Public Square: Digging Deeper into Health Care Reform

Tom Silvestri, publisher: I'm real happy to have two of Virginia's best Congressmen, Bobby Scott and Eric Cantor . . . .We're going to open the Public Square with an opening presentation from Bobby Scott. Sir?

Rep. Bobby Scott: We have a problem with health care that we're trying to solve. The status quo is unsustainable. We are paying more for health care as a percentage of GDP compared to other countries. Total amount per country, per capita, we're paying more than any country on Earth, by far. But if you look at the measures of quality of health care -- infant mortality, life expectancy, and death due to preventable diseases, we're either at or near the bottom. If you have a pre-existing condition, you either can't get health insurance, or you have to pay too much to get it. If you lose your job, you lose your health insurance. Many who have insurance may be losing it. Employer-based coverage is declining. In Virginia, 68 percent of the people had insurance through their employer. It's down to 62 percent. That's just over seven years. Small businesses are giving less health insurance. There's a recent report showing that half the people in America today can expect to lose their insurance in the next 10 years. In fact, one-third of those who've had insurance for the last 12 months may lose their insurance in the next 10 years. About 14,000 people a day are losing their insurance.

We're already paying for the cost of those without insurance. When you go to the emergency room and pay, you have to pay a little extra, because many people are going to the emergency room and not paying anything. That amounts to about $1,000 a year on the average family policy. It's getting worse. Wages have increased along with inflation. But the cost of your health care has more than doubled in the last 10 years. They've also found in the last two years the number of people who have policies with a $1,000 deductible -- that's doubled. Gone from 20 to 40 percent. For small businesses providing insurance, most of them have high-deductible policies now. The cost of the average health insurance policy has risen from 7 percent of the median income in 1987. It's 17 percent of your median income now and expect it to go up to 24 percent by 2020 -- and continue in that unsustainable way.

If you look at the cost of health care in the nation -- health care is about 15, 17 percent of GDP today. But it's on a trajectory to eating up almost 50 percent of the GDP. And in fact, our budget situation, if you look at the percentage of GDP -- all government spending, Social Security -- traditionally, we've been able to make it with about 17 to 20 percent spending and taxes. We could maintain our spending and budget -- we could do that with everything except Medicare and Medicaid, which are going off the chart. If we can control Medicare and Medicaid, then our long-term budget problems will evaporate. People don't have insurance. Those with insurance are losing it. And the budget situation is out of control.

This is the solution that we have proposed. HR3200 is the bill that's pending in the House of Representatives. It provides greater coverage. Businesses, with some exceptions for small businesses, will provide health insurance for their employees, or pay a fee. Private insurance companies will not be able to discriminate based on pre-existing conditions, and individuals not covered by their employers will have to buy insurance, some with the help of affordability credits.

If you like your insurance that you have, you can keep it. The exchange -- those without insurance can go into what we're calling the exchange -- all companies that want to sell insurance will sign up for the exchange, and you will be offered choices within the exchange. It is very similar to what federal employees have today. The benefit package will include the normal package, but prevention and wellness, prescription drugs, and mental health services will be included in the basic package. If you want more than the basic package, you can get a little more, but you'll pay a little more.

Affordability -- there will be a sliding fee, affordability credits, to make sure that you will be able to afford the insurance, up to 400 percent of the poverty level. That's $88,000 for a family of four. Under 133 percent of poverty, you'll be eligible for Medicaid. There will be caps on out-of-pocket expenses, for a family after you've spent $10,000 in medical expenses, the rest is on the insurance company. People are going bankrupt today even with insurance. This will put an end to that. It lowers cost of prescription drugs by closing the doughnut hole in Medicare Part D. Competition from the exchange will hold down costs, and cost-shifting -- that $1,000 will be much less because uncompensated care will be reduced. There will be choices within the exchange. In most states, including Virginia, one company has a 50 percent market share or more. And in nine states, one company has a 70 percent market share or more. So in most states, there's not much choice. But we will guarantee choice by having a public option in the House bill.

Now, government Medicare and Medicaid have polled better than private insurance. People are more satisfied with Medicare, Medicare Advantage, and Medicaid. Medicare is well-run. About one-half of 1 percent of the Medicare dollar goes to administration. Private insurance companies are all over the map, starting at about 7 percent, up to over 25 percent or more . . . .

You get to pick whether you want the public option or the private insurance. The public option will be financed totally by premiums, will not be subsidized by taxpayer dollars. We'll also have wellness and prevention. We'll expand the community health centers. There will be a prohibition on cost-sharing for preventive services. When you go to get check-ups and immunizations, there can be no co-pay on those, and we'll have funds to help local health departments and target health disparities . . . .

To do this, there will be shared responsibility. Employers will have to either pay or play. And they'll pay 72.5 percent of an individual, or 65 percent of a family, policy. Small businesses will be exempt -- very small businesses will be exempt -- those with payrolls between $250,000 or $500,000, depending on the version of the bill. If they're small businesses, instead of an 8 percent fee, they will pay a 2 percent fee, scaled up to 8 percent. Many small businesses will be eligible for a tax credit to help them provide insurance for their employees. If you're not covered by your employer, you will have to get individual insurance -- again, through the exchange -- or pay a 2.5 percent of income fee for not having insurance. And it's deficit-neutral. It will be paid for over 10 years. And here's how we pay for it: The total cost is approximately $1 trillion over 10 years. There will be elimination of over-payments to private Medicare Advantage plans, and other improvements within the Medicare and health care system. Most of the funds -- $544 billion -- will come from a surcharge on the top 1.2 percent of individuals. That is a surcharge starting at 1 percent on that portion of your income over $350,000. And a scaled-up 5.4 percent of that portion of your income over $1 million. We'll raise $544 billion that way.

That is a lot of money, but it has to be put into perspective. Because if you look at other things we've done, the surcharge, half a trillion dollars over 10 years -- if we repeal the estate tax, it'll cost more than that. Afghanistan and Iraq cost almost $1 trillion so far. And by the end of the war, it'll cost probably 2 or 3 trillion dollars, when you count long-term disabilities. If we extend the tax cuts, they'll be about $4.5 trillion. We're looking for a half trillion dollars . . . .Obviously, within the context of what we do, and the choices we make, that is clearly affordable. And if we do it, over half a million people will gain coverage by 2013. Hundreds of thousands more in the next few years. Virginia's economy in 2007 lost billions of dollars because of poor health and shorter life spans of the uninsured. We'll increase productivity. And 123,000 businesses may be eligible for tax credits. That's the benefit of what we're doing. But the important thing to note is that the present course -- the path we're on -- is unsustainable. Too many people are losing their insurance who already have it. Many people can't get insurance. And our budget situation is not sustainable because of the increased costs in insurance.

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Rep. Eric Cantor: . . . The goal this morning is for all of us to gain a better understanding about where we are, in terms of the prospects for health care reform. You've just heard Bobby lay out, in general, the position that is being promoted by the majority in the House of Representatives. I'm hopeful I can lay out for you, in general, the position of the minority. And then, maybe we can all learn together to see how it is we get to a point where we can bridge the gap and the differences.

I want to start by agreeing with several things that Bobby said. Number one -- the current system of health care in this country is unsustainable. Both sides in Washington reject the status quo. For many reasons. And Bobby pointed out many. First, there's too many people without insurance at any given time during the year. Second, the costs associated with health care in this country are going to break the bank. It's going to break the bank for the private payers. It's going to break the bank for the government. And that's why we have got to do something to effect real health care reform. So, those are some pretty significant similarities that we both come to the table with. And that means we ought to be able to produce something to effect positive reform. Now, all of us, I believe, want to continue to maintain the quality of health care that most people have in this country. Because, remember, most people -- almost 85 percent of Americans have health care coverage. And almost 70 percent of those people in the country like their coverage.

So we do want to maintain the quality of care that most people have. We want to offer that -- provide the access to that care -- for the uninsured. And then, we want to keep us on a path of fiscal sustainability. Because, as we know, the money doesn't come from thin air . . . . We share the context of the status quo being unacceptable. We share the goals of trying to provide more access for more people, while sustaining the level of quality that most people in this country enjoy. Now, here's where we begin to differ: [LIFTS A THICK STACK OF PAPER] Bobby's got his copy, and I've got mine, all right? This is half of HR3200. [LIFTS AN EQUALLY THICK STACK] And here's the other half, right here. So, this is what you've got. And when you look through the bill, there are many areas of differences that you will hear us talk about. But fundamentally, what's behind the House Democratic approach to health care reform is really twofold.

One, it is about what you heard the president on TV yesterday talk about. It is about mandating that people have and provide for health insurance. The analogy has been given that we should require people to have health care insurance -- just like in most states we require people to have car insurance. It sounds good in concept. The problem with that is that once you mandate that people have something, especially from the federal level, you are necessarily going to bring about the question of what it is that you are mandating. How do individuals, how do businesses, comply with that mandate? Now, at the state level, that's where the car insurance is done. And currently, that's where health care mandates exist. But if you're going to mandate from Washington, you necessarily then involve federal policymakers, and the entire federal government apparatus, in that question of what it is you are mandating . . . .What we saw demonstrated in the House markups in committee was a real desire to define what acceptable health care means. And what it means would be defined by Washington. That's where we begin to differ. Because all of us want to provide access to more people. You basically do that by bringing down costs. We also want to maintain the quality that most people in this country have and enjoy. And I don't believe, nor do many in Congress believe, that you do that by having Washington define what an acceptable health care benefit is. You do that by providing an even playing field for competition to exist. So, here's where the differences really become accentuated.

What the president, and what Bobby and the Democrats in Congress are proposing, is that they believe you bring down cost by promoting competition. We believe that, too. But they believe you do that best by having the government serve as a competitor -- also known as the public option. That somehow we're going to see the government be the one setting the rules about what's an acceptable benefit plan -- and the government serving as a competitor under those rules. Now, that's where we differ. Just intuitively, I don't think that can make sense. I don't think you're going to see the sustainment of a private insurance system in this country if you have the government do so. And so once that occurs, you see then a shift of people -- there are several independent studies that have been taken -- and you will see, over a period of 10 years, 100 million people in some studies which say they'll go off of their private insurers because they won't be allowed to stay on those, given this bill. And they will go into the government plan. The larger the government plan is, the more costly it is for the government, obviously . . . . The problem is this: Neither party in Washington has demonstrated an ability to keep down costs. Neither party has. So you then enter a situation where you're going to have a very unsustainable situation, unless you take some drastic steps -- and drastic steps being some decisions being made in Washington about how care is delivered . . . .

Let me try and relate to you where I think we can start and actually accomplish some reform and bridge some differences. Number one, I believe you ought to start with three guarantees. You ought to start by saying you will not have a system where the government takes over the decision-making between a patient and his or her doctor. That can't be, because we can't have the kind of quality all of us have become used to. Number two, you can't have a government program, like I was just trying to outline, where you have that many more people in it, and the government's only way of controlling costs is by denying access to care based on any number of things. We've seen in instances in the U.K. and other systems where that care is being denied based on age or gender. You can't have that. And thirdly, you can't have a government plan that's going to break the bank. We've seen that. It will alter our way of life altogether. So, this HR3200 -- these are just some examples. In the bill, Bobby says you can -- the bill says -- you can keep your plan if you have it. Well, the devil's in the details. If you have an individual policy, if you're in that market, the bill basically says the government is going to deem what is acceptable and not in terms of individual coverage. And in fact, we'll end up saying that the kind of coverage you have won't be able to exist, because that insurer won't be able to enroll any more people once this bill goes into effect.

Medicare Advantage. In Virginia, over 133,000 seniors have chosen Medicare Advantage. And all of you who are on Medicare that may happen to be on Medicare Advantage know that you opt for that plan because it is an alternative to government care, and it is a program put in place by Congress to allow you to access private insurance. That, too, will be on the chopping block, where Bobby has indicated some of the savings will occur from Medicare cuts. A hundred and thirty-three thousand seniors will no longer have that choice.

Health savings account. Something that I've been very, very focused on. It's not the answer for everybody, but it certainly helps people have another affordable option for care. It is the health savings account, coupled with a catastrophic plan, that means no one has to be bankrupted by their health care costs. That will be outlawed by this plan . . . .

Again, these are examples of mandates where the government steps in to determine what it is that health care should be. In the middle is a health choices administration. This is where all the action will be. The agency will be opining as to what is an acceptable benefit plan for the rest of the country . . . . Here are examples of survival rates in public systems. You can see very quickly -- breast cancer, prostate. All of the five-year cancer survival for the U.S. versus the E.U., we are significantly higher on every one of those, because of what we've got in our system, versus what they have in theirs . . . .

The president represented the bill as deficit-neutral. The Congressional Budget Office says HR3200 adds $239 billion to the deficit over the first 10 years . . . . There are universal access program proposals on both sides of the aisle. We ought to be able to get that done. And lastly, meaningful medical liability reform. It is time for us -- and this is coming as a lawyer -- time for us to get the lawyers out of the business of frivolous litigation, and allow for health care costs to stabilize.

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Marlise Skinner, Richmond: I'm a registered nurse. I think I bring a unique perspective to this debate, in that I have worked for Blue Cross Blue Shield. I have also spent 11 years in MCV's ER as a charge nurse, and I have also worked in the hospitals, being the one that calls the insurance companies to request the authorizations and beg for the insurance companies to pay. That being said, controlling the cost of health care seems to be the No. 1 issue. And I'm not quite sure how you control the cost of health care, with the exchange system, which seems to be somewhat flawed, or the Republican system, which I don't get at all. I don't see where the cost savings are coming in at all . . . .The public option seems to be the best that's out there so far. What is the alternative out there that would truly control costs? Because I'm hearing a lot of spin, but I'm not really hearing, what are you going do to control it?

Cantor: The best way to control cost is competition. We both agree on that . . . .One side says the public option is the way to reach competition. The other side says, no, you don't have government setting the rules and playing by it and expect there to be competition. It can't happen. That's the underlying essence of the Republican position. You can't. It's counterintuitive to think that.

Skinner: But it would also seem to be counterintuitive to think that the insurance companies are suddenly going to start policing themselves, and maintaining controls. I don't see where you're getting that.

Cantor: We want competition, real competition. There are various ways. When you say you were in charge of trying to go get insurance sign-off, and those insurance companies have to watch what they're doing, because they want to insure their shareholders their profits, etc. -- what should be driving their decision is competition. What should be making them think, when they deny someone the coverage, is the fact that they may lose more business because there's other insurance companies, other offerings out there, competing with them.

Skinner: But that's not happening. So, how do you drive it?

Cantor: How we drive that is not to bring in the government. If you've got a state like Virginia, and this area, where you've got significant penetration by one majority carrier, you ought to have more. We ought to have the ability to go in, and as a Virginian, I should be able to purchase in North Carolina. We should be putting in place incentives. We should be at the federal level saying to a state, "Look, if you don't have real competition, we're going to say: Open up your markets." We should put in place incentives for states to have compacts with one another. That is something both of us could agree on. We could say, "OK, regulators in Virginia. Look at what North Carolina does. What's wrong with what they do? The reason why their prices are lower is because their mandate situation is different."

You can go in as an individual right now, and I think it's $192 cheaper in North Carolina, on average, than it is for Virginia. We ought to be able to go and take advantage of that. We ought to be providing those kinds of competitive forces. The government's not going to provide you a competitive force.

Scott: I think this is an important question, because the thrust of your question highlights the fact that Eric and I agree on 80 percent. Unfortunately, you can't do the 80 percent without some of the 20 percent. And that's where the rub is. When you say we all like competition, but what is the driving force? The driving force is the public option. It's there for a purpose. It's there to create the competition, where in most states, as Eric has pointed out, there is no competition.

Now, the public option, like Medicare -- we expect to be able to run on an administrative expense of about half a percent. Which means it'll be very competitive. We don't tell the private insurance companies how to reduce their costs. But when they have to compete, or lose business to the public option, they will do everything they can to get their costs under control. That is, as you have suggested, the driving force. They've got to compete. The idea of going across state lines -- how are you going guarantee quality and accountability? . . . The idea of going across state lines is OK, if you have the national standards, national regulations, and still it may not work. And if you ask physicians whether or not they want to have their staff trained to do two or three insurance forms or 1,500, I think the public option starts looking a lot better.

Eileen Davis, Richmond: I was in nursing school in 1973, when Richard Nixon stated he wanted to revamp our health care system. . . . Nixon's plan included the ability to join Medicare. That is, and still is, the public option. So, what happened? Well, . . . the Dems, led by Ted Kennedy, were pushing for a single-payer coverage. Neither had the votes. It died. I remember being shocked back then it didn't happen. Because then, even then, the chaos, the confusing paperwork, the patchwork of coverage, and the time wasted away from the providers that my prior sister nurse described, was cumbersome, and impacted care. It really impacted care. And it does more even today. Well, fast-forward 36 years. And despite another 20-year attempt in '93, we are in an even more chaotic mess. . . . Gentlemen, I'm asking you. Will you commit to real reform, with a centrist approach? It cannot be another incremental effort that will quell this debate.

Ben Ragsdale, Richmond: Bobby, I'm glad that Congressman Cantor showed the bill. It shows that a number of you have been working very seriously for a long time. You've been listening to people, you've been finding solutions to our problems, and I appreciate it. On the other hand, I heard from the congressman very little in the way of substance. I heard a lot of negativity, a lot of things that he's against. I heard one or two specifics about liability reform, so forth. We've heard that. He has a little four-page position paper on his Web site. He mentioned, just buried in his remarks, that Republicans have the goal of expanding access. That's the core of this. Are people going to get the care they need? Are people going to be cut off from care? Are the uninsured going have the opportunity to buy affordable coverage? I want to know, congressman, what is your substantive proposal to meet these real, everyday problems that people have? Where's the beef?

Cantor: About your sense that we need to just have the Medicare option for everyone. The problem with that -- . . . it's economically unsustainable. Part of the reason it's unsustainable is the cost. But it's also the cost shifting that goes on. Medicare, in and of itself, is like a price-fixing mechanism. The best nurses, the best hospitals, get paid the same as the worst. Same thing with the physicians. It doesn't allow for merit-based compensation or incentives to be a better provider . . . .Medicare does not allow for that. Not to mention the fact that most providers that I speak to -- and I'm sure Bobby gets the same -- they say they couldn't support their practice if they only saw Medicare patients. Because the reimbursement rates are artificially low -- and not reflecting true practice expense. So what happens is, in a macro sense, these costs are shifted onto the private sector, where the employers are feeling the heat, as are employees -- when you see your co-pays go up, when you see your premium go up, and the share your employer requires you to pay go up . . . .

Let me try to address Mr. Ragsdale's question about where Republicans are -- and what is our program: . . . Make sure government doesn't deny the care. Let's make sure we don't break the bank . . . .We've got proposals on the table -- Republicans and Democrats alike -- that say we can create universal access programs at the state level. Let's get some federal subsidy for these high-risk individuals, and let's just make an individual market work for these high-risk people. That's how you take care of the pre-existing positions . . . .We also have other ideas on the table. We have the ability for small businesses, individuals, to have the same tax advantages that you give to corporations now. That will also expand the market, help bring down prices, increase demand. When the lady asked, how do you bring on competition, if it's not the public option? This is how you do it. You promote more ability to stay tax-free, as consumers. As patients. It's not for everybody. But if you do that, you'll have more patients out there looking for insurance. If you couple that with the requirement that states have competition -- so they look to other states -- you can see the beginnings of a market that would develop.

Scott: . . . In response to the question on pre-existing conditions. Again, that's one part of the 80 percent that we agree on. You should not be denied coverage if you have a pre-existing condition. Unfortunately, again, you can't make that work unless you go into the 20 percent. If you don't have universal coverage, the pre-existing condition problem cannot be solved. Because if people can wait to buy insurance until they get sick, the only people that will buy insurance are those that are sick. And the average cost will go up. They've tried it in several states. Cost went out of control, and they had to either go into a universal coverage situation, or just drop it altogether. So when you start, how do you get universal coverage? You can't force people to buy things they can't afford, so you have to have subsidies. You have to have -- with the present system -- employer mandates. Things that are not popular . . . .

This is where the question came up, how do you get competition? What drives the competition? The public option is what drives it. You're running an operation on a half-a-percent expense. If you want to compete with it, you've got to get your costs under control. Without the public option, trying to get universal coverage, what you end up with is a situation where you are requiring people to buy a product from a for-profit, sole-source corporation, with no check on prices . . . .

Elizabeth Butler, Richmond: In business school, they didn't teach us that the government entering the game would promote competition. That, to me, just for the record, sounds crazy. I'm here today because I'm worried about the national debt. And I'm even more worried about paying additional taxes -- lots of additional taxes. And I'm wondering how in the world can we afford to pay for this?

Scott: We're trying to pay, with the additional taxes, $544 billion over 10 years. One percent tax on that portion of your income over $350,000. One and a half percent of that portion of your income over $500,000, and 5.4 percent of that portion of your income over a million. Now, remember the people paying a payroll tax, which is about 12-point-something percent up to $90,000. No payroll tax over that. So adding what is essentially a payroll tax, income tax on those levels, I think is fair . . . . The question is, if we don't do something, can we afford where health care costs are going? That's what we can't afford . . . .

Cantor: How they're paying for this right now in the proposal is -- as Bobby said -- No. 1, it's through taxes . . . .Right now, let's not forget, health care's a huge issue. But it exists in the context of this struggling economy that we've got. So, if we're going to say to people who want to create jobs, it's going be that much more difficult -- because for every job you create, you're going have to pay 8 percent more of the salary -- you're not going see jobs come back so quickly . . . . Also, we saw that a couple hundred billion dollars is being paid for by cuts to Medicare. And where they go to cut in Medicare is Medicare Advantage. Medicare Advantage happens to be the portion of the program that allows people some choice, to get outside a government program . . . .

Patricia Churchill, Richmond: For me, this gets personal. I have a very close relative -- a woman in her early 40s, who did have a wonderful, high-paying job. Owns her own home, and was a real contributing member of society. She lost her job. Just a couple of weeks ago, she found out that she has tumors in her belly, and that she needs an operation. Her doctors told her that they are growing, and that she needs to get this operation quickly. She has no insurance. I'm just wondering, gentlemen: We can talk about high-flown ideas, and we can talk theory all we want to. But this person is a very close member of my family. She's ill. And she has no way to have this operation. So I'm asking you, what will you do if this were your close relative? Your niece, your aunt, your sister, or whatever? And she was in this situation now. What would your solution be, and how would you be involved in helping her?

Scott: Well, the plan that we have would provide universal coverage without a prohibition against pre-existing conditions. She would be able to get insurance. She would undoubtedly already have insurance. If she lost her job, she would buy insurance. She would not have employer-based coverage. She would buy it through the exchange. You would have the private companies selling insurance, and you would have the public option as a low-cost, competitive choice. The question has been, how can the government afford it? The government is not subsidizing the public option. The public option would be paid for with premiums. And as costs go up, the premium is going to have to go up -- so that the plan is self-sustainable.

Some people mentioned Medicare Advantage. Medicare Advantage gets a subsidy through the government. When they started this thing, the private companies said they wanted to get at and provide the service. And if they could just get 95 percent of what the fee-for-service cost was, they'd be able to make money. Because they felt they could run it more efficiently. Ninety-five percent. Now, they're getting about 114 percent. Not 95 percent, not 100 percent, 114 percent. What our proposal is, is to drop them down to 100 percent. Five percent more than they asked for when they got into the business. And that 14 percent will help pay for the costs of the universal coverage. We believe that the companies will continue to provide it, because that's what they said they would be able to do at 95 percent -- so they'd be able to do it at 100 percent.

So, with your relative, we have a plan that will provide universal coverage, so that she would be covered with health insurance. We need a situation where everybody will have insurance, and she would have had it. And if she couldn't afford it, there are affordability credits, or Medicaid, for her in that situation.

Cantor: . . . First of all, I would ask what the situation is in terms of income eligibility, and the existing programs that are out there. Because if we look at the uninsured right now, there is probably 23, 24 percent of the uninsured that is already eligible for an existing government program. That, frankly, the government has not done an adequate job at going out and making people aware, and signing them up. So, that would be my first question. If I was in the instance that you're in, or the family's in, as to what to do. Beyond that, I know that there are programs. There are charitable organizations. There are hospitals here who do provide charity care . . . . No one, in this country, given who we are, should ever be sitting without an option in terms of health care.

There are resources available. We have a very imperfect system, which is why Bobby and I are both here, saying that the current system is unsustainable. It's unsustainable, yes, because of cost. But yes, because of the human aspects of what happens. That's why we've got to bring down costs. That's why we've got to be very serious on the education effort, as to how to allow for there to be more options to cover different situations.

Makeba D'Abreu, Richmond: My name is Rev. Makeba D'Abreu. I'm one of the millions of working individuals currently without health insurance. I'm among the millions who choose to work in a mission-driven company, who serves the neediest of our country. This is the second time in four years that a work place has discontinued my health insurance due to rising costs. And even if I could afford to purchase insurance on my own, to cover me as a woman would be double of the cost for my husband and my son combined.

And I'm told by an insurance company that I cannot have a child for the first year that I'm insured, if I'm covered. So, people are making decisions about how folks should be covered already, and it's profit-driven. So my question is, how do you address the disparities for women, women of color, people of color, under this health care plan, or any that you would propose? What would you do, how would it insure that people are not dropped if they develop any chronic illness? And last, insurance reform is step one in the debate. But without health care delivery reform, the system will be overwhelmed. What are the provisions to expand prevention and wellness programs?

Cantor: I think we talked about the access point, as pre-existing conditions, universal access programs, otherwise known as high-risk pools. Both parties agree on that. We could get that done. I also would tell you, as far as small businesses are concerned -- and agencies that you may be a part of -- we really need to focus on expanding the opportunities for small businesses and individuals to purchase insurance in that market. Not in the group market. And that's why you've seen, over the years, proffers by the Republicans, say, "Let's have association health plans. Let's have more consumer-driven options." Right now, you can go out and get a health savings account. Our office has worked with several individuals who were unable to afford coverage in any other way but bought a health savings account. And yes, it requires laying out, if you have a family of four, close to $5,000, if you have the problem. But you would never go bankrupt. Because if, God forbid, something really happened to you and you were facing hundreds of thousands of dollars of bills, it's covered . . . .

You asked about wellness, and about prevention. Bobby spoke about it, and HR 3200 tries to go to that. And it tries to do so in a way that you've got the health choices commissioner saying, "This is what plans have got to do." . . . We have models out there that show employers have demonstrated the ability to bring down, or at least hold costs steady. The way they do that is, they encourage good behavior, if you will. Prevention. Wellness programs. They give people incentives to go about their life pursuing that. Right now, this bill takes away the employer's ability to do that . . . .

D'Abreu: Disparities? While you're there, disparities?

Cantor: Well, the disparities are going to exist in an insurance environment, whether it's the government insurance or whether it's private insurance. And there should not be any disparities, in terms of access to care, on any basis. Every one of us should have the opportunities to access coverage that gives quality care. And from where I am, if you ramp up government's role, and you put more people into the hands of the government, you get a situation like we have with Medicare. It's unsustainable. And so, we look to the other systems in the world, like the U.K. and Canada. How they handle disparities, it basically is imposed. It says, "If you reach a point, or an age in your life, . . . and we don't think it is cost-effective and necessary for you, because you don't have that much longer to live, and we need to give it to someone else," that's what happens. That's government-dictated disparity.

Scott: First, on the minimum standards. Somebody mentioned the possibility of an insurance policy covering everything except what they have. That's what the minimum standards are designed to prevent. You can't sell insurance that doesn't cover cancer. You can't sell insurance that doesn't cover diabetes. There is a minimum standard of services you have to provide. Employers -- I think Eric indicated that employers are keeping costs down -- the fact is that costs in the last 10 years have doubled. They're expected to double again. We've got to do something.

And there are two possibilities -- associated plans, to have small businesses save money by coming together. That has been recommended over and over for the past few years. There's one problem with it. And that is, if you get a bunch of healthy people together coming out of the system and going on the side and saving money, the studies are that 80 percent of the public, if we pass that thing, would see their rates go up.

I don't view that as a solution. If you have thousands of dollars to set aside every year for an HSA, then that will help you. But if you don't have the thousands of dollars to set aside, the health savings accounts don't help you. You mentioned gender. That is one thing I think everybody agrees about -- that we're going to eliminate that disparity. On wellness and prevention -- no co-pays on preventive services. That will encourage people to get check-ups and immunizations. And prevention, there's research in best practices, to make sure that physicians get the best information. And finally, you mentioned, people get their insurance dropped. There's a provision in there that once you have insurance, they can't drop you if you get sick . . . .

Kathleen Wilcox, Powhatan: My concern is obviously cost. It's going to cost $2 trillion to start this program. And I'm wondering where the $2 trillion is coming from . . . .If it's a loan, isn't that considered part of the deficit? Because I did watch President Obama two weeks ago say that not a dime would be added to the deficit. And I'm just curious about where it's coming from.

Cantor: I don't think that you will have a fair playing field, when you start mandating what health care must look like from Washington . . . . What happens if the costs get out of control? Who's going to take care of the shortfall? It'll be the federal government . . . . There are models out there that have indicated certain employers have shown they can keep costs down. We need to put flexibility in place for that to continue to happen, and give patients more options, so we can have more competition. And those options are consumer-based health care.

Scott: The public option we believe will work, because we have a model -- Medicare. You know, I think it would have been simpler if they called it a Medicare card, rather than public option, so people would have a better view of exactly what it is . . . . In terms of the start-up for the public option: The money will be borrowed, to be paid back . . . . So, if it's expected to be paid back, the deficit scoring is negligible.

Mary Evans, Richmond: I wonder how much more the American taxpayer can take. The TARP -- you know, I voted Democrat for over 35 years. But when that TARP bill passed -- I know it was under a Republican administration, but it was voted on by both sides, that bill. Including President Obama. That passed. Then we have the $757 billion stimulus bill. That's our money. And then the bailouts at AIG and banks. And now the health care. All in eight months. I can't even wrap my head around it, much less know what's in a thousand-page bill. That said, I wonder how much more we can take.

Number two: I work in an ER. I work specifically with Medicaid patients. I deal with their insurance. I've done it for nine years. If anyone really wants to know about government intrusion in health care, please come and work for a month at my job. I deal specifically with ER accounts. I started figuring out a few years ago, why were people coming in and using the ER for non-emergency situations? Why? They had Medicaid. Why couldn't they go to their doctor? I asked them that. Quote: "I have no primary care." "Yes, you do. Let me see your card. Every Medicaid patient is assigned a primary care doctor." They couldn't get in to see their doctors. They were overloaded. They come into the ER, and 70 percent of the patients I deal with at my hospital are Medicaid patients. So if the government can't fix Medicaid -- which they can't -- why should we turn this over to them?

Scott: . . . Twenty years ago, the portion of your income that went to health care was about 7 percent. Now it's 17 percent, and it's going to 24 percent in the next 10 years. Costs have doubled in the last 10 years, and they're going to double again in the next 10 years. If we don't do something, the question is, how much can the public take? The costs are going through the roof. And if we don't do something, they will continue. There's an old adage that if you don't change directions, you might end up where you're headed. That's where we're headed, if we don't do something. In terms of Medicare and Medicaid, there are a lot of areas where there are few physicians. But we have shown that we can keep the costs down with Medicare. And that's the model. Other people with private insurance have trouble, just like everybody else. We're trying to be a model. It's not easy. Eric and I agree on 80 percent, but you can't do the 80 percent unless you do some of the 20 percent. We're mandating people to get insurance. We are requiring people, employers to pay. Now, he pointed out that that's an imposition on employers. That's right. But, how are you going to get universal coverage if most of the people get it through their employers? That's a decision we made. There is another possibility. Just do a single-payer plan. Instead of having people run around trying to find insurance, everybody gets a Medicare policy.

Lisa Keck, Richmond: My first question is to Rep. Bobby Scott. Since you say that they're going to make up a lot of the money from fraud and waste in Medicare and Medicaid -- can we just start that now? Can we start that now? Cut the waste . . . .I really do feel bad for the people here that have sick relatives. And I had an aunt that was on Medicare, but she moved from Philadelphia to Virginia, and was told, "We're not taking any more Medicare patients at this time." So, that's what happens. And when you're on the public option -- I know that many of you are desperate at this point, and I am very sorry for that -- but you're going to hear that: "We're not taking any more public option people right now." It's not going to be a simple fix . . . . I'm not a Republican, I'm not a Democrat. The last eight years, Bush and the Congress doubled the national debt. Way over $10 trillion. And now we're going to double it again in five years. Now, do you really think that this government is going to be able to manage our health care with that type of problem? No . . . .

Todd VanderPol, Glen Allen: I'm a small businessman in Glen Allen. My wife and I have been married almost 30 years. We've always had catastrophic coverage. For the last 10 or 15 years, we've had a health savings account. So, we have a high deductible. We have four children, 13 through 21. We pay $335 a month for that catastrophic coverage. We have over $20,000 in the savings account that's accumulated over time. So, I hear numbers thrown around of individuals paying anywhere from $1,300 to $3,000 a month for their insurance. Now, what do they get that I don't get? My coverage may not cover everything. But if you look at those numbers, I save $10-to-$20,000 a year that I don't pay on insurance coverage. The first thing that needs to be done is remove the deductibility of health insurance from businesses. Give the deductibility to individuals, so that they have an incentive to go out and purchase their own, and there's a disincentive for a business, such as Media General, to provide perks through the health care system, rather than paying wages, because there's tax savings to that.

The other thing is, I just see no historical evidence that the government can do this, either in a safe way -- provide these services -- and certainly, there's no evidence that they can do it in a cost-effective way. That's just foolish. The question to both of you, yes or no -- if we get a public option, will you swear before God and man, that you will put all your faith in that, and that will be your only coverage individually? Yes or no?

Silvestri: Let them think about that for a minute, we'll come back to it.

Matt Geary, Richmond: My concern is primarily with the rhetoric out of Washington. It has gotten increasingly ugly, and that gets us absolutely nowhere. I learned in kindergarten to be nice. To get to the 20 percent that the two of you do not agree on, if everybody in Congress would follow your model -- you're two of the smartest, most well-respected leaders of your parties. If the rest of those folks would follow your model, I think we would get to that 20 percent and ultimately find some solution to this problem, so we're not back here in 36 years talking about it again. So, thank you all for today, at least, starting out without the rhetoric and the ugliness. That's how we're ultimately going to come to a solution.

John Lanthrip, Highland Springs: Forty-five million people will be thrown into the system right away. You have no new doctors, no new hospitals. The only ones that are ready are the VAs, and we're already being rationed. Where does that leave the veteran?

Cantor: If we could have a forum like this in all 50 states, we'd probably be an awful lot closer to getting to where we could affect positive reform . . . .I want to respond to Mr. VanderPol's question about if a public option is passed, would members of Congress have to live under it. This was an interesting point that we made and tried to discuss in the Ways and Means Committee. Because as you can tell by now, I am not a supporter of a public option, because I believe it will become the only plan over time. So, we proffered an amendment to say, if this goes into law, will you -- and Bobby was not on this committee, so I can't impugn him with this -- but will you say that all members of Congress have to live under that same plan? And it was resoundingly rejected.

Scott: I think several people have talked about the tone of the debate, and I think this is probably the best opportunity we've had to talk about what's really in the bill, what the differences are, where we agree, and where we disagree . . . .There's no congressional plan. We're federal employees -- and get what all federal employees get. The only difference is that we do not have a public option. For people like Eric and myself, we might -- I might -- well choose the public option, because it's more likely to have physicians on board that are in Newport News, in Richmond and Washington . . . . In the last couple of years, we have had significant increases in funding for the VA. It's not enough, it needs more, and we're going to continue going in that direction, because people who have served our country and risked their lives as you have, deserve the best health care we can provide . . . .

Silvestri: Richmond, Virginia, you proved we could have a civil conversation on an important topic.