Hawaii's Health Care System
Price of Paradise · Hawaii Public Radio · aired 1995-04-09
Guests: Deane Neubauer (Professor of Political Science, University of Hawaii); S. Y. Tan (Professor, University of Hawaii School of Medicine)
Duration: 1:05:04

[00:00:01] Randall Roth: Good morning. This is Randy Roth, host of the Price of Paradise Radio show. We're being broadcast live on KHPR 88.1 FM and KKUA 90.7 FM from 7:30 to 8:30 a.m. on Sunday, April 9th. And then we'll be replayed tonight at 8 on KIFO, that's 1380 a.m. Our topic today is healthcare in Hawaii and with me in the studio to discuss it are two experts with different perspectives. Dean Neubauer is a professor of political science at the University of Hawaii. He's had a long-term interest in what he calls the intersect between democratic political structures and the policy outcomes they produce. For the past 10 years, he has actively been involved in the analysis and making of healthcare policy in the United States, Australia, and New Zealand.

[00:00:52] Randall Roth: He has particular knowledge of and interest in the healthcare system here in Hawaii. Good morning, Dean.

[00:00:57] Deane Neubauer: Good morning, Randy.

[00:00:58] Randall Roth: Seated across from Dean is SY Tan, a professor of medicine at the University of Hawaii John A. Burns School of Medicine who also is director of medical and medical legal education at St. Francis Medical Center and an adjunct professor of law at the William S. Richardson School of Law. SY is written and lectured widely on medical, medical legal, and bioethic topics, and like Dean, he has a special knowledge of and interest in Hawaii's healthcare system. Good morning, SY.

[00:01:27] S. Y. Tan: Good morning, Randy.

[00:01:29] Randall Roth: SY, I'm wondering if you could get us started by telling us what is at the heart, if we go right to the core of this healthcare conversation in Hawaii, what are we looking at?

[00:01:40] S. Y. Tan: I say keep your eyes on three things. Keep your eyes on quality of care, on the cost of care, and on access to care. Quality, access, and cost.

[00:01:54] Randall Roth: And cost. Tell us a little bit more about that.

[00:01:56] S. Y. Tan: Well, high quality of care, I think we must always insist on that. And I think the US and Hawaii have quite an excellent medical care system.

[00:02:05] Randall Roth: How do how do we know that? How do we measure quality?

[00:02:08] S. Y. Tan: We know that by looking at the kinds of outcomes with the diseases that we are unfortunate to develop, cancer treatment, transplantation, complex cardiovascular surgeries, etc. Still, this quality of care may not be available to one and all in an even way, which brings up the subject of access. Some people may not be able to get into the system, and we know some 37 million, maybe more, Americans do not have health insurance, and so they may not be able to tap into the system. And above all, the high cost that continues to escalate. We need to have a handle on that.

[00:02:48] Randall Roth: Okay, so quality, access, and cost, those are three things we need to keep our eye on during the next hour as we talk about healthcare in Hawaii.

[00:02:56] S. Y. Tan: If we keep coming back to these three features, we'll be on the right track.

[00:02:59] Randall Roth: Dean, do you agree with that?

[00:03:01] Deane Neubauer: Yes, I do. I think there are some other things that might be said about these briefly. Access has at least two components to it. One is access in the sense of can you get in the door to a medical facility. Do you have the way to pay for that? And so that's essentially an insurance issue. Do people have access to medical insurance? Hawaii is probably ahead of the nation by quite a bit still in terms of providing the closest approximation to universality in terms of healthcare insurance. The we talk about the gap group on the mainland. Those are the people who don't have medical insurance of some kind, variously estimated at 35 to 40 million people, a very large number.

[00:03:42] Deane Neubauer: Another kind of access is if you have healthcare insurance, can you go to a medical facility when you need one. Can you get in? Can you get the appropriate kind of care is care distributed, etc., etc. Here in Hawaii, we've traditionally had a problem of having not universal access in terms of the contribution. I'm sorry, in terms of concentration of medical care. For example, the rural areas on the big island still have problems. We've had difficulties with ensuring that people on Molokai and in rural Maui have the kind of care that they should. So there there are these two different notions of access. On quality, SY is right, but the best experts sometimes differ on in terms of what constitutes quality.

[00:04:26] Deane Neubauer: And certainly one of the great debates in the United States and throughout the world now is how you measure the effectiveness of medical care, and what what we might call the outcomes movement is an effort to find better ways of of talking about and measuring healthcare outcomes.

[00:04:41] Randall Roth: Do you agree with SY's bottom line that we do have high quality in the United States?

[00:04:46] Deane Neubauer: We have high quality in the United States, but I I think that and and always compared with what and the answer is compared with the rest of the world. And then you move immediately to the question of high quality for whom?

[00:04:59] Randall Roth: Okay. And then cost. You agree that's part of the conversation?

[00:05:03] Deane Neubauer: It it's the core of the conversation. It's what the conversation's all about. Why is that? Well, there are let's just do it a couple of ways quickly. The cost of healthcare in the United States, medical care plus anything else we spend on health has risen since 1965, the advent of Medicare and Medicaid at roughly twice the rate of inflation, and during some of those years, the rate of inflation was very high. Those rates have slowed down but they still increase higher than the rate of inflation. We now spend about 950 billion dollars as a nation on healthcare costs. That's the highest in the world. That's about 14, 14.5% of our gross domestic product and it continues to rise.

[00:05:47] Randall Roth: Why wouldn't that level off?

[00:05:49] Deane Neubauer: Well, that's a very long conversation. When when one does that, one immediately begins to break out what are called the factors that drive cost, and they're things like utilization, who's using healthcare, demography, are there more of us? More of us older people? And more of us older people, exactly. But just more of us period. And as the as the population grows, medical care grows. Are there more doctors? Uh, would there there is some fascinating data that indicate that for every doctor that you put into the society, you generate X number of dollars of healthcare over the year. There's technology.

[00:06:24] Randall Roth: Well, let me ask the the question people here in Hawaii, I think wonder about are we a model for the other states? As I look at the the three items that SY said that that we should be talking about, quality, access and cost. I'm under the impression that the quality of medical care in Hawaii is is high. I don't know why I'm under that impression, but but I do have that. On access, I read that the number of people who have some form of insurance is especially high in in Hawaii, much higher than than in other states. And on cost, again, I'm not sure this is accurate, but I'm under the impression that it costs less in Hawaii.

[00:07:03] Randall Roth: SY, are we a model for the rest of the country?

[00:07:07] S. Y. Tan: Well, if we wanted to be modest, uh, we wouldn't want to claim to be ahead of everybody else, but I think Hawaii has, uh, should be proud of, of of its healthcare system. You are right. I believe we have high quality care in Hawaii, and that virtually everyone here in Hawaii is able to tap into the system, especially with the recent QUEST program that has now made it, uh, far easier for those who are less able, poor, etc., [unintelligible — audio glitch] become involved in healthcare.

[00:07:38] Randall Roth: Now, sit tight because I want to ask you why that's true, but do you agree with that, Dean?

[00:07:44] Deane Neubauer: Are we a model for the rest of the country? Well, in some respects we certainly are in terms of the number of people who have health insurance we are. There's some fascinating data which indicate what our costs are, and a lot of these have to do with the sophisticated estimations. But we're we're maybe 2% below the mainland in terms of the percent of state domestic product which goes to healthcare.

[00:08:05] Randall Roth: Why is that?

[00:08:07] Deane Neubauer: Well, Jack Lewen, when he was health director, used to uh to give a talk which is called, uh, the four lessons from Hawaii. He and Peter Sabinski, who was his successor, and very quickly they go like this. There's a plantation tradition in Hawaii and that produced a tradition of primary healthcare despite the fact that we have a lot of specialists in our society. We have, uh, we have a tradition of primary care. We've had, um, various kinds of public policies and economic policies which has kept the number of hospital beds in Hawaii relatively low so that we're we're not dealing with this surplus, um, of beds. We have healthcare policies which have been fairly enlightened in terms of, uh, of of preventive care. And we've had an, uh, an insurance industry which, um, to to use a somewhat technical term, is basically a duopoly. That is to say, Kaiser and HMSA have most of the insurance business.

[00:09:01] Deane Neubauer: But that has contributed to ways in which the the cost of providing medical insurance can be kept lower than it has been on the mainland.

[00:09:09] Randall Roth: Do you personally buy that four prong explanation?

[00:09:12] Deane Neubauer: Well, I think it's a start of something. I think there's some other things there.

[00:09:15] Randall Roth: Okay, SY, you were saying you think in a way we are a model. Do you have an explanation other than what Dean has just summarized?

[00:09:22] S. Y. Tan: No, I think he has done a real good job identifying these factors. Yes. We are perhaps a additional, uh, consideration, we're we're a smaller place. We don't have borders, uh, where people can cross, uh, in and out of. Uh, there's more of a Ohana environment here in the islands. I think all of these things, uh, play a contributory role.

[00:09:46] Randall Roth: Okay, Dean.

[00:09:47] Deane Neubauer: Well, now we have to talk about the other side of the coin. Where where aren't we a model? We, uh, we've struggled over the years for the last two, three decades trying to do the right thing on mental health in in the state, and we've had a hard time doing it. We've had very serious problems with [unintelligible — audio glitch] state mental hospitals, as we all know. Excuse me. There, uh, if we look at the health profile of, um, of people who live in Hawaii, we know with, uh, extraordinary dismay that Native Hawaiians and other Polynesians do not match the profile of of other groups. And that's that's a very, very great problem in this state.

[00:10:25] Randall Roth: Okay. You're listening to the Price of Paradise Radio show. Today's topic is healthcare in Hawaii, and with me in the studio discussing it are UH Professor of Political Science Dean Neubauer and UH Professor of Medicine SY Tan. If you're listening to the Sunday morning broadcast and would like to ask a question or make a brief comment, all you have to do is call 955-8821. Neighbor Islanders are invited to call collect. The number again, 955-8821. Dean, I've talked to you about this before, and I recall you saying something about we don't so much have healthcare as sickness care. Did I get that right?

[00:11:06] Deane Neubauer: Right. It's it it's this kind of distinction. Uh, basically what we call healthcare in the United States is in fact medical care. Uh, to cite anotherism, if you look at all the money spent on on, uh, healthcare in the United States, 97% of that goes to medical care. 3% of that goes to what we might traditionally call public health. Now, the mission of health [unintelligible — audio glitch] medicine and the mission of public health are simply different. The mission of medicine is to, um, um, is is to try to bring health to the sick. It then has another role, which is the prevent preventative, prevention medicine role, which we could talk about. But importantly, public health has a different mission. The mission of public health is to try to reduce the incidence of sickness, disease, and illness in a society.

[00:11:58] Randall Roth: Okay. Uh, we have a caller on the line, Ron from Manoa. Good morning, Ron.

[00:12:03] Speaker 1: Good morning. Thank you for your program.

[00:12:05] Randall Roth: You bet.

[00:12:06] Speaker 1: Uh, the question I have is centered about the role that insurance carriers have in actually increasing the cost of medical care. The reason I ask that is I'm a practicing dental surgeon in town, and I'm old enough to remember the days, the ancient days when there were no dental insurances. And I came from Michigan, but at that time, uh, it was not common for people to have dental insurance, and all be it that a good idea and, uh, and providing that, I have, from my own personal experience, some suspect that by the inclusion of dental insurance carriers into the marketplace, so to speak, with dentistry, although I don't consider my profession a marketplace, uh, that it has actually increased costs.

[00:12:58] Speaker 1: Uh, and it's not the particular fault of the, uh, medical system or the dental, uh, services, but actually the inclusion of the insurance carrier. So I just wanted to ask, uh, the people there what their feeling about that is.

[00:13:15] Randall Roth: Okay. And I know we did a show last year on, uh, on healthcare. And one of our guests at that time was commenting that the existence of insurance is always going to tend to to increase costs. Uh, I want to get Dean's thoughts and SY's thoughts and we got somebody else on the line that I'll I'll introduce.

[00:13:33] Speaker 1: One one other comment. I know that it's easy to set it aside by saying tend to raise the cost.

[00:13:37] Randall Roth: Oh okay, Ron, hang on, I want to come back to you, but I want you first to listen to to their response to your question, but hang on the line. First, Dean Neubauer.

[00:13:45] Deane Neubauer: I think there are two components to insurance that raise the cost. One, if someone's paying for something for you, there's a higher tendency for you to use it. Economists have recognized this for a long time. So when you're paying 100% out of pocket for any service, there is a self-rationing that goes on. And the literature on healthcare insurance points to the fact that historically healthcare insurance was fee for service, and in some cases, uh, it was totally reimbursable, and now it is more common that there that it's perhaps 80% reimbursable. And so there's a tendency to use things when you don't pay for the full amount of it. The second part of it, which is a a great concern in the United States, less so in Hawaii, I would point out to Ron, is that there's an administrative cost to insurance.

[00:14:28] Deane Neubauer: Most insurance companies are private businesses and they're making money on healthcare insurance whatever kind it is. HMSA, for for example, has always argued that it takes the the least amount of the healthcare dollar around 6% for its overall administrative costs. In many blues blues in the mainland, this figure can be much higher and I'm just sorry I don't know what they are for dental programs.

[00:14:50] Randall Roth: Okay. SY, your reaction to Ron's question?

[00:14:52] S. Y. Tan: Good point, Ron. I want to tell you the story of healthcare in Singapore, which consumes about 3% of its national product as opposed to about 14, 14 or 15% here. In Singapore, uh, individuals put moneys aside, both from themselves, from their paychecks and from their employer, into an account, a savings account called Medisave, a medical savings account, and they use that money to pay for their healthcare. And uh, if they use, uh, those dollars uh freely, why, they very soon uh become, uh, uh, low in their account. It's it's their money to use, and it belongs to them after they die or to their family members. So this is this incentive versus the insurance deal.

[00:15:31] S. Y. Tan: However, to be fair, we need some kind of insurance to to spread the risk, especially for catastrophic illness.

[00:15:37] Randall Roth: Um, Ron, before I come back to you, I I assume that somebody would raise the issue of insurance, and so I asked Fred Forton, who's the vice president of community relations for HMSA, uh, to be on another line that we have um uh set up. And, uh, Fred, I'm wondering if you have any reaction to one, Ron's question about insurance and the sort of uh incentives that it provides, and then two, just anything that you've heard from our guests in the studio this morning.

[00:16:07] Speaker 2: Uh, hi, can you hear me?

[00:16:09] Randall Roth: I can hear you, Fred. You're on the line.

[00:16:11] Speaker 2: Great. I'm sorry that when you, uh, put Ron's uh uh put Ron on the line, I wasn't able to hear his comments.

[00:16:19] Randall Roth: Okay. Well, we're still working out the bugs in our system of having a couple people.

[00:16:22] Speaker 2: I get a sense of what he was saying though. It's been a long-term argument that, uh, about incenting, uh, use of service when you have it, uh, nearly freely available through because you have a financing from your insurance company. But I think in a way, it's an old argument now, uh, primarily because the issue that really hasn't been touched on, and where the I think the essence of the political struggle now is going on is in the managed care revolution in the country. Fred, am I correct on managed care? Are we basically saying that rather than just let the consumer and the provider, the patient and the doctor decide what's to be done, that some third party like HMSA, for example, gets involved in that decision? Is that what managed care is all about? Simply

[00:17:29] Speaker 2: I I think that's it's about much more than that. I think it's about trying to have financing mechanisms that uh that incent uh a certain prudence in the system. It talks about sharing risk between providers and consumers and insurance companies. Uh, it talks about trying to um uh look at outcomes, look at satisfaction, um, uh, it talks a lot about a whole range of issues that tries to bring some sense of accountability to the system, financial accountability to the system without uh having an impact on or uh having it lead to some sort of deterioration in quality of care. And I think this is a very broad debate and I I was always amazed uh when we were in the midst of the sort of the healthcare reform uh apex there [unintelligible — audio glitch] last year that somehow the the real revolution was slightly under that, which was the managed healthcare revolution and we saw it in Congress, uh we see it continue to see it in Congress now, and we see it in our own state legislature, in which the whole debate has become much more politicized, especially around the quest program.

[00:18:36] Randall Roth: Mhm. Okay. Well, Fred, stay on the line. I'm sure we're going to want to refer back to you from time to time. Uh, let's go to Ron in Manoa. Ron, did we answer your question?

[00:18:46] Speaker 1: Uh, actually, I apologize, but I did not hear it over this telephone. Well you you didn't hear Fred Forton, but you heard Dean Neubauer and SY Tan. Well, yeah, it was very well said, and I I, um, I especially like what they're doing in Singh

[00:19:00] Deane Neubauer: poor because this is my understanding now of a growing trend within the United States as individual management accounts. I do not agree with the idea that there needs to be a third party to manage the relationship between the doctor patient. I'm a purist in that sense. I feel that that's a sacred time honored relationship.

[00:19:20] Speaker 1: Okay, Ron, I've got some other callers. Um, thank you very much for your call.

[00:19:24] Speaker 2: Bobby and Makiki, good morning. Good morning. Thank you. Uh two questions, comments, prior condition exclusion is common in health insurance policies. One effect is to restrict job mobility. A person will have to remain in a low paying job, for instance, rather than risk catastrophic cost after leaving existing insurance.

[00:19:51] Speaker 1: Okay, do you have a a question or is is it That's your comment, you want to get their reaction to it?

[00:19:56] Speaker 2: Uh well, what what is there a trend going on as to the to uh uh counter this policy?

[00:20:03] Deane Neubauer: Okay. Dean Neubauer, Well, Bobby, I think one could point to three things. One is in the national healthcare debate that centered around the Clinton program. There was a concern for this, which is frequently expressed in in uh in the term of community rating for healthcare insurance, which um puts everybody in a common insurance pool and tries to exclude the uh the sense of uh of how prior conditions affect that. The industry, as you uh probably know, is quite opposed to this, and it continues to be debated in in Congress. Advocates for what is sometimes called a single payer system for which Canada is the most uh common comparative in the United States, although I think it's poorly understood as to what it actually is, uh argue for it, in part because the um the sense of uh of there they're not being any prior condition in that kind of system.

[00:21:00] Deane Neubauer: You just um you have your health record and then and receive the medical care, which is deemed to be appropriate for those kinds of conditions. And now I would see the third, and I want to ask this of SY, is it seems to me [unintelligible — audio glitch] in the Singapore system, in a in a kind of uh medical saving account system, one of the the features of that, is that it ignores prior condition, and in fact puts the burden of of achieving medical care on the uh treatment on the individual. Is that correct?

[00:21:31] S. Y. Tan: Thank you. Go ahead, SY. Well, in a sense, it does, because you are basically responsible [unintelligible — audio glitch] medical expenses, except that the account allows you to buy coverage for catastrophic illnesses, a large expense type, so that uh treatment for ongoing conditions say an ulcer or high blood pressure, which may be uh supportable uh affordable uh would continue to be paid out of of your you're right there. It seems to me at a common sense level, speak speaking as a doctor and advocating for for patients and for the for the public, that you shouldn't be penalized just because you've been unfortunate enough to have developed asthma in childhood or or diabetes and you carried the disease with you throughout life.

[00:22:15] S. Y. Tan: You shouldn't be penalized for that by not having those things paid for out of your insurance plan. This exclusion of pre-existing condition bothers us, uh bothers the doctors very, very much. It's not fair.

[00:22:26] Deane Neubauer: So, so medical care isn't a commodity, it's a right.

[00:22:30] S. Y. Tan: Well, maybe [unintelligible — audio glitch] a little much to say that it's an absolute right. Uh just like education is perhaps, but it isn't simply a commodity. It deals with life and death. It is something which people should have, irrespective of whether they are rich, whether they are poor, etc. Whether everyone should have everything at all times uh is is something else. I don't think that's possible. I don't think so.

[00:22:53] Deane Neubauer: Dean, what do you think of that one? This is such a complex question, it's hard to know where to cut into it. I I want to cut aggressively into it and talk about the difference between what we normally think of insurance for, which is for acute care, and the increasing problem throughout the industrial world of long-term care. And then, of course, individuals with with some kinds of nagging pre-existing conditions are actually people who require long-term care, often very high intervention care for long periods of time. And we have to ask, what is it in the way that we provide a system of medical care that speaks to these kinds of questions? Fred mentioned just briefly uh Project Quest that we'll probably or Hawaii health quest that we'll have a chance to talk to another kinds of ways. It's interesting that um Quest has not yet dealt with the question the age blind and disabled, which is targeted for Quest two.

[00:23:46] Deane Neubauer: And uh as as you know Randy and and as SY certainly knows, the issue of how to finance long-term care in Hawaii has has been an uh an item of public policy in the state for five six years and is pretty unresolved still.

[00:24:00] Speaker 1: Okay. Uh Bobby, thank you for your call.

[00:24:02] Speaker 2: Uh I have one more one comment and uh another comment. Uh why Yes, you got to make it quickly. Yes, it's very quick. Why are insurance companies opposed to prior conditions and then different one is why aren't some sort of yearly physicals required for health insurance, especially with seniors.

[00:24:22] Speaker 1: Okay. And I maybe our guests will have uh a response to those in just a moment, but I need to remind listeners that this is the price of Paradise radio show. Today's topic is healthcare in Hawaii, and with me in the studio discussing it are UH Professor of Political Science Dean Neubauer and UH Professor of Medicine SY Tan. The show is broadcast live on KHPR 88.1 and KKUA 90.7 each Sunday morning, and then replayed each Sunday evening at 8:00 on KIFO 1380 a.m. Those of you listening to our Sunday morning live broadcast can ask a question or make a brief comment by calling 955-8821. Any comments on Bobby's comments before I ask for a a fuller explanation of what quest is all about? Uh Dean?

[00:25:12] Deane Neubauer: Well, I want to do the first part of it, then maybe we can punt to Fred on the second. Um, certainly for most insurance companies, certainly for private insurance companies, they want to get out of prior conditions because they lose money on them. A prior condition is an indicator of of the possibility of uh of of losing money on that policy. Right, so if if the decision It's an actuarial decision. if if you said to the insurance company, do you want to cover someone who's obviously going to require tremendous expenditures, why the answer would be no, they don't want to. If I if I were an economist sitting here, [unintelligible — audio glitch] would point out that uh insurance companies want to want to ensure healthy people.

[00:25:49] S. Y. Tan: Okay. SY, do you have a reaction to Bobby's comments? Sure. But look uh common sense here again. If you're healthy and uh you would be you you wouldn't really need insurance. Huh? The reason you buy insurance is so it can take care of perhaps future needs, uh certainly medical needs. However, if you're already sick, uh someone's going to have to pay [unintelligible — audio glitch] the for the illness and for his care. Uh the person obviously has to bear some part of this obviously is his illness or her illness. Take the example of a [unintelligible — audio glitch] a car insurance where if you are a poor driver, your premiums go up. Of course it goes up because you are more liable to be involved in another accident and it'll cost more uh of the insurance company. Healthcare is all different because the thinking is that perhaps it's not the person's fault, as it is, for example, with a careless driver.

[00:26:39] S. Y. Tan: And that's even debatable because sometimes we are responsible in large part for our own conditions, like lack of exercise, poor diet, smoking, and so on. I think those are some factors. But somewhere along the line, people with pre-existing conditions will have to be taken care of. Uh perhaps uh there should be a added premium. Uh but they should be coverable. They should they shouldn't just be excluded.

[00:27:00] Speaker 1: But aren't you in effect saying that that people have more of a right to healthcare than they do to drive a car or other things? I think so. I think [unintelligible — audio glitch] would be easy [unintelligible — audio glitch] stage. Okay. Now, I want to come back to quest because that word has come up a couple of times, and and I know I'm not at all um aware of what all of all of its implications are. But we have a caller on the line from Wymalo, Ken. Good morning, Ken.

[00:27:25] Speaker 3: Hey, good morning. Yeah, you know you keep coming to this uh issue of whether healthcare is a right, and and I'd like the panelists to maybe uh answer that uh more directly because you know I mean Like a yes or no, right Ken? Well, yeah. I'm I'm very curious 50 years ago, we didn't really think of this kind of thing. Uh, and you know, like communist countries experimented with it. I I'm very curious because we seem to be going in this direction.

[00:27:53] Speaker 1: Well let's see. Dean, is is it is it just unfair for us to say, give us a yes or no answer to the question of whether healthcare is a right or something else, say a commodity we'll call it.

[00:28:05] Deane Neubauer: Yes, it's unfair.

[00:28:08] Speaker 1: Why is that? Well, it's a very difficult conversation. The uh the the question has to do if if we want to roll it all the way back to where rights come from [unintelligible — audio glitch] the Western political tradition and it's very very recent that welfare rights have have emerged.

[00:28:23] Deane Neubauer: What we're now seeing in national politics is a debate over what kinds of utilizations of public money should be directed to what kinds of programs we call those entitlement programs. If you say health is a right, now you're into one of my favorite conversations, which is what is the relationship of medical care to health? If you say that access to medical care is a right, then you raise the issue, well of how much access to what kind of medical care? I mean, this is just not a simple question, and I think any effort to reduce it to a yes/no answer uh trivializes the question.

[00:28:57] Speaker 1: Okay, SY? See if I can do it a little different way. Uh I think it might be fair to say that we should have a right [unintelligible — audio glitch] education, but we don't have a right to to be to to get that education at your and your. I think you should have a right to food, but I don't know if you have a right to eat uh the best gourmet dishes uh daily, and so on, clothing perhaps, but not designer clothes, and housing perhaps, but not a housing kahala.

[00:29:23] S. Y. Tan: I think everyone should be able to have medical care when he or she needs it. This is a life and death affair. However, I'm not sure that everyone has the right to all the healthcare that's available at all times.

[00:29:37] Speaker 1: Yeah, I'd agree with that.

[00:29:38] S. Y. Tan: That brings in immediately the concept of of rationing.

[00:29:42] Speaker 1: Okay. Ken, is is that uh closer to a yes-no answer than we were?

[00:29:45] Speaker 3: Well, no that was very good. I was just curious, but thank you very much.

[00:29:49] Speaker 1: Thank you for your call. Uh next on the line is Eileen from Makiki. Good morning, Eileen.

[00:29:54] Speaker 4: Yeah, I'd like to go back to part of quest and part of Dr. Neubauer's comment. Eileen, [unintelligible — audio glitch] me interrupt and stay on the line, but but I've been wanting to ask a question about quest myself.

[00:30:04] Speaker 1: Let's get Dean Neubauer to tell us what quest is. Okay. And then I want to come back to your question or comment, Dean.

[00:30:11] Deane Neubauer: Quest is an effort on the part of the State of Hawaii, similar to the efforts on the part of other states, to reform Medicaid. Medicaid is a program for the uh for the indigent for which the federal government pays 50 cents, and the state pays 50 cents for every dollar spent. One of the problems for many of the states is that the costs of Medicaid has been rising dramatically. In Hawaii, there's been an effort to deal with, to control the costs of Medicaid for several years. Hawaii Health Quest changes the way in which the state approaches this problem. It used to be the case in Medicaid that those who were eligible and covered for Medicaid would go to a physician and incur a cost and then the state would pay for that.

[00:30:58] Deane Neubauer: There is now what is called a capitated program, that is to say, individuals are enrolled in Quest. The state pays a given amount of money for those individuals, so much ahead. The five private health insurance companies in Hawaii insure those people. As a result of membership in Quest through one of these programs, individuals then obtain their healthcare through managed care. Now, the argument here is that you're doing two things. One of you're you're getting out of the old fee for service system, and you're getting into um capitation and managed care. The the pretense of the program, the purpose of the program is to reduce the overall public's expenditure at both the federal and the state level.

[00:31:51] Speaker 1: So, fee for service is when the patient goes to the doctor and says, what do I need? And the more that's prescribed in the way of service, the higher the cost and so the incentive is on the physician to prescribe more, but a capitated system as I understand it enough, you'll lose presumably. Well, that could be the case. We'll see. SY, would you agree with with Dean's quick explanation of what quest is? No, I think that's an excellent explanation. Okay. Put it differently, uh in a former system, uh there's no limit.

[00:34:52] S. Y. Tan: The doctor's order, the doctor's prescribe, the patients keep going from doctor to doctor and so on, and the costs keep climbing, and the state ends up with a bill, and they're never able to to pay the full bill for a year because it's always more than what's what what had budget it for. This time around, the total amount to be spent is fixed. There isn't anymore money and this dollars are distributed to three or four or five uh carriers and they'll have to make do. They'll have to budget for the entire year the health expenses. So, they put an incentive to save, to to spend less, to spend within that budget, just like a household budget.

[00:35:27] Speaker 1: The carrier has to manage that money well or it's going to run out. Correct. And if they run out, they'll have to pay out of their pocket. They have to take the risk. Okay. Eileen, I I hope you you don't mind that we uh we did that. I I need to understand Quest better. What's your question or comment about it?

[00:35:42] Speaker 4: My question involves quest and the Medicaid portion with regard to mental health services. Mental health services in the state have been rationed as as a part of, for example, HNSA, and certainly as a part of Kaiser. Um the ability of the public mental health clinics to take on clients has been limited because of budget constructions and constraints, and people who qualify for anything other than state services who've got any form of insurance have been punted to the insurance. With regard to people who do need mental health services under the quest and the capitation, I don't think they're going to get an adequate amount of mental health services so they can get up and out and get back to work and get back to being a taxpayer.

[00:36:34] Speaker 1: So what is what is your question?

[00:36:37] Speaker 4: Um what are we going to do with this group, because constitution says you can't discriminate regarding disability, and in that sense, the state has. Okay.

[00:36:45] Speaker 1: Let's ask Dean Neubauer because I know earlier you said we've we've had problems with mental care and hospitals and everybody knows about that, and I know generally, but could you in the context of Eileen's questions question elaborate on that just a bit.

[00:37:01] Deane Neubauer: Eileen points to an area where I think there's still a great deal of uncertainty about what Quest will do. The original Quest program created what was called a behavioral health carve out, which was an effort to uh to assign X number of uh those individuals requiring mental health services to a special part of the contract. There's an upside and a downside to this. The upside of this is that by uh targeting people, the idea is that they will get the kinds of services which are most appropriate to them. The downside which has been reflected by a number of people in the Hawaii mental health community and things that they've written about Quest and conversations that I've had with them, reflects Eileen's concern that there will not be enough money there, that there's not enough being done to um to identify and target all of these people.

[00:37:51] Deane Neubauer: Once again, I think that that mental health services in Hawaii are a real orphan and we do not have an effective way of

[00:38:00] S. Y. Tan: of of dealing with these services, and [unintelligible — audio glitch] just think that Eileen is pointing to something in this program that uh that is still not been effectively resolved.

[00:38:09] Deane Neubauer: Okay, SY, any thoughts?

[00:38:10] S. Y. Tan: Ditto, I was going to use the metaphor stepchild of medicine, mental health, should get far more attention than it that it is presently getting and mental health, Okay.

[00:38:20] Deane Neubauer: Okay, it has to be very quick, Ilean, I've got a number of people on the line.

[00:38:23] Caller: The thing with the mental health is that if you provide the appropriate and necessary services up front, these people can move into becoming taxpayers. If you fail to do that, then you have a lifelong tax burden.

[00:38:36] S. Y. Tan: Thank you, Eileen.

[00:38:36] Deane Neubauer: I couldn't agree more, Eileen. Want to remind listeners that this is the Price of Paradise radio show. Today's topic is healthcare in Hawaii. With me in the studio discussing it are UH Professor of Political Science, Dean Neubauer and UH Professor of Medicine, SY Ten. If you're listening to our Sunday morning broadcast and would like to ask a question or make a brief comment, all you have to do is call 955-8821. We have a number of people on the line. First, Rick from the windward side. Good morning, Rick.

[00:39:06] Speaker 1: Yeah, good morning. Um, I was wondering, I don't want to sound simplistic, but I'd like to talk about the greed factor. Now, I didn't have medical insurance and I got leptospirosis. I went to Castle Hospital for two days and it was like $2,200. I had I checked my bill out really carefully because I had to pay cash for it. They charge $10 for dressing a wound. It was one band-aid covering up an IV puncture.

[00:39:40] Deane Neubauer: Rick, let let me, stay on the line, Rick, but let me ask our our physician, SY Ten, why in the world does it cost so much?

[00:39:50] S. Y. Tan: I don't understand why it should cost $10 for a bandaid or $15 for a box of kleenex.

[00:39:54] Deane Neubauer: Well, because Medical care in general, my hunch is that Rick could go down the list on on his bill and it would all seem awfully high. Why?

[00:40:02] Speaker 1: They overcharge me $800. I I busted them trying to charge me twice for IV um IV solutions and and um the tubes and stuff. They only gave me one set. They charged me for three.

[00:40:13] Deane Neubauer: And and you don't think that was an accident, Rick? You think it's a simple mistake?

[00:40:17] Speaker 1: If you paid, if you pay for insurance, people don't check it out as carefully, but I paid cash and they were very snotty and uptight at me when I was calling them on my bill because I paid cash and I checked everything out.

[00:40:30] Deane Neubauer: As if the insurance company doesn't check it out so closely.

[00:40:33] S. Y. Tan: Rick is one of the full, it's wonderful that you bring this to the attention of the public. I mean, I think it happens, I know it happens. I think it happens in I mean even name the hospital, but it happens [unintelligible — audio glitch] every institution. Uh sometimes and I think most of the time it's it's from carelessness [unintelligible — audio glitch] oversight or what have you. I don't think it's intentional or or deliberate. Uh certainly not by and large. You bring up a you bring up an important item, I think. Uh hospital administrators, if you're listening, uh this morning, I think it is worthwhile for hospital administrators to take a close look at at some of these items with the consumer's interest in mind. Okay.

[00:41:16] Speaker 1: One one more comment.

[00:41:17] Deane Neubauer: It has to be quick, Rick.

[00:41:18] Speaker 1: Okay. Um what is the average doctor's salary because I think that's a taboo subject that people don't want to talk about because Okay, I'm a farmer, okay?

[00:41:26] Deane Neubauer: Well, let let's that's a good question. It's more than a farmer.

[00:41:29] S. Y. Tan: Um, our technicians out there are going to kick out your question. SY, this this is a philosophical question. Is a doctor worth more than a farmer? SY, are you worth more than, uh, Is a doctor worth more than a farmer? Oh god, goodness no.

[00:41:42] Speaker 1: Well, but a doctor makes 20 times more money than a farmer.

[00:41:45] S. Y. Tan: A doctor makes more money than a farmer. I think that's 20 times. 20 times and that may or may not be correct.

[00:41:51] Speaker 1: Well, what's the average salary of a doctor?

[00:41:53] Deane Neubauer: I tell you, I tell you. We all know they make a lot of money and I think what you've done, Rick, is put your finger on what might be an excellent show to talk about why doctors and lawyers and a number of other folks tend to make so much money. But I want to get Dean's thoughts about Rick's comments and then we need to move on to another caller. Thank you, Rick. Rick, there's a side of this that uh that might not be obvious and I don't want to uh to appear to be writing a brief for uh for this side of it, but I spent uh some time a while back listening to hospital administrators talk about various kinds of problems that they have. One of the things that they are involved in is something called cost shifting, which is providing medical care for people who, for one reason or another and the reasons are complex, do not pay for the whole of their bill and and no kind of medical insurance does.

[00:42:40] Deane Neubauer: Part of that cost shifting leaves the hospital with a debt. Uh so what hospitals do, rightly, wrongly, whatever, is to spread those costs on the bills of others. Now when you're paying cash and you're seeing the effects of that cost shifting show up in a $10 bandaid, then uh then that becomes an outrage. So it's it says $10 for one band-aid, but it really it's for your band-aid and then maybe some emergency room treatment for other people who simply didn't pay.

[00:43:07] S. Y. Tan: And it's for every other kind of overhead that you're not seeing. Who pays the lights, etc., etc., etc.

[00:43:12] Deane Neubauer: Okay. Uh I'm told by our technician that that Fred Forton is on the line but hasn't been able to hear the other callers. So I'm going to hold off Fred. We're going to come back to you before uh the end of the hour, but I've got some people who've been waiting patiently and we're going to get them first. So we've got Carly from Kona. Good morning Good morning, Carly.

[00:43:31] Speaker 2: Line one, Jeff. Carly, are you there? Uh, is that better?

[00:43:38] Deane Neubauer: That's better, good morning.

[00:43:40] Speaker 2: Um, I have a question that or a couple of comments and a question that uh may feed into this. Um I wanted to talk about the responsibility of healthcare providers and healthcare insurance people. Uh

[00:43:53] Deane Neubauer: Can you do it briefly because we've got a number of people waiting.

[00:43:56] Speaker 2: Yes. I wanted to find out. It's um you know it seems to me that it's also a philosophical and a sociological question uh in addition to being, you know, purely uh cost-related that uh healthcare providers have a responsibility and healthcare consumers have a responsibility also. So, um I wanted to get your thoughts on that.

[00:44:21] Deane Neubauer: Um, I think our guests are in agreement with that. SY, they're they're both nodding anyway.

[00:44:26] Speaker 2: Okay. So So what is the responsibility on the part of healthcare providers to provide adequate um reasonable cost insurance or reasonable cost care to the people who can't afford it and make it more um you know take up some of the slack in the people who can't afford it.

[00:44:48] S. Y. Tan: Well, just speaking for the doctor, I mean a doctor has a moral obligation to treat patients irregardless of the ability to pay. On the other hand, a doctor, if he or she should treat only patients who are unable to pay, the physician himself or herself [unintelligible — audio glitch] not be able to to survive in this in this materialistic world. So there should there has to be some social policy that will help take care of those who are unable to pay. But a doctor's obligation is to the health of the patient, irregardless of of payment.

[00:45:18] Deane Neubauer: Dean, do you have any thoughts about Carly's comment? Yeah, I have a lot, so I'll give two quick uh things here. One is I think that we're we've always been ambivalent about the extent to which medical care is a business and uh as our previous conversation about doctor salaries uh suggested, we don't know how to factor that in and often as consumers or clients or patients we think that the system takes too much. Uh those who practice it see themselves working very, very hard [unintelligible — audio glitch] uh achieving just compensation. That's one side of it. The second side of it is Carly's question cuts into what is public policy debate in the United States about who should provide healthcare access, either through insurance or through direct services for those who are otherwise unable to afford it.

[00:46:04] Deane Neubauer: If you are born a child say with a an extreme medical condition like spina bifida to a poor family, back to the issue of healthcare is a right, what access, what kind of treatment should you have in that system? What is the society's obligation? If physicians have a moral obligation to treat everyone who needs medical care irrespective of need, what's the moral obligation of the society? That's precisely what we're debating or should be debating in our national healthcare debate. You you're not sure we're debating it now? I don't think so because I think mainly what we talked about last year were the ins and outs of um [unintelligible — audio glitch] health insurance reform. I think we got into it a little bit when when uh when when the president and and Mrs. Clinton decided that the issue of inoculations for children was so important given the the fact of declining inoculation for children, that the government should simply buy all the vaccine and distribute it to children free, that that was a moral obligation of the country.

[00:47:03] Deane Neubauer: It's the most effective kind of preventive medicine one can imagine, and it was vociferously opposed by by a very large number of vested interests because amongst other things, it would it would take the profit factor out of um out of vaccines. Okay. Thank you, Carly. We appreciate your call. We have James from Waialae Kahala. Good morning, James.

[00:47:23] Caller: Good morning. This issue has been touched on a little bit. Who ultimately will decide uh rationing in the case of heart or kidney transplants or prolonging the life of a so called baby without a brain and so forth.

[00:47:37] Deane Neubauer: Or a hip uh replacement for somebody 80 years old or whatever. SY, this is a great question. Tough question. Tough question. Let's begin and understand that if we had all the resources, if if our budget is huge [unintelligible — audio glitch] unending, then of course we'll provide all care for everyone, so long as that care is useful.

[00:47:58] S. Y. Tan: Now, having said that though, there are certain kinds of care that are very expensive and maybe useful to a lesser or greater extent. Care that is very expensive, but it's quite useless, what we've termed futile care, medical futility. Why we shouldn't provide those types of care because it's useless care, unnecessary care. However, if there's some benefit, and frequently there's benefit like transplantation, etc., why those those types of care should be provided. The question is, can we afford to? And if we have a limited budget, then we'll have to draw the lines at some place in at some point in in time. Maybe it's a transplant, maybe it's a hip replacement, maybe age becomes a factor and so on. This is rationing.

[00:48:42] S. Y. Tan: Um it is already with us, it is something which we have to face simply because needs continue to mushroom and our resources are limited. So where we draw the line becomes I believe, a public debate, which will involve many, many people consumers, uh providers, insurers etc. But some line has to be drawn and the Oregon plan is one such example and I know Dean has uh researched greatly in this area. Maybe he could speak on that.

[00:49:06] Deane Neubauer: Dean, you you've said that we've got the ability to spend ourselves broke in this country on on medical care. What's your reaction to James's question about rationing, rationing? My answer compassionately is that we have always rationed care. We have rationed care primarily on the basis of the ability to pay. We are now in a situation only for the last 20 or 25 years, which because of public policy and the particular affluence in the United States, where we have developed the idea that there should not be rationing in care. At the same time that we've developed that belief, medical care itself, medicine, medical medical science has produced a dazzling array of interventions that simply didn't exist 20 and 25 years ago, and they are very expensive.

[00:50:03] Deane Neubauer: So, for me, it's not a question of whether or not there will be rationing, it's a question of how do you approach rationing? Should it be a rational discourse? Should it be uh should it have to do with the uh the holding up of different kinds of values and saying how does this value play in this situation.

[00:50:11] S. Y. Tan: Yeah, because when you ration through pricing, which I think you've said we've done in in the past, that what you're basically saying is, we're going to treat this like a commodity, and the market will determine who gets what, and and you've got votes with with dollars. And if basic healthcare is a right rather than a commodity, then that's a value shift that was going to is going to make a big difference, I think.

[00:51:06] Deane Neubauer: Yeah, I think that's true. There I just want to say one other thing. I know we're short of time, but but we changed our consciousness in the last 25 years, uh last 30 years on this. I mean, if we just go back and read the literature of the 19th and the 20th century, it is just chock full of tragedy, the tragedy of of young children dying, uh needlessly because they had diseases, uh and and for medical interventions that were not made available, etc, etc, etc. Our public policy and the way that we've treated the magic our our notion of magic bullet medicine has led us to believe in the mythology that people are not going to suffer when they become ill, and I think that's a tragedy in our national consciousness.

[00:51:50] Deane Neubauer: Okay. James.

[00:51:52] Caller: A very good discussion. Thank you.

[00:51:53] Deane Neubauer: Thank you. We have a caller from Manoa, Melissa. Good morning, Melissa.

[00:51:58] Speaker 3: Melissa, good morning. Thank you. Um this my question comment has to do with managed care. Um as I understand it and I think this is what we're planning also for national um healthcare, is that um the insured individual has one physician that she goes to prior to going to any kind of other specialist. And um I myself find that um kind of insulting in for my personal um care and which it implies that if I have to go to see a gynecologist, I'm going to have to go to my um primary care physician to do that, or if I have to get my eyes checked, I have to go to the primary care physician which for my uh history of medical care increases the costs actually.

[00:52:53] Deane Neubauer: Melissa, you you've touched on the subject of gatekeeping uh [unintelligible — audio glitch] healthcare delivery. A gatekeeper, the primary doctor or a a family practitioner or a general internist, uh screening all cases before a specialist can see the patient. It will save costs. It will it will save dollars, but it clearly will inconvenience the patient uh in some instances, and it may in some instances, not not always in some instances, uh reduce um or do away with specialist care, which may in fact be useful and important.

[00:53:32] S. Y. Tan: So we've got some dangers here with the gatekeeping system. But you touched on I'm not sure how we resolve this entirely, uh except to say that perhaps one can have an option of going directly to a specialist if one is willing to pay a little more. It does come back to to the to the personal payment thing of personal choice.

[00:53:49] Deane Neubauer: So in in Melissa's case where she knows that she needs the specialist and that's exactly what the gatekeeper tells her, there was an added cost and inconvenience, but there may be two other people out there who go to the gatekeeper and find out they really don't need that specialist. Just briefly, Melissa in many managed care systems, the primary care gate gatekeeper is necessarily only for the first visit to the specialist. Every subsequent visit to the specialist takes place at the discretion of the specialist and and SY is exactly right. The issue here is gatekeeping on cost.

[00:54:25] Speaker 3: So how am I how big is this problem? Why is this so necessary?

[00:54:32] S. Y. Tan: Well, it is an important problem in that the thinking is that under managed care, you've got to have some gatekeepers to to streamline, to triage your cases and to treat cases most of which are relatively simple and and of a primary care nature. Yeah, but how big is the problem? Why is this being established?

[00:55:03] Deane Neubauer: Melissa, let me just try to do it by analogy. In Canada, 20% of the physicians are specialists and 80% are primary care. In the United States, that ratio is just the opposite. So many people are treating specialists as individuals of first instance. They go to them uh whether or not the condition that they bring to that person is appropriate for specialty care, and so it's a large cost problem. Thank you, Melissa. Thank you. You're listening to the Price of Paradise radio show. Today's topic is healthcare in Hawaii. With me in the studio discussing it are UH Professor of Political Science Dean Neubauer and UH Professor of Medicine SY Ten. We've had Fred Forton, who's the vice president of Community Relations for HMSA on the line listening to all of this, and unfortunately our our uh our wire hookup here is such that Fred can't hear when another caller is uh speaking and and vice versa. But Fred, I wonder if you want to take a minute or so to comment on what you've heard from the studio, and then I've got a couple of other callers waiting. Fred?

[00:55:56] Speaker 4: Yeah. I'd love to um uh I'd like to make a just a couple of series of um of clarifications that I think are important. Uh number one, I think that we got to remember on the preexisting issue that uh the overwhelming majority of coverage has nothing has no preexisting uh conditions to it in Hawaii. All of the employer group coverage does not, and it's for a very small percentage of the population that the preexisting uh issues come to bear on individual plans. Okay. Uh the second is uh regarding the Quest uh the primary Quest medical plan is still responsible for mental healthcare, basic mental healthcare, but the behavioral part of that, the carve-out, so called carve-out, is responsible for serving um seriously uh people with serious mental illness and expands the benefits available to them. So it's uh really we're looking at quite a uh a different a different uh scenario than we were prior to uh to the initiation of the Quest program.

[00:57:00] Speaker 1: I think so. I mean, this is a demonstration project, it remains to be seen. But I think the structure is somewhat different in the delivery of care. Certainly not the plans are responsible for providing this expanded benefit to these uh people who are seriously mentally ill.

[00:57:15] Speaker 2: Okay. Hang on just a second, Fred. Dean has a...

[00:57:17] Speaker 1: I just want to thank Fred for clarifying that for me.

[00:57:20] Speaker 2: Okay, and and Fred, for what it's worth, our guest in the studio were talking before the show and commenting that that it is awfully early to really evaluate quest. Okay. You have another point? Yeah, I have another point.

[00:57:30] Speaker 1: I think the moral question that Dean raises is is really one way of constructing it. It's the old question of social insurance. And that is that the young pay for the old, and the well pay for the sick. Uh, we have in some ways, come full circle, uh, back to that question in the early days of health plans, you have a community rate. Everybody paid the same rate, and, uh, um, that sort of equation was mostly in effect. Now, we have a very different situation with, with people who are well, or people who are young trying to pay less for the system, because they don't use the system as much as those who are ill, and who are old.

[00:58:09] Speaker 1: And we really do have to come back to uh, this, I think, moral paradigm where we, as a society, uh, accept the fact that we are going to have to have some uh, a measure of social insurance in order to make the system fair and equitable for everyone, because we are all going to pass through those stages.

[00:58:29] Speaker 2: So that's what Dean was talking about in terms of values, that we have to recognize those of us that are relatively young and relatively well, need to recognize that the other folks out there have a right to the uh, sort of of health care that we can afford to pay for and because it's it's not as great as what they might need.

[00:58:45] Speaker 1: Right, right, right. Uh, the last point I would like to make is that there is a new evolution in the sort of managed care health plans, that's called Point of Service plans. And these are plans in which there is, uh, either an HMO or what we call an IPA, which is, uh, uh, a, uh, an HMO built on independent practitioners.

[00:59:05] Speaker 2: And and HMO HMO is a system kind of like what people here in Hawaii think of as Kaiser.

[00:59:09] Speaker 1: As Kaiser, sure. That's a staff model HMO. And then there are different other models of HMO. But this new evolution and Kaiser has one and HMSA has one, is what's called a Point of Service. In other words, you have a basic HMO structure in place, but if you choose to to see a specialist outside of that structure, it is a covered service usually as a as a lesser benefit, but it is available to you. And I think that's that sort of uh, uh, model is becoming more and more popular. So you try to get the benefits of the HMO in terms of cost, and the coordination of care, which is one thing that wasn't pointed out, I I believe, in the discussion of the primary care provider.

[00:59:47] Speaker 1: It's not only a cost reduction mechanism, but it, I think foremost, it should be a a care coordination mechanism. That is, the records are in one place, you you have the oversight of the medications of prescribed by different specialists, etc. So, um, there are many, many different aspects, uh, to this.

[01:00:07] Speaker 2: Okay. And I think, Dean, that fits in closely with what you were saying before.

[01:00:10] Speaker 1: Yes.

[01:00:11] Speaker 2: Okay. Thank you, Fred. We we appreciate uh, your being on the line for the show and and sharing your thoughts with us.

[01:00:17] Speaker 1: You're welcome.

[01:00:18] Speaker 2: Um, we're down to the last minute and we've got several people on the line. I apologize to to you. If you'll stay on the line, once the hour is up, we want to, you know, talk to you by phone individually and make sure your questions are are answered. But in the last minute or so, what haven't we said? And I know that we've got about uh, three years of things that could be said, and we've tried to pour it into a one hour show. Dean, something that has to be said that hasn't been yet?

[01:00:46] Speaker 1: If we're going to control costs, we have to affect demand. If we're going to affect demand, we have to learn to be healthier people.

[01:00:53] Speaker 2: Okay. SY?

[01:00:54] Speaker 3: Uh, I think that's well said. One other point here. Um, we we've got to come to grips with the fact that, uh, the demand will always, uh, be there and will always grow, and uh, that, uh, we'll have to draw a line, uh, and we call this rationing, uh, somewhere, some somewhere here in this in this picture. And that those who and that a basic health care package, however, [unintelligible — audio glitch] is everyone's right. Uh, but to to have more, uh, to have everything, why, it will cost more, and that people should be able to opt to purchase this. This talks about two-tier medicine. The rich will get a little more, but uh, uh, I think this is just the way life goes. If the president gets sick, let me assure you he'll get much better, much prompter, much higher quality care than you or I.

[01:01:43] Speaker 2: Okay. Well, I want to thank our guests, UH professor of Political Science, Dean Newbauer, and UH professor of Medicine, SY Tan. The producer of our show is Suzy Roth. Technical direction is from Jeff Alardy, and helping this morning with the show and uh, answering the phones and and doing everything else that needs to be done here in the studio, is Jenny Tanji. You've been listening to the Price of Paradise Radio show. I'm Randy Roth. Aloha.

[01:01:23] Speaker 1: to have more, to have everything. Why? It'll cost more. And that people should be able to opt to purchase this. This talks about two tier medicine. The rich will get a little more. But, uh, I think this is just the way life goes. If the president gets sick, let me assure you, he'll get much better, much prompter, much higher quality care than you or I.

[01:01:43] Speaker 2: Okay. Well, I want to thank our guests: UH professor of political science, Dean Neubauer, and UH professor of medicine, SY Tan. The producer of our show is Susie Roth. Technical direction is from Jeff Eilardy. And helping this morning with the show and answering the phones and doing everything else that needs to be done here in the studio is Jenny Tanji. You've been listening to the Price of Paradise Radio Show. I'm Randy Roth. Aloha.

[01:02:18] Speaker 3: This is KHPR 88.1.