Remarks by the President in Discussion of Insurance Coverage at Bipartisan Meeting on Health Care Reform

February 25, 2010

SENATOR McCONNELL:  Mr. President, Dr. John Barrasso is going to make our opening statement on coverage.

THE PRESIDENT:  And then I will call Henry Waxman, and we’ll just go back and forth.

SENATOR BARRASSO:  Thank you very much –

THE PRESIDENT:  And because we are short on time, let’s keep our remarks relatively brief.

SENATOR BARRASSO:  Thank you very much, Mr. President.  For people who don’t know me, I practiced medicine in Casper, Wyoming for 25 years as an orthopedic surgeon, taking care of families in Wyoming.  I’ve been the chief of staff at the largest hospital in our state.  My wife is a breast cancer survivor.  Bobbi has been through three operations, a couple of bouts of chemotherapy.  We’ve seen this from all the different sides of care.

And this discussion needs to be about all Americans because everyone is affected, not just people that don’t have insurance.  And I’ve had dozens and dozens of visits to senior centers and town hall meetings, and visited at service clubs, and if you go to any community in America and you ask the question, "Do you believe that this bill up here — that this bill, if it becomes law, do you believe you will pay more for your health care, you personally?"   Every hand goes up.  And then you say, "Do you believe if this bill becomes law, overall health care in this spending — its spending in the country will go up?"  Every hand goes up.  And then you ask the most personal question of all, "Do you believe if this bill becomes law, the quality of your personal care will get worse?"  Every hand goes up.

And most worried of all are the seniors, when you go to the senior centers, because they know there’s going to be $500 billion taken away from those who depend upon Medicare for their health care, and it’s not just Medicare Advantage.  It’s hospitals; it’s the doctors; it’s the nursing homes; it’s home health, which is a lifeline for people that are home alone; it’s hospice, for people in their final days of life.  That’s all going to be cut.  That’s why the seniors are most concerned.

And even the White House own actuary if this goes into play, one in five hospitals, one in five nursing homes will be operating at a loss in 10 years.  That’s what we’re looking at.

Now, for 25 years practicing medicine I never asked anybody if they were a Republican or a Democrat or an independent; didn’t ask if they had insurance or not; took care of everybody.  And many, many doctors — I know Dr. Coburn, Dr. Boustany — do that, we take care of everyone, regardless of ability to pay.  Doctors work long hours; nurses work long hours.

And, Mr. President, when you say with catastrophic plans, they don’t go for care until later, I say sometimes the people with catastrophic plans are the people that are best consumers of health care in using the way they use their health care dollars, because a lot of people come in and say, my knee hurts, maybe I should get an MRI, they say, and then they say, will my insurance cover it?  That’s the first question.  And if I say yes, then they say, okay, let’s do it.  If I say, no, then they say, well, what will it going to cost?  And what’s it cost ought to be the first question.  And that’s why sometimes people with catastrophic problem — catastrophic health plans ask the best questions, shop around, are the best consumers of health care.

But to put 15 million more people on Medicaid, a program where many doctors in the country do not see them, as Senator Grassley said — you know, you say, how are you going to help those folks?  And, Mr. President, when I talk to doctors, they say, I have a way:  Put all the doctors who take care of Medicaid patients under the Federal Torts Claim Act.  That will help them, because they’re not getting paid enough to see the patients.  But if Medicare — if they accept those patients and then their liability insurance is covered under the Federal Tort Claims Act, I think you’d have a lot more participation in that program.

I do believe we have the best health care system in the world.  That’s why the premier of one of the Canadian provinces came here just last week to have his heart operated on.  He said, “It’s my heart, it’s my life.  I want to go where it’s the best.”  And he came to the United States.  It’s where a member of parliament — a Canadian member of parliament with cancer came to the United States for her care.  They all have coverage there, but what they want is care — so coverage does not equal care.

What we heard from Senator Conrad is also right.  Half of all the money we spend in this country on health care is on just 5 percent of the people.  Those are people, for the most part, that eat too much, exercise too little, and smoke.  And as a result, we need to focus on those people.  So the focus ought to be on the best possible care.  People are happy with the quality of care they get, the availability, but they sure don’t like the affordability because it’s not affordable.

And, you know, Mr. President, the first week in medical school we got our stethoscopes and the professor of cardiology, who just died this past year, he said, this is to listen.  This is to listen to your patients — listen to their heart, listen to their lungs, but it’s a constant reminder to listen to them, listen to what they are telling you.  And it means to listen to the other people in the room.  If you’re seeing a child, listen to what the mother is saying.  If you’re with an elderly person, listen to what their adult child is saying.  And it’s a constant reminder to listen.

And I have great concerns that people around this table are not listening to the American people and are fearful of the consequences of this large bill, which is why only one in three people in America support what is being proposed here.  And that’s why so many people, Mr. President, are saying it’s time to start over.

THE PRESIDENT:  Let me just — there’s one thing I’ve got to — there are a number of issues, as usual, that I’ve got significant difference with.  I’m just am curious.  Would you be satisfied if every member of Congress just had catastrophic care? Do you think we’d be better health care purchasers?  I mean, is that a change that we should make?

SENATOR BARRASSO:  Yes, I think actually we would.  We’d really focus on it.  You’d have more, as you say, skin in the game — and especially if they had a savings account, a health savings account.  They could put their money into that –

THE PRESIDENT:  Would you feel the same way if –

SENATOR BARRASSO:  — and they’d be spending the money out of that.

THE PRESIDENT:  Would you feel the same way if you were making $40,000, or you had — that was your income?  Because that’s the reality for a lot of folks.  I mean, it is very important for us — when you say, to listen — to listen to that farmer that Tom mentioned in Iowa; to listen to the folks that we get letters from — because the truth of the matter, John, is they’re not premiers of anyplace, they’re not sultans from wherever.  They don’t fly into Mayo and suddenly decide they’re going to spend a couple million dollars on the absolute, best health care.  They’re folks who are left out.

And this notion somehow that for them the system was working and that if they just ate a little better and were better health care consumers they could manage is just not the case.  The vast majority of these 27 million people or 30 million people that we’re talking about, they work every day.  Some of them work two jobs.  But if they’re working for a small business, they can’t get health care.  If they are self-employed, they can’t get health care.

And you know what, it is a scary proposition for them.  And so we can debate whether or not we can afford to help them, but we shouldn’t pretend somehow that they don’t need help.  I get too many letters saying they need help.

And so, I want to go to –

SENATOR BARRASSO:  Mr. President, having a high-deductible plan and a health savings account is an option for members of Congress and federal employees –

THE PRESIDENT:  If — that’s right, because members of Congress get paid $176,000 a year.

SENATOR BARRASSO:  — 16,000 employees did take advantage of that.

THE PRESIDENT:  Because they –

SENATOR BARRASSO:  And so, it’s the same plan –

THE PRESIDENT:  — because members of Congress –

SENATOR BARRASSO:  — that the Park Rangers get in the Yellowstone National Park.

THE PRESIDENT:  John — John, members of Congress are in the top income brackets of the country.  And health savings accounts I think can be a useful tool, but every study has shown that the people who use them are folks who’ve got a lot of disposable income.  And the people that we’re talking about don’t.

Let’s go to Henry.  Henry Waxman.

REPRESENTATIVE WAXMAN:  Mr. President, I just wonder if some of our Republican friends would like to have seniors on Medicare have catastrophic coverage only.  I’d say to the seniors in this country, and we’ve heard mention of them being the people who are worried about this Medicare — this health care bill — they ought to worry if we don’t do something.  Because not only will we hear ideas of putting them on catastrophic coverage only, because that will save a lot of money — Paul Ryan has a proposal right now to say that Medicare recipients in the future ought to have just a little voucher, and then they can shop for their own insurance.  They could be prudent shoppers.

Well, yesterday I had a hearing with some people who were supposed to be prudent shoppers.  They were people from California who were told by Anthem Wellpoint that their insurance was going to go up 30 percent — 39 percent.  And could you imagine, seniors, if you have to go shopping with your voucher and then you’re told, oh, by the way, this private policy that you’re going to have to buy just went up 39 percent?  And the way to save the federal government money is to shift it on to the seniors.  That’s where we’re going if we don’t do anything.

Now, what do we do that makes sense?  We’ve got to hold down health care costs.  You can’t — we had some ideas that we seem to agree about to hold down health care costs.  One idea I did find peculiar, and that’s to have the medical malpractice issue at the federal level.  And the Republican proposal is to adopt the California law.  Well, the California law is in effect.  It’s been in effect since the 1970s.  And Californians are faced with a 39 percent increase, so it isn’t holding down their health care costs.  We’ve got to really look at holding down health care costs.  That’s hard to do, unless we have insurance reform so we could get more people buying health care.

I thought Tom Harkin just summed it up so well.  All these issues go together.  If you don’t bring more people in to be covered, segment the groups that are covered in high-risk pools, they pay more money — everybody else is going to get a break.  Well, under the Republican proposal, the people who get a break for insurance are the people who are healthy.  The people who have to pay more are the people who are sick.  Is that what we want in this country?

Now, I hear people all day say, Mr. President, the public doesn’t want your plan.  Well, if I heard the kind of rhetoric over and over again that I’ve heard from some of the Republicans, I wouldn’t want your plan either.  A federal takeover of health care?  That’s not what’s being proposed.  Somebody said that people ought to be able to buy a policy that suits their needs.  Well, how many people are going to come forward and say, I don’t want certain things covered — and then find out that they’re sick and they need that coverage.

We need to have a market like the federal government employees, like members of Congress.  We know what we can choose.  If somebody wants to choose a health savings account, that means because they want to put some of their money away because it’s tax-free and it’s a really great deal if you got a lot of money.  But most people want to know they’re going to have necessary medical coverage for the doctors and the hospitals when they need it.  And you have something that’s basic to everybody.  Well, they ought to have that for people who are buying private insurance as well.

We had three witnesses yesterday.  A woman told us that in her family she had a child with a hole in the heart.  And that — because — that became a preexisting condition.  So she has health insurance coverage through this individual market.  But she says, "I barely use it, because I’m just — I’m afraid to use my health insurance."  She is now told she is going to have this 39 percent increase.  She said her health insurance is going to cost her about as much as her mortgage payment each month.  She is afraid to drop it, because she doesn’t know where she could ever get health coverage again.

Another woman had asthma, and that was considered a preexisting condition.  She was going to face a 39 percent increase, as well.  Now, if they were pooled with everybody else in that small business and individual market, which is what our bill does, then there are more people buying insurance and there’s more — there’s more leverage.  It’s spreading the cost, not making people have to pay more of these costs.

The people who we’re talking about are people in small businesses where the small business can’t get insurance because, well, they got one employee with a real serious medical problem.  So nobody in that group is going to get coverage, the employer can’t afford it.  Or women, it costs more for small businesses if they’re in that workforce, especially if they’re older.  They don’t want to get coverage.  They don’t want to give them coverage either.

We have single adults, a lot of them not very healthy, dealing with chronic conditions, parents and families living on low incomes.  They need help from Medicaid.  We have to hold down the cost by bringing everybody into the system.  Now, in Medicare, what does our bill do?  It protects the solvency of the program for an additional seven to nine years.  For Medicare, we close the doughnut hole, which means that when seniors have to pay for those prescription drugs, they don’t have to do it all on their own.

We keep them with a Medicare policy, and we provide preventative services and they don’t have to pay for them because we know preventive services will keep us from having to pay for more costly care.

This bill is good for people on Medicare and if we don’t get this passed they’re going to get squeezed like crazy.  This bill is good for the American working people.  This bill is good for our health care system.  And for us to take the Republican proposal — we cover instead of 30 million people, 3 million; we wouldn’t hold down the deficit a bit; we would still have all those preexisting conditions that would keep people from getting their insurance coverage.  Maybe if people go and pretend to be patients we could stop some of those false claims, but I’m sure those false claims happen in the private insurance market and not just the public insurance market.

But not only are we covering more people, we’re doing innovative ways to deliver the care that will make it less costly.  And as we develop innovative ways to deliver care, especially with chronic care, that will hold down the costs of care and those ideas would be picked up by the private sector.  They always follow what Medicare does and then they adopt it because they want to hold down costs.

So you can’t solve any problem — insurance reform, holding down costs, protecting Medicare, dealing with the deficit — unless you deal with it all.  And Mr. President, you’re not going to be able to do this piecemeal and I have doubts about whether the Republicans are going to help you because I haven’t heard a lot of willingness to come and work with you now or did I hear it a year ago — I hope I’m wrong.

THE PRESIDENT:  Well, I’m going to be equal opportunity here and say we’re not making campaign speeches right now.  And I think your points I agree with, but I still think that there’s a lot of areas of agreement that we’ve discussed so far.  This is an area, though, that — in which we do have some philosophical disagreements.  And so what I — I think it’s — I want to go to a Republican.

The question I would ask to my colleagues, my friends on the Republican side, would be, are there areas of coverage for people who don’t have health care that you would embrace and agree with beyond what has been presented in Republican Leader Boehner’s bill.  There may not be.  I mean, that may be sort of the threshold at which all of you think we can afford to provide help to people who don’t have coverage, but there may be some other ideas that haven’t already been presented or aren’t embodied in your legislation, John, that I’d be happy to hear about.

REPRESENTATIVE BOEHNER:  I want to yield to Peter Roskam from Illinois.

REPRESENTATIVE ROSKAM:  Thank you.  Mr. President, thanks for your hospitality.  For the benefit of the group I want to take you for a couple of minutes to an experience that I had with then-State Senator Obama in the state of Illinois when he took on a very controversial initiative regarding the death penalty situation.  And lest you think that the death penalty is sort of a junior varsity issue — it’s not.  It’s crimes, it’s claims of innocence, it’s penalties forever.  And then-State Senator Obama approached Republicans and said, look, let’s fix this, let’s recognize the problem here, let’s fix it.

But it was very different than what I sense is happening today.  What I sense is happening today is, "what is it going to take for you Republicans to vote for our bill?"  That’s the subtext that I’m getting.  My sense is that this is a problem of message, it’s not a problem with the messenger.  You’ve got an incredibly skilled messenger who has been out these past several months in joint session speeches and a whole host of other venues, interviews, talking — you’ve all seen it, you’ve all participated, you’ve all listened — and I think the American people, when the conversation first began about expanding coverage, lowering cost, were actually hopeful.

And it wasn’t just a bumper sticker — I think they were actually hopeful about what was going to be happening.  And they listened and they listened and they listened.  And my sense — now, I can’t speak for every one of your districts, but in my district they’ve become increasing disappointed with what they have seen come out of this process.

And this is not a prop — this is the Senate bill.  And my district says, you know what, that’s sure looking like just something that’s now being popped in the microwave, taken out, a little salt, a little pepper, some Republican bread crumbs on the top, and put it back in front of the public to say, well, do you like it now?  And my district really doesn’t.  I don’t know, I suppose you represent some districts that do.

And I think one of the problems, to get to this coverage issue, is that the premise of this bill is that coverage is expanded through Medicaid, welfare.  Speaker Pelosi a couple of minutes ago — or a couple of hours ago, actually said that health care reform is entitlement reform.

SPEAKER PELOSI:  Yes.

REPRESENTATIVE ROSKAM:  Yes.  I would put a brighter light on that and say it’s entitlement expansion.  Think about what we’re doing.  The CBO when they wrote to Harry Reid — wrote to Senator Reid a couple of months ago, they said, look, there’s about 15 million people that are going to be put on Medicaid.  And Medicaid is a house of cards.  Medicaid is not something that is serving the public very well.

The state controller in Illinois — and we all come from states with real trauma — the state controller in Illinois recently wrote that as bond rating agencies continue to downgrade Illinois rankings to the lowest in the nation, the state can’t afford further jeopardizing.

This bill, section 2001 of the Senate bill, takes away all of the flexibility as it relates to changes in Medicaid.  That is making our states I think ultimately hidebound in how they approach these things.  This is something that in my view isn’t sustainable.

Governor Brian Schweitzer of Montana said — let me give you a quick quote — "One of the least effective programs in terms of health care in the history of the country is called Medicaid.  About 20 percent of America is on a Medicaid program and they would like to shift" — "they" meaning Washington — "would like to shift it and grow it to somewhere around 25 or 30 percent."

Now, Medicaid is a system that isn’t working.  Almost everyone agrees.  But what Congress intends to do is to increase the number of people on Medicaid so that they can do it on the cheap.  It isn’t working for anybody.

Look, the foundation of the expansion is Medicaid.  And in my view, and I think the view of folks in my district and I think many, many people across America, it is a flawed foundation.  And we can do much, much better.  A Republican proposal that’s out there would reduce the number of uninsured by 3 million people.

So, look, you heard it today in many, many forms — this — you remember the old — in closing, you remember the old game you used to play as a kid, Etch A Sketch, and you’d start out with the Etch A Sketch, that little thing where you try and draw something and you dial the dials and over a period of time the more you dialed the more crazy it looked and then finally you’d say, oh, let’s just go like that and do the Etch A Sketch.

I’ll tell you what, a year’s worth of work and this is what has come up with?  The American public, as far as the ones that I have heard from, are vehemently opposed to this.  And they say, look, take the Etch A Sketch, go like this, let’s start over, let’s do incremental things where there’s common ground.  I yield back.

THE PRESIDENT:  I want to make sure that everybody gets an opportunity to speak.  But I just want to caution everybody, it’s now 4:15 p.m.  There are a number of folks who haven’t had a chance to speak.  The question I had was, were there ideas about expansion beyond the 3 million that that was in Leader Boehner’s bill, and I didn’t get an answer on it — so in addition to, and it may be that the answer is that’s all we can do.

I should point out this one issue about Medicaid that I think that’s important.  Most of the people we’d like to be in the exchange and giving them subsidies.  And I think over time (inaudible) see as an evolution, if you created a large enough pool, where people could purchase it through an exchange the same way that members of Congress do.

The problem we’ve got right now is that very poor people, they’ve got coverage through Medicaid.  And it’s somewhat flawed.  There are problems with doctor reimbursements, there are problems long-term in terms of solvency both for the state and the federal level, so all those things need to be fixed.  But the fact of the matter is if their kid gets sick, they can go to a doctor.

The people who are really left in the cold are working families who make too much for Medicaid and don’t have anywhere to go.  That’s the group that right now is getting the worst deal.  They’re paying taxes, they’re working, but they’ve got nowhere to go.

Now, for those 15 million people who’ve got nothing, I promise you they would say to themselves having some coverage through Medicaid is a pretty good deal.  I’d prefer to have them in an exchange where over time we’ve got everybody in a pool, similar to the pool that members of Congress enjoyed.  But that’s not the situation that we have right now.  I just want to remind everybody though that the group that is being left out, because you threw out the word "welfare," which is, you know, one that obviously most American people — they don’t want to be part of welfare — the fact of the matter is, is that very poor people right now have coverage that is superior to what a lot of folks who make a little more money, are working very hard trying to support their families, do not.

Now, I know that Max has been trying to get in for a while, but there are some other folks that haven’t had a chance to speak, so I want to call on them first.  And then if I’ve got time, Max, I’ll allow you to wrap up.

But I’m going to go to Chris and Murray — Chris and Patty Murray on our side, as well as Charlie Rangel who want to speak, and what we’ll do is we’ll alternate to make sure that we’ve got — and I know that Joe Barton is interested in speaking, as well, and there may be a couple of other Republicans.

Go ahead.

SENATOR DODD:  Well, thank you, Mr. President, and I’ll try and keep this brief and turn it over to Patty, so we’ll take the time for one person and divide it in two.

Let me first of all thank you as well and thank all of our colleagues who have done this.  This has been tremendously helpful I think today.

It’s been said earlier — maybe it needs to be focused, as well — like many of you, like all of you here, in my state there are 31 hospitals, and they’re terrific people.  Whether or not the quality of care is equal for everyone in this country is certainly questionable, but certainly the quality of the people who are our health care providers — the nurses, the doctors, and others — do an incredible job every single day.

And the sense — I was struck when the REPRESENTATIVE was talking about the death penalty issue that was debated some time ago in Illinois.  I think most of us around this table here would agree today that every person, if they’re confronted with a legal problem has a right to a lawyer.  That’s something we’ve accepted as a country.

It’s somewhat ironic, I suppose — and history may judge us accordingly — that while everyone was entitled to a lawyer, regardless of what you’ve been charged with, that you don’t have a right to a doctor.  And yet at the same time we acknowledge that we provide care:  If you show up in an emergency room, we take care of you.  And that’s a great testimony about who we are as a people.

The problem is of course the costs associated with that.  I think there’s a false assumption that that’s one group of people, and they’re out there, and they have no impact on what happens to those who have insurance today, and somehow they should be taking better care of themselves, they should quit smoking, they should eat better, they should get a job; that somehow the responsibility rests with them.

If you can accept that, which I don’t, the fact of the matter is that sector of our population affects everyone else.  It costs us about $248 billion a year in lost productivity when you have increased numbers of uninsured people in the country.

At this very hour, there’s a cost with every single insured person in this country of roughly $1,100 a year to pay for that cost of that person showing up in that emergency room, or getting that care.  That’s a hidden tax that Americans are paying today when people show up for that kind of support.

There are — today before we wrap up and go back to our offices and go back to our homes this evening here in the District of Columbia, 14,000 of our fellow citizens will have lost their health care today.  And every day that we’re here debating and discussing this, 14,000 Americans lose their health care.  Roughly six to eight people will have lost their lives today as we gather around this table because they’re uninsured, based on a Harvard study and National Science Foundation study; that we lose that many people on a daily basis because we lack — because they lack health insurance.

So there are tremendous costs associated with this.  Henry said it well, Tom said it well, and Mr. President, you certainly encapsulize it very well.  These are not segmented issues.  And while incremental approaches are something I (inaudible) support and approach after 30 years here in dealing with major issues, but this issue defies incremental approach.  You can’t get from one point to the next incrementally unless you deal with it holistically, and that’s really what we’re trying to do.

And you may disagree about whether or not we’re doing too much on mandates or too much here or there — and that’s a legitimate debate — but you can’t get to affordability, you can’t get to quality, you can’t deal with the major economic issues if you don’t deal with coverage.  You just can’t.  There’s no way to do it.  You’ve got to have broadening coverage if you’re going to have any effort or any successful effort in reaching those questions.

Lastly, I’ll just say this to you.  A guy in my state, Kevin Galvin (phonetic) — Kevin employs seven people, a maintenance operation in Hartford, Connecticut.  He wanted to provide health care.  And like the stories you’ve all heard, he lost a fellow of 24 years because the guy had a health care issue, he finally had to take less pay, took another job, because there was health care provided.  But Kevin did more than just tell me a story about himself, Mr. President, and what happened to his seven employees because they couldn’t get health care.

He went out in my city in Connecticut and organized 19,000 small businesses, and they changed the law in Connecticut regarding pooling in small businesses, because here was a small business guy who wanted to take care of his people and watched tragically day after day what happened to individuals because he could not provide it for them any longer.

And I think people like Kevin Galvin exist in every district in every state who want to provide that health care, understand how valuable it is to them, their productivity, and of course the importance of their employees.

But coverage is the critical issue.  We know that in the next 10 years — factually, Mr. President — in the next 10 years every state in this country will have a 10 percent increase in uninsured people.  We know that in 30 states in our country in that same 10-year period there will be a 30-percent increase in the uninsured.  And half the population under the age of 65 will at one point or another in the next 10 years be without insurance.

So it’s not some isolated group out there.  This is the critical constituency that is — this is the lynchpin that holds all of this together.  So coverage is absolutely critical.

REPRESENTATIVE BARTON:  Thank you, Mr. President.  I want to commend you for asking us to come here, and I will say that never have so many members of the House and Senate behaved so well for so long before so many television cameras.  (Laughter.)  So if we ever get to a conference committee, we may want you to be the moderator.

I do think, though, that there is a fundamental difference in the vision that you and your friends on the majority have put forward, and the vision that myself and those of us in the minority have put forward.  It’s the fundamental role of government.  We believe that we should use free markets to empower people and give them choices.  And for the best of intentions, yourself and most of your allies in the Democratic Party seem to believe that the government, either through a mandate or through a regulatory requirement, knows better and will do better for health care for most Americans.  Now, whether you have a mandate or simply give the Secretary of Health and Human Services the ability by regulation to require something, that’s a difference without — that’s a distinction without much of a difference.

So the six commonsense ideas that various Republicans have put out here is not incrementalism in the sense that it doesn’t go together, but it does not radically change the basic health care system of America.  If you give the ability to sell insurance across state lines, and prevent a state from precluding it, if the insurance company can prove that it’s solvent and that it will pay the benefit, health care costs will go down in that state and premiums will go down.

There was a study just out that in the state of California health care premiums would go down 50 percent if Californians could buy insurance from Nevada or Oregon.  If you create a catastrophic high-risk pool and put the cap on it that Leader Boehner did on his alternative on the House floor, and allow small businesses to create the kind of pools that we’ve talked about, you’re going to be able to give those Americans who can’t get insurance because of a preexisting condition and want it the ability to get into those things.  And their premiums will not go up catastrophically.  They will not go up astronomically.

And one of the things that we seem to have agreement on, according to yourself and Senator Durbin, is medical malpractice.  Now, your proposal in the House bill and the Senate bill pay lip service to medical malpractice, but they don’t really do it.  Again, if you take the Boehner proposal that was put together and put up on the House floor, and it’s based on what’s happened in Texas — in Texas, which put in medical malpractice reform in 2003 — premiums for medical malpractice have gone down 27 percent.
Texas has gained 18,000 doctors since this reform was put in.  There are 55 rural counties in Texas that now have an obstetrician.

If that is extrapolated nationally, you’re not going to save the $54 billion that Senator Durbin alluded to and that yourself alluded to.  If you combine the direct savings with the indirect savings, because the price of practicing defensive medicine goes down, you’ve probably saved $150 billion a year.  Now, that’s real money.

So what we’re saying, Mr. President — we’re not talking about incrementalism.  We’re talking about, as Leader Boehner said and Mr. McConnell — Senator McConnell said, let’s start over in the sense that we change the vision and work together to do the things that we agree upon, but do it in a way that doesn’t destroy the fundamental market system that’s made the American health care system the best in the world.  And if we do that, we can make a deal.

Thank you, Mr. President.  Thank you, Leader Boehner. 

THE PRESIDENT:  Joe, I’ll respond to you right (inaudible) because I think we should wrap it up.

You’re right, the proposal that John Boehner has put forward doesn’t radically change the existing system.  And that I think is why 3 million out of the 30 million who don’t have coverage, or 40 million, don’t get coverage.  The proposal that’s been put forward by the House and the Senate Democrats also doesn’t radically change it in the sense that the vast majority of people who currently have health care will still get it, it’s just they’ll see it a little cheaper.  People who do not have coverage will start getting it.  So that’s — it’s not — neither of these proposals are radical.  The question is, which one works best for the American people?  And that’s what we’ll see if we can determine.

We’re running short on time.  I know that some folks are going to at some point have to get going.  I am going to reserve the prerogative of making sure that everybody who has not had a chance to speak is allowed to speak, and then I will wrap up.  That means that we’re probably going to go a little bit later than we had anticipated.  But, as I said, by the standards of Washington, we’re still in the ballpark here.

I’m going to call on Charlie Rangel first.  We’ll go to one of our Republican colleagues.  Patty Murray is going to have an opportunity to speak.  Again, there may be some comments — there may be some other Republicans who are interested in speaking.  We’ll go to — we’re going to actually go to Ron Wyden first.  Then, we’re going to go to another Republican.  And we’re going to end with John Dingell, who was there when the idea of everybody having health care was first introduced by his father many decades ago. 

REPRESENTATIVE WAXMAN:  Mr. President, why don’t you just call on Republicans who haven’t talked, because some of them have talked numerous times?

THE PRESIDENT:  I agree, but I want to make sure that they may want to respond to whatever is said.  Go ahead, Ron.

SENATOR WYDEN:  Thank you very much, Mr. President.  And I think this has been a very constructive session.  For the last six hours, we have essentially heard Republicans talk about incremental coverage and Democrats talk about comprehensive or broader kind of coverage.  And I want to outline something that I think could bring both sides together for just a couple of minutes.

First, on the incremental point, the evidence shows that incremental reform not only does less, it costs more.  And the experts that both Democrats and Republicans rely on have found this — the Lewin Group, for example, that Republicans quote from, they say that and both sides use them.  Also, history.  We have been doing incremental reform in this country since 1994.  Since the blowup of the Clinton plan, that’s exactly what we’ve been doing, and costs have been gobbling up everything in sight in the private sector and in the government. 

So I would submit that instead of this debate about incremental reform or comprehensive reform, we could all be for real reform.  And real reform, in effect, changes the incentives that drive the system and particularly empower the consumer.

Mr. President, I’ve been very pleased that you’ve constantly been coming back to the system for members of Congress.  Folks, all of us can fire our insurance company, every one of us.  And as far as I’m concerned, we’ve got to stay in this battle until everybody in the United States has that right to hold the insurance companies accountable and to fire them. 

And one of the promising points you made this afternoon, Mr. President, that I appreciate is the point on interstate shopping, because this is another opportunity, in my view, done properly — properly to empower the consumer.  Now, colleagues, our system — the one that we enjoy — already allows interstate competition for health insurance.  That’s the way the federal system works right now.  And there are good consumer protections. 

So, Mr. President, when you made that offer to all of us today to work with us on this, not only am I going to follow up on what I think is a very gracious offer to try to bring both sides together, it allows us to build on the exchanges that we have today, which begin to empower people with more choices and competition.  And if we just keep building on that, starting with this effort to bring both sides together on interstate competition, looking in my view at the federal employee system to do it, I think we can resolve a lot of our differences.  So I appreciate the opportunity to speak, Mr. President.  I want colleagues to know that I’m going to be following up with both sides of the aisle this afternoon and your administration to bring this group together.

SENATOR McCONNELL:  Mr. President, all of my members have had a chance to speak at least once, several of them a number of times.  Jon Kyl reminds me that the HSAs, for example, are not exactly for rich people; that the median income of a user of a HSA is $69,000 a year.  All of us are representatives of the American people, but I have a feeling we haven’t been listening to them very carefully. 

REPRESENTATIVE Roskam mentioned what the people in his district think, and I expect all of you are experts on what the people in your districts think.  But we know from the polling that’s been done in this country how the American people feel about this 2,700-page bill.  We know how they feel about it.  This is not a close call.  If you average all of the polls in America, we know that the American people oppose this proposal by — on an average of 55 to 37 percent. 

They have also been asked — and we keep reading in the newspaper that where we’re headed next is to the reconciliation approach.  Well, Gallup also asked that question.  It explained to the American people what it meant so they understood what this word that we use around Washington actually means.  And in the Gallup poll, the American people were opposed using that, 52 to 39 [percent]. 

So this has been a fabulous discussion, Mr. President.  We have a lot of experts around the room.  But I think it’s really important, since we represent the American people, that we not ignore their view on this.  They have paid attention to this issue like no other issue since I have been in the United States Senate.  Health care is a uniquely personal issue.  Obviously, you get more interested in the subject the older you get.  But every American cares deeply about the quality of their health care, and access to health care and cost of health care.  They have followed this debate like no other, and they have rendered a judgment about what we have attempted to do so far. 

The solution to that is to put that on the shelf and to start over with a blank piece of paper and go step by step to see what we can agree on to improve the American health care system, which is already — as all of us agree — the finest in the world.

THE PRESIDENT:  I’m just going to make this remark, and then I’m going to call on Patty Murray — I’m going to save the two lions of the House here for the end — because there’s been a lot of comments from every Republican about the polls and what they’re hearing from their constituents.  And, as I said, I hear from constituents in every one of your districts and every one of your states.  And what’s interesting is actually when you poll people about the individual elements in each of these bills, they’re all for them.  So you ask them, do you want to prohibit preexisting conditions?  Yes, I’m for that.  Do you want to make sure that everybody can get basic coverage that’s affordable?  Yes, I’m for that.  Do you want to make sure that insurance companies can’t take advantage of you and that you’ve got the ability, as Ron said, to fire an insurance company that’s not doing a good job and hire one that is, but also, that you’ve got some basic consumer protections?  Yes, we like that. 

So polls I think are important in taking a temperature of the public.  If you polled people and asked them, is the system working right now and should we move forward with health reform, they’d also say yes to that.  And my hope had been, and continues to be, that based on this conversation there might be enough areas of overlap that we could realistically think about moving forward without — without a situation in which everybody just goes to their respective corners and this ends up being a political fight, because this is something that really has to be solved.

We’ve got three people who have not had an opportunity to speak today.  If you don’t mind, I will — would like to, in the interest of time, just go ahead and let each of them speak.  If there’s an intervention that somebody on the Republican side wants to make, then I will recognize them.  Then I will allow anybody of your choice, Mitch, to wrap things up.  I think Speaker Pelosi may want to say just a quick summary of what she’s thinking.  And then I will talk a little bit about next steps.  And if everybody could keep their remarks relatively brief, that’d be very helpful.

Patty.

SENATOR MURRAY:  Mr. President, thank you.  And this has been I think a very good discussion.  And I think all of us come to this table today having heard a lot of stories and talked to a lot of people and bring their passions with us today.  And I certainly am one of those.  And every time we talk about this — every time I think about this, I remember a little boy that I met last spring who is 11 years-old, whose name was Marcelis (ph).  And he told me that his mom, single mom, taking care of him and his two younger sisters, was going to work every day, had a job managing a fast-food restaurant, was doing okay but she got sick.  And when she got sick she had to take time off from work and because she was missing so much work she lost her job.  When she lost her job, she lost her health care.  And because she lost her health care, she couldn’t get in to see a doctor, and sadly, Marcelis’s mom died. 

I think about him every time we talk about this bill.  And what happened to her is happening to so many Americans who when they get sick today don’t have any choices.  They have nowhere to go.  Either they don’t have insurance or they’ve been denied insurance because they don’t — because they have a preexisting condition or they’re a small business whose premiums have gone up so dramatically that they can no longer afford to provide it for their employees.  Too many Americans today are in a box and they don’t have a choice.

Frankly, it’s why so many Americans today are passionate about a public option.  It was a choice for them that they felt was important to them.  But in the bill that you have presented and that we’ve been working on that is so important is it finally gets some people out of that box of no choices — by giving them an exchange that they can go to, by taking care of the insurance reforms so they’re not denied coverage, by opening up community health centers so people have choices, by making sure that we lower the cost for all Americans because when we provide coverage for 30 million Americans it lowers the cost of everyone who has insurance today by $1,000 a year a family — this is why this is so important. 

And what I have listened for today is whether the alternative proposal that has come before us gives people those choices that they need.  And that’s what I’m listening for and I go back to Marcelis and I think, will that proposal make sure that nobody loses their mom again because they didn’t have a choice?  And that’s why it’s so important that we move forward with what we have and open that door for so many Americans.

THE PRESIDENT:  Thank you.

SENATOR McCONNELL:  Mr. President, Dr. Coburn.

SENATOR COBURN:  If we don’t think about what the key goal is — the key goal is to reconnect purchase and payment so we become good purchasers.  Whether we create — what system we do, if we don’t reconnect the mechanism of payment with purchase, we’re not going to get good value out of our health care system.  And I outlined one out of every three dollars that doesn’t help anybody get well, doesn’t prevent them from getting sick.  And there’s enough potential there in that pool of money that we don’t have to have the government run it.  What in fact we can do is we can create and allow that money for everybody to have the kind of access that Senator Murray wants that individual to have.

The thing that I think is — draws us apart is the level of involvement in the government in making those choices.  And I would just put forward to you that we ought to have another talk like this as we can get closer and closer on some ideas because we all want the same thing, but how we get there, whether or not we’re in charge of it or the individual patient is in charge of it, personally making their own choices with the asset value that is capable, based on what we’re already spending in health care.  We don’t need to spend a penny more in health care in this country.  What we need to do is spend it much more wisely and much more effectively.

THE PRESIDENT:  I’ll pick up on some themes in my close.  Charlie Rangel.

REPRESENTATIVE RANGEL:  Thank you, Mr. President, and I appreciate the fact that you saved the best for last.

THE PRESIDENT:  Absolutely.  (Laughter.)

REPRESENTATIVE RANGEL:  I had really hoped that when we came here that we were really going to push over the top.  We are so close to national health insurance, we are so close to allowing people that go to work every day and don’t know what can happen to them when they lose their job and lose their health insurance.  I know that they call the Senate the upper house, but I was amazed how it seems as though they believe the American people only listen to those from Wyoming and Kentucky.  But having said that, for my New Yorkers, even though we have more self confidence than we need, I would want them to know that they are Americans and that we do listen to them and that the states that oppose this great plan, doesn’t speak for all of America.

Having said that, some people have called those who oppose us as being the "party of no."  I don’t think so, notwithstanding the fact we got five Republicans from the Ways and Means Committee here at your summit.  Now, we spent hundreds of hours in three committees and Ways and Means and there wasn’t one bill before us.  And I would think that instead of taking the President’s time, that this is where the House and the Senate would take care of legislative business, especially if we agree on 70 percent.  For God’s sake, then, for the 10 or 20 percent, why do you say scrap what we got unless it ends up with that you have made up your mind that we’re not going to have a health bill? 

And then I would say that most all of America would find it not more difficult to understand why the bill is so big, or why we use reconciliation.  I think one of the big problems America would have is, why does it take 60 to get a majority?  And I have to explain, well, that’s the Senate and they’re different than most Americans in understanding it.

So what I would hope would happen is that we leave here not thinking that we’re going to start all over.  We can’t get back those times.  This is the last year for a whole lot of people in the House of Representatives who we believe we represent the people, too.  Why can’t we take what we’ve agreed to?  I mean, sick people, scared people, are not Republican and Democrats.  They’re Americans.  And you’ve made it abundantly clear that you have the same sensitivity, you recognize the fiscal crisis, you know what can happen to our country if we’re not educated, if we’re not strong in a healthy way.  Have staff or somebody bring together those issues that cannot be contradicted in terms of what you want.  And I know you want more than just 3 million people insured.  You can explain why it’s difficult for you to do it.  But I know you would want to achieve having most all Americans or all Americans with the same health benefits because that’s so important.

And then, Mr. President, after we start learning to agree with each other, and it’s not a question of no but it’s the Congress working its will for the good of people, then we can work out — and God knows Mr. Camp and I have tried desperately hard, and Jim McCrery before him — to realize people aren’t concerned with the debate.  They’re concerned with what are we going to produce.

And I don’t care what your color is, I don’t care what your party is, that if you’re sick you’re sick, and you don’t check out the doctor.  And they’re not going to check out whether or not you’re Republican or Democrat.

So I just hope that we can change this to a positive thing where you can say let’s leave here at least talking about what we agree on.  Let’s stop knocking each other as who’s the smartest and who’s the most patriotic.  And let’s really, then, confine the public argument to where we disagree.

And rest assured, I can assure you that they won’t be concerned with how big the bill was.  I have no clue as to how big the Social Security bill was, how large, how many pages was in the Medicare bill.  And I don’t really think that someone sick in the emergency room is concerned about the size of the bill that we are trying to help them with.

So I appreciate this.

THE PRESIDENT:  John Dingell. 

REPRESENTATIVE DINGELL:  Mr. President, thank you.  And God bless you for your leadership in this matter.  The country desperately needs you and desperately needs this legislation.  I saw the cartoon, two people are sitting down, and one of them says, "Terrible news.  Our health care rates are going to go up 40 percent."  The other guy says, "Don’t worry, good news is you’re not concerned because you have preexisting conditions."  (Laughter.)  This solves both problems, the bill.  And Mr. President, again, we desperately need your lead.

Now, having said that, when my dad started out on this years ago, Harry Truman said, you know the reason people don’t have health care in this country?  They can’t afford it.  And he was right.  And it’s still the case today.

I saw this morning a statement that was made with regard to starting over.  This comes from a respected Republican leader, Governor Schwarzenegger of California, February 23, 2010:  "I think any Republican who says you should start from scratch, I think that’s bogus talk and that’s partisan talk."

I think we need to buckle down and get to the business of solving the biggest problem that this country has coming down the road at us.  In 2025, the cost of a family’s health insurance is going to double — $25,000.  I don’t know anybody who can afford that.  You can argue about Cadillac plans and other nonsense.  That’s not going to be important.  And in 2080, the cost of all of our health care is going to equal the gross domestic product.  It’s a recipe for disaster.

We have much in common, I want you to know, and I hope and pray you will take a look.  We cover young adults under their parents’ — under their parents’ insurance.  That’s a Republican offer.  We prohibit dropping insurance coverage when the patient gets sick, but we don’t — and the Republicans do, too, but they don’t cover preexisting conditions.  Both of us prohibit annual and lifetime limits.  High-risk pools, we have and they have. 

But high-risk pools carry with them some risk, because it constitutes an incentive for a race to the bottom, whereby people will move their insurance coverage to the place where they have the least regulation and the least protection for the consumers.

And it also includes, and amongst the other 14 items where we’re agreed on, is the availability of health savings accounts.  There are a lot of other things here that we have and we need. 

I would say that I’ve seen some of my friends who I knew before they were virgins.  They were pushing, for example, use of the extraordinary budgetary mechanism, as to get this decided by 51 votes.  Seems like a great idea, if — and I’m curious, why in the name of common sense are we being so fussy about having the decisions in the people’s House and the people’s Senate decided on the basis of a simply majority, 51 votes?  And if there’s something wrong with that, I wish somebody would tell me why we ought not give the people that kind of representation.

I would note that also mandatory coverage, mandates.  That was in a bill introduced by my good friend Bill Thomas, Chairman of the Ways and Means Committee, and 20 members of the U.S. Senate.  They said — and they were not fussy about that.  And I think we ought to look to see, here we have a chance to serve the people.  I have people coming to my office with tears in their eyes.  They can’t get coverage.  They have preexisting conditions.  A young dental surgeon I knew couldn’t get health care.  Why?  Because she had breast cancer years before; she couldn’t get care.  And I’ve seen a lot of other cases like that, people who would have drive-through pregnancies or drive-through mastectomies, and all manner of high-handed abuse by the insurance companies. 

I’m always surprised when I can find somebody that’s defending the insurance companies after the things that they do to the ordinary people in this country.  They could cancel your insurance policy while you’re on the gurney headed into the operating room.  Somebody would — if somebody would explain that to me, I would be deeply grateful.

But the fact of the matter is, we have a chance to do something that Dan Webster one time observed.  I thought it was — I thought it was a very useful thing that he said.  And I think we ought to — he said, "Let us see whether we also, in our day and generation, may not perform something worthy to be remembered."  It’s on — Madam Speaker, as you well know, it’s on the wall of the House of Representatives.  It’s there for us in the House, and my colleagues in the Senate will know it, those few who I see again and serve with us will recognize that as something.

We have before us a hideous challenge.  The last perfect legislation that was presented to mankind was delivered to the Israelis at the base of Mount Sinai.  It was on stone tablets written in the fingers of God.  (Laughter.)  Nothing like that has been presented to mankind since.  What we’re going to do is not perfect, but it’s sure going to make it better, and it’s going to ease a huge amount of pain and suffering at a cost which we can afford, which has been costed out by the Office of Management and Budget — the Congressional Budget Office, saying, it’s budget-neutral and in fact reduces the budget. 

I beg you, my friends, let us go forward on this great task.

THE PRESIDENT:  Thank you, John.

REPRESENTATIVE DINGELL:  Thank you, Mr. President.

THE PRESIDENT:  Speaker Pelosi wants to say a brief word.  John, do you want to say anything in closing?  And then I will wrap up.

Nancy.

SPEAKER PELOSI:  Thank you very much, Mr. President.  As one who has abided by the three and a half minute, I’m going to take a few seconds more now in closing to extend thanks to you, Mr. President, for bringing us together, for your great leadership, and without it, we would not be so very close to affordability, accountability for the insurance companies, and accessibility for so many more Americans to improve their health care, to lower their cost.

Mr. President, I harken back to that meeting a year ago.  At that time, Senator Grassley said — questioned you about the public option.  And you said, "The public option is one way to keep the insurance companies honest and to increase competition.  If you have a better way, put it on the table." 

Well, I bring that up because we come such a long way.  We’re talking about how close we are on this, how far apart we are here.  But as a representative of the House of Representatives, I want you to know that we were there that day in support of a public option, which would save $120 billion, keep the insurance companies honest, and increase competition.

We’ve come a long way to agreeing to a Republican idea — the exchanges.  Senator Enzi has been a leader in that.  Senator Snowe, along with Senator Durbin, had legislation to that effect — bipartisan.  It caused the insurance companies opposed the public option.  They couldn’t take the competition.

We have in our bill market-oriented, encouraging to the private sector, initiatives.  I think the insurance industry, left to its own devices, has behaved shamefully.  And we must act on behalf of the American people.  We have lived on their playing field all this time.  It’s time for the insurance companies to exist on the playing field of the American people.

I believe I have news for some of my colleagues, because we have very much more in common.  Senator Coburn, you had so many positive suggestions, which I didn’t hear much else of, but from you we did.  And I think you’d be pleased to know that after much debate in our House, we came up with value not volume; others have called it quality not quantity in terms of utilization, over-utilization.  Senator McCain, when you talk about Florida, we’re talking about addressing the regional disparities in terms of compensation and health care.

So we have addressed many of these issues in the bill.  I think it’s really important to note, though, and I want the record to show — because two statements were made here that are not factual in relationship to these bills.  My colleague, Mr. — Leader Boehner, the law of the land is there is no public funding of abortion and there is no public funding of abortion in these bills.  And I don’t want our listeners or viewers to get the wrong impression from what you said.  Mr. Camp — Mr. Camp, you said that the Medicare cuts in this bill cut benefits for seniors; they do not.  They do not. 

So I want the record to show, just in those two cases, where we may have differences of opinion and of approach and evaluation of the value of different things, but certain things are facts about our bills that I cannot let the opposite view stand when they are stated.

Yes, it’s hard to do this.  The misrepresentation campaign that has gone on about these bills, it’s a wonder anybody would support them, as Mr. Waxman said.  But the fact is this, the President said many of these provisions on their own are largely supported by the American people.

So this will take courage to do.  Social Security was hard.  Medicare was hard.  Health care reform for all Americans — insurance reform is hard.  But we will get it done.  And as we leave this debate I think that many of the differences that we have are complicated and they’re legitimate.  They’re differences of opinion about the role of government and the rest.  But I think it’s really clear in one point that the American people understand very clearly, they understand that there should be an end to discrimination on the basis of preexisting conditions.  The proposals that we have put forth end discrimination on the basis of preexisting conditions; the Republican bill does not.

With that, Mr. President, I thank you again for the opportunity to discuss the differences and to try to find some common ground on this.

THE PRESIDENT:  Well, listen, this has been hard work.  And I want to, first of all, thank everybody for being here and conducting themselves in an extraordinarily civil tone.  And as I said, given the number of folks that were around this table, the fact that we’re only an hour late is — beats my prediction.  (Laughter.) 

Here’s what I’d like to do — and I’m going to take about 10 minutes.  I want to go through where I think we agree, and I want to summarize where I think we disagree.  And then I’ll address some of the process issues that have been brought up by a number of the Republicans. 

We agree that we need some insurance market reforms.  We don’t agree on all of them, but we agree on some of them.  I think that if you look at the ones that we don’t agree on — since there’s been a lot of reference to what the American people want — it turns out that the ones that are not included in the Republican plans right now, but are included in the Democratic plans, are actually very popular. 

I know there’s been a discussion about whether government should intrude in the insurance market, but it turns out that on things like capping out-of-pocket expenses, or making sure that people are able to purchase insurance even if they’ve got a preexisting condition, overwhelmingly people say the insurance market should be regulated.

And so one thing that I’d ask from my Republican friends is to look at the list of insurance reforms and make sure that those that you have not included in your plans right now are ones in fact that you don’t think the American people should get.  Because I strongly believe in these insurance reforms.  I’ve talked to too many families who have health insurance and find out that what they have does not provide them with the coverage they needed and they end up being bankrupt, or they end up going without care, or they get care too late, as was the case in the story that Patty Murray mentioned.

The second thing I think we agree on is the idea that allowing small businesses and individuals who are right now trapped in the individual market and as a consequence have to buy very expensive insurance and effectively oftentimes just go without insurance could be solved if we allowed them to do what members of Congress do, which is be part of a large group.

Again, the idea of an exchange is not a government takeover; it is how the market works, which is if you have a lot of purchasing power you get a better deal.  That’s how Walmart drives its prices down, because everybody who wants to supply Walmart — Walmart tells them, you give me the best deal possible.  And as a consequence, the supplier gives them a much better deal than they do the mom-and-pop shop on the corner.  Well, we should be able to give small businesses and individuals who are self-employed, who aren’t able to get insurance through a large employer, to have that same deal. 

It sounds like we’ve got some philosophical difference as to whether there should be some minimum benefits in that exchange, some baseline of coverage.  Again, there’s a baseline of coverage for members of Congress.  And the reason we set that up is because we want to make sure that any federal employee who is part of this big pool is getting good, quality coverage — not perfect coverage, not gold-plated coverage, but adequate coverage.  It may be — and I’d ask my Republican colleagues to look and see, is that an area that can be resolved.

There has been a lot of discussion and one of the main tools the Republicans have offered to drive down costs is purchasing insurance across state lines.  This is an idea that is embodied in the House and Senate bill, but, again, the details differ.  The approach that John Boehner and some of the Republicans appear to take is to say, let’s just open things up; anybody can buy anything anywhere regardless of what state insurance laws are, and that will drive competition and cost.

The philosophical concern I have on that is that you potentially get what’s been referred to as a race to the bottom.  And for people who may not be following the intricacies of the insurance market, let me give an example that people understand, and that’s credit cards. 

In the credit card market, part of what happened was we ended up allowing people to get credit cards from every other — whatever state, and there were a few states that decided, you know what, we’re going to have the least restrictions on credit card companies that we could have.  And what ended up happening was that every single credit card company suddenly lo and behold started locating in that state which had the absolute worst regulations in consumer protections, and all these fees and practices that people don’t like, folks weren’t happy about.

So the question I’m going to have is, is there a way for us to deal with the interstate purchase of health insurance, but in a way that provides, again, some baseline protections, because what we don’t want is a race to the bottom.  We want everybody to have the basic protections that make sense. 

And that’s not a big government takeover.  That is a standard thing that we do in almost every area of life.  We protect people with respect to the food that they buy, with respect to the drugs that they purchase.  We license and regulate the medical profession because we don’t think anybody should just be able to cut somebody open.  We want somebody like Tom or John to actually know what they’re doing before they start practicing medicine.  And the same should apply when it comes to how we think about insurance.

Medical malpractice has been mentioned.  Now, look, let me be honest.  This is something historically that Democrats have been more resistant to than Republicans.  I will note that when we had a Republican President and Republican control of the House and Republican control of the Senate, somehow it didn’t happen, and I’m surprised, but we –

SENATOR ALEXANDER:  We needed 60 votes in the Senate, too, Mr. President.  (Laughter.)

THE PRESIDENT:  See there?  So as a consequence, what I have suggested is that we explore building on what we’ve already done administratively without law, asking Kathleen to help states come up with new ideas. I’ve suggested, well, let’s take a look at Tom, the suggestion you had, that gives states even more incentive to start thinking about reducing defensive medicine.  I have to tell you, Joe Barton, that how you got from $5 billion to $150 billion, I didn’t quite follow the math.  It sounded — I’m not sure you did, either, but it’s okay.  But here’s my commitment, is that if folks were serious about getting this done, I’d be interested in seeing if we could work on something.

Now, I actually agree with Dick Durbin with respect to hard caps because of the story that he told about the woman who burned her face.  I think there are situations in which there is actually a very severe problem, and I would distinguish that between some of the frivolous lawsuits that are out there that really do create a defensive medical problem, and OBGYNs are the ones who get hit the hardest because people are so sympathetic when a child is born with severe disabilities, and they can just be crippling on OBGYNs.  The same is true for neurologists and so forth.  So there may be some ways that we can work on that.

Now, I guess what I’m saying is I’ve put forward then very substantial ideas that are embraced by Republicans.  Peter, they’re not — I forget what metaphor you used about — before you popped it in the microwave, whether it was bacon bits or sprinkles or — breadcrumbs, that was what it was.  When it comes to the exchange, that is a market-based approach, it’s not a government-run approach.  There were criticisms about the public option; that’s when supposedly there was going to be a government takeover of health care, and even after the public option wasn’t available, we still hear the same rhetoric.  And it turns out that what we’re now referring to is we have an argument about how much we should regulate the insurance industry.

We have a concept of an exchange, which previously has been an idea that was embraced by Republicans before I embraced it, and somehow suddenly it became less of a good idea. 

With respect to the most contentious issue, I’m not sure we can bridge the gap, and that’s what we’re going to have to explore and that’s the issue of how do we provide coverage not only for people who don’t have health insurance right now but also for people who have preexisting conditions and are being priced out of the market, or potentially lose their jobs and will find themselves in a situation where they don’t get coverage.

An interesting thing happened a couple of weeks ago, and that is a report came out that for the first time it turns out that more Americans are now getting their health care coverage from government than those that are getting it from the private sector.  And you know what, that’s without a bill from the Democrats or from President Obama.  Has nothing to do with "Obamacare."  It has to do with the fact that employers are shedding employees from health care plans.  And more and more, folks, if they can, are trying to get into the Social Security system and the Medicare system earlier through disability or what have you, so that they can get some help.

The point that Tom Harkin made, the point that Chris Dodd made, the point that Henry made, and a number of other people made, I think is very important to understand.  I did not propose and I don’t think any of the Democrats proposed something complicated just for the sake of being complicated.  We’d love to have a five-page bill.  It would save an awful lot of work.  The reason we didn’t do it is because it turns out that baby steps don’t get you to the place where people need to go.  They need help right now.

And so a step-by-step approach sounds good in theory, but the problem is, for example, we can’t solve the preexisting condition problem if we don’t do something about coverage.

Now, it is absolutely true — and I think this is important to get on the table, because we dance around this sometime — in order to help the 30 million, that’s going to cost some money.  And the primary way we do it is to say that, for example, people who currently get all their income in capital gains and dividends, they don’t pay a Medicare tax, even though the guy who cleans the building for them does on his salary or his wages.

And so what we say is, if you make more than $250,000 a year if you’re a family and your income is from those sources, then you should do — you should have to do the same thing that everybody else has to do.  Somebody mentioned the fact that we say to small businesses — I think Jon Kyl, you said, we’re taxing small businesses.  Look, we exempt 95 percent of small businesses from any obligations whatsoever because we understand that small businesses generally have a tough time enough — they don’t need any more government burden.

What we do say is, if you can afford to provide health insurance, you have more than 50 employees, meaning you’re in the top 4 percent of businesses, and you’re not providing coverage and you’re forcing other businesses or other individuals to pick up the tab because your employees are either going to the Medicaid system or they’re going to the emergency room — we don’t think that’s fair.  So we say, you’ve got to pony up some.  It’s not an employer mandate.  It just says you’ve got to pay your fair share, because otherwise all of us have to pick up the tab.  And that, by the way, contributes to the overall deficit that Medicaid is running.

In fact, most small businesses through this program get huge subsidies by becoming members of the exchange.  That’s where the money is going.  The money is not going to some big welfare program — the money is going to give tax credits to small businesses, tax credits to those who are self-employed, to buy into this pool.  And that’s not a radical proposition; it’s consistent with the idea of a market-based approach.

And finally, with respect to bending the cost curve, we actually have a lot of agreement here.  This is an area where if I sat down with Tom Coburn I suspect we could agree on 95 percent of the things that have to be done.  Because the things you talk about in terms of — and I wrote some of them down — in terms of reducing medical errors, in terms of incentivizing doctors to coordinate better and work in groups better, in terms of price transparency, improving prevention — those are all things that not only do I embrace but we’ve included every single one of those ideas in these bills.

Now, the irony is that that’s part of where we got attacked for a "government takeover" because what happened was when we set up the idea of a MedPAC, which is basically a panel of doctors and health care experts who would recommend ways to make the delivery system better so that we can squeeze out that one-third in Medicare and Medicaid that’s wasted — a Republican idea — that was part of the ammunition you all used to say that the government is going to take away your health care.

So if we’re serious about delivery system reform, if we’re serious about squeezing out the waste that Tom Coburn referred to, you should embrace those mechanisms that are in this bill.

I will end by saying this.  I suspect that if the Democrats and the administration were willing to start over and then adopt John Boehner’s bill, we’d get a whole bunch of Republican votes.  And I don’t know how many Democratic votes we’d get, but we’d get a whole bunch of Republican votes. 

The concern I think that a lot of the colleagues, both in the House and the Senate, on the Democratic side have, is that after a year and a half — or more appropriately after five decades — of dealing with this issue, starting over they suspect means not doing much or doing the proposal that John Boehner or other Republicans find acceptable; and that it’s not possible for our Republican colleagues to move in the direction of, for example, covering more than 3 million people; it’s not possible to move more robustly in the direction of dealing with the preexisting condition issue in a realistic way; it’s not possible to make sure that we get people out of a high-risk pool and get them into a situation where, as Tom Harkin put it, healthy people, young people, rich people, poor people, old people, sick people — everybody is part of a system that works.

That I think is the concern.  Having said that, what I’d like to propose is that I’ve put on the table now some things that I didn’t come in here saying I supported, but that I was willing to work with potential Republican sponsors on.  I’d like the Republicans to do a little soul searching and find out are there some things that you’d be willing to embrace that get to this core problem of 30 million people without health insurance and dealing seriously with the preexisting condition issue.

I don’t know, frankly, whether we can close that gap.  And if we can’t close that gap, then I suspect Mitch McConnell and Harry Reid, Nancy Pelosi and John Boehner, are going to have a lot of arguments about procedures in Congress about moving forward.  I will tell you this, that when I talk to the parents of children who don’t have health care because they’ve got diabetes or they’ve got some chronic heart disease, when I talk to small businesspeople who are laying people off because they just got their insurance premium, they don’t want us to wait.  They can’t afford another five decades. 

And the truth of the matter is, is that, politically speaking, there may not be any reason for Republicans to want to do anything.  I mean, we can debate what our various constituencies think.  I know that — I don’t need a poll to know that most of Republican voters are opposed to this bill and might be opposed to the kind of compromise we could craft.  So it would be very hard for you politically to do this.

But I thought it was worthwhile for us to make this effort.  We’ve got a lot of other things to do.  I don’t think, Tom, that we’re going to have another one of these because people don’t have seven, eight hours a day to work some of these things through. 

What I do know is this:  If we saw movement — significant movement, not just gestures — then you wouldn’t need to start over because essentially everybody here knows what the issues are.  And procedurally, it could get done fairly quickly.  We cannot have another year-long debate about this. 

So the question that I’m going to ask myself and I ask of all of you is, is there enough serious effort that in a month’s time or a few weeks’ time or six weeks’ time, we could actually resolve something.  And if we can’t, then I think we’ve got to go ahead and make some decisions and then that’s what elections are for.  We have honest disagreements about the vision for the country and we’ll go ahead and test those out over the next several months till November.

All right?  But I very much appreciate everybody being here.  Thank you for being so thoughtful.  And hopefully we’ll all keep our constituents in mind as we move forward.  Thank you, everybody.  (Applause.)

END
5:21 P.M. EST