Moderator: Good Afternoon and welcome to Viewpoint! Today we have Dr. Robert Goldberg, President of the Center for Medicine in the Public Interest Advance here to discuss a public health insurance plan. Let's get started!

Robert Goldberg: Hi everyone!

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Rockville, Md.: Why is a public solution a bad idea?

Robert Goldberg: Government run health plans wind up rationing care in an effort to save money. In Europe and Canada and the UK, the public option actually spends faster each year than the US. Meanwhile waiting times, rationing for cancer drugs, pediatric surgery, even care for low birth weight babies are put at risk. We can do better.

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Richmond, Calif.: How can we keep our insurance companies honest without a public option? If it works for Congress and the military, why can't it be part of the solution for the rest of us on a pay-as-you-go basis?

Robert Goldberg: I have a better question, how do keep the public option "honest" without choice and competition. When Pres. Obama came to Washington, he enrolled his daughters in private schools. Meanwhile, Congress wanted to eliminate school vouchers that would give children in DC the same choice and ability to force the public schools to shape up.

No private company is perfect but choice and competition are the only tools citizens have to hold economic and political institutions accountable.A public option in each and every case with regard to health care starts out as or winds up as a monopoly because they have the power to tax and set prices. How do you keep that honest without competition?

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Lansing, Mich.: I will be 65 soon and eligible for Medicare. How will this new plan affect me?

Robert Goldberg: Your choice of Medicare plans might be wiped out. Medicare Advantage provides seniors with more services the Pres. praises such as prevention, disease management, access to personalized care that do cost more in the beginning. Medicare advantage allows health plans to compete based on quality and price to provide such services for you at the same Medicare premium you pay now or lower. But the Pres. wants to wipe out Med Advantage and use the $ to pay for putting 119 million Americans into a version of Medicaid. That's not competition, that racketeering.

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New York, N.Y.: Why is it that whenever other countries health care systems are discussed, the only countries mentioned are Canada and the UK? Shouldn't there be mention of some other countries, like France and Germany?

Robert Goldberg: The French and German systems are quite different from ours and each other. However what is never mentioned is that both are continually running huge deficits and as a result raising taxes, reducing benefits, trying to restrict what doctors and patients do. In France the doctor and nursing shortage is beyond belief. In Germany, they had to "steal" doctors from the UK to make up their shortage and still do.

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Atlanta, Ga.: Will the health plan have a provision for catastrophic coverage for those whose health care bills are likely to bankrupt the family even with some health care coverage?

Robert Goldberg: All proposals contain that form of coverage. In fact, if we just required or paid for that form of coverage plus a wellness package tied to lower premiums and rebates we could insure millions of Americans for far less money than the trillions now.

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Brooklyn N.Y.: How can we be assured that a public health plan will not contain all the problems of the current Medicaid plan, including such limited and low rates of reimbursement that most providers will not see patients on a Medicaid plan or the quality of care is curtailed?

Robert Goldberg: Good question Brooklyn!! We can't. In fact, the three Democrat proposals all expect docs to take Medicaid pay and that also includes what extra work they would engage in for prevention!

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Ellsworth, Maine: We see the powerful natural tendency to gain short term acceptance by promising unsustainable long term benefits - a primary cause of GM's down fall, Medicare and Social Security's projected shortfalls, and we saw it in the Maine teacher's retirement package that had to be rewritten in the early '90s because it was going to bankrupt the state. How could a public plan avoid this very same trap?

Robert Goldberg: Great question. I keep saying that "reform" is all about finding the money -- at the expense of changes to improve wellbeing in the long term -- to create a public plan that is already over budget at the get go! That, by definition, IS a public plan.

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Louisville, Ky.: How will we pay for this? How much will it cost? If the CBO cannot give an amount how can anyone?

Robert Goldberg: Hide your money under a mattress. Per the CBO, public plan proponents claim such a system has a better handle on costs. Meanwhile they came in over budget. Remember in 1965 when Medicare was created, the estimators said it would cost $9 billion in 1991. Make more like $66 billion.

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Seal Beach, Calif.: A universal, single payer, government public insurance plan could be funded by eliminating FICA ceiling, rolling back Bush tax cuts to wealthy, leveling decent rate taxes on corporations w/o touching Medicare benefits, is this a viable source for paying for public ins. plan?

Robert Goldberg: Those tax cuts are already "spent" and you are already raising taxes on people and corporations. I share your concern about Medicare benefits. Medicare should be restructured, not shredded.

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Albuquerque, N.M.: How will current excellent health plans be able to get attention with the drive for "universal" health care? As a nurse, I appreciate that insurance should not solely be tied to employment; however my state has a stellar health plan in Presbyterian Health Services and health plan. I believe that people should have a choice to continue with a plan like Pres, or opt for a "universal" coverage; one does not preclude the other.

Robert Goldberg: They should. Indeed, such plans are already investing money in prevention, quality-based outcomes, and all the good things the Pres. talks about. With guaranteed issue the turning of people away for illness is addressed and with incentives to get sick people healthy the system is pointed in the right direction. This cannot be done by a lumbering government system started from scratch.

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Sacramento, Calif.: I would like to know if you have looked at the national health care system used in France and why it is considered by the World Health Organization as the best in the world. Maybe this should be the model that the President Obama should use for the US national system.

Robert Goldberg: I have never been to France. Just don't end up in a hospital there. I don't have a clue why the WHO says their system -- which is broke and left 10000 seniors to die from extreme heat -- is a model.

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Marietta, Ga.: Why can't people purchase health insurance policies from outside the state in which they live? Why can't they take their insurance plans with them if they move to another state? It seems that eliminating the laws prohibiting the above will spur the competition that is needed to reduce costs. Why can't those with a healthy lifestyle and a healthy body/health profile to show for it be rewarded with lower costs in purchasing policies? Those who smoke or have chronic diseases as a result of an unhealthy lifestyle, such as Type II diabetes due to obesity, should be charged more for health care insurance! Why can't the terms of health insurance policies be written in language that a middle school aged child can understand?

Robert Goldberg: Great question. The Bipartisan Policy Center has a proposal that endorses allowing people to shop for health care like they shop for colleges, retirement homes (pre-Madoff!) and investment vehicles. And it encourages promoting wellness.
http://www.bipartisanpolicy.org/

As for clear health insurance policies written in plain English... you are a dreamer aren't you!

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Princeton, N.J.: Every other industrialized country in the world gets better health care as measured by all the bottom line public health statistics (there are 16), and they do it at less than half the cost per person as we spend. And they all have government run systems, mostly single payer. They have already expanded the coverage and lowered the cost as well as improved the quality as compared to the US. Myths about waiting and rationing don't hold up. In the US there are many whose wait times are infinite; they never get treatment. In the US we have worse rationing by wealth and by for-profit insurers who, as we have recently heard, will lie and cheat for profits.

Robert Goldberg: I wish health care debates were driven by facts explained by events and circumstances, not factoids. The assertion that we spend two times as much on health for worse outcomes is errant nonsense. I won't delve too much into it now except to say that our higher infant mortality rates are driven not only by the fact we count a viable life at the first 24 hours of existence (whereas many OECD wait 3-7 days) but by the fact we do more to keep low birth weight babies alive. Maybe we should reduce access to "start of life care" since in 70 percent of the time the children have disabilities. Those are the sorts of judgments made in the UK, Canada, and Germany all the time.

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West Simsbury, Conn.: Why haven't we heard about a plan where private insurers are forced to use a community based rating and insure everybody? Experiential rating has led us down the path where only the healthiest of people are insured by private insurance companies.

Robert Goldberg: The health plans have agreed to insure everyone. The key is work with people to improve their health. This will cost money and the decision on how to spend it should be made by doctors and patients based on good evidence, not the short term goal of cost containment.

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Dayton, Ohio: Why is there health insurance at all? What we need is health care not health insurance. Health care should be like police or fire protection.

Robert Goldberg: Exactly. Health insurance was actually -- and partly is -- designed to cover the big one time event. Medicine has changed and we are treating or controlling chronic diseases. The way we pay for medicine however has not kept up with the technology or our ability to deliver personalized health care to people.

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Kannapolis, N.C.: Private insurers claim they are superior to a government-run health care program. My personal experience says otherwise. I have endured months of "waiting" for approval for procedures, endless paperwork, and denials by an unseen authority that has never seen or treated me. Furthermore, medications I take are virtually dictated by the insurance company, if I want partial payment of the cost of the medication. Others have similar experiences. In my view, their profit margin is far more important than providing me health care.

Robert Goldberg: Good question. I feel, like you do, that health plans should work for us and that the clinical decisions should be made based health and wellness too! So the goal of reform should be to create pots of money for people to join plans that would compete and get paid for doing that...

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Brick, N.J.: How will rationing of care be for a senior work and is this how they will implement cuts to Medicare?

Robert Goldberg: Rationing is already happening in Medicare. Rather than giving people a crack at new technologies and then seeing which ones work best for who, Medicare is demanding long, expensive studies that take years to complete. Since many breakthroughs come from small start ups such a requirement will reduce the number of innovations that could benefit small groups of seniors in important ways.

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Burnsville, N.C.: I can't afford health insurance now so how am I going to be able to afford the government's insurance?

Robert Goldberg: Coventry health insurance offers a plan for $290 a month. If you can't afford that now because of pre-existing conditions that might drive the premium higher under reform you could get a refundable tax credit to choose Coventry or other plans.


PS I do NOT work for Coventry

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Washington, D.C.: You mentioned The Center for Medicine in the Public Interest Advance focuses on reducing health care disparities and health care reforms that expand access and improve health. Could a "universal" plan address this? And if not - what are your ideas on how to address the disparity in healthcare in this country?

Robert Goldberg: There are some great ideas in the Bipartisan Policy Center proposal.

1. Create a $50 billion wellness fund to target areas of high health disparity with ways to prevent disease.

2. Give more money to doctors and plans that tackle disparities and do a better job.

3. Give individuals more information and awareness about how they can live healthier lives.

Even a 10 percent shift in disease burden could increase life expectancy and generate economic growth.

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Madison, Ala.: I would like to know why, when Senators and house members are getting premier health plans at the cost of the taxpayer, are they so adamant about not allowing the rest of the US to participate in the same plan? If they are so against a public option, then let us see what they get. Show us the price each senator pays, the hospitals they can go to and the amount of "out of pocket" expenses that they must pay. Then compare that to the average citizen. If there are senators that do not want a public option, then I suggest that they first opt out of their current plan and use the plan of those of the most poorly insured citizen in their constituency. My guess is that then, and only then, will we actually see true reform in the health care issue.

Robert Goldberg: Great suggestion. Let's have every member of Congress give up their existing benefits and go into the public plan of their "choice." Someone should introduce a bill...

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Arlington, Va.: You say you've never been to France. I have and although I've never needed to see a doctor there, I have read very good things about the French system. Wait times are virtually unknown, and you can go to any doctor/hospital you want. I have been to other Euro countries, including Portugal, where several years ago my wife badly sprained her ankle. (I admit this isn't the most dramatic example, but is something I can speak of from personal experience.) Thinking it might be broken, we went to the hospital in the city of Porto. They saw her after a wait of 30 minutes and afterwards charged us the Euro equivalent of around $20.00. Sorry, but you won't convince me there's something wrong with such European health systems. Public plan? I say go for it.

Robert Goldberg: Ankle sprain? Hey, no problema (that's not Portuguese) I am talking huge delays for hip replacements, cochlear implants, pacemakers for people over the age of 80, bypass surgery, access to new cancer drugs. That's what you get when you make everything in "free" in a public plan. A high price to pay for a $20 hospital bill, not to mention the higher tax burden.

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Washington, D.C.: Do you admit that the system we have currently isn't working? If you don't support a public plan - what is the answer? And how do we get there?

Robert Goldberg: Health care should be more preventive, personalized and predictive in how it addresses health and pays for medical care. We reduce illness and increase life expectancy when we introduce new technologies and approaches that move medicine in that direction. That reduces the cost of disease and generates productivity. The Bipartisan Policy Center plan comes closest to the reform that I believe makes sense and achieve these goals.

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Washington, D.C.: You are making great points, and I am uncertain exactly what we need for reform - public or simply increased competition amongst private carriers. However, what I do know is that we need a change. As someone who takes extremely good care of herself but has a chronic autoimmune disorder, I have many times had to 'stretch' my meds to afford everything because there are no generic prescriptions (another flaw). What I would like you to address are these questions: If a public option won't force competition correctly, what is the solution to lower premiums? Also, what are your thoughts on mandating coverage to ensure those of us already paying high premiums are not then asked to subsidize the uninsured that get regular treatments at state-run ERs, etc.?

Robert Goldberg: Good questions all. There should be a supplemental premium -- almost like the warranty you are offered for products you get from Best Buy -- that would pay for huge medical bills when they hit in chronic cases. People have proposed it but no takers so far. Meanwhile, you should have the resources to take care of yourself and be rewarded for doing so. That might lower premiums or lead to rebates, etc. Premiums will continue to go up but as you note, we need to get more people involved in the system. Offering lower priced health products, tied to wellness is one way. Health is such a personal thing yet all the proposals are one size fits all.

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Washington, D.C.: There is a lot of talk about how we could save a lot of money with preventative care vs. reactionary care. Do you agree with this assessment that increasing preventative care would result in better overall health and lower costs?

Robert Goldberg: Preventive care does not always save money. And it drives me crazy when Obama insists we can save $700 billion just by eliminating care that we "know" does not help make people healthier. That's based on a study that looks at the cost of care in the last two years of life and saw variations in cost across the country. So the researchers assumed -- without knowing how sick the people were in the first place -- that more is not better, maybe that is true in many cases. But why aren't we asking how to keep people living longer and healthier lives? That's what we ask ourselves? So the question is how we spend the money we want to spend on health to achieve those goals. Telling me that I get really sick two years before I die (and I don't have the luxury of hindsight like the researchers) tells me nothing. Tell me and help live longer and healthier...

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Annapolis, Md.: Why do conservatives insist that investor owned HMO's are efficient and competitive when their function is to maximize profit for investors and in Medicare, they need government subsidies?

Robert Goldberg: I don't know why conservative say that. Health plans can certainly be more efficient and competitive. But if you really believe a public option is the key to competition, why didn't we just create a new car company instead of bailing out the failing ones we have? How about government run energy company, or pharmaceutical firm? Or state run grocery stores? This public option is no option any more than invoking competition is a solution. The key is giving people access to the best care in ways that keep them healthy and alive longer. Do we want to engage in a 2 trillion experiment to see if a public plan will do better than what we have now...? That's the question!!

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Moderator: That's all we have time for today. Thanks so much for joining us!

Robert Goldberg: Thanks everyone. Your comments and questions were great and went to the heart of the matter. I enjoyed our "time" together. If you want more info and want to continue chatting you can find me twittering at HndsOffMyHealth or go to our websites at Handsoffmyhealth.org or publicplanfacts.org.

I am going go to the gym after this FYI... trying to do my part.

All the best!

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