Dave Durenberger and Paul Wellstone, Minnesota’s U.S. senators, debate at Minnesota Meeting. The topic of debate is health-care reform. Durenberger is an advocate of managed competition in health care, while Wellstone is an advocate of a single-payer system. Minnesota Meeting is a non-profit corporation which hosts a wide range of public speakers. It is managed by the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota.
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Think public debate these days and you immediately think of healthcare. And if you think of healthcare debate you immediately think of the to Minnesota Senators. Our state has been incredibly fortunate to have two senators out front in this crucial debate. Senator David durenberger has been involved with health care issues throughout his almost 15 years in the Senate. He has argued for a managed competition system based in large part on what he's learned from, Minnesota. Senator Paul wellstone campaigned hard on the health care issue in his campaign two years ago. And when he got to the Senate he became a prominent supporter of the single-issue program. These two senators take very different approaches to solving this problem. But after watching them discuss the issue recently one thing is clear both men have a genuine passion for this debate. They both care deeply about reforming Health Care. They just disagree on how I'm sure you will enjoy both the intellectual content and the Deep caring these two men bring to this debate. I'm now honored and pleased to introduce the senior senator from Minnesota senator David bernburg. Thank you, Tim. And thanks to all of you for giving me this opportunity to talk about health care reform. I've been honored to serve this community in the senate for 15 years and thanks to a lot of you I now have the opportunity to use what I've learned in my 16th year in office to help do Health Care reform, right? The best way to begin is to decide what's broken in the system and what needs to be reformed once we answer that question, then we can proceed to The Next Step which is how to reform it. My friend Paul will tell you that the markets broken and he'll tell you the market so badly broken and needs to be replaced by a much more effective and efficient Problem Solver the federal government or state government evidently four trillion dollars in debt have failed to weaken Paul's faith in the federal government solution. We can talk more on that later as I'm sure he is prepared to what I wanted to do first is disposed of the notion that the market the medical Market is broken. I contend the opposite is true the problem we're trying to solve today as the market for medical goods and services works too. Well for decades, we've told Doctors Hospitals drug companies everybody to do everything we want everything money is No Object and we've said that loud and clear by the way. We've run the system the more doctors do the more they get paid the more doctor do the safer. They are for malpractice suits. There's no incentive for people to watch out for excessive costs because the opposite is true in any other Market the buyer would control costs because the cost come out of the buyer talking but in health care, they don't the bills are paid by somebody else this thing called the insurance company and the insurance company passes the extra cost usually not to the patient, but to the patient's employer or to somebody else in the form of higher premiums rather than having price be a break on demand. We set up a market that was designed to provide the goods and But insulate the buyers from the cause clearly, this is something that can't go on forever when costs rise. So far the people complain about how much they're paying we can no longer avoid the problem of cost. So what do we do about it? Three choices at the national level first some of my more Conservative Republican colleagues believe the problem is solely a demand problem. They argue that if everybody has three thousand dollars to spend on health and could keep what they didn't spend we'd curb demand and cost the problem with that is first no one knows what they're buying second. No provider has any reason to tell us third price is not always a measure of quality and forth giving people a check for $3,000 does nothing to increase the productivity of the system on the other side of the political Spectrum are those who consider the cost problem a supply problem too many doctors too many drugs too many beds too much paperwork and too much profit. They say markets can't work and we should replace them with political decisions. These are the single-payer Advocates the Third. Turn it up or the middle. The one that I'm recommending is to Simply change the instructions the incentives that we the healthcare consumers of America are sending to the market. President Clinton has said our national gold has equal access to high-quality care through a system of universal coverage. That means we want more and we want better for less and the only way to get that is through higher productivity remember in the long run whatever reform system. We adopt we the consumers are going to be paying for it and we have to decide right now who will be more responsive to our demands for high quality and low price the free market or a government bureaucracy the bill I'm co-sponsoring the managed competition act uses the market. It uses the market in a way that already been sixth really successful in some parts of America, especially right here in Minnesota. It's no accident that Hillary Clinton can't stop talking about what minnesotans have accomplished people in our state are already experiencing the direct benefit of a market that is being reformed employers and employees are seeing real savings because the increased competition and Minnesota's Market. We the healthcare consumers and Minnesota are finally telling the health system that costs matter and you know, what the good news is They're listening. There's this audience listening. We formed buying coalition's to drive a bargain on price. The state of Minnesota has the best known example of that for its employees and University employees, Minnesota also provides clear evidence that we change how we Purchase Medical Services cost will also go down but that's only half of what we need to do. Minnesota has proven that Costco down if we change how we practice medicine and hope he'll we are the birthplace of the Mayo Clinic of Hazelden other Ramsey Burn Center of group health of the HMO movement of the best Metropolitan managed competition example in America. Our university has given us break through inventions and inventors and the largest medical device center in the world is located here. If the problem is that doctors are running up the tab then what we have to do is change the instructions that were giving the doctors if we don't care what specific treatment we get. We just want the right outcome if we tell the doctors we want to be healthy and that this and no more is what were willing to pay for then the doctors will be Innovative. And so will the device and Drug people And they'll be they will give us the treatment that is appropriate if we take away the incentive to do more than we might need if we increase the incentive to do only what's really necessary. I love the Park Nicollet example of some of you may have on your table where they looked at at urinary tract infections. The average cost is $133. They figured out how to do it better for $39 government can't do that. The only reason we have not seen more of this kind of intelligent Innovative cost-cutting of the u.s. System is a simple one because we haven't asked for it. The managed competition act would allow these incentives to take hold of the Health Care system from coast to coast setting rules and standards but not dictating treatment. If you take nothing else away from here today remember managed competition means National rules, but local markets in Minnesota. We're doing for healthcare Cost Containment, but Henry Ford did for automobiles. I want to take our model Nationwide and start a truly National revolution of Cost Containment. I will conclude with an honest response would I know can be Paul's first criticism of my bill? It's the president's criticism Market reform will not solve the problem of coverage. I admit that markets do increase quality and they reduce cost but they can't do Equity only political decisions can guarantee Equity. So the best I can do is get us off to an honest start on the issue of coverage First Reform the insurance industry through guaranteed-issue and renewal and portability that makes Insurance more affordable for small business and individual second. The managed competition act provides subsidies will help all low-income individuals in this country up to 28,000 dollars in income afford health plan third a separate proposal to restructure Medicare. So the elderly will get the more comprehensive benefits using the model that there's three of them in this community already where you can get more comprehensive benefits including long-term care rolling out in 45 bucks a month instead of the lousy system that we keep perpetuating and a b and Medigap and forth Grant tax subsidies for basic benefits only we have no right to expect To help pay for any more than the coverage of basic benefits the question of access and coverage and how much it costs and who pays it's simply time for frankness instead of pretending that Health Care is Affordable by just hiding the cost. Let's do what we can do to make it affordable. That's what we're doing in Minnesota. That's what the managed competition act could do for America. Thank you very much. senator Paul wellstone senator my mom has Alzheimer's. And if there isn't long-term coverage, our family is going to go under. Senator I had a bout with cancer. And now the insurance company has raised my premium to 15 thousand dollars a year. Senator I had good coverage, but I lost my job. And I don't have any health care coverage for myself for my loved ones right now. senator we had a major illness in our family. And we're now bankrupt. Senator with my mother and father it was Paul. They're no longer alive. We both have Parkinsons. And now at the very end of our life though, you and Sheila and the children have helped take care of us. We have to be in a nursing home. We wanted to leave what savings we had for our grandchildren to go to college. We don't want to be completely wiped out senator. The dentist because the Medicaid reimbursement so low won't see my child. These are the voices that I hear from Minnesota and around the country. And I want to tell you today. That Health Care is a very concrete and it's a very personal issue and I believe whatever the difference is that there are. It is incumbent upon Democrats and Republicans who were in office to come through for people in the United States of America. With Health Care reform that will work well. Until we get to that point which will be a point of compromised. I'm going to fight hard and be as strong a voice and speak with as much eloquence as I can muster for the American Health Security Act that I introduced in the United States Senate. People also talk to me in Minnesota and around the country in not a very technocratic language. I rarely hear people talk about Single Payer or all payer or no payer or employer mandate or pay or play or managed competition or any of the rest of it people don't get up in the morning and look in the mirror and say which one of those things am I People a say to me and I think they'd say to you all Senator. Will I be covered and will my loved ones be covered? The American Health Security Act the single-payer Bill provides Universal coverage. I am in profound disagreement with Senator durenberger on this point. I think Universal coverage and cost containment go together. Those are really the foundations of the health care crisis in this country. Second thing people say is Senator. Will it be a decent package of benefits? We make sure that there's a strong emphasis in our legislation on family doctors on Primary Care on nurse practitioners on Health Care out in the community outreach Public Health backed by specialist. And we make sure that it is the consumers the patient's the people and the caregivers that decide what kind of care is given not micromanagement by insurance companies with a 1-800 number far away in another part of the country. People say senator will I have choice? I'm a very big advocate of hmos. I think Health maintenance organizations are very important, but I think it is a mistake to set up one big sort of framework of managed competition plans and heard everyone into that maybe people in rural Minnesota and maybe people in urban and Suburban Minnesota would rather participate on a fee-for-service basis. We leave it up to the consumers to decide and if you think it's better for yourself and your loved ones to go to this doctor or to go to that clinic or to go to that hospital that is your choice that is your choice. And finally people say senator, will it be affordable? And I have to say to you all. That it is most interesting that the single-payer plan has the most support in public opinion polls in our country huge support in the House of Representatives with 90 co-sponsors six in the Senate with a working group at least At Large because we are the strongest on Cost Containment so far when you look at the independent studies that have come out not my studies not Democratic or republican studies, but the work of CBO which is going to come out with another report this week Single Payer is the one plan where there is Real Cost Containment Cost Containment because we save a hundred billion dollars a year by streamlining the administration Senator Berger knows that this is not government run doctors clinics hospitals are all the rest. It is private sector. It is the insurance part that streamlined no longer. Do you have an insurance industry that writes the rules of the game deciding who's covered in who's not covered competing to cover healthy people no longer do you? Of the administrative bloat each state decentralized sets up at single-payer could be a Public Authority could be one insurance company and that single-payer number one streamlines the administration number two, we live within budgets and number three has some bargaining power. And by the way, if I could be a teacher for a moment, you look at the comparative data other Health Care Systems around the country and there's not really one very good example of without that kind of single-payer leverage of really controlling costs. CBO Congressional budget office is summer pointed out that 1995 to the year 2000. There was a difference of five hundred billion dollars between single-payer managed competition single-payer 300 billion dollars less than we'd be at managed competition 200 billion dollars more final point. I think the problems with managed competition in its pure form. I have noticed as United States Senator and also as a political scientist that everybody defines the center in terms of where they want the center to be. Let me make a little different argument. The fact of the matter is the president is committed to Universal coverage and comprehensive package of benefits. And that is what we're going to push very hard on the problem with the pure managed competition. The Cooper bill. I think the senator durenberger is also on that bill is as follows. Number one. It's a great theory in a graduate-level seminar class, but it is considered as a castle constructed in thin air and there's no evidence that it's going to control the cost. We haven't seen a study that's come out yet that has predicted that number two people in Minnesota rural, Minnesota and Rural America and other communities are wondering where their choice is. All of a sudden you find that you're within this network and you can't go to another doctor or another clinic. You don't have that choice number three the insurance industry still plays a very large role and I will tell you today that there is real concern as a matter of good public policy about the mergers and the concentration and the consolidation and the corporatization of medicine in the United States of America. The bottom line is not the only line number four people don't know what managed competition is. When I appear before the national citizens jury, the reason that they were so strong for single payers. It's simple people understand it and they see how you can provide decent coverage and have Community out and the commute out medicine out in the community and control costs. And finally this is a big difference of opinion. I think Universal coverage cannot be held hostage people in Minnesota and people in the nation are saying we want to make sure there's a decent package of benefits and that each and every citizen is covered in our country. That's what people are calling for. And since there is no evidence whatsoever a national level that managed competition without some public accountability will get us there. I think that is a proposal that will not be adopted. My guess is that we will ultimately take the best of a number of different plans. But the American Health Security Act is the yardstick for reform. It commands widespread support in the country. And the reason is people understand it. And the reason is it works. And the reason is it's very consistent with what our country is about, which is we streamlined Administration. We keep within private sector and we focus on you main dignified affordable health care for people in this country. Salinger durenberger Paul's mentioning of the polls and his discussion of universal coverage raises. The question has all the talk in the last year and a half or two created an expectation for Universal coverage among voters and among citizens. And how do you deal with that expectation the do the wonderful things that I recall that having having done one was before I ever ever came to the Senate when I participated in this community with the first employer effort to try to deal with cost by giving employees more more choices. The second one was a the only time we've ever had this was back in 1988 or 89. The 1988 election long-term care was the big political issue across the country 1989 Claude pepper went to the House of Representatives and said, I want a big commission to do long-term care and Danny rostenkowski said, oh you're gonna you're gonna steamroll us. He said let's have a commission that those long-term care and Acute Care at that time. They took the six house members in the six Senators that seemed to know the most about health policy put us on a commission with three others. It was called a pepper commission and at the end of that we can we concluded by an eight to seven vote that we would have to deal with the problem of 36 million uninsured by mandating that every employer provided health care for their employees or paid money into it into a tax fund that point it became an issue immediately. Thereafter Harris Wofford ran in Pennsylvania. He ran on the 36 million uninsured and that's how it became an issue President Clinton made it an issue in his campaign in large part, I think because President Bush refused to deal as he should have with this problem Universal coverage is not something we disagree on the disagree on the disagreement we have presently is we want to make sure when we go to Universal coverage it's paid for secondly, you don't have to have a hundred percent of people covered in order to do system reform. We're doing it here in Minnesota right now. And we have 93 percent coverage. Sure wellstone the you talked about the private sector being involved in in single-payer and yet what a lot of people are hearing is well, we're going to Canada. This is socialized medicine. What why would we want to embrace that we fought against it for so many years. How do you reconcile that debate? Can I get 10 seconds on universal coverage or do you not want to take 50 take 10 or 15 seconds? I think the disagreement part of the problem with the managed competition proposal in its pure form. I think managed competition should be part of what we do in the United States in its pure form as presented by the senator Burger is that it still leaves about 22 million people on without any coverage and frankly to sort of say two people have no coverage where you're going to wait till we control costs when there's no evidence you control costs in the absence of a single-payer proposal is what I think doesn't work in by the way if we don't control costs we pay for it. Anyway, this is a shell game at Senator and I agree on that the twice get transferred around uncompensated Care at the hospital gets transferred to those of us who have insurance. So if you don't provide the coverage and focus on preventive health care, we pay for it. Anyway on the socialized medicine in the United States of America. We have been debating this issue of Universal Health Care coverage at least Since Franklin Delano Roosevelt proposed adding this on to Social Security Act him of 1935. And this has been the charge socialized medicine socialized medicine as it turns out that has lost much less currency than it ever did before and I think what people mean by socialized medicine is when the government owns and controls and runs the Hospitals and Clinics and all of the rest which by the way is not the experience in Canada the country that comes closest to that is is England or Great Britain. We are talking about decentralization. We are talking about the insurance part, but we are not talking about the delivery. The delivery of services is within private sector and let me just make one other point here in Minnesota. Something happened about a month or two ago. That was big national news, which is the Minnesota Medical Association came a few votes short of requesting that the state study a single-payer option because they felt that within single-payer. They'd be less micro managed than where they see this state going in for that matter this country going which is the consolidation with these shoes networks and Whew, so we stay within private sector and we make sure they caregivers have high morale. I want to tell you all I think caregivers have been treated unfairly. And I think it is a mistake to assume that when people stand up who are caregivers and wonder about proposals. They're only trying to protect themselves and want to make a lot of money caregivers without high morale are not good caregivers and we have to make sure that we don't micromanage caregivers and we don't do that Tim in the American Health Security Act. There are a lot of doctors who support this family docs pediatricians internist nurses American Public Health Association consumer organizations broad support. Senator durenberger in your message that you talked a lot about Minnesota and you gender a lot of Pride and yet Senator wellstone tells some very dramatic stories about people who are left out of the system. How do you reach Bond of those dramatic stories? And how do we deal in your program with the people who are just left out who have their insurance increased dramatically. How do you respond to those dramatic Stories? The senator told you had you had catastrophic in Medicare like we tried to do a 1987. For example, you'd have you to solve two problems. Number one, you wouldn't have the the financial problems that elderly and disabled people face and these these catastrophic illnesses and secondly, they become wiser buyers of care. They could buy one Health Plan without shopping around for a be Medigap and and wasting a whole lot of money. So reform the Medicare system so that the elderly and the disabled in this country can buy a health plan this At 65 the same way they did it 64 they can get catastrophic coverage. They can get the same comprehensive kind of benefit those three plans. I talked about here in this community who are Under Fire from the from the government-run system in Washington DC because they're efficient those plan give you comprehensive care with long-term with long-term care in Nepal for your folks and the dementias and things like that for a hundred and forty five bucks a month and and we could do that for everybody in America. And that that the second part of it is the low income people. You're going to have some healthy kids our children when they reach 22 or 23, whatever that age is we're going to choose not to buy into the system. I realize that but what Paul seemed that is articulating of the concern we all share in those and that's for those who because of their income are unable to buy protection on the margin the proposal to the President Bush laid out the proposal. We haven't managed competition acted we scrap the welfare approach to Health Care. We scrapped Medicaid half of the money is going into long-term care. Anyway, it's not going into the people that that need it the most and we simply pay the vouchered amount a dollar amount for people to go to be able to buy accountable health plans in this community or any other community up to a hundred percent of poverty, which currently is fourteen thousand three hundred thirty five dollars, you get the entire amount is paid from there to $28,000 a year. It's a graduated amount. So if you're a small business person you want to employ somebody who's very low income at a $6 an hour job. You have the combination going in to get the health plan. They have the combination of the public subsidy and what you contribute it's all logical. It makes sense all we have to do the politicians in Washington who run Medicare and Medicaid the same lousy way since 1965 change it make the decision that the elderly and disabled will be protected by a more comprehensive benefit at a lower price that low-income people should not be stigmatized but All low-income people should be able to come to the system the same way. Well, they're the two problems. Number one. I don't think in the Managed Care Maybe I'm Wrong David. But as I look at the package of benefits and we cover long-term care. I mean, this is a huge expense some of you have been through this either either as with your parents or maybe your grandparents number two. We put a very strong emphasis and we're very specific on home-based care. The block Nurse Program is something Center durenberger and I can agree on is a wonderful model people ought to be able to live at home and is near normal circumstances as possible with dignity, but I want to make it very clear that as a matter of fact. Yeah, you can expand. I personally think it's a mistake to have these programs segmented. I think it leads to a lot of bureaucracy. I think you have universal healthcare coverage so that you don't have a situation when you're under 65, you're not receiving the benefit or when you're too you're not poor enough for Medicaid. You don't receive the benefit and then if you put the Community into this equation and let's not forget the costs. I heard earlier about this four trillion. I really wasn't in Washington during most of that time Senator durenberger. But in addition to that I mean much of that has to do with the effect of Health do it this year Paul's hard. I think not actually I think not bad for your first there. I think I think I think actually if we were to go into the big budget items and we were to take a look at at some of the votes on some of the big budget items. It's I feel very good about voting to end. That kind of waste is a healthcare five times, but but let me just but let me just but let me just make the point that unless you really unless we get very serious and substantive about how we finance and deliver Health Care in this country. We're not going to be able to do it well and we won't deal with the to again twin crises and one of those is that people are not Do not feel the do not have security and second of all we have to deal with the escalating costs and I would insist that that's a big part of the budget problem. So, yeah, if you want to expand Medicare great, I have seen no evidence that that's in a lot of the plants. I think catastrophic care should be covered home-based. Thank you. We've discussed medical Medicaid Medicare and bureaucracy. Tell us just briefly Senator wellstone. How will the single-payer kind of proposal not be a new bureaucracy not be a government-run kind of program that Senator durenberger mocks because of the inefficiency of past government programs. Well, first of all, there's a talk to your caregivers. There's a huge bureaucracy right now. It's a huge bureaucracy. I mean, there's such so many caregivers are so frustrated because they can't practice the kind of Health Care. They thought they would be able to practice when they were when they were in training Tim because they have to get approval here there and there so there's a huge bureaucracy right. Now. What we do is we move away from 1,500 different insurance companies. We move away from the role of the insurance industry, which I don't think has been a positive one and we moved to one Single Payer which streamlines all of that bureaucracy, which is where you get the cost General Accounting Office estimates a hundred billion dollars a year. After that Tim the bargaining over Capital budgets and fee-for-service and operating budgets is done on an annual basis with no micromanagement whatsoever and it's within private sector that's far less bureaucracy than we now have within the system and far less bureaucracy. Then you'd have with these conglomerates in turn having to be accountable to someone but it's not clear accountable to whom so in many ways. I think that's the very strength of The Proposal which is the administrative Simplicity. Let's go to the audience for questions good. Thank you Tim for our radio audience. You are listening to Minnesota. Senator is Dave durenberger and Paul wellstone speaking before the Minnesota meeting. They're debating Health Care reform in our debate is being moderated by Tim McGuire who is the editorial editor of the Star Tribune have a first question here from Dave Tesla with the Minnesota Medical Foundation. Thank you for your enlightening comments has been very interesting to hear what you've spoken about. However, I think there's one issue that you haven't addressed that is of importance to some people are hope many people throughout the state and throughout the country. I think both of you are aware of the fact that the state of Minnesota has long been a leader in medical education and medical research nationally and that leadership I think is enabled this state to have the high quality of Medical Healthcare Delivery Systems that we have in this state there seems to be grave concern on the side of both proposals as to what the future of medical education and medical research might be in this state as well as in the rest of the country in your particular plans. I'd like to have you comment on that. Please let me begin if I may just the tag comment on what Paul said if anybody in this audience believes that streamlining bureaucracy is anything other than an oxymoron, I'd like to know that I and many people throw around this notion that Medicare is efficient because it only cost the government 3% to administer. Ask your doctor's your nurses your caregivers how much it cost to administer ask your age parents how much it cost to try to figure out that that system I think efficiency comes only when you get productivity and that only comes in choice and competition medical education is a necessity but it's also difficult. It's like it's one of those Equity issues that is difficult to trust to a Marketplace when we open the spigot on medical education 30 years ago so that we don't have enough Doc's we don't have enough nurses. We're going to go to capitated education. We increase the number of medical schools in this country by about 50% We now have a hundred twenty-eight medical schools that that's an Institutional phenomenon that thrives on on on students. The other thing we did on drgs and I know this because I I tried to take all of The Graduate medical education money put it in Block Grants and send it back to the States and I heard from every private medical school in America. They said oh don't do that because the public the public schools are going to take all the Honey, so we instead created what's called a teaching reimbursement and The Graduate medical education reimbursement. What happened to that? We used it to pay hospitals to hire interns. They'll pay them twenty-four twenty-five twenty-six thousand dollars a year and they'll pick up seventy or eighty thousand dollars from Medicare to do it that part of the system is responsible at least in part for the excess of economic specialization and real specialization medicine. I think we're going to have to we're going to have to be explicit in a competitive market about how we Finance medical education many of us favor changing the the Medicare reimbursement so that we more appropriately reimbursed for the broad spectrum of people we need to train particularly primary care. But secondly, we're going to have to put an explicit tax across the board on accountable Health Plan premiums. I think that's probably about the best we could do maybe a half a percent and then figure out How in the world we're going to appropriately get that money to the educational institution the in the American Health Security Act that Congressman McDermott introduced in the house and I introduced in the Senate Congressman McDermott is the doctor himself. We put a very strong emphasis on research and academic centers of excellence. One of the things that really saddens me right now is that I think and you see it in the NIH budget as well that it's myopic to really cut down on some of the research end because we're so much further ahead and I look at some of those budgets for research and any number of different areas and it really saddens me because people will come in and into my office and some will be talking about what can we be doing in Parkinson's somebody else will be talking about breast cancer. Somebody else will be talking about Alzheimer's and what happens is you find one group of people struggling with illness pitted against The group and I think the research part and the centers of excellence is absolutely critical if Senator durenberger and I are going to be exchanging Barb's. I'll pick up the level a little bit and I will just say to the good Senator that Medicare has its faults. But if you ask the caregivers. What their experience is with Medicare? Given what some of them have to put up with right now with the worst of managed competition, especially managed competition run by third-party outside providers. They will tell you a different Tale. And while it is easy to put down Medicare and I've heard the put down of government more than once I want to make it crystal clear to Senator durenberger that in the case of my mother and father and in the case of many of your families as well. If not for Medicare passed in 1965. It would have been total economic Devastation for many people who are not wealthy and do not have their own Capital Medicare has made a huge and positive difference hasn't gone far enough because it doesn't cover catastrophic expenses hasn't gone far enough because it doesn't cover a prescription drugs, but make no mistake about it ask older Americans and ask their children and grandchildren whether they would have preferred that we not pass Medicare or have a Medicare program. Well, there's no one that you're on this platform with that has ever advocated getting rid of Medicare and Medicaid. I was the author of The catastrophic act that added catastrophic that added prescription drugs that added long-term care. There is no argument about the value of providing Universal coverage for the last whatever it is now 25 30 years. There is an argument that says unless we change that system. We are depriving all elderly and disabled Americans are kind of care David. There isn't all were talking about is how to read no. No, there is an argument David because the reason That the president and mrs. Clinton differ so sharply with you on this kit on this question. The reason that I do is you don't provide for Universal coverage you don't we do for the elderly or talking about the oh now I'm to you just mentioned Universal coverage and when it comes to older Americans, I'm just simply reminding you when you engage in these Nifty put-downs of these government programs. All of which could be improved as could Social Security. Please remember that for the beneficiaries, they represent the difference between being able to survive and not survive. No one's claiming heaven on Earth. I just simply want to remind people what's at stake here Kent. We've got a question or thank you senators from Steve spring rose. He's the president of a medical equipment manufacturer in Plymouth. Senator wellstone I pay for the insurance for 40 individuals and I've run the numbers in the Clinton plan and my insurance costs would double under that plan and would wipe out our entire profits for the year and we happen to have hired a sales manager who lives in Canada and this person can't wait to get out of there. We're trying to get him a green card and I pay his insurance and I can tell you for what I pay. Its no bargain and I guess what I'm seeing from where I sit is that the programs that are being proposed are not helping this small business. Well, there's two issues here one is the president's plan and and one is a single-payer. Let me try and both real quickly on the president's plan as you know, it's a sliding scale from I think 7.9 percent down to three point two percent. And that's based upon number of employees and also based with that's the cap and also and also based upon Prophet made. I think it's a pretty good Progressive sliding scale from all that. I've heard your experience sounds like you don't think it would work so well, but that's the that is the basic underpinning of the president's plan in our plan. I will just tell you two or three things number one that given the Cost Containment and the amount of money saved one of the things that business people worry. The most about is they don't they don't mind paying a 6.5 percent payroll tax, which of course depends on how many employees you have is to how much you pay but they want to make sure that it isn't just open ended and it goes up and up and up and up. I think one of the strongest features of our plan is the Cost Containment on Canada while every planet is an American plan. I think what they do best in Canada is they streamline the administration of it I think will do much more with health maintenance. Shins, I just would simply say to you that your experience with your employee. I mean everybody has their First Amendment right to you know, say they agree or disagree with the plan. But boy you compare the public opinion polling in Canada and the United States and its startling New York Times had a piece 97 percent of the people in Canada support their Health Care System. That's pretty strong overwhelming support. Marty thank you. We have a next question. The the Clinton plan is you've already factored out the Clinton plan. I'm going to give you some figures on the single-payer plan and I'm just reading from the bill and you can take these home and see what you can do with that increases the corporate rate of Taxation four percent increases personal rates between three and ten percent depending on what brackets you're in. It's the first bracket is up 3% And then the the highest bracket people make over a million dollars. It goes up 10% the the pay employer health insurance payroll tax increases the 7.9% just the same as in in the Clinton Bill. It increases the amount of Social Security tax subject to taxation up to 85% which we've already done. So I'm assuming they'll have to get money for that somewhere else it disallows 20% of advertising expenses and requires amortization of the balance over four years re imposes withholding taxes on there's a variety of other other. Taxes and that's the cost side of a single-payer bill that Paul hasn't yet talked about and the cost and the other cost side of it which is sort of interesting what we including what we don't include is that we costed it out. There's not one person in this room nor one citizen who should be treated. As if they're anything less than fully intelligent you pay for health care one way or the other we're paying nine hundred billion dollars a year plus as a nation you pay out of one pocket or you pay out of the other and it is true that you pay less you either pay out of one pocket with your private health insurance plan that costs you money. And in addition what's not covered and in addition to dr. Bowles and co-pays and in addition what you pay for all the uncompensated care that's transferred to you or you pay out of another pocket which goes into a health care trust fund single-payer. That's all it goes for with Cost Containment for the bottom 95% of the population people pay less out of that pocket. Thank you. We have a next question here from Tom Swain who is chair of the Minnesota Healthcare Commission. Yes, gentlemen, my question is not how we're going to get to nationally to Health Care reform but a concern about the share of minnesotans are going to have to assume and accomplishing this let me just set the stage first. We have unsurpassed quality of Health Care in Minnesota. Nobody touches us and in terms of cost were already about 18 percent below the national average in cost make one National employer based here told us that cost for their Minnesota employees are 15 percent below the national average and in California, it's 36 above. So we're doing well in the Medicare side of it Medicare now covers to Minnesota senior citizens for what it covers one in Philadelphia has some money left over so or already through medicare premiums and tax burden subsidizing. They very high health care costs and the rest of the nation where it would appear a little effort has been made to do much about accomplishing Cost Containment, which we've done well here and are doing something further and the next level and the cost of covering the uninsured Minnesota's down to about 7 percent of its population uninsured. That's not very not something to be proud of we've got to do better, but it's half of what the national average is at 14% Mississippi is 20% So when we go to cover these people that considering the political superiority in terms of Congress people in New York, Florida, Texas California other high-cost states, it seems inevitable that Minnesota already assuming more of its Fair burden will be called upon to further subsidize the health High health care costs and the coverage of uninsured elsewhere. Now if that premise is correct, what are we going to do about? How are we going to ensure that? We don't end up picking up the tab for the lack of effort and other states to accomplish what we've already done. I think it's I think it's last a lost forward. I'm I'm smiling Tom because I think it raises a kind of an interesting dilemma because I think most of us are committed to the proposition that you want to decentralize this and you want to leave it up to the states. I mean, I'm committed to the proposition that the package of benefits a set of the federal level. I think that's the way it should be. That's the national part, but then you get into what states really have the capacity to really change some of their delivery and to do the kind of negotiation and bargaining that's necessary to do. So, if you wanted to make it national National obviously and set National standards and with all of the monitoring and compliance that you didn't call for it you could you could get a better handle on what you're talking about. My guess is that what we'll end up doing in the in the final bill that's passed is we will have some fairly clear guidelines that have to be met with some monitoring with some some pressures on states and And the right kind of incentives as well. I don't think that's going to completely solve the problem. However, we are further ahead as are some other states and their many behind and I think I think you kind of I don't know that there is a way in terms of public policy of making it a rectifying the problem that you're talking about. Of course Santa hats number. Yeah, just trying to get to the the ultimate of what what might pass and so forth and looking at the looking at the Senate and where senators are at right now and in part this I believe this this gets to the answer to your question and I may have this wrong and Paul said six co-sponsors and I only have I only have four on your on your bill. Maybe I have more but as far as I know when when the pardon they do have a I've got Danny Inouye on hard nuts and Bob and Carol Moseley Braun and Paul Simon is co-sponsors, but what what happened when when health and Feingold, pardon me, but anyway right when when I count when the president When the president introduced his bill most if not, all of Paul's co-sponsors signed onto the presidents bill and the significance. They didn't leave Paul's bill. I mean they're they're also on the single-payer bill, but the significance of that is that there is an interest among everyone in managed competition. The more interesting thing is that 22 Democrats did not sign on to the President Bill. And I think that's because the presidents bill, you know, they're not on Paul's Bill and they're not on the presidents bill and I think that's because they want to know more about how managed competition works and they don't like the regulatory aspects of this bill 32 states in this country are like Minnesota there below a national average in their Medicare reimbursements and everything else and they would like to know that National rules and local markets really work that regulation doesn't work because if you put a budget across this country or state by state, if you put on premium controls you put on price controls, you penalize all the 32 good States and I think those people are just waiting for the opportunity to get the clintons to move in the direction of pure managed competition one last quick question quick response David the just just you know, it's always two two views here the six I count so I'm five and Russ. Strong single-payer supporter as well. And then there's another working group as you as you well know with Tom daschle and others but the point is the single-payer people one interesting thing, which I think is kind of a common ground here baby. Is that the reason that we decided I think you remember the last second negotiations for some single-payer supporters to support the president's plan is that we were we were able to obtain language which makes it clear that if States want to opt for single-payer option they can do so, I'd personally like to see states have an opportunity to try some different things and then we take a look at what works and what doesn't work. That was the why that negotiation there's I have a quick question here from Bill when Mark who is the president of the National Association for Ambulatory Care great thank Senators. Just a quick question. I have a honor of sitting at the Metropolitan waste commission's table here and there are certainly close to the bottom of the food chain. But as a provider with 33 practices here in the Twin Cities, I can tell you that I feel on behalf of 25,000 Physicians that primary Are that we feel like we're at the bottom of the food chain, and I can tell you about ownerís Federal legislation that has been on our backs to carry for many many years. I'm concerned desperately with what we hear from our patients. And that is they don't want anything to do with a government-run system. In fact, the clear statement is that 43 percent of the of the federal budget right now is medical-related entitlement programs. And the only reason the government wants to control a trillion-dollar industry is to get some more cash flow. Clearly that is not something that we want to bear as a burden out here is providers. Very quickly, maybe one one point and I know how close we can beat agreement on this that hasn't been a lot of things. We haven't covered unfortunately, but one of them about the benefit package and mrs. Clinton told us both very honestly that when they describe the benefit package they got very specific e58 page has a very specific procedures and everybody goes to look at it and see whether they're in there. They're not in there and and then they want to get in or whatever the case may be ours is a very comprehensive approach. It's only five pages and it says all all of the preventive and wellness diagnostic therapeutic and rehabilitative services that are necessary to keep the member well and to and to restore their medical health and then we leave to the health plan to decide how most appropriately to do that. And I think that is a one of the things that the clintons right now are hung up on is this pricing pricing thing. You know, how much will it save how much can you use for? For Universal coverage and every time somebody says you're not going to be able to get that savings over here. Then they have to take a benefit of Paul and all of us argue like mental health and so forth. They have to keep taking benefits out of their specific package in order to get their thing to bottom Out hours relies on the fact that you can get more benefits more better services to people if in fact you allow the health plan to meet people's needs in a local community at the local level. Well, I think that there's a it is a significant difference because I think the problem is first of all from the point of view primary care I couldn't agree with you more and I think we put a strong emphasis on that and again, I would argue that especially among family docs and nurses pediatricians interns strong support because again, we're not taught we're talking about private sector and we're talking about really emphasizing with the right incentives primary care. I think the problem with keep it having very kind of nebulous language as to what benefits will be included in what won't and Even it up to the plans is it depends upon the amount of money you have to buy what kind of plan and you know, this is an obvious difference. I believe that each and every citizen ought to receive high quality Healthcare and I would be very worried if we sort of left it Broad and then said each plan designs and then people go out on buy it on the basis of what they can afford that takes us right back to all of the tears and all the stratification and then finally on your 40% figure. You're right. That's absolutely correct. Now one of the problems of course is that when costs are saved somewhere in the system and people aren't covered in this way or that way then it gets thrown onto the public sector. I mean, you know, we don't deny people Health Care in this country. Somebody does have to pay for it. And I think we have to remember that that's the public sector part all too often. I promised you all genuine passion and I think you'd all agree. We got just that.