One year ago today, President Obama signed into law sweeping changes to the nation’s health care system. The Patient Protection and Affordable Care Act re-organized a sector that accounts for one-sixth of the national economy. Some of its more popular elements have already kicked in. Insurance companies can no longer deny coverage to children with pre-existing conditions. And some preventative treatments are now free. But the law faces threats. In a mostly symbolic vote, the GOP-controlled House voted to repeal the Act as one of its first actions. And portions of it could be overturned by the Supreme Court. Health and Human Services Secretary Kathleen Sebelius on the health care overhaul law.


  • Kathleen Sebelius Secretary,Department of Health and Human Services (HHS)

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Health and Human Services Secretary Kathleen Sebelius responds to a caller in Nantucket, Massachusetts – a small-business owner who is paying $1,600 per month for health insurance coverage for her family of three, with a $5,000 deductible due to her son’s pre-existing condition. “At this point, unfortunately, there aren’t a lot of new provisions available,” Sebelius said. “Right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn’t have insurance who is coming through emergency room doors accessing the health care system, often in a very expensive way,” Sebelius said. The Secretary added that more insurance options for small business owners will be available in 2014 as the health-care exchange system expands:

Health and Human Services Secretary Kathleen Sebelius responds to a caller who objects to the part of the health care reform law that requires individuals to purchase health care. The caller argues that she and her family are in good health and don’t utilize the health care system enough to warrant having to pay for insurance cost:


  • 10:06:54

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Americans don't seem to know much more about the health care reform now than when President Obama signed that law a year ago today. A new poll finds 52 percent of the public admits they don't understand how the law affects them personally. Joining me for this hour is someone who can provide clarification, Secretary of Health and Human Services Kathleen Sebelius. She is here to talk about what's changed since the law's enactment, what's left to be done and the challenges they had, including what could be a likely showdown at the Supreme Court.

  • 10:07:54

    REHMThroughout the hour, we'll take your calls, 800-433-8850. Send us your email to Feel free to join us on Facebook or send us a tweet. Good morning, Madam Secretary. It's good to have you here.

  • 10:08:20

    SECRETARY KATHLEEN SEBELIUSThank you, Diane. Great to be with you.

  • 10:08:22

    REHMThank you. Health care reform passed one year ago today. Why do you think the public is still so confused?

  • 10:08:34

    SEBELIUSWell, I think the law is comprehensive, and it phases in over a 10-year period of time. And for most people, they haven't seen a big impact. If you have insurance through your employer, which a lot of Americans do, or if you're on Medicare, which a lot of Americans participate in, there have been relatively few changes so far and, frankly, for a lot of people with large employer coverage. So if they work for a big company or they work for the government, they really won't see much of a change at all, except that, hopefully, over the course of time, their health care will actually get better. We're driving some incentives to coordinate care better and have doctors and hospitals work more closely together, and the costs should come down.

  • 10:09:33

    REHMBut, you know, here's one of the first emails we've received this morning, and maybe this will enter into the confusion discussion. It's from a person named Jagdish, (sp?) who says, "Why did the administration hand over the microphone to the opposition right after passing the health reform law? People will believe when John Boehner repeats a million times that the U.S. has the best health system in the world and that the new health reform law will destroy that. And at the same time, the administration keeps completely mum and defensive."

  • 10:10:27

    SEBELIUSWell, I would tend to disagree about completely mum, Diane. I think that we have been not only advocating the law for the two years prior to the passage, but actually out and about every day talking about it. Doctors and nurses are beginning to engage in it. I think that, you know, health care is so personal. People really want to know how it impacts me and my family, not so much the theory, but what happens to me. That conversation is more complicated and difficult than bad things will happen. And, unfortunately, the opposition has been pretty good at quick sound bites and often lots of misinformation. What I'd love to be able to do with you is walk through a family who has seen some of the early impact of the law and talk about how each person in that family may benefit from what's in place so far and what's coming down the road.

  • 10:11:26


  • 10:11:27

    SEBELIUSSo let's take a woman -- since both of you and I are here -- who is a young mom and a small business owner. So she has been shopping in the insurance marketplace and had a difficult time because she doesn't have the size to negotiate for affordable coverage. She and her employees can be medically underwritten. So a company can say we're not going to cover your employee with a heart attack, or we're not going to do this because there are not many laws around the small group market. And she pays typically about 25 percent more for exactly the same coverage as does her competitor who has 1,000 employees down the street. So she's been in a bad place.

  • 10:12:16

    SEBELIUSShe also is a woman. So women in the insurance market could be given extraordinarily higher rates because they might get pregnant at some point in their lives, or the insurance company would just refuse to cover anyone who was a woman because of a potential pregnancy. Some of those rules have already begun to change. She, now, is eligible for a small business tax credit. So she can return about 35 percent of the amount of money she was spending on her employee coverage will come back into her bottom line. Good news for her. Insurance companies can't discriminate any longer...

  • 10:12:59

    REHMMm hmm.

  • 10:12:59

    SEBELIUS...against the kind of health conditions in the small group market. This woman is also a young mom. And she has a child who was born with a heart defect, but it got fixed. And the child is now five and totally healthy. That's a so-called pre-existing health condition. That child, for the rest of his or her life, under the old regime, under -- before Affordable Care, could be discriminated against by insurance companies at every step along the way. Insurance companies could deny coverage to that child. When her son became an adult, they could say, we don't want you ever in an insurance pool, or we're going to charge you three or four times as much as anybody else. That's now illegal in this country, thanks to the Affordable Care Act.

  • 10:13:48

    SEBELIUSChildren with pre-existing health conditions cannot be denied coverage, and they must be included in the health pool. By 2014, that will apply -- that same rule will apply to all adults. So young mom, business owner, not only has gotten a break for her employees, but she knows that her child will be able to get affordable coverage for the rest of his life. She's also -- like most young moms -- looking after her elderly parents, taking care of them, getting them to the doctors, following up on their medications. The parents are both over 65 and are Medicare beneficiaries.

  • 10:14:27

    SEBELIUSOne of the focus points of the Affordable Care Act is a stronger, better Medicare, and, Diane, this was one of the real disservice during the course of the debate, that opponents said Medicare will be destroyed, benefits will be cut, people will have a very difficult time. That often really scared a lot of seniors. Nothing could be farther from the truth. So young businesswomen owners' parents now have yearly annual visits that have become part of their guaranteed Medicare benefits, thanks to the Affordable Care Act.

  • 10:15:10

    SEBELIUSThey no longer have to pay out of their own pocket a co-pay to get the mammograms and cancer screenings that are recommended every year to identify cancer at the early stage because the Affordable Care Act has a premise that says getting preventive care is better than getting sick in the long run. And if they use a lot of prescription drugs, they're already seeing a discount on the prescription drugs they use, so Medicare has gotten stronger. Small business owners are seeing some benefits. And children with pre-existing health conditions no longer have to worry that they'll be shut out of the insurance market.

  • 10:15:47

    REHMAnd I can see that we already have many callers who'd like to join the conversation with Kathleen Sebelius. She is secretary of the U.S. Department of Health and Human Services, the nation's highest ranking health care official. She served as governor of Kansas from 2003 to 2009. You can join us, 800-433-8850. Send us your email to There's a big if in everything you've said. And that big if is what happens if the courts overturn not just a portion of this law, but find the whole shebang to be unconstitutional?

  • 10:16:56

    SEBELIUSWell, clearly, that would go back to square zero. But I think that that possibility is highly unlikely. And I say that not just because of the confidence I have in our legal advisors, but in what's happened so far in the federal courts. Thirteen federal judges have dismissed the challenge against the law altogether, just threw it out, said, we're not even going to look at it. The law is fine. There are five judges so far in different courts, in different parts of the country who have ruled on the merits, and not just procedural issues but looked at the whole law. Three of those five, including Judge Kessler, recently here in Washington, D.C., have said the law is fully constitutional, and it should move ahead.

  • 10:17:45

    SEBELIUSOne of the judges, a judge in Virginia, said one portion of the law is unconstitutional, but full implementation should continue. We should go on about our work. And one judge in Florida said one provision is unconstitutional, but he -- one could argue is sort of a judicial outlier -- said the whole law should be struck down and all implementation should stop. He then reconsidered that decision and essentially issued a stay on his own decision and said, implementation should continue until the Supreme Court. So, I think, the numbers would suggest that the vast majority of judges find the law to be constitutional.

  • 10:18:31

    REHMKathleen Sebelius, secretary of the U.S. Department of Health and Human Services. Short break. We'll be right back.

  • 10:20:03

    REHMAnd welcome back. Secretary of Health and Human Services Kathleen Sebelius is with me. We are talking about the health care law, which was passed a year ago. Today, here is Sen. Lamar Alexander's statement on the first anniversary of the health care law. He says, "I will continue working to repeal this law and replace it with reforms that lower costs step by step, so more people can afford insurance rather than expanding a system that already costs too much." How do you respond?

  • 10:20:51

    SEBELIUSWell, with all due respect to Sen. Alexander, who has been in the Senate for some time, there really wasn't a great suggestion by the Republican senators of what is the alternative to comprehensive health reform.

  • 10:21:09

    REHMWhy do you think that was?

  • 10:21:11

    SEBELIUSWell, I think that, while some ideas were talked about, there was never really a great interest in taking on the status quo in addressing not only the now 50 million Americans who have no coverage at all, but also those Americans who are underinsured, struggling every day to pay bills and the cost increases year in and year out. So looking at a comprehensive reform bill that both looks at how to lower overall cost -- and there are some very exciting ideas coming out of the health care community about how to do that. Actually, delivering better care at a lower cost is going on in some pockets of the country right now but is not there universally. And, frankly, the Medicare system, the payment system encourages people to do more -- more procedures, more tests.

  • 10:22:12

    SEBELIUSThat's how you get paid right now, not necessarily what happens to the patients.

  • 10:22:19

    REHMSo is it your belief that Republicans did not come up with their own proposals because they didn't want any health care reform, or because they simply wanted you to come up with your own plan?

  • 10:22:41

    SEBELIUSWell, I think, Diane, if you look at the history of this debate, Republican and Democratic presidents have tried for 70 years to promote some kind of comprehensive health reform. The last really big step was the passage of Medicare and Medicaid in the mid-'60s. That's been a long time. And if you think back on those days, it's almost impossible to think about a country where half of the seniors had absolutely no health insurance. That's the state where we were in the mid-'60s.

  • 10:23:15

    SEBELIUSAnd, now, really, we're looking at the rest of the population who both were uninsured but also those who are insured. We're looking at double-digit rate increases year in and year out. So addressing the underlying cost, addressing the fact that America spends two-and-a-half times what any country spends on health care. And yet our health results don't really measure up to what's happening in many countries in the world. We have ways that we can encourage doctors in hospitals to work better to keep folks out of the hospital in the first place, to...

  • 10:23:52


  • 10:23:53 on health and wellness and preventive care.

  • 10:23:55

    REHMSo much of health care costs currently go toward the end of life.

  • 10:24:03

    SEBELIUSWell, it's both end-of-life, but it really is acute diseases, people who have multiple chronic conditions. Two of the major factors that lead to those chronic conditions are smoking and obesity. If, in this country, we seriously try to tackle those two issues, drive down the smoking rate, which has been pretty flat at 20 percent for almost a decade, and really help people adjust their diets and adjust their exercise, we can dramatically lower health care cost by not having as many people end up with diabetes or chronic heart condition or strokes, all of which are directly as a result of those conditions.

  • 10:24:48

    REHMBut you've heard, as I've had -- as I have, the criticism, for example, of Michelle Obama, the first lady, trying to get people focused on the right kind of diet and the right kind of beginning, fresh vegetables and fruits for young children, saying the government should not be talking about what I eat or how I choose to eat.

  • 10:25:21

    SEBELIUSWell, I think what we need to do -- and I believe this very strongly -- is get information into the hands of consumers so parents can make choices for their kids. I don't know a single parent who wants to have a child who is sick for the rest of his or her life because of what they ate in their younger years, or says, I really would much rather not have the information about what kind of food is healthy for my family and not. So part of this is really empowering parents and others to make good decisions, getting information on the front of a cereal box, making sure that people understand what the difference is between fresh fruits and canned fruits, how to make better choices.

  • 10:26:12

    SEBELIUSIt's also what we're feeding our kids in school. A lot of children get a lot of their nutrition by the breakfast and lunches that they eat in schools. And part of the effort is really to serve better food. That certainly is something that we all should encourage, I would think. We want our children to have better food when they go to school.

  • 10:26:34

    REHMBut aren't you, to a certain extent, talking about an idealized lifestyle when so many people in this country move toward fast food because they find it quicker, cheaper? That's what the kids want. They don't read labels. They just buy.

  • 10:26:57

    SEBELIUSWell, I definitely think we've gotten into a, you know, quicker is better and people are very busy. Again, I don't know a single parent -- and I'm a parent myself of two kids. I have a busy work schedule and trying to, you know, drive car pools and get the boys to sports. I still wanted to know how to keep them healthy, how to make them better. Any information that I could get about choices I could make was helpful to me. Nobody is saying we're going to have rules for parents. It's information. And it's letting people make good decisions and better decisions for themselves and their families. And I think people are excited about that.

  • 10:27:39

    REHMAnd here's an email from Joseph in Cleveland Heights, Ohio. He says, "So happy when health care passed, but now my wife is coming off COBRA. She has pre-existing conditions. She -- the only thing available is a less than great plan: $5,000 deductible, 50 percent co-pay, at a cost of $1,400 per month. This is not reform of any kind. Why did the law put the six-month no insurance requirement in? It left out the work of coming off COBRA. What else is available?"

  • 10:28:32

    SEBELIUSWell, unfortunately, Joseph is right. For -- right now, the option for adults, like his wife, with a pre-existing health condition, COBRA was her work-related insurance, which she can keep in place for 18 months and then it expires. So there are new high-risk insurance pools available in every state in the country for those adults. But they do require a six-month gap between the time that you had available coverage and the time that you come into the risk pool. It was the same kind of gap that Congress wrote into the new CHIP health insurance when it was passed.

  • 10:29:15

    SEBELIUSThe good news for his wife is that, in 2014, when the new marketplace is up and running, his wife and others like her -- all the adults with pre-existing health condition -- will have some new choices. Companies will no longer be able to deny coverage to adults with pre-existing health conditions. But that is only the law right now for children.

  • 10:29:39

    REHM2014 is...

  • 10:29:41

    SEBELIUSIs a long way.

  • 10:29:41 a long way away.

  • 10:29:43

    SEBELIUSAnd we're trying to have a bridge strategy. There are lots of people, Diane, who are suggesting we're moving too fast. And others, in the situation you've just described, say, why couldn't it be done sooner to set up new competitive private plans, new rules for insurance companies? Unfortunately, it takes some period of time. I would tell your caller to go to the website, He can type in a zip code, and a few questions are asked. And every private plan available in his market, by price, is listed.

  • 10:30:19

    SEBELIUSHe can sort them by the amount of deductible he's willing to pay, the amount of premium he's willing to pay. And, for the first time ever, consumers at least can get some shopping help, some idea of what is available because each market is different. And is a great one-stop shop.

  • 10:30:40

    REHMAnd, of course, we'll have that posted on our own website, to which you can go, And you'll find the link right there. One last email, then we'll go to the phones. This one from Tim in Norman, Okla. "What does the Affordable Health Care Act provide to promote preventive care?"

  • 10:31:11

    SEBELIUSWell, for the first time in the history of the country, there is a wellness and prevention fund that is available. And each year, decisions are made about how that fund is used so that some of that money in 2010 went to train new health care providers, doctors and nurses who will serve in the most underserved areas. Some of the fund is actually going into health and wellness efforts in communities throughout the country. Everything from new fresh fruits and vegetables being available in neighborhoods, where they weren't available, to strategies for additional community efforts for exercise programs and preventive checkup so that the fund is a backbone for the public health system in this country, who does a lot of the wellness and health efforts.

  • 10:32:06

    SEBELIUSAnti-smoking efforts are underway. Nutrition and health and school efforts are underway. Reaching out to communities for prevention screenings are underway, and that fund will be replenished each and every year.

  • 10:32:20

    REHMKathleen Sebelius, she is secretary of the U.S. Department of Health and Human Services. We're going to open the phones, 800-433-8850. Send us your email to Join us on Facebook or send us a tweet. And you're listening to "The Diane Rehm Show." Let's go first to Nantucket, Mass. Good morning, Robin. You're on the air.

  • 10:32:59

    ROBINYes. I have a -- I felt like you were talking to me. I have a son who has had two open heart surgeries and is now doing wonderfully. And...

  • 10:33:08


  • 10:33:08

    REHMI'm glad.

  • 10:33:10

    ROBINI have my own -- thank you. I have my own business. And my family...

  • 10:33:14

    SEBELIUSIt was you. I was describing you.

  • 10:33:16

    ROBINYou were. I have a family of three -- we are three -- my husband, myself and my son. And we have Blue Cross Blue Shield at the cost of $1,600 a month with a $5,000 deductible.

  • 10:33:29


  • 10:33:30

    ROBINI know. And I did go to to, you know, be a good consumer -- I could do. And there was much alternatives. I can get a lower monthly and a higher deductible, but it's like I'm back to where I started. And I'm all for the health care reforms. It's very fantastic, but it didn't do anything for me.

  • 10:33:51

    REHMAnd there she is in Massachusetts, where Gov. Mitt Romney did put health care reform, his own brand, into place. What alternatives does she have, if any?

  • 10:34:08

    SEBELIUSWell, I would say, at this point, unfortunately, there aren't a lot of new alternatives available. I think that provisions for her son have changed so that companies now can't eliminate her son from an insurance pool. And what we're going to see is rates, according to the Congressional Budget Office, which come down over time as we bring others and, frankly, more healthy people into insurance pools that helps to share the risk. Because, right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn't have insurance who's coming through emergency room doors or who is accessing the health system often in a very expensive way.

  • 10:34:57

    SEBELIUSI would say that there are also going to be additional insurance options for small business owners once we get, again, to 2014. Even in Massachusetts, they are looking at ways to further expand their exchange system. And I know, Diane, one of the things that Gov. Patrick in Massachusetts has talked about is that the Massachusetts' effort tried to address access first, bringing everybody into the insurance market. And that was the reformat that Gov. Romney signed into law. He has spent a lot of time and energy looking at cost as step two because that wasn't a part of the overall conversation, and he recognizes that some of that can be done in Massachusetts. A lot of it has to be done nationally.

  • 10:35:47

    SEBELIUSSo the work that we are underway right now, in terms of addressing the rising cost, the underlying cost, will actually help the family as significantly as anything that's happened in Massachusetts.

  • 10:36:02

    REHMBut, in fact, you've got a number of states that have opted out on portions of the health care law.

  • 10:36:14

    SEBELIUSWell, actually, not so much. We have governors who are, on one hand, encouraging their attorneys general to join the lawsuit and, on the other hand, working on implementation of the Affordable Care Act. So it's a little bit of a catch-22.

  • 10:36:31

    REHMOh, boy.

  • 10:36:33

    SEBELIUSBut the way the law works is that this is not a government takeover. It actually empowers governors in states across the country -- and I am a former governor, so I understand this -- to increase the oversight of insurance companies, making sure that insurers are charging fair premiums, looking at setting up their own exchange program. And most states around the country are in the process of doing just that, even if they are a party to the lawsuit.

  • 10:37:04

    REHMWhat a complicated situation you find yourself in trying to explain this to a public that, to a certain extent, was skeptical to begin with and now finds itself confronted with a very, very complicated mechanism for health care reform. Kathleen Sebelius is here. When we come back, more of your calls, your email. I look forward to hearing from you.

  • 10:40:03

    REHMAnd we're back, and it's time to go back to the phones. Let's go to Moore, Okla. Good morning, David. You're on the air.

  • 10:40:14

    DAVIDGood morning, Diane. I have two questions.

  • 10:40:17


  • 10:40:17

    DAVIDThe first one is what about the hidden provisions in the -- that require doctors to be in contact with her department? And the other question is -- well, I have to comment. I'm on the insurance committee for the city of Moore, and all the insurance costs are going to go up 25 percent this year. And I'll take my answer off the phone.

  • 10:40:46

    REHMHold -- why don't you stay on? I think Secretary Sebelius may have a question for you.

  • 10:40:56

    SEBELIUSHi, David. You asked about the hidden provision in the bill about doctors having to be in touch with our department, and, frankly, I have no idea what that is about. There is no provision that doctors have to be in touch with our department.

  • 10:41:15

    DAVIDOkay, so I'm under a misconception. That's fine.

  • 10:41:18

    SEBELIUSOkay. And in terms of your company's insurance costs or your city, if I'm correct, Moore is a township or a city in Oklahoma?

  • 10:41:27

    DAVIDIt's a -- right. It's a municipality.

  • 10:41:30

    SEBELIUSOkay. You are describing a rate increase, which, frankly, has been, you know, part of the issue that was brought about, I think, the discussion about health reform that businesses and government entities and families have been seeing double-digit rate increases year in and year out. And, in fact, over the last 10 years, insurance premiums are up about 135 percent over where they were, well ahead of any inflation in any other area. You're absolutely right that some of those costs are not coming down immediately because that trend line is underway.

  • 10:42:12

    SEBELIUSBut over time, and I know that it's -- we are very impatient to get these provisions in place, having a more stable insurance pool, having more insurance oversight -- so the Oklahoma insurance commissioner now has new authorities to review rates and to make sure that companies are charging rates based on medical trend. And too often that didn't happen. They have to pay 80 cents of every premium dollar to health benefits, not to overhead, not to CEO salaries. That's a new rule. And there will be new competitive markets which, in and of themselves, will make those rates begin to be adjusted.

  • 10:42:53

    SEBELIUSSo, while you won't necessarily see relief right away, according to the Congressional Budget Office, you will see rate relief as we move through the course of this bill. And, in fact, those concerned about the deficit -- and I think all Americans are -- the Congressional Budget Office says in the first 10 years of the bill, the overall federal deficit is lowered by about $230 billion, and over the next 10 years by a trillion dollars. So both businesses and families will see rate decreases, but the government will see underlying health cost go down.

  • 10:43:28

    REHMYou know, Madam Secretary, I'm interested in David's first statement regarding so-called hidden provisions that require doctors to report to HHS. Now, that's precisely the kind of misinformation that may be out there in people's minds. How do you get to that?

  • 10:43:57

    SEBELIUSWell, it's very difficult because, unfortunately, the misinformation is repeated over and over and over again, and has been for the last two years. So trying to address -- telling people what's really in the bill, what will be the benefits for seniors, for families, lower costs, more choices, for business owners -- they have a tax credit. They'll have a new market. For seniors, you know, Medicare will get stronger, but that is difficult to counter the misinformation that people have been told about over and over again.

  • 10:44:38

    REHMAll right. To Salisbury, N.C., and here's a caller. Good morning, Sandra.

  • 10:44:45

    SANDRAHi. Good morning.

  • 10:44:47

    SEBELIUSHi, Sandra.

  • 10:44:48

    SANDRAHi. I appreciate your call and thank you so much, Diane. I listen to you every day.

  • 10:44:53

    REHMThank you.

  • 10:44:53

    SANDRAThis is such a great honor. My concern is -- and I will be very frank -- I have lived my life. I am in my 40s. I've given birth to three children, and they were all '86, '86, '93, giving birth and in and out of the hospital -- no problems. And I live my life very health consciously. And we, as a family, do not have any health problems. The thing that I see as a problem is that the government is trying to warrant some kind of health proposal upon our family when we actually do not utilize -- in all honesty, we do not utilize the health care system as, you know, I do not go with every sniffle to the doctor. I do not do any of these things. And if it was a life and emergency kind of situation, I would do this, but why would I be penalized, in my opinion, to subscribe to a health care plan that I really don't partake or believe in?

  • 10:46:01

    REHMAll right. Excuse me for just asking one question, Sandra. Do you have any health insurance at all?

  • 10:46:12

    SANDRAAt this time, I do not. And I have lived my life without health insurance. So I'm kind of in a position where, right now, you know, based upon the new administration, I will be forced to carry this health insurance. And I've never -- even when I had health insurance through my employer, I've never met my deductible. So I'm paying these premiums, you know, and the insurance company is, you know, getting richer off my fat. And I don't even utilize the benefits because we simply do not go to the doctor. I mean, we're all healthy...

  • 10:46:44

    REHMSecretary Sebelius, do you want to comment?

  • 10:46:48

    SEBELIUSWell, Sandra, first of all, I think you've been enormously blessed.

  • 10:46:51

    REHMI should say.

  • 10:46:51

    SEBELIUSAnd good for you and your family that you haven't had any health issues and that your children were all born healthy. That's terrific. And count your blessings every day. I think you are also one of the folks who would suggest that you don't have any intention of using health care. But, frankly, if -- God forbid -- a car accident happened tomorrow and you and your children were hurt, you will end up in a hospital, and you will be treated, as will your children, for those injuries. If one of them is discovered to have an illness later in life, he or she will get the treatment that they need.

  • 10:47:39

    SEBELIUSSo part of the issue is whether or not, like car insurance, even if you don't have wrecks, states require you to have car insurance in order to drive a car in the event that you or your family are involved in an accident, whether or not that's your fault. The same theory is there about health insurance. Families will be given lots of choices, high deductibles, lower costs. You will have a choice of plans. But given the fact that, in the event of an illness, which you cannot predict -- in the event that someone comes down with cancer or is involved in an accident, you will, indeed, use the health care system. Hospitals cannot deny you.

  • 10:48:25

    SEBELIUSYou will have thousands of dollars worth of bills. The -- it is a pool of insurance that will cover that. The trade-off for everybody coming into the pool is to say to insurance companies, never again can you deny Americans with pre-existing health conditions coverage. And in order to do that, we need everybody in the pool.

  • 10:48:50

    REHMAll right. A couple of things here. An email that gets to the idea of having more flexibility to implement the health care law. Our caller says, "I understand Vermont is working on having a single payer plan, sometimes called Medicare for All. And as a result, they have over 200 general practice doctors, plus a number of medical students, saying they will move there if it passes. What do you know about that? What do you think about that?"

  • 10:49:33

    SEBELIUSWell, when the Affordable Care Act passed, there was a provision already in the law that said, in 2017 -- and I know this sounds a long way off, but it's not so far away -- states could apply for a waiver. Come to the Department of Health and Human Services and say we have a different way to ensure our population, to make sure that we don't put additional costs on the citizens in our state, and we would like to put our alternate path in place. The president recently suggested to the nation's governors when they were here in Washington that rather than waiting until 2017 for that alternative feature to be in place, he would support the bill, the bipartisan bill, that's pending in Congress right now that says let's move that date up to 2014.

  • 10:50:28

    SEBELIUSSo let's have governors who know their markets well, who know their states well and who might have a different alternative than setting up an exchange with certain programs -- be able to execute that from day one. So that's the proposal. Gov. Shumlin, the new Vermont governor, has suggested that he would actually look at a strategy to have a single payer system. Others are saying, we'd sort of like to bring everybody into one, big pool -- private business owners, Medicaid patients, Medicare patients, who are going to come and talk to you about that possibility. The governor of Arkansas is interested in that. North Carolina is looking at a whole series of clinic proposals and expanding that statewide.

  • 10:51:14

    SEBELIUSSo the kind of innovative conversations that are going on in health markets across the country, I think, are very exciting for the citizens who live there and for potentially good ideas that we can spread to other states.

  • 10:51:26

    REHMAnd what about the doctors? How will their lives be improved by the new health care system if at all?

  • 10:51:37

    SEBELIUSWell, part of the focus of a new system is really to look at ways to keep Americans healthy in the first place. We now spend about 75 cents of every dollar on acute care, on illness, but people would argue we don't have a very good preventive care and wellness system. That focus has to be around primary care doctors. And so there are both provisions in the bill, which would train more primary care providers -- not only doctors but nurse practitioners and mental health professionals, people who really work at the community level to keep folks healthy in the first place. There are new strategies, Diane, to pay primary care providers more.

  • 10:52:23

    SEBELIUSRight now, if you are a specialist doctor, you can make three or four times as much as a primary care doctor. And if we really want to encourage, frankly, more medical students and others to choose primary care in the first place, part of it is leveling out that pay a little bit. So there's pay incentives, and they're with electronic health records. There is care coordination that is much more possible with a new delivery system, so doctors can actually help a patient keep track of multiple tests and multiple strategies and really have a health home around a primary care doc.

  • 10:52:59

    REHMHealth and Human Services Secretary Kathleen Sebelius. And you're listening to "The Diane Rehm Show." And here is a caller in Eugene, Ore. Good morning, Bill.

  • 10:53:14

    BILLGood morning. One-fourth to one-third of the people in the United States expect to be diabetic in 10 years. One-sixth of the people in the State of Oregon are now on food stamps. The government has actually helped cause our big health care system by letting people on food stamps eat any processed and junk food that's not cooked at home. Why not make the only food that people can get on food stamps be healthy food they have to cook at home that is non-processed, which is already part of the program in the WIC program, which is a food stamp program that -- whereby mothers with young children can only get food that is cooked at home, relatively healthy but mostly non-processed?

  • 10:53:52

    REHMAll right, sir.

  • 10:53:54

    SEBELIUSWell, I know that that debate has been underway for awhile about the government actually directing what people can or cannot buy and what they can or cannot eat on food stamps. I think the better idea is really to get more information and more education at every step along the way and encourage parents and consumers to choose healthier diets. The notion that people who qualify for food stamps would have more limited choices than anybody else in their neighborhoods doesn't make a lot of sense. But serving healthier school lunches, getting information to folks, having regular checkups and having doctors -- pediatricians are now committed to having conversations with parents about what the kind of food choices do to the health of their children. I think all of those strategies are going to be very helpful.

  • 10:54:54

    REHMAnd one last question. I know this administration is also focused on jobs, jobs, jobs. Is the health care law a job killer or a job creator?

  • 10:55:10

    SEBELIUSWell, I think every evidence is that it can be a huge job creator, not only more health care jobs for a variety of health care practitioners, doctors, nurses, mental health professionals, but community health workers around new health models that are encouraged in the bill, the primary health homes. So, Diane, if you were in the hospital and released from a hospital, one of the things that we know is that if you have some follow-up care, if someone actually checks on whether you filled your prescription and whether or not you're having any problems or issues with your care when you get out of the hospital, you're much less likely to go back into the hospital. You're much more likely to actually have a better recovery period.

  • 10:56:02

    SEBELIUSCommunity health workers in that situation can be enormously not only helpful to patients and their families but cost effective. Your trip back to the hospital is far more expensive than you actually recovering at home.

  • 10:56:19

    REHMBut how can you win the argument when you have Republicans saying this is a job-killing bill?

  • 10:56:30

    SEBELIUSWell, in the year that the bill has passed, the economy has added about one-and-a-half million private sector jobs. So there's no evidence at all that passage of this law stop bill. We have hundreds of thousands of jobs in the pipeline for everybody, from health IT workers to health care workers. And lower costs for particularly small business owners in health care, will help them grow their businesses and not spend it on insurance.

  • 10:56:59

    REHMKathleen Sebelius, secretary of health and human services, thank you for coming on. I hope you'll come back and continue the discussion.

  • 10:57:11

    SEBELIUSWe'd like to celebrate many more birthdays with you, Diane. Thank you so much.

  • 10:57:14

    REHMThank you. And thanks for listening, all. I'm Diane Rehm.

  • 10:57:21

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth and Sarah Ashworth. The engineer is Tobey Schreiner. Dorie Anisman answers the phones. Visit for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information.

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