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{ timecode: 0, handler: 'blob', id: 1, data: {text: 'DAVID WHITE: It gives me a great deal of pleasure to introduce to you the person at CTAA, who for, I guess, 14 years now, and at least 10 of the last 14 years has been leading the fight here at CTAA on '}},
{ timecode: 20, handler: 'blob', id: 2, data: {text: 'behalf of all of you to bring to our nation’s leaders and leaders in state houses around the country your concerns regarding medical transportation and has made some, has had some really great '}},
{ timecode: 41, handler: 'blob', id: 3, data: {text: 'successes in that on behalf of you and our association in the area of Medicaid, in the area of raising the issue of nonemergency medical transportation for Medicare and in the area of raising the '}},
{ timecode: 59, handler: 'blob', id: 4, data: {text: 'really troublesome issue of transportation, disjointed transportation for our nation’s veterans. It gives me a great deal of pleasure to introduce our executive director and my friend, Dale '}},
{ timecode: 73, handler: 'blob', id: 5, data: {text: 'Marsico. DALE MARSICO: Good morning! The members of my staff who did not stand up and cheer when I came up, Ginger has your names, you’ll be required to be out front after my presentation. The '}},
{ timecode: 98, handler: 'blob', id: 6, data: {text: 'rest of you people, if you want to take that pub break, I suggest this would be a good time. What can I say after seeing how many of you are in the medical transportation business? You know, if my '}},
{ timecode: 120, handler: 'blob', id: 7, data: {text: 'mother was here the first thing she would say is, “God love ya”. And you know quite frankly if you’ve been in this business on the provider’s side for the last 10 years, '}},
{ timecode: 132, handler: 'blob', id: 8, data: {text: 'that’s about the best thing we could say, because I know it has been an extremely difficult piece of work that makes absolutely no sense when you consider the people that all of you are trying '}},
{ timecode: 151, handler: 'blob', id: 9, data: {text: 'to serve. How is it that in our country doing something that is so right and so necessary has become such a difficulty for all of us? I was involved in the first court settlement that created the '}},
{ timecode: 176, handler: 'blob', id: 10, data: {text: 'Medicaid transportation program back home in Texas in the 1970s. A court decree from a federal court in Texas that required the state to provide transportation to health facilities was easier to '}},
{ timecode: 198, handler: 'blob', id: 11, data: {text: 'manage than the current programs that exist throughout the country. We must wonder how it is that this easy-to-understand needed, service has become so complicated, difficult, expensive and quite '}},
{ timecode: 223, handler: 'blob', id: 12, data: {text: 'frankly, although few people mention it, probably except for yourselves, so confusing to the people who need the service. I know sometimes from our perspective as transportation providers that we '}},
{ timecode: 239, handler: 'blob', id: 13, data: {text: 'think that we are the only people caught up in this mess. But as Dave just pointed out, and if you look at your USA Today, and if you pay any attention to the news, you’ll realize that the '}},
{ timecode: 253, handler: 'blob', id: 14, data: {text: 'health system in the country is the real problem. And many times, somebody suggested to me recently, what you’re doing in handling medical transportation is attempting to compensate for the fact '}},
{ timecode: 272, handler: 'blob', id: 15, data: {text: 'that the bigger system is broken. Today we face extraordinary challenges in that system, and I thought it might be good since we have worked so long and hard that sometimes I feel that people have '}},
{ timecode: 289, handler: 'blob', id: 16, data: {text: 'actually forgotten what our link is to the bigger health care system and how we actually got to this place that we are today. Since Dave was mentioning two words, I’ve got two words too for '}},
{ timecode: 309, handler: 'blob', id: 17, data: {text: 'today. One word is fantasy. The other word is reality. Fantasy. What would fantasy in our field be? Well, we know that fantasy is politics. Politics and reality. People are very strange sometimes when '}},
{ timecode: 334, handler: 'blob', id: 18, data: {text: 'they talk about our medical transportation policies because they somehow seem to think they’re supposed to make sense. But, most of our policies are written in far away Washington as Doug Birney '}},
{ timecode: 349, handler: 'blob', id: 19, data: {text: 'pointed out, much further than Hawaii. And reality. What is the reality in this case? What is our fantasy and reality? It’s how the political system provides health care, transportation for '}},
{ timecode: 364, handler: 'blob', id: 20, data: {text: 'people who need it. Politics versus reality. What’s my favorite political movie? I’m sure this will be your favorite political movie too. Lord of the Rings. Now, how many here, I know '}},
{ timecode: 379, handler: 'blob', id: 21, data: {text: 'we’re already tired of these polls, how many here have actually seen all three of those movies? I always thought they were such a good historical interpretation of the Clinton years, but we '}},
{ timecode: 390, handler: 'blob', id: 22, data: {text: 'don’t want to talk about that today. But, the second movie was my favorite, and my favorite character in that movie was that guy, who was a king who rode all those horses. Remember him? King '}},
{ timecode: 403, handler: 'blob', id: 23, data: {text: 'Theoden. And he was of a country or a tribe where everybody rode a horse and they would ride into battle. And you remember in the second movie they were trapped by all the evil creatures in their '}},
{ timecode: 415, handler: 'blob', id: 24, data: {text: 'little mountain fortress. Right? The walls were coming down, everything was bad, most of his people had been wiped out, they were standing in this room and he’s looking at his chief aide and he '}},
{ timecode: 430, handler: 'blob', id: 25, data: {text: 'says, “How did it come to this”? As everything was literally falling down around him. I thought that movie was especially important maybe for day two of the Obama Administration. Because I '}},
{ timecode: 445, handler: 'blob', id: 26, data: {text: 'have a feeling that probably Rahm Emanuel came in that day and among another group of other things that were so bad. Someone probably said, “You know the health care system, it’s even '}},
{ timecode: 459, handler: 'blob', id: 27, data: {text: 'worse than the rest of the economy". And his response was probably, "How did it come to this"? As opposed to something else. I thought today it might be good to address for you my '}},
{ timecode: 475, handler: 'blob', id: 28, data: {text: 'vision of how it has come to this. Where this crazy quilt of health programs and services that have become dependent on transportation came from. Believe it or not, it isn’t all that long ago. '}},
{ timecode: 500, handler: 'blob', id: 29, data: {text: 'And I would like to say that I have this version of history to present to you, which is my own, and that it is not the opinion of my employers, and it is not the opinion of the Community '}},
{ timecode: 515, handler: 'blob', id: 30, data: {text: 'Transportation Association of America. It is my own. So, I will accept responsibility for all the people I will offend. You’re supposed to laugh at that, but you know, this is a tough audience '}},
{ timecode: 528, handler: 'blob', id: 31, data: {text: 'early in the morning. So, I’ve chosen my slide here as you can see, ‘Making Sense of Health care and Medical Transportation’. The symbol on the top, which I got for free in my Power '}},
{ timecode: 543, handler: 'blob', id: 32, data: {text: 'Point kit at Apple, is really a symbol of the actual atomic structure of U2-35 right before it explodes. So, I thought that was an appropriate subject to use here about making sense of the health care '}},
{ timecode: 563, handler: 'blob', id: 33, data: {text: 'system. Where did this system come from? Who is responsible? Where is it going? How do we fit into it? That’s what I want to talk about. In my next slide here, who is responsible for all of this '}},
{ timecode: 577, handler: 'blob', id: 34, data: {text: 'mess? Okay. And I know that some of you have seen this man before in one of my little exposes, but all of you who haven’t been to one of my previous presentations, put up your hand if you tell '}},
{ timecode: 590, handler: 'blob', id: 35, data: {text: 'me who this is? If you know who this is? Okay, now. Dave Raphael, would you stand up? Just stand up. You all see Dave Raphael back there? That’s not him. Okay, so if you were going to guess Dave '}},
{ timecode: 605, handler: 'blob', id: 36, data: {text: 'Raphael, that\'s not him. Okay, I saw Dave O\'Connell\'s board chairman, who is the finest board chairman for community transportation in America hold up his hand, Mr. Chairman, who is '}},
{ timecode: 616, handler: 'blob', id: 37, data: {text: 'that man? Double jeopardy, he\'s right. Now, what is Otto von Bismarck got to do with our medical transportation system? Huh? Let me tell you. The Germans, of course, efficient that they were, '}},
{ timecode: 634, handler: 'blob', id: 38, data: {text: 'back in the 1800s when Otto was busy creating the new Germany, he had a big army. You know, thought that was a good idea. Having a big army was a good thing. Course, if you’re German all armies '}},
{ timecode: 648, handler: 'blob', id: 39, data: {text: 'are big. Secondly, not only is having a good army a good idea, we must do away with the opposition. And who was the opposition in his time? Some group of people that are apparently making a comeback '}},
{ timecode: 664, handler: 'blob', id: 40, data: {text: 'in Washington, they were called Socialists. And Socialists were demanding change in Germany and Otto didn’t like change, he wanted that big army and so he came up with two things. One, when '}},
{ timecode: 678, handler: 'blob', id: 41, data: {text: 'young people were going into his army, half of them were physically unfit. This was in 1873. Unfit. Secondly, he needed to do something about the pesky Socialists. And the only thing he could come up '}},
{ timecode: 699, handler: 'blob', id: 42, data: {text: 'with was that I will out Socialism, the Socialists, and people will like me more. He invented two things. One, social security for everyone who lived in Germany. Similar to our own system from the '}},
{ timecode: 716, handler: 'blob', id: 43, data: {text: '1930s, so that everyone in Germany would have an income when they were older, and secondly that there would be a national health service in Germany in those years so that people would be ready for the '}},
{ timecode: 737, handler: 'blob', id: 44, data: {text: 'army. 1873 he is actually the most reactionary politician of his time, but in terms of health care and human services, the most advanced. So, other Western countries, Britain and France in '}},
{ timecode: 760, handler: 'blob', id: 45, data: {text: 'particular, followed his lead as did others in Western Europe and those ideas actually spread to our own country, but not until much later. So, it\'s to Otto von Bismarck, is the first person who '}},
{ timecode: 778, handler: 'blob', id: 46, data: {text: 'should be on your list responsible for the mess you’re putting up with. Next. Now, what about the American experience and the federal government managing health care. Otto, believe it or not, '}},
{ timecode: 793, handler: 'blob', id: 47, data: {text: 'back in Germany, there were states too, United States, states right? We had states too and the federal government’s first real experience in managing health care in our country comes from the '}},
{ timecode: 806, handler: 'blob', id: 48, data: {text: 'Civil War and from World War I. Now, the Civil War was a lot easier on us because 90% of everybody who was wounded died. So, the health care system did not exist in the beginning of the war and in the '}},
{ timecode: 825, handler: 'blob', id: 49, data: {text: '1860s our government had no requirements for being a doctor to serve in the U.S. Army. You apparently just walked in and said, “Hi, I’m a doctor”. It is true and a historical fact '}},
{ timecode: 839, handler: 'blob', id: 50, data: {text: 'that you can check, that the majority of doctors who worked for the Union Army in particular were barbers. Double role, I suppose. After the war, we had the first health care benefit program for '}},
{ timecode: 855, handler: 'blob', id: 51, data: {text: 'Americans who actually served in the Union Army in the Civil War. Sadly, if you served in the Confederacy, you didn\'t get any help. Interestingly enough, for those of you who remember your '}},
{ timecode: 869, handler: 'blob', id: 52, data: {text: 'history, President Grant, the great union general, became head of our country a few years after the Civil War and his administration was beset by a great scandal that almost drove him out of office. '}},
{ timecode: 885, handler: 'blob', id: 53, data: {text: 'And what was that scandal over? His brother-in-law and several other people stealing the money set aside for health care for our veterans. Gee. Interesting. Along comes World War I. We now have '}},
{ timecode: 902, handler: 'blob', id: 54, data: {text: 'doctors in the United States, and guess what? They got drafted. Not happy with it. And as you can see here, I know I was going to make a terrible joke saying that, “Gee, this is actually the '}},
{ timecode: 913, handler: 'blob', id: 55, data: {text: 'wrong picture if it’s a new VA facility that just opened up. But, in reality, this is World War I medicine, where the attrition rate of our soldiers was much less. But, we had many people with '}},
{ timecode: 924, handler: 'blob', id: 56, data: {text: 'long term disabilities after World War I because of the problems with gas in the war. What happened after World War I? President Harding got elected. What was the biggest scandal besides Teapot Dome '}},
{ timecode: 939, handler: 'blob', id: 57, data: {text: 'in the Harding administration? The inability of the government to manage the medical benefits program for our veterans. So, our history with health care at the federal level in those years was always '}},
{ timecode: 956, handler: 'blob', id: 58, data: {text: 'bad and always negative. These I’ve chosen as steps along the way to talk about our health care procedure after the Civil War. We began with Social Security in the 30s, we’re going to talk '}},
{ timecode: 971, handler: 'blob', id: 59, data: {text: 'a little bit about that, we went on to Medicare in the 60s and Medicaid. A lot of people think Medicare and Medicaid have been around a long time, but actually they are only creations of the mid '}},
{ timecode: 982, handler: 'blob', id: 60, data: {text: '1960’s and we have stopped at Medicaid when we assumed more responsibility for health care at the federal level and we’ve been talking about national health care for at least 50 years. '}},
{ timecode: 998, handler: 'blob', id: 61, data: {text: 'This is the arc in which our government has moved by tying these three major health care programs to a new target today, which is the subject of that newspaper article on national health care. In the '}},
{ timecode: 1016, handler: 'blob', id: 62, data: {text: 'cycle of history I\'d like to talk about this morning, there\'s really two different divisions. The first division occurs around the New Deal in the Great Depression followed by this trend '}},
{ timecode: 1030, handler: 'blob', id: 63, data: {text: 'into the Great Society in the new federalism and then in post Nixon America our health care system begins to experience a great deal of difficulty which we\'re still living with today and for '}},
{ timecode: 1045, handler: 'blob', id: 64, data: {text: 'all of your biblical scholars out there I adopted the phrase, “house of sand”, since that as it’s written, if a house is not built on a firm foundation, not gonna survive. So, those '}},
{ timecode: 1058, handler: 'blob', id: 65, data: {text: 'are the two dividing lines I\'ve chosen. What happened after President Nixon\'s time and what\'s happened since? Well, we all know about Wall Street crashes. Whatever comes around goes around'}},
{ timecode: 1072, handler: 'blob', id: 66, data: {text: 'This was not a picture taken last week, although it looks like it some respects. It’s the same building. I guess we haven’t learned our lesson. The 1929 crash. One of the things about '}},
{ timecode: 1084, handler: 'blob', id: 67, data: {text: 'American health care that’s really strange is that when things are really bad, and we have these enormous financial dislocations, an enormous budget deficit, people in Washington decide they '}},
{ timecode: 1098, handler: 'blob', id: 68, data: {text: 'need to make social progress. It’s like unless you have a disaster, you can’t address any of these issues. So, we have this disaster in 1929 that leads to the Great Depression, which if '}},
{ timecode: 1112, handler: 'blob', id: 69, data: {text: 'you’ve been to Washington D.C. this is the monument there, where one-third of the American people lost their jobs, one-half of the American people lived under the poverty line, and 60% of all '}},
{ timecode: 1130, handler: 'blob', id: 70, data: {text: 'the states and local governments in our country went bankrupt. These are some other things as you might remember, we had farm income. America was at that time still an agrarian society, suddenly '}},
{ timecode: 1146, handler: 'blob', id: 71, data: {text: 'became more urbanized. We had the collapse of Wall Street investment firms; you know they just seem to collapse at the slightest touch. We had the Dustbowl. We had the collapse of international trade '}},
{ timecode: 1158, handler: 'blob', id: 72, data: {text: 'and of course we had the collapse in the great depression of the banking system. All creating all this economic dislocation in our country and driving people into these nationwide searches for jobs. '}},
{ timecode: 1173, handler: 'blob', id: 73, data: {text: 'Now, health care and the backseat driver. This is where the federal government really gets off on addressing health care and social security. You all recognize the great Franklin Roosevelt on the '}},
{ timecode: 1189, handler: 'blob', id: 74, data: {text: 'right. When he passed away someone wrote this really cool obituary that said he was like America’s bus driver. That was supposed to make you feel good. He was like America’s bus driver. I '}},
{ timecode: 1205, handler: 'blob', id: 75, data: {text: 'like to think of him as the great community transportation provider. And here you see him driving his car and behind him as a passenger he has this troublesome woman who was well known politically as '}},
{ timecode: 1223, handler: 'blob', id: 76, data: {text: 'not helpful and her name was Eleanor. Eleanor is engaging in what she always engaged in, in the Roosevelt administration: backseat driving. And, no matter what F.D.R. tried to do for human services or '}},
{ timecode: 1223, handler: 'blob', id: 77, data: {text: 'not helpful and her name was Eleanor. Eleanor is engaging in what she always engaged in, in the Roosevelt administration, backseat driving. And, no matter what F.D.R. tried to do for human services or '}},
{ timecode: 1241, handler: 'blob', id: 78, data: {text: 'health care, it was never enough. And here you see her like some of your riders, in the backseat telling him what he needed to do. Next slide, please. And here is what he decided to do. After much '}},
{ timecode: 1257, handler: 'blob', id: 79, data: {text: 'angst, congress passed the Social Security Act, which was the foundation of Social Security, but also the foundation of our health care delivery and this is a picture of President Roosevelt at the '}},
{ timecode: 1273, handler: 'blob', id: 80, data: {text: 'time among conservative it was said that it was a picture of him signing the nation into bankruptcy. Presidents have been doing that ever since. This is what was in the Social Security Act, and these '}},
{ timecode: 1287, handler: 'blob', id: 81, data: {text: 'are title. As you know, everybody\'s got titles, Title I, and Title II. The thing I was going to point out here is that public health, Title VI, is the first time the federal government goes on '}},
{ timecode: 1299, handler: 'blob', id: 82, data: {text: 'record in saying that we must have a federal commitment to public health. Some of these other things have been with us a long time as well, including, besides that, we didn’t even have '}},
{ timecode: 1311, handler: 'blob', id: 83, data: {text: 'unemployment compensation before the new deal, so again almost every one of these titles, and I think I have some on the next page as well, let’s flip over, existed. In that German example, in '}},
{ timecode: 1329, handler: 'blob', id: 84, data: {text: 'the 1870s, in terms of other special needs, you see that the government decided in title 10, which is another interesting thing, that people who were blind needed special federal help. That in itself '}},
{ timecode: 1347, handler: 'blob', id: 85, data: {text: 'was the first effort to address anybody with disabilities in our country and providing special financial assistance under Social Security as well as job opportunities with the government. So, all of '}},
{ timecode: 1361, handler: 'blob', id: 86, data: {text: 'that came about in the Roosevelt years. President Roosevelt was succeeded by the man on the right. One of America\'s most dynamic and was once America\'s most unpopular president according to the '}},
{ timecode: 1375, handler: 'blob', id: 87, data: {text: 'polls, before President Bush fixed it, and Harry Truman was a great believer in the New Deal and he decided since he succeeded President Roosevelt, he was really going to finish the job in a couple '}},
{ timecode: 1375, handler: 'blob', id: 88, data: {text: 'polls, before President Bush fixed it, and Harry Truman was a great believer in the new deal and he decided since he succeeded President Roosevelt, he was really going to finish the job in a couple '}},
{ timecode: 1390, handler: 'blob', id: 89, data: {text: 'key areas and I think in my next slide, you’ll see that he had a program called the Fair Deal. This was in 1948. He promised Americans a “fair deal”. And as part of his “fair '}},
{ timecode: 1407, handler: 'blob', id: 90, data: {text: 'deal” there was a special piece of legislation that passed, the Employment Act of 1947 which guaranteed every American the right to a job, but he also made some efforts in the health care field '}},
{ timecode: 1421, handler: 'blob', id: 91, data: {text: 'and President Truman is really responsible for inventing the Medicare program. His idea about what Medicare was for seniors is pretty much the Medicare program that would later be enacted into law. '}},
{ timecode: 1434, handler: 'blob', id: 92, data: {text: 'And as a matter of fact, when it was signed into law, it was signed into law by President Johnson in his library out in Independence, Missouri. The other thing that Mr. Truman came up with was '}},
{ timecode: 1447, handler: 'blob', id: 93, data: {text: 'hospital insurance, which becomes, I think the first noted effort about health insurance in our country for people who were not elderly, and at that time there was a great deal of problem in helping '}},
{ timecode: 1464, handler: 'blob', id: 94, data: {text: 'people finance their trip to the hospital. Not so much their doctor visits, this would have been for middle class and low income Americans, just for hospital insurance. Truman also engaged in a great '}},
{ timecode: 1481, handler: 'blob', id: 95, data: {text: 'deal of public works and made a bunch of financing programs available to expand the number of public hospitals and public works as building public hospitals. Interestingly, that was tied up to another '}},
{ timecode: 1494, handler: 'blob', id: 96, data: {text: 'kind of Bismarck idea, which was that there needed to be a larger number of hospitals in the United States because we were facing a serious threat from overseas and they had decided in the Truman '}},
{ timecode: 1506, handler: 'blob', id: 97, data: {text: 'years, which are the years that America still had a preponderance of nuclear weapons that the government should build more hospitals in our country just in case we needed to take the wounded of a '}},
{ timecode: 1518, handler: 'blob', id: 98, data: {text: 'nuclear war someplace to fix. So, he did all of those issues. After him, of course, President Eisenhower was, you know, kind of, “You know I’m not here to make any major changes.” '}},
{ timecode: 1530, handler: 'blob', id: 99, data: {text: 'These two guys were running for president in 1960 for awhile. The gentleman in the back who looks concerned is President Kennedy and he had major issues in health care and of course the other '}},
{ timecode: 1544, handler: 'blob', id: 100, data: {text: 'gentleman is of course my favorite president of all time, the very restrained and quiet and unassuming Lyndon B. Johnson, who you can see in the picture that in a campaign rally, Mr. Kennedy is '}},
{ timecode: 1559, handler: 'blob', id: 101, data: {text: 'working very hard to restrain him. President Kennedy, as you know, was assassinated and then there was no one left to restrain President Johnson. Let’s go to the next one. Lyndon decided that '}},
{ timecode: 1578, handler: 'blob', id: 102, data: {text: 'America needed to be made over and the new deal needed to be finished. And he had this lovely portrait in his office of F.D.R. over the fireplace and you know it was said that President Johnson used '}},
{ timecode: 1589, handler: 'blob', id: 103, data: {text: 'to talk to pictures in the White House and that during the war he would go and talk to the picture of Woodrow Wilson, you know, and I’m not exactly sure what he would say to him, but he would '}},
{ timecode: 1600, handler: 'blob', id: 104, data: {text: 'stop by the F.D.R. picture, they say, everyday, and he would say, “I’m workin’ on it, I’m workin’ on it, I’m working’ on it.” Every single day. And, so '}},
{ timecode: 1609, handler: 'blob', id: 105, data: {text: 'his idea of working on it was to create the periphery of government programs that we knew as the Great Society, and some of them are listed here. The two most important programs, well maybe the three '}},
{ timecode: 1623, handler: 'blob', id: 106, data: {text: 'most important programs, for our concern in that he was the father of the urban mass transit program, which eventually led to federal financial assistance in transportation. But, he was the father of '}},
{ timecode: 1634, handler: 'blob', id: 107, data: {text: 'both Medicare and Medicaid. The two biggest programs that affect the health care services that we deliver. How did this come about? President Kennedy, before he died, campaigned heavily on health care '}},
{ timecode: 1653, handler: 'blob', id: 108, data: {text: 'insurance for the elderly which was then called hospital insurance for seniors. Pretty much like the Truman program. And, for proposing this we probably forget in hindsight based on the books that '}},
{ timecode: 1670, handler: 'blob', id: 109, data: {text: 'were written. But, that was not very popular with the American people. And it was certainly not very popular with physicians in this country or the American Medical Association who engaged in these '}},
{ timecode: 1684, handler: 'blob', id: 110, data: {text: 'huge political advertising buys, which we’ll see later again, to condemn Medicare because the government will be taking over your health care. I know, it’s shocking, shocking. So President '}},
{ timecode: 1701, handler: 'blob', id: 111, data: {text: 'Kennedy wasn’t able to move that process further. Lyndon came around, what do I have on my next slide? Oh, let’s go back one; we’ll come back to him. Lyndon came around and, you '}},
{ timecode: 1714, handler: 'blob', id: 112, data: {text: 'know, he decided to capitalize on President Kennedy’s passing and made a big issue of passing civil rights legislation and Medicare and Medicaid and he got Medicare passed. But, the real reason '}},
{ timecode: 1728, handler: 'blob', id: 113, data: {text: 'he got Medicare passed really wasn’t so much the sympathy vote, he visited with the AMA and some doctors and he said, “You know, I think you guys are right. This idea about having health '}},
{ timecode: 1743, handler: 'blob', id: 114, data: {text: 'care for hospitals, it isn’t fair. We should pay you too.” Suddenly, the opposition said, “Excuse me, Mr. President. What did you say?” “Well, I don’t think '}},
{ timecode: 1754, handler: 'blob', id: 115, data: {text: 'it’s fair that we should just pay for hospitals, we should pay doctors too. How do you feel about supporting that?” And of course, Medicare passed about 2 weeks later. As was his style. '}},
{ timecode: 1770, handler: 'blob', id: 116, data: {text: 'That took care of the beginnings of our senior issues. But, at the same time there was also a tremendous situation going on in our states for health care for elderly people and for poor people. If you '}},
{ timecode: 1788, handler: 'blob', id: 117, data: {text: 'are old enough to remember that before Medicare, states had the financial liability for older citizens in their states who did not have health insurance and did not have nursing home insurance. And '}},
{ timecode: 1808, handler: 'blob', id: 118, data: {text: 'during that period of the 60s, the cost of those services was moving up leaps and bounds. A group of governors came to President Johnson and said, “Oh, Mr. President. Now, that you’ve '}},
{ timecode: 1823, handler: 'blob', id: 119, data: {text: 'solved that problem, I need you to help me with my state financial problems with the old people, is what they referred to, and the poor folks because I can’t afford their health care '}},
{ timecode: 1836, handler: 'blob', id: 120, data: {text: 'anymore." But, Lyndon by then was having a great deal of financial trouble himself because he was trying to finance the Great Society, give everybody a tax cut, and plus pay for the war in '}},
{ timecode: 1853, handler: 'blob', id: 121, data: {text: 'Vietnam all at the same time. Didn’t work out so well for him either. So, he drove a harder bargain with the states, which is that, “Look. I can’t afford to take on all of these '}},
{ timecode: 1870, handler: 'blob', id: 122, data: {text: 'financial responsibilities at the federal level today. But, in a couple of years after I win the war, we’re going to be able to do that, so for now let’s just do something temporary. '}},
{ timecode: 1887, handler: 'blob', id: 123, data: {text: 'Let’s just create a medical assistance program, and that’s just going to be temporary until I can pay for the whole thing in two years and we’ll call that Medicaid.” That was '}},
{ timecode: 1900, handler: 'blob', id: 124, data: {text: 'in 1966. Okay? So, let’s see ’66 was at least 42 years ago, right? Forty-three. Forty-three years later the federal government is actually paying 100% of the cost of Medicaid for the '}},
{ timecode: 1920, handler: 'blob', id: 125, data: {text: 'states during the stimulus program, but that two years lasted a long time. Consequently, in that period as well costs for health care services began to go up. And then the end of the cycle that saw us '}},
{ timecode: 1936, handler: 'blob', id: 126, data: {text: 'starting without anything and moving from about 1936 to about 1968 this tremendous growth in the federal role of health care, the tremendous growth of the federal partnership with the states to help '}},
{ timecode: 1959, handler: 'blob', id: 127, data: {text: 'pay for it, and all of that came up upon this man, who became President. The famous Richard M. Nixon who became our President in the 1968 election. I think, do I have a slide on Nixon next? '}},
{ timecode: 1980, handler: 'blob', id: 128, data: {text: 'Let’s just go ahead. Yes. You know, the real author of the new federalism. Let’s go back to President Nixon. President Nixon is one of those colorful characters in history that has so many '}},
{ timecode: 1993, handler: 'blob', id: 129, data: {text: 'personalities that he defies imagination. He was supposed to be a conservative. I’ve never really been sure about how that happened, but he was by no stretch of the imagination a conservative '}},
{ timecode: 2008, handler: 'blob', id: 130, data: {text: 'when it came to health care at all. It was very unlike all the other things that he talked about. Let’s go to the next slide. President Nixon had quite the colorful history, and it does turn out '}},
{ timecode: 2020, handler: 'blob', id: 131, data: {text: 'that many of our presidents who have taken leadership in health care, who haven’t had a backseat driver, have had some personal connection with it. President Nixon, when he was born, was raised '}},
{ timecode: 2034, handler: 'blob', id: 132, data: {text: 'in a very low income family in California. His younger brother died, I believe of tuberculosis. His mother and father and him and his other brothers and sisters cared for that child in their family '}},
{ timecode: 2053, handler: 'blob', id: 133, data: {text: 'home until he passed away. And when it came to issues of doctors and medical care, it seemed to have colored his perception about the federal role in health care and he would often go out on the '}},
{ timecode: 2066, handler: 'blob', id: 134, data: {text: 'campaign trail vigorously criticizing the New Deal and vigorously criticizing liberal things, but he came up with some very strange things as president that he proposed to Congress. Patrick Daniel '}},
{ timecode: 2080, handler: 'blob', id: 135, data: {text: 'Moynihan, who was a democratic senator from New York had his first job, he was a very liberal senator, working for President Nixon on health care and welfare reform. Nixon came up with the guaranteed '}},
{ timecode: 2095, handler: 'blob', id: 136, data: {text: 'national income. That no one in the United States in 1970 should ever have less, and this was based on the times I suppose, $3600 a year as income, whether they were poor, whether they were working '}},
{ timecode: 2115, handler: 'blob', id: 137, data: {text: 'poor, that everybody would have an income of that amount, it would never drop below it. And, in addition to that, there would be a subsidy program created to pay for health insurance for all '}},
{ timecode: 2127, handler: 'blob', id: 138, data: {text: 'Americans, not poor Americans, not middle class Americans, but like social security, all Americans. One of those proposals was that 50% of the health care premiums in the country would be provided by '}},
{ timecode: 2141, handler: 'blob', id: 139, data: {text: 'federal assistance. That was some of his conservative ideas. Let’s go on. So, I call that the triad. The three cornerstones of Nixon’s program, which we are living with today, was that '}},
{ timecode: 2158, handler: 'blob', id: 140, data: {text: 'Medicare would be the federal payer of almost all the health care for the elderly, that existed at that time, and that the states would be handling poor people and seniors who needed special help, and '}},
{ timecode: 2174, handler: 'blob', id: 141, data: {text: 'that has his subsidized theory of insurance would make it possible for the insurance industry of the United States to take care of everybody else. The problem, according to President Nixon would be '}},
{ timecode: 2188, handler: 'blob', id: 142, data: {text: 'solved. Kind of like Lyndon Johnson, you might remember, he was also going to solve the war in Vietnam too and seemed to have some difficulty there too, and the Nixon health care triad, as I called '}},
{ timecode: 2201, handler: 'blob', id: 143, data: {text: 'it, was the end game of everything that started in the New Deal that would have brought us stronger federal participation in health care, stronger state participation, and a strong private sector. The '}},
{ timecode: 2217, handler: 'blob', id: 144, data: {text: 'missing link, of course, was that the insurance industry was supposed to provide the care for American families. Gee. The private sector could not offer policies cheap enough for everyone to buy. '}},
{ timecode: 2234, handler: 'blob', id: 145, data: {text: 'Secondly, as you recall there was some difficulty in the second term of the Nixon administration and he was forced to leave office. Gerald Ford was not interested in pursuing his subsidy program for '}},
{ timecode: 2252, handler: 'blob', id: 146, data: {text: 'insurance companies because in the legacy of Watergate, it turns out that President Nixon had taken a few campaign contributions from insurance companies and that people thought well there might be a '}},
{ timecode: 2264, handler: 'blob', id: 147, data: {text: 'connection there. I’m sure there wasn’t. Next. The other missing link was, of course, people stopped dying. Health care for our seniors actually got better in a big hurry under Medicare. '}},
{ timecode: 2279, handler: 'blob', id: 148, data: {text: 'People went to the doctor more. They got better health care. They were living longer. And they needed alternative living arrangements, especially if they had some physical problem or disability and '}},
{ timecode: 2293, handler: 'blob', id: 149, data: {text: 'the nursing home institutions as we know them came up as a free market solution to fill the rising service need for seniors who could not be cared for at home. This is back in the ‘70s when '}},
{ timecode: 2309, handler: 'blob', id: 150, data: {text: 'people looked at health care a little bit differently. Medicare has never paid for nursing home care. It’s paid for rehabilitation, but not for nursing home care. So, we have the first two gaps '}},
{ timecode: 2323, handler: 'blob', id: 151, data: {text: 'coming up. This missing link for people that are requiring a different technological solution and for families to have affordable insurance. The 1980’s, while that crisis was going on, as you '}},
{ timecode: 2339, handler: 'blob', id: 152, data: {text: 'know, Congress was busy fixing the health care system by adding more things to it that nobody wanted to pay for. In the 1980s we had all of these new waivers for Medicaid, if you recall where lots of '}},
{ timecode: 2356, handler: 'blob', id: 153, data: {text: 'people that were not income eligible became eligible for Medicaid services. And we have as an offshoot of the terrible discussion in this country about the abortion situation, a huge increase in our '}},
{ timecode: 2371, handler: 'blob', id: 154, data: {text: 'commitments from Medicaid and the federal government for prenatal, natal, and postnatal care. A huge increase that was assigned to Medicaid. The other issues are, in which I call the picking up the '}},
{ timecode: 2388, handler: 'blob', id: 155, data: {text: 'five, there were other related issues in mental health, there were issues in drug treatment, there were issues in specialized care, there was, you know, a national investment in chemotherapy '}},
{ timecode: 2403, handler: 'blob', id: 156, data: {text: 'treatment. All these other things are part of my five, which were also responsible for a great deal of financial increase in what we were paying out in Medicare and Medicaid and in federal '}},
{ timecode: 2415, handler: 'blob', id: 157, data: {text: 'appropriations, but we didn’t raise any revenue for them. And, even though they began in the 1980s, they have been growing ever since. Back to the insurance companies. All of you who actually '}},
{ timecode: 2434, handler: 'blob', id: 158, data: {text: 'are working somewhere where you buy insurance for your employees or are an employee trying to buy your insurance for family members know that it’s getting more and more expensive. Now, some '}},
{ timecode: 2450, handler: 'blob', id: 159, data: {text: 'people believe in markets and some people don’t, but there is a market here and the market is getting smaller because even before AIG had its insurance problems, insurance companies have been '}},
{ timecode: 2462, handler: 'blob', id: 160, data: {text: 'leaving the insurance market for health care by leaps and bounds. You have less people in there writing insurance; consequently the price keeps going up higher and higher. There’s no way that a '}},
{ timecode: 2479, handler: 'blob', id: 161, data: {text: 'shrinking market of providers helps the consumer. So, as long as insurance companies are going out of business there is no solution for the rest of the people in the insurance world that’s '}},
{ timecode: 2496, handler: 'blob', id: 162, data: {text: 'financially reasonable. Which is why you have so much difficulty when you go and buy insurance. Well, this is another great German transportation thinker, Albert Einstein, one of the favorite people '}},
{ timecode: 2511, handler: 'blob', id: 163, data: {text: 'in our office in Washington. Because Einstein had this little saying that, “You know, if you keep doing the same thing over and over again, why do you expect a different outcome?” And, it '}},
{ timecode: 2523, handler: 'blob', id: 164, data: {text: 'seems that up to this time we never faced the responsibility of paying for the health care that we\'re generating and we keep adding to it. And then once a year, like two weeks ago, someone comes '}},
{ timecode: 2538, handler: 'blob', id: 165, data: {text: 'on TV. and says, "Gee, the Medicare trust fund is running out of money". Or the states can no longer afford to provide Medicaid. Of course in Medicare we provided a huge prescription drug '}},
{ timecode: 2552, handler: 'blob', id: 166, data: {text: 'benefit. A good idea. There’s now more Americans eligible for Medicare than any time in the nation’s history, so gee if we don’t put any money in obviously we’re going to have '}},
{ timecode: 2563, handler: 'blob', id: 167, data: {text: 'a hole here. What are the results? Back to that U-235: and explosion. Obviously, let\'s go to the next one, we can\'t make it right. Why? Demographic changes in our country really do matter. '}},
{ timecode: 2583, handler: 'blob', id: 168, data: {text: 'More people are eligible for subsidized health care; more people are eligible for Medicare than any time in the nation’s history because mathematically the country is getting older. I know, this '}},
{ timecode: 2597, handler: 'blob', id: 169, data: {text: 'is a real Einsteinian principle at play here that requires deep thinking. If the American people, when Medicare started had 20% of the people in the country over 65 and eligible, one would assume that '}},
{ timecode: 2614, handler: 'blob', id: 170, data: {text: 'when 40% of the people in America are over 65 the number of people eligible would go up. And, that to pay for twice as many people it would actually cost more money. Now, you may not believe this, but '}},
{ timecode: 2633, handler: 'blob', id: 171, data: {text: 'I encourage you to watch C-SPAN when you have a chance. Anytime somebody\'s talking about Medicare and they say, "We need to return the expenditure level back to what it was in the '}},
{ timecode: 2633, handler: 'blob', id: 172, data: {text: 'I encourage you to watch C-span when you have a chance. Anytime somebody’s talking about Medicare and they say, “We need to return the expenditure level back to what it was in the '}},
{ timecode: 2645, handler: 'blob', id: 173, data: {text: '‘60s and ‘70s. I don’t know what happens to all the other elderly people who came along or how their care suddenly becomes cheaper. But, again back to my fantasy versus reality. The '}},
{ timecode: 2658, handler: 'blob', id: 174, data: {text: 'reality here isn’t created by runaway spending. It’s created by runaway population growth and the fact that no one ever assumed when they wrote this law that we would all live as long as '}},
{ timecode: 2672, handler: 'blob', id: 175, data: {text: 'we do. Additionally, we have had as a major effort in trying to save health care, what we call de-institutionalization. There was a huge hand show here a minute ago about dialysis. Do we remember that '}},
{ timecode: 2688, handler: 'blob', id: 176, data: {text: 'originally dialysis was done in a hospital? And early dialysis meant you went there for three days. And you stayed there and then you went home. I always like to talk about the old broken leg or the '}},
{ timecode: 2703, handler: 'blob', id: 177, data: {text: 'heart operation. If you had a broken leg you went to the hospital for a week. Now, you go 15 minutes. You go for chemotherapy. You used to be in a hospital for a month. You go for brain surgery, you '}},
{ timecode: 2714, handler: 'blob', id: 178, data: {text: 'can be out the same day. Nobody stays in health care institutions. Besides that, we decided that the way we warehoused elderly people in nursing homes, people with disabilities, people with mental '}},
{ timecode: 2729, handler: 'blob', id: 179, data: {text: 'disabilities in these government institutions was not legal in the United States. So, we’ve been exploring health care options that take people out of those institutions. But, like a lot of '}},
{ timecode: 2742, handler: 'blob', id: 180, data: {text: 'other things that the government does, no offense, we never really actually figured out how to pay for them, but we felt good because they weren’t in the facilities anymore and they’re '}},
{ timecode: 2752, handler: 'blob', id: 181, data: {text: 'a part of the issue we have to address. The insurance industry as we know it today is the bankruptcy of General Motors. One would have never thought that we would see the day General Motors would '}},
{ timecode: 2765, handler: 'blob', id: 182, data: {text: 'disappear. Believe it or not, there have been little General Motors disasters going on everyday in this country in the insurance industry. It is disappearing before our eyes. Unless we come up with '}},
{ timecode: 2776, handler: 'blob', id: 183, data: {text: 'some new alternatives we will not have that as part of it. And then, of course because the price of health care is so expensive, the government also engages on knocking down the fees that are paid to '}},
{ timecode: 2789, handler: 'blob', id: 184, data: {text: 'health care providers. All of you who are in direct health care probably know that you submit your bill, it costs you 50 bucks to provide the service and you’re lucky to get 35%. Gee. If '}},
{ timecode: 2802, handler: 'blob', id: 185, data: {text: 'you’re in the transit business, feel good. You’re being treated like a doctor and a nursing home. We expect you to provide this service and give us a big discount too. We had a big '}},
{ timecode: 2813, handler: 'blob', id: 186, data: {text: 'argument about this about a year ago with CMS, my favorite people in Washington. They live and work, is there anybody from CMS here? They live and work in a building in Baltimore that should be open '}},
{ timecode: 2826, handler: 'blob', id: 187, data: {text: 'for tours. It looks like a palace. It looks like an insurance company. It’s got all this marble in it and these fine woods. It’s just amazing to see what a nice building it is. We had a '}},
{ timecode: 2838, handler: 'blob', id: 188, data: {text: 'conversation with them about transportation two years ago and we went in there to visit them and said, "You know, you know transportation\'s costing more than this. We\'re saving you guys a lot '}},
{ timecode: 2849, handler: 'blob', id: 189, data: {text: 'of money because the nonemergency transportation is so much cheaper than an ambulance." And this person who was there said, "Oh really? What would you like us to pay?" I said, '}},
{ timecode: 2859, handler: 'blob', id: 190, data: {text: '“Well, don’t you think you ought to pay what it costs?” And they said, “Well, let’s see. Yes. Let’s compare that to what else we do. Huh, we don’t pay the '}},
{ timecode: 2867, handler: 'blob', id: 191, data: {text: 'full cost for a heart transplant, maybe about 25%. We haven’t paid the real cost of a hospital bill or a hospital room in 35 years. We don’t pay anywhere near the real cost of prescription '}},
{ timecode: 2881, handler: 'blob', id: 192, data: {text: 'drugs. As a matter of fact, we only pay what we want to pay. Why would we want to pay you more?” I tried, “Hey, we’re really nice people. We’re really good folks. A lot of us '}},
{ timecode: 2894, handler: 'blob', id: 193, data: {text: 'are non-profit.” And they said, “Well, they always charge too much anyway.” So, alas, we’re stuck with this system that does not want to pay us or you, or a doctor, or a '}},
{ timecode: 2907, handler: 'blob', id: 194, data: {text: 'pharmacy what it actually costs to provide the service. Next. Ahhh 1992, anybody old enough to remember that? A Bill Clinton quote, “I know a mess when I see one”. And believe it or not in '}},
{ timecode: 2924, handler: 'blob', id: 195, data: {text: '1992 he and the first President Bush were running around the country saying that this was an election on health care. Right? Does anybody remember that but me? I know a lot’s happened. Yes. '}},
{ timecode: 2936, handler: 'blob', id: 196, data: {text: 'Good. I see one person who remembers the 1992 election. Your Social Security and Medicare check will be here in five minutes. That was the issue. Health care. And, we were promised health care reform. '}},
{ timecode: 2949, handler: 'blob', id: 197, data: {text: 'Right? And the next two people promised to give it to us. Right? Who remembers Hillary care? Who remembers the Hillary Bill Show? Who remembers all that stuff about the government\'s going to take '}},
{ timecode: 2963, handler: 'blob', id: 198, data: {text: 'over your medical program. The government will pick your doctor. The government will pick your insurance company, and all of that stuff. And that will bankrupt the nation. Hmm?? Shades of the 1930s. '}},
{ timecode: 2975, handler: 'blob', id: 199, data: {text: 'Well, Bill and Hilary were not able to get their health care reform passed because guess what? One of my favorite reasons was, the health care systems is so complicated in this country, by the time '}},
{ timecode: 2989, handler: 'blob', id: 200, data: {text: 'they got done explaining what it was eight years had passed. That\'s about the best spin you could give to the Clinton health care plan. The Clintons did give us some things though which '}},
{ timecode: 3001, handler: 'blob', id: 201, data: {text: 'are on the next slide. We had the collapse of the Big Fix of course because we didn’t have the insurance industry. What did the Clinton administration do in regard to trying to do something in '}},
{ timecode: 3014, handler: 'blob', id: 202, data: {text: 'health care? It gave out more waivers for Medicaid, to make more people eligible. It didn’t provide any new money. And, it invented the CHIPS Program. I mean, seriously. What country in the '}},
{ timecode: 3028, handler: 'blob', id: 203, data: {text: 'world, a leader such as ours should not have guaranteed health care for poor children? I mean, it’s just crazy, right? I mean, it’s America. So, they invented that. But, then they decided '}},
{ timecode: 3039, handler: 'blob', id: 204, data: {text: 'to fund it. And they worked really hard looking for money for it. And where did they find the money to pay for CHIPS? And they didn’t find it in China and they didn’t print it. We’re '}},
{ timecode: 3050, handler: 'blob', id: 205, data: {text: 'coming to that. Where did they find the money for CHIPS? No one. Who used to be a smoker in here? The cigarette tax, if you recall, went way up to pay for CHIPS, and that worked well for the first '}},
{ timecode: 3067, handler: 'blob', id: 206, data: {text: 'couple of years and then what happened? People quit smoking, and geez it’s like the gas tax in transit. There’s not enough revenue. So, what did they do? They charged it to Medicaid. Next. '}},
{ timecode: 3081, handler: 'blob', id: 207, data: {text: 'Ahhh, President Bush. There’s a true visionary when it came to health care. Fellow Texans who I am, there was a bold dynamic leader if I ever saw one. Next slide. President Bush gave us, '}},
{ timecode: 3104, handler: 'blob', id: 208, data: {text: 'President Bush gave us the biggest expansion of Medicare since 1966. He rescued the seniors with drug related financial problems, but couldn’t go as far as he and Congress wanted to because they '}},
{ timecode: 3127, handler: 'blob', id: 209, data: {text: 'did not want to raise the Medicare premium. So, instead of getting a real drug bill, we got the famous donut, which is that thing that they used to show on the charts where you paid in this thing and '}},
{ timecode: 3143, handler: 'blob', id: 210, data: {text: 'then you went to this hole, and then you went over there and bottom line is, we’ll help you with the first 250, you’re stuck after that, but if you go past 5,000 we’ll help you. A '}},
{ timecode: 3154, handler: 'blob', id: 211, data: {text: 'major improvement and a major need because in actuality the progress in this country on drugs and treatment for illnesses with drugs can reduce in patient costs, so he should get credit for that. '}},
{ timecode: 3171, handler: 'blob', id: 212, data: {text: 'Next. Ahh, but there are things that he shouldn’t get credit for, or maybe he should get credit for, because we’ve spent a lot of time hassling with the Bush administration over these '}},
{ timecode: 3182, handler: 'blob', id: 213, data: {text: 'three issues in health care that affected transportation. One, was the Deficit Reduction Act. Congress, which was at the time worried about the deficit. I mean, because the deficit that year was like '}},
{ timecode: 3196, handler: 'blob', id: 214, data: {text: '100 billion dollars as opposed to, who knows what the deficit is today? Does the number 1.9 trillion strike you as right? They were in a panic over the 100 billion dollar deficit, so they passed the '}},
{ timecode: 3209, handler: 'blob', id: 215, data: {text: 'Deficit Reduction Act and 70% of the cost savings in the Deficit Reduction Act were going to come from two places, Medicare and Medicaid. That was hard to do when you had increased the eligibility for '}},
{ timecode: 3229, handler: 'blob', id: 216, data: {text: 'Medicaid and a bit fantastic when you consider that you just gave every American a drug bill, who was a senior. So, the administration proposed eliminating some Medicaid programs instead, including '}},
{ timecode: 3244, handler: 'blob', id: 217, data: {text: 'the Medical Transportation Program because there was no need for that because in private insurance if you actually could find any, they don’t pay for transportation. We worked, Dave’s '}},
{ timecode: 3257, handler: 'blob', id: 218, data: {text: 'here, Valerie’s here, a couple of other people are hanging around here, we worked really hard to change that in the Deficit Reduction Act and get that idea to terminate the Medicaid '}},
{ timecode: 3271, handler: 'blob', id: 219, data: {text: 'Transportation Program removed. And after a long hard ugly fight, we did. It was out of the Deficit Reduction Act. But, the administration decided instead well if we don\'t get it that way, '}},
{ timecode: 3286, handler: 'blob', id: 220, data: {text: 'we’ll just make up some new rules about transportation because we’ve got to reduce the cost or eliminate it. One of those rules was the brokerage rule, which is still in a rather, '}},
{ timecode: 3298, handler: 'blob', id: 221, data: {text: 'something we should talk about later, and secondly the proposal to allow states to adopt insurance programs of their own to be paid for by Medicaid and the only service not to be included or required '}},
{ timecode: 3313, handler: 'blob', id: 222, data: {text: 'in these benchmark plans was medical transportation because they had a new theory, the administration did that private insurance companies don’t provide medical transportation so we '}},
{ timecode: 3331, handler: 'blob', id: 223, data: {text: 'shouldn’t provide it in Medicaid. That was a brand new theory two months after it was brought up before. So, we struggled with the Bush administration. Let’s go to the next one. This is a '}},
{ timecode: 3345, handler: 'blob', id: 224, data: {text: 'little art, I just wanted to take a higher level of discussion here. We struggled with the Bush administration, but by the truth is, by the end of his administration, it is very clear that the health '}},
{ timecode: 3358, handler: 'blob', id: 225, data: {text: 'care system is totally broken, which takes us back to my story about fantasy and reality. But, I decided we should be artistic here and this is what the health care system looks like if you were '}},
{ timecode: 3370, handler: 'blob', id: 226, data: {text: 'thinking of it in terms of a mobile phone. You know, adding a little class to the discussion, don’t you think? Next. Ahh yes. Now comes Obama, and I adopted the phrase from Henry the V which is '}},
{ timecode: 3387, handler: 'blob', id: 227, data: {text: 'in the Shakespeare play where he says, “Once more into the breach”. A new president, a new administration that has to fix the health care system. How will it turn out? Do I have a clue on '}},
{ timecode: 3402, handler: 'blob', id: 228, data: {text: 'the next slide? Yes. There’s America’s greatest communicator right there. No. Who knows, right? We have to do something though. We have reached the point where we can’t just let it '}},
{ timecode: 3427, handler: 'blob', id: 229, data: {text: 'fly on autopilot. The future looks like the past. Increased demand for transportation because more health care will be outpatient. Greater distances to health care because the pricing in health care '}},
{ timecode: 3445, handler: 'blob', id: 230, data: {text: 'means that smaller institutions will continue to close and people will need more transportation. There will be a greater role in government financed health care; the continuing aging of our society '}},
{ timecode: 3462, handler: 'blob', id: 231, data: {text: 'makes it impossible to think about health care solutions without transportation. So, we have a blank here. I’m going to cover a short version of medical transportation, but I’m going to '}},
{ timecode: 3475, handler: 'blob', id: 232, data: {text: 'stop right now and say, I’m open to a couple criticisms or questions, criticisms if you dare, of my vision of how we got into this mess. So, who wants to take me on? I see Sorel’s back '}},
{ timecode: 3489, handler: 'blob', id: 233, data: {text: 'there. What about you Sorel? That\'s enough out of him. Who\'s next? No. Hold it, hold it. We\'re getting you a mic, John, you want to be heard. JOHN SOREL: While in principle, I '}},
{ timecode: 3504, handler: 'blob', id: 234, data: {text: 'don\'t disagree with much of what you have said. DALE MARSICO: Thank you very much, John. Who else has a question? JOHN SOREL: However. DALE MARSICO: Oh, I knew that. JOHN SOREL: What I\'ve '}},
{ timecode: 3513, handler: 'blob', id: 235, data: {text: 'found ominously missing was any discussion of tort reform and the litigious nature of society and the impact that has on the insurance industry which then has a cascading effect on the provision of '}},
{ timecode: 3529, handler: 'blob', id: 236, data: {text: 'health care. And unless, as Shakespeare Bill the Barber said, kill the lawyers, we ain\'t gonna fix this. DALE MARSICO: Well, despite what you might think, I did not get as much time here as I wanted. '}},
{ timecode: 3545, handler: 'blob', id: 237, data: {text: 'And you’re right. There is a relationship between litigation here and that’s an entire session of its own. It’s a good comment and if I wouldn’t have been limited so much I '}},
{ timecode: 3561, handler: 'blob', id: 238, data: {text: 'would’ve brought it up. Next? Oh, how about you, the lady that was kind enough to volunteer that she could remember things like I did. AUDIENCE MEMBER: Well, actually it was fascinating, I was '}},
{ timecode: 3575, handler: 'blob', id: 239, data: {text: 'at a community wellness conference two years ago in our little town, and we had a national speaker who was putting on a chart the rise of the cost of health insurance in our country and there was this blip in about '}},
{ timecode: 3587, handler: 'blob', id: 240, data: {text: '1993, \'94 where it actually went down and stayed stable for a couple of years and then kept going back up. He says, "Anybody know what this blip was?" And I went, "That was the Hillary '}},
{ timecode: 3594, handler: 'blob', id: 241, data: {text: 'Clinton effect." Insurance companies actually gave us rates. I actually would like to respond to the fact that in addition to tort litigation, we want to make sure that we remember that the insurance '}},
{ timecode: 3605, handler: 'blob', id: 242, data: {text: 'companies have a couple of things going on, which is they spend over 60% of the money that they spend in tort litigation resisting paying claims and defending those claims. They, in fact themselves '}},
{ timecode: 3618, handler: 'blob', id: 243, data: {text: 'are a great part of the system and so are their lawyers. The other positive thing with health insurance is that unlike many other publicly regulated utilities or things we think the public needs, such '}},
{ timecode: 3628, handler: 'blob', id: 244, data: {text: 'as electricity or natural gas in your area, where companies are regulated as to the amount of profit they make. So, if they make a reasonable profit versus any amount of profit or they take their '}},
{ timecode: 3640, handler: 'blob', id: 245, data: {text: 'profit and they speculate in the market and lose money and then have to make it up in health insurance premiums, health insurance is a totally unregulated market, very limited regulation by the Feds '}},
{ timecode: 3651, handler: 'blob', id: 246, data: {text: 'and pretty weak regulation by most states. So, we have to look at the litigiousness, but we also have to look at when we were younger insurance companies were staid, conservative kinds of '}},
{ timecode: 3662, handler: 'blob', id: 247, data: {text: 'organizations. They didn’t go put their money in the stock market, they put their money in conservative things and now we’ve gone through 20 years or so, maybe 30, where insurance '}},
{ timecode: 3671, handler: 'blob', id: 248, data: {text: 'companies are speculators. So, we have to look at both sides of this equation. Thanks. DALE MARSICO: Yes, I remember when actually banks, you actually knew who wrote your mortgage too, so we’ll '}},
{ timecode: 3682, handler: 'blob', id: 249, data: {text: 'have to get together and discuss old times. Absolutely. Santo, you have your hand up. SANTO: I was just wondering, if Obama tries to take on health care reform and he has the support of the Senate, '}},
{ timecode: 3700, handler: 'blob', id: 250, data: {text: 'etc. why won’t we be back in the same position that Johnson was in etc. where you’ve got wars on a couple of different fronts going on and trying to pull out health care and revise that. '}},
{ timecode: 3712, handler: 'blob', id: 251, data: {text: 'So where do you see that intersection coming in, between the wars, all the wars we’re doing and future Pakistan war etc. etc. and health care? DALE MARSICO: I actually have no good answer to '}},
{ timecode: 3726, handler: 'blob', id: 252, data: {text: 'that, except the Einstein slide. It’s hard to imagine it would be different right now. However, I think that so far we’ve seen the administration being unafraid to boldly borrow and you '}},
{ timecode: 3744, handler: 'blob', id: 253, data: {text: 'know, your guess is as good as mine. I think we’re going to have to see what comes out of their idea. I do think it‘s interesting that at the Senate and House levels there’s much '}},
{ timecode: 3756, handler: 'blob', id: 254, data: {text: 'more about how revenue will be raised to pay for this. There are some legitimate arguments, I think that need to be made that require, obviously a lot brighter minds than mine to figure out how the '}},
{ timecode: 3772, handler: 'blob', id: 255, data: {text: 'inefficiency in the system can actually be translated into less spending and I think there’s something to be said for what we heard just a second ago that we spend so much time saying, '}},
{ timecode: 3789, handler: 'blob', id: 256, data: {text: '“no” we’re using up a lot of resources like that. The administrative cost of insurance in this country and one of these congressional things was that it was 45%. So, if you were '}},
{ timecode: 3801, handler: 'blob', id: 257, data: {text: 'operating your transit business with a 45% overhead, I’m sure we could find some way to do it. But, I think all that needs to be looked at, but I don’t know how they will get that done in '}},
{ timecode: 3812, handler: 'blob', id: 258, data: {text: 'a year. So, a least I hope we get a dialogue on it and I’m hopeful that, you know, there are solutions that will come forward, but you know, kind of like the Einstein thing, I’m not sure '}},
{ timecode: 3824, handler: 'blob', id: 259, data: {text: 'yet. And if anybody actually has the solution, I’ll be around later to talk to you about a contract. Anybody else before we go one? Yes. AUDIENCE MEMBER: The answer is a single payer system. '}},
{ timecode: 3837, handler: 'blob', id: 260, data: {text: 'That’s the problem. We have, even in our industry, there’s 52 different people, we’re billing different codes, different regulations and requirements. If we had a single payer '}},
{ timecode: 3848, handler: 'blob', id: 261, data: {text: 'system, we’d take out a lot of that administrative overhead. The codes all match up. DALE MARSICO: Well, let me say yesterday if you were at the rodeo. I was the only one who knew the words to '}},
{ timecode: 3858, handler: 'blob', id: 262, data: {text: 'the Canadian National Anthem, and I sang it. So, I’m not saying that’s what my theory is, but you’re absolutely right. I mean, that issue needs to be discussed and debated as part of '}},
{ timecode: 3871, handler: 'blob', id: 263, data: {text: 'the process and needs to be identified in an honest way and I don’t know if you’ve seen many of the TV commercials lately about the Canadian system, from you know my own experience with it '}},
{ timecode: 3885, handler: 'blob', id: 264, data: {text: 'and my own readings. Like most television ads, I don’t think there’s a single thing in those that’s true, and you’re right. We need to have that discussion. Absolutely. Okay. '}},
{ timecode: 3895, handler: 'blob', id: 265, data: {text: 'Anybody else before we go on to finish up on medical transportation? I’m going to take 10 more of your minutes. I have just a few more slides. So, let me run through these fast. I did want to '}},
{ timecode: 3905, handler: 'blob', id: 266, data: {text: 'say something about medical transportation. I didn’t want to leave you without talking a little bit about medical transportation and here you see the noble medical transportation people of our '}},
{ timecode: 3918, handler: 'blob', id: 267, data: {text: 'industry out there in the snow, helping people go back and forth to the doctor, doing the Lord’s work, like they do every day. This was the first medical transportation provider in America. Who '}},
{ timecode: 3936, handler: 'blob', id: 268, data: {text: 'recognizes him? Another age question. Who is this? Doc who? Where did Doc Adams work? Dodge City! And you remember that a doctor would sometimes go out in his buggy, usually when somebody was '}},
{ timecode: 3954, handler: 'blob', id: 269, data: {text: 'expecting a baby. Remember this? And every other show he’d get on that buggy of his and go off there and then some bad guy would come into town and get shot. But, that was Doc Adams and he '}},
{ timecode: 3964, handler: 'blob', id: 270, data: {text: 'represents the idea that in health care in our country for many, many, many years doctors went to visit patients. Next. The role of mobility in health care. Going, going. The doctor used to go to you. '}},
{ timecode: 3980, handler: 'blob', id: 271, data: {text: 'Again, a little age here. I remember when the doctors actually made house calls. Does anybody else remember that besides me? Who else? Come on. The doctor actually came to your home. Can you '}},
{ timecode: 3990, handler: 'blob', id: 272, data: {text: 'imagine such a thing today? It would cost you a million dollars if you had Medicare. So, go back, go back, go back. So, the key phrase. Go back one, can you? The key phrase is “going to”. '}},
{ timecode: 4003, handler: 'blob', id: 273, data: {text: 'You know, simple things. Everybody in this country, when you ask them what they’re doing, they’re going to the doctor. They’re going to the dentist. Going to the pharmacy. '}},
{ timecode: 4012, handler: 'blob', id: 274, data: {text: 'They’re going to the lab, they’re going to the eye doctors, they’re going, going, going, going. They go to these medical facilities and it’s made it so common that it’s a '}},
{ timecode: 4022, handler: 'blob', id: 275, data: {text: 'very big part of our own language. Going to the doctor. Okay, medical transportation as we knew it. I just thought I’d put a couple of things up here, you know the early days of medical '}},
{ timecode: 4034, handler: 'blob', id: 276, data: {text: 'transportation were provided by our friends in the funeral industry, right? Who could remember that? Oh, it’s great in Texas of course when I was younger all the ambulances were privately owned '}},
{ timecode: 4045, handler: 'blob', id: 277, data: {text: 'by insurance companies and it was such an easy arrangement if you didn’t make it, they just took you to the other place. Such a simple solution. And then of course we’ve had medical '}},
{ timecode: 4058, handler: 'blob', id: 278, data: {text: 'transportation, we did a great article on the original pandemic flu and medical motor services. One of our members got started in that in the 1900s. We go to the doctor on our own. From the earliest '}},
{ timecode: 4071, handler: 'blob', id: 279, data: {text: 'days of public transit, trolleys, buses, trains, people went to the doctor and of course many people went to the doctors on taxis. That was our primary method of going back and forth to the doctor and '}},
{ timecode: 4083, handler: 'blob', id: 280, data: {text: 'today it still is. I like to call this nuclear option. I like to use this argument with Medicaid all the time. If you don’t provide nonemergency transportation, somebody gets really sick, what '}},
{ timecode: 4094, handler: 'blob', id: 281, data: {text: 'do they do? They go in an ambulance. How much is the ambulance Medicare reimbursement rate for an ambulance in this country? For a one-way trip? Jeopardy. How much is a one-way ambulance trip in most '}},
{ timecode: 4108, handler: 'blob', id: 282, data: {text: 'of the United States for Medicare today? Eleven hundred? Did I hear $1,100? Did I hear $1,100? Who said 11? Seven? Do I hear $800? Who said $800? Okay. Do I hear $1,100? Eleven hundred. Going once, '}},
{ timecode: 4129, handler: 'blob', id: 283, data: {text: 'going twice, anybody else? The average price is six to $1,300 max. One-way. Non-emergency. Not life support. And our argument, which was borne out years ago by a big study that the General Accounting Office'}},
{ timecode: 4144, handler: 'blob', id: 284, data: {text: 'office before they changed their name said that in many of our states seniors in particular were dialing 911 when they needed public transit and of course we like to do that. I have some great numbers '}},
{ timecode: 4155, handler: 'blob', id: 285, data: {text: 'one time when I found out that the average trip, in I believe it was Iowa was $7.51 and the ambulance charge was $975 at that time. I would say, well what would you choose? And they said, well we '}},
{ timecode: 4170, handler: 'blob', id: 286, data: {text: 'don\'t want to give people a choice. Oh, perfect. Next. In our time we\'ve been involved in development of new systems, Paratransit, human service transportation agencies providing a lot of '}},
{ timecode: 4183, handler: 'blob', id: 287, data: {text: 'transportation. Accessibility issues that opened up transit for other folks, the rise of rural public transportation, almost I would say a significant percentage of rural, if not more than half is '}},
{ timecode: 4199, handler: 'blob', id: 288, data: {text: 'dedicated to some form of medical transportation and in the other public transportation at least 40 to 45% of it’s going for some form of going to the doctor. Next. The rise of medical '}},
{ timecode: 4213, handler: 'blob', id: 289, data: {text: 'transportation continues again the de-institutionalization, lack of coverage for low income people means that there’s much more need for more people flowing into Medicaid. We have a continuing '}},
{ timecode: 4227, handler: 'blob', id: 290, data: {text: 'crisis on infant mortality. We have problems with vehicle affordability. So, if we were a McDonald’s prognosticator and I mean McDonald’s the hamburger guys, we would know that if we '}},
{ timecode: 4240, handler: 'blob', id: 291, data: {text: 'looked at the medical transportation business that we’re involved in, the nonemergency medical transportation business, that the growth of that market is almost unmeasurable. Next. Ahh, a word '}},
{ timecode: 4252, handler: 'blob', id: 292, data: {text: 'about Texas. It doesn’t come across very well, but that’s a take on the death star from Star Wars. I couldn’t get anything on, you know, Lord of the Rings. But, you know a word about '}},
{ timecode: 4263, handler: 'blob', id: 293, data: {text: 'Texas. Next one. Smith v. Vowell: It’s a very important court case in history because it does mandate that Medicaid in federal government have to realize that transportation is an important '}},
{ timecode: 4278, handler: 'blob', id: 294, data: {text: 'ingredient for people who are on Medicaid and that the state agency is responsible for providing transportation under Medicaid and through a variety of regulations and through a variety of court '}},
{ timecode: 4293, handler: 'blob', id: 295, data: {text: 'decisions those rules were the basis of the Medicaid program as we know it. Because one gentleman in 1972, who lived in San Antonio, Texas who had a wheelchair could not go to a doctor for his health '}},
{ timecode: 4315, handler: 'blob', id: 296, data: {text: 'care. A group of lawyers decided that what good was Medicaid or health care coverage if you couldn’t get there and even the most conservative federal jurisdictions ruled in his favor that '}},
{ timecode: 4329, handler: 'blob', id: 297, data: {text: 'Medicaid had a responsibility to provide that transportation. We’ve been wrestling in this business with that decision since 1972 trying to figure out how to do it best. We’ve tried a '}},
{ timecode: 4343, handler: 'blob', id: 298, data: {text: 'bunch of things, we’ve tried a bunch of things the same time, we’ve done the Einstein thing a half of dozen times, we’re still at it. I don’t think we need to worry that '}},
{ timecode: 4354, handler: 'blob', id: 299, data: {text: 'we’re ever going to find the right solution. We’re going to still be at this, searching for the right solution until we create a system that better allows local people to decide about what '}},
{ timecode: 4366, handler: 'blob', id: 300, data: {text: 'that system looks like. Yeah well, the results, we’ve already talked about that and of course the most important thing on this slide is the last line which is, “Medical transportation is a '}},
{ timecode: 4378, handler: 'blob', id: 301, data: {text: 'long and hard process of benefit implementation.” It is a long and hard process and quite frankly, it’s a long and hard process for you every day. It’s been a long and hard process '}},
{ timecode: 4392, handler: 'blob', id: 302, data: {text: 'from day one. One last word about the Bush years, I’d thought I’d do a little football which was the discussion of trying to block the administration’s attempts to do away with the '}},
{ timecode: 4403, handler: 'blob', id: 303, data: {text: 'medical transportation benefits and I thought that was a very symbolic picture. That’s me in the white shirt there and the CMS person is in the gold helmet, because you know that’s exactly '}},
{ timecode: 4416, handler: 'blob', id: 304, data: {text: 'how that felt. Next. Do we have anything else left? From here, where do we go? You know, I’m not going to read the slide because they’re already over there and saying that I should get '}},
{ timecode: 4425, handler: 'blob', id: 305, data: {text: 'off, but let me just say that we need more ideas. We need more experience. One of the things about the conference is we need to have more ideas. The one thing I learned about Medicaid transportation '}},
{ timecode: 4434, handler: 'blob', id: 306, data: {text: 'when I would talk to people around the country when we were trying to get some legislative things together is, there is no uniform standard for what’s medical transportation. People are doing a '}},
{ timecode: 4447, handler: 'blob', id: 307, data: {text: 'collection of what I’d like to call, the best possible best practices. There are no two medical transportation programs in this country or probably in this room that are run the same. That '}},
{ timecode: 4458, handler: 'blob', id: 308, data: {text: 'doesn’t mean they’re bad. That doesn’t mean they’re inefficient. That doesn’t mean they’re not the solution for their community. We need to figure out how in our '}},
{ timecode: 4471, handler: 'blob', id: 309, data: {text: 'legislative process we can fix the notion in the mind of Congress and the administration that we must trust you first because the people who are experts in the field really know how to do it right. '}},
{ timecode: 4486, handler: 'blob', id: 310, data: {text: 'One of my favorite legislative proposals has been to expand the concept that the federal government has called negotiated rule making, and that if we can get, and we’re still trying to pass a '}},
{ timecode: 4497, handler: 'blob', id: 311, data: {text: 'Medicaid reform bill for transportation, that would require the government before it writes rules and policies to meet with a cross section of the providers of this service to write the rules. Not on '}},
{ timecode: 4516, handler: 'blob', id: 312, data: {text: 'their own, not with some consultants, not with somebody else, but with the very people who provide the service. We will never get it right unless the people who drive and do the service help make the '}},
{ timecode: 4531, handler: 'blob', id: 313, data: {text: 'decisions. You should have applauded at that one. Next. Ohhhh, go back, go back one more big one. Foreign languages for 300, another jeopardy question. The one thing I have here study foreign '}},
{ timecode: 4548, handler: 'blob', id: 314, data: {text: 'languages and methodology. My goodness, I know that you’re up to your ears in Medicaid stuff and transportation. Medicine speaks a whole different language and we’ve been trying to work '}},
{ timecode: 4562, handler: 'blob', id: 315, data: {text: 'together with the medical industry and medical providers so we can actually talk the same language and I think progress is being made, but the most important thing about health care transportation '}},
{ timecode: 4574, handler: 'blob', id: 316, data: {text: 'it’s all very confusing. Thanks to Valerie and some of the efforts we’ve been doing, you’ll find a nice place on our website that talks about some of these terms, terminologies and '}},
{ timecode: 4585, handler: 'blob', id: 317, data: {text: 'issues, so I’d encourage you to, when you walk out of a meeting with medical providers, if you’re half as confused as I am, I mean it’s too bad that we don’t have a '}},
{ timecode: 4594, handler: 'blob', id: 318, data: {text: 'Webster’s dictionary like Dave does, a hard back on, what the heck were they talking about. So, I would urge you to pay attention to that. It’s a huge issue. And one of the barriers I '}},
{ timecode: 4604, handler: 'blob', id: 319, data: {text: 'think that come up in the other related issues of coordination is that we’re not speaking the same language to these people and they’re certainly not talking our language. And certainly '}},
{ timecode: 4614, handler: 'blob', id: 320, data: {text: 'when it comes to CMS and the medical transportation directors in some of our states, I’m not even sure that the language we’re using is from this planet, but you need to be working at '}},
{ timecode: 4626, handler: 'blob', id: 321, data: {text: 'that. And last, but not least, fear not. We have been in this circle for a long time. We have to get used to the idea and the concept that there will not be a solution to our concerns and that we will '}},
{ timecode: 4643, handler: 'blob', id: 322, data: {text: 'never have a system that does what we want to do without us having to continue to work hard on it. We can create, you know, security for the program in Washington, we can try to get regulations that '}},
{ timecode: 4659, handler: 'blob', id: 323, data: {text: 'make things best for you, but in reality it will be you that has to deliver the program yourself to meet the needs of your communities, and I think if you ask what we were fighting for, that’s '}},
{ timecode: 4673, handler: 'blob', id: 324, data: {text: 'really what it is. We want to create an assurance that the government is going to be there to help us provide the revenue for this service and to create the climate where you deliver the service you '}},
{ timecode: 4687, handler: 'blob', id: 325, data: {text: 'know is best. So, that’s all I have. I’m sorry I’ve taken more of my time I will be around the rest of the week and if anybody wants to, besides Sorel, talk to me, I’m '}},
{ timecode: 4699, handler: 'blob', id: 326, data: {text: 'available. Thank you very much and good luck with the rest of the conference.'}},
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