Thursday, June 26, 2008

Session 4: Ethical Questions in the Reform of Health and Medical Care: A Panel on Three Policy Proposals, continued

Stephanie Woolhandler, M.D., Harvard Medical School

Len Nichols, Ph.D., New America Foundation

James Capretta, Ethics and Public Policy Center

 

CHAIRMAN PELLEGRINO: I'm going to move ahead and ask each of these panelists to briefly state why they think — I hope this isn't too aggressive a question — why they think the program that they're most closely associated with is a morally acceptable one or perhaps if they're really bold, want to say why it's more moral than any other one.

But, really, we're talking about how they feel about the ethical implications of what they're saying. And they've agreed in our little huddle here that I'm to go off tackle but they are to present quickly and expeditiously, and then we have two members of our own Council to open the discussion.

However you want to go and in whatever order, whoever speaks up first and be first.

DR. WOOLHANDLER: Well, I think that the single-payer proposal is the only ethical one on the table because it's the only one with proven effectiveness. I think that many of these proposals up here are known to be ineffective. They've been tried, and they failed. Perhaps the best you could say about some of them is they're an experimental treatment.

So I just think if we're concerned about 18,000 deaths each year from lack of health insurance, we're actually obligated from a moral point of view to go with something that's proven, which would be some form of nonprofit national health insurance.

CHAIRMAN PELLEGRINO: Thank you very much. A workable plan is a morally defensible plan.

DR. NICHOLS: Well, as I think you know, I base my vision on my interpretation, and I'm not a theologian. I am a simple country economist, but I base my plan on interpretation —

CHAIRMAN PELLEGRINO: We'll give you a choice.

DR. NICHOLS: — my interpretation of Leviticus, which I believe was continued in many ways in the traditions that followed. And what I like about that vision of the prophet's description of community is that seems to me to be the only way to reconcile all the conflicting forces at work here.

On the one hand, you had the admonition to leave food in the field. Why? For the widow, orphan, stranger, for those who could not have eaten otherwise. So preventable starvation was unacceptable.

In my view, health care has become like food, a unique gift. We absolutely know people will die without it. It was unacceptable to let people starve back then. It's unacceptable to let people go without health care now. In my view, those are morally equivalent.

But what I love about the gleaning metaphor in Leviticus is that it does not say, "Give the same amount of food to every person." It does not say, "Give all the food to one person who happens to be hungry." It does not say, "Bring the poor home and cook for them." It says, "Leave the food in the field, and the poor have to go get it."

So there's a mutual obligation. There's a mutual responsibility, and that's why I see that reflected perfectly in the combination of personal responsibility, including individual mandate to purchase, and shared responsibility, that is, to make it possible for each individual to achieve their own objective.

CHAIRMAN PELLEGRINO: Thank you very much. Mr. Capretta ?

MR. CAPRETTA: Well, I think the program I put forward is the ethically appropriate way to proceed for several reasons. First and foremost, the more that financial resources are put in the hands of patients and consumers to make decisions, the more the system is responsive to those patients and consumers.

In other words, complex organizations respond to whoever is holding the purse strings. That's just a fact of life. And to the extent that, with oversight, a market can be set up so that people are selecting and purchasing care with the individual more in control, the system will become more responsive to what they want. And I think that is fundamentally putting the patient in the center of the system.

The second is that I think it's the most practically plausible and workable approach. It deals with the system as we have it and makes changes from there to improve efficiency and market incentives without undoing everything and trying to start over.

And I guess the third thing is that it doesn't cede to the federal government all centralized control, which I think for a lot of people would be troublesome in the sense of many medical ethics questions would all end up getting handled probably in the governmental bureaucratic sense, which I think would be problematic.

And, finally, controlling costs is either a matter of efficiency or queuing, in a sense. And market incentives, financial incentives with oversight can get to more efficiency, trying to do things where people decide on their own that this is less valuable than the price we've been paying and not doing it anymore, which I think is better than just putting people in line a little bit randomly.

CHAIRMAN PELLEGRINO: Thank you very much. I'm going to ask Professor Carl Schneider and Professor Gómez-Lobo to open the discussion, and then there will be an opportunity for the panelists, who have been very faithful to my request in being brief and to the point, to expand on their own impressions.

DR. SCHNEIDER: I take that as an implicit invitation to be brief, so I will ask one question. We've now heard from a number of people who have a number of different analyses of the present crisis, if that's how — I shouldn't have used that word — the present difficulties in American health care.

And many of the people have spoken with extraordinary confidence and force and have been quite willing to say that the alternatives to their program are highly unsatisfactory. These arguments are all based on data and empirical evidence and arguments that we are entirely incompetent to evaluate. And I take that to be common ground.

DR. WOOLHANDLER: I don't understand your point. Why would you be incompetent to evaluate these arguments?

DR. SCHNEIDER: Because, for example, I think that there are other ways to read the Rand study than the one that you suggested. In order to take the argument about the Rand study seriously, we would need to look at the Rand study to see what it said.

So my question is is there any useful role that we can play, given that we are incompetent to choose amongst the many programs, not just today, that we've heard about?

CHAIRMAN PELLEGRINO: May I ask the panelists to hold until Professor Gómez-Lobo has his chance to open the discussion. Alfonso ?

PROF. GÓMEZ-LOBO: I'll probably be not as brief as Carl , but brief enough, I take it.

What I'm going to do is I'm not going to enter into the merits of each of the three proposals because I take my task to be to take the different views we have and to try to reach some basic ethical view that I hope might govern our own deliberation about this.

Now, we have heard quite a bit about helping the poor or helping the needy, and I disagree with that. I'd like to argue that universal coverage for health care and therefore access is an ethical issue in the sense that it's a question of justice. It's not a question of charity. It's something that we owe to each other. And I would like to make a brief argument to show that.

It seems to me that when one joins an insurance group, what one does is one enters into a kind of covenant in which those of us who are healthy are going to pay for those who are ill at that moment in exchange for reciprocal treatment at a later date. So I'm healthy, but if I'm sick, you are going to have to pitch in from your contributions to help me.

Now, I don't take that to be charity or care for the poor. I would use the old Polish word solidarity. And so if an insurance group, assuming profits are reasonable or don't exist — an insurance group is practicing that virtue. And then the question I raise for myself is, well, why don't we extend that to the whole country? Why don't we accept the fact that we all share in a political community? We're all in pursuit of flourishing. Health and therefore health care are goods that we distribute among ourselves in such a way that we owe to each other certain services, certain benefits.

Now, this, of course, creates something that may be called a positive right. Someone has a right to the behavior of someone else, and I'm very anxious to hear what's going to happen tomorrow in our discussion of the American political panorama because I'm aware of the fact that there are people who argue strongly for negative rights, for the idea that I have the right to be left alone.

And, in a way, we have had that appear in the papers we have read, the question of those who could have insurance because they have the resources and do not buy insurance. What do we do with them?

Let me leave it at that. I know this is somewhat provocative, but I would say that the goal, the ethically basic goal of any proposal for reform of the American health and health care system should be coverage for all as a matter of justice and not as a matter of charity.

CHAIRMAN PELLEGRINO: Thank you very much, Alfonso . Now, the panel has an opportunity to respond and expand. We can start with Dr. Woolhandler .

DR. WOOLHANDLER: I'm again just a little amazed at the comment that this group is not prepared to decide on these questions. There are so many IQ points in this room, and people spend so much time thinking about ethics. I mean, the material I present is not rocket science. The Rand study is not rocket science, either. There's a book about this [holding her fingers about an inch apart] thick that you could probably read in an evening if you want to read it yourself.

So I think saying we're not prepared to decide is actually saying we're going to step away from a problem that we recognize is very serious and is resulting in 50 deaths today as we meet here and 18,000 deaths a year in the United States .

DR. NICHOLS: I would just like to say to Dr. Gómez-Lobo your concept of justice and my concept of community are the same, that in fact — and I think it will allow me to answer Professor Schneider 's question. What you could do that would be phenomenally helpful would be to say, "We ought to do this as a nation for justice or efficiency," whatever reasons you believe, and just stop there and leave the details to the process.

I mean, I believe it was you this morning who said, if I'm not mistaken, once you get into a negotiation, then ethics often gets muddied. I agree. You've been to Washington ; I have, too. That's where we live. But I will say, that's the best we've got.

And the thing is, if you don't help them start from the ethical starting point, it's going to be harder for them to come to an outcome that approximates justice. And I would submit what I believe — and I agree with Stephanie, it's an experiment that we're talking about that I think has a chance of bipartisan support — but precisely because we are at a place in our nation where right now we do have a chance.

We can see it within reach because those 14 senators have agreed to put their reputations on the line and take great flak from their colleagues to say, "Here's a way we could maybe agree with this. Let's talk about it to get ready for the '09/'10 discussion, regardless of who wins the White House."

DR. SCHNEIDER: You say "Let's do this. It's possible." What is the "this" to be done?

DR. NICHOLS: I mean to pass legislation that would set in motion a series of steps starting with Jim's incremental but moving forward to where we end up with every American having decent health insurance to find in the future by some other body and having the delivery system be made more efficient over time.

CHAIRMAN PELLEGRINO: Mr. Capretta ?

MR. CAPRETTA: I'm an amateur political philosopher. I don't do this kind of stuff for a living. I really am more into the programs and policies and how they work and so on. So I come into this with a little trepidation.

But I guess what I observe is that we're struggling with how to make the current system more just in a practical way that can actually pass our legislative process. And it's not that the current situation is totally unjust. There are injustices that occur. It's disorganized in too many ways. People do fall through the cracks. It doesn't work optimally, that is for sure.

But I think we lose sight of the fact that we've enacted large amounts of programs aimed at trying to give access to care to people. I mean, we have a Medicaid program. We have an SCHIP program. We have community health centers. We have large amounts of public subsidies that go to hospitals. We have a lot of things, all of it, perhaps, inefficient, disorganized, not well run.

But it's not like our society has been indifferent to this and not tried to do some things. It's just not in a systematic way that I think a lot of people would like to see. So our efforts here are starting with a very mature system, even as bad as it is in some sense, and our effort is to try to make it more just, not start from scratch and create a whole new system.

CHAIRMAN PELLEGRINO: Dr. Lawler .

PROF. LAWLER: That was a fine statement, but from a purely ethical point of view, which is not available to me, necessarily. Dr. Woolhandler seemed to have this ethical theory that when it comes to medical care there should be no exchange of money. So co-pays are immoral. Deductibles are immoral.

Whereas your other two, to some extent or another, think actually to introduce a bit of cash here is helpful because understanding yourself as a consumer makes the person delivering the product more responsive and introduces choice.

So if I wanted to go to the doctor and the doctor recommends a test right now to me that's for a disease that I really, really probably don't have, but just in case, because I have somewhat decent insurance now, I could get it for free, and I would say, "What the heck? I like tests."

But if that test would cost me, say, $500, I would say, "Let's talk." But if I were a really poor guy, which I'm not, I might say, "No tests. I can't afford it." If I were a Silicon Valley guy I might say, "Give me 20 because I like tests."

So doesn't this introduce a certain unjust inequality into the system? That's not actually my view, necessarily, but it's a question on the level of ethics we have to consider.

CHAIRMAN PELLEGRINO: Sorry, my peripheral vision didn't pick you up.

DR. WOOLHANDLER: I mean, I work in an institution where we see some Harvard professors and students, but we see an awful lot of poor people, and I have indeed had patients die because they had a heart attack and stayed at home for two days seeing if the pain would go away and then showed up too late to get the clot-buster drugs that would save their life. I'm talking about a 47-year-old man, father of three, employed as a truck driver.

So I've seen people die because of co-payments and deductibles. But this is not just anecdotes. Co-payments and deductibles were studied in the Rand experiment. They've been studied a couple of times in Canada where they've introduced small co-payments and deductibles, and they always have the same effect.

Rich people are not affected by them a bit. Low-income people get less care. They get less elective unnecessary care. They also get less life-saving and completely necessary care, and that's the basis on which I think they're immoral.

CHAIRMAN PELLEGRINO: Dr. Dresser , did you want —

DR. NICHOLS: I just wanted to say — as this country economist I have to say that it can be immoral. It does not have to be. And when I go back to my vision of the community and the justice therein, an obligation for leadership is stewardship. We have to have stewardship.

This can be a tool of stewardship if it's done wisely. Wise would be free for the poor and very low for the near poor. But for you and me, frankly, it ought to be nontrivial so that we can help make the stewardship decisions that make the system better.

MR. CAPRETTA: I'll just add to that, it's imperfect, but our laws do reflect the sentiment that you're mentioning, which is that in the Medicaid program cost-sharing and deductibles are very, very low. We just enacted a new drug benefit. It is essentially free for everybody below 135 percent of poverty, and then they start phasing in some cost-sharing and premiums for people above that.

It still may be pinching for some low-income seniors, but the sentiment of trying to do what can be done to make it near free for those who are the neediest is pervasive in our political culture, and people are trying to do that. It's just a matter of practicality: How do you do it better? How do you make it more just?

CHAIRMAN PELLEGRINO: I apologize to the panel for not being able to see their body language. It's like conducting when all the cellos are in a row. Professor Dresser .

PROF. DRESSER: Thank you. I have a question for Dr. Woolhandler and for Mr. Capretta . For Dr. Woolhandler , I'm probably mangling this philosophically, but I think Kant said, "Ought implies can." And so, you know, I love your idea, and if I were queen of the world or the US I would say, "Okay. Go for it."

But I just wonder, if it's not realistic in this country, then it's a placebo. So how do you think we're going to get from here to where you are politically?

And then, Mr. Capretta , could you talk more about this consumer model of health care? I don't think that ordinary people can be very good consumers about health care. On the margins, yeah, but deciding, "Well, do I want a plan that covers, I don't know, any kind of care that most people would think was necessary," I would not — I guess talk about how you think people can make informed decisions like that.

DR. WOOLHANDLER: Well, I think the argument you're making is politics is the art of the possible. But I actually disagree with that. I actually think politics is the art of creating the possible, and what's possible is what people believe is possible.

So who would have believed before Rosa Parks that we would have a civil rights movement and a Civil Rights Act? Who would have believed in the mid-1980s that the Soviet Union was about to collapse?

So you can't just sit here and say based on what you're seeing today that no change is possible. We've got to create the possible, which I think is a challenge to this group and, you know, partly why I reacted so strongly to the suggestion you couldn't understand it or come to grips with it.

You have tremendous moral suasion. You have the power as a group to make a statement that universal health care is the only ethical policy alternative and that the only proven way to get universal health care is through nonprofit national health insurance.

If you went public with that, you would be creating the possible. You know, you would be creating the possible and helping people believe that this real change is possible. And when I look at those polls about the American people, the American people say they want national health insurance.

It's not that the people don't agree. It's the insurance industry that's blocked this from debate. They've used their full political power and economic power to block it and, frankly, the pharmaceutical industry, as well. And they've always opposed this.

And when I first got in this business I was shocked about the pharmaceutical industry opposing it. Well, it turns out they knew something that the American people just learned later, which is every nation with national health insurance negotiates for price discounts on drugs. They knew that, and they were completely and totally opposed to any sort of national health insurance covering drugs because they were going to get lower prices.

So we've got the American people endorsing it. We've got some very powerful folks opposing it. We need to get it on the agenda, and the one real power you have and you can use it, or you can turn your back and say, "We don't understand this." You can use that power to put this on the political agenda.

CHAIRMAN PELLEGRINO: Thank you. Mr. Capretta ?

MR. CAPRETTA: I think your question on consumerism is an excellent one. We are nowhere near a system where that's going to operate easily. I would commend you. Secretary Leavitt , actually, is talking about — he uses different language, but he calls it a value-driven health care system, where a couple of things would have to happen.

One is there would have to be a lot more clear price transparency at the provider level, hospitals and physicians and clinics and labs, on a more uniform basis, so people could start making comparisons, and not just individual consumers but their intermediaries.

That is, you know, there could be a marketplace where consumers are picking between bundled services so they don't have to decide each individual care decision, but they're deciding, "I'd rather get my care through this network for this fee, and they're going to provide this package of benefits when I need it."

And that becomes a little bit easier for consumers to look between plans because some will have more controls on it and some won't. But it should be provider-driven, provider-organized with the information on individual services more transparent. I don't know if that helps.

PROF. DRESSER: Well, I just think maybe when somebody is in great health and they have a month to set aside to read about all these things they can think about these, but if you're a patient choosing what hospital you're going to go to and you really need to go in the hospital, you can't research it.

And the other thing is, okay, so people make trade-offs, and they say, "I want B plan instead of A plan," and they have an illness where they need A plan. So then we're going to say, "Well, sorry, you only have B plan. So therefore you go into bankruptcy or you don't get the care."

MR. CAPRETTA: Yeah. I think most of the decisions should be made well in advance of actually needing care so people are buying into systems of care that they hopefully stay with over a number of years.

I think it should be more about not coverage but sort of the mechanisms through which they access services. Do they want to have a very wide access network of physicians and hospitals, or are they okay with one which is a little bit more controlled: "I'm going to have to go to this set of doctors and this hospital and this lab if I need this service."

And I think those are the kinds of trade-offs consumers can make more so than, you know, "My plan doesn't cover x procedure, and I really need it. How am I going to get it now?" I think those get to be more problematic. Like everything else we've been saying, I'm not sure we have to get to those kinds of questions, though, in the immediate future. I think there's so much that can be done on just the disorganized system and making it better.

CHAIRMAN PELLEGRINO: Dr. Meilaender ?

PROF. MEILAENDER: Well, I'm as always very frustrated with this topic. I want to make a couple of points. Peter , I don't understand your notion of what ethics requires. Equal treatment is not necessarily the same as identical treatment. Very few people have ever thought that those were to be equated. And so treating people equally doesn't necessarily mean that they all have to get exactly the same sort of care.

And that brings me around, Alfonso , to wondering about what you mean we owe to each other in justice. If we owe universal care to each other, what does that mean? All the care that's available? All the care that anybody can get? Some minimal level of care? Catastrophic coverage? It means almost nothing to say that we owe universal health care in justice to each other unless you can say something about what that involves.

And my main concern about that is not whether it's possible — I mean, there may be questions about whether it's possible — but what's desirable. I do not like the consumer language with respect to health care, partly for reasons that Rebecca raised, but partly for some other reasons.

I mean, I don't think of dealing with the body as dealing with a commodity, precisely. I do think that vulnerable people are not in a good position to make these decisions. I can hardly figure out the explanation of benefit forms that my insurer sends to me.

Consumers don't really share risk in the way that fellow insured people do. So, I mean, I don't like that consumer language very much at all. But I can see how one might be driven to it, Dr. Woolhandler , when you tell me that no one in his right mind would take a certain treatment.

But that's a very old way of talking that a lot of patients reacted against. Though I'm hardly the strongest proponent of autonomy, I react against, as well. You know, what people in their right minds will do is a pretty complicated question, and what constitutes a right mind?

And we're driven to consumer language over against an oppressive medical system that thinks it has all the answers. So I'm not very happy with some of the arguments for universal care unless they can really be clarified in ways that they're not clear to me right now. I'm not very happy with the consumer language as an alternative model. And that leaves me kind of stuck, really, and unsure.

CHAIRMAN PELLEGRINO: Dr. Carson ?

DR. CARSON: Well, first of all, before the afternoon is expended, I just want to thank all three panelists because it's been very enlightening, and you have obviously put a lot of thought into this, and it's much appreciated.

You know, the program that Congress has for their health is frequently touted as something that's quite superior. And every time a congressman or senator wants to curry favor they say, "Well, I wish you had the program that we had."

So, first of all, what is the program that they have? And then secondly, you know, looking at what we spend already, twice as much as anybody else, is it enough for everybody to have the program that they have? Too much? Too little?

DR. NICHOLS: Well, Jim and I both lived in it, so I guess we can both talk about it. I'm sure he'll have stuff to add. But, briefly, when, for example, senators say, "I'd like for the American people" — and it gets to your point, sir, about "I'd like the American people to have what I have."

Typically they're thinking about in their mind the Blue Cross/Blue Shield standard option, PPO, the, if you will, proverbial modal policy in the United States right now. And it's the number one choice, I think, still in the federal system. But the federal system is built upon the notion of choice.

So the Office of Personnel Management runs something like a connector or an exchange, and it says, "If you want to sell to federal workers, here are some conditions." They do not specify a specific benefit package. They do negotiate to make sure the actuarial value difference is relatively small, i.e., manageable and not likely to provoke much adverse selection. And they allow choice based upon what plans are willing to offer in different parts of the country.

So in northern Virginia you might have 12 offerings, and in Idaho you might have three. In California you might have 20. So it really does depend upon the local area. And there's a formula by which the federal contribution, the employer contribution the federal government makes, is calculated, which is based upon enrollment and stuff, but basically it's like a fixed dollar amount accepted.

It varies a little bit by how people vote with their feet, but then the employee has to pay a share. So the point is, very expensive plans will cost the employee more. And so there's some incentive built in, gentle, but some incentive built in to select plans that deliver care in some sense more efficiently.

So it is a model of choice. If we just opened the gates and said all Americans could come in and somehow we, I don't know, find oil somewhere and finance it that way, the advantage would be we could probably sign everybody up within a year because electronic portals exist and all that stuff and insurers are already everywhere, so they could handle it.

But it wouldn't do anything to change the delivery system. It is a financing system to pool risk. It is not a system trying to drive care. If you look at health care cost growth over time within the federal system versus the other employers in the nation, basically it's like a snake. Over 20 years they're the same, which is not shocking, because they're buying from the same health care system. So it's not a device for controlling costs.

CHAIRMAN PELLEGRINO: Dr. Gómez-Lobo , would you like to respond to Dr. Meilaender 's comment?

PROF. GÓMEZ-LOBO: Yes, very briefly. Of course, I'm aware that concepts of justice need to be expanded and further developed. I think what I was trying to do was what Dr. Woolhandler pointed to, namely, this idea of making things possible.

What I had in mind was this, that, say, ten years ago most of my European friends of course took it for granted that everyone should be covered by health insurance. But many Americans did not think that way. In fact, I know many people who still are not convinced that everyone should be covered. They believe that people should go their own way, et cetera. So my point was really minimalistic. It was let's put up front there as an ethical imperative the goal of having everyone covered under some kind of insurance that gives them access to health care.

CHAIRMAN PELLEGRINO: Dr. Lawler, would you like to respond and anything else you want to add?

PROF. LAWLER: Well, let me try to figure out why everything is unsatisfactory to me, and let's just forget about the uninsured right now. Most Americans, for a couple of generations, have been covered by employer-based insurance where they haven't had to give much thought to the details of it.

Now, this is bad in many ways we've gone over, and it's not appropriate for the emerging more individualistic no-loyalty-based economy. So it's toast. A lot of intermediary stuff is toast, like unions, public and private pensions, yadda, yadda, yadda. It's all gone.

And so we have two possibilities, both of which seem bad. One is to give it to the government, and it could use it in an unjust and tyrannical way, as Bill pointed out. The other is to push all the way back to the individual. The individual will be kind of overwhelmed with choice, a choice individuals, in fact, aren't well suited to make in many cases, and it seems cruel or reductionistic to refer to the person who needs health care as a consumer.

So we have — because this intermediary thing is broken down due to the character of our economy, it seems like all of the schemes are undesirable. But, nonetheless, there was something good about the old time. The insurance was provided by an intermediary association. It didn't push it all back on the individual. On the other hand, it didn't put it in the hands of the providers.

And so in a certain way that's not exactly a crisis, but it's a very new situation. So I agree. I don't think the government should be able to tell me that this procedure is ineffective and I can't get it, even if I'm a millionaire and use my own money. There's something really tyrannical about that.

On the other hand, too much medical choice repulses me. A friend of mine was talking about over lunch he has early stage prostate cancer. So what he secretly wanted was to go to the doctor and the doctor just tell him, "Well, we're going to do this, and you'll be okay." But, no, he gave him ten different treatment options with cost and benefits, and it really was complicated medical trade-offs. He would have been thrilled to have been relieved of the burden of that choice.

I'll give you another example. It's not medicine, but we used to have pensions. I've heard rumors about them, but now we have TIAA and you have to save your own money. And then we have to put it in various funds, so we have to become experts in the stock market.

So I don't want to be doing that. I tell you the truth even though it shows I'm pathetic, as an individual I'd rather have these things decided by some competent authority and have the money when I retire.

So in general, America is becoming more individualistic, and there are a lot of good things about that. I'm basically a free market guy. But in the area of health care it puts us in two undesirable extremes. You can think of people as consumers or in a way that money should have nothing to do with this at all as if I had no responsibility for it at all. I don't agree with that opinion. I just put that opinion out there to see what you guys would say.

DR. WOOLHANDLER: I just want to go first. In terms of something that, quote, no one in their right mind would get, you've sort of inverted the meaning, or maybe I was unclear of my meaning.

I think the reason people go for things that don't make sense — and by that I mean things that are actively harmful — is because the medical establishment pushes it on them. And I can sit here all day and give you clinical examples.

We were talking about some in the ladies room, EPO that was supposed to raise your blood count if you were in kidney failure or getting cancer treatment, only the doctors were paid more to give you higher doses. So they gave people so much EPO that they raised their death rates by 30 percent.

So I don't think someone should have — that isn't a consumer decision that I want to give someone — you know, "Here, take this EPO and raise your death rate." But it wasn't a consumer decision. The doctors were pushing it onto the patients because they were making money off of it.

Similarly, we never had good evidence that stent placement for stable coronary disease worked, but it was a 20-billion-dollar-a-year industry, not because the people, the patients had autonomy and were demanding it, but the doctors were recommending it because the doctors and hospitals were making lots of money doing it.

And finally now there's evidence that it's absolutely not needed and it may, in fact, be harmful. But let's see how fast the doctors and hospitals stop doing it. I don't see them stopping it. They're coming up with new excuses and new ways of doing it that are still yet unproven.

So the point I would make is that the standard for coverage is — if it's effective it's covered. If it's known to be ineffective, we should discourage it, whether people are willing to pay or not. And we still may have a gray area, and then that's where you put it before the patient with ten choices or whatever. But we need to try to shrink that gray area and cover everything that works.

MR. CAPRETTA: Just on the question of complexity and choice, you know, they started the Medicare drug benefit in 2006, and it was kind of rolled out with a lot of stories about too many choices and suddenly seniors were faced with 50 different options in some places, and there were lots and lots of available different ways of getting your drugs, et cetera.

And it sort of sorted itself out, though. I mean, like these things generally do, there were information campaigns to help people. Then the ones that were big and credible kind of got the most enrollment. And more or less it sorted itself out pretty rationally.

Now, that was just pharmaceuticals, so that's a narrow part of the medical system. But to the extent that people are given choice in advance of needing care — and there are lots of intermediaries trying to help them sort through it, which there were — you know, it can work.

DR. NICHOLS: If I could add, not only was that choice seemingly overwhelming, but I think the satisfaction poll is in the mid-eighties now. I mean, people sort of like what's going on. They're getting drugs and help to pay for it. That's a good thing from their point of view.

But I also want to just caution you, please, it's not just a choice between extremes here. I exist, and I'm just a metaphor for what's there in Washington to talk about different ways of trying to meld these different schemes.

And I would submit the point of the new market is to create and hold onto what was good about the employer system. You've got the risk pool, and you've got the economies of scale. You've got, if you will, managed choice. There's not going to be 150 options because once you set those rules in place, the little bitty insurers will quit. They'll sell their book of business that night, and the big guys will do this, and we'll have seven to 20. And that's all we need.

CHAIRMAN PELLEGRINO: Dr. Hurlbut ?

DR. ROWLEY: Can I just respond? Yes, because you only have to go a couple of blocks south of here and you see Blue Cross/Blue Shield, which is one of the buildings right on the park. It's now expanding. It was, I don't know, 25 stories, and it's going to go up to some other number.

And Stephanie 's picture of the two tall buildings in Boston — these building are not being built on speculation. They're built on profits that the health insurance companies are making. And if we could have a system where all of the health care was nonprofit, then it would go a long way to covering the costs of the uninsured.

And I would agree that the insurers have a vested interest in seeing that the present system is maintained. And when one health insurer buys out another one, the CEO gets some enormous millions and millions and millions of dollars of compensation. And I think that's all borne by not only us, who have the insurance, but also by the lack of care for others. And I think it's unconscionable.

DR. HURLBUT: I'd like to know about these publicly traded companies making these huge profits so I can do better investing. Maybe instead of all this we should just have the federal government invest in these companies to make these do profit — well, I'm just kidding.

But, you know, here's the question that comes down: Carl said earlier that we didn't have the expertise to adjudicate and weigh all these properly, and Dr. Woolhandler said, "No, there's a lot of IQ points in this room." There's a lot of IQ in the panel, and you guys don't agree, right? That's my first question. And you are more or less waiting on us to come out for universal single-payer coverage. I mean, that's what you were hoping we would do. I think you said that, is that right?

DR. WOOLHANDLER: I'm sorry. You're actually asking me why I don't agree with my fellow panelists?

DR. HURLBUT: So what I really want to say is that I — apart from the truth of what he said, I think our Council would have a special calling towards certain moral dimensions of this, not — you guys have spent your lives on this. This is hard stuff. We come with different perspectives.

What I'd like to understand is specifically what do you think our Council can contribute to this? Did I understand you earlier implying that you were sort of hoping we could come out and endorse your plan?

DR. WOOLHANDLER: I believe that the moral choice at this point in history is nonprofit national health insurance. I believe that there's no other method ever used by any nation on Earth to achieve universal health care, ever, that other methods have been tried in the United States , in several state experiments, and it failed repeatedly. So the only proven way to achieve universal health care in the planet Earth happens to be nonprofit national health insurance.

I would expect that this group would have the courage to endorse the idea of government-guaranteed universal health care. I would hope that you would say nonprofit. To be honest, I think you will. I don't really know. That would be a leap for you to take a position that was that opposed to the business interest of the insurance industry and pharmaceutical industry. But you're not an economics panel. You're an ethics panel. People look to you for moral leadership, and political decisions are moral decisions. And I think you need to decide what you think is moral and say that.

And Lord knows, if McCain is the next president, you may be losing your jobs if you do this. You may not be reappointed to this if McCain is the next president and you say, "We endorse universal national health insurance. We endorse nonprofit universal national health insurance."

PROF. LAWLER: But Obama is sure to keep us.

DR. WOOLHANDLER: I have no idea. But, you know, the question is what you think is the moral choice right now, and I actually think saying, "We can't figure it out" — that's a total cop out, and you can say you don't agree with it, that "We don't agree with universal health care," or you can say, "We want universal health care, and we're going to pretend that someone has figured out a way to get there without nonprofit national health insurance" or "We're going to invent something that no one on the planet Earth has ever done before to get to universal health care."

But if you're going to say, "We're going to try something proven," you're going to have to say nonprofit. It doesn't have to be Canada , but it's going to have to be one of the nonprofit national health insurance models used by every other developed country to get to universal health care.

DR. NICHOLS: I said before, and I still maintain quite a bit of respect for Stephanie 's interpretation of data and history. But I will point out the Netherlands and Switzerland both have universal coverage, and they have competition among nonprofit insurers. They are nonprofit insurers, but they do have competition. Could I just finish the point?

DR. WOOLHANDLER: Yeah, but I want to talk a little bit about that.

DR. NICHOLS: Okay, fine. But I'm just saying there are examples where insurance is actually multiple payers and they manage to get everybody covered and they have individual mandate, by the way. So it's not like it's absolutely only in a dream.

But I will say that in my view the moral issue that you have to weigh is the balance among all these competing objectives. And that's why I submit while Stephanie 's system would satisfy a number of objectives, in my view, something more like the bipartisan approach I'm talking about is much more likely to balance everything, and that's why I come back to reasonable cost-sharing, good subsidies, market rules, and delivery system.

CHAIRMAN PELLEGRINO: Gil , I thought you looked like you wanted to ask something.

PROF. MEILAENDER: I just wanted to ask —

CHAIRMAN PELLEGRINO: Oh, you haven't finished, Bill . I'm sorry.

DR. WOOLHANDLER: Can I just point out that both Holland and Switzerland got to universal health care by a nonprofit national health insurance mechanism. They did. Now, within the last two years both of them have allowed private insurance firms to become involved, but that's not how historically —

DR. Nichols: But they are the system now.

DR. WOOLHANDLER: That's not how they got there. That's something very recent. We don't even know the results of it. Again, maybe if you're already at universal health care you can reintroduce for-profits that may pan out. But no one has gone from a system where you had uninsured people to universal health care using a for-profit model.

DR. HURLBUT: I'm still struggling with what our Council can reasonably do on this issue. And it strikes me one of you — I think it was Dr. Nichols — mentioned that the American health care system carries a little more baggage than some others that it's often compared to. And by that you included higher levels of trauma.

But also, I think, implicitly, at least some positive things — I mean, I don't know this to be an absolute fact, but my impression is that the United States health care system pushes the boundaries of care in special ways with a lot of technology.

And I'm at Stanford Medical School . We certainly do a lot of interesting things there that move medicine along. I'd like to hear — let me rephrase that. I sense what each of you are saying to us, there's some agreement on principles. There's quite a lot of disagreement of boundaries of prudential decision, what's going to work the best, real political views.

But there seems to me also some differences in implicit moral assumptions and also expectations of what a health care system should be. I mean, for example, if I turn to my colleague, Alfonso, with whom I have a great deal of agreement on many issues and I asked him, "Well, you said it was simply a matter of justice," I would put back to you would that include the right of health care coverage under Stephanie's plan, which would have no other medical providers? So would that include abortion?

Now, that's an issue of what a plan is going to include. I don't mean just simply what level but a whole category. Now, this strikes me as a moral issue as well as a very big practical issue. I'm not trying to cloud the waters here, although, let's face it, abortion is — I guess it's the most common surgical procedure in the United States , one every 30 seconds or so.

DR. SCHNEIDER: I think cataracts are more —

DR. HURLBUT: Cataracts. Okay. But I'm just searching, grasping for something that our Council can address in this without having to claim to be authorities over something that you three can't completely agree on and is obviously very difficult.

Maybe we could affirm the things that you all do agree on. That might be possible. But what are the special categories of moral concern that we are searching for as our special contribution to this.

And just one more thing I want to point out. I'm picking on you, Stephanie , but you made several statements that seem to me to carry moral assumptions. You said, for example, that the rich would have to have the sort of moral courage to give up the high-level special care that could be provided by complimentary private offerings, right? Just say "right."

DR. WOOLHANDLER: I don't actually think that's correct.

DR. HURLBUT: You said you didn't want anything like the UK where there was a parallel provider system.

DR. WOOLHANDLER: But everything effective needs to be available. Everything effective needs to be free. And I don't actually think that the quality of care is better at private hospitals in Great Britain than in the National Health Service hospitals. It's more luxurious. But if Ms. Thatcher , when she had her gallbladder out, had gotten a complication, they would have put her in an ambulance and shipped her to the National Health Service hospital since those are the — tertiary care, top quality hospitals are actually NHS hospitals.

The private hospitals in Britain are the, quote, nursing homes, although they're really a hospital. You know, they're luxurious. The food is better. The room is private. It's quieter. But it's not better care.

And I don't expect anybody to give up the quality of life-saving care — the actual quality of care. What I do say is that people need to accept that they may be lying in the bed next to a janitor, okay? And that's what's true in American top tertiary care centers. Probably at Stanford Medical Center you've got a CEO in the ICU next to a janitor. We're not asking for anything more than that.

DR. HURLBUT: This does not comport with what I understand of medical reality. When somebody in my family gets sick, I seek out the person with the best reputation and one I feel like I can really trust. You know, if I want Dr. Carson to do my brain surgery that's because I trust him, I know him, and I think he's going to be better than the guy down the street.

If medical care were all even, then it seems to me what you're saying would be true. But it just strikes me that that's not the way things actually are in the real world.

DR. WOOLHANDLER: Let me just clarify something. In a national health insurance system, the patient has complete free choice. They can go to any doctor or hospital they want. So you could still travel to Dr. Carson to get brain surgery for your child, I guess you're assuming.

And people do that in Canada . They go around and look for the best surgeon. So there is in some level free choice in terms of doctors and hospitals. You just can't choose one insurance plan or another. Everyone has the same insurance, but once you've got it you've got much more choice than anyone has in this country because you can go to any doctor or hospital you want.

DR. HURLBUT: Just, finally, can you tell me what your system would lose? I mean, there must be something good we would also lose in the process. Maybe each of you can tell us what that is. And, more specifically, can you tell us what you think our Council should do?

DR. WOOLHANDLER: I think I've said what I think the Council should do. I think you need to take a moral stand and support universal care and a nonprofit national health insurance system.

You know, I actually think the thing you lose is there is a certain politicization to medical decision-making. Now, we have that already in the Medicare program. And one of the things Jim said which I really agree with is Medicare is the main lever that's used now to shape how health care is delivered.

And you're actually expanding that lever in some ways by going to a single-payer system. And Medicare has made a lot of mistakes. It covers a lot of stuff it shouldn't cover. It wastes a lot of money it shouldn't waste. So that's an issue.

And a lot of silly stuff ends up going through Congress about coverage decisions, and we're just going to have to deal with that through the political process.

But I sincerely think — you know, there's 301,000,000 American people that probably 300,000,000 of us would be better off with a national health insurance system. There's probably a million people who own insurance companies and drug companies and might find themselves worse off.

DR. HURLBUT: What would you do with an issue like abortion, for example?

DR. WOOLHANDLER: I think the issue of abortion has to be decided by a group of experts and community members. It's a very highly charged issue. And there's not going to be something in a national health insurance law that specifies every procedure. It's going to specify a process about how these decisions should be made. And what they do in Canada is they have a panel that has medical experts and also has community members, and they make these decisions.

CHAIRMAN PELLEGRINO: Dr. Meilaender , I think you have the last word. Forgive me, I can't see out of the side of my — go ahead, Doctor.

DR. NICHOLS: Well, I was just going to offer, if I could, I think it would be ideal if the Council would endorse the concept of justice that says every American ought to have access to health care and we think health insurance is probably essential to make that happen and the system ought to become more efficient and however else you want to say that.

I think you should be indifferent, frankly. I think you shouldn't be discouraged by the fact we disagree. We're selected because we come from particular points of view. So that's normal.

On the specifics of who would win and who would lose if my vision or something like it came into being, I think it's unambiguously true the losers would be the proceduralists who are doing surgery and some diagnostics that have what I will call a shorter trigger than their colleagues, the ones who do way more than is sort of normal for given population indications.

The overutilizers are largely driven by provider self-interest, and they would lose. I think it's true we could figure out a way to pay people to orient their behavior in a better way, but some of those high-end proceduralists are going to lose, and therefore some of the device companies which are less inclined to compete on a scientific basis and more inclined to use marketing would end up losing because the evidence base would grow over time and it would be harder for those who didn't have true scientific value to be enhanced.

The flip of that is the people who would win are precisely those you want to win, and they would be the primary care and coordinating care medicalists who can help us all get healthier in a more efficient way and the device companies and the drug companies.

The difference in me and Stephanie is I have no problem with people making money as long as what they're doing is adding clinical value and improving our health. I want to change the incentives to make that happen and change the rule, and that's really what it's all about.

MR. CAPRETTA: In some sense I was hoping not to answer this question, but what should the Council do? You know, I guess my sense is that the political process has — I think as Dr. Lawler said this morning, there's widespread agreement that they'd like to make the medical system, the health care system better, you know, for everybody, more just in a certain sense, as I was trying to say earlier, better than it is now.

I don't think it's so much a question of admonishing people that they're not doing the right thing. I think a lot of it has to do with how to do it and, you know, taking steps that are practical and consensus-building. You know, that's just my own judgment, having observed this. So I'm not sure that's enough direction for you or not.

But regarding what we would lose, I do think that we should probably think about health care reform not as a point-in-time once-and-for-all decision but as, you know, we're going to be working at this probably for 25 years, and so we should be trying to set ourselves up for further success.

What are the things we can set in motion that can be built upon, that can be adapted, that can change with new medical discovery, that can change with science? And I'm worried that we will set up a system that will become less flexible and less responsive to new opportunities than we otherwise would. So that would be the one thing I would worry about losing.

CHAIRMAN PELLEGRINO: If I haven't missed anyone on my periscope — Dr. Meilaender, you have the last — okay. Thank you very, very much, members of the panel, members of the Council, exploring a very difficult issue in detail. Thank you.