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President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Final Meeting
Thursday, March 12, 1998

Agenda
Final Consideration of the Executive Summary and Chapter Ten

(1:11 p.m.) Secretary Shalala: I think what I'll do is move to the Executive Summary to see whether -- it's the one part of the report that we didn't agree on. I also want to point out to you that the Consumer Bill of Rights that we've already approved will be included as part of the printed document.

I think it was the Chair's view that the document ought to be stand alone, and even though it adds a number of pages that we've already put out in an interim report, it seems to me that when people ask about the Commission's report they are going to want the whole thing, not just what we've done today.

So, we will be taking the 70 pages that are in the interim report and printing that with the rest of this document, so that future readers will have a single document to work from.

But, let's look at the Executive Summary and see if anyone has any comments.

Governor Ray, you had a comment on the second paragraph.

Commissioner Ray: Well, I just think that we start now with a statement that makes it appear that the health care system is running along smoothly and everybody is doing the right thing.

I know why we put it in there, and I think it's smart and wise for us to not criticize everybody in the health care business, but it isn't exactly what makes you think we are in a crisis or that we're going to be by reading the first opening paragraph.

I was wondering, since I don't think we are going to change that, in the second paragraph where it says, "While most Americans receive high-quality care, too many patients can receive sub-standard care," I was thinking you could at least delete the word "can," because I think many patients do receive sub-standard care and we prove that point throughout the entire report.

Secretary Shalala: Without objection. Anything on page two? You have a correction?

Executive Director Corrigan: Since the last meeting, we received correspondence from several groups that questioned the data that are extrapolated. If you look at that first bullet on page two, the avoidable errors, the study that was conducted by Lucien Leape and his colleagues was based on a sample of hospitals in a particular part of the U.S. In a subsequent publication, Doctor Leape made an extrapolation from the original data to get to this 180,000 figure for those who died, as well as to get to the estimate of this being equivalent to two major airline crashes.

Well, apparently, several groups, and there was sort of an ongoing debate as to whether that extrapolation was appropriate, and we think it's best that the Commission avoid getting into that debate, that's really not our issue, and there are many studies that support this issue of errors.

So, we are recommending that we replace those two sentences, so let me read you what this would be replaced with. We thought we would cite two different studies, the original Leape study and the actual findings, which were in a peer review journal, and then a second study by another author that support avoidable errors. So, what we would put into this is, many Americans are injured during the course of their treatment and some die prematurely as a result of avoidable errors. For example, a study of injuries to patients treated in hospitals in New York State found that 3.7 percent experienced adverse events of which 13.6 percent led to death and 2.6 percent permanent disability. That's the actual finding from the Leape study, no extrapolation, actual finding.

And then another study, this would say, a recent study found that from 1983 to 1993 deaths due to medication errors rose more than two-fold with 7,391 deaths attributable to medication errors in 1993 alone. That's a study by Phillips Nicholas & McGlenn.

Secretary Shalala: Now, that's a national study as opposed to a New York study?

Executive Director Corrigan: Yes.

Secretary Shalala: We may have to clarify that --

Executive Director Corrigan: It's out of Lancet.

Secretary Shalala: -- because you are following New York data with national data.

Don, how does that --

Commissioner Berwick: That's a Lancet study that just came out, and I have read the abstract but not the study.

Leape's figures are the lowest reported in recent literature, we should know, so we are still on safe ground.

Executive Director Corrigan: Better to have the two.

Secretary Shalala: But, this is a solid way to put it, in your judgment?

Commissioner Berwick: Yes.

Secretary Shalala: Okay.

Any other changes on page two of the Executive Summary?

Commissioner Reardon: May I ask a question?

Secretary Shalala: Yes, Doctor Reardon.

Commissioner Reardon: Thank you.

Don, on the next paragraph are under-utilization they say, "For example, 18,000 people die each year because they are not using beta blockers," is that an assumption that they all would have lived if they'd been on beta blockers? Do we know how many would or would not have died had they been on beta blockers? I mean, we are throwing a figure out there, can we not say that many patients die unnecessarily because of lack of use of beta blockers?

Commissioner Berwick: That figure comes -- it's actually not cited correctly here -- the figure comes from, the Sumerai study showed under use of beta blockers in people over 65 years of age, extreme under use, only 21 percent got the beta blockers. So, Sumerai was able to document under use.

Chassen extrapolated Simerai's figures, combined them with the randomized trials on beta blockers, and said that if the randomized trials could be applied then on a national level it would be 18,000 deaths.

Commissioner Reardon: Here again, we are talking about an extrapolation, which makes me nervous about using absolute figures.

Commissioner Berwick: Yes.

Commissioner Reardon: I agree that the beta blockers are grossly under utilized, and the figure for under use is 21 percent.

Executive Director Corrigan: There actually is a difference here. The groups that we heard from, the Physician Liability Association, have I got that right, at any rate, had tried to identify and figure out how Doctor Leape and his colleagues came to the 180,000 figure, and they were not able to identify how he reached 180,000 from the extrapolation.

So, it wasn't entirely an indictment of extrapolations, it was the particular one that was made and whether there was an error in making the extrapolation.

But, we certainly can, if you think it's better, we can go back and cite the actual beta blocker results, the actual study results, rather than the extrapolated data.

Commissioner Reardon: If I may, I think the point we're trying to make, that there is a problem of under utilization of beta blockers, which would be very beneficial, and I'm wondering about the absolute numbers that we are using as --

Secretary Shalala: Let's get as solid as we possibly can in terms of, so that there's no question about -- if we are making the general point then we don't have to use the exact numbers.

Any other, Don?

Commissioner Berwick: We can do that off line.

Secretary Shalala: Perhaps, you and Tom could just work and make sure we get that accurate, okay, in the most solid way we possibly can.

Anything else on page two of the Executive Summary?

If not, we'll move to page three.

Commissioner Malone: Madam Chair?

Secretary Shalala: Yes.

Commissioner Malone: I thought that last time someone had mentioned using the term "the National Advisory Council for Health Care Quality," and I didn't know whether that had been settled or whether we were -- so, was this an omission that it's not the National Advisory Council or is this something we just didn't really agree on?

Executive Director Corrigan: It was our sense that there wasn't agreement on that. We did, however, talk about it at the staff level, it came up, but it was our sense that there wasn't agreement. That's why we didn't incorporate it.

Secretary Shalala: Other comments on page three?

Page four. Alan?

Commissioner Weil: On page four, the paragraph that begins in bold, "Group purchasers," the very last sentence, I would just request that it say a small but growing group of private employers have been pushing for greater focus on quality, and then say, while public purchasers have also been emphasizing quality, so it's not just the federal, it's public purchasers at multiple levels.

Secretary Shalala: Right.

Anything else on page four?

If not, we'll move to page five. Yes, Mary.

Commissioner Wakefield: I just have an addition on behalf of Randy, who is away from the table for just a second, so I'm carrying his water, Madam Secretary, and it is on the fourth paragraph that begins with, "The Commission is pleased...," at the end of that sentence, after the word "Americans," he would like to see added, an estimated one third of Americans, and employers and health plans have also voluntarily committed to assure these protections to an additional 60 million Americans.

Secretary Shalala: That's fair.

Commissioner Wakefield: Okay.

Secretary Shalala: Absolutely.

Anything else on page five?

If not, we'll move to page six.

We're going to wrap up the Executive Summary. Okay, the Executive Summary is done.

Let me, as we're bringing in the copies to finish up Chapter 10, say a little about follow-up. There will be a number of things that will be available. I will write, Secretary Herman and I will get together and write to you about the follow-up on the Commission's report, including the availability of senior members of the staff to follow up with you and any organizations you may belong to.

I was suggesting to them that we do a video tape presentation, in part because I would like my department around the country to hear a presentation on the report. We will make those available too, there will be a number of different follow-ups.

The staff will disband as of the 1st of May, though I'm trying to encourage at least a couple of people to stay on for the follow-up, so we could make sure there is a follow-up, but we will detail this in a letter from the two of us as to how we will wrap this up, including how we are going to make copies available and other kinds of follow-up, as well as bringing you up to date on where we think the legislative process are, and we'll periodically update you through this congressional session, in particular, I think as to how things are moving along, as well as how some of these are being integrated as we get responses from the private sector in particular as they integrate parts of these recommendations.

And, about the follow-up, particularly on the consuls that we've recommended, both the outside one and the inside one, the inside one will certainly require congressional legislation and will have to be linked, but we will -- you'll get from us a follow-up document and an easy way to get answers to questions inside of our organizations as part of how we are organizing ourselves. I don't know whether you want to say anything more about that, Alexis.

Commissioner Thomas: Madam Secretary?

Secretary Shalala: Why don't we see whether anyone has any questions. We can also do the details of tonight tomorrow.

Commissioner Thomas: Is it confirmed that the Bill of Rights will be printed in the same final report?

Secretary Shalala: Yes.

Commissioner Thomas: Okay.

Secretary Shalala: I've asked that it be done, so I'm assuming that it will be done.

Commissioner Thomas: May I take the liberty of just saying that I'm afraid that I have to leave now for an out-of-town conflict, but I just wanted to say before I leave that this has been the most professionally satisfying experience of my life, and I really have enjoyed my time working with this Commission. Prior to the most contentious issue of the entire Commission's deliberations I plan to exit stage left.

But, please know that I've enjoyed working with each and every one of you and thank you very much, I appreciate it.

Secretary Shalala: Thank you, Peter, for your leadership.

(Applause.)

Commissioner Thomas: No applause line necessary.

Secretary Shalala: Okay, thank you, Peter.

Do you want to -- I've gone through and said we'll communicate with the members of the Commission two weeks from now as to what kinds of follow-up we're going to do and what kind of materials we'll make available, including we actually want to do a video so that we can send it in HHS around the country to inform our employees about what's in the Commission, and we'll pass it out to other people just as well.

But, would you take us through what we are doing tonight and tomorrow, and let's do the mechanics right now, since they are reproducing them. I take it we are few minutes away from actually getting -- I don't want to start the discussion without having the document in front of us, though I'm prepared to take any other comments on Chapter 10, other than the areas we've already discussed, but why don't you go ahead and tell us about the mechanics, where people should be tomorrow.

Executive Director Corrigan: Is this something burning, Herb?

Commissioner Pardes: If I could just make one comment. I would like to just suggest, and I wonder if other Commissioners feel the same, that having been a participant in creating this product, that there are a number of us that want to be helpful in seeing that it sees the light of day and has as much impact as possible.

So, I'll just say for myself, I suspect you'll get virtually similar feelings around the room, that any way we can help we are happy to serve.

Secretary Shalala: And, you'll be the key people on explaining what all of us did.

I just want to make sure we get materials to you in a variety of different ways so that they are useful.

Alexis?

Secretary Herman: But, I think taking what Herb has said a step further, I think it would probably be useful, though, if we could maintain, at least for the next couple of months, that we would have some staff presence of those of you who will be able to speak in public forums, or if you are able to use the materials in some way, that we can have more of a coordinated feedback opportunity through some kind of speaker's kit even, in terms of talking points, what we'd highlight, and maybe target audiences that we'd be talking to.

Commissioner Pardes: That would be very helpful, I suspect. I know I already have included this in some of my presentations, and I imagine other people have as well.

If you can give us whatever you think might be helpful that would be very good.

Secretary Herman: Right.

Executive Director Corrigan: A couple of things. We had hoped to -- we do plan to put together sort of a strategy for how to inform key groups and constituencies, both at the national level and the regional and local levels, of the work that the Commission has done on both consumer protection and quality of care. So, we will put together a speaker's kit for you. We have put together a set of slides, which one Commission member has seen and asked that he might have a copy, and I'll go ahead and send them out to everybody after they are updated after today's meeting to actually reflect all the final findings, as well as other information that I think would be particularly useful to you in hopefully going out and speaking about the Commission's work. And, we'd certainly encourage you to do as much of that as you can.

But, from the staff level, we will put together a list of key associations, as I said, both national and state and local, and then try to identify Commission members that would be able to go out and speak and hopefully spread the word.

Secretary Shalala asked me to go over what you can expect sort of tonight and tomorrow. We are going to be making the final changes to this document, in fact, that's why half of the staff isn't here because they are out making the final changes to various chapters of the document. That is then sent off to the group that's doing the final editing and typesetting, and they put it together overnight. They will be working a good deal of the night to be able to have this ready tomorrow.

This evening, we do have the event that the Secretaries are hosting for you, that is from 6:00 to 8:00, and it's at the Department of Health and Human Services on the sixth floor, and we'll have arrangements for you to get into that building and that will be set up. I have someone checking on transportation as well, so we can make that as easy as possible for you. It's in Secretary Shalala's office.

Tomorrow, the event at the White House is scheduled for 2:40. We don't know exactly where in the White House it's going to be, but you will want to arrive probably right around 2:00, would be most appropriate, and since they haven't notified us as of the exact location in the White House, the last we heard it might be in the Rose Garden, but I think that depends in part on weather.

As soon as they give us a confirmation on that we will tell you what gate to go to, so hopefully we will know that soon. We are trying to get them to nail that down, but one way or another we'll let you know about those arrangements as well.

It will probably be about a week before we actually get the bound copies of this document, maybe even as much as ten days. We are trying to get that done as quickly as possible. As soon as we do get the bound documents, in the meantime we will be able to provide you with a hard copy, it just won't be the pretty copy with the cover and the actual final, but we will be able to provide you with a final copy within the next couple of days. We'll have enough ready for press tomorrow and others that need to get their hands on it quickly, but as soon as we get the bound copies we'll be sending those out to you, and we'll also let you know if you want to order sizeable numbers of them to distribute to groups, we'll be glad to facilitate that process for you as well.

Secretary Shalala: Questions for Janet about the follow-up on the Commission or any ideas people may have?

If not -- yes, go ahead.

Commissioner Malone: Janet, how long do you expect the event with the President to last?

Executive Director Corrigan: About 20 minutes to a half hour. And, we did plan to -- we will have some cabs lined up for you, because I know many of you are going to be trying to get to National or Dulles for 4:00 flights. We don't anticipate you'd have any trouble with a 4:00 flight, it may be a little tight if it's something before that, but 4:00 and later should be okay, and we'll have the transportation ready.

And, I did, by way of update, just before I came back I went and checked with the small group that are working on the statement, and they all nodded affirmatively that things were going well and they thought they were almost there. They are putting the final touches on. We have had it typed up, and they are making their final changes and somebody will be off copying those, so we do expect that they are going to arrive in just a couple of minutes.

Secretary Shalala: Now, assuming that what we are going to see is a proposed recommendation three, and some other paragraphs related to the broader discussion that we had this morning, is there anything else in Chapter 10 that anyone else wants to raise so that we can get those recommendations and have them stand alone? Don?

Commissioner Berwick: Two on what I hope is the non-controversial part of the chapter.

Secretary Shalala: Okay.

Commissioner Berwick: I think the chapter should be titled differently, error free is not technically where we can head. I would suggest something like reducing errors and increasing safety in health care would be technically better.

Commissioner Malone: That's friendlier.

Commissioner Berwick: That's friendlier, too.

Secretary Shalala: Friendlier, yes, exactly.

Commissioner Berwick: Because technically you mitigate the effect of error, instead of going to zero.

Second, I've received a number of phone calls from the community that's expert in this, cautioning us to be careful not yet to recommend a national error reporting system. It's not a political issue, it's a technical one, which is what level of aggregation is really helpful or not.

So, I'd like to suggest we just take a look at the language. Error reporting systems are essential, but a comprehensive national one may not quite be where we'd turn out to need to go.

Secretary Shalala: Okay.

Paul?

Commissioner Montrone: On page seven there's a -- the last paragraph before "variation in current remedies," there's a statement, I'll read that, "Implementation in independent external review by public and private, et cetera, is an essential element in reducing the number of Americans injured by inappropriate coverage denials." It's the word "essential" that I'm focused on.

Secretary Shalala: What page, Paul?

Commissioner Montrone: Page seven. It seems to me, I interpret that as saying that without this we cannot reduce the number of these individuals, and I don't think it's essential in that sense. I'm just wondering if we could have a better word.

Executive Director Corrigan: I'm sorry, Paul, I got waylaid, can you try it one more time?

Secretary Herman: Say it again, Paul.

Commissioner Montrone: That's fine, page seven, the paragraph before the subcaption "variation in current remedies," the word "essential," I'm reading the word "essential" as meaning without it we are not going to be able to reduce the number of these Americans, and I don't that that's quite the case.

Executive Director Corrigan: An important element?

Commissioner Montrone: Yes, important element or something.

Secretary Herman: So, you want to drop that word, Paul?

Commissioner Weil: I knew we'd have a chance to disagree before the day was over.

This was in our Bill of Rights, as part of what we felt people should have access to, and I understand the sentiment, but I think important moves us further away from where we were when we said everyone should have it.

Commissioner Montrone: Well, what do we suggest?

Commissioner Weil: I was so happy with essential I didn't give it any thought until a moment ago, but I can react to important and say I don't think that's where I feel like we were when we put it in the Bill of Rights.

Commissioner Montrone: Well, you do agree that we could find other ways, additional ways, perhaps, of reducing the number of such injured Americans, right? So, if we didn't do this we could still reduce it, right? So, you are good at words, Alan.

Secretary Herman: So, Paul, is your objection to the word "essential"?

Commissioner Montrone: That's my objection, I'd like to see the word changed to something important but not essential.

Secretary Herman: Significant?

Secretary Shalala: Tom, let's see if Tom can give it.

Commissioner Reardon: Paul, I'm going to disagree also. I don't think essential means it's the only way, but that it's a very important way, and the way we've felt, I think, we should go.

I'm not taking essential as being the only way.

Commissioner Montrone: No, but essential means without it you are not going to get it, it's essential, you have to have it.

Commissioner Reardon: And, I think it's what we found was the best way, and the way we wanted to go, and having external review.

Secretary Shalala: Critical?

Commissioner Montrone: Critical? We could say critical, if you want to say that we recommend it as the best way, that's fine. Do you like that better?

Commissioner Reardon: This wordsmithing, I think we are getting -- I don't think it's the best way and essential are any different. Who has their Webster's?

Secretary Shalala: It doesn't sound to me like we have any agreement on changing what we've got. Good try.

Do you have another one you want to try?

We are -- let me tell you where our little group is. They are coming in to lay out some language for us. They had a problem in the software they are using, they are typing up now and they are going to reproduce it and bring it right in to us. So, it's not a debate that's going on in there, it's the mechanics of the production process. They had a compatibility problem with the software, apparently, held up by technology.

Kathleen?

Commissioner Sebelius: Madam Chair, again on page four, I continue to be a bit troubled by the fact, and this is not at all a criticism of the Department of Labor. In fact, I think the Secretary has agreed with us before that in order to expedite grievances you need a grievance mechanism in place that really isn't there now, and the Department of Labor has never been given the resources or the mandate to do that.

We've talked about that on several occasions, but it never has actually appeared in the text. We continue to focus on expediting the process as opposed to actually having a system that can be expedited.

And, I remember Secretary Herman at the last meeting also echoing the fact she thought I was actually making a budget endorsement, and I probably am, but I think when we discuss internal appeals, and the Department of Labor looking at expediting, we also need to recognize that they may need resources to put in place a mechanism throughout the country to respond to complaints, whether it's 180 days, or 20 days, or two days, it doesn't exist now. So, expediting is a piece of the puzzle, but having the resources to do that is the other piece.

Secretary Shalala: Do you have a sentence suggestion, Kathleen?

Executive Director Corrigan: We are at the bottom of the page, the paragraph that begins, "On February 20..." --

Commissioner Sebelius: Right, yes, something that just talks about, yes, the resources needed to respond to consumer complaints.

I'm sorry, we are talking about the internal appeals system and the Department of --

Secretary Shalala: Page six, paragraph --

Commissioner Sebelius: -- two paragraphs.

Secretary Shalala: Two paragraphs. It starts, the paragraph starts -- read the beginning of the paragraph.

Commissioner Sebelius: Well, paragraphs four and five on page six talk about the Department of Labor looking at revising regulations and expediting appeals. I think we need a sentence to recognize that they may need additional resources to respond to the complaints as they come in. That's my concern, not that anything that's here be changed, but in addition to expediting we need the mechanism to respond, and the resources to respond, because they are not there.

Secretary Shalala: So, you just want to add a resource sentence. We can do that in the editing of it.

Mary and Steve.

Kathleen, did you have something else?

Commissioner Sebelius: No, I'm just wondering, I don't think it changes the substance.

Secretary Shalala: No, it doesn't.

Commissioner Sebelius: And, in fact, I think it's been agreed to several times, we just need to capture it.

Secretary Shalala: Mary?

Commissioner Wakefield: Again, I'm asking this question on behalf of Randy. I think I'm being asked to ask these questions by virtue of where I'm seated. But, this is a question, since he's not here, that he'd like to have raised, and that is on that very same paragraph beginning, "On February 20th...," his question is, is the 15 days on the third line, is that correct or should it read 15 -- or, is 15 days a typographical error? So, is it 15 days, or is that a typographical error?

And, related to that, he's also saying, can it be done in 15 days, is it necessary for it to be done in 15 days? And then, his last question is, should it be the same as Medicare, i.e., 60 days?

So, those are the questions he wanted to have raised.

Secretary Herman: It is 15 days, Mary, and there is a provision that provides for longer time for claims that are not complete.

Commissioner Wakefield: And then, is there any view on whether or not there should be some consistency between that number and Medicare's? The question was fully explored?

Shock to you, but I'm carrying your water for you.

Secretary Shalala: The idea that Medicare could make a decision in 15 days is overwhelming to me.

Commissioner Weil: Isn't the right answer that if he'll agree to consistent remedies we'll agree to consistent time lines?

Commissioner Wakefield: I'm sure --

Secretary Shalala: We'll leave that one out.

No, no, we are talking about non-urgent care decisions. What's the answer to this question for the staff?

Executive Director Corrigan: It stands as is, that's what the Department of Labor's position is.

Secretary Shalala: Yes, that's our position, based on the public comment period.

Executive Director Corrigan: We are just reiterating what their position is.

Secretary Shalala: Okay. So, we are just repeating what that position -- that it is really 15 days. Okay?

Any other questions about Chapter 10? We are going to get into the changes.

Yes, Beverly?

Commissioner Malone: I just want to mention, on page four, the first paragraph that begins under, "Identifying and reporting errors, Efforts by the medical profession...," and I'd like that changed to efforts by the health professions.

Secretary Shalala: Okay, but, well, we might say medical and other health professionals. Did someone get that change. Okay.

Go ahead.

Secretary Herman: Are we ready?

Secretary Shalala: Yes, Val?

Commissioner Halamandaris: Madam Secretary, it's a small point in the context of Chapter 10, and I'm making reference to the chart on page eight, which refers to the fact that there are 124 million people in ERISA covered points. Nothing is more maddening than inconsistent data in statistics.

In Chapter two, we use a different number, we use 122 or 123 million. May I make a plea to have a final read and make sure that we are consistent --

Secretary Shalala: Yes.

Commissioner Halamandaris: -- with the use of numbers?

Secretary Shalala: Yes, did someone get that?

All right, let's go.

Yes, we'll make it consistent.

Any other changes to Chapter 10?

I'm going to move to Sandra for presentation. We have the pieces, have we got it?

Sandra, why don't you talk.

Commissioner Hernandez: Yes, what is coming around to the Commissioners will be two documents. One of them is the proposed recommendation number three, which I'd like to go through first. This really picks up on the point, Betty, I think you made earlier this morning, and is one that I think, I hope, we can agree to.

On the one that's being handed out, if you would make -- I want to read it as it would be amended, there's two words that have been added to the copy going around now. Does everybody have one? Copies? Would you raise your hand if you don't have a copy? It's a very short one. That's it. "Proposed Recommendation Number Three," is what it says at the top of the page. "Policymakers should engage in a national dialogue regarding the current state of existing remedies for individuals in public or private plans who are injured as a result of inappropriate health care decisions. They should carefully consider the cost, intended and unintended consequences of both the status quo, as well as any revisions to existing policy."

Secretary Shalala: Read it again.

Commissioner Hernandez: "Policymakers should engage in a national dialogue regarding the current state of existing remedies for individuals in public or private plans who are injured as a result of inappropriate health care decisions. They should carefully consider the cost, intended and unintended consequences of both the status quo, as well as any revisions to existing policy."

There's two words that --

Secretary Shalala: She's adding two words, that's why I had Sandra read it twice to you.

Commissioner Hernandez: For grammar, it was important that we were looking at consequences intended and unintended of both the status quo as well as to revisions. That's the emphasis added in both.

The intent here really was in trying to reflect this morning's discussion and previous discussions, and the reality is that there is ongoing national dialogue about this. We think that this recommendation, we hope this recommendation serves to clarify what the later document, as we're going to propose to be amended, would reflect in terms of, in essence, a do nothing status quo scenario and what the consequences are or not of that, as well as consequences intended and otherwise, as we've heard articulated I think fairly clearly from Randy and others on the conference call about consequences potentially of revising existing policy.

So, I think that says, let's keep talking and keep trying to move this ball a little further down the court, and does add a recommendation to that.

Secretary Shalala: So, this recommendation also refers to the text change that you are recommending.

Commissioner Hernandez: That's correct.

Secretary Shalala: Would you please go to the text change, and we are going to take it all up at once.

And, would someone retype the proposed recommendation and bring it back in, so we have it in final.

Commissioner Hernandez: The proposed additional page that was handed out would, in effect, if you'd turn to page nine of the chapter as it was introduced today --

Secretary Shalala: We're talking about Chapter 10, the red line version.

Commissioner Hernandez: Chapter 10, page nine, where it says, "Issues for Consideration." What we would propose is starting that section with the recommendation I just read, and then following with the handout.

Secretary Shalala: Let me clarify that. The recommendation is going under the recommendation section --

Commissioner Hernandez: It's going on page one.

Secretary Shalala: -- on page one.

Commissioner Hernandez: And, it is also going --

Secretary Shalala: And, it would go here under "Issues for Consideration."

Commissioner Hernandez: -- as the beginning of that section.

Secretary Shalala: Okay.

Commissioner Hernandez: It would then follow, Secretary Herman and Commissioners, with the following three paragraphs, and let me just give some context to the paragraphs.

What we were trying to do here is summarize the varied expert testimony heard by this Commission on the issue of remedies, but does not draw a conclusion, it simply is meant to try to define, as we heard varied expert testimony on this issue. It does not attempt to say which is the right or wrong read on the situation, or to draw any significant conclusions, but we think it better articulates the positions that expert testimony gave to this Commission over the course of five or so panels that we heard from.

So, it does not lead us to any change in the conclusion whatsoever, it's added text that we think better captures the positions that we heard from expert testimony.

Secretary Shalala: Let me remind everybody where it goes. We are talking about page nine, the bold head is, "Issues for Consideration," the recommendation goes first and then the three paragraphs that describe, essentially, the testimony that the Commission has heard and does not come to any conclusions, but describes that testimony as a way of describing the issues in this debate.

Go ahead.

Commissioner Hernandez: Many Commissioners asked us to recognize in the text that there are multiple options, and the first paragraph, basically, sets forward that notion, that we've heard a lot of testimony, that there are different ramifications to individuals in public and private plans, and that multiple options should be carefully considered. It then lays out, fairly cleaning, I hope, the two relative positions about how aggressive to be in pursuing reform, or what the potential position would be on a status quo situation.

Secretary Shalala: Let me remind you again that the entire section, "Issues for Consideration," that you now see would go out, and what would be substituted is the recommendation and these three paragraphs. And, I want to give everybody an opportunity to read through this before I take comments on it.

Commissioner Sebelius: Madam Chair, I have just one question.

Secretary Shalala: Yes.

Commissioner Sebelius: In addition to the recommendation appearing as cited on page nine, would it also --

Secretary Shalala: Yes.

Commissioner Sebelius: -- appear on page one?

Secretary Shalala: It would appear on page one, too. So, the recommendation number three appears on page one, it appears again after "Issues for Consideration," we would strike what currently is in the section on "Issues and Consideration," and substitute the recommendation plus these three paragraphs.

I will now take comments on the proposal.

Tom?

Commissioner Reardon: I, Madam Secretary, would just like to compliment the group that worked on this. This is a contentious issue, it's had a lot of debate. It's very difficult for certain people at the table, I know, including Randy and others, and I want to compliment them. I think this is a good addition.

Secretary Shalala: Additional comments?

Alan?

Commissioner Weil: I just have a question. I completely agree with Tom, this is very nicely done.

On the recommendation language, it says, in the third line, it says, "inappropriate health care decisions," that could mean both plan denials and medical decision and, therefore, would get into the whole malpractice issue, and I just want to be clear that the intention is to raise this issue with respect to both of those subjects. Otherwise, I think we should be more precise.

Secretary Shalala: Sandra?

Commissioner Hernandez: I think we've heard from this Commission a sense that we need, in fact, to look at both. This is worded such that you can, in fact, do that, and it was quite intended.

It also reflects language in the text where we specifically talk about what we mean by inappropriate.

Secretary Shalala: Beverly?

Commissioner Malone: I think that the subgroup did an outstanding job. My question has to do with how many times "heard testimony from witnesses" is used throughout the statement. For example, in the third paragraph, in the first sentence, "The Commission also heard testimony," in the second sentence, and it's sort of very thoroughly repeated, repeated again and again. It would seem that if at the start you could say you heard testimony, that then you could say and the summary of that is as follows. It's as if we want to put it at such a great distance from ourselves that we don't want to be associated with it.

And, I understand that a little bit, but I would think that --

Secretary Shalala: Why don't we let Sandra respond to that. It's an editing point, I think, and a substantive point.

Commissioner Hernandez: It is both. I think the editing point is extremely well taken. What we were trying to exercise extreme caution about was not to be divisive by representing positions of specific Commissioners, although clearly some Commissioners would choose one set of expert opinions versus another.

Secretary Shalala: Yes.

Randy?

Commissioner MacDonald: Because I have been self-nominated on the grammar of this, I understand really very clearly the repetitious, but it is, in my mind, clearly by intention.

Secretary Shalala: Fine.

Marta?

Commissioner Prado: I was just going to ask Sandra, on the fact that we're going to put the third recommendation under that heading, none of the other recommendations are repeated as a recommendation throughout the document. And, I just think for uniformity, if we are going to put just that one recommendation, either we put all the other ones, or we don't put just one by itself.

Secretary Shalala: I think I -- Sandra, I think that's an editing point, but not necessarily a substantive point that Marta is making.

Commissioner Hernandez: It isn't, and if we are going to be consistent then what I'd ask is, is that we repeat the recommendations of the other two in the document, because it is a good preamble for this section.

Secretary Shalala: We'll figure out how to do that.

Other comments? I want to go around the room on other comments, specifically, on this recommendation from the group.

Gail?

Commissioner Warden: I'm fine with that.

Secretary Shalala: Okay.

Bob?

Steve?

Marta, you are fine?

Sandra? Okay.

Val, Don, Sheldon, Gerry, Governor Ray?

Commissioner Ray: Well, just not a very substantive matter, but the sixth line down in the second paragraph, "... to the extent necessary to allow damages," it seems to me like it ought to be for recovery of damages or restitution, or something.

Secretary Shalala: We'll figure that out.

Chris?

Sylvia?

Commissioner Ivie: Does the -- in proposed recommendation three, do we have to limit it just to policymakers? Is there any broader category of people that we might mention?

One of the great strengths of our debate has been that the public has had an opportunity, through our conversations and the various testimonies, to learn about this topic, and I would like them to continue to learn about it.

Commissioner Hernandez: I think that's a valid point. We could certainly say policymakers and other stakeholders.

Secretary Shalala: Okay.

Alan?

Commissioner Weil: How about, policymakers should lead a national dialogue, because we do need them in it, but then, they are bringing others in.

Secretary Shalala: But, the problem with the word "policymakers," it suggests that it's politicians as opposed to the private sector, too, and I think that we want to be careful about that.

But, Sylvia, I think your point is well taken and we'll figure out a way to broaden it. I think other stakeholders may do it.

Commissioner Montrone: I'll comment here. In the last paragraph, it seems to me that the thrust of paragraph two is we need better remedies. Then we go next into watch out for these remedies, and buried down there near the end, where we say "finally," that sentence there, "The Commission heard testimony that the current system has provided a framework...," et cetera, it seems to me that that should be the lead in to that last paragraph.

Secretary Shalala: Randy?

Commissioner MacDonald: Just move it up, reorganization.

Secretary Shalala: Just move it up, okay.

Randy, any additional comments?

Commissioner MacDonald: None.

Secretary Shalala: Mary?

Kathleen?

Commissioner Sebelius: Good job.

Secretary Shalala: Alan?

Richard, you are out of it.

All right. Done.

(Applause.)

Secretary Shalala: Let me congratulate Sandra for a masterful job, and thank Randy for his leadership.

(Applause.)

Secretary Shalala: And, everybody else.

And, let me turn over the Chair to -- Nan, you were great, and Ron and Alan, whoever, everybody that was in the pot, everybody who was in the pot -- let me turn the Chair over to Secretary Herman.

Secretary Herman: Thank you very much, Secretary Shalala, and let me again thank the leadership of Chapter 10 for getting us to this point.

And, what I'd like to do now in bringing the meeting to a close, is to take a few moments to go around the room and to literally give each of you the opportunity, or to go on the record with your fellow Commissioners, in terms of any final comments that you would like to make regarding the work, the report.

Obviously, we are not back to any substantive issues on the report, particularly, having just concluded the infamous Chapter 10, but certainly, I think it is an appropriate time for each of us to add our own expressions of commendation or any comments that you would feel appropriate at this time.

And so, I'm going to begin to my left, and to ask Alan if you would like to make any concluding comments for the record, Alan?

Commissioner Weil: Well, I have found this a very rewarding experience as well, without belaboring the points. I particularly want to thank the Co-Chairs for the incredible investment of time and leadership on this issue. I think this would not have happened without the personal involvement of the two of you, and I have enjoyed working with all of you.

I have in my back pocket a resolution to extend the life of this Commission for an additional year, and I would like to put that on the tape.

Secretary Herman: We'll rule you out of order on that last comment, Alan. Thank you for the other comments.

Kathleen?

Commissioner Sebelius: Well, I, too, have found this kind of a remarkable process. I must confess to being frustrated at times, but I think because of the importance of the work that we attempted to tackle here, the frustration is a natural outcome of arriving at some consensus.

I continue to be amazed that two Cabinet Secretaries have been with us on the kind of constant basis that both of you have. I expected, when I saw the names listed as Chairs, that there would be a brief cameo maybe at the front end, a couple photo ups, and, you know, some kind of signed picture, and I have been extraordinarily impressed with, not only the time and dedication given your schedules, but awed by the expertise that both of you brought to the table in the discussion. I don't have any doubt that the dialogue would have been far poorer had you not been here.

I know that I've learned far more than I have contributed to this process, and whatever happens with this on a national, local level, I certainly have picked up lots of resources to use in my job on an ongoing basis. So, it has been extraordinarily rewarding.

I'm sorry I cannot join you tonight or tomorrow. I regret that, because it would be nice to be there for the finale, but it's been a wonderful opportunity.

Secretary Herman: Thank you, Kathleen.

Ron?

Commissioner Pollack: I feel like I'm going to be an echo. I very much appreciate the work of so many people seated around this table, and I, too, would want to start with the two Secretaries.

As I said to Secretary Shalala, for the brief moment I was in the lunchroom, that I thought she, and I say now to you, Secretary Herman, the two of you are extraordinary leaders, you are extraordinary in handling a group dynamic that is very difficult. I think I learned a great deal watching the two of you. The two of you have very complimentary skills and served us very well.

I also want to say it was a good experience to work with various colleagues seated around the table, those who I agreed with, and those who I occasionally disagreed with. I found that the spirit of those discussions I thought was positive, and I hope that a lot of other difficult decision-making can be done with the same spirit that each of you brought to this table.

Lastly, I want to say, once again, this staff is extraordinary. This staff has performed so incredibly admirably. When I looked at other commissions that I've been interested in, though, not been a party to, I think one of the real differences is the quality of the staff work that has been consistent throughout this process. It's been done with cheer, under the most difficult circumstances, and when arms had to be twisted they were twisted with dignity, and I very much treasured having that opportunity to work with the staff.

Lastly, I want to say, as much as I felt I learned from the process, I hope all of us feel good that we've made a contribution to the American public. And, I think we have, and I hope that we see our words put into action.

Thank you.

Commissioner Wakefield: Well, I guess I'll just echo the echo.

I, too, want to say that it's been a real privilege to serve under the leadership of both Secretaries and the tremendous job that they have done. It's also been a privilege to serve as a subcommittee chair.

I would like to commend both of the Chairs and the staff as well, and to say that I found what I think were one of the strengths of this Commission to be its incredible openness to opinion, views that were expressed by people who were not Commissioners. So, for example, the fact that a web site was set up in order to better disseminate information, the fact that every time someone picked up the phone to call me and express a concern about some focus of our work, that when I referred them to the Commission staff, any one individual staffer, there wasn't one of those individuals from outside of this Commission who came back to me and said, my views weren't adequately addressed. So, the openness on the part of the staff I think was just commendable.

And also, the willingness to entertain and the encouragement to entertain views from members who testified before this Commission, so that there was always an opportunity for individuals to come before the Commission and have their views heard. I just really want to say that I think the openness with which this Commission was run is absolutely commendable, and it should serve as a role model.

The last thing that I guess I would say is that, well, two last points, one, I frequently thought about, in the course of our dialogue, about a quote that kept coming back to me, that was attributed to a journalist who was from Europe, and this was many years ago, he was commenting on the formation of the European Union, and this is what he said about the different countries as they struggled with that formation, he said: "We all share the same sky, we just have different horizons." And, I think all of us brought very different horizons to this discussion, but without a doubt in my mind every single person here at this table was concerned first and foremost, I think, about consumers. So, we all shared a same concern, we just brought different horizons. I think it was very applicable to the work of the Commission.

And finally, I guess my final point is just this, thank you to the staffperson who sat me between these two wonderful, bright, articulate individuals on this closing Commission meeting. I can't think of two individuals for whom I'd have greater respect about how well they articulate their views, even though I might not have always agreed with them, it has truly been a delight to work with both of them and the rest of the Commission.

Thank you.

Secretary Herman: Thank you.

Randy?

Commissioner MacDonald: Well, it's somewhat scary, Mary, because as Ron spoke I looked down at the notes that I had written, and what's scary, Ron, is that I was going to say the exact same thing. We have finally found common ground.

I actually think that we have found common ground many times. There's three components here, when you think about it. It's the staff, it's your leadership, the Secretaries, and it's us, the Commissioners. And, if you looked at what made this work in my mind was that there were four attributes. We had the chemistry, we had the candor, we had the maturity and we had the professionalism. And, I think when all is said and done, I'm not sure exactly what history will say, I was always fascinated by people talking about historians, but if there's one thing I would hope for it is that the historians would recognize those attributes as qualities that we should find in all of our government.

In addition to that, I would suggest that I hope that our efforts ultimately end up as the benefit for all of our fellow citizens.

Thank you.

Commissioner Montrone: Well, a lot of this is echoes. I can't help but agree with my colleagues.

I would just frame it like, what is the most impressive, what was I most impressed with, and I guess, number one, in addition to the leadership, especially the element of the leadership that decided this should be a consensus group, I think that was a brilliant, brilliant move, and I think that that set an atmosphere for a high level of civilized debate and respect for the views of others.

And, I think what Mary said about us coming from our different vantage points, I think the learning process that we all went through, having come from one specific aspect as a health care industry, and the respect that we gave each and every one of our other Commissioners, I think was a very impressive point to make.

The second one, again Mary brought up, which I think this looks like a Commission of 34 members, but really incorporated the thoughts and ideas of a much broader, broader region to the industry, and I think that our work will go on a lot stronger because of that.

I think that we -- I didn't expect this, but I think we are producing a report, but I think it's really we became a focal point for the debate, and I'm impressed by the fact that the debate that we've encompassed in this report is something that people can start with. We've martialed the debate, we've martialed the evidence, and people can begin, once again, to go from there.

I think, as I go back and look at high points, I certainly think that the high point, I tend to look at the entertaining side of things, will certainly remain Sheldon's retrying of that case against AT&T that he won five or ten years ago, right here in front of the Commission. All you members weren't present for that. And, there are other great high points, but that was the one, Sheldon.

So, I'm honored and very grateful for having the opportunity to participate with all of you on this project.

Commissioner Pardes: Well, I feel I'm speaking as a representative of the city, which is the national capital of civility, and I first want to indicate to Randy that I'm going to, as an ambassador from Ed Giuliani, I'm going to bring back that term of dignified arm twisting, because I think it can facilitate our campaign dramatically in New York.

Second, I think everybody in the room, I resonate to the comments regarding the extraordinary talent in the staff, the wonderful Commissioners that were put together, and the phenomenal leadership of Secretary Shalala and Secretary Herman, who, not only put an enormous amount of time and led the way, but also conducted this, I must say, in an atmosphere which made us feel as friends and really people trying to work out something together.

I think that for me we've accomplished a lot. However, I wouldn't be fully expressing my opinion if I didn't say that I think we are a work in progress, and that, perhaps, many of us in different ways have goals that we'd like to see for the ideal health system you never quite reach, and I think we made a number of steps in that direction, but I think there are going to have to be a number of subsequent efforts.

For me, it's intolerable that a number of people in this country don't have health insurance and that it's not for everybody, and I suspect there are others who feel that way around the room. And, on the other hand, we respect the many colleagues who also tell us about that very other critical side, which is the financial.

So, I'm delighted and will be a proud booster and advocate in our alumni association, which we are forming right as this closes, because we will probably meet on regular events, and do fundraising, and banner wagging, and I just want to thank you all for the experience, my experience, of being able to work with and learn from so many good new friends.

Secretary Herman: Betty?

Commissioner Bednarczyk: Well, so much has been said already, but I do want to add my thanks to the Co-Chairs who have shown such wonderful leadership, and to a fabulous staff who has worked with us all this time, and I can truly say they have worked.

But, I do want to say how impressed I have truly been with this whole Commission, with the openness, the honesty and the respect that has been shown for other people's views. It has truly been a privilege for me to have worked with all of -- everyone on this Commission and to have gotten to know them, and it has truly been a wonderful experience.

Commissioner Nudelman: I, too, want to echo all the kudos to the staff, which was truly outstanding, and to Co-Chairs.

The mutual respect that developed with the Commissioners I think is outstanding. I think those who have observed the openness of the meeting are not aware of the amount of tremendous contact that went on between individuals outside of the meetings, just one on one to share opinions and views.

My only regret in the whole thing is that we spent a lot of time and effort up in the northwest keeping the rain in California so you could come to Seattle, but you never really made it and we'd like to invite you all to come at any time.

Commissioner Ivie: My concern with the Commission, which I have greatly enjoyed and learned from, has been involved principally with the status of poor people, women and minorities in this country, and how they are faring in all of the changes that are going on in this country.

I was very gratified at the meeting at the White House yesterday to hear from a variety of women's leaders about how extremely impressed they are with what we have been able to accomplish for women in this country, who are facing all these changes. I think we need to take this as a first very important step in terms of amassing just a great deal of current important information to get it to poor people, poor people's representatives, minorities, minority representatives, so that the learning that has gone on at this table can also reach those constituencies.

And, I'm hopeful that the video that's being developed, and that talking points, and that the work of each Commissioner will bear the need of those constituencies to participate in what we've been doing here, because this is information that those constituencies desperately need, and we've put together something that I think, even now with our Chapter 10, those constituencies can understand and can move on in their own interests to get reform that is needed in all these different areas.

So, I'm very grateful for the opportunity to have learned and to bring this information back to those communities, and I share everyone's statements, it's been extraordinary.

Commissioner Queram: This has been a richly rewarding experience for me, and it has, indeed, been a privilege to serve on the Commission, and I agree with everything that's been said about the caliber of the staff, and the leadership from the Co-Chairs, and the participation of all of the Commissioners.

One of the observations that I'd make is, being involved in something like this provides you with an unexpected but very real bully pulpit to take the work of the Commission back into the communities or the organizations in which we serve or reside. And, I've been, at times, a bit dismayed, frankly, at the tendency of people who are considerably far removed from the work of a group like this, to dismiss it as somewhat immaterial, or insignificant, or in some cases to perceive it as a stalking horse for something that might be more insidious or harmful to a particular organization's interests.

And, I think one of those strengths of consensus process, and I choose to view it as that, as a consensus process, is it provides all of us, I think, with the ability to leverage our agreement on difficult issues to stand up for what we believe in as opposed to what we oppose.

And, I would just echo, I think, a comment made from both of the Co-Chairs to exhort all of us to provide leadership within our organizations and within our communities to ensure that all of the time, and the energy, and the effort that we've put into our recommendations on both consumer protections and quality does not end up simply on a bookshelf in various offices.

So, through all available means I think we have the ability intellectually and emotionally around the table to see that our work leads to significant improvements for all.

So, it's been a privilege and I appreciate it very much.

Secretary Herman: Thank you.

Commissioner Ray: First, I want to ask some forgiveness of Sheldon, because what I want to say is that I've listened to all of my fellow colleagues here speak so eloquently, and they had something to say, and they said it in brief, which means they are not lawyers.

I want to add my sincere thanks to you who are the leaders of this Commission. Janet, you've done an outstanding job, and when it comes to the staff I think the applause that you heard this morning speaks a lot louder than words for the significant contribution that you all made and the appreciation of this Commission. And, the two Secretaries, I don't know where there could be better leadership than what you have given this Commission. And, you know, what's interesting about it is, I'm a devout Republican, and it makes me feel kind of good to say that about Democrats.

This report is the result of a lot of good effort from a lot of people who are very intelligent, very knowledgeable, and brought a lot to the table. I think it's amazing the debate that was so civil, and yet, accomplished so much, the Bill of Rights being a beautiful example of how something was forged by a number of people with varying opinions, and yet, it is significant. And so, I would hope that all of us will not only speak favorably about that Bill of Rights, but will promote it, because it will help health care, and the delivery of health care, and the health of the people of this country.

I just would say thank you for giving me the opportunity to serve with this group of people and to observe the leadership of you people.

Secretary Herman: Thank you very much, Governor.

Gerry, I'm going to ask if we could take a break and go to Gail --

Commissioner McEntee: Sure.

Secretary Herman: -- who I've just been informed has a plane to catch. So, we are going to go out of order to you, Gail, so that you can catch your plane.

Commissioner Warden: I apologize for going out of order, but Kathleen and I are on kind of a tight time frame.

As a Commissioner, I would echo what's been said about the quality of the staff, and the collegiality of this Commission.

I guess my comments would be very brief about a couple things. Number one, I am very pleased with the products that have come out of this Commission, the Bill of Rights, the fact that we finally are putting on the table some national aims for the health system, and the fact that we, on the one hand, are admitting that there is room for improvement, but we also are proposing a way that this Commission can be followed through on through the public/private partnership.

One of the great concerns of our subcommittee was that the report would end up on someone's shelf and that there wouldn't be a way to implement it. And, I think the public/private partnership should allow us to do that.

And, the final thing I would say is that, when I was asked to co-chair the fourth subcommittee with Sandra, who I did not know before, I was willing to do it but I didn't realize what an opportunity it was to get to know her and what a great person she was going to be to work with. And, Sandra, I want to thank you for all you've done, too.

Thank you.

Secretary Herman: Thank you, Gail.

Gerald?

Commissioner McEntee: Sitting next to the Governor, and he said he's a devout Republican, I must preface my remarks that I'm a devout Democrat.

I would have to say that I think it's a remarkable document that has been produced on an extremely difficult subject.

When the Commission began, really with this kind of Commission that represented such diverging points of view on this subject, and probably on a lot of other subjects, to bring it all together in a document that has been accepted by all, and through a process that we don't, in the labor movement, use very often, I mean, you refer to it as consensus, but to a large degree it was unanimity. And, that's truly, I guess, one of the secrets of this Commission and the document that it produced.

I remember the first time I talked to Janet, and we had an argument about the formulation of the subcommittees, but I mean that the staff, and the leadership, and the Commission members that have all worked extremely hard to put it together, I think have done an absolutely remarkable job.

And, I think that it's a Commission and its work, somebody said earlier work in progress, and I think it will be a work in progress. It's important to note that it's already generated discussions in a lot of other places on the subject of health care consumers and on the basic subject of health care. I said earlier this morning that we've been talking in the AFL-CIO about diverging points of view, in terms of ERISA and coming together on an important issue, and I think that this Commission generated that kind of discussion, that kind of hallmark.

And, I think that the document will produce a lot of things in this country and across the country, and I would just applaud, as I said, the staff and the leadership, both Secretaries, and I guess I would ask Secretary Shalala, as I watched how she runs these meetings, and we in the labor movement have an awful lot of meetings, that besides receiving a document I'd like to take your gavel with me when I leave, Secretary Shalala, but it's been a pleasure and a remarkable experience, and I thank everybody that participated.

Secretary Herman: Thank you, Gerry.

Sheldon?

Commissioner Weinhaus: Yes. I'd like to say I am truly highly privileged, and have always felt that way, to be named to this Commission, having no constituency and simply working in the hustings.

And, I appreciate the work of the Chairpersons, and from my viewpoint of operating in a very contentious atmosphere most of my life, to really meet people who all were of good will and tried to reach agreement. It's refreshing for me.

From my own point of view, it was always a difficult problem because so many people, or so few people can really afford attorneys, or find attorneys in this case, and the fact that we might win some cases and alleviate these problems does not really address the question of what do we do for people. There is more people out there than attorneys can really afford to help or have the time to help, even if they wanted to.

And, we feel that while we are attempting to make law, unless we get a case in the Supreme Court where we do help to establish law, we do nothing. So, I feel particularly honorable to know that we have set a course here that, while we talk about sometimes litigation and other things, in fact, in my view, it will reduce litigation because it will help people to be able to speak for themselves and to take care of their own problems on their own basis.

Thank you.

Commissioner Berwick: I also feel privileged having been part of this really honored -- and I've never seen better Chairs, and I've never seen better staff, and I don't think I ever will. I'm very grateful to you all, and to my fellow Commissioners.

I want to say a word on the document. I think it's superb, the focus on improvement, the focus on the real issues we were asked to deal with, the level of documentation, the detail, this is an archival piece of work that will stand the industry in good stead for quite a while.

It doesn't say everything I wish it did, and I think everybody in the group feels that, but every time I felt that I took a step back and reminded myself, this is a trillion dollar industry in a 20-year transition, really. For the first time that I know there exists a document now to guide further direction and work toward real improvement and real change in the industry. That's a landmark, it's a threshold piece of work, and I expect it is important.

It will be important only to the extent, though, that people take action on it, and I do hope we all find ways to move this on to the next step, and speaking as Herb Pardes did earlier, as a Commissioner I look forward to any way I can help to move this into action. It ought to be a call to arms.

But, I thank everybody that's contributed to it, and I'll miss you all, although I won't miss Flight 1603 at 6:00 in the morning from Boston.

Commissioner Halamandaris: Madam Secretary, I, too, want to add my thanks to my fellow Commission members for allowing us to be together to discuss these issues.

I'd particularly like to thank the President of the United States. I don't believe anybody has mentioned him to this point, but last I heard there were about a 1/4 million people who put their names in who wanted to be on this Commission, and he selected the 34 of us, and I think that's damn good work on his part. So, we certainly want to give him credit, and, hopefully, we've vindicated the wisdom of his selection. I think that's to be proven yet, but for the most part we can say, each and every one of us, that we did our best.

I would like to echo the comments about the leadership provided by the two Secretaries, Secretary Shalala, Secretary Herman. I thought it was extraordinary. I think all of us learned a great deal from watching you, having the privilege of being in the same room with you for this period of time, it was a high privilege for us. I want to say that and put it on the record.

I want to thank the individuals who sacrificed most, and that is Janet's children, but for their forbearance and allowing us to share, share you with us, we could not have achieved everything we've achieved. And, I've said it before, I've seen a lot of Commissions, but I've never seen such an extraordinary staff. So, I commend you, too.

I think on the part of my Commissioners, we did something I hope we would do, which was people were able to take off their hats, whatever was the self-interest, I did not hear one person stand up here and say, in my industry, or this or that, I think everybody took off their self-interest and was considering the broader view of what is good for the American public, and I do think that is an extraordinary achievement.

So, I want to thank everybody. It's been a pleasure and a privilege to be here.

Secretary Herman: Thank you, Val.

Sandra?

Commissioner Hernandez: Thank you, Madam Secretary.

I, too, want to just express the privilege that I felt to be able to work with both of the Secretaries. It's always wonderful to watch other people try to chair consensus and diverging opinions, and it has been a very educational process for me. And, as Kathleen said, I think when you think about trying to come to a table and make a difference, you hope that you give at least as much as you are able to take away, and I took away a tremendous amount. I learned a lot from fellow Commissioners.

I want to give a very personal thank you to Ann Page, who I don't think as a subcommittee we've had the opportunity to do, but she really represents the entire caliber of your staff, Janet, but was really exceptional, not just in professionalism as has been expressed, but also in patience, tolerance and wisdom, which is a conglomeration of attributes for staff that I think is really quite accurate.

And lastly, let me just say that I hope we've changed the leftist image of San Francisco, so that we can sort of think of the bridge role of San Francisco, and now, Phil, I know who to blame for all the rain that we've had there.

It's been a real pleasure to serve. I am very proud of the document that we put together as a group and with staff. I do think that in two years, and in four years, we need to pick it up and sort of say, did we move it? And, if we have at all we've made a significant improvement towards quality in the industry, and that's something that I think we can all be proud of.

Commissioner Prado: It's so hard to find some words that sound a little bit more unique than have been said before, but I also wanted to thank the President, who appointed two great Co-Chairs, who hired wonderful staff, who led us in an incredible lesson in government into sunshine, as it should be, because I don't think that there was any issues that were not able to be discussed.

I want to thank Ms. Coochak for having kept us on our toes, and I want to thank the Commissioners, for me it has also been an honor and a privilege, and I'm very proud of the document, but I think that we would be remiss as a Commission if we did not take the step further about an issue that we have discussed, and while it was not the privy of the Commission that we don't stop looking on the issue of uninsured and that we don't forget about the many Americans in this country who do not have access to health care, and the universal access to health care would essentially limit the debate of quality in health care to a great deal.

I want to make sure that we all do our part to make sure that that is not forgotten after we walk away from this table.

Thank you.

Commissioner Chao: I would like to thank the Co-Chairs, as well as Commission staff, and I hope in the years to come the Americans will enjoy the benefit of the Commission work.

Thank you.

Commissioner Hunter: I would echo all the appreciation of the Co-Chairs and the staff. It feels like one of those rare occasions in one's life to see people perform in just such a stunning, stellar way that it makes you feel good, or makes me feel good, to see the quality of work that has been done for this Commission. It's really incredibly impressive.

I think that we collectively had an opportunity to assess and try and identify issues facing the health care system as the health care system itself was at this point of transformation. And so, it seems to me like we've all participated in a very remarkable and singular kind of process.

I think the thing that I feel best about is that, given the limitations within which we worked, which were very real, I nonetheless feel that we collectively stepped up to the plate and did our best to really assess what could be done to protect consumers and enhance quality as the American health care system goes forward. And, I just hope that we can see as our legacy that this document becomes a reality for all Americans.

Commissioner Reardon: Thank you.

I, too, want to say what a privilege and pleasure it's been for me to work with the Commission, have the opportunity to work with the Chairs, who through their leadership I think, we've forged two very important documents.

Also, it was a time to again renew an acquaintance to Janet Corrigan, who I had the opportunity to work with several years ago and her very capable leadership, but also I want to thank Beth Docteur for her tolerance and understanding as we worked through our subcommittee discussions, which at times I think we needed some real direction, and she was able to help us with that.

I think the most impressive thing to me with this Commission is the diversity of the Commission as we came together, we were able to work through that, we were able to bond together and the collegiality developed, and forging two documents which will be one. One is the Bill of Rights and, of course, the second is the Quality Improvement, but it's truly impressive to me that the diversity of the group was such that we had a common goal, and that was to improve the health care system and work together, and I thank you for that opportunity.

Commissioner Sharfstein: I'm quite proud to have participated in this sub-process with you all, everybody in the room. It's been a fabulous experience.

I think that the shift of the debate from cost to quality is a very important shift. We've been so obsessed in the medical marketplace with the issue of cost, that there's been too little concentration on quality, and I think the Consumer Bill of Rights and this report on quality will really help make that change.

I had the opportunity in the '70s to actually work as a staff to a presidential commission, it was the Commission on Mental Health, so I have a great appreciation for the kind of staff work that's taken place, and this has been, I think, without question, some of the finest staff work that I've ever seen, and Janet and your entire group has just been absolutely wonderful.

I learned a lot from the two Secretaries, in terms of how to chair a meeting, and I will certainly take that away. That's been very important.

I will not be there tonight because my board, it's a Quaker board, is meeting in Baltimore, so I will be dealing with a different kind of consensus tonight. I'm familiar with the culture, but I will be there tomorrow and hope that we can figure out some kind of reunion at some point, when we can bring the Commission back together and assess the impact of this work.

Thank you.

Commissioner Georgine: Secretaries Shalala and Herman, we've worked together for a lot of years, and I've always admired both of you, and you certainly have proven that you really can do a job and do it well.

I chair a lot of meetings in the labor movement, and I couldn't -- I can't even match you, I tell you, you were really fantastic, how you get things done.

We tried for consensus, but we have really long meetings. But, I also want to say that Janet and Ann were just fantastic, Sandy and Gail, my two co-chairs on our committee, were really wonderful and patient, and we had some sticky issues.

When you talk about consensus, and when you talk about the accomplishments of this committee, a lot of people suspect consensus, but when you see what happened late this morning, early this afternoon, where we came to consensus on the ERISA issue, it just shows how people working together, who want to get the job done, and want to do the best they can, can really put strong emotional feelings in their pocket and do what's in the best interest of the people that we're trying to help.

And so, this has been a great experience for me, it really has, and I really can't -- I can't go beyond what everybody else has said, except to say that this job was necessary. I think that, like everyone else has said, that we've really done a great job. It's really going to be a good thing. I think that we have to get people, we have to work at it, and we have to get organizations and people to adopt the Bill of Rights, and we have to continue to keep doing the kinds of things that we talked about here today. It's not easy task.

I worked with the First Lady on her health care program, and I know what disappointment is, and this is from disappointment, this is real joy, and I want to tell everyone here that, as a little body in the labor movement, I think that you all have really been super great. I've learned from all of you, and I'm going to really treasure these two days out of every month that you took out of my lifetime.

But, thank you very much for having me.

Commissioner Malone: I'm privileged to even speak. I'm delighted to be here, and I want to thank, of course, our outstanding Co-Chairs. I think that if you feel elevated it's just because you really do outstanding work with us, we know that.

I believe that the work that we've done in this Commission has been centered around the consumer, and I think because we lined it up with the consumer I think there was plenty good room for everyone to be here.

I think, sometimes it's very hard to find space in a group especially of 32 people, 34 at times, and I think that because it was about patient care, because it was about consumers, that that created the space, and it created enough safety for people to be candid, and for them to be -- for me to be as straightforward and caring as we possibly could be.

I want to thank my subcommittee chair, Sheila Leatherman, who is not here today, and I have to tell you that I did not like the idea of being put on a subcommittee. I love to hear everything at the same time, and so I like large groups, and so, the idea of breaking down into smaller groups was not something that I just would move to with affection. But, I found that the subcommittees was really the place of stability, was really the place where I started to get to know the people that I worked with, and provided a foundation for how then to work with the rest of the Commission.

So, I believe that the subcommittee work was just so essential to what -- essential, Paul -- to what we are doing now, and to get to know that I can always depend on Alan to do just this superior intellectual stuff that also makes good sense and that, you know, I don't have to carry the piece about minorities and poverty because I know that, I'm carrying it anyway just because I live it, but I know that Sylvia is going to come through and be there for me on that. So, knowing that different folks are carrying different pieces meant that I had the privilege of looking at a certain piece, and so I want to send a special note of thank you to all my physician colleagues around the table who continually heard me say, "change that phrase from medical to provider," and the willingness, and the openness, to allow that to happen.

A big thank you for all the encouragement that was received and given in this meeting, but also outside. The Commissioners were very encouraging of each other, so just a big, big thank you and a real privilege to be here and serve.

Secretary Herman: Janet?

Executive Director Corrigan: Well, I can't say how nice it has been to hear all of the comments around the table, and I really feel like it's been my honor to have been able to work with each and every one of you. This has been a very enriching experience and a very satisfying one that I just can't imagine how I'm ever going to top. It doesn't get much better than this, it's been a terrific year.

I would like to thank both Secretary Shalala and Secretary Herman for providing the leadership that they did, and I have learned so much under them, working with them, and also, in particular, Secretary Shalala for talking me into taking this job.

There were a few moments when I did question that decision after that early conversation with Gerry, but we got over it, and we found the middle ground, and we found a consensus and moved forward, and I think that's really what this whole process was all about.

I also want to thank my husband, who has been taking care of the kids, and reminded me this morning that as of Saturday morning he's going fishing for an extended period of time, and Richard, in particular, who has just been a wonderful colleague throughout this process, and was always there on those nights at 5:00 when I said I have to get out of here at 5:00 because preschool shuts down at 6:00, and he would stay into the evening and we just couldn't have done it without him, and he's really just been terrific, as well as all of the rest of the staff, truly have been just wonderful.

The other group that I think hasn't been thanked here, other individuals that I just want to mention, and it's really as a result of this open process, you've probably now all noticed that there really is quite a following that this Commission has. There are individuals from every major association in town, as well as quite a few who come from out of town, and they have had a lot of input into this process. We've received written comments, we received phone calls, and extremely helpful input that I believe has made this document much stronger as a result of their input, and not only those who come from associations, but individual consumers who have written to us and provided their comments and direction, I think, to the process has really been very, very helpful.

Now, I need to turn for just a second, I know it seems a little bit odd, but to some of the housekeeping issues before I turn it over to Secretary Shalala.

We'd also like to thank our faithful transcriber, Corbett Riner.

(Applause.)

Executive Director Corrigan: He's been with us since the first meeting.

Special thanks also go to Terry Porterfield-Fisher, the Director of Conference Operations at Natcher Center. She and her staff have been crucial to the smooth running of the three meetings, and a couple of other issues.

The event tomorrow at the White House will begin at 2:40 in the afternoon. If the Commissioners would please arrive at the northwest gate, which is on Pennsylvania Avenue, and you should arrive by 2:00 p.m. Weather permitting, the event will be in the Rose Garden.

Secretary Herman: Bring your coats.

Executive Director Corrigan: Bring your coats.

And, for the dinner tonight, which is in Secretary Shalala's offices at the Department of Health and Human Services, that's 200 Independence Avenue, S.W., if you would please take cabs that's probably the easiest way to get there.

And, just after we finish the closing comments, we do plan to -- the photographer is going to be taking a picture, so if all of the Commission members would please come forward we'll be taking a picture up here at the end. That would be just at the end.

Secretary Shalala: I think, Corbett, if you can get away from work and you'd like to join us at the White House, we'd be delighted to have you.

(Applause.)

Secretary Shalala: This has been a remarkable process. Over the course of the last 12 months, this Commission has shaped a national agenda. I think that I said 12 months ago that we were going to have to be nimble to be relevant to the national debate. We have done exactly that, and do not underestimate, not simply the patient consumer Bill of Rights piece, but the impact the rest of the Commission document will have.

The process that we set up, the new organizations, will be just as important, because all of us were anxious, not just to take a snapshot of the health care system, but actually to be able to get out ahead of it and to anticipate some of the changes that need to take place.

I want to thank Janet, Richard and Ann. They have been absolutely first rate. This as good as it gets, in terms of quality staff work. I'm delighted that after I interviewed everybody I went back to Janet and said, tell me what it will take to get you to do this job, and then I convinced Richard this was the right career move for him at the same time.

We have far exceeded my expectations, and I want to thank every member of the Commission. Just to get me to sit still this long is an accomplishment, but it's been very good for me, and I'm sure it's been just as good for Alexis, to sit through these sessions and to actually consume new substantive information and to hear the debate in terms of the impact it will have on our leadership of our departments in the years ahead.

And, since within this Administration we control about a third of all the health care expenditures in this country, the fact that we can translate, particularly, the quality agenda, we've already moved on the Consumer Bill of Rights, into what we do every day, I believe that this Commission will have had a remarkable impact.

I want to thank all of the Commissioners. It has been just a terrific group of people. I knew about half of you before we got started, and it has been a wonderful opportunity for all of us.

Also, I have been conscious, not only of the decision-makers who we obviously speak to in our fundamental responsibility to the American people to take steps that will improve the quality of their health care, given the substantial resources that all of us devote to health care in this country, but I also want to say something about the people who work in the health care business in this country, people that get up every day and they work in Sylvia's clinic, they are nurses, and they are doctors, they are health care workers, they work in home care that Val knows very well, they work in skilled nursing facilities, they work in nursing homes, and they have been made by the changes that are going on in the health care system more insecure because they don't see where their futures are going to be in the business. And, there have been layoffs in different institutions, their roles have changed within health care, and I hope they'll see in this document a vision that will provide for those who choose health care as a profession, whether they are at the entry level, or whether they end up working at the highest levels of policymaking, opportunity for quality jobs and to be part of this quality movement.

I have been very conscious of them as we've been working through this document, and I hope they see hope in this document, as much hope as the American people do in what the outcomes are.

And, finally, let me say to my colleague, Secretary Herman, Alexis Herman and I have been friends for 25 years. We've worked on and off together, but never in a sustained way. It has been a pleasure and an honor.

As I've said to everybody, I thought the idea of two Cabinet officers devoting this amount of time was just not possible, but I think we both made it possible.

Our personal staffs at the Departments have been very much an integral part of these responsibilities to produce us and quality documents and to make sure we were very much engaged in this process.

So, Alexis, to you, it's been a wonderful partnership, and let's not volunteer again for the next couple of years, but we have a lot of follow-up that I think we're committed to together, and, again, I think the word quality applies to the Commission and to the staff, and to the President and the Vice President's clear idea that this could be done, that it was possible to push the field to make improvements for the American people.

Secretary Herman: Well, thank you very, very much, Donna, for your kind words, and thank you for your leadership. It certainly has been my distinct pleasure to have served with you through this great work on this Commission.

When you said 25 years, you know, I'm always reminding Secretary Shalala, we no longer talk about old friends anymore, we talk about friends now of long standing. So, she's been my good friend of long standing, and when she first talked about it we thought of this idea of a consensus model, we both looked at one another and said, you know, this is a real risk that we're taking, but given the caliber of the individuals that the President has asked to serve on this Commission it's a risk that is well worth taking.

And so, I thank you for, not only your courage and your leadership, but for investing the time in what has truly been a remarkable experience and a remarkable process.

I want to congratulate and thank also each of my fellow Commissioners. I've learned from each of you, you brought your own unique style and wisdom to this table, including your tenth grade teachers, and we thank you for that, Randy. And, Val, as you talked about the President's decision to appoint this distinguished group of national leaders, I could not help but travel back to my own days in the White House when the President was making that decision. And, you are right, there was literally a line around the White House for all of the individuals that potentially would have served on this Commission.

But, I don't believe that even the President in his wisdom could have anticipated the candor, the professionalism, the real quality of work that has emerged from the group of individuals that have served around this table.

It's fair to say that we've had constructive comments, we've had constructive criticism, but the real proof now, I think, is to make sure that we have real constructive action to follow, and we've laid out, I think, in this document a real blueprint for that to happen.

I especially want to thank you for living up to the spirit of this Commission in the final hours, in the final minutes. I said I was, perhaps, a bit premature in talking to both the New York Times and to the Washington Post at the break, when they asked the question of whether or not we do anything more with Chapter 10, and I said that, "Perhaps, I shouldn't say this, but I can't believe in the spirit of this Commission that we won't rise to this last challenge," and we did, and I thank you for doing that, each of you.

I also want to thank you as your Labor Secretary for the extraordinary work that was done, especially on the whole question today of health care workers that is so eloquently laid out in this document. It is a real contribution to the overall discussion of quality health care in our Nation today.

And finally, I want to say that as we conclude this final meeting, that I hope that you will see this as a very important and historical beginning, and not the end, because you have truly opened a new door for all of us into the 21st Century to make sure that we leave here, I believe, united in a belief that while we have a great health care system in this country, through this work of this Commission you have proved that we can make it even greater.

I thank you for that and now I want to invite each of you to come forward, not only for the concluding picture, but to participate in the transmittal letter that the Secretary and I will sign now to the President and to the Vice President of the United States.

There's one thing I didn't say, and that's to you, Janet, to you, Richard, and to this entire staff, you've heard it going around this table, but I want to say it also for the record from me, you've been extraordinary. You've been essential, you've been critical, and for the chairs of this Commission you have been medically necessary.

(Applause.)

(Whereupon, the meeting was concluded at 2:55 p.m.)

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