STEVE INSKEEP, host:
How to pay for medical problems like that is on the mind of the man we'll talk with next. He oversees President Obama's proposed budget - all $3.6 trillion.
Mr. PETER ORSZAG (Director, White House Office of Management and Budget): People often ask me whether I'm having fun, and my response is I didn't take the job to have fun and it's living up to expectations.
INSKEEP: Budget Director Peter Orszag is trying to make the numbers add up, and he says everything depends on a subject that is both complicated and politically explosive: health care. The rising cost of health care is a drag on businesses, employees and even state governments. And when the president himself tried to set aside budget money to expand health care, lawmakers turned aside his tax proposal to pay a big part of the bills - it's still not clear where the money's going to come from.
Still, Peter Orszag knows that his boss, the president, insists that Congress do something about health care this year.
Let's say that he gets what he wants. How is the world, or health care specifically, different a year from now?
Mr. ORSZAG: I think perhaps the way I ought to answer that question is that we would be on a path towards a much more efficient system. When you go to see your doctor, that doctor will have much more information about what specifically is likely to work for your diagnosis, and will have better incentives to be providing high-quality care to you, rather than just more care.
And, in addition to that, the number of uninsured people in the United States will be dramatically lower than it is today.
INSKEEP: I'm already interested in the fact that you didn't say that first. There's, you know, tens of millions of Americans - take your estimate - who don't have health insurance. You didn't give that as the very first thing that you want to change. You're thinking more about the cost of the system.
Mr. ORSZAG: Well, I think it's a package. We want to constrain costs and move towards a more efficient system. Part of that involves bringing in people who are currently left out of the system.
INSKEEP: How are you going to get the cost of treating and caring for the average person down dramatically? Down by half, say?
Mr. ORSZAG: Estimates suggest that as much as $700 billion a year in health care costs do not improve health outcomes. It occurs because we pay for more care rather than better care. We need to be moving towards a system in which doctors and hospitals have incentives to provide the care that makes you better, rather than the care that just results in more tests and more days in a hospital and what have you.
INSKEEP: You have just hit on something, though, that's going to worry some people. Because you're saying if I'm not feeling well, if I go to a doctor, you want to set the system to encourage the doctor to do a little bit less for me, not to run as many tests, maybe not to prescribe as many medications.
Mr. ORSZAG: Not necessarily less, but rather, higher quality. Right now, if you get sick - let's say you have that heart attack in Miami instead of Minneapolis or if you have the heart attack and then you go to Mayo Clinic instead of UCLA Medical. The car that's delivered to you is going to be dramatically different for reasons that can't be explained by medical science.
And the difficulty is that the places that do the more tests and that spend more times in the hospital and have you visit lots more specialists don't seem to generate better outcomes. More is not always better in health care, and we're wasting a lot of money because we have not transformed the system to take into account that realization.
INSKEEP: Is the patient part of the problem there? I'm thinking about the fact that if I take my kid into the doctor and the doctor says, well, we can do this, we can do this, my natural inclination is do everything. I don't care what it costs. I don't care if you pay, I don't care if I pay, do everything. And isn't that going to be the inclination no matter how rational you think it is to do less in some cases?
Mr. ORSZAG: In most cases, I think - this is not always the case - but in most cases, we tend to appropriately defer to the doctor. And that's why I think it's so important to make sure that doctor has the best possible information and also does not have distorted incentives to be tilting, perhaps, towards more intense approaches that don't actually yield better outcomes.
The other thing I'd say is, when you actually sit people down and say, okay, a more intense approach that involves lots of days in hospital, lots of tests, verses a less intense approach, in most cases, the people do choose the less intense approaches. And yet, the irony is, our current health care system has all of the incentives towards that more intense alternative.
INSKEEP: A few weeks ago we spoke with Stan Greenberg, who had been a pollster to President Clinton during a failed effort for health care changes in the 1990s. And he says that even now this is the most difficult issue that he polls. It makes people very nervous. How are you going to get past the political minefield in order to make serious changes where so many other people have failed?
Mr. ORSZAG: Well, I think there's a lot that's changed since the early 1990s. Partly, for example, legislative strategy. We are not marching up to the Hill with a huge binder and saying, here's the plan. Instead, we're saying, here are some ideas, and we want to work with you.
Secondly, since the early 1990s, health care costs have continued to rise and they are now a larger share of the economy than they were then. And then finally, in terms of the Congress, if you go up to Capitol Hill, you do get the sense that they want to get it done this year.
INSKEEP: What if you blow it? Your calculations are wrong, the politics prove to be a little messy, you don't get everything you need. What if it goes wrong?
Mr. ORSZAG: Well, yeah, we have to, again, compare it to the alternative. We are on a path that is fundamentally unsustainable. Even if things are not perfect this year, if we get 50 percent of the changes or 75 percent of the changes, that will be dramatically different than not doing anything at all. But let's hope that we get everything.
INSKEEP: Peter Orszag, thanks very much.
Mr. ORSZAG: Thanks for having me.
INSKEEP: He's director of the White House Office of Management and Budget.
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