Jonathan Cohn uncovers Sick: The Untold Story of America's Health Care Crisis - and the People Who Pay the Price.
In a tiny village tucked into the Catskill mountains, a man whose job stopped providing insurance watches his wife die from cancer. In a booming suburb outside of Austin, a mother fights with an insurance company so that her disabled baby can get the therapy that might someday help him walk. And in the middle of the prairie heartland, a retiree sells his house because it's the only way he can pay for the medications that keep him and his aging wife alive.
To uncover the startling truth about the state of America's health care system, Jonathan Cohn raveled the country, listening to stories of those who are learning the hard way that citizenship in no way guarantees access to medical care. "Sick" is a fascinating, first-hand account of our failing health care system and the consequences that could someday affect us all- Cody's Books
Jonathan Cohn is nationally-recognized journalist covering domestic policy and politics for The New Republic, with a particular emphasis on health care, social welfare, and labor. The author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, Cohn has been acknowledged as “one of the nation’s leading experts on health care policy” by the Washington Post and “one of the best health care writers out there” by the New York Times. He is a recipient of the Sidney Hillman and Harry Chapin media awards, and has been a finalist for Robert F. Kennedy and Helen Bernstein Book Awards, as well as the Livingston Award for Young Journalists. Presently a member of the National Academy of Social Insurance, Cohn has also been a senior fellow with Demos, a media fellow with the Kaiser Family Foundation, and a Griffith Leadership fellow at the University of Michigan. Cohn grew up in South Florida, where he became a devoted fan of the Miami Dolphins, and graduated from Harvard University, where he became a devoted fan of the Boston Red Sox. But his biggest devotion is to his wife and two children, with whom he lives in Ann Arbor, Michigan.
Larry Levitt is Vice President for Communications and Online Information and Editor-in-Chief, kaisernetwork.org for the Henry J. Kaiser Family Foundation.
Before joining the Foundation, Mr. Levitt was a senior manager with The Lewin Group, where he advised public and private sector clients on health policy and financing issues. He previously served as a Senior Health Policy Advisor to the White House and Department of Health and Human Services, working on the development of President Clinton's Health Security Act and other health policy initiatives. He co-chaired the working group on cost containment in conjunction with the President's Task Force on Health Care reform.
Prior to that, he served as the Special Assistant for Health Policy with California Insurance Commissioner John Garamendi, where he co-authored Commissioner Garamendi's California Health Care in the 21st Century proposal. Before joining Insurance Commissioner Garamendi, Mr. Levitt was a medical economist with Kaiser Permanente, where he worked on insurance reform and other public policy issues.
He previously managed new program development for the Massachusetts Department of Medical Security, the agency charged with implementing the universal
health care plan in Massachusetts. He was responsible for the design of new health programs under the plan, and for management of the fund used to reimburse hospitals for uncompensated care. He also served as a senior analyst with the Governor's budget office in Massachusetts, where he helped develop that state's universal healthcare legislation.
He holds a bachelors degree in economics from the University of California at Berkeley, and a masters degree in public policy from Harvard University's Kennedy School of Government.
System for the advance financing of medical expenses through contributions or taxes paid into a common fund to pay for all or part of health services specified in an insurance policy or law. The key elements are advance payment of premiums or taxes, pooling of funds, and eligibility for benefits on the basis of contributions or employment without an income or assets test. Health insurance may apply to a limited or comprehensive range of medical services and may provide for full or partial payment of the costs of specific services. Benefits may consist of the right to certain medical services or reimbursement of the insured for specified medical costs. Private health insurance is organized and administered by an insurance company or other private agency; public health insurance is run by the government (seesocial insurance). Both forms of health insurance are to be distinguished from socialized medicine and government medical-care programs, in which doctors are employed directly or indirectly by the goverment, which also owns the health-care facilities (e.g., Britain's National Health Service). See alsoinsurance.
Tonight we have with us Jonathan Cohn who will speak about his book Sick. But beforeJonathan speaks we have with us Larry Levitt an Economist with the Kaiser Foundationwho will talk to us a little bit about healthcare in America.Thank you. It is always nice to introduce the introducer. As said, I am Larry Levitt fromthe Kaiser Family Foundation. For those of you who aren't familiar with us, we are ahealth policy institute based out in Menlo Park and probably most important is what weare not. We are not affiliated with Kaiser Permanente, the Health Plan or KaiserAluminum or Kaiser Wilhelm or the Kaiser Chiefs or whatever Kaiser you can possiblythink of. And I am very pleased to introduce Jonathan Cohn, Senior Editor of the newrepublic and author of Sick a book we help support through our year long mediafellowship. Or at least hope Jonathan will agree that we help support him. And you know,they say in real estate, that the key is location, location, location. Well in politics andpolicy the key is timing, timing, timing and Jonathan's book could not be timed anybetter. It's clearly a crisis in healthcare which I think has probably not surprised anyonehere over the last six years. Health insurance premiums have risen 87 percent, far fasterthan people's ability to afford them. And as a result the number of uninsured in theUnited States is now at 45 million and growing by at least a million a year in recent yearsbut until recently politicians have not recovered from the failure of President Clinton'shealth plan over 10 years ago. I mean, I have been willing to step up and tackle the issue once again.But that that seems recently to be changing in fact quite recently to be changing in factquite recently. Any every democrat on the campaign trail running for President is nowsupportive of universal coverage in comprehensive health care reform. Even a fewRepublicans are supportive. Now as well, Governor Romney is running for President,former Governor Romney of Massachusetts enacted and signed a Bill in Massachusetts toprovide universal health coverage which is now being implemented.Governor Schwarzenegger, I am not sure if there are any Governor Schwarzeneggervoters in the room. But Governor Schwarzenegger put out a I think what many wouldconsider a surprising plan a few months ago in January to provide universal coverage. Idon't agree with all of the you know, but Jonathan with agrees with all of it either. But forsomeone like the Governor to come forward and feel the need to offer a plan which, Ithink, has a decent chance of passing this year is assigned that the issue has a great deal ofmomentum and Jonathan's book is timed perfectly to tap into that momentum. And Ishould say I have been doing this for a lot of years. Pretty much had a career of failing athealth care reform. So I am sitting out this debate. So maybe it has a chance, a chance ofsucceeding but I have to admit that you know, I have written a lot of, lot of drawing andboring studies and reports over the years. I mean, I was in a lot of bad legislation. But no,no driver report that I can write can do with Jonathan's book can and has done which is totell the story of the healthcare crisis not only in political and economic terms but alsothrough the lives of people who experience it. And for those of you who have not read ityet, I would certainly encourage you to do so.It's an extremely powerful book and I hope, hope Jonathan is not quite as jet lagged as Iam because we both were in Washington this week where we hosted a debate betweenJonathan and a somewhat more conservative commentator at the free market orientedCato institute. And I would say frankly Jonathan won hands down. He is appearing alone heretonight so I think, he has the upper hand tonight as well but in all seriousness he issomeone who can absolutely hold his own against anyone and I am pleased to introducefriend and colleague Jonathan Cohn.Yes sure I did. I debated somebody at the Cato Institute earlier this week and if you wantto talk about jetlag and whiplash. It's quite an experience, I have done this is my thirdreading on the so-called book tour. I have so far, I have given readings in Ann ArborMichigan where I live, Greenwich Village, Home of the Strand Bookstore and now hereand to have sort of the Cato Institute debates sandwiched in between there it's a veryinteresting perspective. I actually expect, I see Don McCanne in the audience so I amlooking forward to getting a lively debate going from the other side from where I wasearlier this week and you know, but then again like I said living in Ann Arbor and comingto Berkeley I look forward to those opportunities. I want to thank Cody's, I want to thankthe Kaiser Foundation.The Kaiser Foundation, for those of you not familiar with them, they inform the healthpolicy debate in this country. Most of the information you see frankly use by both sides, Iwould argue some what more disingenuously, disingenuously by the other side comesfrom the Kaiser Foundation. They do enormously significant work, and they also dosupport the work of journalists and one of the great thing about their fellowship is thattheir fellowship, they offer to journalists really is a very hands-off fellowship, pick outpeople who they think are doing good projects. I see one of my fellows, former MarkSchiffer here in the audience and then they let you do you are thing. And that's a goodthing, because the timing that Larry mentioned is entirely accidental. This book wasactually supposed to be done two years ago. And unfortunately for me I was not verygood at meeting that deadline. It turned out to have been good bit of timing, proves forthat sometimes procrastination does payoff.I am going to start, take all these readings, so I am actually going to read from my book. Iam going to actually start with the very beginning of the book which is it takes place inmy adopted hometown in Boston.It was 4:43 on a clear November afternoon when the paramedics found Cynthia Kline,pale and short of breath, slumped against a bedpost in her double-decker Cambridgehome. Although Kline was in obvious pain, she seemed keenly aware of what washappening inside her 55-year-old body. One of her blood vessels had closed off, blockingthe flow of blood to her heart. Minutes before, she had phoned 911, taken thenitroglycerin tablets prescribed for such an emergency, then waited for help to arrive-anordeal that stretched out an agonizing extra few seconds while the rescue workers, havingfound the front door locked, scampered in through an open second-story window. Now,while the paramedics worked busily over her, noting vital signs consistent with cardiacdistress, Kline turned to one of them with an anxious plea: "Take me to Mount Auburn Hospital."Kline, a teacher who worked with special- needs children, had no formal medicaltraining. Yet her instinct about where to go was as sound as a seasoned cardiologist's.Nearby Mount Auburn Hospital, a private teaching facility affiliated with HarvardMedical School, had some of the city's finest doctors and nurses. More important, it hadan intensive cardiac care unit that specialized in cases like hers. A few days earlier, staffat Mount Auburn had treated Kline's advanced coronary disease by inserting a ballooninto her circulatory system and then expanding it, in order to open up a partially blockedblood vessel. A variant on the very same procedure, "cardiac catheterization," could beused in an emergency like this one, when the flow of blood through a vessel was almostcompletely cut off. Cardiac catheterization had saved literally thousands of lives acrossthe country. And it had the potential to save Kline's life, too, just as soon as she could getto the hospital and receive it. But getting there was precisely the problem.On the way to Kline's home, the ambulance driver had checked with a dispatcher abouthospital availability. Mount Auburn was no- go. The emergency room there wasoverflowing, with no space to handle new patients. So as the paramedics wheeled Klineinto the ambulance, one of them told her they would have to deny her request: "Ma'am,we're going to Cambridge Hospital instead." Kline accepted the news, and maybe for amoment she thought it would be for the best. Although Mount Auburn was less than twomiles away, Cambridge Hospital was even closer-just a short trip through the crooked,disjointed streets that surround Harvard Square. It was also a highly regarded medicalfacility in its own right, with a top- notch medical staff and a recently renovatedemergency capable of handling the majority of trauma cases that came its way. HadKline's condition remained as it was, it probably could have handled her case, too.But just four blocks into the journey, Kline's condition suddenly deteriorated. Theinstruments tethered to her arm could no longer detect a blood pressure; her heart rate,seventy beats per minute just moments before, was down to thirty-eight. Kline, strappedinto a stretcher, was conscious through all of this-and increasingly agitated. At her sideone of the paramedics, a kind-looking thirty- year-old, tried to calm her, explaining thatthe hospital was just seconds away. But as the ambulance made a right turn around onefinal corner, bringing the tall redbrick facade of Cambridge Hospital into view, Klinebegan to cry out: "I'm going to die. I'm going to die."It was 5:04 p.m., just twenty-nine minutes after Kline had first called 911 and about anhour into the heart attack, when the green-and-white ambulance pulled up to theemergency bay. Informed of the patient's newly worsened state, attendants hustled thegurney into the hospital as the medical team began administering intravenous medicationto increase Kline's heart rate. For a while it looked like she might pull through. Her pulsewent back up to forty- five beats per minute-a far cry from normal but at least not "verylow," as it had been in the back of the rig. Her breathing was more regular, too. Soon,however, a cardiology exam confirmed that Kline needed catheterization, something theCambridge Hospital staff could not do. A nurse began inquiring about available hospitals,but now it was two hours since the chest pains had first begun-and time, finally, wasrunning out. At 6 p.m. Kline's heart stopped altogether. The doctors began performing thefamiliar ritual of cardiopulmonary resuscitation (CPR), pumping her chest and usingelectrified paddles to shock the heart back into a regular rhythm. It made no difference. At7:03 p.m., the trauma team relented and Cynthia Kline was dead.Fifty-five- year-old women, particularly those who have a family history of coronarydisease, die from heart attacks all the time. So as a forensic matter, at least, Kline's deathwas unremarkable. But the technology that might have kept her alive existed-and itexisted at a hospital that was less than five minutes away from her home. There was noguarantee that Mount Auburn could have saved her. Still, as one source familiar with thecase told the Boston Globe, whose story on the matter sparked a state investigation,"Within an hour and a half they would have started to open her artery with a catheter. Ifyou get the artery open there's a 50-50 chance." None of which would be so troubling ifthe overcrowding at Mount Auburn on that day in November 2000 were an isolatedincident. It wasn't. During a one-week period shortly after Kline's death, a survey ofseventy- six Massachusetts hospitals found that sixty- seven of them had used emergencycrowding procedures or had diverted ambulance traffic. Massachusetts General Hospital,Boston's largest medical facility, was closing its emergency room to patients forty-fivehours per week. On the day of Kline's heart attack, MGH was the next closest hospitalwith a cardiac cath unit-just three miles away. But it wasn't taking emergency patientsthat day, either. And even if Kline's wasn't the only known fatality from ambulancediversion, there was plenty of reason to think that the overcrowding epidemic wasroutinely jeopardizing the well-being of patients.In 2000, when the Massachusetts College of Emergency Physicians surveyed the directorsof more than sixty emergency room facilities, four out of five said they'd diverted trafficat some point-and nearly 40 percent said overcrowding had led to "adverse healthoutcomes." Sometimes it was a matter of forcing ambulances to drive longer distances inorder to find available hospital beds, sometimes, as in Cynthia Kline's case, of shunting,you know, the case for shunting people to hospitals less able to provide acceleratedtreatment. And sometimes it meant that patients who got to the right emergency roomshad to wait for many hours before receiving treatment. In some cases, patients actuallywaited inside the ambulances.Boston in other words had an emerging public health crisis on its hands and it wasn'talarming. In Atlanta an ambulance crew carrying a patient for respiratory distress had topull over and wait on the side of a highway for 18 minutes because the nearest hospitalwas full and the paramedics were busy trying to find an alternative. When the mother of40 year old Cleveland male with liver failure called a local community hospital, staffthere referred him to Metro Health Medical Center which had more advanced facilities.So when the ambulance arrived, Metro Health was on diversion. The man ended up backat the Community Hospital where 15 hours later he died.In suburban Houston where a 21 year old man was hit by a car the local trauma centersturned him away because they had no room. He ended on a helicopter ride to the nextclosest trauma hospital in Austin more than 150 miles away and died shortly after arrival.Fed up with incidence like that a Texas neurosurgeon named Guy Clifton started anadvocacy organization called Save Our ERs. The group's first order of business was tocompile data on Houston's emergency services and have produced some sobering results.The cities two level one trauma centers the hospitals that are capable of dealing withthe dire emergencies were simultaneously on diversion for extended periods of onceevery two days. I have been in the business, for 25 years Clifton said and I have neverseen anything like this.It has been more than 10 years since the United States last had a great nationalconversation about health care. But the conditions in our emergency rooms are a reminderthat another conversation like it is long over due. If you talk to the experts they will tellyou that ER over crowding is actually a symptom of broader deeper elements reflectingAmerican healthcare like the rising number of peoples without insurance, to fill ERs tocapacity or the downsizing of unprofitable services like psychiatry which causes backups,that hospital staffs search desperately for empty beds into which they can put their mostdire patients. And while all trends may seem unrelated at first they are all consequencesof the unique way we pay, America pays for its medical care. A system that is nowcrumbling before our every eyes. Many people have heard the statistics 43 million, thenumber of people at anyone time who don't have health insurance.16 percent, the percent of our national income that we spend on health care more than anyother country in the developed world. $12000 is the average price of the family insurancepolicy which you needless to say, is more than lot of families can afford. But if everybodyhas heard these statistics, I don't think everybody really understands what they mean.After all the majority of Americans still do have health insurance. They like it and theycan get affordable health care when they need it. They may know that millions of otherAmericans aren't so lucky, but they have a hard time imagining themselves in thoseshoes. They may grasp that the uninsured sometimes don't get quite the same treatment asthe insured. But they believe that alternatively somehow, someway, everybody reallygets the medical care that they need. This ambivalence, I think, goes a long way toexplaining why our healthcare system looks the way it does.You know, lot of people look back on the debate over the Clinton health care plan in1993 and 1994. They think ruefully of the opportunity missed and they focus blame onthe Clinton administration for the mistakes they have allegedly made. Or on the specialinterests for piling on all the misinformation that scared so many people and spread somany lies about what was actually in Clinton Healthcare plan. Now I actually think thereis some credence to both of these theories. But at the end of the day I think neither ofthem fully explained why we didn't get Universal Healthcare in 1994.I think the biggest problem in 1994 was the fact that the public honestly didn't feel thatinsecure. The possibility of losing access to medical care didn't seem real enough. Thepotential consequences that might result didn't seem awful enough to warrant a wholesalechange in the system. And when presented with the possibility of creating a UniversalHealth Insurance system a possibility that inevitably even in the Clinton plan meantasking the government to do something that in this country we were offering the lot onthe private sector to do, a majority of the public looked and said no thanksA few Americans realized just how vulnerable they were, or how that vulnerability wasabout to grow. And that is really what this book is about. Another train noise is going by.This book is about how our decaying healthcare system has put ordinary hardworkingAmericans at risk of financial and medical catastrophe and it's a story I tell them, not justthrough statistics although there are statistics in there for those of who like to readnumbers. It's a story I primarily tell from the story of eight individuals from around thecountry. Eight people I selected from hundreds of people I interviewed over the years.Eight people who all found themselves in the medical crisis that quickly became a financial crisis.One of them is Gary Rotzler, we care up we catch up with Gary in the early 1990s whenhe and his wife, his high school sweetheart have set only to a tiny idyllic village locatedin the foothills of the Catskill Mountains in upstate New York. They have three youngchildren. He has a good paying job as an engineer and a defense contractor. They arereally living the American dream. And then one day he gets outsourced. He loses his job.And he is able to make up the income partly with part time job and temporary work andeventually he gets his old job back at the defense contractor with one small wrinkle. Nowhave is a temporary employee and he doesn't get health insurance. As a result his wifedecides to put off some routine medical care. She decides not to get few ailments checkedout, some back aches, some fatigue that is a decision that will come to haunt them andresulted in a medical and financial catastrophe.Sick also introduces readers to Janice Ramsey. A spark plug of a real-estate consultant inCentral Florida, who, happens to have diabetes. She worked hard her whole life and she ismaking good money but because she is self employed she has to buy insurance on herown and once insurers hear that she has diabetes, they don't really want any part of her.Eventually in her struggle to find a affordable insurance, leads her through ordeal thatsounds almost too good to be true and then it turns out to be too good to be true. Andsomebody who had never paid a bill late in her life, who had built herself up her ownbusiness on her own hard work suddenly, finds herself in a mountain of medical debt.We meet Elizabeth Hilsabeck resident of an upscale suburb west of Austin, Texas and amother of twins born several weeks premature. Her son develops cerebral palsy and needsphysical therapy to walk some day the doctors say, but her insurance, her excellentinsurance provided by her husband's very well paying job at a bank will uncover it. She isdetermined to get her son, the treatment he needs and I will tell you right now, that shedoes but the question is not whether she gets the treatment but what she has to sacrificealong the way and then there is Lester Sampson a veteran of the US navy and a 30-yearemployee of the Morrell meat packing company in Sioux Falls South Dakota where hestarted as an 18-year-old scooping the brains of pig carcasses. He retires with the premiseof a lifetime health benefits. A precious bit of financial security upon which he and hiswife will plan the retirements and then one day he will open his newspaper and he willfind out that that company changed its mind and then he is not offering retiring benefitsany more. And the lives will be changed forever.I chose these four people and the others in the book because they represent the vastdiversity of American life economically, geographically, racially, education but whenpeople read these stories, I think, they'll find a little bit of themselves in everyone of them.None of these people are so different that not for a change in lack or circumstances theycouldn't be you. And that really is take home message of this book. This is notsomebody else's problem. Maybe you are healthy and maybe your financial situation issecure, but don't for a second think that with the right or wrong combination incircumstance you couldn't end up like one of the people in this book and what makes thisalso incredible is that it doesn't have to be this way. It doesn't have to be this waybecause the American healthcare system didn't come by - come to be this way byaccident. It is the result of choices made and choices not made. America's historic faith inindividualism and antipathy for the state that strange brew of optimism and skepticismthat makes us unique in the developed world.This is the other story I tell in Sick, the one I hope that will move us from anger andsympathy maybe finally to action. The origins of the American health insurance systemdate back to a late 1920s and 1930s which is really the first time that American healthcarebecame sophisticated enough that it was worth charging money for and that was a greatthing. We developed cures, hospitals began to learn to do operations and surgeries. Forthe first time you could go to the doctor and actually get better but of course, there wasone downside to all these medical advances, they cost money. And then in late 1920s andearly 1930s I found a group of foundations established what was called the committee onthe cost of medical care to take what was really the first national survey of medicalspending in this country and it quickly became, apparent two things. The first was thatlots of people were suffering. That people suddenly, they couldn't pay literally afford tobe sick. A week in the hospital was worth a month's salary to the average American. Butthere was a bright side to all of this. That only a few people at any one time suffered thesewhere in this situation. Medical expenses were concentrated among a very small groupof people. If you could just find a way to get everybody to pay into a pool to get healthypeople to contribute with the knowledge that maybe someday they might be the ones whowould be, needed the financial assistance you could create an insurance system and takecare of everybody.Well that was great, but of course, that raises another question, what kind of insurancesystem to have? Now in the 1930s we had a new president, we had a new political spirit,and we know from the history books that Franklin Roosevelt fought hard about addingNational Health Insurance to the Social Security Act but he was worried. He was apolitician and he really cared about getting the Social Security Act passed. And hisadvisors told him that if he included Health Insurance as part of social security, statemedical societies would rise up against him and then only when they had bought NationalHealth Insurance they might derail the entire Social Security Act.So FDR ditched National Health Insurance and now it's a fateful decision because itturned out patients weren't the only people stepping with medical bills, hospitals weretoo. In the 20s they had expanded, they had built all these new facilities, taking advantageof all this new technology and now the wards with former patients who couldn't pay theirbills. And if the patients couldn't pay the bills well eventually neither could the hospitals.So they needed a way to come up to pay with their bills. They needed a way to stayfinancially afloat and they were the ones who invented modern health insurance.They started in Dallas Texas at the Baylor hospital when the new superintendent therewho had worked at the Dallas schools approached the Dallas schools and said, went to theteachers and said if each of you contribute a small amount every week or every month wewill provide 14 days of medical coverage. And now is the first health insurance plan aswe know it today. These plans proliferated and eventually the proprietor of a plan inMinnesota thought it would be a neat idea on his advertising poster to illustrate his newinsurance plan with a Blue Cross and that's how we got the blue cross system.The Blue Cross system actually operated a little bit like what you would call a socialinsurance system. After all it was designed for the benefit of the hospitals. They wantedas many paying patients as possible. So it started by approaching large businesses. Thatway they knew that if you got a large group of people and healthy people there will beenough healthy people paying into the pool to cover the cost of these few that were sickbut they also had a pretty open door policy to individuals. If you came to Blue Cross andyou had the money to pay for one of their plans they would give it to you and they didn'task whether you had recently had cancer or whether you had risk for a heart attack. Againtheir goal was to insure as many people as possible and so overtime this system evolved.There were a few tax breaks that helped it along the way. Wage and price controls inWorld War II and before you knew, we had what we have today and the system of privatehealth insurance based on employment.It was assumed that the majority of working Americans would get their health insurancefrom their jobs and from the 1920s up through the 1970s this system worked well. Or as Ilike to say, they worked well enough for enough people. That effort to dismantle it failedand at a time when medical care was relatively cheap employers liked this arrangementbecause it was a nice easy way to buy worker loyalty. And unions and workers liked thisarrangement because at a time when you stayed in the same job for your whole life was ita liable way to get health benefits and even people who weren't employed were okay withthe system. Because as I said the early insurance plans had a pretty much an open door policy.Of course, they were always those left out of the system, the poor, the elderly who evenmanaged to fix those problems. Sort of in the 1960s when we created Medicare andMedicaid and so you ended up in a situation by the 1970s where 90 percent of thepopulation had health insurance. It wasn't perfect but had gotten a lot better than where itstarted. And it wasn't perhaps unreasonable to think that it would keep getting better.Only then the economy changed. Unions became weaker, employers suddenly feltsqueezed, by competition abroad and competition at home. And this all happened at thesame time that Medical care suddenly got a lot more expensive and if up through the1970s all the incentives weren't placed to load up, and to give employees, good generoushealth benefits. Starting in the 1970s incentives reversed. And I think the best illustrationof this is you think of the model corporation of the 1950s is General Motors whicheagerly loaded up its employees with very generous health benefits. Well what's themodel employer today? Its Wal-Mart, it strives very hard not to give it's employees goodhealth insurance and of course when you have Wal-Mart driving, not giving itsemployees' good health insurance, well, then all the other companies feel pressured to dothe same thing. And that is the big reason why employers suddenly find themselves orunder all this pressure and you see employers, slowly getting out of the business ofproviding health insurance.Now n the 1990s we had managed care and managed care was supposed to save all of us.It was going to give us good high quality care, it was going to save money and theClintons actually had the idea that you could actually use that savings to deliver insuranceto everybody. Of course the Clinton plan didn't pass but we still got managed care anyway, despite what Louis said and in the end the only difference was the money didn't gointo providing health security, instead it went to profits and it went into employee wages.And that wasn't entirely a bad thing. Higher wages was good, and more securityinsurance was good but there were no rules about managed care had to behave and oftenwhen they squeezed heath cost to save money they squeezed it in ways that hurt peoplethat needed the insurance the most.All of which pretty much brings us to where we are today. Managed care doesn't savemoney any more, at least not like it used to and players are getting out of the business inhealth insurance. The safety net, it is expanding, but not fast enough to keep up with thegreater demand for it. So what's going to happen next? I actually wish I knew. I do knowthis much, we do have a conversation starting about health care and we do have aconversation in which we have at least one presidential candidate, John Edwards who hascome out and offered a detailed plan for universal healthcare. Now some of hiscompetitors have said, they were going to do healthcare too, although it was not clearwhether they will have detailed plans or, even a set of principles but whether perhaps theywill just campaign on the slogan and hope that's enough to get by.But there are other signs positive signs that something could happen. One of them is thechange in the business community. You have the CEOs now starting to embraceUniversal coverage and not just support it, but actually advocate on behalf on it. Oneparticularly striking example is Steve Bird the CEO of Safeway. Now anyone who isfamiliar with Steve Bird will know that he would be never be confused of having ableeding heart. This is the man who helped to lead the California grocers into a strikewith their unions a few years ago because the unions wouldn't accept skincare healthbenefits. Well if talk to Steve Bird today you will find out he has become a passionateadvocate of universal health care.Now he is not doing this out of any sense of social solidarity, he is doing it out of a senseof business. His company is being squeezed by Wal-Mart too. And he thinks this ishurting American competitiveness. Now I will be the first to admit or maybe the second,because I think he would be the first to admit, that he and I don't exactly agree on whatUniversal Health Care should look like or why you should do it? But the fact is that whenyou have Steve Bird getting up there, sending along side a union leader, or next to aDemocratic Senator saying yes we need Universal Health Care that gives the idea ofpolitical respectability. And I think that political respectability is important becauseeven with Steve Bird endorsing Universal Healthcare, it's hard to know whether we willget it right this time. For every Steve Bird and every Safeway and you still have WalMart. For every lobbying group that is slowly turning around the way the doctors have, Ithink, because they've realized that managed care can be just as frustrating as agovernment bureaucracy, you have other interest groups that remain just as opposed touniversal health care as before. You may hear that business roundtable making nicenoises about universal healthcare but I guarantee you you won't hear it from theNational Federation of Independent Business, which is one of the most hard - hard coreopponents of universal health care in 1993 and is emerging as one of the most hardcore opponents today.And one sobering lesson of the Clinton healthcare fight is that it takes just a few verycommitted lobbyists to help bring down the plan. You think back to the Clintonhealthcare plan and I am not going to put Larry Levitt on the spot here to talk about this,although we could.It was actually a great deal for the big insurance companies. It was basically a guaranteeof business for life and I liked the plan but they didn't lift a finger to fight for it.Meanwhile the small insurance companies, the ones you really leave off screening theircustomers and keeping out the patients for the pre-existing conditions. They hated it.They are the ones who gave us hearing in Louise. And I can guarantee you that inverselyany kind of Universal Health Care system they would fight again. So what do you doabout that kind of opposition, well one school of thought holds that the best thing you cando it is to be very clever. To come up with a plan that will navigate these shawls betterthan the Clinton healthcare plan might have. To come up with just the right combinationof gimmicks and whistles and bells and gadgets, to make the plan more acceptable to thelobbying groups. Also you will find I am not against any plan that would get us toUniversal Healthcare, I think any serious plan for Universal Healthcare deserves a fairhearing. By I am also worried of promises that with just the right amount of policytinkering, you can get this right. Because I think the way you get to universal health careis that you build momentum for it now. Not in January of 2009 but before the nextpresidential election. You need to build a mandate. If not around a specific plan, thenaround a specific set of principles. Still when the fight does come back, when you areelected president in the next election and the lobbyists fight you can play that card andsay, I was elected to do this. And you can say to members of Congress, you were electedto do this. And if you are afraid of being attacked by the lobbyists because you won't - ifyou are afraid of losing your contributions, just remember that you will face a voterbacklash if you don't do this. And the way it is, I think, involves a lot of education. And Ithink that means in the next years you have to do a couple of things. I think it needs tostart by getting rid of some of the myths about Universal healthcare, you need to tellpeople that the stories they have heard about England and Canada are a) wildlyexaggerated. b) Not indicative of what Universal Healthcare has to look like. I happen torefer to talk about other countries. You will hear me talking a lot about France orGermany or Japan and Switzerland. Four very different systems for Universal Healthcare,with systems that I think Americans in general would be pretty comfortable with. Theyhave a large degree of freedom, they don't have waiting lines. It's not the waiting line thatwe have heard about. We actually have around the United States, that's the other part, youknow, they had, they have very high quality healthcare. They managed to cover everybody and yet they managed to spend less than we did. Fancy that.You remind people of what they have right here what is the most popular insuranceprogram in the United States. It's Medicare, a big bad government run single payerhealthcare system and the beneficiaries love it. Poll after poll shows it is more popularthan private insurance policies in this country and you should remind people, they seemskeptical about Universal Health Care that every time this subject has come up, theopponents of Universal Health Care said that the private sector can do it better. That theprivate sector can solve it on their own and then you turn to them and ask them, theprivate sector has done such a great job of solving this problem, why do we keep havingthis debate, every 10 to 15 years. And then last of all, if you do, if you do read this bookremind them of the people you met in them. In these pages, remind them about GarryRoxboro, the engineer from upstate New York. And how quickly he went from living theAmerican dream to the brink of financial and emotional reeling. Remind them aboutElizabeth Hilsabeck when the HMO decision to deny treatment was able to break theshield of financial and vulnerability, she once thought her husband's job guaranteed,remind her about Lester Samson how he spent a lot of time hacking away at pig guts andhow he did it for a promise of life time health benefits that evaporated just because thecompany decided it didn't make profit, it wasn't profitable any more. And remind him ofCynthia Kline, the Boston school teacher who might have survived a heart attack only ifthe local ER wasn't overwhelmed with so many patients. You remind them in otherwords that this will be their problem sooner or later. If not today, then maybe tomorrowand maybe it won't be then, maybe it will be a friend or a loved one, it will be somebodythey know. Ask them about that, ask them if they want to live in a society that takes thosechances, that makes life in effect a big role of the dice particularly when it doesn't have tobe that way. Thank you.