block grant where each state gets a certain amount of money each year to run its program. When the Bush administration did propose this they suggested that it would be like the CHIP program for children's healthcare, CHIP standing for Children's Health Insurance Program and states have actually really liked the CHIP program for a lot of the reasons that David and Marianne actually both alluded to in terms of its control of its budget, when you have a block grant you know how much the budget's gonna be year after year after year, it can only be that amount you're not getting any more from the government if you're a state. The thing is though that when you're dealing with very vulnerable populations like the serious and mental ill block grants don't do that well because you do need that flexibility of the entitlement program in order to reach those most in need. That's ultimately why the proponents of Medicaid were successful in keeping the entitlement as an entitlement. The question then becomes from the Bush administration why do they then oppose the CHIP reauthorization when it came time to do so if they like the CHIP program so much? And it really came down to a question of well how much responsibility should government have for healthcare? The Bush administration said not very much. The Obama administration says much more. Yes. Yes. Is there any merits in the we allow all the states to compete in in-state markets thereby creating a degree of competition that rarely exists within the interest state markets around the time? Yes. The question is, is there the Republican proposal to allow insurance companies to operate across state lines into increased competition? I guess the major concern among opponents is that many states, all states probably have some mandates about what should be covered. And there are very cheap watered down policies that don't offer much and people may be attracted to them because of the price and would be quite surprised what it doesn't cover when they become ill. And there is a real great range among states in how many, what kinds of mandates they have. And if you allow complete openness to purchase anywhere, people might not knowingly purchase insurance which doesn't cover many of the essential things you need if you're really sick. It raises an actually larger issue about how these insurance exchanges are gonna be set up. And a lot of that's not really covered in the legislation, it's gonna be dealt with in the implementation process. But the basic problem is that you don't want these new insurance exchanges to be kind of a dumping ground for the people that the insurance companies don't cherry pick. And it's gotta be done right. Yeah, you know, just so you know, insurance companies do operate across state lines but it's just that they are subject to state laws as they operate now. So we have in Michigan, for example, Wellpoint Health Plan is here in Michigan. It's a California plan, but it's selling in Michigan but it's governed by the rules of the state insurance commissioner. So what it would do is accept or preempt those state rules which is where the mandates come from. Gonna try to move around. There was a question over here? Sure. Short question for anyone who would like to respond. Has to do with political culture. The American public, it seems to me, is cross-parsher. There's pent-up demand for health insurance and for coverage, at the same time, there's great anxiety about budget deficit. Leave aside what may happen two, three, four years from now. How does a dynamic of the deficit influence your thinking about likelihood of passage? The question is how does the issue of the deficit influence the likelihood of passage of a bill, given that there is a strong favoring of more coverage for the population? That's why this reform has been sold as a way to reduce long-term debt. And there's something to it. The Congressional Budget Office estimate of the Finance Committee Bill says that it actually would reduce long-term debt over the longer period of time. As far as a larger kind of issue of American political culture, the big problem is that Americans tend to want it all. They want government services and they don't want to pay for them. They prefer to have impressive health insurance coverage but they don't want higher taxes. My wife's Norwegian and I've talked to her cousins in Norway a lot. They have a very different view about what government is all about. They don't like taxes anymore than we do but their view is we get all these benefits and we gotta pay for them somehow and if I can say so, they're kind of grown up about it. But in this country, a politician who says, wait a minute, if you want all this stuff you're gonna have to pay for it. It runs, it runs, it runs, pal mel into this anti-tax, limited government kind of culture and it's really hard to deal with. You take one over here, yeah? You think that we're going to eventually go to the single payer option? I listen to the question is will the political process and pressure eventually lead us to a single payer option? There, it's gonna take many, many, many years and I don't know that we'll have single payer in quite the way that you're thinking of it. But the Republicans, Oren Haas just said this the other day, they're fond of saying that this public option is a stalking horse for single payer. I think they're right, actually. The difference between me and them is that I don't think it'd be such a bad idea. But the point is that if you really had a public option structured right and it was in competition with these co-ops and with these insurance companies, it's possible in a lot of states it would beat out the private market just because it would be a better deal for consumers and they'd sign up for it. And it would take many, many, many years but it could be that it would eventually, more or less take over the insurance market. I was gonna say that and this also relates to the previous question that I think that the American, we don't actually know how the American people feel about some of these issues because the voices of many are drowned out by the very loud protests of a few and David and I were both at a meeting last week in which somebody was presenting information about a different topic but putting people in the different buckets based on responses to a survey and I just sat there thinking this is the same as with healthcare, it turns out that if you really survey people about their preferences, the overwhelming majority of Americans want universal coverage, they wanna share responsibility, they're willing to pay for it and the majority want to change end of life care but you would never know that from what happened in August and when I was on a nonpartisan citizen's healthcare working group we had 100 town hall meetings all over the country, we had a website survey, we heard from thousands and thousands of people and in every state we went to, whether it was Utah or Massachusetts, Florida or Oregon, we, the lowest, the lowest percent we got who were in favor of universal coverage was 69% in Utah and the average was 85% with thousands of people participating in a hundred different places and every place we went as well, at least one person would raise this issue of end of life care and saying, we want the system to be different. We actually don't wanna die in the hospital all tied up, I don't want my child to die that way, my parent, my spouse, but the insurance only pays for it that way so they were giving us feedback that that was not their choice so I actually don't think that the system reflects what the majority of Americans want and so although I agree with John's comment I actually don't think Americans are that different in terms of what they want out of healthcare, they just haven't found the way to express what they want and have it represented in the way the legislature works. They're more than 50 surveys in the last few months, national surveys, polls on what people think about healthcare and actually there's been very little erosion in support at the abstract level for universal coverage, for public option, majority favor all those things. What is a little troubling of concern is as a result of the public discussion more and more people are reporting that they think they will not benefit and may be harmed by health reform and are worried that they're not gonna get this good care or they're not gonna have the same access and that it might be a problem for them and their families and that's the dynamic that can be very destructive but at the general level of support we yield more power in the ultimate decision making so though I think we might have a trigger for a public option and even though I think some people theoretically saw that as the stalking horse for single payer I think the way it will actually be structured in legislation would make it extremely difficult to compete with the private sector in any way so I think the reality is we're not gonna get single payer and we ought to look at what we can get and work from there. Yes, I understand. I think it's a great system. I just don't think we're gonna get it and I think we need to be realistic. We have to relinquish the auditorium in a little while so I'm gonna take one more question. Oh, I hear the head of the Mayo Clinic saying that there are opportunities for real healthcare reform. I'm concerned we're gonna have a huge expense on our children to just pass the decision. One of the things that I've talked about in this book on agendas is about windows, policy windows open and we've got one now and it's gonna close and because they always do. One of the things that's gonna happen is if your historical experience is any indication the Democrats will lose seats in the off year. They always do in the House of Representatives. They lose seats. So you got a chance now and that's the reason for the rush because if you don't take advantage of your opportunities it's gonna take decades for them to come around again. That's right. No? I don't think we'll ever figure out exactly how to do it right. We're always gonna have to iterate. We're always gonna have to modify. The perfect is the enemy of the good and I think that's what Hillary Clinton learned in 94. They could have done something then too. We need the foundation and then we can make change. Always beware of comments from leaders of medical organizations. Yeah. Yeah. There is tremendous inertia. Medical organizations like it the way they have it. That's cool. I think I forgot to repeat that last question but it was basically why are we rushing ahead when we might be able to get it right and better if we took our time. I'm sorry we don't have time for more. I hope you will join me in thanking the presenters. I hope they have a good discussion in the US Congress as we've had today that the coverage mission is there.