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Interviews
Senator Bob Bennett
State of Utah
Interviewer
I know you've described our current system as a monster. Are we in a crisis?
Bennett
We are in a crisis in the sense that we're spending far too much money on healthcare and getting perverse results in many, many areas. We are not in a crisis in the sense that most Americans still getting a better healthcare outcome than people do any place else in the world. And you see that by virtue of the fact that people in other countries, if they're really sick and they really have something that they need, they come here. So, there are a lot of people who say, “Gee, everything is fine with me so everything is fine with the system.” But when you look at the system overall, it's broken and it needs to be fixed.
Interviewer
What's broken about it?
Bennett
Well, people say we have all the uninsured; we have people who don't have coverage. In fact, we have no one who doesn't have coverage in this sense. Anyone can walk into an emergency room and get treated and then say, sorry, I don't have any health insurance, give the bill to somebody else. And the bill then gets passed on to the people who are paying premiums or whose employees are paying premiums. So we do have universal access. But it's the most inefficient, expensive way to deliver healthcare that it could possibly be. And we could do a whole lot better than that and be a whole lot smarter than that. That's one of the ways it's broken.
One of the other ways it's broken is that, and this is the fundamental change that Ron Wyden and I are working on. The individual who receives the services does not control the money that pay for the services. Consequently, the person or most cases, the organizations that does control the money has a different agenda than the person getting the services. The person controlling the money has the agenda of let's spend as little as possible. The person getting the services has the agenda of let's get as much as possible. You set up that tension, the provider has to say, well, I want to take care of the person. And at the same time, I want to maximize what I can earn so I will, they won't use this term and people don't think of it in this exact way, but I will game the system so as to get the maximum reimbursement and then at the same time, if I can take care of the patient, I will do that too. But there are all kinds of perverse incentives built into the system as it currently exists.
Interviewer
It terms of global health, we don't have very good outcomes for infant mortality, life expectancy, some of the more generalized...
Bennett
Yeah, I see those statistics. I'm not fully persuaded by them. I'd like to get down into the details. I've long since learned that a single statistic, many times masks details. People talk about the Canadian system, one of the reasons it works as well as it does is that people in Canada who have real problems can come south across the border and get them taken care of. In ways they couldn't back home. And I don't know how that shows up in any kind of analysis between how healthy they are and how healthy we are.
Interviewer
Why are you joining Senator Wyden in proposing the Healthy Americans Act now?
Bennett
Well it's time for a variety of reasons. Congress isn't doing very much. I was just interviewed where it became clear that people are saying, “Gee, they're just sitting around.” We're not just sitting around but we're spending too much time arguing with each other about other things and more and more on both sides of the isle people are saying well can't we find something we can do together. Well everybody wants the healthcare situation fixed. And it would politically be good for both parties to be seen as cooperating on dealing with healthcare. So the political situation is favorable for this.
Secondly, it's a matter of memory and timing within Congress. A lot of people don't remember how bitter the fit was in 1994 over healthcare as proposed by Hillary Clinton, then the First Lady. And there was so much blood on the floor when that was over. Her system/proposal was not voted down, it simply died of its own weight. With all of the arguments that were going on around it. And President Clinton himself acknowledged that when his next State of the Union message. I remember he said we practically came to blows over healthcare, now can't we sit down and work together. Well the answer was no. Memories were too fresh, there were too many wounds. They had run too deep and it sounded good for the President to say, well we need to start over again. You had to wait until some of those memories had, had disappeared. Well now they have. And people on both sides of the aisle are not trying for pay back or prove that they were right or any of the emotions that surrounded the old debate. It's kind of clean sheet of paper time, let's address this and that's another reason why now is a good time to do it.
Third, we do have some things that are coming up for reauthorization. SCHIP that is the State's Children Health Insurance Plan is coming up and there's going to, there's a debate about it. And how do we do it. And there are some who quite frankly, surreptitiously want to change the "C" to "A". Instead of children's health insurance plan they want to put a lot of adults in there and they think, OK this is how we'll get to a single payer system, if we just expand CHIP, SCHIP to cover everybody. Everybody by definition becomes a child and we've covered everybody and then we've gotten there. And of course, those of us who are opposed to a single payer system are saying, not on your life. Well, we're having the debate. So in the context of the debate of what to do about SCHIP, we can say, hey we can do a better job in the whole system. Here's a new proposal. Oh, well we're having the debate, let's at least look at what Wyden and Bennett have to say.
Interviewer
How's the proposal being received?
Bennett
I may be naive but I have the feeling that the whole landscape of the healthcare debate has shifted as a result of a number of things, one of them being the Wyden-Bennett bill. But we've caught a wave if you will. Massachusetts, Governor Romney in Massachusetts said, okay, everybody ought to have access to healthcare. Everybody ought to be covered in at least some kind of basic plan. And we're going to do it at the state level. Now what he did at the state level is very similar, in many ways, to what Senator Wyden and I are proposing, but it's not in some other ways. And he himself says, this wouldn't work anywhere but Massachusetts. It was framed for the particular circumstance that he had there. But a number of policy makers in Washington, including a number of Democrats, have looked at Massachusetts and said, “Hey wait a minute. That might be the way out. Because it's not a single payer government run system. It does have some market forces in it, which we Republicans like. And it's proving to be a good cost containment kind of thing. It's not costing as much as they originally thought that it would. And it's getting a better outcome. Okay, well let's take a look at that.” The governors have now come out with statement of principles on healthcare. Healthcare should have A, B, C, and D. Their principles are very much in line with the Wyden-Bennett bill. And they draw from the experience in Massachusetts. Now the President has said, let's see if we can't do. Okay, you got the President, you got the Governors, you got a couple of Republicans/Democrat senators and we've found Republican/Democrat house members to be with us. We've picked up endorsement from Steven Burd, who's the chief executive of Safeway. So that's big business, NFIB, those are little businesses and Andy Stern, who is the president of the biggest union in the country. Now, it's easy for them to hold a press release and say, yeah, I think this is wonderful and then you get into the details and they say I'm out of here. But the point is the debate is now taking place on a different playing field than it used to. We're in a very different place taking about these things than we were back in 1994.
Interviewer
Do you think the states are calling the federal government to task? Whose roll is it to reform healthcare?
Bennett
Well the states can't fix a problem they didn't create. And the dominant problem in the present situation for the whole nation is the federal tax law. Because the federal tax code drives you towards an employer-based system. The employer can deduct the cost of, the employee can't. That's the heart of what Senator Wyden and I trying to do. We are trying to change the tax code so that the employee, the individual can get a tax break for the dollars that are being spent and therefore, the dollars can shift from the employer to the employee without a tax burden on the employee and the employee can then direct the dollars as to where he wants them to go. And when that starts to happen, OK, the employers says, we're going to put everybody in this HMO. And the employee says, I don't want to be in that HMO. Right now, to bad, that's it. Employee says, wait a minute, I'm going to take my dollars and I'm going to go to the HMO down the street and join that HMO because I get a better experience down there. The people running this HMO are going to say, wait a minute, we don't want that leakage of customers, as long as they are locked into their employer, you can't do that. But now, wait, we want him back. Maybe we ought to cut costs to cut prices here. Maybe we ought to clean up the waiting room and get newer magazines or whatever it is that caused him to leave and try to woo him back and then the one that he went to says, well, we better do a better job. You'll see costs begin to come down. Instead of the perverse incentives now, you will have real market incentives, real competition, better equality, and lower cost. All throughout the whole system, it can be demonstrated that better quality, usually, brings, almost always, brings lower cost.
Interviewer
Is it based on anything that exists right now? Have you taken models that exist in the real world?
Bennett
Well, John Goodman has done a piece in the Wall Street Journal where he's talked about healthcare quality. And he said, interestingly enough, the best quality in healthcare is available in three cities in the United States: Seattle, WA, Rochester, MN, which you think of because that's where the Mayo Clinic is, and Salt Lake City, UT. And they say if you get your healthcare in Salt Lake City, UT, and I won't name the entity because it would be advertising for them, you get as good a quality as available anywhere in the country and if every American got his healthcare at that place, it would cost one-third less than it costs now because as they focused on quality, the price has come down. Now, you give that information, that's one of the things we call for in our bill, is transparency. Yes, we want portability that people control their own dollars so they can control where they go, portability and transparency. So people have to say, well, in our hospital it costs so much and our quality rating is so much and the guy down the street says in our clinic it costs so much less and the quality rating is so much more. Okay, we don't have transparency now in the healthcare system. We need to get it in order for competition to work.
Interviewer
There are some people who say that healthcare shouldn't be profit driven.
Bennett
Yeah, Michael Moore.
Interviewer
Actually, I'm thinking of people directly involved in healthcare policy. I’ve talked to several doctors working in the area of public health. They question whether people should be able to profit off of healthcare.
Bennett
Profit creates incentives. See, incentives create innovation. And innovation creates quality. And right now one of the things that you see in healthcare is that the incentives drive you towards inefficiency, the monetary incentives drive you toward inefficiency and bad quality. I'll give you an example. Somebody shows up at a hospital and the incentive is to make as much money as they can. Well let's order this test and let's order this test and let's order this test.
Another incentive driving that is frankly malpractice insurance. I want to be absolutely sure I don't get sued because I've done all this. Now, he may very well know, or she, that what this patient needs is this. But this doesn't make very much money so the incentive is, order these tests, make the money off the tests and then do this and they get cured and we get paid. And one of the things that happens in the three cities that they've talked about was the protocol in this particular entity is, they come in, this is what they've got. The protocol, says this is where they go. And the tests are not included in the protocol because the diagnoses drive you this way. So that's how you get better quality and lower price. Now if you take all of the profit out, they have no incentive to try to develop this better protocol because they're not going to get any additional volume of patients. If you say, OK, and you can do this and by transparency everybody will come to your door, alright, I now have a profit motive to bring to price down, to be innovative, to be creative. When you take the profit motive out of that, you turn everybody into bureaucrats. I know doctors don't say that, they say, I'm in this to cure people and I applaud that and I acknowledge that on the part of many, many doctors. But for the system as a whole, if you take the incentives out, you're going to see it stultify around rules, around regulations and disaster.
Interviewer
One aspect we’re examining for our documentary is if healthcare is a privilege or a right. What do you think the role of the federal government is inside the notion that healthcare is a right?
Bennett
I don't think healthcare is a constitutional right. But I do think society now demands, indeed we've passed laws that says, that say, you go into an emergency room, you can get treated whether you can pay or not. So we have, we've crossed that threshold in practice even though we have not created a constitutional right. The role of government, I believe, is not to be the owner of the system, but the organizer of the system. And again, we're back to the Mass. model. The Massachusetts, the government of Mass. does not run the system, but they've created what Gov. Romney calls a connector. The government acts in the role of connecting the individual to the plan or program that will allow the individual, ever individual in Mass. to have at least a basic plan. Now if you want something beyond the basic plan, you can get it. And up to a certain point you can get it with tax free dollars. But the present system says the CEO of Enron can get whatever he wants and it's all with tax free dollars. And we say, no, the tax free dollars only go up to certain point and above that if you still want a Mercedes plan, fine but you're going to have to pay that extra yourself.
Interviewer
A lot of the people we're working with fall between the cracks. They make too much...
Bennett
They make too much for Medicaid but not enough. And again, the Mass. model, Gov. Romney said it's cheaper for the state to simply buy them a policy than it is to run all of these other programs. That's the basis. And how do you get them to the policy. Well, that's where the Connecter comes in. Connector, what they're doing, so they walk in and say, gee, I don't have any insurance. And the answer is, yes you do. You just didn't know about it. Now here are three choices. You identify which one you want to be signed up with and that's where we'll send the bill. Instead of, well, we'll just put it to our general overhead and then make it up by charging higher premiums to your employer and my employer.
Interviewer
So basically would even more people be covered under...
Bennett
Everybody would be covered.
Interviewer
Everybody would be covered, but would it be more affordable. Would it take care of that in-between class?
Bennett
Absolutely, absolutely. It would have to or it wouldn't work.
Interviewer
They are worried. The people I’ve talked to say they can’t afford much not even $60 a month.
Bennett
Well, if they really are at the bottom, then they qualify for Medicaid. But we discovered some interesting things. I held some hearings when I was chairman of the Joint Economic Committee on this and talked to people who do nothing but cash and carry. Doctors who said, look, I, I have had it. I want to practice medicine and in the present situation, I cannot practice medicine. I am buried with regulations and requirements from Medicare, Medicaid, insurance companies. The insurance companies are just as bad as the government. I don't want deal with any of them. So I'm opening this cash and carry, you come sign up with me, you pay a $1,000 a year or whatever it is and I'll keep you well. And if you get anything that requires something else then, I'll charge you for at a going rate and we'll work it all out and so on. And he says it's great, because I'm practicing medicine now. And I'm focusing on the patients now and I'm earning an adequate living and it's all fine. And I don't have to have this enormous staff and infrastructure and paper work and all the rest of it. Alright, we heard from him. We heard from the next one. He said I will take insurance forms for the big stuff, for the catastrophic stuff but I do the same kind of thing. And I have lower class people than he has because they can't afford that kind of thing but I do fine. Alright, then a woman came in and she said, I'm in the inner-city. Most of my customers are Medicaid and they come to me for the services Medicaid won't cover. Because you see the government is all about eligibility. Well you're eligible for this but you're not eligible for that. But I need that, too bad. The government rules say this is what you're eligible for and that's not what you're eligible for. She said, I not only make an adequate living, most of my, as I say, most of my customers are in the inner-city and if they absolutely, absolutely can't pay, I don't charge them. But they're so anxious to get what they really need that they will say I can pay you so much, I can do this much and they're thrilled to have somebody focusing on them. And she said, I've cancelled all the insurance except catastrophic for me and my family. Because we're getting care at our own clinic and we're getting better care than we get when we're under the insurance thing. There's a great lesson to learn from that.
Interviewer
What is the lesson in the nutshell?
Bennett
If you have true market forces, that is, the individual who is getting the service is the individual who is paying for it. Wherever the money comes from, it may be government money but I control my government money. It's employer money but I control my employer money. It's added on my money. I control my money. If the individual who is getting the service controls the money that is paying for the services, the services will get better and the price will come down.
Interviewer
It is the bottom line.
Bennett
It happens in everything else, why shouldn't it happen here?
Interviewer
There are those who say the market doesn’t apply quite so neatly to medical care—that healthcare isn't a commodity because as a consumer, I don't choose to get a kidney transplant just because it's on sale.
Bennett
That's true. And that's where the catastrophic thing comes in. But let's talk about insurance for just a moment. I have a homeowner's insurance that is wonderful. If my house burns down, it not only replaces the house, it replaces the car in the garage, it replaces the painting on the walls, it replaces the toilet paper in the bathroom, everything. But I don't file and insurance claim for mowing the lawn. The dog scratches the front door, I don't file and insurance claim to paint the front door. In healthcare, we've got the notion that, quote, insurance should pay for everything. My homeowner's insurance pays for the catastrophe. Sure you should have insurance to pay for a kidney transplant. I've got a daughter who has PKD and she's going to be facing a kidney transplant. Absolutely, that's something that should come out of a large pool. But you don't file insurance for a flu shot or for many of the things we do. We've got it in our mind, well that's not covered.
Let me tell you an experience my daughter had. She got a degree in speech therapy and was working in a nursing home - her first job - run by Easter Seals. She was called in to consult on a woman who had some swallowing problems. The doctor said, I'm not familiar with this sort of thing but you deal speech therapy? She said, yeah, I know about swallowing and speech and so on. And she said this is the kind of therapy that will solve this problem. The children of the woman said, not on your life, until we can be assured that Medicare will pay for it. OK, my daughter says that's easy enough. Will Medicare pay for this? She called me up, woke me up. She stays up later than I do. Dad! You're a senator; you've got to fix Medicare. And she was screaming about this experience. It took three days to find out whether Medicare would pay for this procedure. She said Dad, do you know who the highest paid person in this facility is? It's not the doctor, it's not the administrator, it's the Medicare lady. It's the lady who sits in the office with all the regulations in front of her and paws through them to determine what gets paid for and what doesn't. And it took the Medicare lady three days to come up with an answer. My daughter has had patients die on her because they couldn't determine. Now, they're in a nursing home, they are old, they probably would have died anyway but it's a fairly traumatic experience for a young woman in her twenties who is out to save the world. Just gotten a degree in a helping kind of service and knows what to do and then the bureaucracy gets it. Once again, if the individual who needs the service is controlling the money, the individual says, pay for this. This is what I need, pay for this. The bureaucracy goes away and you've got better service and cheaper.
Interviewer
We have a lot of people who have a lot invested in insurance companies, in the status quo. Where do you thing the hurdles are going to be in trying to pass healthcare reform?
Bennett
Well as I've talked to people in the insurance industry. They are ready for a change. Because they recognize that if you break the present mold and healthcare is now available to everybody that will create a whole new series of markets to go after. Only they will be able to go after them in a much more rational way than they service the present market. So they are ready to break the mold. Employers are ready to break the mold. I don't know where the push back is going to come. Because quite frankly as Sen. Wyden and I have gone forward with this, nobody has pushed back yet. Everybody has said, gee, this is probably the thing to do. Now we have had a lot of, "I've got to see the details", "I'm not sure your tax provision is going to produce the result you say it will." "Now I'm not sure about this, that and the other." So we are getting that kind of push back, which frankly we welcome because it will help us fashion a better bill. Our bill, as best we've done to put it together now, probably we wouldn't vote for it now because we don't know what's going to happen in certain areas. But we have created a dialogue and we have created a momentum of the way I've just described with unions and business, some health insurance companies, doctors, a lot of people. And in the Congress, we've had a hearing on it. The chairman of the committee, Democrat, ranking member, Republican, both said, you’re on the right track, this is the way we have to go. So we'll just see where the push back comes.
Interviewer
It sounds so hopeful to me I don't want to be cynical. I don't want to say nothing is going to change.
Bennett
Don't give up. Along with the people that I have described, we have the Secretary of Health and Human Services who is driving in this direction as strongly as he can. Somebody most Utahans know, Mike Leavitt. He tells an interesting story if I can steal it from him. He's over 50 and his doctor told him you should have a colonoscopy. And he operates with a health savings account. Back to what I was saying about insurance should be for insurance, should be for catastrophic things not for routine kinds of things. So he said, alright, I will get a colonoscopy. I'll get Jackie to get a colonoscopy and what will it cost. So he calls the hospital and says, I want a colonoscopy and what will it cost? They say we don't know. He says, what do you mean you don't know? They said we don't know what a colonoscopy would cost because we don't know whether you're going to do this and should we do that and so on. He said, and so we basically created a bid sheet. OK, I'm going to buy this, I'm not going to have that and so on and we made a bid sheet for the colonoscopy and this is what I have, what's it going to cost? And they told him $6500. And he was stunned. Because before he got on to the health savings account and it was supposedly all his employers money or the insurance company's money and it didn't matter and it was all covered nobody cares what it was going to cost. And he was thinking 2 or 300 and it's $6500. So he calls another hospital. Shopping around, see? And they said, well, we don't know. Well, here's the bid sheet. They went down the bid sheet. $5500. Now can I get some transparency as to which one is better? Is a $6500 colonoscopy better than a $5500 colonoscopy? Then somebody says why don't you try Utah? Because this was all in Washington. So he calls Utah, pretty good healthcare in Utah. $3000. OK, he's going to use Utah. He's going to use Utah he's going to do it in Utah because he is paying with his own money. If we had that kind of nationwide system going, the folks in Washington would discover, we better change our protocols, we better be able to do this for $3000 because it can be done for $3000. It can be done at a profit. We'd better start shifting. If the Congress is passionate, if the Secretary of HHS is passionate, if the President is asking for it, if labor and business are for it, we got a shot.
Interviewer
There is a lot of incentive in terms of wellness. There's a lot of emphasis on primary care. How important is that and then the second phase of that are we equipped as a nation to have, to provide that kind of primary care.
Bennett
Well, wellness and primary care is of course very important because if you can keep somebody well, you save enormous costs at the back end. Uh, I've, I've heard different estimates, some, the lowest is 50%, some as high as 80% of the Medicare dollars are spent in the last 30 days of life, which raises all kinds of ethical questions. Can we really afford to continue to do that and if we don't what do we do. But the people who take care of themselves are the ones who quietly die in their sleep. Now it's an over generalization and of course you know somebody of whom that's not true. But, the healthier you are, the cheaper you are. Not only in your growing up years but your middle years and your end years all the way through. The healthier you are the cheaper you are. So there should be incentives for healthy behavior and we had built them into the bill. If you go to Switzerland, where they have a similar kind of thing, that is individuals control their policies, they are portable. And they have built into this they do it in 5 year contracts. I'm not sure that would work here, but at the end of 5 years, they review what you have spent and if you have remained healthy to a certain level, they give you money back. It's possible in Switzerland for you to get $25,000 at the end of your 5 years by virtue of how well you've taken care of yourself. That's a pretty strong incentive and we've tried to build that principle into this legislation.
Interviewer
Is there anything you'd like to add?
Bennett
One of the things I learned early on in getting into this healthcare debate is that there are more barriers for coverage or treatment than just money. I was giving a lecture and a woman came up and she said, Senator you really understand this, that was beautiful lecture and you don't have the slightest idea what you're taking about in the real world. And I said, OK, tell me what I need to know in the real world. She said for the poor, it's not that they don't have the money. In many instances they can't navigate the system. It is so daunting, the forms that have to be filled out, the questions, go to this room, to that room and they just can't do it. And I've discovered with that kind of tutelage that value of the community healthcare centers. And I've walked into a community healthcare center and I don't know whether they recognized me or not. You can never tell unless they say, oh, Sen. Bennett. But immediately someone was there. Hi, welcome to the center, what can we help you? Well, OK, I'm just here to look around, I'm Sen. Bennett. Oh, that's fine. But you could tell that anybody walked in, immediately someone was there at his elbow to work him through the system, help him fill out the forms and so on. In all of this discussion, we must not loose sight of the importance of that kind of service. And we've got to find a way, if it's tax dollars or whatever, to see to it that those people continue to get paid, the navigators that can lead the poor through the labyrinthine system that we have. Because otherwise they are just defeated, even if they have control of their dollars on paper because our system says they do, they're still not going to get the access that they need.
