Gerson: Let's take a minute at least on the health care implications of the [pending] Supreme Court decision [on the Affordable Care Act]… Bruce, as a major player in insurance markets, what will happen if the individual mandate is struck down, but not the other insurance market reforms that are part of the act, such as the guaranteed issue dealing with pre-existing conditions?

Bodaken: We introduced the Universal Coverage Plan in 2002, very early on, many similarities to the Affordable Care Act (or ACA). But at the heart of it was the individual mandate. And the reason for that is that if people have the option of going in and out the door when they're sick or when they're well, the biggest concern, of course, are those people that are young and healthy. As I used to say, we need their money to make a pool that actually is diverse enough and funded well enough so that they're in the pool for those of us who are a little bit older and need care.

And so the fact is, if the individual mandate goes, I think we have a fundamental problem whether or not [our system] can be sustained over time. We've seen in Washington that that program had no individual mandate, had guaranteed issue, it failed. In New York, they have guaranteed issue, no individual mandate, prices are probably 30 percent higher than the rest of the country for that reason alone. So an economically sustainable program simply has to have a way in which, sick or well, we all have a responsibility to be part of the program.

Gerson: What if the Supreme Court strikes down not just the individual mandate, but says that's not severable from the other provisions of the act. What happens then?

Bodaken: Well, we’re left with the very same problems that we started with when the president introduced the plan. It's very clear, we've got 50 million people without insurance. Not having insurance means you have much less access to health care, which means you have a lot less access to good health…

Gerson: Melody, let’s just talk about that and try to understand how we got to this point. As Bruce just said, 50 million people don’t have insurance. Many more are underinsured. Almost all of us in this room, unless we're fortunate enough to have Medicare, are one job loss away from having no insurance at all. Coming up to the 2008 election, there seemed to be widespread, even bipartisan support for health care reform. Economists of all stripes, many business leaders, were advocates for this. Now, two-thirds of Americans are against what its opponents have very brilliantly now called in the public mind Obamacare. What happened? Is this a messaging problem? Is it a political problem? Was it bad legislation? How did we get here?

Barnes: I think there are a number of variables that have come together for this moment. I'm always struck by exactly what Bruce was talking about, what life looked like prior to the ACA. And I remember traveling around the country during the campaign, and I was in Montana and Michigan and North Carolina, Pennsylvania, all over, and a number of people raised this question themselves as a problem. And they’re business people and individuals and family members and government folks.

So everyone recognized that there was a problem, and there was a rallying around or a consensus for the idea that we have a problem that needs to be fixed. But then the devil is always in the details and how people respond to those details, so the consensus around the how. And what we saw over that year-plus of debate was a back-and-forth, a protracted debate, with a very, very loyal opposition, not only to some of the ideas in the health reform bill, but also the idea that this president would have a significant domestic legislative victory, and [there was] a hardening on those lines.

Because when you remember that in the individual mandate—which has now become the subject of so much discussion and is at the heart of the Supreme Court debate—was an idea that was actually founded in conservative ranks, during the time that the Clintons were trying to address this problem. So the Heritage Foundation and others actually supported this idea that has now become public enemy number one for many conservatives. So, one, there was a political decision made to oppose this, but two, this is such a complex issue. You've got Medicaid and Medicare, and many people who benefit from those programs don’t even understand them and their relationship to government.

Gerson: Shannon, you've written a great deal about the health care system and its size and complexity and the economic interests at stake. You've also suggested that really given the fundamental problem of escalating costs, what the Supreme Court does or doesn't do really isn't going to make much of a difference. It may be a disaster in the short run. But longterm, have we even begun to deal with the critical problems that we have?

Brownlee: Well, the ACA does start to deal with it, but we haven't really dealt with it in its entirety and its enormity. Health care is going to eat our lunch, basically. It accounts for about 20 percent of unemployment right now because of the drag that it exerts for private employers… It is eating into what states and federal government can devote, can allocate to other things that we value like education and defense. The federal government now spends more money on health care than it does on defense. That line was crossed last year. It is a remarkably inefficient and unproductive industry. The delivery side of health care is incredibly inefficient and unproductive. And we keep paying more and more and more money into this enormous industry. So we have to grapple with that, and it is a delivery-system problem. And by that I mean that we have to change the way we pay, and we have to change the way health care is delivered so that it’s better care, it's more efficient care, it's less wasteful care.

Gerson: So why is it that we seem to have such a difficult time understanding or grappling with this? We keep hearing all the international statistics—how we spend much more, yet our outcomes aren’t any better. Bruce, do you agree with Shannon’s prescription and the size of this problem?

Bodaken: Absolutely. This is the one area that science hasn’t penetrated yet. You know, I sit on the Institute of Medicine board for what was [called] "evidence-based" care—now it's "value and science-driven" care—and we don't bring evidence to bear like we do in other industries where we actually measure, where we actually know what quality looks like, and we won’t pay for something that is not high-quality. And for a variety of reasons, there are hundreds of entrenched constituencies in health care, and they're not going to give up easily. So what we do need is, I think, both from a public policy standpoint and, frankly, from a patient accountability standpoint, we need to bring to bear what's happening in the rest of the market, which is that we do have metrics that tell what quality looks like. And we’re changing our reimbursement system to pay for outcomes: not for the amount we do, but for the good that we do.