TRANSCRIPT: 'Questions for the President: Prescription for America'

Medicaid. There are a whole host of rules both at the state and federal

level governing how health care is administered.

And so the key is for us to try to figure out, how do we take that

involvement, not to completely replace what we have, but to build on

what works and stop doing what doesn't work? And I think that we can do

that through a serious health care reform initiative.

GIBSON: But you say we have to figure out how to do that. Don't we

have to do that first, figure out so people have a good sense that my

medical care is going to be sufficient for me?

OBAMA: The...

GIBSON: That's what people are afraid of...

OBAMA: Well...

GIBSON: ... that they're not going to get...

OBAMA: ... absolutely, people are afraid of it. People are

Charlie Gibson President Obama & Diane Sawyer.

(IDA MAE ASTUTE/ABC News)

concerned -- they know that they're living with the devil, but the devil

they know they think may be better than the devil they don't. And --

and that's understandable.

Look, every time we've made progress in this country on health care,

there has been a vigorous debate. You know, senior citizens love Medicare now, but there was a big debate about whether we could set up Medicare. Children's Health Insurance Program, which provides millions of children health care across this country, that was a big debate.

So there's -- these things are always going to be tough politically. Let me tell you, though, that we actually do know in a lot of instances what works and what doesn't. What's lacking is not knowledge. We've been debating this stuff for decades.

What's lacking is political will, and that's what I'm hoping the American people provide, because genuine change generally does not come from Washington. Whether we like it or not, it comes from the American people saying, "It's time for us to move forward." And I think this is that moment.

SAWYER: And when we come back, Mr. President, from the break, we're going to be talking more about the centerpiece of this in many ways, primary care doctors and providers. And I'm going to turn to Hershaw Davis here, who's a nursing student and also an emergency tech at Johns Hopkins. Stand up, if you will, because how bad is our shortage out there?

HERSHAW DAVIS, NURSING STUDENT: It's bad, sir. Currently, our patient load is increasing due to patients not having access either to insurance or primary care. And I want to ask, what's the administration going to do to place primary care providers -- physicians and nurse practitioners -- back in the community so the E.R. is not America's source of primary care?

SAWYER: All right.

GIBSON: Let's leave that question on the table.

SAWYER: On the table.

GIBSON: We'll give you a second to think about the answer, and we'll take a commercial break. Be right back.

(COMMERCIAL BREAK)

ANNOUNCER: Questions for the President, Prescription for America continues. Once again, from the East Room of the White House, Charles Gibson and Diane Sawyer.

GIBSON: Mr. President, before we went to break, Hershaw Davis raised what is an elemental question, which is, any kind of new system needs to be built around primary care, and not all the specialists with all the tests, but primary care physicians who can then farm you out, in effect.

So how do we reorient the system very quickly to get better primary care and more primary care?

OBAMA: Well, first of all, we need more people like Hershaw, who are going to school and committed to the kind of primary care that's going to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously, training physicians, training nurse practitioners, that takes years of work.

But what we can do immediately is start changing some of the incentives around what it takes to become a family physician. Right now, if you want to go into medicine, it is much more lucrative for you to go into a specialty. Now, we want terrific specialists, and one of the great things about the American medical system is we have wonderful specialists, and they do extraordinary work.

But increasingly, medical students are having to make decisions based on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are going to make substantially less money and it's going to be much harder for them to repay their loans.

So what we've done in the recovery act, we've started by seeing if we could provide additional incentives for people who wanted to go into primary care. Some loan forgiveness programs, I think, are going to be very important.

But what we're also going to have to do is start looking at Medicare reimbursements, Medicaid reimbursements, working with doctors, working with nurses to figure out, how can we incentivize quality of care, a team approach to care that will help raise and elevate the profile of family care physicians and nurses, as opposed to just the specialists who are typically going to make more money if they're getting paid fee-for-service?

GIBSON: Is Mary Vigil in the room? Mary Vigil, there you are. You're a -- you're a medical student, right? Coming out -- and how much debt will you -- can we get a microphone to Mary? How much debt...

SAWYER: (OFF-MIKE)

GIBSON: How much debt will you have?

MARY VIGIL, MEDICAL STUDENT: I'll be in about $300,000 in medical education debt.

GIBSON: And you would -- you would like to go into primary care?

VIGIL: Definitely. That's -- that was my primary motivation in going in to medical school.

GIBSON: But you know you will be remunerated at a lesser level than a specialist?

VIGIL: Yes.

OBAMA: Right. And so one of the things that we've got to figure out is how to change that calculation. Now, you may still go into primary care -- and I hope you do -- but I don't want to make it tougher for you. I want to make it easier for you.

And one of the things that I'd like to explore -- and I've been working with the administration and with Congress is -- are there are loan forgiveness programs where people commit to a certain number of years of primary care. That reduces the costs for their medical education. That would make a significant difference.

GIBSON: But let me ask a basic question, which may sound silly and naive. But we've got 46 million people who are uninsured in this country.

OBAMA: Right.

GIBSON: And one of your goals, one of the goals of health care reform is to get those 46 million people insured.

OBAMA: Right.

GIBSON: We only have X number of doctors in the country. If you add 46 million people to the insurance rolls, you can't get an appointment now, Mr. President. How are you going to get an appointment then, when there's 46 more million people competing for that doctor's time?

OBAMA: Well, this is going to be a significant issue. First of all, I think it's important that, whatever we do, we're going to phase it in. It's not going to happen overnight.

If we provide the right incentives, I think we're going to start seeing more young people say that going into medicine is a satisfying, fulfilling profession, especially if we can eliminate some of the paperwork and bureaucracy that they have to deal with right now.

And I -- I have a lot of friends who are doctors, and they complain to me all the time about the administrative and business sides of the practice when they actually got into medicine because they wanted to heal people.

But I also think that one of the big potential areas where we can make progress is what Hershaw talked about, and that is, how can we get nurses involved in more effective ways?

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If you look at what's happening in some states like Massachusetts, where they tried to create a universal system -- and they haven't quite gotten there yet -- they have had a problem with an overload of patients.

But one of the areas where we can potentially see some savings is, a lot of those patients are being seen in the emergency room anyway. And if we are increasing prevention, if we are increasing wellness programs, we're reducing the amount of emergency room care, then that frees up doctors and resources to provide the kind of primary care that will keep people healthier, but also allow them to see more patients and hopefully give more time to patients, as well.

SAWYER: I want to turn to someone who thinks we should follow up on what we were talking about a while back, namely about, in some way, reducing the vicious cycle of lots of tests, lots of treatment, what's necessary, what isn't necessary, and saying that somebody has got to enforce this. It's not going to happen if somebody doesn't. And, by the way, he is James Rohack from Texas, and he is president of the AMA, the American Medical Association.

DR. J. JAMES ROHACK, PRESIDENT, AMERICAN MEDICAL ASSOCIATION: Thank you. Mr. President, clearly, when you spoke to us last week, you said that we entered the medical profession not to be bean counters, not to be paper pushers, but to be healers. And we totally agree.

How are you going to assure the American public that medical decisions will still be between the patient and the physician and not some bureaucracy that will make decisions on cost and not really what the patient needs?

GIBSON: Once again, we'll leave that question on the table.

OBAMA: All right.

GIBSON: You answer it when we come back from commercial break. "Prescription for America" will continue.

(COMMERCIAL BREAK)

GIBSON: So, Mr. President, you remember the question.

OBAMA: I do.

Well, first of all, I want to thank the American Medical Association. I did appear before them just last week in Chicago, my hometown, and had a terrific exchange of ideas. And we're continuing to work with all stakeholders -- doctors, nurses, insurers, and obviously patients, you name it. Folks out there are interested in seeing this happen.

The most important thing I can say, James, on this issue is, if you are happy with your plan and you are happy with your doctor, then we don't want you to have to change. In fact, if we don't do anything, if there's inaction, I think that's where the great danger that you lose your health care exists, because of the cost problems that I already talked about.

So what we're saying is, if you are happy with your plan and your doctor, you stick with it. If you don't have insurance, if it's too

much for you to afford, if your employer doesn't provide or you're

self-employed, then we will have what is called an exchange, but you can

also think of it as a marketplace where essentially people can compare

and look at what options are out there.

They'll have a host of different health care plans available, each

with their own physicians network. And you will be able to sign up for

the plan that works for you. We will help people who don't have

insurance get insurance.

Doctors are not going to be working for the government. They're

still going to be working for themselves. They're still going to be

focused on patient care. And in terms of how doctors are reimbursed,

it's going to be the same system that we have now, except we can start

making some changes so that, for example, we're rewarding quality of

outcomes rather than the number of procedures that are done.

And this is true not just for doctors, it's also true for

hospitals. One of the things that we could say to hospitals is, reduce

your readmission rate, which is also often a sign that health outcomes

have not been so good.

And it turns out that hospitals, when they're incentivized, actually

can find ways to do it that, every study shows, does not have adverse

effects on outcomes.

GIBSON: You keep coming back to that point, about, if you like what

you have, you can keep it.

OBAMA: Right.

GIBSON: I will return to that subject when we get to the issue of

the public option and whether the government should be in the insuring

business.

But one of the things when we talk about the kinds of changes that

may occur, the elderly are affected. Medicare will be affected.

Twenty-eight percent -- 26-28 percent of money in Medicare is spent in

the last year of life. The elderly are very critically affected.

Just a quick sound bite from a couple of people to lay out the

parameters of the problem.

(BEGIN VIDEO CLIP)

DR. MICHAEL JENSON, MAYO CLINIC: I'm Dr. Michael Jenson

at the Mayo Clinic in Rochester, Minnesota.

I see too many patients who have terminal illnesses or no hope of

recovery who receive weeks or months of intensive care unit treatment,

only to prolong their death. I find this approach very distressing and

the waste of money is appalling.

We just can't afford to provide all treatments to all people.

ROBERT WASSON: My name is Robert Wasson. My mother is 74

years old. She has terminal cancer in the stomach lining that has

spread to the lungs. She deserves to be treated medically to the best

of their ability.

To say it's too expensive is not right. I just don't think you can

put a price tag on quality time with loved ones, especially at the end

of their lives.

(END VIDEO CLIP)

SAWYER: And we have with us a couple of people who really represent

the opposite ends on this spectrum too. I want to talk, if I can, to

Jane Sturm.

Your mother, Hazel...

JANE STURM: Caregiver for 105-year-old mother: Yes.

SAWYER: Hazel Homer (ph), 100 years old and she wanted...

STURM: She's 105 now. Over 105. But at 100 the doctor had said to her, I can't do anything more unless you have a pacemaker. I said, go for it. She said, go for it. But the arrhythmia specialist said, no, it's too old.

Her doctor said, I'm going to make an appointment, because a picture

is worth a thousand words. And when the other arrhythmia specialist saw

her, saw her joy of life and so on, he said, I'm going for it.

So that was over five years ago. My question to you is, outside the

medical criteria for prolonging life for somebody elderly, is there any

consideration that can be given for a certain spirit, a certain joy of

living, quality of life? Or is it just a medical cutoff at a certain age?

OBAMA: Well, first of all, I want to meet your mom.

(LAUGHTER)

OBAMA: And I want to find out what's she's eating.

(LAUGHTER)

OBAMA: But, look, the first thing for all of us to understand is

that we actually have some -- some choices to make about how we want to

deal with our own end-of-life care.

And that's one of the things I think that we can all promote, and

this is not a big government program. This is something that each of us

individually can do, is to draft and sign a living will so that we're

very clear with our doctors about how we want to approach the end of life.

I don't think that we can make judgments based on peoples' spirit.

That would be a pretty subjective decision to be making. I think we

have to have rules that say that we are going to provide good, quality

care for all people.

GIBSON: But the money may not have been there for her pacemaker or

for your grandmother's hip replacement.

OBAMA: Well, and -- and that's absolutely true. And end-of-life

care is one of the most difficult sets of decisions that we're going to

have to make.

I don't want bureaucracies making those decisions, but understand

that those decisions are already being made in one way or another. If

they're not being made under Medicare and Medicaid, they're being made

by private insurers.

We don't always make those decisions explicitly. We often make

those decisions by just letting people run out of money or making the

deductibles so high or the out-of-pocket expenses so onerous that they

just can't afford the care.

And all we're suggesting -- and we're not going to solve every

difficult problem in terms of end-of-life care. A lot of that is going

to have to be, we as a culture and as a society starting to make better

decisions within our own families and for ourselves.

But what we can do is make sure that at least some of the waste that

exists in the system that's not making anybody's mom better, that is

loading up on additional tests or additional drugs that the evidence

shows is not necessarily going to improve care, that at least we can let

doctors know and your mom know that, you know what? Maybe this isn't

going to help. Maybe you're better off not having the surgery, but

taking the painkiller.

And those kinds of decisions between doctors and patients, and

making sure that our incentives are not preventing those good decision,

and that -- that doctors and hospitals all are aligned for patient care,

that's something we can achieve.