June 24, 2009 -- Diane Sawyer spoke exclusively with President Obama on ABC's "Good Morning America," today about the prospects for passing a health care reform package this year. The following is a transcript of that interview.
DIANE SAWYER: Do you still expect to get health care by the end of the year?
PRESIDENT OBAMA: Yes.
SAWYER: If you don't, is it over for four years?
OBAMA: We're going get it done. So, I won't engage in hypotheticals in which we don't. And the reason its going get done is because the American People understand it has to get done. I travel all across the country. And I've done so for the last two years now. Every town I visit, every city I go, people ask me, you know, "Why is it that my premiums have gone up-- two, three times in the last nine, ten years? What can I do when my employer says to me, 'We just can't afford to provide health care anymore'?"
Governors who say Medicaid is-- breaking the bank. We're dealing here in Washington with a enormous federal deficit and debt that is largely driven by health care costs. So, with its families, businesses, or government, we know that we're going have to-- reform this system. And I'm confident that-- if everybody puts their minds to it, we can get it done.
SAWYER: I'd like to start with family experience of health care.
SAWYER: If I can. Because we hear over and over again, from both sides, from all sides, that we are locked in a vicious cycle of quantity not quality.
SAWYER: As one doctor wrote. We pay doctors for what they do to to patients, but not what they do for--
SAWYER: --patients. Is it time for Americans to recognize they're going to get fewer scans, fewer procedures, fewer tests, because the vicious cycle has to stop?
OBAMA: Well, I think what's important is to say to the American People that you should get the best possible care to make you well. And that the measure of the quality of care is not quantity, but whether or not it is making you better. Now, what we've seen is that there's some communities and some health systems that do this very well. Mayo Clinic, a classic example. In Rochester, Minnesota. People go there. They-- spend about 20-30 percent less than some other parts of the country, and yet have better outcomes.
And in other cases, you've got more spending, worse outcome. So, what we've said is let's put out the research. Let's study and figure out what works and what doesn't. And let's encourage doctors and patients to get what works. Let's discourage what doesn't. Let's make sure that our payment incentives allow doctors to do the right thing. Because sometimes our payment incentives don't allow them to do the right things. And if we do that, then I'm confident that we can drive down costs significantly.
SAWYER: Will it just be encouragement? Or will there be a board making Solomonic decisions--
OBAMA: Well, what I-- what I--
SAWYER: --about best practices? And--
OBAMA: What I've suggested is-- is that we have a-- a commission that helps-- made up of doctors, made up of experts, that helps set best-- best practices.
SAWYER: By law?
OBAMA: Well, what it does is-- that if we know what those best practices are, then I'm confident that doctors are going want to engage in best practices. But I'm also confident patients are going insist on it. Because one of the things they're going say is, "Well, gosh, Doctor. If-- if-- if-- what I'm hearing is, is that I just need one test instead of five. Am I paying for the other five?"
Employers are going start asking, when they're shopping around for health systems for their employees, "Are we getting the best deal possible?" So, I-- I think that-- we-- we shouldn't be overly cynical. In some cases, people just don't know what the best practices are. And certain cultures build up. And we can change those cultures, but it's going require some work.
SAWYER: But a lot of people when you read through the polling say they're very concerned--
SAWYER: "I'm very concerned that there's going be a reduction in treatment someplace in all of this." And-- and the question is-- if there is a board that is recommending, that's one thing. If there is a board that is dictating through cost or through some other instruction, that's another thing. Will it have the-- will it have the weight of law? Will it have the weight of regulations?
OBAMA: Well, first of all, Diane, I-- I think that we're still early in the process. All these issues are getting worked through. I-- I don't think that there's anybody who would argue for us continuing to pay for things that don't make us feel better. That doesn't make any sense. And that's the reason why, in America, we typically pay 50 percent more for our health care than other advanced countries that actually have better health care outcomes.
Obama: 'We're Going Provide a Menu of Options for People'
So, we want to go with what's smartest and going make us feel best. Number two, people right now-- I would dispute that their biggest concern right now is simply that-- you know, their doctor's going say, "You know what? You don't actually need this test. This is the better way to go." They generally trust their doctors. I think that the biggest threat that families are concerned about is the cost of health care that eventually is going-- mean they don't have any coverage. And we're seeing that everywhere we go.
And here's the problem. If we don't change. If we don't reform the system. Then people are going to lose their health care. Or it's going take a bigger and bigger chunk of their paycheck. Or their employer is going start dropping coverage. Or the Federal Government is going stop-- being able to reimburse everything on Medicare and Medicaid. And so, you know, the situation that we confront is do nothing. In which case, the trend lines are such that American families are going be more and more vulnerable. Or we make common sense sensible changes, based on good medicine and good science, which helps us to drive down costs. And allows everybody to have the coverage they need.
SAWYER: And the decision has not been made yet on who is going to be the-- the body that decides about best practices. About the--
OBAMA: Well, keep in mind-- I mean, I'll give you an example. Because I-- I think that-- there may be some confusion about what happens, in terms of public programs, like Medicare and Medicaid, versus the private sector. In public programs like Medicaid-- like Medicare, the Republican Congress, several years ago, instituted something called Medpak (PH), which every year recommends ways that Medicare could be more efficient. And provide the same quality of service to our seniors at less cost.
SAWYER: That cost--
OBAMA: The problem--
SAWYER: --is still going up.
OBAMA: And the reason is, is because Congress never implemented (LAUGH) any of these plans. So, part of-- on the-- on the public side, one of the things that we have said is, let's have this-- medical board actually-- you know, have a little bit of teeth. Let's allow recommendations that they make get voted up or down by Congress, as opposed to Congress just putting those recommendations into-- a file somewhere.
In terms of private plans, what we think is going happen is, we're going provide a menu of options for people. If you have health care, you can keep your health care. If you like your doctor, you keep your doctor. We're not going to-- tell that you've got to switch one way or the other. But like Federal employees, you will suddenly have a menu of options that you can take a look at. And we think that the forces of competition, good information, consumers are going be making good choices, all that is going help drive down costs, give people better quality, and allow more people to get coverage.
SAWYER: People have been hearing you say these-- these words about if you like your doctor--
SAWYER: --you'll keep your doctor period. If you like your--
SAWYER: --health plan, you'll keep your health plan period. Yet, I thought today in the press conference I heard you amend it to say, "If your employer decides to change it, we don't have control over that." So--
OBAMA: Whoa, whoa, whoa. But, of course, there-- I mean, that's-- that's the case whether we pass health care or not. I mean, the-- look, the-- the-- the fact is that right now, all across the country, people are losing their health care. Every day. You-- you can travel-- into Washington, D.C. And you'll find somebody on the street whose employer just dropped them from health care. Or who has decided to increase their deductibles. Or increase their premiums.
So, those choices are being-- made by employers constantly, right? I can't pass a law that says, "I'm sorry, employers, you can never make changes to the health care plans that you provide your employees." What I can say is that the government is not going force you to-- your employer or you to join a government plan, for example. If you're happy with it, and your employer's happy with it, keep it.
If your employer is not providing you the health care that you need, then we're going give you a set of options to make sure that you continue to have health care. And I think that is the kind of commitment that-- the American People expect-- and, you know, it-- and I think is achievable, as long as we stay focused on driving down costs, as well as expanding coverage.
SAWYER: On cost.
SAWYER: And I've been out with my pen and pencil all weekend.
SAWYER: Please tell me some of this is complicated for you.
Obama: 'The Burden Should Be on Those Who Say We Do Nothing'
OBAMA: It is very complicated.
SAWYER: It makes it hard-- for the average American Citizen--
SAWYER: --to follow a lot of this. $950 billion you've identified through the-- set aside, that you've talked about more than $600 billion.
SAWYER: A part of that is tax in-- tax deduction changes--
SAWYER: --for the high incomer. You say back to the Reagan years.
SAWYER: Twenty-eight percent. But Members of the Senate have said, "No, wait. We're not going do that."
SAWYER: Including the Democrats have said that.
OBAMA: I would say that it's early in the process. And-- look, if-- if you polled-- Members of Congress, or for that matter, if you ask me, what would be ideal. I would say, "I would like to provide health care for everybody very cheap, and-- no-- changes to the system at all." Right? I mean, we could-- it'd be nice if we could say, "This is going be easy." There's a reason why it has-- it hasn't been done (LAUGH) for 40-50 years. It's hard.
And-- this is a big system. It's a big part of the economy. But what we have done, as you've suggested, is we've identified $600 billion that will be reallocated from existing health care expenditures by the government, but-- expenditures that just aren't very efficient. They're not making people healthier. For example, $177 billion of insurance subsidies that we give to insurance companies, under Medicare, that haven't proven to make people who participate in those plans healthier.
So, that's where-- the bulk of the money's going come from. What we have said is-- is that we're going need some additional money, particularly on the front end, to make sure that people that don't have coverage or are underinsured are getting some assistance. And to do that, we've suggested that-- we should take the deductions that currently wealthy people, like myself or you, take. Drive them back down to 28 percent. If we did that, that affects two to three percent of the population. And we would raise enough money to actually make sure this thing is paid for. Now, Members of Congress may have other ideas about how best to do this. I'm happy to listen to them. I still think that's the best way to go about it.
SAWYER: You know about the vast skepticism out there that these numbers are going to add up. That this is going to happen. That this is going be sufficient to… cover an ever-escalating health care system. If you look at Medicare, there was a 25-year projection that it would cost, what? Some $12 billion. And it ended up costing more than $100 billion in 25 years.
OBAMA: And-- and that's because there were never any-- serious cost controls. There was never an attempt to actually to change the delivery system in a serious way so we weren't just paying people for doing more, as opposed to doing smarter medicine. Now-- I think the-- in this debate, the burden should be on those who say we do nothing. Because-- there's-- there tends to be-- the attitude of "We've got a great system, (LAUGH) and-- if-- we just don't mess with it. And-- there's-- you know, Obama folks aren't trying to do too much, that somehow we'll be okay." That's just not the case. Doing nothing means more people losing their coverage. Higher cost per families. Higher cost per businesses. And Medicare and Medicaid will go bankrupt.
SAWYER: If you don't get the tax--
OBAMA: So-- so, if-- so, if we-- if we don't make these decisions, we'll be worse off. If we do make these decisions, are there going be some difficult changes that we're going have to go through? Absolutely.
SAWYER: Are you--
OBAMA: But I think it's the course that will allow us to grow over the long term.
SAWYER: Are you open to taxing benefits?
OBAMA: I have identified the ways that I think we should finance this. I think Congress should adopt them. I'm going to wait and see what ideas ultimately they come up with. I suspect when they start saying-- what the options are, they might end up concluding that actually-- the options we're presenting are the best ones.
SAWYER: So, you're not going say one way or the other, at this point.
OBAMA: I don't want to prejudge what they're doing. We've put forward what we think is best.
SAWYER: Is there a point at which you will say, "I will wait. I will not accept it at this cost"?
OBAMA: Yes. I-- I think that if any reform that we get is not driving down costs in a serious way--
SAWYER: You won't do it?
OBAMA: If-- if people say, "We're just going add more people onto a hugely inefficient system," then I will say no. Because-- we can't afford it. If-- there aren't some basic game changes in the system, additional incentives for prevention. Encouraging-- you know, family care physicians. If we're not-- you know-- looking at what systems work best and trying to duplicate that. All those things that drive down costs. If those aren't in there-- then-- I'm not for the Bill.
Obama: 'The Status Quo is Unsustainable'
SAWYER: Listening to all this, riding the rapids here--
SAWYER: --as we approach this conversation. I just wonder, have you talked with Secretary of State Clinton about her experience? Have you--
OBAMA: You know what--
SAWYER: --asked her advice to this?
OBAMA: You know, I-- I mean, I've spoken to-- Secretary Clinton before. I've talked to President Clinton-- about this, in the past. And I think that they made a valiant effort back in '93, but I think there are things that are different between now and '93. I think businesses are feeling much more pressure from health care costs than they were feeling back in '93. I think that families have seen additional cost burdens. Higher deductibles, higher premiums, even if they have health insurance.
So, there's an eagerness to bring about change. Now, you know, the-- the devil you know sometimes better than the devil you don't. And I think that this debate is always vulnerable to scare tactics and people saying it's going be worse if we make changes. My simple point is that the status quo is unsustainable. So, change is going happen whether-- we pass a Bill here in Washington or not.
If we don't, then the change is going happen is-- is that the higher costs, more people suffering under-- prohibitions of pre-existing conditions. Drug costs that are soaring. You know, hospitals that are-- losing money. All those changes are going occur. It's just that we won't have planned those changes in a way that are better for the American People. And I'd rather guide the change-- and I think that's where most Americans are.
SAWYER: Will you accept mandates with fines for individuals if they don't sign up?
OBAMA: Now, mandates are an example of-- of something that I was resistant to-- during the campaign.
SAWYER: Against it during the campaign.
OBAMA: But I-- I have to tell you that-- this is an area where-- people have-- made some pretty compelling arguments to me that if we want to have a system that drives down costs for everybody, then we've got to have healthier people not-- opt out of the system. And-- I think that you have to be careful to make sure that there's a waiver. So that if we haven't made health care affordable yet, you're not punishing people, not only because they can't afford health care, but-- now giving 'em an additional fine.
And any program that we put in place, I think there will be some phase in period. So that we can calibrate and adjust to make sure that-- there really is affordability there-- before we start-- trying to penalize people. But-- I think-- my thinking on the issue of mandates has evolved. And I think that that is typical of most people who study this problem deeper.
SAWYER: Ninety-five percent-- you said today. See, I'm shameless on asking the human interest questions. But--
OBAMA: Yeah, I-- well, I-- this is-- a favorite for every reporter. So, the-- you know, I-- I've answered it as often as I can. I'm sure I will continue to answer it.
SAWYER: But is there a time of day that's the hardest?
SAWYER: Most people find--
OBAMA: --you know, I think-- I've answered that one.
SAWYER: I think people wonder-- at the end of the day, should we all be assuming personal responsibility in a different way. And should there, in fact, be some cost to all of us if we don't take care of ourselves. Or this new, "We're all in this together." We're--
OBAMA: I think everybody does have responsibilities. And-- I think that you're seeing most employers-- who provide health insurance starting to think about how can they ramp up wellness-- programs for their employees. One of the things that Michelle and I working diligently on is how can we-- engage-- kids to start-- healthy habits. And-- you know, and-- I think everybody understands that-- perfection is not the goal. But moving in the right direction is.
SAWYER: Thank you so much.
OBAMA: Thank you. Great to talk to you.
SAWYER: Great to talk to you.