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Economist Karen Davis

Economist Karen Davis, president of The Commonwealth Fund. She is a member of the Institute of Medicine's panel studying ways to improve health care. She supports improving on existing plans such as Medicare and employer coverage. She served as the Deputy Assistant Secretary for Health Policy in the Department of Health and Human Services from 1977-80 and was the first woman to head a U.S. Public Health Service Agency.

19:13

Other segments from the episode on December 9, 2002

Fresh Air with Terry Gross, December 9, 2002: Interview with Marcia Angell and Quentin Young; Interview with Karen Davis ; Review of Mike Skinner's music album “Original Pirate Material.”

Transcript

DATE December 9, 2002 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Dr. Marcia Angell and Dr. Quentin Young discuss the
need for single-payer health insurance plan in the United States
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

If it weren't for the steady beat of war drums, health care would be front and
center in the political debate, according to Dr. Marcia Angell. She's the
former editor in chief of the New England Journal of Medicine and is a senior
lecturer in social medicine at Harvard Medical School. Many doctors and
patients agree that our health-care insurance system is inadequate and
dysfunctional. Today we're going to talk about possible ways of fixing.
First we'll discuss the single-payer plan, which Dr. Angell advocates. She's
the head of the Physicians' Working Group, which was founded by the Physicians
for a National Health Program, an organization of more than 10,000 physicians
who support single-payer national health insurance. Also with us is Dr.
Quentin Young. He's the national coordinator of Physicians for a National
Health Program. He's also a practicing internist and a clinical professor of
preventive medicine and community health at the University of Illinois Medical
Center.

I asked Dr. Young to describe some of the problems he and his colleagues face
within the current health-care system.

Dr. QUENTIN YOUNG (Physicians for a National Health Program; Professor,
University of Illinois Medical Center): Well, there are a number of major
problems, starting first with the enormous bureaucracy I have to penetrate
each day of work, a bureaucracy of paper and people at the end of the phone
giving you permission or denying you permission to do things you need for your
patient. There's been an interposition of corporate interests into my very
consultation room, which is awful. Beyond that, of course, we have people who
don't have the private resources to get the medication or get the tests that
are indicated. That's always a huge strain on a doctor trying to do his best
for the patients.

Beyond that, you have--and this is probably the harshest criticism I can
make--the terms of engagement in the consultation room where the patient and
doctor are attempting to solve the patient's problem have been changed. And
from a prevailing mood of optimism and hope and confidence and affection, it's
been slowly but steadily transformed into one of mistrust, hostility and even
rage. That is inimical to good health-care events, and I feel that the
standard of health in this country faces a decline because of this widespread
reality in American medicine practice.

GROSS: What kind of practice are you in? Do you belong to an HMO, a group
practice?

Dr. YOUNG: I'm a general internal medicine doctor, a primary care doctor if
you please. I'm in a group of eight doctors, all of them wonderful,
younger-than-me doctors. And we practice in a community in Chicago where I
started some 50 years ago. And I myself am not in any of these HMOs, but some
of my colleagues do belong to these arrangements. And it's an everyday
experience to see how that impinges.

Let me give one example of the huge waste. We have about 13 full-time
equivalents to service we eight doctors: nurses, technicians, clerical.
Fully five of those people are doing nothing but pushing paper to keep the
practice afloat, to communicate with the various 1,600 insurance companies.
That's how many we have. And when we say single-payer, if I may make the
definition right now, we speak about one insurance company, which is what we
have practically for Medicare, our system for the elderly, which is flawed,
but it's so much better than the reality for the rest of us who are not in the
over-65 government insurance plan. So I see it every day, Terry, in our
practice. And it's oppressive, it's confounding and it really detracts from
our ability to give care.

GROSS: Dr. Angell, you've said if you had set out to design the worst system
that we could imagine, we couldn't have imagined one as bad as we have. One
or two compelling examples of what makes our current system so bad, in your
judgment?

Dr. MARCIA ANGELL (Former Editor in Chief, New England Journal of Medicine;
Senior Lecturer, Harvard Medical School): Too few Americans have access to
comprehensive health care. In fact, most of us don't have access to
comprehensive health care, even when we have what's considered a fairly good
insurance policy. The employers pay a portion, an increasingly small portion,
of the premium to health-care businesses, largely investor-owned managed-care
plans. And here the deal is that the managed-care plans cover all of the
enrollees in the particular workplace for a year for a set premium. And if
they can cover these people for less than that premium, they get to keep
whatever is left over. And if it costs them for the medical services more
than the premiums, then they lose money and they have to raise the premiums
the next year.

So here there's an incentive not to provide medical care. And indeed, these
managed-care companies, these for-profit managed-care companies, talk about
the medical services they have to provide as a medical loss ratio. And they
brag to their investors how low they can keep that. Some of them will brag
that they have a medical loss ratio of only 70 percent, which means that 30
percent of the health-care dollar is kept for administrative costs, for
marketing expenses and for profits.

So you can see that the way they gain is by providing fewer and fewer medical
services. Doctors now work for these companies. And in a sense, doctors are
becoming double agents. On the one hand, they are supposedly agents for
their patients, as the Hippocratic oath requires them to be and thousands of
years of history requires them to be. But on the other hand, we now find them
being agents for their employers, managed-care administrators who are
pressuring them to do less and less and less for their patients.

GROSS: Now you're both advocating a single-payer plan. What does that mean,
Dr. Angell?

Dr. ANGELL: Well, it means that the funds, the financing of health care, goes
through a central agency. In the case of Medicare, for example, it's the
Medicare and Medicaid--the Center for Medicare and Medicaid Services. It
goes through a central agency so that it can be distributed rationally and
coordinated. And that is very, very much more efficient and cost-effective.
If you look at Medicare, which is a single-payer system embedded within our
larger market-based system, if you look at Medicare, its overhead costs are
about 2 percent. Compare that with the private health insurance market, where
the overhead costs right off the top--now there are more overhead costs as you
go downstream; as Dr. Young said, in his office there's plenty of overhead
costs. But right off the top, the managed-care plans cream off for marketing,
administrative costs and profits on the order of 10 to 25 percent, 10 times as
much as Medicare takes.

GROSS: Dr. Young, is the single-payer plan that your group is advocating
based on a plan that another country already follows?

Dr. YOUNG: Well, it turns out that every other country in the world that
resembles us in the sense that they have an advanced industrial base and a
democratic system of one form or another, every country--whether you're
speaking of Western Europe, Scandinavia, Canada, Japan--has, over the
centuries--the first one was Germany in 1886, and the most recent one, believe
it or not, is Thailand just last year--every country has come to the
conclusion that health care is so important to the society that it's the
responsibility of that society to guarantee access to decent health care.
That's in the national interest. That makes for a healthier population, a
better work force and just a more congenial environment than what we've been
describing, the kind of struggles to get care and the disappointment. And
indeed, we haven't even mentioned the bankruptcy. The number-one cause of
personal bankruptcy is unpaid medical bills in this country that expends twice
as much as any other country each year on health care.

Well, these countries have learned that by this one reform--and each country
differs a little bit, and ours will differ from every other country, if for no
other reason we have so much more resource to start with. Imagine having more
than twice as much as most countries per capita to spend on health care. And
instead of squandering it the way we do now, we would cover everybody and
begin to use--and this is a very important concept--the best of modern medical
science, best practices, population-based decision, a new emphasis on
prevention. And we could change the character of illness in our aging
population and the experience with illness by having a system that ended the
economic barriers.

Dr. ANGELL: The underlying problem is that we are the only advanced country
that treats health care as a market commodity to be distributed according to
the ability to pay and not as a social service to be distributed according to
medical need. That is the fundamental problem. And so we differ from every
other country in the extent to which health-care funds are diverted to
overhead and profit.

GROSS: My guests are Dr. Marcia Angell and Dr. Quentin Young of Physicians
for a National Health Program. More after our break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guests are Dr. Marcia Angell and Dr. Quentin Young of Physicians
for a National Health Program, a group which advocates reforming our health
insurance system by instituting a single-payer plan.

What would a single-payer system mean for consumers on a practical basis?

Dr. ANGELL: Well, on a practical basis, they would have a right to
comprehensive health care. Now the package of health care could be designed
in different ways. Medicare--which, as I've said, is a single-payer
system--is not perfect. It doesn't cover everything. It doesn't cover
prescription drugs, outpatient prescription drugs, and it should. It doesn't
cover long-term care. It could. You could change Medicare in those ways, and
I think that it should be, although the prices would have to be regulated.
But you would design a system of benefits and everyone would have a right to
that. You wouldn't be giving them a voucher or giving them $1,000 to go out
in the insurance market and buy whatever they could get for it. They would
have a right to all of those services, and they would be paid for from the
first dollar. There would be no deductibles, no copayments.

The way you would pay for it could differ. The other countries, all of
which--the other advanced countries--have single-payer systems, collect the
money in different ways: some of them from employers; some of them, as in
Canada, directly from taxes, income taxes. Medicare here is payroll taxes.
You could have the money come from a variety of sources, but the important
thing is that it would be administered, it would be distributed and
coordinated through one source.

We now pay for our health care--we pay probably twice as much as we should, in
multiple ways. In a sense, we're nickeled and dimed. We pay for it through
our paychecks, through the prices of goods and services, through taxes at all
levels of government, city, state and federal. We pay for it increasingly out
of pocket, through deductibles and copayments. So we already pay for it and
we pay in spades in many different ways. A single-payer system that makes the
most sense, you would pay for it just once, and the most progressive way would
be through an earmarked tax on income. But the total would be less.

GROSS: There are so many Americans who are distrustful of the American
government's ability to run a system or, you know, particularly suspicious of
government bureaucracies.

Dr. ANGELL: Yeah.

GROSS: So if the health-care system was basically put in the hands of a
government-run bureaucracy, are you confident, Dr. Young, that that
bureaucracy would be any better than the bureaucracies you face now?

Dr. YOUNG: Well, that's a very important question. Those of us who are
advocates know that you can't have a conversation before the issue of
government and taxes is raised. And ideologically the conservative view that
we need no government and we should cut all taxes is very powerful. But I
find that almost an irrational position. First of all, our experience with
government medicine is excellent.

Let me give you a few examples. The National Institutes of Health are a
purely federal project which is the envy of the world for distributing
billions of dollars in research, and arguably the American predominance in the
field of bioscience is based on that federal project called the National
Institutes of Health.

A few other examples: Medicare has been mentioned. It's flawed. Those flaws
could be removed. I speak of the absence of a decent pharmaceutical benefit,
the absence of long-term care and not enough money in place for mental health
needs. But those are easily remedied because of the vast amounts of money we
have.

Think also, if we talk government medicine, of our public health system, which
in turn is undernourished but nevertheless is our bulwark, all the more
vividly dramatized in this period of bioterrorism. Our public health system
is a defense of our nation, and it's public, a government tax-driven
arrangement.

GROSS: Now your group, Physicians for a National Health Program, is
advocating for a single-payer medical plan in the United States. One of the
obstacles you would have to overcome to make that happen is dealing with all
the medical insurance companies in the United States, who would of course
object to a single-payer system because it means that their business would be
out of business; they'd no longer be necessary. Do you think it's even
conceivable in the United States that a single-payer system would be seriously
contemplated given the amount of power that the insurance industry has?

Dr. YOUNG: That's a very pertinent question. The power is enormous. I would
put it in terms of having corrupted our political process. The amounts of
money the drug companies and the HMO organizations spend in winning
congressional favor is obscene. And there's no denying a serious discussion
of this reform bumps into the question: Is it politically feasible?--with
many people who are even congenial to the idea saying `That can't happen.' My
argument is that it must happen. Unless we reform our system, then we will
have an ever-increasing inequity here which will be defined in terms of human
suffering and early death, and that's beginning to happen. And that, the
American people won't stand for.

We've had, Terry, equivalent mountains to climb. I'm old enough to remember
the civil rights movement, which grew out of the legalized segregation and
denial of voters rights and other rights to people of black complexion. In
1950, which is like where we are now in the health system, the people who felt
this was unfair also felt there was no way to overcome the power of those who
profited from the segregated system. And in a relatively short time, this
country's capacity to meet great challenges was fulfilled. I mean...

GROSS: I don't want to stop you. Are you suggesting that there needs to be
some kind of mass movement, the equivalent of the civil rights movement, with
protests and demonstrations, in order for there to be changes? Is that the
way you see it happening?

Dr. YOUNG: I think that'll be part of it. That's the way this country works.
We have freedoms and we exploit them to change. That's the glory of this
country. And the answer to your question is yes. I believe that that's
happening. More and more we see medical students, the American Medical
Students Association, hold twilight vigils all over this country. I've
been to a half a dozen myself. These are medical students, the future
doctors, saying, `We want a decent system.' And I would point to Al Gore, the
man who got the popular vote in the last election, who for up until his recent
pronouncement was not a supporter of single-payer, said he's come to the
conclusion, as he put it, reluctantly, that it's the way we have to go.
Well, if you're talking about political feasibility, if the premier leader,
so to speak, of one of the two parties says he feels its necessary, I think we
have a different term of engagement.

GROSS: The National Academy of Sciences is recommending that the Bush
administration sponsor demonstration projects in five different areas of
medical health so that new kinds of programs can be tested and then expanded
if they succeed. And these areas include tax credits, expanding Medicaid and
children's health insurance, alternatives to medical malpractice litigation
and so on. What do you think of that approach?

Dr. YOUNG: Well, let me say I talked to the chair of that committee, who
happened to be an old friend, Mr. Gail Warden, and I congratulated him on
this prestigious committee's recommendation for experimentation and told him,
`As you know, all of the proposals that you're making are doomed to failure,'
because these partial measures are exactly the problem we have. It's the
multipayer, patch quilt, jigsaw puzzle arrangement that is the burden on the
American people. While I welcome this obviously important statement from a
very prestigious source, at the same moment, we've done the experiment. The
last 20 years has been a catastrophic event for the American people, a trial
of for-profit, market-driven arrangements that has brought great suffering and
is now in its final throes of failure. Employers, who are the heart-blood of
market system, are off-loading their responsibilities to employees. They're
either cutting the benefits or not covering the family or letting the worker
pay for the premium. All these systems are obviously not the answer to the
problem. And I really want to emphasize the glory part of our message. We
have the resources to fix the problem. We just have to get as smart as many
other countries in allocating these wonderful resources.

GROSS: Dr. Young, Dr. Angell, thank you both so much for talking with us.

Dr. ANGELL: My pleasure.

Dr. YOUNG: Thank you very much as usual, Terry.

Dr. ANGELL: Thank you, yes.

Dr. YOUNG: Wonderful interview.

GROSS: Dr. Marcia Angell and Dr. Quentin Young of Physicians for a National
Health Program, which advocates reforming health insurance by instituting a
single-payer plan. More options for reforming health insurance in the second
half of the show.

I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

(Announcements)

GROSS: Coming up, more options for reforming our health insurance system. We
talk with Karen Davis, a health policy expert who's on the Institute of
Medicine's committee studying ways to improve health care. And Ken Tucker
reviews the debut CD by white British rapper Mike Skinner, also known as The
Streets.

(Soundbite of music)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Interview: Karen Davis discusses options for reforming the
country's health insurance system
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

We're talking about ways to reform our health insurance system. My guest,
Karen Davis, is an economist and health policy expert who's on the Institute
of Medicine's committee investigating ways to improve the health-care system.
She's president of The Commonwealth Fund, a national philanthropy, engaged in
research on health and social policy issues. She's the former chair of the
Department of Health Policy and Management at the Johns Hopkins School of
Hygiene and Public Health and served as deputy assistant secretary for health
policy in the Department of Health and Human Services from 1977 to 1980.

I asked her what she thinks are some of the best options for making health
insurance available and accessible to everyone.

Ms. KAREN DAVIS (Economist; Health Policy Expert; President, The Commonwealth
Fund): Well, there are a number of options out there. There are some people
who support a single-payer system, similar to the Canadian system, or perhaps
expanding our Medicare program for the elderly to cover everyone. President
Bush has a different proposal on the table, which is to give people tax
credits to buy individual health insurance on their own. And there are other
options of building on our current system, which is basically an
employer-based system of private health insurance coverage, and looking at
ways of expanding that, as well as expanding public programs such as Medicare
and our Children's Health Insurance Program that covers low-income children.

GROSS: You've been studying this for a long time, so I'd be interested in
hearing your opinions on some of these options. Let's start with the
single-payer plan. Do you think that that's a workable option?

Ms. DAVIS: I think it has strong features. It certainly would cover
everybody, it would be very simple, and there--evidence that it would be
efficient. The difficulty with it is that it really requires a huge increase
in federal taxes to finance it. Currently employers are spending $350 billion
on health care. If you dropped that and went to a single-payer system, the
federal government would have to pick that up. So I think in our current
economic and budgetary climate it's really not very realistic to think about
single-payer in today's times.

GROSS: Here's what I'm wondering: You know, a lot of people say, `I don't
want my taxes raised.' On the other hand, everybody seems to be complaining
bitterly about the health-care system, the expense of health-care insurance; a
lot of people are uninsured. If it was put to people, `Well, look, your taxes
are going to go up; on the other hand, you're going to be guaranteed decent
health care, you know, for the rest of your life and so will your family,' do
you think that they might go for the higher taxes?

Ms. DAVIS: Well, I think people value health care very highly and I think
they would be willing to pay both higher taxes and contribute toward their own
health insurance coverage. But you have to have amounts that are affordable
for people. And the real problem with the 41 million uninsured is they really
can't afford to purchase health insurance on their own. And there about 30
million people who are underinsured, who even though they have insurance, it's
really inadequate to help them pay their medical bills.

So I think the most realistic approach is one that would really get
contributions from everyone. It would have employers contribute to health
insurance coverage, it would have working families contribute a part of the
premium, a part of the expenses, and it would have taxpayers providing
assistance for those who particularly have low incomes or are very sick or
disabled and really couldn't afford to pay for their own insurance or their
own care.

GROSS: But in answer to that question of, you know, if it was put to the
public, `Yes, your taxes would go up, but you would be guaranteed of good
health care and so would your family,' do you think they might choose to have
the higher taxes and a single-payer system?

Ms. DAVIS: I think Americans would be willing to pay higher taxes or to
forgo tax cuts that are currently on the books. I don't think people really
understand the tax cut that was enacted in 2001. They think about their $300
or $600 tax rebate and think that's what the tax cut was about. But there are
many tax cuts that are scheduled to take place over the next few years. In
2004, everybody's taxes will go down by 1 percentage point. So if they're in
a 29 percent bracket, it'd go down to 28; if they're in a 15 percent bracket,
they go down to 14. So one option would be simply to forgo some tax cuts that
are on the books to take place in January of 2004 or January of 2007, and I
think many Americans would be willing to forgo that. If you forgo just one of
those, that would generate $40 billion a year in federal revenues that could
be used to really fill the gaps in health insurance coverage.

GROSS: Let's look at the tax credits option. This is the option favored by
President Bush. What exactly would that mean? What's an example of how that
might work?

Ms. DAVIS: President Bush's proposal, for example, for an individual would
provide a thousand dollars that you could write off of your taxes. Or if you
didn't owe taxes, you'd actually get a thousand dollars in cash to go out and
buy your own health insurance policy. And that might work reasonably well for
a healthy, young person where when they go to buy health insurance they might
find a premium of $2,000, $2,500. For a person aged 60--when they go to find
a health insurance policy on their own, the premium's going to be $6,000, and
that's if they don't have a health problem--if they haven't had cancer, they
don't have heart disease, haven't had a stroke, don't have diabetes.

So tax credits really--it's one thing to say a tax credit, but there are two
problems with it: Is it enough money to really make the insurance affordable?
And two, can you really buy coverage if you've got a pre-existing health
condition? And that's not the case for many people.

GROSS: Well, you've just gotten to a real paradox in the health-care system
and because the health insurance companies and the HMOs are profit-oriented
systems, if you're sick, no one really is enthusiastic about insuring you
because you're going to cost them a lot of money. And if you're trying to get
insurance and you're sick, you're going to find it hard to get.

Ms. DAVIS: That's right. And that's why I think the real secret here is
group health insurance rather than people's buying insurance on their own.

And one mechanism we have now--most employers do provide health insurance to
their workers. Now some workers can't afford to pick up even their share of
the premium. So the federal government could do more to provide some premium
assistance to those low-wage workers. And some employers, particularly small
businesses, don't offer health insurance to their workers because they find
the premiums high. Well, the government, either the federal government or
state governments, could reinsure coverage to protect them against having a
particular worker or dependent with high costs driving up premiums.

So there are ways of making health insurance options available to small
employers and lowering those premiums to make them more affordable by
providing premium assistance and by providing some form of what's called
reinsurance or stop-loss coverage to protect against catastrophic expenses.

GROSS: One thing critics might say of that plan is it's creating an even
bigger bureaucracy because it's adding state bureaucracies into the HMO and
health insurance bureaucracies that already exist, it's expanding an already
confusing system. There's a lot of critics of the so-called `patchwork'
approach to reforming the health-care system.

Ms. DAVIS: That's right. I think we need a seamless health-care system; we
need some way of automatically signing people to health insurance coverage,
and there are mechanisms. For example, electronic insurance clearinghouses
were recently recommended by an Institute of Medicine report, a committee on
which I served, to really make it much easier for people to get enrolled in
insurance or if they lose insurance because they change a job to make sure
that they actually stay in some insurance system through an electronic
insurance clearinghouse.

So I think we do need to make the current system simpler. I think modern
information technology has a lot of promise to help do that, as well as
achieve economies in the administration of insurance.

GROSS: But wouldn't that still be creating like a new bureaucracy if we're
adding a new type of insurance for the people who are unemployed? I mean,
thank goodness they'd have insurance, but still, for the medical system, is it
further complicating and bureaucratizing it?

Ms. DAVIS: Well, I think it's important that we build on what exists.
Because anytime you take something that's brand-new, it's very complicated.
So what I would do at the federal level is take the plan that now covers
members of Congress, a congressional health plan, if you want to call it that,
and open that up to small businesses and individuals rather than creating
something totally new--we know how that works; there are 170 different health
insurance plans that participate in that; it's very good coverage--and really
make that more widely available throughout the country.

GROSS: What would that mean for individuals? How would you get access to it?

Ms. DAVIS: Well, there are different ways that it could be done. Again, I
think it would be good to have Internet administration, so a small business
that wanted to sign up could go on the Internet and say, `I'd like to enroll
these employees and here are their Social Security numbers,' and pay their
premiums over the Internet. So that's one way it could work.

Another way it could work is really through the income tax system, just really
checking off on the income tax system that you're uninsured and getting your
enrollment package just as a federal employee now gets an enrollment package,
with a list of choices. So I think there are ways of doing it.

I think the most difficult problem is really, though, with what we touched on
before, people who are very disabled, very sick, really not in a position to
afford much in the way of a health insurance premium. And for those people, I
think expanding public programs really makes sense. Currently with our
Medicare program we make the disabled wait two years before they qualify for
coverage. So if you have MS or if you have some other kind of disabling
condition, like a major stroke, we really just ought to cover those people
right away. In addition, there are a lot of people over age 55, over age 60
who are uninsured. Letting them buy into the Medicare program early--it's a
program that exists and they're going to be on it at age 65.

So I think there are things we can do to pick up different groups of people by
building on the Medicare program. And states do have in place now very a
effective program for low-income children; each state has its own name, but
it's basically a children's health insurance program. Certainly that could be
expanded to cover parents, to cover other kinds of low-income childless
adults.

GROSS: My guest is health policy expert Karen Davis. We'll talk more after
our break. This is FRESH AIR.

(Soundbite of music)

GROSS: We're talking about options for reforming our health insurance system.
My guest, Karen Davis, is one of the health policy experts on the Institute of
Medicine's panel investigating ways to improve health care. She's also the
president of The Commonwealth Fund, which researches health and social policy
issues.

Now you're on the committee organized by the Institute of Medicine to create
demonstration projects to reform the health-care system. What's the
demonstration project going to be like regarding health insurance?

Ms. DAVIS: Well, this is to test out some new approaches providing to health
insurance. I think, quite frankly, from my point of view, people are
frustrated by the gridlock in Washington and starting to turn to states to
really provide some innovation and really move us forward and to tackle this
problem, because we're really not making much headway.

So what the Institute of Medicine report recommended is that the US Department
of Health and Human Services issue a proposal to states and say, `We're
willing to fund three to five states for 10 years to cover virtually everybody
in the state if you come forward with some good ideas about how you might do
it.'

And the Institute of Medicine committee recommended two strategies to test out
tax credits and to see if that works, perhaps using the states' income tax
system, or to expand public programs, such as Medicaid, the Children's Health
Insurance Program, to cover every uninsured person in the state, or perhaps to
provide a combination of approaches that would help small businesses have
options for providing health insurance coverage, as well as expanding public
programs, including expanding the Medicare program.

In addition, the Institute of Medicine recommended that the states set up an
electronic insurance clearinghouse. First of all, when you go the doctor's
office, the doctor could check what insurance coverage you have. And if you
don't have insurance coverage, they could then help you get signed up right
there over the Internet with a form of health insurance coverage that works
for you and your family.

So the Institute of Medicine is really recommending that we turn to states for
a leadership role and to test out some of these ideas and really see if this
won't generate universal health insurance coverage for the state, provide
stable health insurance coverage and to try to make some changes in the
health-care system that would promote efficiency; for example, just having
people pick out a doctor that they would go to so they wouldn't use emergency
rooms and to have that doctor responsible for making sure they're getting
regular preventive care--if they've got diabetes or asthma, that those
conditions be well-maintained, and really to stick with the doctor. Because
what we know if you keep the same insurance coverage over time, you keep the
same doctor, you get to know that doctor; in fact, they can do a good job at
keeping you healthy and keep the costs down in the long run.

GROSS: Now we've been focusing on the availability and affordability of
health insurance, but let me ask you something about the current health
insurance options that exist now; I'm referring specifically to for-profit
HMOs. There have been a lot of complaints both by doctors and patients that
HMOs that are profit-making have to report to their shareholders and make a
profit; therefore, they often overrule doctors when doctors want to give their
patient an expensive test or procedure; the bureaucracy within health
insurance companies in HMOs is so expensive that a lot of the health-care
dollar that we spend really goes to fund the bureaucracy. What do you think
of these critiques of existing health insurance?

Ms. DAVIS: I think the US experience with managed care over the last decade
has been very disappointing and it really has not delivered on the promise
that was held out when we embarked on shifting large numbers of people into
managed-care plans. I think people who advocated that approach had in mind
the non-profit group and staff model, health maintenance organizations like
Kaiser Permanente, that have produced high-quality care and really been able
to satisfy a lot of patients. But instead, what came into the industry, as
you mentioned, were for-profit companies that were more interested in getting
discounts from hospitals and doctors and denying many claims, requiring people
to get prior approval for all kinds of services, and that wasn't based on any
kind of scientific evidence of what was best for patients or the kind of care
that they really needed or what was necessary vs. unnecessary care. And it
drove up administrative costs. We certainly know that many of those
managed-care plans had administrative costs that were 15 to 20 percent, so
that a lot of the health-care dollar, instead of going for health care, really
went for this kind of overhead. And I think we've now seen a movement away
from those forms of managed care plans.

GROSS: Two of the guests I was speaking to earlier who advocate the
single-payer system, they think that what is required right now is a mass
movement of Americans rising up in demonstrations to say, `We need a new
system. This isn't working. You must fix it.' Would you like to see that?
Do you expect that to happen?

Ms. DAVIS: Well, I think people are concerned, but I don't think that
concern's well-orchestrated or being heard. So I think letting people in
positions of influence know that health care really matters to Americans is
important. But I think--we do a lot of surveys of people and really ask them:
`What do you want?' And when we ask people if they want to give up their
current coverage and move into a new system, a new kind of government-run
system, most people don't want that. They want to keep what they have. So
the real problems are those people who don't have health insurance coverage,
those who don't have good coverage, those who want improved coverage or they
want prescription drugs if they're elderly, they want lower premiums if
they're working.

So I think people are concerned about health care. I'm not sure there's
universal support for just totally junking and scrapping what we have now. I
think people are very nervous about that. And anytime you start talking about
taking away the coverage they have now and giving them something new and
untried, I think people have a lot of qualms about that. So I think you're
far better off saying let's build on what works. For people who have good
coverage, let's just help them keep it; let's help them keep it when they
become unemployed; make sure that they can still hold on to their employer
health insurance coverage; and let's help everybody who's working get access
to the kind of coverage that those workers with better jobs now have.

So I wouldn't totally scrap what we have. I don't think it's realistic given
our current economic and budget consideration. And I really don't think
there's broad-based support for it.

GROSS: Karen Davis, thank you very much for talking with us.

Ms. DAVIS: It's my delight to be here.

GROSS: Karen Davis is the president of The Commonwealth Fund and is on the
Institute of Medicine's panel investigating ways to improve health care.

Coming up, Ken Tucker reviews the new CD by the white British rapper who
records under the name The Streets. This is FRESH AIR.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Review: Mike "The Streets" Skinner's debut collection "Original
Pirate Material"
TERRY GROSS, host:

Mike Skinner is a 23-year-old from Birmingham, England, who records under the
name The Streets. His debut collection, called "Original Pirate Material,"
was recorded in the basement of his mother's home. But rock critic Ken Tucker
says it sounds anything but primitive or amateurish.

(Soundbite of "Original Pirate Material")

Mr. MIKE "THE STREETS" SKINNER: Has it come to this?

Unidentified Backup Male Rapper: Oh.

Unidentified Backup Female Rapper: Oh. Oh. Oh.

Mr. SKINNER: Original pirate material.

Unidentified Backup Rapper: You're listening to The Streets.

Mr. SKINNER: Lock down your aerial.

Has it come to this?

Unidentified Backup Male Rapper: Oh.

Unidentified Backup Female Rapper: Oh. Oh. Oh.

Mr. SKINNER: Original pirate material.

Unidentified Backup Rapper: You're listening to The Streets.

Mr. SKINNER: Lock down your aerial.

Make yourself at home. We got diesel or some of that homegrown. Sit back on
your throne, turn off your phone, 'cause this is our zone--videos,
televisions, 64s, PlayStations, Web Henry with precision, few herbs and a bit
of Benson, but don't forget the Rizla, lean like the Tower of Pisa. These
are--a ways a--and this is a day in the life of a geeza.

For this ain't a club track. Pull out your sack...

KEN TUCKER reporting:

Over the course of the 13 tracks on "Original Pirate Material," Mike Skinner,
in a thick Birmingham accent, describes what he repeatedly refers to as `a day
in the life of a geezer.' And by geezer he means a young fellow like himself,
a guy who likes to drink beer, smoke some pot, hang out with his mates,
and--and here's one way he's distinctive--fall in love with an unabashed
intensity that's rare among boasting blokes like this.

(Soundbite of "Let's Push Things Forward")

Mr. SKINNER: (Rapping) This ain't the down, it's the upbeat. Make it
complete. So what's the story? Guaranteed accuracy, enhanced CD. Latest
technology, Darts at Treble 20. Huge non-recoupable advance. Majors be
vigilant. I excel in both content and deliverance. So let's put on our
classics and we'll have a little dance, shall we?

No sales pitch, no media hype...

TUCKER: That's Mike Skinner. Sorry, Mike, but I just can't bring myself to
call you by your preferred recording name, The Streets, even though I don't
doubt you come from them and from the sound of it probably still spend a lot
of time on them. Indeed, it's this English mateyness of Mike Skinner that
provides him with so many good lines about eating junk food, drinking, getting
in arguments and fights. The streets--and here I mean the streets of
Birmingham--have given Mike Skinner the material for a series of character
sketches on a tune like the "Irony Of It All."

(Soundbite of "Irony Of It All")

Mr. SKINNER: (Rapping as Terry) Hello. Hello. My name's Terry and I'm a
law abider. There's nothing I like more than getting fired up on beer. And
when the weekend's here, I exercise my right to get paralytic and fight. Good
bloke fairly, but I get, well, leery when geezers look at me funny. Bounce
'em 'round like bunnies. I'm likely to cause mischief. Good clean grief you
must believe and I ain't no thief. Law abiding and all, all legal. And who
cares about my liver when it feels good? What you need is some real manhood.
Rasher Rasher Barney and Kasha pulling people's backs up. Public disorder,
I'll give you public disorder. I down eight pints and run all over the place,
spit in the face of an officer. See if that bothers you, 'cause I never broke
a law in my life. Someday I'm going to settle down with a wife. Come on,
lads, let's have another fight.

(Rapping as Tim) Uh, hello. My name's Tim and I'm a criminal. In the eyes
of society...

TUCKER: You might have noticed by now that Mike Skinner doesn't rap like
American hip-hoppers do. And as a white guy, he doesn't mimic
African-American speech patterns as, say, Eminem does. Skinner, using simple
looping rhythm tracks, rhymes both with and against the beat in a refreshingly
novel way. His timing is different and striking. But Skinner is also much
more of a romantic than most popular rappers, as you can hear on this dreamily
intense composition "It's Too Late."

(Soundbite of "It's Too Late")

Mr. SKINNER: (Rapping) She said, `Meet me at the gates at 8. Leave now.
Don't be late.' She said one day she'd walk away because I was always late.
Thought things were OK. Didn't care, though, anyway. Say, `Sorry, babe, I
had to meet a mate,' tempting fate. We first met through a shared view. She
loved me and I did, too. It's now 7:50. Getting ready. Better be nifty.
Do my hair quickly. Step out, it's cloudy. Mate bells me to borrow money. I
got two Henries and a dealer to pay. Call up on geezers to rid these green
trees of my reeking jeans. Got a you think I care out-glaring geezers'
stares. I'm here and I'm there. Couldn't see past the end of my beer what
was getting near, all the silence after the cheers.

Backup Singers: I didn't know that it was over till it was too late.

TUCKER: Over the course of this CD, Mike Skinner comes across as a stubborn,
proud, but sensitive guy. At one point, talking about a crush, he remarks,
`Once bitten, forever smitten.' At another point he says punningly, `I excel
at both content and deliverance.' And later he says, `This ain't a track,
it's a movement.'

I hope Mike Skinner really hasn't started a movement. It would be just a
feeble imitation of his distinctive haranguing, an original voice.

GROSS: Ken Tucker is critic at large for Entertainment Weekly. He reviewed
"Original Pirate Material" by The Streets.

(Credits)

GROSS: I'm Terry Gross.

We'll close with a recording by jazz pianist and composer Mal Waldron. He
died a week ago at the age of 77 of cancer. Here's his 1961 recording of his
composition "Warm Canto" with Eric Dolphy on clarinet.

(Soundbite of "Warm Canto")
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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