Title: Can We Afford Health Reform?

" This is radio Boston I'm -- place finish. Massachusetts spends more on health care than any other state in the nation more than a third above average. Our residents pay the highest premiums are government pays the most in subsidies. And yet there are problems among them Bostonians on average have to wait two months to see a primary care doctor. While health reform has successfully insured more than 97% of bay -- mounting costs and threatened to topple the entire system. As the health care debate rages in Washington Massachusetts continues to serve as both a poster child and a punching bag on the national stage."

" Wow Massachusetts is in trouble here all of -- hidden -- gets everybody in Massachusetts insured and we did it without putting government into the insurance business program it's very natural and out of control one point three -- Massachusetts since 2006 have been running experiment for all of us and then we can go to school on makes them at Romney that's our. -- governor -- thanks to Mitt -- and it's very clear what happens private insurance goes away. More people go on the public plan costs explode."

" So what's really going on in Massachusetts. Costs are out of control. And the same people who brought insurance reform to the commonwealth are proposing a bold new way of paying for health care. As Ted Kennedy says the work goes on. Listeners health care professionals what are the problems with the Massachusetts system where is the waste where is scared insufficient. You can join our conversation today -- 181438255. That's 1843. Talk. Or comment on line at radio Boston doesn't work."

" Primary care is scarce in many areas but there are people working to bring quality accessible primary care even to the most neglected neighborhoods. Back in the 1960s. On Dorchester is Columbia point Senator Kennedy helped capitalize and nationwide movement toward community health centers. Holistic primary care facilities that serve those who are least likely define care in the mainstream system. Many of those neighborhoods -- have seen an increase in patients after health reform. And his radio Boston's David -- reports this thriving model of care in Massachusetts. Could have lessons for all of."

" They happens trying to help senator was started by the upper corner health committee in the early seventies. Primary care providers would -- me."

" They left to retire to join hospitals to pay them more but to start more profitable practice and its suburbs. As operations manager -- I Redondo says this she's giving me a tour six films and comprehensive range of medical and social services. As diverse as neighborhood itself. Some that hasn't -- and -- thought receptionist Maria Gonzales these speaks for agreeing to patients I speak to admitting real."

" I speak Portuguese I speak Spanish speaking."

" At Haitian creole French in Vietnamese. Into the mix of some 220000. Visits by patients last year actually ended -- just. In its first year albums corner at 200 visitors in just -- Now the neighborhood health center provides comprehensive care to --"

" Yes and in fact it's a much tighter system of care. Then -- find in the big epidemic medical centers people have access to us pretty much all the time patients walk in and we see them. So -- vehicle will willingly here. Ross to this doctor Jeff mode Destin served most of his career leader in most of the health centers as -- its medical director. This patient this morning -- news coming into wealth as."

" And Ali pimping him and seeing him she complains that she's too -- to -- before so this is one of my patients who have known -- Oh probably twenty years or so. Now was even the suburbs whose primary care physicians and what's become an acute nationwide crisis. Mode desk points to the neighborhood Wilson as a model. At the very time the country's health system needs models. Take Ernestine. The ocean at heart surgery twenty years ago she's done very well by seeing the doctor regularly. If you have really good primary care that people can get access to. Which means you have enough primary care providers in the community. And people are accessible. That you can avoid a huge amount of cost in terms of hospitalizations and unnecessary emergency room visits it's really get -- to the doctors. Just when you well I'm a day and rocked the as a nurse practitioner here I -- come here when you well don't always continuing -- tech. Knowing your patients well and providing full services including home visits can allow even greater savings as urgent care nurse was Blair."

" We can often prevent emergency room visits for example Leno and we have a patient column complaining of something. My coworker reverent about ten actually did home visit last week preventing one of my patients and going to emergency program. He is able to treat that person at home and threaten other readmission because you know the patients we can make certain. They're not going to be using its resources on the eighteenth."

" It. Over in Dudley sq and Roxbury at another facility operated by the albums corner health center. Doctor Adam Burroughs talks to some seniors playing dominoes. Here with the -- services program. Seniors who are eligible for nursing home care but have chosen instead to live at home. Spend their days and exercise recreation. Social activities therapy and medical care the goal is to hopefully produce unnecessary utilization on -- of resources. Keep people out of nursing homes and institutional settings and Abel and remain living at home the model is called pace program for all inclusive care for elders. And doctor borrows the medical director says it's made a big cut in the rate of hospitalization. On average this population of nursing home eligible seniors. Which spend seven to eight days a year in the hospital in the pace model we hospitalized after about two and half days. Per year. But what we're doing is taking those resources that might otherwise go. To prevent hospitals today. And re allocating it towards this comprehensive system of community based care it's covered by Medicare and Medicaid which is to say what we're seeing here. He's part of public option already hit play. Quality of care is terrific says Jack Johnson one of the men playing dominoes -- It's wonderful thing. The elderly people set appointment in his room. I'm husband may have been ten years never had a complaint inside we find his mother Frances Pope Francis. I don't net today. I'm glad to hear it white -- Johnson sits in a wheelchair wakes from an -- I've Francis for a nine year old she has an extraordinarily. Strong and Francis -- advanced alzheimer's disease and she also has severe heart failure initiates personally care for and believe in fed every day. And treated for any medical problems the staff provides home care as well. On average the senator get 65000. Dollars a year for full care for patients like Francis. Was she put in a nursing home doctor Burroughs says Medicaid would pay up to 75000. Dollars a year just for the stay. Then add to that the cost of any medical care medicines and hospitalizations. As well do you like it."

" I hate it and a -- important. But -- do remove this. I do most."

" Until France's leaves the area -- dies the problems corner health center will be committed to all her care. In many ways as a patient she represents all the issues of their health care debate. Cost and quality care community choice and dignity. Advocates of the community health here's -- thank you Francis. You're. Thank you your beautiful."

" Rating of Boston's David -- Joining -- and the studios James Hunt president and CEO of the Massachusetts league of community health centers. Also with -- in the studio doctor Alice coombs president elect of the Massachusetts medical society she also serves on the state commission dedicating to control. Healthcare costs welcome both of you to the program. Thank you thank you. Jim -- we just turn a lot of happy stories from people who are getting great care sounds like a -- health centers you argue that this is a model of care that also saves money is that because these senators are federally subsidized or because they're just intrinsically more efficient."

" Well probably all the above first of all starts with community and has. We just heard it's reflective of the needs of patients within that community be it cultural language. He is care for the elderly or care for pediatrics. Senator Kennedy who was mentioned during the peace. Often said if we didn't have health service with have to invent them. So the first one that started at Columbia point in 1965. And is now the target Gibson -- Was replicated across the country to we -- today we have over 3000 wholesalers serving seventeen million people across the country it's really been an amazing growth."

" So tired of the quality of care and we heard a little bit about it in the piece but it is secure better than what you might have received in the mainstream health system medicine."

" Well first -- one stop shopping in this customized to the cultural linguistics and reflective of the needs of those patients that served by the health Serbian population group or. Particular piece of geography. But it's very clear that tells her patients get more comprehensive care they get a medical home where all of the needs of -- Taking care opened a one stop shopping basis and frankly as we've just heard. Reflective of tech and the sensitivity and the closeness that you confined in communities."

" Community health centers were initially created to serve poor and minority patient populations and into a large extent people without insurance. And so when health reform was passed in Massachusetts and most people got some kind of health insurance you're worried you might see your patient numbers drop but that is not what happened."

" Yeah we were we were very concerned that. That sometimes the understanding. -- what and -- card means for health and their patients we provided access regardless of anyone's ability to pay. For all time and we were worried that. Of course a marketing could have some of those patients exit exit our senators. The irony of it is in the 2007. We gained 50000 patients in Massachusetts in 2008 we gained another 50000. So we're still bursting. From the seams and even growing even attribute those numbers. Well my sense is that the best word of mouth is the word of mouth here in Massachusetts and just as you've heard in these stories. We have been studied. Pretty much by everyone the Kaiser commission just came in and didn't report the White House website recently cited health services the number one program. And it's because of the quality and because of sensitivity."

" After -- and let me bring you in here it sounds like -- community health center remodeled. Good accessible primary care is the key to controlling costs would you agree with I think that primary care senator an essential piece of herbal medicine."

" And one of the things that it's just mention is that whole notion. I -- a culturally competent workforce which is really important. I think patients I know and feel more comfortable and a setting where people understand the cultures that exist in the community. And one of the things is. That patient's ability to navigate through health care system also is one of the things that it will drop patients and the works for us throughout the community."

" 121 of the claims made about health for reform in Massachusetts that more people. When they gained access to this preventative care through primary care it's structures. Hospitalizations. And emergency room visits would actually go down say the system millions of dollars is there evidence that that has happened is happening in Massachusetts."

" Well it's a very interesting that -- Massachusetts Health Care reform didn't cause. Problems that -- exacerbate the primary care. Well I should say this that that that the health care reform and of itself. May have had some changes within the system in terms of people being able to access. Certain practices."

" And that me. Have really to a number of things including the fact that -- apartment here work."

" Force there were shortages before that went to win it."

" More. Residents having now. Insurance. They can actually access the system but it doesn't necessarily mean that they can actually. See -- position or might take longer for them to get into the health care system I have more questions about those primary care doctors and and where they -- in Massachusetts but I wanted to call first in Newton David's."

" Maligned David let the majority of Boston hello. Sorry I'm well go ahead."

" Well I welcome to stated. Massachusetts primary care is not well a position and when my son. Firefighters -- creation for the crime of turning 21 Ike could not find. Primary care. Positions for them. I."

" Trained at University of Massachusetts my residency. And one. Even before we established university. Medical center at reed medical school and among the highest per capita. Medical student -- a population in the country. We built medical school citizens cost and medical school -- not graduating or incentivizing. Students to go into primary care most of them deal. They're used to be a very vital primary care residency program -- withering. And the incentives are quite -- There to -- his diminished. Substantially if they've promised to practice. In Massachusetts. Have to be have subsidized training. -- such as medical school but they don't have to practice in primary care."

" Well that's interesting point David I want her to discriminate Mexicans -- agreement because according to the American Medical Association Massachusetts has more. Primary care doctors per capita than any state in the country so how is it possible that we have this primary care shortage let it sit."

" Very interesting when you look at the numbers and workforce. Here in Massachusetts we may have members of -- doctors calculated per 100000 residents. But it as it turns out the number of doctors don't necessarily reflect the number of full time. Practicing clinical doctors it reflects a number of doctors who do research some doctors are partly retired. So that the actively engage. Clinicians that are involved direct here. That number probably is artificially elevated and relative to the never doctors that are actually."

" And in the community practicing Jim -- one of the incentives that you use to get primary care doctors into your system well first of all we have a very robust than brand new loan repayment program and we are trying to attract so positions and by helping them pay off their debts and we've expanded that not a nurse practitioners and -- it says dentists and others in the future. I agree with an -- to say you are having problems getting in attracting -- primary or don't we Aaron it's gonna take a number of years to turn around not only the entrance requirements in the form medical schools but what we call the primary care pipeline and we're working with the medical society and others try to make that happen when I do wanna say though is that some baby steps have been taken and not to correct the caller -- I agree with much of what he said. But to -- new statute which we call health care reform to it was actually chapter 305. Actually expands the UMass medical school. Program. And experience the residency program including establishing residency is that our community health times. And then not finally I think it's really important to. To note that. That there are organizations even my own and we can get into the Slater who to help people find primary care physicians and get them into."

" Here I wanna talk about another model that's out there for -- primary care that is a significant contrast actually on mr. hunt to the community health center model. Article minute clinics. You know them well it started here in Massachusetts a couple of years ago he go there for quick. Test for strep throat check for an ear infection. The -- to some patients inside the Porter Square at CVS minute clinic this week and here's what one of them told us."

" I call my doctor she wasn't going to be able to see me that day I mean I've actually had them say -- well you know we don't have an opening until three days from today. Well if you if you have something like a bronchitis or any thing you -- three days to go see somebody. That's a Janine her -- in telling a common story supporters of minute clinics doctor -- say that they make basic primary care more accessible. They -- the whole system money do you agree or work at that speed for the -- that causes that were not against."

" Retail clinics in many Clinton that he was saying but what we are before is coordinating patient here and there are some clinicians in these and this."

" Setting that may be able to take care of your aches sore throats things along those lines."

" But as you well know that sometimes patients come into the office of minor complaint and it leads you to."

" Duke comprehensive check for other chronic diseases are discovered so I think -- for care coordination. There is no replacement."

" Absolutely no replacement for a meaningful primary care relationship. Okay fair but isn't there a portion of the patient population that really could use this."

" There are some instances where it may be helpful but the problem is is I've been able to distinguish."

" The proportion of population that -- see a good Indiana -- primary care practice. And also have a medical home where they can be they can receive comprehensive health -- what do you think of a minute clinic and it is sort of bare bones primary care Jim well --"

" Beginning we were very very skeptical that in fact minute clinics with the very limited set of diagnoses could in -- that affect. The consumer demand was out there. What we found is that consumers do want this kind of option for simple testing etc. but what we've been pushing minute clinic -- and all those retail clinics. Is the possibility of interoperability with existing and that by that I mean connection to existing primary care practices. Because as the state of the Commonwealth of Massachusetts has indicated. Everyone should have a medical home and that medical home should be with a primary care practitioner and then we can connect with minute clinics hospitals and others."

" It's possible cams well right now visit is a concern about. Two medications and drug drug interactions or some medications that -- that patients may receive."

" And the prime natured actor not be aware of that and so it's really really important piece of it to have the information transfer."

" That the doctor knows what medication the patient has received at."

" A retail on the face of and it may sound good and maybe it is good but beyond that the cost issue their real medical concerns as -- and actually. Absolutely let's go back to the phones a merry Laura is in Jamaica Plain she's been winning welcome of the program mayor Laura."

" Hello -- god. So I'll make my point Mary are shortly though it you know all that that they are difficult subjects here. But I would like just said that message is that should not be an example for the nation. Because private insurance that being given -- monopoly. We do we need that it's public option and I want to keep you just very quickly some effects to illustrates. How -- this so called reform has affected middle class people like me."

" We'll what did you tell us how it's affected young applicants to break up."

" Yet might have been worked for a company with twenty employees we have to buy all our own insurance that the outfit from July to a separate. Due July 2008. The monthly. Bring him with blue cross blue -- what 800 -- Dollars mom with no deductible. The next year July 2008 to 2009. We in order to keep that same monthly bring him up. We need that -- to accept a plan without a thousand dollar deductible per per -- in the then came July 2009. And now. We have the very cheapest plan offered by -- across the ratio. Up messages that they're put to the people. We opting not -- 132. Dollars per month. And we each have 82000. Dollar deductible. I think the figures are talking about himself."

" Merry Laura thank you very much doctor coombs Vista speaks to that cost individuals it's rising exponentially and and I think that's one of the."

" one of the reasons why the payment reform. Commission was initiated because of the need to really rein in costs and the costs not directly as this caller has said so. Spoke so wildly at well about the notion of."

" Rising costs would not necessarily increasing demands or increasing services that are meant."

" This is one of the things UMass medical society is addressing on multiple levels not just the payment reform commission but also. Two other agencies that can control and deal with the insurance costs and."

" to declare mr. Jim -- the overall health care system and it community health centers gets four dollars of savings for every what one dollar spent on care at the -- honor -- it's gone up overtime and -- very proud to say that by reducing emergency room visits and working with food system and a comprehensive way. That patients directed to community also received money. We're talking about strategies for making health care affordable home listeners are you happy with your level of health care coverage. And even affected by rising health care costs. Give us a call 181438255. That's 180423. Time for comment online radio Boston dot org. Coming up will speak about a radical new way to pay health care providers. Some say it's not so no it's just an HMO by a different name from the we'll take a look at the proposed global payment system. Back in sixty seconds I'm -- place and this is where you lost."

" And a."

" News -- and I'm Jane Clayson we're talking about health care reform this hour looking beyond the question of covering the uninsured. To efforts to rein in out of control health care costs. Listeners what you think we should do to reduce costs in the system. Are the so called minute clinics we just talked about a good way to provide health care cheaply. Have you experienced in efficiency in your dealings with health care providers. You can join our conversation -- 1804238255. That's 18143. Time. With -- yeah this hour Jim Hunt head of the Massachusetts league of community health centers. And doctor Alice coombs see incoming head of Massachusetts. Medical society. Mexicans who serve on the commission as you mentioned that was tasked with recommending ways to reform the way health care providers are paid. And hopefully save the state money you've recommended that dropping the so called fee for service model of payment. In favor of something called global payments. And you books explain what global payments. Well."

" Before we go on to the explanation of what global payments are have a right to say that there are some situations and physician practices in some areas. Whereby fee for service will still be in operation. Because the nature and the Senate but the practice. That fee for service will be the only thing that will be. State that they will be able to do with them -- services and services that are geographically isolated. To the geographical isolation Pacific's not necessarily geographically. Isolated but also the infrastructure. For some practices may not be in place for them to transition into global payments so. One of the things before I talk about what global payment is is that it's necessary for. You'd have an infrastructure within your practice in order for you to transition into global payment of and so so global payment as a method to integrate here among hospitals physicians and other providers more effectively. And am hopefully moderate. And -- cost increases so yes there is a budget. The dollar Q -- care for per capita per pretty patient. But. The difference between global payment has many -- global name it sounds like managed care sounds right -- most HMO him or her capitation. But. Global payments are very different in that you're taking consideration. The quality of medicine that's -- practice an addition you also take into consideration patients who have more -- morbid conditions in which a physician has to spend more time coordinating here. It doesn't. -- mean you're transferring a lot of risk. Onto the doctors themselves and he's not the -- insurance companies to absorb that risky time quality care absolutely is the jobless insurance companies to absorb risk and it is something called insurance risk. And insurance -- that's something that. A provider has no control over. That's the risk that's worn on the insurance company position should I have to. -- at the risk. Certain. Events that happened in patients' lives of it that. That is the physician is. A provider and takes care of the patient conditions. He can and monitored by quality indicators which are really important. But but for instance if someone. Had had some un expected event -- some on toward accident. That's that's an insurance risk that's not -- provide service so so integrated care. Moderating annual cost -- in these -- the basic -- headline issues associated with global payment is there precedent for this anywhere else has it been tried. We have as many examples of global payments there's equal payment systems in Minnesota there's the Geisinger clinic guys' -- health care system. And Pennsylvania and they actually show that you save. Many in addition to more importantly is that quality is improved. And that really is the most important part is if you save a dollar and and the burden of disease increases that that were wanna go we want to make a difference and the outcome in terms quality indicators that's what -- important part of this whole pieces."

" Let me bring another perspective into the center coombs doctor Arnold and Roman is a professor emeritus at Harvard Medical School former editor of The New England Journal of Medicine. He writes about the Massachusetts global payments idea in an article that -- will appear in the journal in a couple of weeks nice to speak with you again doctor -- hello."

" What -- you don't longtime critic of the fee for service modeled that this global payments ideas strike you as a viable alternative."

" Well and in general terms it's a good idea that is to say. The payment commission. Has made the right diagnosis. They say the big problem and controlling costs is the way we pay doctors on the peace work fee for service basis. Basis they're absolutely right about that but I cannot. Agree with there -- ideas about. Where you go from there how are you get rid of -- reservist. And replace it with global payment it's much too complicated. Involves private insurance companies. And it involves risk adjustment and payments for quality. It involves about complicated. Arrangements that are not going to be practical and won't work and most doctors won't accept this."

" So what's the best way to your mind to change the way doctors are paid."

" I think doctor should be paid a salary. As members not for profit. Group practices there are many models in the country now. That show this can be very acceptable to doctors to provide excellent care patience. And certainly. Keep cost down. The Mayo clinic pays his doctors but salaries. Of the -- The Geisinger. That does. Kaiser does. As Scott White many many clinics employed doctors on them not for process. Salaried basis and that's the future of Madison."

" So we have a very unique medical infrastructure if you will now and in Massachusetts is that. It that the best way to do it here will it work here like it works and these other places."

" No it won't because the solution has some national solution I admire Massachusetts for its innovative -- willing to face the problems. Expanding coverage was a great step forward. But Massachusetts cannot solve the basic problems with the health care system it's a national problem and it can only be solved on a national basis."

" Doctor -- responses to doctor Juan Roman achievement one of the things that physicians are very concerned about is the notion of."

" Now what they do with."

" They're clinics they're panels how -- natural barriers to practice within their. Practice which is just the administrative burdens this and that they that they are faced with in terms of having to have. Designated to people within their office just solely to deal with claim filing and and."

" The paperwork is necessary to be in existence than mere. Viable practice. Overhead is enormous."

" And so physicians are faced with the dilemma. Do I stay here in practice or two I go practice somewhere else where the dares to practice are much less. But Tibetan that the doctor -- point and in Zion is what he's saying global payments to doctors will have to share. Their payments and a broader network. I mean it."

" That includes is exactly right -- Doctors now in the system we have now are playing -- administrative difficulties in dealing with multiple private insurers. What I'm proposing is a radical change get rid of private insurance we don't need private insurance companies at all. Let's have a public tax supported system. Which -- news groups. On -- per capita basis. With salaried doctors well salaried at managing their own their own practices. Who went with their own management. And pay doctors for doing what doctors ought to be doing namely. Provide their patients with the best possible care. Without concern. For the effects of their decisions there individual decisions on there income to use. -- wealth without risk without concern for profit. From these for service."

" So -- the physicians our control are concerned about what control they have in terms of their patients panels in terms of where they can go and what they can do you."

" One of the things that we've actually talked about it commencement society is."

" How how could how how is it possible that are in transition into global payment and and our. Our geography here we have. The majority of patients that are covered by private insurance is unlike many areas where you might have 30% -- 40%. The."

" Residents are covered by Medicare or Medicaid we have a smaller portion of patients covered by Medicare Medicaid to more private insurance. Exists in Massachusetts so. The most reasonable thing is to transition to global payment within those structures."

" For practices and providers who can actually do it they have to have the infrastructure. And the -- the government has the share in the responsibility. The providing providers with the infrastructure cannot happen it will not be six success though. Successful must have happened Jim -- about the patient's perspective and how will global payments how would global payments affect the experience of a patient under the current system."

" Well the first thing -- it -- primary care in Massachusetts and across the land. The CHC's -- of their patients consumers need to be positively and -- For systems savings right now the savings goes in the back for the public pare back the insurance company. So don't think there's anything wrong at all and by the way we do salary all of our positions. -- providing incentives took four primary care. And not get into punishing basically providers but get into the consenting both providers and consumers to do more primary care to work with. Those minute clinics to work with the hospitals the specialists and others remember in our case an enabling services of language transportation. And basically getting patience and to care they -- cost money so we have to get our -- back."

" Let's get another Collin you're from Boston Joanna is on the line -- welcome."

" All I -- only in support of what cops and you're not cheap it's -- looking for insurance provider being filled out pork and or a 11 man shop. I had very limited -- and in turn look like I have let my insurance provider. And some of the vendors brokers for our private insurance company. To. Had told me. You know all you could pay -- get in italics and employee. 50800. Dollars reinsurance coverage I'd say -- you're young you're -- And without even looking medical record. Me medical attention need would be if he can't click go to the emergency girl but what will -- you coverage and they have to pay. The government -- not. Having insurance which part of it's cheap it's helped form brands that. And and well in -- in our growing and creating a healthier communities are needy. That -- you straighten out. Its goal to people but just -- amount got to correct you rarely eat duck or prevent carry -- and your primary recognition. --"

" Doctor -- it's a terrific point John thank you for calling I I am so sensitive to what you've just said because -- at one of the busiest hospitals in terms of emergency services that without your hospital. And that is exactly what we do not want to happen. Now we would prefer that people get their care from their primary care doctors and not -- an emergency room. And it is true that in terms of the week. The amount of money that is spent in emergency services that cost. That here per patient goes up astronomically when you don't have -- here."

" Medical home."

" And that is exactly what we don't want in terms. Outcome in terms of maintenance and chronic illnesses we would prefer that."

" You do have a medical office that he shows that we have a medical and you improve quality and you say doctor element which speak to the caller's point."

" Well I agree with -- problems that emergency services for people who have no insurance is no solution that'll. Look well I want a repeat what I said. The problem is not really very complicated. We want to see that everybody is covered everybody. And the only way we can do that is to put everybody in the same. Insurance pool mainly through a public plan. Supported by -- earmarked. Public tax everybody in it. So everybody's covered now quality control costs -- when you control cost is to have. Society. To side. How much they wanna spend on health care for their own health care and -- the doctors -- hospitals doctors. Here's the amount of money we wanna spend on health care personally averaged. You know give us the best possible here you can. Put that money. If it's not enough will have to tax ourselves more. If it's too much tell us you pay yourself a salary he learned not in business. -- Laura profession. And we'll pay you good salary you pay your cells of the salary under. Rules and regulations that everybody can agree on but you'd have to get rid of these for service payment. And you have to get rid of private insurance."

" Here's a net from Dorchester welcome to the program and that's what thanks for -- going."

" Talk about -- I. Am not sure I. It but again if you're talking about my appetite -- to -- the conversation back to me health centers and and that talk about these service that we receive -- yet out opt out that there wasn't. Act agnostic and I indication that the target I would very much identify. In my family as middle class. Yet been notion that the tactic of factors are carefully to provide -- apparently."

" And it thinking is and that's a fee for service patient torrent HMO patient. HMO well it's interesting because in by managing care we we. We have our own community based HMOs than they would health plan as well as three other plans and we found. That by providing more services more access. That lowest cost of course the savings only goes the system today. But for instance and it would help plan has a comprehensive program. That where if you do use the emergency -- some of the calls you up ask you what the couldn't get into care whether or not there was a problem -- summer. Trust to coordinate that. That -- to avoid the second trip the emergency remember. Many times in in in in places across this commonwealth and across the nation. Edwards who -- was the only source of care for many many of them was for many many years it's hard to break that paragraph."

" Here's a band in Brookline Ben welcome to ready -- Boston --"

" I hope thank you very much I'm actually are almost got a -- adopt overall Wednesday concert when. I'm I'm I'm -- in the country for twenty and I never could understand why we have built into mediators between companies in between not in the darker than the the whole statement -- off. Are fully inflated cost life. Because we have insurance in the middle ensure that blocked. They'll -- here and take expenses for the auto four quote don't be."

" Are so that doctor roller is exactly right he's got it right on the button that's the problem fragmented. We allow insurance to be a private for profit business that is for people under 65. And we do not put everybody in the same insurance risk pool in other words to say everybody. Has a stake in providing good care for everybody. And we do that through a progressive reasonable. -- the money is no problem in the United States we're spending more than enough money now to cover everybody with excellent care."

" So doctor Roman what kind of system do you think will eventually end up Winston and how long does it take to gonna take to get --"

" I think and handwriting is on the law the fragment business. System we have now with many many different insurance arrangements and many many different ways of providing care. Simply go to work because it's going broke. The Congressional Budget Office and everybody who knows anything about the economics of health care says it can't last. How long it will take for there to be the general realization by the public. And by the congress and by our profession by the medical profession that we need a radical change I can only guess I would say. Probably wouldn't a decade but not immediately."

" Well it'll be interesting to see how how this reform shakes out amounts to conduct Arnold Wellman professor emeritus at Harvard Medical School I really appreciate your time doctor thank you for your perspective. And James Hunt president of the Massachusetts league of community health centers I appreciate your time Jim thank you closure. Doctor alaskans stay with us we're talking about making health care affordable this hour I'm ready in Boston and when we come back. We'll be joined by the Massachusetts secretary of health and human services Judy and big big. To talk about how Massachusetts health reform might be affected by the national health reform efforts. Listeners have you been watching the national debate wondering health federal reform might impact your coverage here in Massachusetts. This is your chance to get your answers -- questions answered give us a call 181438255. And Jane Clayson as we head into the break Bostonians on the street weighed in on the prospect of national reform overtaking what we dirty hands here in Massachusetts --"

" I would like to see everyone get health care when my son was an employee he didn't have health -- for him or his children. We think the government should stick away from healthcare to bad deal it's a bad deal for the taxpayer I have a health plan and I'm pretty well covered so I haven't fallen."

" The health care or. Program is poorly thought out there will only increase deficits destroy the health insurance coverage Duca."

" And."

" This is -- Boston I'm Jane Clayson -- everybody does their part many in the insurance reforms we seek. Especially. Requiring insurance companies to cover preexisting conditions. Just can't be achieved. That's why under my plan individuals will be required to carry basic health insurance just as most states require you to carry auto insurance."

" It was a bold statement from President Obama Wednesday night but the individual mandate is very familiar to us in Massachusetts. I'm joined this hour in studio by doctor Alice -- president elect of the Massachusetts medical society. And joining me now from Beacon Hill is governor Deval Patrick's secretary of health and human services Judy and big day after the be welcome factory of -- As we just appreciate your time as we just heard President Obama came out stronger really than ever. -- tonight for an individual health insurance. Mandated like. What we have here in Massachusetts. Some curious if congress were to approve a national. Nationwide mandate. Would we want to eliminate our state mandates."

" Well that's a good question I think it depends on what panic conditions are out to mandate that. The federal government might. Included what we have an aptitude it's that can mandates for anyone who has access. To affordable coverage to take about. And they don't have access to affordable coverage. We have here's some of those individuals that State's subsidized plans though. We would want to make show awards that maybe. Conditions that'd be affordable and that the definition of affordable is consistent with what we have to act."

" So but if we didn't eliminate our state mandates. And a national mandate was instituted would bay staters face double fines if they didn't buy health insurance."

" It would probably be. A -- don't find that again I wanna say pat. The individual mandate -- that's where can Massachusetts it's an effective and getting people -- and insurance and therefore increasing their -- cool. But our concern would be if we're looking at the federal mandate and whether it's a state mandates matches up to it. Is to make sure at -- It's affordable. That there's an option if there is an affordable insurance and that peak time. Would not put people. At a double whammy thing temperature --"

" So people on commonwealth care and we should they be concerned or worried that they might be transferred to a different national plan if one -- to to to come to fruition."

" I'm I don't think that. Right now at bat. It's something they would need to worry about. You know even if there was a public plan. We would see how that would lineup it's something like eight state subsidized plan like commonwealth care. Which I'll I would state supported its pocket through practice and and it's scary."

" And that as one of the founders of health reform in Massachusetts how do you think it's holding up. In the national spotlight these states."

" Well I think it's a lot of this information out scared but fortunately we have a lot of people whose. Are keeping track of what is actually happening we with the relief that the news and has. Data on -- uninsured that they ranked Massachusetts began as. The state well it's rated on insurance that -- figures show we had continued to. Decrease the number of uninsured. And the -- A lot of misinformation about the -- but we've had many studies including. And the Massachusetts taxpayers. Editions that shows that. -- this is not yet about two two in the state. That the cost to actually quite modest given what we've been able to achieve what are more than 97%. Of people covered."

" Let's about the phones now Betsy is in -- she's been waiting patiently Betsy look entering -- Boston hello."

" Hi thank you for taking my call well not just myself but sort. Other -- doesn't flush. Part time in order to college faculty and."

" Other part time college faculty at. And UMass who who don't get covered under. -- state employees. Trust coverage and who also. Make a little too much manage to qualify under commonwealth care as an individual. -- sort of mid level. Policy 736. Dollars. And ninety cents every single month that's about 25%. Of my annual income. So yes insured but I don't so insured. And I thought there's which I initially going to be sliding scale. Back."

" Betsy thank you victims and would you respond. The you're and then the category that I think. And we look at the initial. Transition into a universal health care there was a there was -- 11%. On it and insurance rate in Massachusetts and the 11%. Probably less than half I think qualify for the commonwealth how. Health plan. And so it's unfortunate. That it takes so much you hear. Income to pay for insurance rates and on a global payment. This to be something that would benefit you particularly because. It would be. Hopefully the Europe and premium to be reflected by the fact that your cost of -- down and that's one of the goals is to decrease across. Not just of to the -- payers but also to. The -- of the year."

" Residents -- You know there's so much to talk about I have pages here. An additional information I wish you can go another hour or two we will in the future there's more to come. -- coombs doctor alaskans president elect of the Massachusetts medical society really appreciate your time to doctor thanks. And doctor Judy and big beat Massachusetts secretary of health and human services -- big thanks so much for your time. Our program today was produced by an average Casilla and Jessica -- with help from our interns -- heart. Our field -- sustainable weary teams go with our technical director in the senior producer of radio Boston's Marc. I'm Jane Clayson enjoy your weekend and will look for you -- next week on radio Boston."