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SCOTT SIMON, host:

And as the health care discussion continues, there are many questions that linger. Donna Shalala was Health and Human Services secretary in the Clinton administration. She is now president of the University of Miami and joins us from her office in Miami, Florida. President Shalala, thanks so much for being with us.

Ms. DONNA SHALALA (Former Health and Human Services Secretary): You're welcome.

SIMON: One concern you've raised is that there is a shortage of doctors, and I wonder - if millions of more Americans get health insurance, can we fulfill it?

Ms. SHALALA: Well, the shortage is related to primary care. We have lots of specialists in this country. We'll need more primary care physicians. In part that gap can be filled by nurses. There are lots of examples around this country of nurse-led primary care facilities. But in addition to that, with all the advanced practice nurses that we have in this country and more to be trained, there is a special role for nurses in our expansion of health care for all.

SIMON: President Shalala, the 1990s and what happened to health care - proposed health-care overhaul during the Clinton administration - is seen by many people as a cautionary tale. You had a popular young president, support in the opinion polls, but in the end no result. What can the Obama administration learn from that?

Ms. SHALALA: Well, they've already learned a lot. For one thing, the American Medical Association, the insurance companies, the American Nurses Association, the AARP, the hospitals, everyone now has stepped up to the plate - and the most recent, of course, the pharmaceutical companies - and said, let's do health reform now. So most of the stakeholders are in fact part of the discussion and have stayed with the discussion, even as more controversy was created.

SIMON: Now, may I ask, are you involved in any capacity with the current administration's plans or aspiration to overhaul health care?

Ms. SHALALA: Well, many of the people that I've worked with over the years are deeply involved. So I've been in and out of Washington and certainly have had conversations with them. I think it's moving along and those of us that are experts in this area feel like that there has been substantial progress made.

SIMON: You oversaw the Medicare and Medicaid programs during the Clinton administration. Do you think, as some people suggest, that improving the efficiency of Medicare and Medicaid, there are gobs and pots of money to be discovered that could pay all that will be necessary to cover the - I guess it's 47 million uninsured?

Ms. SHALALA: Well, I think that Medicaid is drastically under-funded, so I wouldn't consider them in the group. Medicare, we certainly can get savings. Drug costs are much too high in the Medicare program, compared to the real costs of that a large program ought to be paying. And there certainly is fraud in the system that we ought to simply get out of the system. We worked on it very hard during the Clinton administration and had huge responses to our efforts to get rid of the waste and fraud in the system.

SIMON: When you talk about efforts made to root out fraud during the Clinton administration, let me just point out, it's 15 years later and there's still an awful lot of fraud.

Ms. SHALALA: There is. And some of it is locked into the legislation, because of the way we pay for the system. If you continue to pay on the basis of everything you do for a patient, everything you order for a patient, as opposed to having an integrated system, or bundling payments, so there's an incentive for the hospital to keep costs down and to coordinate care, then we're going to continue to have both fraud in the system and waste in the system.

Once someone is caught with fraud, they ought not to be ever reinstated. They ought to be banned from the program forever. We can clean up the Medicare system.

People love Medicare. If you ask the vast majority of Medicare recipients how they feel about Medicare, they say keep government out of our Medicare. Someone actually said that to me once. So I think that what's important here is to change some of the rules so that we can squeeze waste and fraud out of the system.

You ask every American what they think the highest priority ought to be and they'll say waste and fraud. But fundamentally, we have to stop paying on the basis of volume. We have to straighten this out. We've got to pay on the basis of value, on the basis of making sure the people stay healthy.

SIMON: Donna Shalala was secretary of the Department of Health and Human Services under President Clinton. She is now president of the University of Miami.

President Shalala, thanks for being with us.

Ms. SHALALA: You're welcome.

SIMON: And our coverage of the health care debate continues at the new npr.org, where you can also read the NPR Science Desk's health blog. Just go to npr.org/health.

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