Well you're settling in for our second
panel on health care policy and economics.

I want to introduce the chair of that
panel Bill Todd who I also met during my

first year at Georgia Tech because
the School of Public Policy gave him its

public service award in that year and
I want to point out that he

is actually also a recipient of
the Ivan Allen prize for progress and

service I'm sure you have your crystals
somewhere prominently displayed.

From that this was the predecessor
of ward to the Ivan Allen prize for

social courage so Georgia Tech has
been recognizing Bill's talents for.

For quite a while he
now introduces himself

as a beginning professor just getting
used to the classroom but this

shows the kind of humility that we've been
talking about over this day and a half.

If you take a look at his resume which is
in your even the brief urging of it which

is in your your folders you will find
that he has done a lot of other things in

addition to being now a professor
of practice back in his album

mater in the College of Management here at
Georgia Tech after he left Georgia Tech

he had a whole series of senior
positions in Health Care Management at

Emory at the Woodruff Health Sciences
Center and then he was asked

to head the Georgia Research Alliance
which has been a crucial force in bringing

knowledge to bear on economic development
here in the the state of Georgia.

He went from there to be the head of
the Georgia Cancer Coalition before coming

back to us here at Tech and
we're really delighted to have him back.

He's leading a health care
research initiative for

the campus thank you very much Bill for

taking on the task of leading this panel
and I will now handed over to you.

Thank you and
I want to thank Dr Bill face for

inspiring this topic of health care and
global health.

For this today of it.

You know in another role that I

am privileged to play here at
Georgia Tech working with Steve Cross.

I'm assigned to go out and in and

try to corral all of the health care
initiatives that we have on this campus.

It turns out there are some fifty
institutes centers laboratories

that deal with human health and
that's a well kept secret.

They won't be for long.

This is the first step in that but I think
people are beginning to realize that

the contributions all across this campus
are significant and human health.

Last week we had a business
plan competition

thirty eight business plans were
submitted to a peer review panel.

One was selected half of those
were health care applications and

the one that one is
a health care application.

An alternative to a lower end just cope.

Bus and bow medical Engineers last week or
this week we had the inventor Prize

two of the six finalists were in health
care and the winner was in health care.

So it's growing in our
school our department joint

department with Emory Obama to Clinton
airing our first engineering discipline

this more than fifty percent women by
the way is the fastest growing college

fastest growing discipline in the College
of Engineering and making great waves.

So there's a lot of health care at
Georgia Tech including in the policy and

economics arena.

Week after next.

The Supreme Court will take
up the constitutionality of

the Affordable Care Act.

It will be from the twenty
sixth through the twenty eighth

the Supreme Court has decided to work six
hours a day which is almost unprecedented.

The last time they did that was the one
nine hundred sixty S. legislation that.

What Alan Jr testified about.

Justice Roberts is in is likely
to write the opinion himself.

Whichever way it goes.

This is the most
significant legislation and

most significant review of legislation by
a Supreme Court in a generation and so

it will affect health and health care in
this country and likely around the world.

So this panel has a little different
personality than the last one

where coming from it a little differently
maybe from a different side of the brain.

That's public policy in economics.

A fundamental enabler

of some of the good work that we
heard about in the last panel.

And I'm honored to have three
distinguished faculty members here with me

era Levine is assistant professor
of in the School of Public Policy.

Of the far and.

Kim I sit is associate professor
in the School of Public Policy and

went through faculty orientation
with me back in August.

Invictus all is in the middle here and
he's a professor and

director of the batter's program
in the School of Economics.

You've got there and we really
don't want to take up any more time

with what you already have and
encourage you to read.

It's very impressive.

But we really want to get into it.

We want to create some conversation.

That's why we changed the seating up here.

We want this to be conversational
among these panelists and

then eventually with you.

So we'll do it a little bit differently.

I'll ask each panelists to talk for
eight minutes or so

and then we'll have a little
conversation among us.

And then after the third when we'll
open it up to the to the audience and

we'll expect some difficult
question about three colleagues.

So we'll begin with Dr Levine who will
talk about emerging technologies and

ethics and I know of no other side.

That need more help.

In ethics and so we're pleased that
he's here to to get us through that.

There.

Thank you Bill and and thank you Susan.

For the invitation to speak at this panel
on this really special event today.

So as Bill said My interest is in
the intersection of public policy and

ethics and particularly in the ethics
of emerging technologies so

I want to just raise two questions.

Briefly two issues for us to think about
and potentially an address in conversation

first building off bills comments
on the Affordable Care Act and

the ongoing litigation I'd just like to to
briefly suggest that there is an ethical

case to be made for health care reform and
talk about some of the ethical principles

that are at play there and then I'd
like to talk just briefly about emerging

technologies about potentially paradigm
shifting innovations in medicine and

health policy makers can can think about
integrating them into the health care

system and
some of the the challenges that emerge.

So first since I'm going first
today just a word about the U.S.

health care system in the context
forty four book Care Act And

I don't think I need to dwell on it and
in this audience but

I think it's safe to say that the U.S.
health care system is highly variable.

There are some people who really do get
quite excellent care in the United States

but there are also many people who get
unfortunately rather abysmal care and

yesterday at lunch our distinguished guest
talked about how the health care system in

the States in some ways was
actually an embarrassment.

When you look at it.

Our health care system
in in the aggregate.

Two things jump out one we spend a lot of
money on health care when you compare us

to our our peer nations we spend more than
essentially any other country on a per

capita basis but the health outcomes we
get are not that high in fact we trail.

Many of these peer nations on a whole
range of important health outcomes

things like life expectancy
infant mortality and so on.

And so
I think this setting really lays the.

Work for an ethical case for
health care reform.

And there are several ethical
principles of play here.

I draw in part on work by
Norman Daniels some of you may know

this is in the Harvard School
of Public Health.

But the two main principles
I just want to touch on and

maybe discuss later the first we heard
about in the initial panel this morning.

The idea of equity in
some way we owe it to

people broadly to in this context
people in the United States but

indeed I think we can extend this to
people around the world to provide access

to some set some service array
of health care services and

and the claim here is certainly not that
we owe it to everybody to provide access

to all health care services that
is probably not feasible at all.

And this is a panel economics in part
after all that's not something we want to

claim but some basic array of health
care services that facilitates

each individual's opportunity
to live a full life.

Free to the extent possible of illness and
disability.

I think we can make a claim that
there is an ethical obligation there.

And so that the claim of equity.

There's also I think an ethical
claim in the area of official and

this is a little bit more unusual we don't
often think about ethics and efficiency or

attention to economics but when you look

at the cost of our health care system
when you look at the amount of money we

spend on health care in Unfortunately the
relatively poor results that come from it.

I think there is a case to be made that
there isn't a moral obligation towards

efficiency towards cost containment of
some sort in our health care system and

there are two sort of ideas here that
I think are worth keeping in mind and

one to the extent that we promote a more
efficient health care system we get

a better return on our
health care investment.

It really greatly facilitates the pursuit
of this goal of equity of increasing

access to a broad population and

let's that's one point
the second is that health.

Well certainly an important social
good is not the only social good.

And the extent to which we control.

Costs in our health care system to
which we promote efficient health care

allows us as a society to
pursue all sorts of other

social goods that may be
strongly morally justified.

And indeed anyone who's looked
at the the US budget today or

even more frightening leave the trends for

the US budget in the future rapidly
recognizes how much of a squeeze

the health care costs are putting on on
the rest of the budget overall And so

I think there are are ethical cases to be
made there in favor of health care reform.

I'm going to defer for for the time being.

Whether or not the Affordable Care Act
is really moving in this direction or

how far it's moving.

I think there's a case to be made
that there is progress there.

But there's a lot of of
a political mess there as well and

it remains to be seen how implementation
plays out how these sort of political

compromises hinder or maybe in some cases
assist the success of moving towards

these these normative goals.

So it was the first point I wanted to
mention the second is the idea that

that health technologies that
were at an engineering institute.

There are new technologies exciting new
technologies coming down the coming down

the pike all around the world but but
right here in Atlanta Georgia Tech.

I think it's crucially important for us as
people thinking about the policy process

to say how will these technologies be
integrated into our health care system.

And I think you have
sort of the you here and.

In discussions of the military all
the time that the Army is always prepared

to fight the last war not the next war and
Granted there's lots of improvements going

on it in that context but I worry that
there's certainly a possibility that when

we embark on something enormous like the
Affordable Care Act every one of the very

important piece of legislation in the
courts are debating now if there's a risk

that the that we form included in that act
address the old health care system and

may not be optimal for for new changes
that are there are coming down the road.

And so that's not a certainty but I think
we always need to be on the lookout for

sort of paradigm shifts in.

And that may really change
health how health care works.

And so a lot of my work focuses on
regenerative medicine and the areas of

stem cell research and so I want to touch
on this briefly to illustrate this point.

So in some ways we did in medicine

offers great promise to facilitate
traditional health care.

So I was at a talk last
week where a leader at G.E.

so large enormous well established company
was using stem cell based technologies and

actually quite contentious stem cell based
technologies but to facilitate traditional

drug development to streamline the process
of small molecules things like Pfizer or

more Johnson and
Johnson would would develop in and

I would argue that that is going to fit
quite easily into our healthcare system

and great that could be great benefits
there for forty minutes one of healthcare.

But there's another set of interesting
advances in regenerative medicine that

don't fit into the standard model
that aren't drugs that a physician

prescribe the pharmacist passes out in
a patient's take what day after day for

the rest of their lives they would have to
be administered in very different ways.

And might have very different impacts on
the cost structure of health care and so

on and I'm worried that the health
care system is not as well prepared

to deal with these sorts of potentially
paradigm changing innovations and

just two points on the on
the challenges there one.

We never know in advance which health
care technologies will really pan out and

which will not so
it's difficult to plan for embracing a new

technology that might ultimately
improve not to be that successful.

So that's one challenge.

There are challenges cost.

We talked earlier about this
ethical mandate for for efficiency.

Unfortunately the history of of new health
care technologies in the United States and

around the world to some degree
is not one of cost reduction but

one of cost increases for the most part
and there are notable exceptions so

vaccines of course are a huge exception

dramatically positive from a cost
benefit point of view but many other to.

Knology is well they may extend or improve
the quality of life do so at greater

rather than reduce costs and so I think
that is a real challenge to think about.

And then just one closing note as we as we

think we've been talking a lot
about compassion and about hope and

I think there are enormous benefits that
from the health care system from advancing

research from the world of public
health providing hope around the world.

I was struck by by a comment that
the Jennifer made in the previous panel

a built criticism one
group about false hope.

And I don't think we want to to lose hope.

But in the area of Emerging Technologies
one of the challenges I've been seeing and

looking at in my research is this is
a real promise of problem of false hope of

desperate patients being exploited
by scam artists in some degree but

literally in the world
of stem cell research.

There are now more than six hundred
companies and maybe a thousand companies

around the world that promise cures cures
that unfortunately don't exist today.

But take people's life savings by offering
the slimmer of hope and ultimately make

them worse off both health wise in finance
wise and so I think there is a challenge.

We think about new technologies but
how to make sure we harness hope for

good rather than for poor or for or for

evil and that's something I
don't want us to lose sight of.

What I will leave it there and
wait for discussion.

Thank you.
Looking.

Just Monday to mustard it's.

Talking about the efficiency of our U.S.
health care system.

The United States is number one in
spending per capita in the world

by a long shot but
number thirty seven in the world.

If you use life expectancy as a proxy for
outcome.

Just ahead of Slovenia
just behind Kosta Rick.

So with that with the panel agree that
no matter how the Supreme Court rules

them out of how the election goes and
what might or

might not be repealed is health care
reform inevitable given that in.

Efficiency.

I think that we're at a breaking point and

we see that a lot something that I'm
working on now with a group of students

in the school public policy
is some insurance reforms.

We're working with a client of
the Multiple Sclerosis Society and

one of the things that we see is there
have been really great innovations

in pharmaceuticals for
people living with multiple sclerosis.

But when we look into the insurance.

That is that covers the life saving and

life enhancing drugs they are being moved
to Forth hears and insurance companies and

insurance plans which means that people
who need these drugs that are chronic and

debilitating have to choose
between having quality of life or

eating because insurance companies
are moving these drugs these

you know high technology innovations
into a tier of insurance that

requires the recipient to pay eighty
percent or more of the cost of

those drugs which can be some estimates
are around eight thousand dollars a month.

So I worry about access to
innovations under the current

insurance schemes and
just that just with that example

we need to understand how to give people
good quality of life at a reasonable cost.

That doesn't break our health care system.

There's some very interesting
numbers on children's income groups.

If you look at the census statistics.

If you look at the group income seventy
five thousand dollars or more per year

seven percent of this group voluntarily
choose not to buy insurance.

The group that is fifty thousand dollars
or more something like ten to eleven

percent of this group voluntarily
chooses not to buy health insurance.

These are clearly
self-employed individuals

who are choosing not to
buy in private markets.

Before we get into equity issues that
thing can if you look at insurance markets

individual these these are obviously young
individuals who are professionals or

owning quite a bit and
the voluntarily choose not to buy it and

this is replete in
the census data everywhere.

So I think there's a real problem here in
the sense that there is too much focus on

technology that is driving
the costs to the moon and

there is not enough focus on
looking at how markets work and

how you look at efficiency and
cost efficiency.

So I think just focusing on one side of
it is a problem because then individuals

volunteer not to buy this insurance.

I'm going to talk some
more in my insurance but

I mean I think this is more a technology
is not a solution to everything here

because you need to understand the
interface between setting up policy and

how private companies in this
market react to this policy and

I think in the current Affordable Care Act
there is inadequate attention

to understanding this nexus between
policy and private strategies.

But about one of the main components
of the Affordable Care Act And

that is these exchanges
insurance exchanges and

she'll talk a little bit about service
delivery is the new form of coverage.

So we know that the Affordable Care Act
will provide and

millions more Americans with
access to health insurance.

But that's just how to insurance and

sometimes we often forget that
health insurance isn't health care.

And so the question is How
will health care be delivered

under the Affordable Care Act and

how and out of that traditionally
under-served population.

And so.

First I'm going to answer
the question of who.

So who is currently going to be affected
the most by the Affordable Care Act.

And currently under served.

The ranks of swollen
because of the economy.

So millions of people
have lost their jobs.

We have very high unemployment rate and
so we have scores of

individuals who used to have
insurance that no longer do but

don't qualify for one reason or
another for public health insurance.

And so
because of the economy we do have a larger

percentage of under underserved
population at the moment but

when we look at the traditional
population that are under

served by the health care system they
are disproportionately people of color.

Greater than half of the under-served
population in the United States

are low income people of color.

And there are well documented disparities

of other health care for those
populations and when I say disparities.

I mean the amount in the quality of
health care that people receive.

And when we woke at the types of

diagnoses that people in
the under-served populations have.

They are disproportionately affected
by cardiovascular disease cancer AIDS

in each of the diabetes viral
hepatitis mental health issues and

oral health and
with the exception of cancer and

mental health all of these
diagnoses are preventable and

even some forms of cancer if we
think about environmental exposure

as well as mental health with
post-traumatic stress disorder in

low income populations all of these or
some component of all of these.

Health care diagnoses are preventable.

And.
So we have an ethical responsibility to

try to think about how we can care for
people in underserved

populations particularly with
preventable health care diagnoses and

the costs that go along with them and so
we need to remember that many of these

diagnoses don't get treated until they're
very very far along in the progression and

often these people have to
choose between going to work and

earning their hourly wage and going to
health care clinics to have treatment and

if you have children at home.

My guess is you're going to put off going
to a clinic as much as possible in order

to feed them and so
we have that ethical responsibility to

these underserved populations which have
not only disproportionately been people

of color but these health care diagnoses
are also greater and people of color.

So it's a it's a it's
a compound a problem.

So how the Affordable Care Act the way
it was intended serve this population.

Well when in twenty fourteen

Affordable Care Act will cover
individuals up to a hundred thirty three

percent of the federal poverty level which
increases the eligibility for Medicaid.

For the people that don't qualify for
Medicaid but

still aren't insured by private coverage.

They will be able to achieve
tax credits in order to buy

in the insurance exchanges.

And the Health and
Human Services Department of Health and

Human Services under the leadership
of Sebelius has put forward

a plan to decrease health
disparities in the United States by

twenty thirty I believe the goal is and
there are dedicating much.

More resources than in the past
to expanding access to federal

federally qualified health centers and to.

Thirds of the populations that receive
their health care in federal federally

qualified health centers are low
income ethnic and racial minorities so

this will provide a point of access to
get that health care that they now can

receive they will have an expansion of
the National Health Care Service Corps

which is the program that
provides financial aid for

medical students if they agree in
exchange to serve in underserved.

Areas.

And they are making an effort
under the expansion of

the National Health Care Service Corps to
recruit at historically black colleges and

universities and this is important because
we know from the cultural competence

literature that people of
color get better health care

when their providers match their
ethnic and racial backgrounds.

And they will be an expansion of
interpretive services in the professional

corps that provides perf
interpretive services for

those people who still struggle with
English as of as a second language and

all of this combined with the Mental
Health Parity Act will not force people

anymore to choose between getting their
serious and chronic depression for

example treated now with
federal mental health parity

insurers are now required to provide the
same level of mental health outpatient in

inpatient days that they get for
other kinds of chronic diseases.

Well all of this is well and good but
there is still a population of folks who

are not included under the Affordable
Care Act and the largest population there

are undocumented immigrants and
this is important to us because undocument

undocumented immigrants
are disproportionately employed in

the construction agricultural fields which
economic study after study has shown

that are coming economy would actually
collapse if we didn't have undocking

of undocumented workers in these fields
and these girls are also high risk feel.

Lots of illness and
preventable injury can occur

as of now twenty five percent
of the uninsured in under-served

population are undocumented immigrants and
that will grow

under the Affordable Care Act because many
more people will be able to apply and

receive for Medicaid and
get the federal the federal subsidy for

buying health care but
undocumented immigrants are barred

in the legislature from Access accessing
any of the Affordable Care Act provisions.

It's actually in there that they are bored
and so this is important because.

We still pay for their health care
when they go to hospitals with.

Illnesses that are too far
gone to be turned away or

injuries from working in
the fields of Agriculture and.

Of of the construction industries so

they will be the biggest accessors of
our social safety net in hospitals and

they will also be the largest proportion
of uncompensated care in hospitals and

so while the Affordable Care Act does
make some progress in thinking about

some social equity issues and
some social justice issues.

There's a very real population out
there that keeps our economy going.

That we will be forced to think about
the ethical issues much more clearly.

I'm in much more sharper contrast
after the Affordable Care Act if it

does if it does be implemented
as it's intended with

what to do with illegal
immigration in this country and

particularly how it pertains to
health care and health care costs.

You know I'm so glad that you
brought up the word prevention.

Because our has devoted his whole life
to the and if we didn't say that we're.

Or address that issue he would have
been the first when it came to.

So what's wrong with the compassionate
make up of this panel.

But does the panel believe this
health care reform movement

begins to move us in the direction of
prevention may not solve it completely but

begins the process of moving
from acute care to prevention.

So that the statistics again in
the single woman nonwhite category.

I think something like thirty thirty
two percent have no insurance.

So this.

And I think one of the most remarkable
things that I've come across is one of my

friend she's colleges breast
cancer surgery at Grady and

she was describing her woman of
color come in to get diagnosed that

they're asked to come in and follow up and
other stuff and then they disappear.

So they never bothered to show up and
so they implemented fairly good I.T.

system tracking system which is fairly low
cost but you essentially keep better tabs

of these women and essentially you force
them back in and the whole argument is so

that they will call they will do things
they will send people to their houses and

they would basically track and
force them back into the hospital and

essential argument is that when
you look at breast cancer.

A lot of a lot of the cost can
be kept down with very early

preventive care and
I think this isn't a very good example

of fighting what the fordable
Care Act will do.

I think it'll increase the dollars that go
into these types of care and these types

of fairly low cost interventions
that should improve care thing.

Just because we give people insurance or
access to insurance and

access to health care facilities they
still have to physically go there.

So we can't buy into the myth that just
because we build it they will come because

there are historical reasons why
people of color do not access the.

Health care system and so
there's are very real and

we need to work as a society to think
about how how that has been cause.

Perpetuated and
how it can be addressed in the future so

that people of color do come
into health care facilities and

access the preventable health
care services that are available.

I'm so glad you brought up the rich
example of meditative way to deal with

the issue know that project well funded
it with the Georgia Cancer Coalition

in the two other parts of it
other than the innovative use of.

One is the very human element
of using nurse navigators and

lay navigators peers of these
women who will hound them

go find them and hound them and
get them back for their trick but

Dr Cheryl Gabriel wrote a paper
published in a reputable journal

that showed during a certain period
the outcomes of breast cancer

in African-American women that grading
was equal to Piedmont Hospital.

So it can work.

Well.

Vivek Why don't you continue and
talk to us about the insurance markets and

premiums many people say that
the Affordable Health Care Act is

insurance reform health care reform.

So help us understand that we want to
make various studies to look at as I

mentioned briefly a while back interface
between setting up policy and economic

Cajuns private businesses in the markets
essentially react to these policies.

So there's talk of.

Very selected elements of
the fordable Care Act and

this treating said I want to
talk about one is coverage for

young adults twenty six you're on
the apparent scale if you want to be.

Essentially defect
insurance premiums overall

is a wash because these people are healthy
young if they went out on their own and

they got private insurance they
would get lower rates to begin with.

So I think if you look at defect
our national insurance rates.

It's basically a wash to things that I
see as creating significant problems.

No denials because of
preexisting conditions.

And the second one is no annual
dollar limits and coverage.

These are very difficult
economic problems.

If you look at it purely
from an equity standpoint.

Obviously if somebody is a preexisting
condition from an equity

in a moral standpoint you want this
person to be covered and be treated.

If you look at the dollar limits of
the same problems if somebody is really

sick and they run up huge bills for
a year or the new

Affordable Care Act says you cannot
reduce the amount you cannot set a cap or

two million or three million whatever
is the amount has to be paid for.

So this is what I'm going talk about
briefly to look at how insurance works

in the reason why automobile
insurance rates can be kept low

is because our insurance companies
essentially can screen individuals better

if you're a bad driver they will raise
rates and they will raise deductibles and

you and make life very difficult for you.

So essentially discipline you for bad
behavior health insurance very disappear

very different in a sense
that if somebody is securely.

You can't really discipline the person
this is a very different type of insurance

but having said that I mean if

you look at it from the perspective
of private insurance companies.

I'm in there to run a business and

the moment you say that you
have to cover high risk people.

So all of a sudden a whole bunch of people
in the market who are not covered are now

forced to be covered by these
private insurance companies.

They said caps on a million or
two million.

Now these caps are a lot.

And I just downloaded
the Kaiser Family Foundation study on

this which is done late twenty eleven and
they found miraculously

that insurance premiums nationwide went
through the roof in twenty eleven.

The employer contributions increased
to one hundred thirteen percent.

This is inflation.

Worker contributions inflation was
one hundred thirteen percent one

hundred thirty one percent.

The policy makers were appalled and
the administration officials were

absolutely appalled at this stunning
increase in their premiums and

I did a test in my health economics class.

I gave Mr and

said Here the provisions what do
you think this will do to insurance

markets fifteen out of eighteen predicted
correctly that it would go to the moon.

And it was so
I think the administration is really

caught between delivering on sort
of social moral equity issues.

But there is this complete oversight
on how the markets are going to

react to this.

So we are living in a system where
you can't impose price caps.

You can't tell the insurance company that
you can or charge a high premium rate.

So they're doing exactly what they expect
they expect their costs to go up so

they raise premiums accordingly and.

It is called Affordable Care Act but

from an insurance standpoint this
is becoming very an affordable.

Every institution is paying more
every individual is paying more.

And we're looking at some states where
the premiums actually in the last two

years have gone up thirty
to forty percent rate and

you see Georgia Tech you see there
changing what they're covering

they're reducing options I mean
all kinds of service changing.

So I think this is a real dilemma and
I'm not sure how to really solve this but

I mean what is essentially happening
is that by pushing social and

equity issues into private markets.

Yes you are getting a response
from private markets which is

a very significant increase in cost.

So I am not entirely sure this is
going to be that affordable and

other thing that's going to happen is
that they have kept premiums not to go up

by more than ten percent a year
after twenty eleven attempt and

these companies have done exactly what
you'd expect from an economic standpoint

go and
raise rates before these caps at him.

So so I think that to me looks
a little bit dismal a tank.

I think they're innovations
that are going to be efficient.

I think this health information exchange
or community based exchanges that will

allow insurance premiums to be sort of
capped and be a bit more efficient.

I think this could work.

My fear is that in inch in
health insurance markets you'll

get exactly what you pay for.

I think the notion that you
can get low cost insurance

when you get good insurance is
going to be very difficult.

And my fear is that in these exchanges.

I think more institutions including
places like Georgia take three

four years down the line could push all
its employees to go by in these exchanges.

What I foresee happening.

So I do foresee this happening
down the line but equally or

foresee that what is being covered under
these community based exchanges will

be distinctly inferior to what is being
covered under existing insurance schemes.

So I have some so on.

The one hand I think the some
very good aspects of it.

So I think there is more primary care
being provided more preventive care being

provided more care for kids.

I think those are all highly desirable and
necessary but

I see on the opposite spectrum of this
rise in insurance premiums and rates.

It's going to make things very difficult
from an affordability standpoint.

So I see a contradiction in terms.

So fordable care which is
becoming kind of on afford them.

It's almost read between the lines in
your comments that you're getting for

individual mandates in order to bring all
the low risk people into the total pool.

I think there are two tier
system is going to work better.

That is you have some bright.

Primary care insurance basic
theory care insurance and

catastrophic care needs to be bumped up
to a higher level but with higher rates.

I think pooling because if you
look at insurance markets.

It works.

Fundamentally and

do things one is responding you
have a large pool pool risk.

Second is that insurance companies should
be allowed to discriminate against

people but this is difficult when you put
all treatments and at the same umbrella.

So I think you need to have
a two tier system with primary

basic coverage under a low rate.

And catastrophic coverage and.

You just ask a follow
up on on your point and

it seems like you're you're highlighting
some some real challenges when profit is

the driver of the health care system and
if i'm curious.

I know this is a question.

It's always risky to ask an economist but

where are we in a case of a market failure
here where there needs to be some other

goal something besides the market that's
driving how health care is provided and

I'm thinking of single payer systems that
are adopted to deal with the sorts of

issues that are around the world and what
your what your reactions would be to that

sort of idea with that help
solve this problem or are not so

Germany's under a single payer system and
I travel there a lot and I've yet

to hear a German complain about the health
care system and I see them as healthy and

happy as we are in fact
I complain a lot more so

I think a single payer system
does effectively contain cost.

It provides a lot more primary care which
over the lifespan of the individual

leads to better health outcomes.

So yes I think that that I
think in the long run sense

is much more efficient but
you run to the problems.

The Pritish national health services where
they have set caps on what they were

before so the British came up with as
innovator one one one million dollar one

years like so if you look at
cancer treatments they will not

find treatments that cost more than
a million and don't extend your

lifespan been more than a year because
what they're arguing is that when you look

at overall health care costs a lot of
it is driven by disappear tale of very

high expenditures that extend
your life to late three months so

that more slate is breast cancer
treatment was actually denied coverage in

both in Germany and U.K. because this
said it is they phenomenally expensive.

Giving it to you treat a five
months of extra Lay spent so.

Yes.

I suspect we've generated some enthusiasm
among the crowd with this topic.

Everybody seems to have an opinion whether
it's a formed an informed opinion or not.

Everybody seems to have an opinion and
class Monday started this group of

fifty six students who's for
the Affordable Care Act who's for

health care reform about a third
of the students were for it.

And the rest of them were pretty
pretty clearly against it and

then I started down the list.

Well already for this and
I talked to pieces of it.

Do you think it's a good thing that
there's not a lifetime limit do you

think it's a good thing that prevention
is covered and all of the little issues.

It was almost unanimous every
student thought it was great.

It's only when you package it that it
becomes unattractive for some people.

I think this is the time
to open it up to the floor.

Thank you panel for
stimulating what I believe is going to be

a situation where I have to
keep track of who all is next.

And there is our first one that is and

undoubtedly going to be
a difficult question.

Perhaps it would be helpful if the.

Questioners would state their name and
where they're from that would give

the panel a little of perspective
even though we all know you and

Richard Berke from
the School of Public Policy

touched on my question at
the very end of his last comment.

The whole idea of policy in
economics is to allocate things and

as Karen said you can't allocate
everything to everybody.

There's not enough to go around so
that means choices and

the eight hundred pound elephant or
maybe donkey in the middle of the room is

the allocation of health
care at the end of life.

The last six months last six weeks
last six days of of care and we don't

seem to have a vehicle in this country for
talking about what is what would normally

be called rationing of health care
especially end of life health care.

Other than talking about death
panels other kinds of kind

of inflammatory labels.

So my question for perhaps all four
of you is do we have some sort

of a framework a theory even narrative
a set of metaphors that you think would be

useful in this discussion going to
schedule about health care reform that

we can use to address in some sane
rational but compassionate way.

This question of Into of life
health care of a chair and

provide the first answer I'm sure we'll
all have some thoughts about this for

six years I served on
the board of directors of

the American Cancer Society
the National Board a billion dollar your

organization the largest voluntary
health organization in the world.

And in my parting comments on song
challenge my colleagues who are remaining

and the new ones coming on to take up
this issue of the end of life care.

The greatest disappointment about the
debate that led to the formal Care Act was

that they had been astray should folded
like a tent when that issue came up it was

became talk radio driven as
opposed to policy driven.

There are.

Almost no other cases that I can think
of where you could increase the quality

of care and decrease the cost.

But the only way you can get to
that is to have a national law and

I've concluded that it's too
important to be left to government.

It has to be done in the private
sector That's why are encouraged

the American Cancer Society the to do it.

I don't think they will because they are
afraid of hurting some of his feelings and

the spalling a donor.

But I think that this is an issue.

A private university with
a better course school and

a divinity school needs
to take the lead on

the other Richard end of care initiative

a see if you look at cancers which are the
most expensive end of life treatments.

So the data that I've looked at which
comes from Netherlands Germany U.K.

the US If you look at this
competitive statistic.

It is amazing that bear
effectiveness is only

marginally below ours if you look at in
terms of extra months that people live.

We are looking at in the marginal one to
two months for type of cancer rate but

add that margin we are spending like six
to seven times as much as they are so

what is going on.

Essentially is that here it is
become the birthright to get

the highest end treatment even at that.

Good going to give me two extra months so
I think this is a national debate I

mean at some point to be have to say
look this two months is maybe as good.

I don't know but
this is where the cost is coming from.

So I think Germany takes care of end
of life issues as well as we do it.

You know so but.

And you look back all the way

to Bill's question earlier is this
health care reform inevitable.

I think that Richard question
this idea of rationing or

your choices is alternately what
makes health care reform inevitable.

We have to deal with this and

in some way the somewhat frightening part
of it is looking at our political system

I have very little faith will will deal
with it in a thoughtful or effective way.

So Bill suggestion that this this
hard lift the heavy lifting.

Here comes from outside
of the halls of Congress.

I think might be a necessity.

I would suggest that there are people
who deal with this quite well

at the low level.

So if you go from policy for everybody
to individual health care decisions made

with families physicians and ethicists
in places like hospitals in Atlanta.

People are thinking very thoughtfully
about this on the the individual level.

And it's a challenge I think to
see if we can build up from there.

So now it's not just individual
patients and families but

smaller institutions and so on and
maybe long term still not optimistic

there can be somewhat rational changes at
the higher policymaking levels as well

I think my my thoughts
will be pretty quick.

I think that the country and
all of us as individuals

need to think about the tradeoff
between quality of of end of life.

And extraordinary health care at
the end of life because those two

things don't always mean the same thing.

So you can have extraordinary
chemotherapy or

radiation therapy to cure your cancer but
if the last two months of your life you're

going to be very ill because you got
that treatment are those two months.

Of a low quality of life worth.

You know a treatment free
high quality of life or

a shorter period of time and I think
that those are individual questions

I don't think that any
policy could address that.

But I think that that's a struggle that
too many Americans don't have as that

said it becomes a birthright
to get that high end care and.

I'm not sure that a lot of families
who have gone through those struggles.

I would say that those
extraordinary things were helpful.

Right.
It has to become individualized how we

scale it from very good performance at
the local level to the policy that is.

It's difficult but
the first step is to talk about.

I've had experiences on both
sides of miserable death in

the hospital with tubes and
wires and resuscitation and

all sorts of low quality of life
outcomes that I've had experience

with a beautiful home pain free with
the family surrounding the person.

Dr Brown did you get
the microphone good school of

public policy not a health policy expert
but I did want to comment on one issue.

I think that we need to have that
institution you're talking about to

take hold of this problem be one that also
has a law school because there are many

legal issues.

The one that I'm most appalled
by due to some coverage

I read about the treatment of living wills
is the fact that we can't even seem to

manage to interpretation of them and even
the location of them I heard one bit of

advice on the radio the other day saying
that you should put your living will.

In your freezer wrapped up in a plastic
bag that that's where some hospitals

are now recommending because
there is no standard for

where the living will is to be found and
how to access that went to do that.

How do you interpret it.

So I too have had some experience recently
with dealing with a living will on my for

this position from my father said well
we'll says something about feasible.

You know now I can interpret it.

Interpret these a bull
in many different ways.

So the language of these living wills
why are we not able as a modern

industrialized society to handle the
management and interpretation of living

wills that seems to me to be an easy
way to cut those in of life cost.

Call on some of our physicians and
a audience to comment.

All this fricken love this burden falls
disproportionately on the physician.

Absent a good policy.

Or a good education for a family.

Or doctor faking it.

We're all this together.

You're the reason why we're here.

So you're going to have to give us some
wisdom in this very difficult area.

This is why I have tattooed
my living will on my back.

The way these questions are very

important the last time I did
an appropriations hearing for C.D.C..

Mark Hatfield who was a friend
asked the subcommittee chair.

If he the chairman of the full
committee could actually do the hearing

as an as he did this for me.

He asked me a question that I thought.

I wish I had known he was going to ask
because I think I could have answered it.

He asked how would you set up funding for
public health.

If you were making the decisions.

And I told him that I would first
of all look at programs that

have a positive benefit cost ratio but
that means for every dollar you put in.

You not only spent save
people from misery but

you get more than a dollar out there
aren't a lot of them but the vaccines you

mention the vaccine programs if they
fall in that category and I said.

They should become entitle months and

never again compete with
the rest of the budget.

To do anything else does
not make any sense at all.

Number two I said I would
index prevention and

public health programs to
total health expenditures.

And I would accept what
ever the percentages to.

Because Total Health in New Jersey
are going to continue going up

the proportion for
prevention will continue to go down.

Try to accept today.

And then let's index it to
that number number three

come up with measures of health outcome.

And figure out how to
reward health plans for

improvement in health outcomes
rather than health process.

Our debate keeps going
about access quality and

cost if we simply switch the two
outcome quality and cost.

We'd have a totally different discussion.

And then the fourth thing would be where
do we in fact come up with rationing.

And you know if the British could do it.

Whether you like that solution or
not if they were able to do that.

What's wrong with us.

I mean why can't we not have that
discussion and come up with some

reasonable answer and be prepared to
change it if it just doesn't work right.

You know one of the one

of the issues that you see in the legal
side is that individual patients

families they basically
do get treatments and

then the one so on the one hand you
can say why countries a decision but

the point is that B.C. huge number of
episodes by individual families assuming

providers to provide this care which runs
into two million dollars And get this

patient two extra months of life literally
that doesn't that's what's going on.

And the point is that given the society
we live in this cannot be mandated out.

I mean you kind to this is that
the Supreme Court is never

going to buy this right.

So I think this is the problem on
the one end to get talk about crime you

can preventive care.

But the legal system and the individual
rights is interfering with exactly this.

Problem.

Just two quick comments responding to
the last two comments on the floor and

I think Bill's point that if we can
someway turn the focus on to the outcomes

rather than process.

Actually.

Is the one idea out there that offers some
ability to work within the constraints of

our market driven system where right now
it's profit but it can somehow profit is

tied to better health rather than more and
more eyes which is not necessarily better

health and that may offer some way forward
without a complete overhaul into a single

payer system which is sort of unthinkable
in our current political climate.

So I think that's one thing just to
return to Marilyn's point real quick.

So living wills health care directives
in one way is an enormous advance.

There are cases where they
they work very well but

there are no other cases where they
really don't solve the problem they

they cause lots of challenges
though as I want to come up.

This is one area where there is a fair bit
of empirical research into to when they

work well and when they don't work well
in one of the things that is become clear

is if you want these documents
to work they need to be more

than than just a document they
need to be in a document and

a conversation in some ways an ongoing
conversation that the person who is

writing the Living Will has with
the the trustee for the well so

in my it my mother passed and
gave me her a living will at some point.

And we talked a little bit about it but
in retrospect not enough.

I know you can run into these situations
where interpretation becomes very much

an issue and how we institutionalize
that how we get people one to even have

these documents which is a huge problem
but to to actually take the step and

discuss something which frankly is
not very fun or pleasant or discussed

when everyone is healthy but what needs
to be discussed is still a big challenge.

And been listening to this really thought

provoking conversation and much more sober

when we first started by the challenges
that are here but not like for

each of you if you can as you come in
to really focus on where you think the.

Hope is here.

There.
Been there been options brought forward.

But in the context of the challenge.

Can you please help me out as the eternal
optimist here by saying where you think

the hope is in the product of the chair of
the last and the last errand to leave off.

Excellent.

When you said problem I thought
you would talk first not less.

And I think there's a couple
things to say here.

So one I do think in some ways
the inevitability of reform.

The fact that we're approaching more or

at putting in your point of view
crisis in our health care system.

Although it is frightening offers
some hope when there are changes and

dramatic changes there are opportunities
for for new innovations new systems new

approaches to health care and I think
there's reasonably there are incentives

that may lead to to improvements
in some cases it's not a given.

I think there's enormous political
challenges particularly at the national

level here.

I don't focus excessively on technology.

I don't think technology is the solution I
think there are much bigger problems but

I do think there are parts where
technology can be part of the solution it

to the extent that there are technological
approaches that that lower cost.

That are on the vaccine model essentially
I think that can be something that is

a positive and buys us some time to deal
with these challenges we haven't really

got into the broader social determinants
of health today as much as we heard about

yesterday but there is of course very
increased recognition of these issues and

I think at least that's a start in dealing
with the social determine is a also

a huge concern but but
at least recognition in the mix talked

about some steps in this direction so
I think there.

There is reason for hope.

Despite the challenges.

So I wrote minority the vanished.

OK.

I think the biggest gains from the.

Affordable Care Act will be
preventive in primary care.

I think there are significant initiatives.

If you look at early life so
both early life and early treatment.

So given a disease.

The question is the disease the life
cycle you want to early treatment.

I think the fordable Care Act is going to
make it happen in a very significant way.

And I think for kids.

It is going to provide significant
benefits in spite of my comments about

the macro us.

Health insurance issues which
are not going to go away.

I think those segments including
the under privileged people of

color single woman I think they will stand
to benefit substantially from this and

I think the hope then is that in the
longer run as you look at the life cycle.

Maybe takes ten fifteen years in
the preventive care issue it's not a not

an immediate issue it shows up and
ten fifteen years down the line and

you see better health status overall and
that introduce cost.

So I think that that's the most
significant benefit Affordable Care Act I

think you're morally hopeful about
I'm hopeful that the increase.

Awareness that mental
health is a health issue.

It is equal to the kinds of

physical ailments that we think
nothing about getting treated

is finally coming to be
any one partner that.

That people with depression
which one in five people suffer

from depression at some
point in their life.

So it affects everybody and everybody
knows somebody it's affected by you know

hopefully when we start thinking
about mental health and

things like depression as
normal because it is that

will have better treatment outcomes for
individuals with mental

illness as well as those individuals
with substance abuse problems.

Because substance abuse and
mental illness are so wrapped up in.

Physical health and exacerbating existing
health systems and even increasingly on

said the early onset of different health
care issues physical health care issues.

Once we start looking
at people as a whole.

That health outcomes will be better.

And that if we start thinking about
prevention and thing and stop

thinking about health care as a deficit or
health illness rather than help wellness.

That we can make better strides in and
help.

Well I'm hopeful and optimistic but

because of the increasing
evidence that people

are learning that they have some control
over their own health that previously

the whole system is based
on a fatalistic concept but

increasingly because of successes in
prevention and education that people know

that if they put their seatbelt on they're
less likely to suffer consequences

negative consequences they understand
that they can choose not to smoke and

improve their health and
I think that it's going to continue.

And that's going to be a key component of
a fundamental shift what it really means

is the life work of Dr Bill Faith
is coming into the limelight.

Thank you.