ANNOUNCER: FOR MANY YEARS NOW, EVEN DECADES, ONE OF THE MAJOR ISSUES IN AMERICAN POLITICAL LIFE HAS BEEN HEALTH CARE, BUT THE FOCUS OF THAT DEBATE HAS BEEN ALMOST ENTIRELY ON HOW HEALTH INSURANCE ARRANGEMENTS AND REQUIREMENTS GET PAID FOR.

WHILE THIS IS OF COURSE AN IMPORTANT QUESTION, WHAT ABOUT ALL THE OTHER QUESTIONS WE NEED TO ASK ON HEALTH CARE?

WHAT IS IT ALL THIS MONEY, TRILLIONS OF DOLLARS, IS BUYING?

ARE WE BUYING HEALTH, THE BEST HEALTH POSSIBLE, FOR AMERICANS OR MERELY FEEDING A MEDICAL/INDUSTRIAL COMPLEX?

THIS EPISODE OF "THE WHOLE TRUTH" WAS MADE POSSIBLE BY...

THE MILL SPRING FOUNDATION, THE DORAN FAMILY FOUNDATION, AMETEK, AND BY... FOR HUNDREDS OF YEARS IN ENGLISH-SPEAKING COURTROOMS AROUND THE WORLD, PEOPLE HAVE SWORN AN OATH TO TELL NOT ONLY THE TRUTH BUT RATHER THE WHOLE TRUTH.

THE OATH REFLECTS THE WISDOM THAT FAILING TO TELL ALL OF A STORY CAN BE AS EFFECTIVE AS LYING IF YOUR GOAL IS TO MAKE THE FACTS SUPPORT YOUR POINT OF VIEW.

IN THE COURTROOM, THE SEARCH FOR TRUTH ALSO RELIES ON ADVOCATES ADVANCING FIRM, CONTRADICTORY ARGUMENTS AND DOING SO WITH DECORUM.

ALL THESE APPLY TO THE COURT OF PUBLIC OPINION, WHAT JOHN STUART MILL CALLED "THE MARKETPLACE OF IDEAS."

THIS SERIES IS A PLACE IN WHICH THE COMPETING VOICES ON THE MOST IMPORTANT ISSUES OF OUR TIME ARE CHALLENGED AND SET INTO MEANINGFUL CONTEXT SO THAT VIEWERS LIKE YOU CAN DECIDE FOR THEMSELVES THE WHOLE TRUTH.

FOR ABOUT THE LAST 10 YEARS, THE FINANCING OF HEALTH INSURANCE, WHO GETS IT AND WHO PAYS FOR IT, HAS BEEN ONE OF THE MOST CONTENTIOUS ISSUES IN AMERICAN POLITICS, A KIND OF THIRD RAIL, FIRST FOR DEMOCRATS IN THEIR SUPPORT OF PRESIDENT OBAMA'S SIGNATURE AFFORDABLE CARE ACT, AND THEN FOR REPUBLICANS IN THEIR EFFORTS TO REPEAL AND REPLACE THAT SAME LAW.

LOOKING BEHIND THIS GREAT DEBATE, HOWEVER, ARE EVEN POTENTIALLY GREATER QUESTIONS ABOUT AMERICAN HEALTH CARE.

EVEN WITHOUT PROVIDING HEALTH INSURANCE TO ALL OF OUR CITIZENS, WHY DOES OUR COUNTRY STILL MANAGE TO SPEND SO MUCH MORE, TWO TO THREE TIMES MORE PER PERSON ON HEALTH CARE THAN MANY OTHER ADVANCED NATIONS?

AND EVEN GIVEN ALL THAT SPENDING, WHY ARE OUR HEALTH OUTCOMES NOT BETTER, AND IN SOME REGARDS WORSE, THAN THESE LESSER-SPENDING NATIONS?

WHY AREN'T AMERICANS LIVING LONGER AND HEALTHIER LIVES?

ON TODAY'S EPISODE OF "THE WHOLE TRUTH," WE WILL TRY TO LOOK BEYOND THE QUESTION OF HOW TO PAY TO TREAT THE SICK AND TOWARDS THE QUESTION OF WHAT MORE WE CAN DO AS A SOCIETY TO ENSURE BETTER HEALTH.

JOINING ME HERE TODAY ARE JONATHAN ROTHWELL, SENIOR ECONOMIST AT GALLUP.

DR. THADDEUS POPE, DIRECTOR OF THE HEALTH LAW INSTITUTE AT THE MITCHELL HAMLINE SCHOOL OF LAW.

AND DR. BON KU, ASSISTANT DEAN FOR HEALTH AND DESIGN AT THOMAS JEFFERSON UNIVERSIT.

WELCOME, EVERYBODY.

WE'RE TALKING ABOUT THE QUALITY OF HEALTH CARE IN AMERICA, AND I'LL START WITH A LARGE, UH, A LARGE QUESTION, UH, AND THEN WORK BACKWARDS PERHAPS.

IF A KNOWLEDGEABLE PERSON OF THE WORLD WAS TOLD THAT HE OR SHE WAS GOING TO GET VERY SICK AND IN NEED OF THE BEST AVAILABLE MEDICAL SCIENCE AND ASKED WHERE IN THE WORLD HE OR SHE WOULD WISH TO BE TREATED, ALMOST CERTAINLY THAT ANSWER WOULD BE THE UNITED STATES.

MANY OF THE RICHEST AND MOST POWERFUL PEOPLE IN THE WORLD CHOOSE TO COME HERE WHEN THEY FIND THEMSELVES IN THESE SITUATIONS, AND I THINK THAT'S STILL TRUE.

IF OUR COUNTRY HAS THE BEST MEDICINE AND THE BEST MEDICAL TECHNOLOGY, DO WE HAVE THE HEALTHIEST PEOPLE?

DO WE HAVE A SYSTEM THAT IS DELIVERING THAT TECHNOLOGY TO THE AMERICAN PEOPLE FOR THE MOST PART?

I BELIEVE THE NUMBERS THAT I'VE SEEN IS THAT AMERICA SPENDS MAYBE DOUBLE ON HEALTH CARE THAN OTHER ADVANCED NATIONS.

WHY DOUBLE?

WHY IS OUR HEALTH CARE SYSTEM SO EXPENSIVE?

THAT'S A VERY LARGE NUMBER.

THAT WOULD IMPLY THAT WE'RE OVERPAYING FOR HEALTH.

OBVIOUSLY, I DON'T THINK WE ARE OVERPAYING FOR HEALTH NECESSARILY, AT LEAST ON AN INDIVIDUAL BASIS.

WHAT'S YOUR REACTION?

WHY DOUBLE?

I THINK WE ARE OVERPAYING, AND I THINK THERE ARE A FEW FACTORS THAT I THINK ARE THE MOST IMPORTANT THAT ARE DRIVING THE EXCESSIVE SPENDING IN THE UNITED STATES.

IT IS, OF COURSE, WIDELY DEBATED AMONG HEALTH CARE ECONOMISTS AND OTHER HEALTH CARE PROFESSIONALS.

BUT FOR ME, IF-- IF YOU BREAK DOWN THE MOST IMPORTANT CAUSES, ONE WOULD BE ADMINISTRATIVE WASTE.

THERE'S NO DOUBT THAT WE SPEND FAR MORE THAN OTHER COUNTRIES ON BILLING AND PROCESSING MEDICAL CLAIMS.

AND FOR COMPARISON, WE SPEND ABOUT 4 TIMES AS MUCH AS CANADA DOES ON A PER PHYSICIAN BASIS.

UH, IF YOU BROKE IT DOWN BY HOURS, THE TYPICAL NURSE IN THE UNITED STATES SPENDS 20--18 MORE HOURS THAN THE TYPICAL NURSE IN CANADA ON BILLING AND PROCESSING ADMINISTRATIVE TASKS, AND CLERICAL WORKERS SPEND AN ADDITIONAL 27 HOURS IN THE UNITED STATES.

SO THAT'S A HUGE PORTION OF IT.

I'D SAY THERE ARE A FEW OTHER ISSUES THAT ARE CRITICAL.

ONE IS THE WAY THAT WE REGULATE HEALTH CARE, AND PARTICULARLY AT THE STATE LEVEL.

37% OF HOSPITALS ARE IN CITIES WHERE THEY ENJOY SOME MEASURE OF MONOPOLY POWER IN TERMS OF THE PRICING, ACCORDING TO A RECENT STUDY BY ZACK COOPER AND SOME OTHER ECONOMISTS.

AND THAT HAS AN IMPORTANT EFFECT ON HEALTH CARE PRICES.

ANOTHER FACTOR IS THE WAY WE REGULATE OCCUPATIONAL LICENSING AT THE STATE LEVEL.

SO PHYSICIANS ARE PAID ROUGHLY TWICE AS MUCH AS NURSE PRACTITIONERS, YET NURSE PRACTITIONERS ARE TRAINED TO PROVIDE FAMILY AND GENERAL PRACTICE CARE AT THE SAME LEVEL AS PHYSICIANS.

EISENHOWER: RIGHT.

IF YOU WOULD COMPARE THE UNITED STATES TO OTHER COUNTRIES, WE PAY OUR PHYSICIANS FAR MORE THAN OUR COUNTERPARTS IN EUROPE, BUT NURSES MAKE ABOUT THE SAME AMOUNT.

WELL, THAT RAISES ALL KINDS OF QUESTIONS THAT I WANT TO FOLLOW UP ON, BUT, YES, WHAT'S YOUR PERSPECTIVE?

EVERYTHING.

I AGREE WITH EVERYTHING THAT JONATHAN SAID.

I THINK A BIGGER FACTOR-- AND THIS GOES BACK TO WHAT WE WERE TALKING ABOUT, THE DIFFERENCE BETWEEN HEALTH AND HEALTH CARE-- IS THAT'S JUST WHERE WE PUT THE DOLLARS, RIGHT?

WE OVERSPEND.

SO THERE'S A GREAT METAPHOR FROM THIS POEM.

IT'S FROM THE EARLY 1900s, ABOUT THE AMBULANCE AND THE CLIFF, RIGHT, WHERE PEOPLE KEEP FALLING OFF THIS CLIFF, AND SO THE COMMUNITY BUYS MORE AND MORE AMBULANCES TO PICK PEOPLE UP AT THE BOTTOM OF THE CLIFF AND TAKE THEM TO THE HOSPITAL TO FIX THEM UP.

AND AS MORE PEOPLE FALL OFF THE CLIFF, KEEP BUYING MORE AND MORE AMBULANCES.

BUT WHAT WE DON'T DO IS BUILD A FENCE AT THE TOP OF THE CLIFF TO KEEP PEOPLE FROM FALLING OFF IN THE FIRST PLACE, RIGHT?

IT WOULD BE WAY CHEAPER AND WAY MORE EFFECTIVE, BUT WE'RE NOT BUILDING FENCES FOR THE MOST PART, WE'RE BUYING MORE AMBULANCES.

SO, THAT--I MEAN, IT'S JUST THE WAY THAT-- IN WHICH WE ALLOCATE OUR RESOURCES.

HOW ABOUT THIS EXPENSE QUESTION?

SURE.

THE BIGGEST DRIVER FOR EXPENSES--MY PEN.

IT'S A DOCTOR'S PEN.

SO IT'S THAT QUANTITY OF SERVICES AND TESTS AND PROCEDURES THAT WE DO.

AND THE WHOLE SYSTEM IS SET UP TO REIMBURSE ME FOR DOING MORE, FOR SEEING MORE PATIENTS, FOR DOING MORE STUFF TO PATIENTS.

AND WE'RE NOT-- WE'RE NOT-- THE SYSTEM'S NOT DESIGNED TO PAY FOR QUALITY.

SO UNTIL WE PAY PHYSICIAN, WE PAY PROVIDERS FOR QUALITY, WE'RE GOING TO HAVE EXCESSIVE HEALTH CARE COSTS.

NOW, HOW DO WE GET THE HEALTH CARE SYSTEM TO FOCUS ON QUALITY, THAT IS, OUTCOMES OF CARE?

THIS IS A, UH, UH, THIS IS A RATHER REVOLUTIONARY IDEA IN MANY WAYS.

BUT, UH, IS--WHAT KIND OF DISCUSSION IS THERE WITHIN THE PROFESSION?

THERE IS A FEW THINGS.

ONE, PAY DOCTORS FOR QUALITY, NOT QUANTITY.

IT'S A SIMPLE THING TO DO.

AND WE'RE--WE WERE SEEING A LITTLE BIT MORE PAYMENT SYSTEMS GOING TO A VALUE BASED CARE.

BUT THEN ALSO GETTING THE PATIENTS INVOLVED IN THE CONVERSATION AND GIVING PATIENTS DATA ON QUALITY, AND THEY DON'T HAVE THAT RIGHT NOW.

SO--FOR EXAMPLE, I WAS IN NEW YORK CITY LAST WEEKEND, AND I WAS THERE FOR SOME MEETINGS AND NEEDED TO BOOK A HOTEL ROOM, AND I COULD GET ALL THIS DATA ON DIFFERENT TYPES OF HOTELS, LOCATIONS, THE AMENITIES WITH THEM, THE FIRMNESS OF THE MATTRESS, AND REALLY ROBUST DATA ON WHERE I'M GOING TO SLEEP FOR ONE NIGHT.

BUT IF I GOT SICK IN NEW YORK AND HAD TO GO TO A HOSPITAL AND TRIED TO FIGURE OUT WHERE IS THE BEST QUALITY, WHERE'S THE BEST SERVICE, I WOULD ONLY GET A FRACTION OF THAT DATA.

SO BECAUSE PATIENTS DON'T HAVE THAT DATA, THEY DON'T HAVE THE DATA ON QUALITY-- WELL, A RANKING SYSTEM WOULD JUST REVAMP THE WHOLE DIALOGUE ABOUT IT.

EVEN--LET'S GET--LET'S-- I'M JUST SAYING GIVE US AS MUCH DATA ON HOTELS AND RESTAURANTS.

I MEAN, I COULD OPEN MY SMARTPHONE AND GET AS MORE-- MORE DATA ON WHAT RESTAURANT I WANT TO DINE IN TONIGHT THAN ON THE HOSPITAL I WOULD GO TO IF I NEEDED MY APPENDIX OUT.

THE PROFESSION BY AND LARGE HAD RESISTED THIS, OR THEY ACCEPT IT, OR WHAT IS THE ATTITUDE?

LAWYERS DID NOT PERMIT OTHER LAWYERS TO ADVERTISE FOR MANY YEARS, SO HOW ABOUT DOCTORS AND RANKING SYSTEMS?

INITIALLY WHEN THEY STARTD TO REPORT OUTCOMES, THERE WAS A BIG RESIS-- THERE WAS A BIG BACKLASH AGAINST IT.

PHYSICIANS DID NOT WANT I.

BUT THAT TIDE IS SHIFTING RIGHT NOW, BECAUSE WE SEE THAT-- WE SEE THAT PATIENTS WANT THIS.

AND WE'RE GOING TO HAVE TO MEET THOSE DEMAND, AND WE'RE GOING TO HAVE TO PROVIDE QUALITY, AND WE HAVE TO BE TRANSPARENT WITH OUR DATA.

FOR TOO LONG, MEDICAL-- THE MEDICAL CARE, MEDICAL ESTABLISHMENT HAS BEEN VERY PATERNALISTIC.

IF YOU HAVE A SERIOUS ILLNESS, IF YOU NEED A LIVE-SAVING OPERATION, ME AND MY COLLEAGUES, WE WILL SAVE YOU FROM DYING.

AND I THINK NOW, WITH THE AMOUNT OF DATA THAT'S AVAILABLE TO BOTH PATIENTS AND PROVIDERS, AS CONSUMERISM IS RISING IN HEALTH CARE, THAT WE CAN'T WITHHOLD THIS TYPE OF DATA.

WE'RE GOING TO HAVE TO PUBLISH IT.

IT'S GOING TO GET MORE AND MORE TRANSPARENT.

YEAH.

WHICH RAISES A KIND OF PHILOSOPHICAL QUESTION, WHICH IS THE PROFIT MOTIVE.

THE FEE-FOR-SERVICE SETUP IS DEFINITELY A PROBLEM, AND IT PUTS DOCTORS IN CONFLICT WITH WHAT WOULD BE THEIR MORAL AND NATURAL IMPLICATION TO PREVENT PEOPLE FROM GETTING SICK AND TO MAKE SURE THEY DON'T COME BACK TO SEE THEM.

AT THE SAME TIME, INSURANCE COMPANIES ARE ON THE OPPOSITE SIDE, WHERE THEY GET PAID UP FRONT, AND THEIR INCENTIVE IS TO LIMIT HEALTH CARE.

AND THAT'S THE WAY OUR COUNTRY'S BEEN SET UP FOR 80 YEARS OR SO.

BACK IN THE BEGINNING OF THE 20th CENTURY-- THE INSURANCE COMPONENT IS MUCH MORE PROMINENT NOW.

IT IS.

IT IS.

BUT THERE IS A DIFFERENT MODEL, AND TO SOME EXTENT YOU CAN SEE IT ARISING NOW EVEN.

AND THAT'S-- AND IT WAS VERY PROMINENT IN THE BEGINNING OF THE 20th CENTURY, WHERE DOCTORS HAD PREPAID GROUPS, AND PEOPLE ESSENTIALLY WERE INSURED BY A GROUP OF DOCTORS THAT THEY SAW.

THERE WERE THEIR PRIMARY CARE PHYSICIANS BUT ALSO COULD PROVIDE THEM EMERGENCY CARE, WOULD HAVE AFFILIATIONS WITH HOSPITALS.

AND THIS GOT THE INCENTIVES PERFECTLY RIGHT BECAUSE THE DOCTORS HAD A STRONG INCENTIVE TO PROVIDE HIGH-QUALITY CARE, OTHERWISE PATIENTS COULD GO TO A DIFFERENT PHYSICIAN GROUP.

BUT THEY ALSO HAD A STRONG INCENTIVE TO LIMIT COSTS, BECAUSE THEY WERE ESSENTIALLY THE INSURER AND THE PROVIDER.

TO A STARTLING DEGREE, CONSUMERISM HAS TAKEN HOLD IN MEDICAL CARE.

UH, PEOPLE ARE BEING ASKED TO CHOOSE BETWEEN INSURANCE PLANS, BE THEIR OWN DOCTORS, UH, TO DECIDE WHAT KINDS OF CONDITIONS THAT THEY WANT TO BE COVERED FOR, UH, WHAT KIND OF, UH-- HOW MUCH THEY WANT TO GAMBLE ON THE AMOUNT OF HOSPITAL COVERAGE THAT THEY WOULD HAVE.

THIS IS A HUGE CHANGE, IS IT NOT?

AM I RIGHT ABOUT...

UH, I--WELL, YEAH, I THINK THAT'S RIGHT, AND I THINK THAT IS GOING TO MOTIVATE A MORE MARKET BASED SYSTEM.

TRADITIONALLY, HEALTH CARE HASN'T WORKED LIKE ANY OTHER MARKET.

BUT IF PEOPLE, FIRST OF ALL, THEY'RE MORE AND MORE FINANCIALLY RESPONSIBLE.

MORE PEOPLE HAVE HIGH-DEDUCTIBLE HEALTH PLANS, RIGHT?

THEY'RE MORE FINANCIALLY RESPONSIBLE FOR A LOT MORE OF THEIR HEALTH CARE, SO THEY'RE FORCED AND DRIVEN TO BE BETTER CONSUMERS.

AND I THINK THERE IS MORE INFORMATION.

THERE ARE LOTS OF APPS, ZOCDOC AND OTHER APPS, WHERE PEOPLE CAN GET MORE AND MORE INFORMATION TO MAKE INTELLIGENT PURCHASING DECISIONS.

AND TRADITIONALLY, PHYSICIANS HAVE BEEN VERY PATERNALISTIC, AND THEY'RE STILL VERY PATERNALISTIC, BUT THERE IS A GOOD SIGN FOR HOPE, AND THAT'S WITH THE USE OF PATIENT DECISION AIDS.

PATIENT DECISION AIDS, YEAH.

THIS IS SOMETHING I'VE NOTICED IN ADVERTISING.

FOR INSTANCE, CANCER TREATMENTS AND SO FORTH.

IT APPEARS THAT A CANCER PATIENT IS GOING IN AND FORMING A BOARD OF DIRECTORS.

YOU KNOW, HE'S GOT-- FORMING A TEAM, AND THE TEAM FORMS ABOUT THIS INDIVIDUAL AND THEY COLLECTIVELY APPROACH HEALTH DECISIONS.

IT'S WHOLLY DIFFERENT FROM AT LEAST MY CONCEPT OF WHAT THE GENERAL PRACTITIONER WAS AND THEN CHECKING INTO THE HOSPITAL AND HANDING YOURSELF OVER TO OTHERS FOR CARE.

DO YOU SEE PROBLEMS WITH THIS?

NO, I THINK--THE PROBLEM IS, TRADITIONALLY, RIGHT, YOU RELY UPON YOUR-- YOUR PHYSICIAN, RIGHT, YOUR ONCOLOGIST, FOR RECOMMENDATIONS, AND THE PROBLEM IS, THEY HAVE BIASES, THEY HAVE FINANCIAL CONFLICTS OF INTEREST, THERE'S LIMITATIONS TO THEIR ABILITY TO BE ON TOP AND HAVE UP-TO-DATE INFORMATION, AND THERE'S LIMITATIONS ON THEIR ABILITY TO CONVEY YOUR RISKS, BENEFITS, AND ALTERNATIVES TO YOU IN A CLEAR WAY THAT YOU CAN COMPREHEND.

SO I THINK THE IDEA, IF YOU CAN GET EVIDENCED BASED EDUCATIONAL TOOLS, LIKE VIDEOS OR INTERACTIVE WEBSITES, THEN YOU'RE GETTING A FAIR AND BALANCED PRESENTATION OF YOUR OPTIONS IN A WAY THAT'S COMPREHENDIBLE TO YOU, AND YOU MIGHT NOT HAVE GOTTEN THAT IF YOU JUST HAD A FACE-TO-FACE WITH YOUR PHYSICIAN.

SO I THINK TECHNOLOGY ACTUALLY IS GOING TO HELP SOLVE SOME OF OUR PROBLEMS.

YOU'RE A BIOETHICIST.

NOW, WHAT--WHAT WOULD YOU SAY ARE THE BIG TOPICS IN THAT FIELD RIGHT NOW?

IN OTHER WORDS, UH, AGAIN, THIS EXPLOSION OF TECHNOLOGY.

WE'RE TALKING ABOUT TECHNOLOGY, UH, AND THE ADVANCED FEATURES OF THE AMERICAN HEALTH CARE SYSTEM AND HEALTH.

IT IS CREATING DILEMMAS, IS IT NOT, FOR US?

WE HAVE PEOPLE IN OUR INTENSIVE CARE UNIS WHO ARE PERMANENTLY UNCONSCIOUS, RIGHT?

IN A PERSISTENT VEGETATIVE STATE.

AND THERE IS--LIKE I SAID, THERE'S AROUND A THIRD OF AMERICANS WHO WANT TO THINK THAT ALL LIFE IS VALUABLE, NO MATTER WHAT THE STATE OF THAT LIFE IS.

RIGHT?

THEY CAN'T INTERACT WITH THEIR ENVIRONMENT ANYMORE.

THEY'RE PERMANENTLY UNCONSCIOUS.

BUT THE FAMILY WANTS THEM TO STAY IN THE ICU, BECAUSE WE CAN KEEP THEM ALIVE.

WE'RE NEVER GOING TO BE ABLE TO MAKE THEM BETTER, BUT WE CAN KEEP THEM BIOLOGICALLY ALIVE.

AND A LOT OF HEALTH SYSTEMS ACROSS THE COUNTRY ARE ASKING, CAN'T WE STOP, RIGHT?

WE'RE USING THIS ICU BED.

THERE'S SOMEBODY ELSE WHO COULD BENEFIT FROM THIS ICU BED.

THIS PERSON CAN'T BENEFIT FROM THIS ICU BED.

BUT NEVERTHELESS, WE'RE HAVING TO SAY NO TO SOMEBODY ELSE, RIGHT, WHO'S IN OUR EMERGENCY DEPARTMENT OR WHO'S AT A SMALLER COMMUNITY HOSPITAL.

SO WE HAVE A REAL JUSTICE IN EQUITABLE ALLOCATION OF RESOURCES PROBLEM.

MM-HMM.

THERE'S A LOT OF TALK ABOUT SINGLE-PAYER SYSTEMS.

UH, APPROACHING SOCIALIZATION OF MEDICINE.

WOULD THAT MAKE A HUGE DIFFERENCE IN THE FIELD, DO YOU THINK?

WOULD A LOT OF DOCTORS NOT BECOME DOCTORS ABSENT THE PROFIT MOTIVE?

OR COULD AMERICA SAFELY SOCIALIZE MEDICINE?

I--I THINK IT'S A MYTH TO PRETEND THAT DOCTORS AREN'T, UM, SUBJECTED TO ECONOMIC LAW.

WE--EVERYONE IS DRIVEN BY PROFIT.

AND YET, BUT HOW CAN DOCTORS BE INCENTIVIZED TO DO BETTER FOR THEIR PATIENTS?

AND I THINK IT'S WHAT WE WERE TALKING ABOUT BEFORE, IS REWARDING AND INCENTIVIZING QUALITY.

AND ALSO, I THINK WE IN THIS COUNTRY NEED TO MAKE A DECISION ABOUT WHETHER WE THINK HEALTH CARE IS A HUMAN RIGHT OR NOT.

WE'VE ALREADY MADE A DECISION THAT EMERGENCY HEALTH CARE IS A HUMAN RIGHT.

IN 1986 IT WAS A GOOD YEAR.

THE METS WON THE WORLD SERIES, AND ALSO CONGRESS PASSED A LAW, CALLED EMTALA, THAT BASICALLY SAID, ANYONE WORKING IN EMERGENCY DEPARTMENT HAS TO PROVIDE CARE REGARDLESS OF ABILITY TO PAY.

SO I CAN'T TURN ANYONE AWAY.

I HAVE A FEDERAL MANDATE TO DO THAT.

AND SO WE THINK EMERGENCY CARE IS A RIGHT, AND YET WE DON'T BELIEVE THAT NON-EMERGENCY CARE IS A HUMAN RIGHT.

AND SO, UNTIL-- I THINK THAT'S A QUESTION THAT WE NEED TO ANSWER FOR OURSELVES.

HAS GALLUP IDENTIFIED PROBLEMS IN PUBLIC PERCEPTIONS-- UH, PUBLIC PERCEPTIONS?

ARE AMERICANS CRITICAL OF THE HEALTH CARE SYSTEM, OR ARE THEY BY AND LARGE SATISFIED WITH IT?

WHAT'S THE GALLUP PERSPECTIVE?

FAIRLY CRITICAL.

IF YOU ASK PEOPLE WHAT ARE THE TOP PROBLEMS THAT THE COUNTRY'S FACING, NUMBER TWO ON THE LIST IS HEALTH CARE.

NUMBER ONE WOULD BE SORT OF QUALITY OF GOVERNANCE, LEADERSHIP ISSUES.

AND THEN IF YOU ASK PEOPLE WHAT THEIR CHIEF FINANCIAL CONCERN IS, NUMBER ONE IS HEALTH CARE.

SO PEOPLE ARE DEFINITELY WORRIED.

THE GENERAL PUBLIC UNDERSTANDS THAT HEALTH CARE IS A MAJOR ISSUE AND THAT THE COST IS A MAJOR PROBLEM THAT WE NEED TO SOLVE.

UH, THIS IS BECAUSE HEALTH CARE HAS BEEN MADE AN ISSUE AND PEOPLE FEEL THAT THE SYSTEM MIGHT CHANGE?

WE'VE GONE FROM 9% OF OUR GDP BEING SPENT ON HEALTH CARE IN 1980 TO 18% MOST RECENTLY.

I CAN'T IMAGINE THAT WE'RE GOING TO CONTINUE TO DEVOTE SUCH A MASSIVE AMOUNT OF OUR NATIONAL RESOURCES-- SO IT'S GONNA PLATEAU SOMEWHERE.

I WOULD THINK SO.

AND EVERYTHING WE WERE TALKING ABOUT IS WAYS TO TRY TO MAKE THE MARKET SOMEWHAT MORE EFFICIENT.

RIGHT.

WELL, YOU-- SO I WOULD SORT OF POSE AS A GENERAL QUESTION, A PHILOSOPHICAL QUESTION, KIND OF IN CONCLUSION FOR OUR GUESTS HERE, AND THAT WOULD BE, DO YOU SEE A SILVER BULLET OR A REFORM OR AN APPROACH THAT, UH, PUTS SOME SORT OF CAP ON THE EXPANSION OF THE MEDICAL FIELD?

WE'RE TALKING ABOUT THIS MASSIVE EXPANSION OVER THE LAST 40-50 YEARS, AND I WOULD SAY THAT-- LONGER.

HARRY TRUMAN IS THE ONE WHO COMES UP WITH THE IDEA THAT THE NEXT STEP FOR THE NEW DEAL IS TO GO INTO MEDICAL CAR.

AND, UH, WE'VE HAD REPEATED ATTEMPTS AT THE NATIONAL LEVEL TO ADDRESS A PROBLEM.

WHAT WE HAVE IS A-- IS A GROWTH SECTOR OF OUR ECONOMY, UH, AND, UH, IS THERE A SORT OF REFORM OR A SILVER BULLET OR A NEW APPROACH OR SOMETHING THAT YOU FEEL IS GOING TO IN ONE WAY OR ANOTHER STABILIZE THIS FIELD?

WHAT'S YOUR...

SO, I THINK GENERALLY INJECTING MARKET COMPETITION INTO HEALTH CARE AND MAKING IT WORK MORE LIKE MARKETS FOR RESTAURANTS AND RETAIL AND AUTOMOBILE PURCHASES WOULD GO A LONG WAY, AND SO THERE ARE CERTAIN WAYS TO TRY TO GET THERE.

UNFORTUNATELY, NONE OF THEM ARE REALLY ON THE TABLE IN TERMS OF NATIONAL CONGRESSIONAL CONSIDERATIONS.

BUT MOVING AWAY FROM A FEE-FOR-SERVICE PLAN IS DEFINITELY PART OF THAT.

THAT COULD LOOK LIKE A VARIETY OF DIFFERENT-- THAT COULD TAKE A VARIETY OF DIFFERENT FORMS.

MY PREFERENCE WOULD BE-- TO FIND THIS QUALITY.

I'D LIKE TO SEE SOME PREPAID PHYSICIAN GROUPS BECOME MORE PROMINENT SO THAT THE INSURANCE AND PRACTITIONER/PROVIDER INCENTIVES ARE BETTER ALIGNED.

I'D ALSO LIKE TO SEE US... DO AWAY WITH THE ADMINISTRATIVE BLOAT THAT CURRENTLY DRAGS DOWN OUR SYSTEM.

THAT COULD BE ACCOMPLISHED VERY SIMPLY BY HAVING STREAMLINED PAYMENT AND BILLING PROCESSES THAT WOULD BE ANALOGOUS TO WHAT A SINGLE-PAYER SYSTEM COULD GIVE YOU, EVEN IF WE DIDN'T GO ALL THE WAY TO A SINGLE-PAYER SYSTEM.

WHAT DO YOU THINK?

TWO THINGS-- WE HAVE TO SET CAPS.

WE'RE GONNA HAVE TO BE MORE LIKE THE U.K., AND WE'RE GONNA HAVE TO HAVE LIMITS ON HOW MUCH DOLLARS WE'RE WILLING TO SPEND PER QUALITY ADJUSTED LIFE YEAR.

RIGHT?

WE'RE NOW SPENDING A MILLION DOLLARS A YEAR ON CANCER DRUGS THAT MIGHT ONLY EXTEND LIFE BY 6 WEEKS.

IN OTHER WORDS, WE'RE GETTING VERY LITTLE FOR SOME OF THE INVESTMENTS THAT WE'RE MAKING.

SECOND, WE'RE GOING TO HAVE TO EMPOWER CONSUMERS TO BE MORE ACTIVE PLAYERS IN THEIR HEALTH CARE.

IF THEY KNEW--FOR EXAMPLE, TO TAKE THAT CANCER DRUG--- THAT THEY'RE GOING TO HAVE A YEAR OF INCREDIBLY SERIOUS SIDE EFFECTS FOR ONLY 6 EXTRA WEEKS OF LIFE, IF THEY KNEW THAT THAT WAS THE TRADE-OFF, MANY WOULDN'T MAKE THAT TRADE-OFF.

SO I THINK A LOT OF THE HEALTH CARE DOLLARS THAT WE'RE SPENDING, THIS 18% GDP, IS CLINICIAN DRIVEN.

RIGHT?

NOT PATIENT DRIVEN.

IF THE PATIENTS REALLY KNEW THE RISKS AND BENEFITS OF THE TREATMENT THAT'S BEING PROPOSED, A LOT OF IT WOULD BE DECLINED.

IT SEEMS TO ME THAT GETTIG SOME SORT OF FORMAL CONSENSUS ON THAT WOULD BE VERY DIFFICULT, HOWEVER.

I MEAN, YOU'RE ASKING PEOPLE TO MAKE A--MAKE A CHOICE THAT THEY'D BE RELUCTANT TO DO, IN SO MANY WORDS... FOR 50 YEARS, WE HAVE A DOCTRINE OF INFORMED CONSENT.

THE PROBLEM WITH THAT DOCTRINE IS THAT IT'S BEEN A ONE-WAY THING, WHERE THE PHYSICIAN MERELY SAYS, "HERE'S WHAT I THINK WE SHOULD DO," AND THE PATIENT SAYS, "OK, DOC."

RIGHT?

SO THE PATIENT IS CONSENTING OR GREENLIGHTING, AUTHORIZING THE PHYSICIAN, BUT THEY'RE NOT REALLY AN ACTIVE PARTICIPANT...

THEY'RE NOT-- UM, ENGAGED IN MAKING THE DECISION.

ALL RIGHT.

I THINK THAT THE HEALTH CARE SYSTEM IS BLOWING UP.

IT'S BLOWING UP.

WE'RE IN THE MIDDLE OF THIS THING CALLED A DIGITAL INDUSTRIAL REVOLUTION.

SO, EVERY--IT'S TOUCHED EVERY SECTOR OF OUR SOCIETY.

I PULL OUT MY SMARTPHONE, I DON'T HAIL A CAB ANYMOR, I UBER IT.

I DON'T BUY MUSIC, I LISTEN TO IT ON SPOTIFY.

AND THE LAST HOLDOUT HAS BEEN HEALTH CARE.

I WAS GOING TO ASK-- DIGITIZATION TO SOME DEGREE IS COMING INTO HEALTH CARE.

WHY IS THAT NOT DRIVING DOWN COSTS IN HEALTH CARE?

IT'S DRIVING DOWN COSTS EVERYWHERE ELSE.

WE'RE AT THE EARLY STAGES OF IT, AND THE FUTURE OF MEDICINE IS GOING TO BE DIGITAL.

IT'S NOT GOING TO BE DIGITAL HEALTH ANYMORE, IT'S GONNA--THAT WORD DIGITAL IS GOING TO FALL OUT JUST LIKE ONLINE BANKING.

WE DON'T CALL IT ONLINE BANKING ANYMORE, WE JUST CALL IT BANKING.

THAT'S GOING TO BE THE SAME THING BUT WITH HEALTH CARE.

I'M OPTIMISTIC THAT THAT IS GOING TO TRANSFORM THE DELIVERY OF HEALTH CARE.

THERE'S A COUPLE OF TRENDS I SEE-- THAT CARE IS NOT GOING TO HAPPEN IN HOSPITALS AND CLINICS.

MOST OF IT'S GOING TO BE DIVERTED TO A PATIENT'S HOME.

DIGITAL HEALTH CARE IS GOING TO ALLOW US TO DO THAT.

SO HOSPITALS ARE GOING TO LOOK LIKE PRIMARILY ICUs, E.R.s, AND O.R.s WHERE ONLY THE VERY SICK GO.

AND I THINK PATIENTS ARE GOING TO BE A LOT SMARTER.

THEY MAY EVEN BE AS SMART AS DOCTORS.

AND I'VE SEEN THIS WHEN-- THEY'RE BECOMING THEIR OWN DOCTORS IN A WAY.

WELL, INITIALLY WHEN I SAW PATIENTS DIAGNOSING THEMSELVES ON THE INTERNET, IT USED TO ANNOY ME, BECAUSE WHEN YOU GOOGLE YOUR SYMPTOMS, THE WORST DIAGNOSES COME UP, AND SO THERE'S A LOT OF REASSURANCE THAT YOU ARE NOT GONNA DIE OF A HEART ATTACK.

YOU'RE 22 YEARS OLD.

YOU'RE GONNA BE FINE.

BUT THERE'S A SHIFT THAT HAPPENED, AND NOW PATIENTS-- I HAD A PATIENT WHO CAME TO ME WITH A HEADACHE AND VISUAL DISTURBANCES, AND SHE GOOGLED HER SYMPTOMS AND SAID, "I THINK I HAVE AN OCULAR MIGRAINE."

AND I SAID, "YOU'RE RIGHT" AND THAT BLEW ME AWAY.

AND THAT-- BECAUSE PATIENTS ARE MORE SAVVY BECAUSE THE INTERNET'S GOTTEN MORE SAVVY.

THE TOOLS THAT THEY HAVE ARE MAKING THEM AS SMART AS PHYSICIANS.

SO WHAT'S THE FUTURE OF HEALTH CARE GONNA LOOK LIKE?

IT'S BLOWING UP.

IT'S GONNA LOOK A LOT DIFFERENT.

OH, YEAH.

ALL RIGHT, WELL, THE THING IS, IT'S, UH-- AND I CAN'T IMAGINE A SYSTEM THAT IS CLOSER TO THE HEART OF EVERYONE THAN A HEALTH CARE SYSTEM.

AND AS A RESULT, SOMETHING DIFFICULT TO APPROACH, I WOULD SAY, POLITICALLY.

PEOPLE FIND THEIR WAY THROUGH A HEALTH CARE SYSTEM NO MATTER HOW COMPLEX.

AND THEY DEVELOP A PLAN FOR THEMSELVES AND THEY'RE VERY RELUCTANT TO SEE THE THING CHANGE, BUT I THINK THAT CHANGE IS INEVITABLE IN A FIELD LIKE THIS.

I'M VERY GRATEFUL TO YOU FOR YOUR INSIGHTS, AND THANK YOU VERY MUCH FOR THIS DISCUSSION.

THANK YOU.

THANK YOU.

THE UNITED STATES INVENTS A VERY HIGH PERCENTAGE OF THE WORLD'S ADVANCES IN MEDICAL SCIENCE.

THIS IS PARTLY BECAUSE LARGE SECTORS OF OUR HEALTH CARE SYSTEM ARE IN THE BUSINESS OF MAKING PROFIT, AND FREE ENTERPRISE MAXIMIZES INNOVATION, WHILE MOST OTHER NATIONS TREAT MEDICINE AS A KIND OF NOT-FOR-PROFIT PUBLIC UTILITY.

BUT THE OTHER SIDE OF THE SAME COIN SEEMS TO BE THAT AS AMERICAN HEALTH CARE FOCUSES ON THE APPLICATION OF TECHNOLOGY TO INDIVIDUALS WHO ARE ILL, THERE IS FAR LESS FOCUS IN THE SYSTEM ON BROAD MEASURES FOR PUBLIC HEALTH COMPARED TO OTHER NATIONS.

FOR EXAMPLE, AMERICAN HOSPITALS AND DOCTORS WILL ROUTINELY PERFORM COMPLICATED AND EXPENSIVE SURGERIES LIKE HIP REPLACEMENTS ON 85- 90-YEAR-OLD PATIENTS, AND EVEN OLDER IN SOME CIRCUMSTANCES, WHILE SUCH PROCEDURES ARE FAR MORE RARELY PERMITTED IN THE MEDICAL SYSTEMS OF OTHER ADVANCED NATIONS.

BUT IT TURNS OUT THAT EXTENDING THE LIVES AND QUALITY OF LIVES OF A NUMBER OF ADDITIONAL INDIVIDUAL PATIENTS THOUGH HIGH TECHNOLOGY DOES NOT EXTEND OVERALL AVERAGE LIFESPAN OR OTHER GENERAL MEASURES OF THE HEALTH OF THE NATION AS A WHOLE.

AS WITH SO MANY OF THE ISSUES WE DISCUSS ON THIS SERIES, THE WHOLE TRUTH OF THIS COMPLICATED AND IMPORTANT QUESTION SEEMS TO ME TO BE THAT HEALTH CARE POLICIES ABOUT PRIORITIZING, AMONG A NUMBER OF VALUES, EACH OF WHICH IS IMPORTANT IN ITS OWN RIGHT, BUT ALL OF WHICH CANNOT BE SIMULTANEOUSLY MAXIMIZED.

THIS IS A TRUTH OUR POLITICIANS MUST BECOME MORE WILLING TO ADDRESS PLAINLY FOR THE NATION TO MAKE INTELLIGENT CHOICES.

FOR "THE WHOLE TRUTH," I'M DAVID EISENHOWER.

THIS EPISODE OF "THE WHOLE TRUTH" WAS MADE POSSIBLE BY...

THE MILL SPRING FOUNDATION, THE DORAN FAMILY FOUNDATION, AMETEK, AND BY... AND BY CONTRIBUTIONS TO YOUR PBS STATION FROM VIEWERS LIKE YOU.

THANK YOU.