City Hall
1221 SW 4th Avenue
Portland, Oregon

Thursday, September 22, 2005
8:30 a.m.


Mr. Randall L. Johnson, Chairperson
Ms. Catherine G. McLaughlin, Vice Chairperson
Mr. George Grob, Executive Director
Dr. Frank J. Baumeister, Jr. Member
Ms. Dorothy A. Bazos, Member
Ms. Montye S. Conlan, Member
Mr. Joseph Hansen, Member
Ms. Therese A. Hughes, Member
Ms. Patricia A. Maryland, Member
Dr. Aaron Shirley, M.D., Member
Ms. Deborah R. Stehr, Member
Ms. Christine L. Wright, Member
Ms. Connie Smith, Staff
Ms. Jessica Federer, Staff
Mr. Andy Rock, Staff
Ms. Jill Bernstein, Staff

Also Present:

Tish VanDyke


8:30 a.m.

CHAIRMAN JOHNSON: Hope you had a good dinner last night and a good night of sleep. My focus was on the sleep rather than the dinner. I overslept this morning but I still got up earlier than most I bet. I'm trying to stay on Central Time and Eastern Time.

We have two items of business I would just like to talk about briefly. The first one let me just start by saying this way. As we get to be my age we all find that we have parents who are aging and who are going through struggles. In our stories we have a story of Pat Maryland's mother and what happened to her as she dealt with health problems.

I personally have been dealing with some in the last several weeks. In fact, I took a couple days off a week or so ago just to deal with my mom. I think, at least, some of you are aware that Catherine's father-in-law passed away. We would be remiss if we just didn't say our condolences to you, Catherine.


CHAIRMAN JOHNSON: In the spirit of knowing how these issues touch us personally.

VICE CHAIR MCLAUGHLIN: As I told Randy, it was interesting that it happened after Boston because my father-in-law at 89 definitely had what they said was a good death so our family is actually rejoicing that he had a good death. Thank you.

CHAIRMAN JOHNSON: Just another matter that we want you to be aware of. Michael O'Grady has decided to retire. I don't know if we caused him to do that or not but he has. He called me a couple of days ago just to let me know that. He said it will be out in the press within a day or so, and it is, as I understand it.

In his conversations he indicated that the likelihood is that he would be replaced by someone who the Secretary of Health and Human Services would appoint to replace him. I indicated that I was not speaking as the Working Group, just personally, but I wondered to what extent he would be open to continuing to service as the Secretary's designee if the Secretary, who has the authority to appoint and we don't, but if the Secretary would be open to doing that.

So my question to you for your consideration, and maybe we can come back to it at the end of the morning after you've had a chance to reflect on it a little bit, to what extent would you like us to consider that as a working group? The way we would do it is we would go back to the Secretary of Health and Human Services and say something like, "Since Mike has been with us he has a foundation of knowledge and experience in working with us.

If you were to have him stay on as an appointed person, we would be supportive of that. If, on the other hand, you're uncomfortable with such an approach, we'll let it drop. It's just an idea for you as a working group to consider. That's why I'm bringing it up.

MR. HANSEN: I don't want to think about it but what's the other side of it? Who would replace Randy -- replace Mike? I just saw that little blurb somebody had -- you had yesterday. It looked like Mike was going to start his own business. Would he be able to --

CHAIRMAN JOHNSON: I talked with him just briefly. I have not had a lengthy conversation but, first, there is some speculation of who might take his place but that's not known to the best of my knowledge. When I talked with him it was not known. He said it's still the Secretary's appointment to make. A person who has been contemplated, whose name has been thrown around, and who was potentially going to come to this meeting, is Don Young.

With respect to his job, my comment to him was if he were merely to be in some consulting where he is doing some middle-of-the-road stuff, and I didn't term it that but that was the concept, that might be something that the working group could live with.

If he were going to go to work as a lobbyist for a drug company or DAMA or for the business round table or AARP, we probably would not be able to have him continue to serve. I think he understand that. Let's reflect on that and then we'll come back and talk about that in just a little bit.

PARTICIPANT: Didn't he also serve on the Medicaid Commission?

CHAIRMAN JOHNSON: He is serving on the Medicaid Commission.

PARTICIPANT: Will he drop off of that?

CHAIRMAN JOHNSON: I don't know. Didn't ask him.

Just before we get into the meeting proper, I would like to introduce Tish VanDyke. What I would like to do is go around the circle. Do we have anybody else who is here for the first time that we need to talk to? Okay. Let's introduce Tish. Has Christian gone home?

PARTICIPANT: No. Christian is in the hotel working to get changes made on memory sticks and things like that.

CHAIRMAN JOHNSON: Okay. Thank you. Why don't we introduce Tish. Why don't we start with you, Catherine.

VICE CHAIR MCLAUGHLIN: I am Catherine McLaughlin.

MS. CONLAN: Montye Conlan.

DR. SHIRLEY: Aaron Shirley.

MS. WRIGHT: Chris Wright.

CHAIRMAN JOHNSON: Andy Rock. You've met Andy.

MS. MARYLAND: Patricia Maryland.

MR. HANSEN: Joe Hansen.

MS. HUGHES: Therese Hughes.

CHAIRMAN JOHNSON: And do you know our colleagues over here?

PARTICIPANT: I think I do. Yes.

CHAIRMAN JOHNSON: Okay. What I would like to do is share some reflections and some alternatives this morning. It's going to take me a few minutes to go through my comments as we get started. I would like to ask -- give me a few minutes and I know that you will, and then we'll open our discussion up.

The first is some reflections on where we have been and what we've been doing. When we were at Salt Lake City we talked about two reports and there were some comments made in the Salt Lake City meetings regarding both reports. As you recall, we also didn't have lots of time. We probably didn't get all of our comments on the table.

But, in fact, in my estimation -- and I'm going to speak from my perspective now for the next several minutes and you'll have a chance to do the same thing. From my perspective our long report was not as compelling as we needed it to be. We said that we are going to review this again in Boston.

When we came to Boston, in my judgment, but others as well, our report was still bland and not compelling, the long report. I personally felt the clock was running out. We needed to make more progress and more sufficient progress. As a result of that, we identified a PR from -- I wish Frank was here because I would like to make some comments that would be for his benefit in light of his comments.

When he comes back I might do that. We have not employed a PR firm to put spin on our report. What we've done, from my perspective, is to hire a PR firm for the reports to make them more understandable, more easily communicative, and to have them more readily and more likely to be read.

I did not select Edelman. That was a process that included the Communication Committee and the staff. I have to say that I have been pleased with their work. In my history, my personal history, I personally don't believe that the people who work at a consulting firm are necessarily just because they work at a consulting firm they don't walk on water. We don't worship the consultants.

My suggestion would not be just because they are consultants we take their word and we follow what they're doing. But, in fact, they do have in this particular case experience in doing the kind of work that has been successful in the past.

We set up a time table a number of meetings ago based on 9/29. My sense has been that it's been very difficult for us to accept the time table for whatever reason. I think we have a number of reasons in our minds but, in fact, we have felt it necessary to set up a time table that would be something that we would follow out of necessity because as we look at 9/29 we need some time to develop final recommendations.

Then we have recommendations that have to be exposed to the public for 90 days. That gets us back to potentially our thought processes by May 1st. Then we felt we needed to have a certain period of time for the meetings. We started with a four-and-a-half month period of time and we've ended up going from November 1st through May 15th -- April 15th. We backed up from that to have a 10/6 press conference. Let me stop there for just a second.

Tish, let me introduce you to Dr. -- what's your name? Frank Baumeister. For all of you, this is Carolyn Dell. She works with Margaret and George and Connie and has been helpful to us in setting up schedules and meetings and so forth.

MS. DELL: If you have any requests like problems with your hotel rooms or anything to do with the facility, just let me know. I'm around.

CHAIRMAN JOHNSON: Okay. Thanks, Carolyn. So, Frank, just before you came in, a comment I wanted to make to clarify was that we have not employed Edelman to put spin on the report. We have employed Edelman to help us make the report more readable. We haven't made that -- maybe I haven't made that as clear as we should have but that has been the intent.

I made a comment yesterday regarding another report. In my estimation I said that other report is quite good. My guess is that because I said it's quite good, when it comes out if you happen to see it, you'll say, "My report is better than that one." It's just our nature.

My intent isn't to say that our report needs to be like anyone else's. It's merely to say that when we go -- when I go to any place, Capitol Hill, to a press conference, to a community meeting, I have to -- I need to feel very comfortable and pleased that this is a document that we can be feeling okay with.

I also indicated yesterday that I'm unwilling to give my proxy to the report committee for approval of the report. I would like to clarify that. Do I have respect for the report committee? Of course. Do I have respect for their ability? Of course. Each of our report committee members has just a wealth of experience and a wealth of expertise and lots of intelligence.

In that respect I just want to make sure that it's understood. The perspective of the report committee is different than mine and it's different than yours. If we have some of you who would like to just like to yield your proxy to the report committee or yield your proxy for part of the report to the report committee, that is certainly up to you. That's your call.

As I've looked at the report I have not looked at the footnotes. I'm saying I understand that Jill Bernstein, Catherine McLaughlin, and Richard Frank, Brent James, and George Grob and Michael O'Grady, they are smart about that stuff and that's not where I bring any added value at all.

It's not only trusting them to have footnotes correct but it's trusting them to have good data as well. But their perspective is different. Their experience is different than mine. Catherine and I probably the very first time we met we talked about one subject where she and I have a difference of opinion in part because of my experience compared with hers.

Our philosophies are different and we are different in a number of ways. That is why I am personally not willing to yield my proxy to the report committee. Nor would I give it to anybody else. I feel it's incumbent on me to represent my best insight and input.

So let me stop there. I think before I talk about options as I see them, what I would like to do is ask George Grob to share input. We shared these reports with both Senator Wyden and Senator Hatch. I'm going to ask you, George, to share the feedback that you have received from both of them for the report committee to understand. Then what I would like to do is talk about options and where do we go from here.

MR. GROB: So we did share them and we have received comments from both offices. Senator Wyden's comments had basically two sets of comments. The first really was in the presentation and introduction of the report. He wanted us to strengthen the part of his report that would tend to convince the reader that the Congress and the President, particularly the Congress, could use the information.

We had said in our introduction that the Congress would consider the information. He thought that was too bland, that he wanted to say that the Congress would hold hearings. He wanted to be very concrete about that. He also said to take action, to accept or decline the recommendations. The words that he gave us were really to emphasize that point.

By the way, I had mentioned to you all before that I thought I had it covered with a general statement but he just wanted to be more concrete about that and that was the only thing in the introduction.

The other thing is, you know, we did include in the report some sample questions. For four of those questions he offered some wording changes and the wording changes were primarily to bring them down to Earth. There was no real change in the concept of them but in the way they were worded. He had just an ability to sort of relate this to many people so he offered some different expressions.

CHAIRMAN JOHNSON: For about four or five questions.

MR. GROB: I think four or five. That really did not reach the substance of the matter. Now, as far as Senator Hatch is concerned, they raised a variety of issues. They requested that we include the information in both reports on the research. The first time around he had many editorial comments.

You will all recall that we were only including the scope of our direct health care services to people. We were not -- well, we had talked about the funding for it in a general way but we were not making recommendations about health care research or anything like that.

Senator Hatch is a very strong supporter of health research. You've heard him talk about it. He wants us to include some information. He believes that health research should be part of the scope of our work. They wanted references in both the short and the long versions to that effect.

VICE CHAIR MCLAUGHLIN: Do you mean health services research?

MR. GROB: Biomedical research.

VICE CHAIR MCLAUGHLIN: Biomedical research. Okay. I just wanted you to be clear.

MR. GROB: I'm sure when it comes to health services research, too.

VICE CHAIR MCLAUGHLIN: Let's put an updated section on that.

MR. GROB: Like I said, we had limited our scope to the services that are actually performed.


MR. GROB: So we did not take a comment but --

CHAIRMAN JOHNSON: We took the comment but we just didn't change anything.

MR. GROB: Yes, we considered it. We took the comment but we didn't adopt it. There just has not been the time in the last day. We are going to get back to them and explain to them each and every one of them. The subject came up while Senator Hatch was taping his presentation speech for the October 6th event. He spent some time on this on the research. Patty mentioned to him that this had not been covered and please cover it.

The other one has to do with mental practice insurance. The way we have it right now in the report we have a short paragraph about medical malpractice in the section called, "What Accounts for the Cost?" We took that out of the short version because we just didn't need to cover everything.

Senator Hatch does not believe that medical malpractice is really driving costs. They asked us to remove that from the report. I took it out of the short version but I left it in the long version because others were interested in it but I modified it to reflect the fact that -- our statement was really that it was not a big driver but, nevertheless, physicians and others were quite concerned about it. That was a kind of softening of what was in there before.

I have not heard back from them on that but I am expecting that they are going to want us to take that out of the long report, too. She hasn't come back and said that to me yet but I just wanted to let you know that was a comment that they gave that we didn't use, we didn't take.

VICE CHAIR MCLAUGHLIN: Here's an out that reflects what Jill and I originally had for malpractice which is certain positions and certain specialties in certain geographic locations are, in fact, withdrawing from the market, particularly OBs, because of malpractice premiums so it could go into the quality or access issue where we talk about the fact.

We don't have it as a driver for cost because I agree totally with Senator Hatch and have all along, but we do say -- in fact, you can get figures. I hate to say that because Jill will send darts my way. That means I have to get the figures, but there have been reports on shortages, particularly OB, because of high malpractice premiums that they face.

That might be a way to be quite honest about the effect of malpractice which I think we need to be. At the same time honor Senator Hatch's concerns which I think the research certainly supports his opinion on malpractice and cost.

MR. GROB: Some of you had many line item kind of things from Senator Wyden the first time they sent this out. None rose to the level of these two. So those were the comments that we received from them.

MS. MARYLAND: You know, what's interesting about -- excuse me for interrupting but I just need to make this statement. If there had been transparency so that the full committee could have seen that feedback, it might have been very helpful as we looked to some of the changes that were made to the report. The transparency wasn't there.

I didn't know that those were the comments because I was the one that kept talking about the fact that it may not be the most significant driver for health care cost. However, it is a concern from my end of quality and access and soften the language to at least appease their needs but, at the same time, not lose the context of making sure that was the statement that was made in the report I think was important.

DR. BAUMEISTER: It's interesting. I remember the first meeting we had in Rockville that Senator Hatch made a big point about. That was one of his major contentions with the trial lawyers that suing was raising the cost. That was one of the major issues he made. The other issue he made was about the FDA. Those were his two big points.

CHAIRMAN JOHNSON: I'm not sure that I would agree with George's take on Hatch's comment. I think Hatch didn't like the statement that we said there's not much of a cost differential. I think that's Hatch's perspective that, in fact, he differed with that comment and, therefore, he wanted it removed.

MR. GROB: There were actually two statements, one of which was, "But, on the other hand..." I took it that he was taking exception to the "on the other hand" statement.

CHAIRMAN JOHNSON: No, I don't think so. MR. GROB: In fairness, we have not -- they have not come back to us on the malpractice one the way they came back to us on the research one. I can leave it alone or I think your suggestion of moving it to the access makes more sense because we have it in the cost driver section and they say it's not a driver so it seems a little condescending but that's an easy fix.

CHAIRMAN JOHNSON: My personal concern about that is that if we address it regardless of how we address it, it's going to be challenged. We are not going to add much value on the medical malpractice subject because the stakeholders are firmly aligned in Washington on this already so we are not going to add much value. To the extent that we put one position or another in the report, we just alienate them, 50 percent of the stakeholders.

VICE CHAIR MCLAUGHLIN: I think this is a good example, Randy, as some of these were talking about yesterday. Putting in -- I totally agree with you. President Bush made a big deal about malpractice and lawyers. We all know he made a big deal about lawyers all together in the last campaign. He clearly has a firm stake and a lot of Republicans over there in that camp with him that it's the lawyers' fault and we have to have court reform, etc., etc.

The fact of the matter is that even lawyers in the health care field who have studied this agree with the research that shows it is not a primary driver. This is something that Mike O'Grady and Richard and I would not feel -- you were saying no matter which way we go we would not feel comfortable putting information in this report that suggest it's a major driver because it's just not true.

That doesn't mean it's not a political issue. I totally agree with you. Then the question is what do we do? We certainly are going to alienate some people if we bring it up with truth. Mike O'Grady and Richard and Brent James and I are not all on the same political team so this is not a political issue. This is just reflecting research and what the evidence tells us.

The evidence tells us it is not the primary driver. What we all agree to, however, and we talked about this in Salt Lake City, is that for certain physicians there is good evidence that the malpractice premium pushed them over the edge in terms of labor supply and they are marginal affects.

No one thing does everything but the malpractice premium increases in the last 10 years pushed them over and they went, "I'm retiring," or, "I'm not delivering babies anymore." It did change their practice. That we are willing to stand behind. Okay, fine.

Then the question is do you draw them all together? We had this discussion. If we drop anything about malpractice because we're going to offend all the people who think it is the lawyers' fault who want reform. The question from people then is, "Why are you not practicing here?" That's why I bring this up.

This is a good example of if we as a working group want to have research integrity in our report, then there are certain things we cannot say even though we know some people out in the political world won't be annoyed by that. Do we stick with what research supports or do we not say anything at all when we know people will then say, "They don't have malpractice in here. Why isn't malpractice in here?" I think that is the kind of question that we have to talk about.

We talked about it explicitly with respect to malpractice back in Salt Lake City, the reports that we did. Administrative cost is another one we talked about for the same reason. There are some of these things that all four of us and we come

-- we really do have different political -- we are diverse, the four of us. We talked about these and tried to come to some kind of agreement. It's up to the working group to decide how are we going to handle this.

CHAIRMAN JOHNSON: Well, that's one subject but a small subject of our total report. Joe, if you have a final comment on this, let's take it.

MR. HANSEN: I have comments on what you said and what he said. I'll start at the end then. I am a little concerned about the signer's involvement. Are they doing the writing? Are they doing the editing of this? Is this their report or is it our report? That's a fundamental question.

CHAIRMAN JOHNSON: We had a discussion on this and here is where at least I come out and the way I've been approaching this. One of the senators likes to be involved. The other one said, "No, you go off and do what you want to do." Up until now neither of them have pushed us on any particular policy.

Both of them have endorsed doing whatever we can to expose the working group and its project to the rest of the world. They have been very -- Senator Wyden especially has been very geared toward exposing the working group to as many people, getting the name out there.

He's had a huge desire to make this project work. He has not come to us and said, "This is a policy position I want to endorse," or, "This is exactly something that you have to have in the report." The one comment we've had regarding that, Pat, has been this one from Senator Hatch on the research.

He really reemphasized that yesterday and the reason it really became an issue is he talked about it for several minutes on this videotape and then he learned that we don't have it in our report. that's why he came back or his colleague came back.

MS. CONLAN: Plus the fact he's not the only one. Remember I brought it up.

CHAIRMAN JOHNSON: We have, at least I have, and I think this is George's position as well. They have talked principally with George and Catherine and myself, although my guess is that Senator Wyden and Frank talked as well. That's a doctor and personal relationship rule or whatever but I'll just speak for myself. He may have talked with more of you and I'm not aware of it but I'll just speak for myself.

If the idea that he brings, I believe, is worthy of consideration, I'm going to treat it just as if my brother gave it to me or my mother or a work colleague or Andy Stern. On the other hand, if I differ with it, I'm not going to personally take it. That's kind of the approach I've taken. It's a work from my perspective. It's a working group report. It's a working group product and it's got to be working group recommendations.

MR. HANSEN: That is not the way it sounded to me a few minutes ago when George gave his report. It sounded to me like they were actually doing some editing. I certainly think that they ought to be involved in looking at it and talk to all of us about that. They've got to carry the water for this once we get it done so I don't have a problem with it if that's the case.

CHAIRMAN JOHNSON: Senator Hatch didn't look at the report, I don't think. I think he had his associates look at it. Senator Wyden has and Senator Wyden has wanted our language to be such that it would be readable and understanding. That's why when George talked about the questions, Senator Wyden did have some input on the questions as well.

MR. HANSEN: We didn't even get to the questions. Let me just respond to a couple of things you said when you opened it up because they kind of left. They were pressed for time.

CHAIRMAN JOHNSON: Yeah. I would like to go through some scenarios as I see them for us but if you want to talk first, go ahead.

MR. HANSEN: You laid out some things that make me somewhat uncomfortable and you said them again. We talked about the time table and I know there's time limits but the dates are somewhat arbitrary. If it can't be October 6th, maybe it's October 10th or something like that but I understand there are some time limits.

What really kind of got me thinking last night was this other report that you referred to and you brought it up again. Every week that goes by somebody is issuing a report or they are coming out with stuff like that. You put big emphasis on it last night and the word you used, I think, was compelling. I will be concerned what's in that report if we are going to have competing reports or if there's things in that report that came out of some of the meetings we had here. Those are the type of things that are going through my mind, Randy, and I'm not going to leave them buried.

VICE CHAIR MCLAUGHLIN: Just one thing. Can you give us the date on that report? You said two weeks.

CHAIRMAN JOHNSON: No, I don't know what it is.

MR. HANSEN: Catherine, let me just finish.

VICE CHAIR MCLAUGHLIN: I'm trying to figure out how close it was, Joe.

MR. HANSEN: So, you know, it does bring some concerns. There is also something that you said, you know, that maybe we can't do a report and we got into this whole thing about proxy. I don't think anybody -- when Patricia said that she wasn't going to give her proxy, she clarified that very well at the end. But I don't think it's your report or Catherine's report or Montye's report or my report. I think we all need to sign on.

I think that we have come too far. We've heard too much data. Many of you put all types of time into this. I put some staff into it and stuff like that. I think we've got to work this thing through. If we don't, you know, we are running the risk of having one report and having a minority opinion out there which would be bad for us and bad for the Senators.

I think we all need to sign on and I think we are all willing to work to make that be done. I just don't think we can get it done in a couple of hours. The other question was about the Senator's writing and their attitude to the reports and you answered that already.

CHAIRMAN JOHNSON: Okay. Let me respond to the reports and then I would like to go into options as I see them and invite the rest of you all to talk.

Joe, my reason for coming back to talk about "the other report" today is to say I was just using that as a reference to say that report is compelling. I have not tried to take anything from that report into ours or vice versa. It's a different subject although it deals with health care. This report should stand on its own without regard to that. That's what I was trying to say just a few minutes ago because I realize that there were some questions about my comments. I would like to share four option with you. I don't know that any of them are going to be acceptable to all of you, or any of you maybe, but let me share them.

Option No. 1 is we take the report that we have seen so far and approve that. Pilot test it, announce it on the 6th of October, and use questions from the short report. That's Option No. 1.

Option No. 2 is to take the report with Richard's refinement yesterday that George discussed and staff edits to the extent possible to pilot test that and to have a 10/6 press conference and to use questions from the short report.

Now, Joe, you made a statement yesterday I actually agree with. Honestly I agree with most of your statements but that is that you are not willing to sign off on something you haven't seen. So part of Option 2 is that George and staff would get out to us by the end of the day today the edits that's they've made including Richard's language.

Option No. 3 is to rewrite the report taking all the comments that have been made and try to rewrite the report in a way that takes all of the comments and more completely digests them and puts them into a report format.

The challenge with that is our comments don't agree. Richard's and Catherine's comments don't agree. Dottie's and mine don't agree. It's not only Dottie's and mine but Dottie's and some of the others and mine and some of yours don't always agree. What we would have is a real challenge.

Second issue is time precludes us from doing that before the press conference so we would not be able to have a 10/6 press conference and we would not pilot test any of the information.

By the way, the readability and what makes sense could come out of the pilot test, pilot focus groups I should say. When we run focus groups that might help us get at what is readable. It's pretty unknown on which we would agree.

Joe made some comments yesterday that he has concerns about. Dottie has made comments about which she's had concerns. Richard and Catherine have both made comments and so I'm not sure if we would get to a point of agreement but it would take some time to get there in all likelihood.

I'm not sure when we would have a press conference. We have set up the date of 10/6 some weeks, if not months, ago to get everybody there. When we get everybody there for the future I don't know, in part because we don't know when we get a report done but to schedule senators and even us is a problem.

DR. BAUMEISTER: Randy, what are you willing to compromise on?

CHAIRMAN JOHNSON: Well, let me just go to the -- I'm almost done. I have personally read all the reports and I have read almost all of your comments. I have to admit when I saw the comments of one person I kind of gave up in this time. But I've read all the comments of just about all of you and I've dedicated -- I'm going to talk just for about 35 seconds on a personal basis.

I dedicated an awful lot of time to this project in the last five months. I've got to get back to my real job starting tomorrow and I'm out of pocket personally for two weeks. I'm missing a board meeting this week because of the working group and I'm scheduled to be at another board meeting on the 6th which I have scheduled to miss.

I know all of you are missing stuff from your job as well. I personally am not able to continue to dedicate the time that I have been dedicating to this project. When we would get to a report that everyone would have buy-in to, I don't know how many more editions that would take but I'm really questioning can we do that.

That gets to my last comment. Joe has almost addressed it already. Maybe we just come to a conclusion -- that's Option 4. I'm not recommending it but it is an option -- we're not going to come to an agreement on what we want put on this report. I mean, if we can't come to an agreement on a report, how in the world will we come to an agreement on recommendations.

This is merely what we've heard from others, not what we think is the right thing to do. The recommendation is a totally different story. Those are the options that I see. Frank, to your comment, I have already compromised. I haven't told anybody here what I've compromised on but I have already compromised a whole bunch of stuff.

When I read the report, I haven't looked at particular words. I have not tried to edit that. That is something that the staff and the firm who writes this stuff who are experts in this. Not me. Just like I haven't tried to review all the footnotes and those kinds of things. I have done a whole bunch of compromising already.

What I am unwilling to compromise on, Frank, is including the initiatives that we have heard in our hearings and just having a report that reflects what all the think tanks and research have found because if we were going to do that, then we didn't need to go to all the hearings.

DR. BAUMEISTER: Including or not including?

CHAIRMAN JOHNSON: They have to be -- in my estimation they have to be in the report because they give a foundation for potential ideas for the public to say, "Yes, I can buy into some of those," or, "No, I can't." Those are the options that I see. Now let me listen to you. Do you want to start, Aaron?

DR. SHIRLEY: I would think that your question should be asked of all of us.

VICE CHAIR MCLAUGHLIN: We did that yesterday. Randy went around the table to each one of us and asked, "Are you willing to sign off? If not, what are the sticking points?" We actually -- Randy had all of us state that yesterday.

CHAIRMAN JOHNSON: We didn't hear from you. I don't know, would you like to share your perspective or is it premature for that?

DR. SHIRLEY: I think that this community is made up of a group of reasonably intelligent human beings. We have been working together for --

PARTICIPANT: Reasonably but very stubborn.

DR. SHIRLEY: Intelligent and reasonable human beings. I really think it would be a travesty if we can't agree on the report. I just would hope that everybody would be willing to give and take so that we can come out with something that will make a difference.

CHAIRMAN JOHNSON: Go ahead, Montye.

MS. CONLAN: I wanted to say yesterday, but we got out late, about the initiatives. I had at one point suggested maybe we have -- I don't think I would call it an appendix but a list of initiatives because I know at one point you put out the word are there additional initiatives that you would like to submit.

I kind of invested some time and energy in bringing some to Catherine. I was concerned in the very beginning that the hearings committee would be in a sense skewing some of the results by making some choices and inviting some people to participate in the hearing. At that time I kind of felt like that was dismissed but this seems to be a way to address that concern to include an expanded list of initiatives. I hope everybody submitted some more. Well, I did so I would like to see them on the list of initiatives and maybe enlist everybody's support. Maybe there are other ones that we could include. I felt that was mandated by the statute so that was a central request that we could meet to just list them. That was a simple request that we could meet to just list them.

CHAIRMAN JOHNSON: Here is what I would like to do if we can. I would like to put a pretty narrow parameter around our discussion. The parameter that I would like to include is what steps do we take. Tish was flown here -- where in the world are you from? Washington, D.C., to help us on PR discussions so we would be remiss if we didn't take some part of our time to do that. If we can dedicate potentially an hour to this discussion and then plan to cut it off then and see what our next steps are. That would be helpful. Pat.

MS. MARYLAND: Your one recommendation that we would take Richard's input and revise the report accordingly and try to still meet the October 6 date concerns from the perspective that you put together -- you formed a report. I'm going to go back to what I stated yesterday.

The report committee is made up of four individuals all coming from slightly different backgrounds and approaches. I don't understand why we don't use that committee in its totality to filter comments and feedback to see if they can come up with a revised version that will be more satisfactory to the full group.

I appreciate Joe's comments earlier about the fact that I never gave up my proxy. The term that I used was filter. My filter is how the members of the report committee feel about the report because I'm concerned about the accuracy of the information and I'm relying on that committee to make sure that whatever we put out there is supported by research, by documentation, by publications.

That was my intent in terms of what I was saying. Then, of course, I'm going to support if the report committee feels that it is reliable, valid information that is being presented. And if I feel comfortable that the other filter is the PR firm to say is it something that can be well understood and is written in a way that can be well understood by the general public, then I'm okay with the report and I'm willing to sign off on it.

CHAIRMAN JOHNSON: Pat, can I just respond to that? Thank you for your comment. In option 2 I think there would be an opportunity for what you would like to do happen because what I suggested would be that we would review this and George and staff would send it out for an up or down vote. We would all have to understand what the ramifications are.

If you wanted to discuss and get hold of the report committee and ask them, "What is your opinion on this? Are you signing off?" you could certainly do that but we would need to take that kind of action and pilot test some of this if we are going to pilot test it. If, in fact, we are not willing to do it that quickly, that gets into an extended date. Thanks for your comment.

Go ahead, Joe.

MR. HANSEN: One and two are problematic. One is right where I was yesterday. Two does not incorporate some of the other comments that were made. What I am mulling over in my mind here is how difficult a rewrite would be with the committee. In my mind it comes down to -- there's two problems. One is the style and that goes to the language. That works and we can figure out stuff like that with our help.

I don't think the language is right. I think it's too bland. I think when you say ethnic minorities instead of Blacks, Native Americans, Latinos, I think that loses emphasis and stuff like that, but those are words. Those are easy things, you know, stuff like that. The substance, I think, is a little bit harder but I don't know if it's that hard that it couldn't be done on a very short track. Yesterday and today was the first time we've had a real discussion about the substance of the report. We didn't do it in Boston. We skirted around it and all the rest as been e-mails. I don't see it as a surmountable problem, Randy, that the committee couldn't get a revision. We are all going to have to be somewhat reasonable and compromise is part of this situation.

That's what I've been doing for 40 years so I certainly know how to do that but I think we can still do that and maintain some core principles here. I would like to give that a shot if the committee is willing to do it.

I would try to put some help into that as far as the technical stuff if that would help. It is something we all want to be proud of not only as the substance of it but all types of people are going to be reading this. I read it again this morning and I still get that feeling of dismay, that it doesn't get the job done.

MS. BAZOS: I just wanted to clarify and respond to your comments from yesterday. You said that you thought I wanted the whole report rewritten, start from ground zero. Perhaps it is the way you read my comments but I actually don't feel that is true. Last night I took that to heart and I went, "I really can't let this go because it's not true."

I think that what we have in the report is really the nugget of the good report. Just like Richard is sort of focused on the end, I'm sort of focused in my mind what it didn't do to me was help the average American understand well enough for him to understand the initiatives and how they would be interrelated. So I took responsibility for that last night and did what George does. Woke up in the middle of the night, sweated a lot, and said, okay, if someone said to me fix it the way I want it fixed, what would you do?

Everybody has things that they want fixed. Maybe we need to think then if you've got this brilliant idea about what you need, what will fix it? I actually think a table or a chart that actually pictorially or graphically showed the fragmentation of the payer and delivery system and how the system was a little more interrelated added to the report would be helpful.

My other major concern was the way we leap into the language of tradeoffs. I don't think it would take weeks or months or negotiation to change that. I think it would take some sensitivity to how it's read. A lot of my comments were not about rewriting the report but reading it really, really carefully to say, "Okay, what is missing? What's not missing? Are we getting the message across?"

I actually think I had a responsibility to read it line by line and to comment line by line because some of the changes that I was suggested line by line I thought made it much more clear. I just wanted to say I was not suggested to throw the baby out with the bath water. I think we did that once and I think it was a mistake. I'm trying to figure out what happened.

At Salt Lake City we had a report we thought we heard but Senator Wyden thought it didn't grab us enough. I remember the report committee then bolstered themselves and everybody else in the room to get more comments, putting comments. There was another read by the committee and edit but I never saw anything back from that.

Then we did take it then to Edelman but not only was it pepped up but some content was changed so we sort of -- we kind of made a little more work for ourselves, I think, in the process so we are going back to -- it's like we're reading a new report which I think has been a little bit inefficient. However, I don't think that we need to be -- I think we can still make the October 6th deadline.

I think there is another alternative that we could think about that we didn't mention yesterday. What do we need by October 6? We need a report that is going to go on the web. We would like to drive people to the website to answer some questions. Do we need -- I think we need to ask ourselves do we need the 10-pager on October 6th? Does that have to be an out?

I think if we come to some agreement about the 25-pager, that it's a dynamic report, which we all agreed about to begin with, that it would change as we go out to all the communities, then it would be easier I think for us to come to consensus on the report if we agree that it's dynamic, if we agree that it tells the story, it's good enough, it can be read, it's up there on the web, we could still on the 26th go and announce the roll-out of the report but the start of the dialogue as well.

It is another option that we can think about and meanwhile really work hard on the 10-pager which we really haven't discussed and the questions which we haven't discussed which I think are going to take a great deal of discussion. I think there is -- I don't think we disagree.

I don't think we are this far apart, Randy. I think we're only this far apart. I do think it would take -- I do think a lot of coming to consensus is sitting in a room and really talking about the content and writing it down and getting it down together. We haven't talked about the contents until now.


VICE CHAIR MCLAUGHLIN: Just to build on what Dottie was saying, I think that several of the things embodied in your options, Randy. One is, again, the thing that was brought up yesterday about pilot testing the long report. That is something that we didn't originally have in mind. We were only going to pilot test the short report.

That's what was discussed in Salt Lake City and, in part, because, as I reiterated yesterday, the short report is going to be printed and you can't say, "Oh, gosh. We just printed 10,000 and found out it's not clear." Whereas, the long report only on the web the pilot test is really having it up on the web and having people respond to it. That's not the accuracy thing.

You want to be accurate when you go up there. Joe was saying it goes on the web and people are going to read it so it has to be accurate. It cannot have mistakes. But the introductory paragraph if we find that people don't understand it can be changed. Right? That's the beauty of having something up on the website.

If you find out that certain segments of the population that were driving are saying, "I don't understand this first page." That can be changed. This is what I was saying in Boston. The report that we gave you in Boston, I said, "I can tell you this is safe. It's been vetted heavily by researchers. It's safe."

There was nothing in there that was false, that was fabrication that we would be caught short saying, "That's not 30 percent. Where did you get that number?" It was safe. It was not compelling. It was not exciting. It was safe.

Frank is going to keep saying to us, "Isn't that what we want? Why do we have to have the long report? Let's focus the PR and everything else on the short report, make that compelling." I think we do need to think that. I agree with Dottie. I think we could have a long report on the web by October 6th. I really do. I agree with Dottie.

I think yesterday we talked about separating clearly initiatives from ideas making it clear the initiatives we heard in the hearings. Be very clear about it so that people know we got this from the hearings. We went out there and we did what we were supposed to do which fulfills your sense of obligation. I think that's correct.

It also is presented as dynamic in saying, "So let us hear about your initiatives." We keep updating it. I think there are several issues that we are really not that far away from and that there are other ones that will take a little bit more work but since we are not going to print it, and I don't think we need to pilot it, the long report, I think we can make October 6th.

The bigger one for piloting to me is the report in brief. I think that needs a lot of work. I agree with Dottie about the questions. We've never discussed the questions. Yesterday some of us talked about them and it's quite clear that I think the majority of the working group is quite unhappy about the questions. When you say two of your options were to pilot test the long report, blah, blah, blah, December -- I mean, December. Ugh -- October 6th and use the questions from the short report.

I think that is where we may not be ready by October 6th. We may be ready with some very broad questions but I'm not sure we are going to be ready since this is it. We don't have another meeting. October 6th is in two weeks which is why I was asking you when you said your report is in two weeks, supposedly our report is released in two weeks so I was thinking oh, my gosh, Randy, you're going to be running from one roll-out to another.

CHAIRMAN JOHNSON: I'm not involved with the other roll-out. I've just seen the report.

VICE CHAIR MCLAUGHLIN: I'm just saying the dates, though. That's why, Joe, I was asking two weeks. That's ours is two weeks so it's like oh, my gosh, the same week. I think that does argue --

The third piece I just want to add -- I'm sorry I'm taking so long -- that Dottie and I were part of a conference call with Tish and Connie talking about the roll-out event in which it became clear to me from the information they had sent me and from the discussion that the roll-out, the press conference in October, is no longer about the report.

As I said in that conference call, that's probably a good thing that the focus has been introduced who we are. That's what Tish and Connie are pitching to us on the communications committee. Make the roll-out who we are. We're here. It's not about the report anymore. That's not the piece de resistance.

In some ways that makes -- why go through this? You're saying figure out when the senators are available. Stick with October 6th. I don't think we need the report in brief October 6th to still have the press event that Tish and Connie have been pitching to us. They haven't been relying on the report for the President.

I think having a long report on the website available that day, as Dottie said, as part of the announcement of, "Here is our website and we've got all these resources on our website. We've got links and we've got this and we've got that and we have this detailed report, as Frank is saying, it really gives you the facts.

It puts it all together in one piece. Blah, blah, blah. You can get state stuff, you know. The website will still be interesting, will still be of value, and the report, the long report, will be up there. I think we can do it.

CHAIRMAN JOHNSON: Hang on. I want to make sure that all of the working group members have a chance to share their perspective. Tish, I'm going to ask both you and Connie to share your perspective in such a little bit. I would like to give some feedback regarding what I've heard as well but I want to give everybody else a chance to talk.

MS. CONLAN: I guess I think this is instead of an obstacle an opportunity to kind of practice what we preach, and that is that we are not the experts that know everything. We are not dictating to people. We have gone through this process. It doesn't have to be all controlled and perfect.

Get all our ducks in a row before we have this big day but this is our best effort and some sort of disclaimer not identified as such but letting the public know that this is dynamic, this is the process. That is included and the report is open to comments and all of that and we will consider that, I think. I think it's an opportunity to demonstrate that.

CHAIRMAN JOHNSON: Other comments? Deb, you want to say anything?



MS. WRIGHT: I heard what Catherine just said. I think we can meet that October 6th deadline. I think that is not a compromise. In order to stay on time we have to go out with something on October 6th. I think what we have in the long report were things that we have heard. Have we heard everything? No. What we are starting to now want to include are our own personal, or some of our personal opinions as far as malpractice. Did I miss something in one of these hearings about malpractice? Okay, thank you. I mean, I think that long report needs to incorporate what we've heard in the hearings. Will it stimulate -- at the beginning is to stimulate more discussion and to open up the discussion with the American people.

It's not to give them answers or solutions or narrow them down one path because I guarantee you depending on whatever population I'm talking to whether it's blue collar workers they are going to be worried about the insurance and the cost to the employer.

If I'm talking to a group of physicians at the AMA, they are going to bring up the malpractice to me and what's happening. We have a solid background here. I think it just needs a little tweaking but we need to hold to that deadline.

CHAIRMAN JOHNSON: A couple comments and then I would like to turn to Connie and Tish and George for any comments that you've heard-- comments that you have regarding what you've heard. I was told once that when you are making a presentation you get 10 seconds to create your first impression and we've got one paragraph to create our first impression.

We have already had a press conference where the group was introduced. We had ABC there. We had a bunch of other folks there. We've had that press conference already. Now, if we want to reintroduce ourselves again, you know, that is something that --

PARTICIPANT: What press conference was that?

CHAIRMAN JOHNSON: When Senator Hatch and David Walker and Senator Wyden introduced the Citizens' Working Group they announced who we were on the 28th of August -- the 28th of February. Not all of us were there, of course, but we were introduced then and we've had other press conferences, the day before yesterday. In fact, yesterday morning we had a meeting. Now, was this a broad nation-wide thing? No. That would be my first response and, again, look to Tish and Connie for their thoughts.

I'm not sure that we will get what we want if we think we are going to revise the 25-pager. The 25-pager is not going to be read more than once and in my mind the primary customers, if I can put it that way, for the 25-pager are going to be the staff members who are going to be invited to the press conference to hear about what we've heard so far.

It will be something that can be used by our nurses, our employee benefits folks, and so forth. It's not going to be read by most people but the primary people who will read this that we want to try to influence are those folks who are going to have to address some of the issues that we have. That's the 25-pager.

If we don't have this prepared in such a way that they will read through it, then our effort is not going to be as effective as it might have been otherwise. Those are some feedbacks to you for your consideration. Connie, you wanted to talk. Before you do, Therese has another comment.

MS. HUGHES: I guess I'm concerned on this level and I'm speaking solely for myself so please understand that. I happened to agree that we have one chance to get our first impression out as a group in a report. I'm sure that many of you here at the table agree with that as well.

I also happen to agree that we need to stick to the October 6th date. I think it does not pull us together with respect to say we can't meet the date because the majority of the people here have said we need to meet the date. I think that we need to refocus on how we are going to meet the date.

I think it is critical that the report, which will be read, and we all have difference audiences we want to read the report, but when we're looking at the final outcome of what we are as a committee, this report has to resonate to the people on the Hill. Whether you like it or not it has to resonate to them.

I agree that they are the primary people that it has to go to because they are the policy makers that are going to listen to us down the road again and we are just opening the door to them. Having said that, I think it is also critical that we get this short report out and that be done so that it can go to focus groups whenever the dates are or the times are that has to be done.

However, I have a very small concern and my small concern is that we need to put on the table what our concerns are. I've heard from Catherine and Catherine's concern is accuracy. I've heard from Montye and Montye's concern is initiatives that represent everybody. I don't know what your concerns are. I don't know what Aaron's concerns are. Dottie's concerns are that it's readable to the majority of the people. Pat's concerns are that it reflects the audiences -- that it is accurate and that it reflects the audiences that we all work with. All of us work with very similar audiences in the same level of where business is.

I have to say I don't know exactly what your concerns are. I could guess and I would be -- I could be way out of line but I could guess that one of your concerns might be, and this is assuming, and we know what assuming does, is that the report may be too left tended. I could be wrong but maybe some of what you want is for it to be equally left tended and right tended. Okay?

I'm just saying I don't know but this is just something I -- which would provide a balance which would be important to have. I think that one thing we all need to do is to -- I think if we as a whole -- if all of us agree that whether the report is important as it's written, if it's written well enough for on the Hill, everybody doesn't have your experience and my experience and your experience in working with Hill people.

Some people do and some people don't but I think if it doesn't meet the highest standards for the Hill, you know what? I'm willing to go with that because it's all of us. I can't help but think that with the experience that we have at the table that it's not going to meet those standards.

The points that are pulling us -- that are not allowing us to -- that we haven't arrived at yet are maybe smaller points than what we realize. Everybody at the table has to give and take and we're not there yet.

CHAIRMAN JOHNSON: Let me just respond, Therese. Thank you for your comments. An example of the compromise I would just like to share an example that Catherine had in compromise because on some of the initiatives she had a suggestion that at least for some of us would work.

When we talked with Richard, and the idea was to put some of the initiatives in some boxes, Richard was not of the opinion that needed to be eased in trying to keep the initiatives right in the text so I'm up front. I haven't apparently communicated very well.

MS. HUGHES: Well, I --

CHAIRMAN JOHNSON: Let me just continue. I personally am willing to sign off on Option 1 or Option 2. Option 2 probably, in my mind, makes a better report because it does include some of the input from us as a working group and it includes Richard's suggestions which I think have merit. I'm inclined to go along with that.

I am also wondering who helped the readability, if I can put it that way, for those who are not going to be inclined to even look at the seven to 10-page report. Was it Dottie that suggested maybe a three-page report that is even simpler, shorter, briefer than the 10-pager.

MS. BAZOS: It might have to work for three years.

CHAIRMAN JOHNSON: Is that an alternative that would help us get to close the door on the whole process here and allow us to move forward? We haven't discussed that but I'm just wondering aloud.

VICE CHAIR MCLAUGHLIN: I have two things. One, I'll have to report to Richard how important he has become and how wonderful it is that you and George keep saying -- in fact, the whole option is if we do Richard's. But Dottie and Joe, I think, yesterday made a very valid point about the system and doing a better job.

I don't think we do a good job at the beginning. I mean, we had the health care building on the 10-page which was our attempt of trying to saying something about the system. I think it has fallen away so quite frankly I don't think it's enough just to do Richard's refinement.

I would like to respond to Dottie's and Joe's comments because I think they are equally valid and they made clear yesterday that they would not sign off unless there is a response. I do think we need to do something about the system both at the beginning of the report and at the end of the report because otherwise one of my comments about the initiatives is that none of them are looking at the system. It's presented in the report now with the language lots of initiatives to deal with the complex system and that's not true. None of those initiatives.

All of them are piecemeal which is then in another paragraph but I do think that is an opportunity to come back to the system issue and to have at the beginning so I would encourage the staff to try to respond to their comments as well because I thought they were very valid and when they said it yesterday I went, "You know, they are right." They articulated them again today and I still think they are right.

The second thing is we do need to think about -- I mean, you guys are alluding to the fact that the Hill, that's the audience, the staff. If that is the case, then we should only pilot test it to the staffers. We're saying we want the staffers to read it.

PARTICIPANT: The long report.

VICE CHAIR MCLAUGHLIN: I'm talking about the long report. I wasn't sure what focus groups. Kristen didn't really know yesterday who was in the focus groups. If for the long report the primary target is the HR folks and the staff, then that's who our focus group should be that we tested it to. If we are not trying to get to a broad swath of people with the long report, then we shouldn't spend the time. The focus groups that Edelman has come up with should be again on the short report and the questions.

The third thing is I think you both are right, that the first impression is important and Joe pointed this out yesterday. I think that is actually true. However, that doesn't mean that the long report can't be dynamic. It may be that people only read it once.

You may be right. There are ways, because I've seen other sites do it, of letting people know what's new. You say, "We've added more initiatives." There are ways of getting people to look at different pieces. But I think you are absolutely right. The first paragraph matters. I agree.

CHAIRMAN JOHNSON: Let's take a second to hear from you who are kind of our experts. Why don't we start with you, Connie, and then Tish and then George, and just hear your perspectives.

MS. SMITH: For those of you who don't know it, my background is in radio and in radio we say you are only as good as your last mike break. If your last mike break was in February, nobody knows who you are. The event on October 6th has many layers to it. As Catherine said, we had the phone call and I tried to express the several layers that we are putting together for that event so that people get the totality of what is going on.

Yes, we are reintroducing the working group. Yes, the report is playing a significant role. You as working group members, one of the concepts behind the October 6th event is to really get the working group members, which is the whole citizen piece, to sit front and center. Yes, it's wonderful. It will be on the Hill. It's wonderful. The senators are going to be there but because this is a citizen led initiative, that is what is making the difference. The concept was for us to really play up the citizen initiative and to shine in the sense that these are the many vehicles that we have lined up to engage this whole process, the website roll-out, discuss the community meetings, and all the things, the time line, so it's many layers to October 6th.

The report may initially in concept have been the whole event but because we've got a major task with many layers, that October 6th has to reflect all the layers that the working group is working on. I don't want you to think if we decide to do something different with the report, it doesn't matter. Yeah, it does matter because the report is a big layer of October 6th and I don't want that to get glossed over in any way.

MS. VANDYKE: I agree with everything that Connie said to start and just to tell you a little bit about my background, where I come from. I actually started out in neuroscience and if you want something difficult to communicate, that's where it is. It was during the decade of the brain and some of you may have remembered that and been involved in that.

Like Connie said, you know, you are as good as your last mike break or if someone remembers the seven-second sound byte you got. That is something in communications we know as very true and that sound byte is getting shorter and shorter and shorter as the world of communications becomes larger and larger and larger meaning more cable networks, more radio networks, more vehicles online to get your word out, things like that.

Your sound byte has gone from seven seconds 20 years ago to probably four or five seconds today if you watch news reports or anything like that. What I see as really important here is what we've talked to Dottie about and George and Randy and everybody and Catherine as we've been on the phone or in meetings which is how do you get this out so that real citizens are part of this?

It is -- what we have heard from the very beginning when you all introduced yourselves to us was we are citizens and this is about citizens making a difference. This is about, you know, real people coming together to put together a report and asking real people for feedback. This is not about special interest. It's not about behind closed doors.

This is a true exercise in democracy. If that's the case, that goes along right with what Connie is saying. This is about real citizens and that's what makes you special and different. We really saw the event on the 6th as emphasizing that piece of it with the 25-page report to back you up knowing that the average American, especially when it comes to health care, doesn't have the time in their day to read a 25-page report.

You know, I know for work I have to read them all the time. What I do is I take them home at night. I get maybe halfway through it if it's a good and then I fall asleep. Then I try to make up for it on the Metro the next day whether I'm going to work, coming home from work, that kind of thing, to finish but I don't always finish them so the reality is a 25-page report does not resonate with everyone and we know that but we've got to try to make it resonate with people who are really going to have time to read it. There are going to be people out there whether on the Hill or otherwise, you know, employee benefit managers.

You know, people in -- you know, there's just a lot of different folks who will be interested. Even the media as we have discussed. Robert Pear from the New York Times will be interested and C. C. Connelly from the Washington Post, Julia Appleby from USA Today. Folks like that.

But I think the other thing we've got to remember here is that there are other vehicles like Connie said. Catherine, you came up with at one point a very nice piece that we could take and turn into maybe a brochure type piece that could be printed and used for community meetings and it would give snippets and sort of -- I hate to use this word because I know some of you don't like it in the short report -- snapshot of what health care is about in this country. There is no reason why we couldn't take that and use the graphic design that we are using on other pieces of material and apply it and turn it into something that could be used.

The slide show certainly is something that if we -- what we tried to do with the slide show is make it -- bring people in and make it try to tell a story and make it interesting and give them, dare I say it again, a snapshot of what is going on in the health care system.

Also, we've got to -- I mean, the other thing we need to think about with the event on the 6th is, okay, great, we are sitting in a room on capital hill and we have Senators Wyden and Hatch up there saying, "We don't agree on everything but we agree on that, that this is an exercise in democracy and we are reaching out to people and we are going to get however many millions of people and get their feedback.

We are going to try -- you know, we are going to hold these committee hearings and we are going to make this into something. We've got the Citizens' Health Care Working Group out there helping us to do that.

I mean, that is going to be really important but the question is, okay, so you've got the Citizens' Health Care Working Group. You've got the vehicles that are going to communicate everything, the reports, the report in brief, and the brochure, if we decide to use that, and the slide show and the video. How do you reach people?

You reach them -- think about in your daily life how you get information just through talking to people, through hearing about things in the media, whether it's reading the paper in the morning or seeing something on TV or getting something from a colleague or getting something, a newsletter from a group you belong to. "Oh, there's a little piece in there about this and that looks interesting so maybe I'll go in and look at it."

We need to think about the different vehicles that get to the citizens who we are trying to reach so that needs to be thought through as well because you can have great, terrific materials but you've got to get people to use them so that is the other thing I think we need to think through in all of this.

I know that adds yet another layer to the multi layers we're talking about. I think also, if I can just say, maybe on the 6th I think we are closer on the 6th with some of the -- what I'm seeing in the long report is if we just have a long report for the 6th I worry that's not going to be enough.

We need to have something on the 6th we can give to not only Robert Pear but that we can give to the producers at Good Morning America and they will actually understand. I've done a lot of focus groups with folks on the Hill who say to me, "Don't give me a 25-page report. Don't give me a 50-page report. Give me three pages with bullets because like all of us they don't have the time in their day to go through that stuff.

MS. BAZOS: But that's different. I'm asking a question. Is that different than producing a shorter 10-page document than would be used to lay the framework for community meeting? I mean, is that different? I mean, if we are thinking about bullets for the press, that's a different thing than what I thought our 10-page report was supposed to be.

That's an opportunity for really compromising here if we are worried about getting a 10-pager for the average citizen so they understand and are informed versus getting a 10-pager for the press to go, "This is the nugget." It's very different. Maybe that would be a helpful conversation to have.

DR. SHIRLEY: I was thinking your comments were more event specific for the 6th and that whatever we have available wouldn't necessarily be the report or the 10-pager but an attention grabber. I didn't see her comments as replacing.

MS. VANDYKE: What you could do is actually, if need be, keep the date of the 6th, have your event, have one or two things ready to go. The website will be ready to go and those things should be on the website.

As we talked about with many of you in our meetings and on calls, you've got to think through that the 6th may be one event but you've got to also think about what are the key milestones following the 6th that are going to continue generating interest and continue the momentum that you build on the 6th. Maybe with the community meetings and the finalization of the long report and the report in brief, you use those as yet another milestone that you can use.

VICE CHAIR MCLAUGHLIN: That's the thing. We could have a press kit that has the bullets for those people. But I think having the website, and those of us in the communication community already had a preview, I think that's going to be cool when it's going to be ready.

Having the long report on the web is not going to be the Robert Pear find but in the press kit, as Aaron was saying, we have the bullet. But the community meetings, having a map with the community meetings community and then the working group can decide where those meetings are going to be which maybe we'll get to. That could be part of the 6th, too, as you said, an introduction of the community meeting.

MS. VANDYKE: I also have the slide show ready for the 6th. And if we could do this brochure, I think that might be useful, too.

CHAIRMAN JOHNSON: Joe and then Pat and then Dottie.

MR. HANSEN: When we started this thing we talked about the report, the press event on October 6th wasn't even talked about. I always looked at the long report as the bedrock of what we were going to do all the way to the end and that would be the basis of what we worked off at the community meetings, the big meetings, and everything else.

Now this October 6th event is taking on another life. It's not a criticism. It's not a bad life but really the report has nothing to do with it, you know. It's what we can do to get attention to kick this thing off. That's what I hear you say. Whether that's a slide show, the short report, a three-page report, I think we've got to separate them and that again reaches back to why I think the big report has got to have more thought and something that I think we can all agree upon.

MS. MARYLAND: I shouldn't raise my hand but I guess I would reiterate what Joe said. I think the larger report is key. It's key to all our reputations, too. That's an important piece. I don't need to go any further than that. The credibility of the information in that report and whether or not we feel that we can stand on this is that we believe in it and that we deal on many different constituencies throughout our lives given our profession.

I want to be able to proudly say when I meet with physicians or meet with a group of other health care executives that this report is sound and it's based on sound science. That's why I've been really key on the academic types have the time to validate the data. That's all I have to say.

The report committee is made up of academic types who can help validate the data so that when I stand before a group of individuals, I am comfortable that data represents exactly what's happening in the field and that it's been tested and it is reliable. Nothing to do with what we're talking about but that's been in the forefront of my mind for a while that I just want us to reiterate.

MS. BAZOS: I just think playing out this scenario if we need to stay with the October 6th date, I mean, we did set it and I understand it was from working backwards but I always think you can change dates. However, going with October 6th we have enough of the report that we agree on actually now. A lot of it is already in the slide show.

For the hour-long presentation that we do and, Catherine, you would be doing this so I'm asking you, you could talk about the fact that we are developing a report. It is getting whatever language we use but you could talk about what's in it now because there is enough of it that we all do agree on, that these are the major contents of it at the October 6th meeting.

CHAIRMAN JOHNSON: Twenty minutes ago I asked if George would be available to share his perspective and we need to have a little bit of thought regarding that.

Tish, I would like to ask you when George is done, we've had some discussion regarding the bullet nature of the short report. It's been prepared in that format for a reason. I would like to ask you to discuss that if you would.

George, we've got 20 minutes left before we are going to put a halt to this discussion. We need to come to a closure on it, I think. You have been hearing all of this. Tell us what your thoughts are.

MR. GROB: I have mixed thoughts. I would like to preface the remarks by telling you where I'm coming from in making these comments if I may. I need to be very clear about one thing. I do want to assure you all that the one thing that I have no bias on whatsoever is the substantive direction of the recommendations of the content of that. I spent a whole career and would have never survived doing everything that I've done if I really --

CHAIRMAN JOHNSON: George, it's hard for everybody to hear. Why don't you speak forward.

MR. GROB: I just want to make sure because, you know, I've heard some questions about tendencies of thought. I have always been in the middle. I enjoy being there. I just want to clear the air. Nothing that I have to say has anything to do with the kind of recommendations we'll make or the emphasis of the report at all.

I would like to address my remarks to two things. One is just the logistics of the enterprise. I promise to you that I will meet any deadline you give me. I think I kept that promise so far and I'll do it again. If you say October 6th is what we're going to do, we'll do October 6th and get it done.

I would now like to venture into new ground which is I would like to call upon my own career of being in the report writing business, the report selling business, someone who is engaged the Congress, engaged the public in a very good way. I'm going to make some very stark comments here to share with you that I would like to lay on the table.

My first comment is that if October 6th consist of the reintroduction of our group and the posting of the large report on the website, then I think it would be a deadly blow to our future. I believe that would be an absolute killer. I think it would cause people to yawn in Washington, to create negative publicity, to deride our effort, to say that we have nothing important to do and that we are a bunch of amateurs floating around the country. That is my stark statement to you.

As far as the 25-pager is concerned, I have established in my own mind and discussed that the criteria would be that, of course, it would be absolutely settled. I also thought it needed to be compelling so somebody would be like, "My gosh, we better do something." I thought it should be engaged which is the people of the country will embrace it. That's a pretty high combination of things which I don't think is impossible.

I would tell you that there was no person that I know of who have read the 25-page report who did not immediately come back to me and say, "This is a sleeper. This will not engage anybody. It's difficult to read. It's hard to say what this thing means." My concentrated efforts have been to say, first of all, what does it say? Let alone how compelling is it but simply can I reduce it to what I call the Mom test, found it extremely difficult to do. I thought that when we decided upon the three things, the quality and the access and the cost, that sort of did the trick, that was compelling. I think that the part about the systems which is very important to all of us was something that most people I talked to felt that they were obliged out of responsibility to slob their way through and it stood in their way in the middle of the report of getting to the thing that everyone would want to get to. I'm not saying it shouldn't be there. I'm just sort of saying that's what it is.

I think that if we are going to have an event to introduce ourselves with the website and other things, I would say that there has to be some content there. I would say that I don't see the point of telling the world that we exist and have a 25-page report. I think if they are going to go on the website, we are telling them that we want to engage them. If we don't have questions for them to answer, I don't see the point of telling them we would like to hear from them.

If we don't have information that is easy when we're saying that we are trying to get them to understand, and if we don't have a variety of material available for them easily so they can understand, then I think so many people in this country of all different levels that we need to have a variety of materials so that each one can find the type of presentation that they are feeling comfortable with that I don't think that anything will happen.

I don't think we will be engaging the nation and I don't think that people will respond favorably to it. I don't really think we have all that much to say beyond that there's another commission in Washington and another technical report. It is my own view that unless we have a pretty full package that the October 6th event, that there's not much traffic in it.

Now, the question then is can we get to October 6th with a set of materials that would do that? I believe that an intense effort on our part could get us some questions that we could feel comfortable posting. We may need to generalize them and we may need to limit them to the four that are in the law.

We may need to do some other things, a smaller list. There is a series of questions I think we all agree should be there and many that we can't agree yet should be there but I think we can find enough that would engage the public.

I think the 25-page report does need another round and I do think that can be done, at least to get it ready for being on the computer -- on the web. I'm less doubtful unless you took the option of sort of seeing what we did with comments you've already given us including a healthy review by everyone involved. I am less confident that we could have a printed version ready by October 6th. I think you would only have a web version which is what we've suggested. I think the other material --

CHAIRMAN JOHNSON: How detrimental or what are the pluses and minuses of that. I would like you and Tish to comment on that.

MR. GROB: I think that if you had -- I'm going to give you an opinion now which will be a new thought for you. I believe that the 10-page report that Edelman has produced is a good practical summary of what we've done. It is not the engaging report but it may very well be the kind of brief version of the report that if we weren't in the mode we're in now, if we were in any other mode say, "Well, here's a 10-page version of what we have," and say, "Here it is."

My guess is that could do the trick and that the 25-page reference could be the deeper reference. I think we could declare that the 10-pager is the report to the American people and the other one is a resource to back it up.

In the form it's in now it actually looks like a formal report instead of that engaging document that we had talked about earlier and were all attracted to. I think a separate engaging document in various forms could still be used for all these other purposes.

I would defer to Tish and others as to whether we could see our way through to that by October 6th. My sense is unless we have the full package of the questions on the web, the opening of the web, materials that of a broad cross section of the country could relate to, a report to hand out that looks like a report, that I don't see what we are offering except a boring commission in Washington. That's my opinion.

CHAIRMAN JOHNSON: Tish, can you talk about just briefly George's comments including the idea of not giving out a printed 25-pagers and just putting it on the website?


CHAIRMAN JOHNSON: And just putting other materials on the website. Take this home, Tish.

MS. VANDYKE: Okay. One thing I just want to add to what George is saying. My sense is from what Connie and myself and George are saying, we all pretty much on the same page. Hopefully you are hearing that because that's what I'm hearing. One think I think hasn't been said here which is -- this, once again, makes the Citizens' Health Care Working Group very different from anything else in Washington. I want to emphasize that not only do you have a report which is trying to have -- trying to inform people about what we call this health system is all about and trying to get them to understand there are problems and possible solutions and that kind of thing.

Not only are you going to be telling people you are going to have these community meetings which is going to create dialogue and hopefully discussion around not only the report but what are the problems in the health care system and what are the things we need to do? What are the payoffs and what are the tradeoffs?

What are the kinds of things, decisions we need to make to really make it better and fix that system. The final thing is a call to action. Basically what makes this different is that we are actually saying to people, "We want your input."

Now, we're not saying we are going to take 100 million people, or however many million people, and we are going to get their feedback on very easy questions and say, "Okay, Congress, X percent said this, X percent said this, and X percent said this." But what we're doing is we are saying is, "We want your feedback. We want your input. We want you to go to this site or we want you to call this 800 number and answer a set of questions for us." That is a call to action and that also makes it very different from a lot of other commissions that are out there. I think that point is very important in all of this.

Now, as far as only being available on the web, you all know as well as I do that not everyone in this country gets things only on the web. Many of us have Internet capability in our offices. Many of us have them at home but we are not the average person. What we've got to be concerned about when we are out there talking to the media is, "Great that you're out there and great you're on the web," but what about those people who don't have web access?

If the situation down in New Orleans taught us one thing it was how huge the gaps are in this country between the haves and the have-nots. That is really an important point here. Not everyone has web capabilities. If you are really looking for a wide variety of feedback, we need to keep that in mind so we need to have an 800 number or we need to have another way that we are telling people this is going to be available to them.

VICE CHAIR MCLAUGHLIN: He was talking only about October 6th not having a printed version. That not we wouldn't have one but the importance of only having on the web October 6th. It may be in the press October 15th but it's only on the web October 6th. I just want that clarification. I don't think Randy had any intention of not having a printed version. Maybe multiple printed versions.



MS. VANDYKE: Okay. I think, yes, we can do that but we need something on October 6th that is going to be some hard copy of something. Something I think has confused a lot of people, and I was talking about this just this morning. I was talking to George about it.

The draft of things you've seen are purposely text only at this point because we need to come to an agreement on text before we can take something and give it to designers to put into that sort of compelling, engaging look that everyone is looking for.

When you come up, and many of you have worked on reports before, you know that you've got to get the text down before you can give it to a graphics person to get it into place to make it look pretty to put all the cool in it whether it be boxes or pictures or graphs, whatever. That is really important.

What we have delivered to you has solely been with the exception of a slide show which we wanted to put some graphics in there as well as -- when I say graphics I mean design type stuff and we want to get the graphs and charts in there so you could see eventually what things are going to look like.

As far as the actual report whether it's the 25 or the 10-pager, at this point we need some agreement on common language before we can get that design built into it. Does that make sense?

CHAIRMAN JOHNSON: You still haven't answered the question, Tish. The question is to what extent do we have to give something -- two questions, actually. To what extent do we have to give something out, i.e., the 25-pager, in this press conference as opposed to merely saying we have this report on the web.

MS. VANDYKE: I think you could say --

CHAIRMAN JOHNSON: And then the other question I would ask, if you would respond to, is you did the 10-pager, the brief report, in somewhat of what some of us have been calling the bullet format. Talk to us a little bit just briefly, moving on, why you did that.

MS. VANDYKE: Okay. I think you can have the 25-pager on the website but I think somebody like Catherine is going to have to be up on the platform or whatever, the podium, on the 6th to talk about in about 15 minutes what's in that 25 brief page report and give a very top-line view of it and then encourage people to go online to see it. But I also think if you are going to do it that way and you are not going to have a printed 25-page version of the report, you've got to have the 10-pager ready. Does that make sense?

Then to answer -- I'm sorry. I'm not answering all your questions as you ask them. The 10-pager, the reason why we did that in bullet format, is because we know from these kinds of reports even when we did the 9/11 commission report last year, which was a good example of a very long complex report, that you have to.

When we work with California Health Care Foundation, which is probably closer to some of the stuff we're talking about here, when you release a report that is so substance heavy you are quite correct. The 25-page report is a synthesis of a lot of different data and outcomes and research that's out there.

The way people read things, and George said it, which is the people he's talked to it doesn't pass the Mom test because it's text heavy. What you need to do, and we know this from experience, we need to give people something that is visually engaging and also reads in a way that they feel like they can get quick snippets of what you are talking about.

That's what bullet points do. When you're trying to get -- we are trying to get to a huge audience here, it's really just for readability purposes more than anything else. It's a way of helping people making it easier for people to read more than anything else because if you have dense paragraphs, people tend not -- it's not as easy for people to get through. This is heavy stuff.

CHAIRMAN JOHNSON: Okay. We've been talking -- thank you very much. We've been talking for two hours and Catherine's departure has reminded me that we've been talking for two hours and probably need to take a stretch break. Let's take 10 minutes, if we can, and reconvene and then come back and see if we can come to a course of action. Thank you for the good dialogue. It's been helpful and hopefully you are finding it to be informative as well.

(Whereupon, off the record.)

CHAIRMAN JOHNSON: You noticed probably that during the break I asked both George and Tish and Connie for their comments. Let me try a couple of things for your consideration.

First, I'm going to share a recommendation with you that will include some project dates and then I'm going to be quiet and ask Tish and George and Connie if I've got their understanding what is doable correct and go from there.

What I have understood is that at least most of you would like to see us try to hit 10/6. So then the question is what can be done and what are the garget dates for 10/6. One thing that we can continue is to do the focus groups that were planned today using the current materials that we have for the 10-page report. That will give us some feedback that will be helpful to us. Then the question is if we are not going to try to put the 25-pager on the web -- I'm sorry, if we're not going to try to give that out -- excuse me.


CHAIRMAN JOHNSON: I think what we are coming to is a conclusion that we could put the 25-pager on the website but not give it out in printing. That will save us some time. The other thing that we could do is take some feedback from the focus groups and see to what extent they have comments that we should consider.

If we do that, George and Tish, as I understand it, have said that they have to have the report exactly ready to go to print on Wednesday of next week. If, in fact, we try to do that, then the question is when can we get materials out to you that will take into consideration all the comments that we can get into these reports that would be information that would reflect our comments and discussion to the extent that we can.

We probably would need to take some time to do that but potentially get that out by the end of the day tomorrow. And to help some of us with -- we haven't discussed this with Catherine but my recommendation, Catherine, would be to the extent that you would be willing to work with George and the staff to do that, that would help us facilitate some of that.

That would be a recommendation if you are willing to do that. Here is what we are thinking of as a proposal and I'm going to ask again George, Connie, and Tish to see if I get it right. Focus groups tonight and the materials that we have including the 10 questions that are in the short report.

Materials refined to the extent that we can and sent out to the working group at the end of the day tomorrow with comments from Catherine. Final, no further changes Wednesday, which would mean that if we were to get changes to George on Wednesday night, it's too late because we have to have them finalized at that time.

It's almost a sign-off of what George and team are sending out tomorrow. If we don't sign off on that, then the result is whatever changes are made the rest of the working group wouldn't see them. Have I presented your thoughts, Connie, first?


CHAIRMAN JOHNSON: And what we would provide in the press conference would be the 25-pager on the website with some comments regarding that. The short report with the potential to come a -- I'm going to use a three-pager but it might not be three pages but it might be a brochure or something to catch the attention of people who might not want to read even the 10-pager or the report. That may not be done by the press conference because of everything else that would have to be done.

Tish, go ahead.

MS. VANDYKE: No, that's fine. That's exactly --


VICE CHAIR MCLAUGHLIN: What 10 questions are we talking about because I'm not seeing ten.

CHAIRMAN JOHNSON: There are 10 questions that are included in the --

VICE CHAIR MCLAUGHLIN: On the long or short?


PARTICIPANT: Let me just say for the focus groups tonight what we are trying to do --

CHAIRMAN JOHNSON: Don't go there.


VICE CHAIR MCLAUGHLIN: I want to make sure I understand because reports, reports, reports. I'm getting lost. What is it that you want to have as a target for primetime on December 6th? October. Why do I keep saying that.

PARTICIPANT: You're wishing it was December.

VICE CHAIR MCLAUGHLIN: Exactly. October 6th is the long report on the web but what print is the handout? That's where you lost me.

CHAIRMAN JOHNSON: The short report.

VICE CHAIR MCLAUGHLIN: The 10-pager. The one that we never even got to talk about yesterday.

CHAIRMAN JOHNSON: Correct. That's the proposal. Now, as a group we can say no, we're not going to do that, but if we don't do that, then --

VICE CHAIR MCLAUGHLIN: Because once the 10-pager is printed, it's printed. I guess I would have a friendly adjustment to that. Speaking for myself, I don't think we are going to be ready on the 10-pager to have it get to the printer and the graphics and look nice and everything else by October 6th.

What may be ready is an abbreviated version of what you guys did which is part of a press kit that is bullets. You don't even need pretty graphs. It's not mass produced, mass printed. I'm just worried. I don't know. Maybe I'm wrong but so many people come up to me about the style and liking what I did much better than the bulleted kind of thing.

Not what I did really, Jill back in July before she left for Spain, and the team did. I'm not sure we're going to come to agreement with me working with Jill and George and Craig before we go to Frank's tonight and then I don't know when tomorrow because we have public hearings tomorrow.

CHAIRMAN JOHNSON: You want to comment further just regarding the proposal?

MR. GROB: The only thing I can say is that we did request comments on both the short and the long versions and we received them. We received the members’ comments on both the short and long. I have all those comments.

VICE CHAIR MCLAUGHLIN: Yesterday when we talked about it, George, I thought that almost everybody had not given you comments on the short on the short report.

MR. GROB: It was a mixture. I would say some did and some gave comments on both. I have the comments I received. I did receive them. I didn't get many real comments on the 10-pager in the sense that people said, "Yes, this is an easy read. I understand it." There were some things.

In fact, when we prepared, I actually could turn the material over there. When we got the comments I basically spent about two hours with Tish where we simply assembled all the comments that we got on the short report as well as comments on both and we systematically went through every single one of them.

VICE CHAIR MCLAUGHLIN: Okay. Yesterday my recollection is that I even held my up and said I have tons of comments on here that I did on the plane. Dottie and several other people said, "Yeah, I read it on the plane yesterday and have lots of comments," and we didn't talk about it because we ran out of time.

MR. GROB: What I'm referring to is the reports that led up to the preparation of this thing. When it went out on the 19th, this one reflected the comments that I received.

VICE CHAIR MCLAUGHLIN: You don't mean the 19th. You do mean the week before.

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: The 19th was this one.

MR. GROB: The one that led to -- on the 16th. Thank you very much. That reflected the comments that I received from sending it out.

CHAIRMAN JOHNSON: Now, if the focus groups will tell us to what extent this is readable or understandable so whether it's a bullet format or whatever, the focus groups will help us provide information. And it would be our intent before we send information out to you to take the feedback from the focus groups and share that with you.

VICE CHAIR MCLAUGHLIN: I think the thing is, Randy, that we haven't talked about the 10-pager at all on the questions.

CHAIRMAN JOHNSON: And the questions are a central part of what --

MS. BAZOS: I'm getting a little frustrated. I'm sure everybody else is. I think what George said about us being dead in the water if we just put out a 25-page report. I we should listen to that. But then that leads me to believe that the press or the hoopla that makes us different are the questions.

Since we have not talked about them yet, I'm really worried that by pushing a decision about -- we're focusing on the report. The question is so we have the 25-pager. We are going to talk about the 10-pager. The question to me is the question. How or when -- what is the process for us agreeing on the questions that are going to be -- that's going to be the story on the 6th. I'm very, very worried about that.

CHAIRMAN JOHNSON: What are your suggestions?

MS. BAZOS: Well, I think, first of all, we need to ask people did they love the questions, yes or no, up or down. If they didn't, then I think -- I don't know. I just think we've got to agree on the questions. The questions will be I think the key to our engagement with the public when we get out of the box. I think we are close on the 25-pager.

I don't think people have given all of their comments on the 10-pager. I think we are coming to agreement on different things about the 10-pager. I think the crux of the conversation that we need to have that I thought we were going to talk about today were actually the questions. I'm a little worried that we're not going to agree on the questions in time to do the October 6th.

I'll say that right now. If we don't agree on the questions, my vote then would be that we set the date of October 6th. It's a date that was set. I know working back I don't think it would kill us to wait four weeks, set another date, and get it all out of the box at the same time if it is something that we agree. I'm sure that we can come to an agreement. I don't want to go out there with questions that make us look like amateurs. That's my worry.


MS. HUGHES: I've voiced pretty much that I have concerns about the questions. I will say this today that listening to some of the things that have been said about the processes of which some aspects are new to me, I'll be honest, so I'm prey to the biases of somebody who thinks they know but doesn't know.

I think that if we -- I don't know how much we will agree or disagree on the questions. I think we ought to discuss the questions because they are the thing that make us different. I think we need to discuss that.


MS. HUGHES: And then the other thing is I wanted to ask you the focus group looks at all of this and they don't see it with any -- they just see it as we have it here.

MS. VANDYKE: Yes. They will see the latest version. I don't know because I wasn't here last night or yesterday to get that but I know Kristen is getting those materials back to the east coast because the focus group is actually starting in about three hours. What they are looking at is specifically do you understand this. If you read this, would you be motivated to go and go further into this website and answer questions? Would you be willing to go look at other materials we have on the website? It's that kind of thing. Okay.

MS. HUGHES: Okay. It's readability, usability, ease of use, that kind of stuff that we are really looking at. Are there things in here that you have no idea? When we talk about access does that definition of access mean anything to you? Do you need to clarify further?

Things like that is what the focus group is doing so when this comes back to us after having gone to the focus group, are you going to track and change it with highlights so we can see what the differences are rather than just having to sit down and compare ourselves what are the differences?

CHAIRMAN JOHNSON: Let me just respond to that and ask Connie and George. I would expect that if they were going to make any changes they would merely give a summary of the comments back to us and then we would have to decide to what extent are we going to respond to it.

MS. HUGHES: Okay. Where do I fit in that process? I'll just be selfish and ask where do I fit into that process?

MR. GROB: Well, the standard way would be for us to see whether we would want to suggest some changes to the report based upon the feedback that we got and then send that revised version out to you tomorrow late.

MS. HUGHES: So that's what we're talking about here for this time line that you just presented.

MR. GROB: Here the time works for us that if Tish sends us the results of the focus group discussion, we will probably get them by noon tomorrow.

MS. VANDYKE: I'm meeting with the research people at 11:00 east coast time tomorrow. They are going to give me feedback. I told George, Connie, and Randy that what I will do is take those and put them in an e-mail -- it's not going to be in an attachment so nobody has to worry about that -- in an e-mail to these guys tomorrow so they can turn that over to you and you will see the feedback from this. It will be top line. It takes about five to seven days to get the actual report pulled together but it would be top line feedback from the focus groups that are taking place tonight.

MS. HUGHES: What does top line mean?

MS. VANDYKE: Top line means sort of the overview, the big comments. Then what they do is they go into more sort of scientific and they pull quotes and all that kind of stuff. They won't have time to do that tonight but what they will be able to say is overall they don't care that Congress wants their feedback. Overall these questions motivate them. They want to go in and talk about this. Overall quality, access, and cost means nothing to them. That is the kind of feedback we are going to be getting.

MS. HUGHES: Okay. Okay.

MR. HANSEN: Does it matter what we think about these questions at all then?

MS. HUGHES: That's what I was going to ask, too.

VICE CHAIR MCLAUGHLIN: Does it matter that these are the questions to which we want answers whether or not they want to give us those answers. I think that is the point that Dottie has been making and Joe and some other people. The comments last week and again this week is that you only get answers to the questions you ask and so the questions are not just important in terms of clarity.

They are not just important in terms of inspiring people to answer. The questions are critical for determining what information we get. We will steer the conversation, the dialogue, with the American public through the questions that we ask them. There has been some e-mail exchange, comments, responses to George expressed by some members that they don't think these are the right questions. That's part of the problem, Tish. I think what you guys are doing sounds terrific. It sounds exactly on target. The problem is that we may get feedback about questions that most of the working group doesn't really care about hearing about. That, I think, is a big part of the problem.

CHAIRMAN JOHNSON: The nature of some of the feedback that we've had on the questions has been that the working group is widely divided in their thoughts. We have some feedback that would say that our questions should be, "Tell us about your experience with health care." It would be very broad, very open and that would be the type of questions.

Another person has said the question should be much more specific. Tell us how you would feel about increasing the deductible. Some of them are yes or no types of questions with a very short limited type response.

The questions that are in the report basically are intended to try to be middle of the road in terms of some closed, some open, but an attempt to balance those two perspectives to be somewhat more in the middle and to deal with some of the topics that we need to deal with. There is no doubt, Dottie, we haven't had a full discussion. And, Catherine, we haven't had a full discussion of this.

MS. STEHR: Looking at the questions I think they are reasonable questions and not everybody is going to answer all of them. You are just going to concentrate on what areas you are familiar with but nobody is going to answer all of them. I think in a way it is a good mix of questions. It may not answer everything we want to know but I think it is a fairly decent set of questions.

CHAIRMAN JOHNSON: George, what we have does not request some of the changes to the questions that you have received. Correct?

MR. GROB: I actually have not received any comments that have been specific to a particular question. The only time I received any questions is the general one that you mentioned that I got from Richard who felt that the orientation should be much more to finding that to be the experience.

CHAIRMAN JOHNSON: And Pat gave us feedback.

MR. GROB: And Pat did, too, on the earlier version. That's correct. They were opposite in the sense that Richard's questions were more generalized to experience. Pat's questions tended to focus in on particular policy options. On the policy options that we put in there, we basically tried to find the middle ground that is sort of a broader statement of policy.

CHAIRMAN JOHNSON: I think also that as we move along we will need to expand the questions based on the responses we've received to what is in this report. We are going to have additional questions that will take place in different settings in the future. But, in fact, this would be a starter set, so to speak.

VICE CHAIR MCLAUGHLIN: I mean, for example, in the access the three questions here are only about insurance so we are not going to find out anything about access for disparities. We are not going to get any information on it. The quality ones, there's nothing there about technical versus interpersonal aspect of quality, what they value, what they are willing to trade off.

There's nothing about whether they want more of a regulatory mechanism as is true in the airline industry or the restaurant industry for safety and to reduce medical errors. Most of the questions in the quality section are really about cost and efficiency. They are not really about quality.

The ones on the cost, they are two very broad ones that -- well, one very broad one but nothing really about what tradeoffs you are willing to make in order to have your personal cost reduced, what tradeoffs you foresee -- we can use different words, Dottie. I'm just using those to have our vernacular -- to have the cost of the whole system be reduced.

For me, George, it was difficult to give you a response. As you can see, I gave you lots of response details that I haven't turned over to you yet -- I had them yesterday by the deadline -- that aren't there. It's the type one versus type two thing. There's just a lot I am interested in hearing about with people's values, people's -- you know, how they are viewing this that aren't even there. Yes, I can give you responses to these questions like that question is not worded quite right or it doesn't quite get at it or blah, blah, blah. But the bigger thing for me are the missing questions quite frankly.

In the computer world we say garbage in, garbage out. You put data into the computer and then you analyze those data but you only then get answers that the data will allow you to get. These are data generators. These are generating data for us. I look at this and I see half of these questions and I don't really care what we find out about them because those aren't the data that I want.

Then there are all these missing data that we are not going to be able to analyze because we are not even asking them. That's my problem with the questions, Randy. It has nothing to do with whether they are general or specific. I believe we should have a mixture. I think that is absolutely right.

This came up yesterday. We should have some true/false, some scales, some long. I mean, I think we should have a mixture. The point with these 10 questions is that I don't think they hit the mark. I think we missed the opportunity.

MS. BAZOS: But the question is why do we have the questions in the report?


MS. BAZOS: Yeah. We originally had --

CHAIRMAN JOHNSON: The reason why is because we are saying we are going -- you are asked to make tough choices so the intent is to say, "Here are some of the questions that you need to begin to think about and we would like your response on it." That's what we're saying. Otherwise, it's the engagement thing, Dottie, that you've been talking about.

MS. BAZOS: I understand but I think what we have set up is the same thing we kind of set up with the initiative. It's like once you make the -- it's the same issue we had with who should sit on the stage. It's like once you make the list, then you have automatically excluded a group, either the people who are sitting on the stage or questions that aren't asked.

I mean, I think the engagement piece is, yes, we are going to ask questions. We are going to have hopefully, George, a survey of questions that none of us have seen yet. Catherine's initial question about the questions is what would they be used for?

I guess my question about the questions is are these the questions we would use at the community meeting? Are these an example because, if they are an example, it didn't come across as an example and there would be more. I just think that plunking them down at the end of the report seems to me that this is what we are going to focus on.

It seemed to narrow the field and narrow the conversation immediately. That is my concern with the questions so I didn't really give much of a response to George yet because I just read them on the plane.

CHAIRMAN JOHNSON: Go ahead, George.

MR. GROB: Just a technical thing. We actually prepared, and I have with me a larger set of questions that we sent around to everybody. Indeed, in the report here these were meant to be. These are some examples of the kinds of questions that we would ask you so I think it actually says that in the short report.

Then in the long report then we said let's go ahead and just use the same one. We have a slightly longer version but I think for now they should be set as examples. I do have that larger set of questions. That wasn't made available. The purpose of that larger set of questions, which might pick up some of the persons that you were interested in --

MS. CONLAN: I never knew there was a larger set of questions.

MR. GROB: Yeah, it was sent to --

PARTICIPANT: Monday at 6:00. Montye was just saying, of course, she wasn't there so she didn't get it.

MR. GROB: Okay. And those questions the way we had it set up the longer set was for the website. The longer set. Yes, thank you. The one you have there. It was for the website.

PARTICIPANT: Oh, I thought these were the same ones.

MR. GROB: For the website. Then the shorter one, which is in the report, were meant to be examples of the kinds of questions that people would be asking. That the technical answer to your question.

DR. SHIRLEY: I don't know how much time was spent on the report yesterday but this morning we spent about two hours and it looks like we are about to get into another marathon on questions. It seems to me that our purposes could be better served if anyone has problems with the questions rather than put aside the questions, come up with what you would suggest is the better option.

CHAIRMAN JOHNSON: Aaron, we would welcome those kinds of comments. I think what we are dealing with is a need to come to a conclusion quickly, I think, regarding what our action plan is going to be. George has made a comment that I neglected to make. We say that these are examples of questions. Obviously they are going to have to be more and we'll have to vet more and we'll be able to put more on the website. These will be questions that would be in the short report potentially. In our meetings we can build on these. We don't have to be limited to these. This is, as I mentioned, a starter set.

Let me come back to what we indicated was a proposal for your consideration. I'm not trying to push this. I'm just throwing it out there for your comments to try to bring together not everyone's idea about what we should be doing but try to bring back different pieces of feedback regarding how we might approach.

The concept is we work to get out a revised 25-pager and revised 10-pager to reflect comments by tomorrow night and that we have final sign-off by Wednesday, whatever that date is, next Wednesday, and that we try to continue with the press conference. The press conference would have a handout of the short report.

It would have a reference to a website and we would have some other things that would be part of the press conference. In fact, we would not have the 25-pager handout. If we don't take an approach similar to that, then we end up pushing back the press conference. We have no idea when that will be, when we get the senators together.

I personally think the earliest would be no earlier than two weeks from the 6th of October in all likelihood because we are still unsettled as to what we would include in all these reports. Who knows what we would have as a potential press conference. Then when do we start the meetings? Those are some -- it goes back to what we talked about earlier.

Joe, you look like you have a problem.

MR. HANSEN: Yeah, I do. I think -- you didn't say the questions because I think we need questions on October 6th whatever they might be. I don't have a comment on the questions one way or the other. I haven't thought about them yet as much as I do about the extra questions. I think that the October 6th date is probably doable along those lines, Randy. My only problem is comments on the 25-page report by tomorrow night which is going to be pretty hard for me.

CHAIRMAN JOHNSON: No, no. What would happen is George would work together with staff to try to assemble a lot of but not all of the comments to try to assimilate those.

PARTICIPANT: How are you going to get it out to people?

CHAIRMAN JOHNSON: It is basically a response, Joe, to your comments earlier that you didn't want to sign off on anything that you hadn't seen so it would be bringing together to the extent that we can a consolidated 25-pager and what I'm going to call a 10-pager with feedback from the focus groups and everybody would have a chance to look at that and say yeah or nay. We would have to do that by Wednesday in order to do the 10/6 press conference.

MR. GROB: Would it be helpful for you to know what the nature of the revisions would be on the 25-pager?

MR. HANSEN: No. I want to live in suspense for a while. I'm just trying to get it clear. The 10-pager might need some revision. That would has got to be solid, though, by Wednesday.

MR. GROB: I would say by tomorrow I can promise you that we would send you the comments from the focus groups, the 10-pager, and along with, if you wish at that time, a rewrite of the 10-pager based on the staff's view of handling the comments for your approval or disapproval by Wednesday of the 10-pager.

MR. HANSEN: We have made October 6th such a date and what concerns me is there will be tremendous pressure from both Wyden and Hatch to keep that date. I think we have to be mindful of that so we have to have something. It's whether we have something of substance that I'm trying to get my arms around. A 10-pager, the questions, a grabber piece. Is that still part of it? A three-pager or something like that? Maybe, maybe not.


MR. HANSEN: A grabber piece or something.

MR. GROB: It's hard to say. I guess Tish would know.

CHAIRMAN JOHNSON: That is something that I think we would like to be responsive to. At least it would be my hope that we could but we wouldn't necessarily have it in the press conference.

MR. GROB: And the 25-pager on the website.

MR. HANSEN: That might be harder to do.

PARTICIPANT: You refer to a participant's guide in this 10-pager.

MR. GROB: We could change that to just the short report.

CHAIRMAN JOHNSON: Okay. It's 20 after 11:00. I'm going to ask to go around the corner and just say are you open to doing this? Is this something you'll agree to or not? Then we are going to have to decide.

Pat, you have a comment first?

MS. MARYLAND: The only comment would be we have the rest of this afternoon. I know we have an agenda for the committee meeting but I wonder whether or not it might be better served to take time to walk through and to get the input today from everybody about this for the 10-pager so that we can come to some closure on that before we leave here. I mean, can we not change the agenda in order to serve the needs of getting this 10-pager report closer to something that will meet most of our needs, or is that problematic?

CHAIRMAN JOHNSON: Let me talk to Aaron and Dottie. You have committees that you wanted to get together. What are your thoughts about that?

DR. SHIRLEY: We can defer most of it. We just completed our recommendations. If we can -- I would recommend that our committee be as flexible as possible so that we can bring closure to this morning's discussion.


MS. BAZOS: I think it would really help as a group to work together on something concrete like the 10-pager. Catherine has her 10-pager that she started with. We have this other 10-pager. I'm really worried that no matter how much we rush the process if we don't have a face-to-face meeting we are not going to come to an agreement on this on what is going to happen on the 6th or whether we can approve or buy into what is going to go on.

I think it would be very helpful to change the agenda to all work on the 10-pager, to learn from each other and see where we can get to by the end of the day. It certainly will give staff input. It will help us, I think, to articulate what it is we disagree on. I think working together would just help this group.

Unless someone from the communications committee feels strongly, we have a lot of work ahead of us. We can't really do our work without some content at this point. It's very hard to think about PR and what we're going to do when we haven't yet agreed as a group about content.

CHAIRMAN JOHNSON: George, in your mind what does it do to change the agenda? What are the ups and downs of that?

MR. GROB: I think that can be handled. I think that can be worked by October 6th is proceeding the case. I'm not aware of any decisions about that that need to be brought to the working group for decision making. I think the same thing is true for the community meetings group that should work. I think October 6th is a good time to bring a lot of decisions for that. We have something here. If you are asking me, I think that can be done.

DR. SHIRLEY: May I suggest if there is a room in this building that has a strong lock, all of the members who have differences lock them up, give them two hours.

PARTICIPANT: Put down mats so they can wrestle?

DR. SHIRLEY: No water, no toilet.

CHAIRMAN JOHNSON: Okay. Any other comments or suggestions? It sounds like we have some concurrence. We haven't had any objectives to changing -- objections to changing the agenda for this afternoon. Frank is going to have enough wine and booze, I suppose, to drown our sorrows this evening.

PARTICIPANT: I don't know about that.

CHAIRMAN JOHNSON: You don't think he's got enough?

Okay. How would you then like to proceed assuming that we are able to iron out some differences this afternoon as we have been proposing to you? Is there anybody who would object to that?

MS. MARYLAND: I think that we will all be better served if the process is transparent today. We get all the issues on the table and try to work through as many of them as possible and leave with a document that hopefully will meet 95 percent of all of our needs so that we can check and know that we are going to be prepared for October 6th. That's my opinion.

MR. HANSEN: We're talking about this 10-page thing?

MS. MARYLAND: Yes, the 10-page document.

MR. HANSEN: But that's going to a focus group while we speak. Right?


MR. HANSEN: Okay. So there will be

some --

MR. GROB: There will be some reaction to that, too. I think if we meet this afternoon on it, including how we want it to be, we can then adapt as well in the focus groups, turn that around tomorrow based on what we did today and get that out for you.

CHAIRMAN JOHNSON: Say that again, George.

MR. GROB: Basically if we meet today we'll have a body of comments from the members on the 10-pager tomorrow by noon. Again, remember that noon is 3:00 your time. We would then have the reactions of the focus groups. There is a big meeting here tomorrow. Right?

But some of the staff that we have don't need to be at that meeting to the extent that we can make a quick determination about where that stands we ought to be able to turn that around, the 10-pager. It's not that long. The question is how do we handle the comments that we get.

MS. VANDYKE: I think, too, if I can about the focus group because I don't want people to get worried that we are going into focus groups today and think, "Oh, my gosh. You all are going to be sitting here working on this stuff today."

Really in a focus group that is two hours long with eight people sitting around the table, they are not going to be able to get down into the weeds the way you guys can. Their comments are really going to be, like I said, about usability and tone and does this motivate you to want to go to other places on the site to do more, to answer more questions, to look at more information, that kind of stuff.

Really you guys are the experts and you are the ones who really can inform. Like so many of you have said, really bring the credibility to the reports whether it's the 25-pager or the 10-pager that needs to be brought. What the focus groups are telling you is simply they are giving you feedback on, "Okay, I don't understand this word access and I don't understand this definition that you have given me." So it's giving us the feedback, all of us, "Okay, we've got to simplify that a little bit."

They are not going to get down in the weeds. They are not going to change what the report is about. They are not going to change the credibility of the report. I think that is something very important to remember.

MS. SMITH: If I may, Randy, this is not the only focus group. There will be another focus group because, Catherine, I know you have a lot of concerns in terms of the questions so there's time to sweep the questions and get them to the place where all the working group members are comfortable for the next one.

CHAIRMAN JOHNSON: When is the next focus group?

MS. VANDYKE: Actually it's not until after October 6th so I was going to suggest -- I am sorry because I'm fairly new to all of this. I've only been working on it for two weeks. I didn't realize that the questions -- that some of the questions that are in the report, we have been under the impression that those are examples of questions that are going to be on the site that we are going to be looking at feedback.

That's the way we have proceeded with the questions. I was also going to suggest as we talk about milestones and momentum and that kind of stuff, another thing we could possibly think about doing, hopefully your web people won't have a heart attack with this idea, is during the course of this project putting different questions up at different times along the way.

CHAIRMAN JOHNSON: We've already discussed that.

MS. VANDYKE: Okay. I'm sorry. Okay.

MR. GROB: Can I clarify a couple things to help clarify the objectives? I think that it is true that these were clearly meant to be examples of questions with a longer list but here we are. My guess is that I think it may be achievable to agree upon a starter set of questions that do correspond to what is in the report, although that wasn't the initial intention but the idea that we have more time to lengthen it out and to get a broader set of questions on the website.

I'm not as optimistic that we could create a set of questions for the website that is a full list this afternoon. If you all would like to work on that, I am willing to do it. I'm trying to be realistic in terms of what can be achieved.

MR. HANSEN: Some of the questions, not the additional questions that were not on the report, I was looking at those and some of those have preconceived answered to the questions. The very first one kind of blamed the doctors for the problem. Then you are going to turn it over to the insurance companies to make judgments. If it comes down to questions like that, my vote is no.

CHAIRMAN JOHNSON: Joe, that is one of my concerns about some of the questions that we've had submitted to us, as well as some of those that you are referencing. There has been an attempt -- I'm going to share a few personal things now because I'm not going to be here this afternoon. I'm very bothered by the fact that we are going to have discussions and I don't have a chance to participate.

MR. HANSEN: Either will I, Randy.

CHAIRMAN JOHNSON: But the questions are intended to not lead a reader to a conclusion or to imply a problem where there is a leading potential answer to the question. Some of the questions that we've had have had that. The questions that we have now in the report are really trying to avoid that. They are examples but they are trying to avoid leading a person to an answer. It's really in my mind pretty important to do that. I'll share a couple of other biases with you before we close. You can do with it what you want. I personally like the 10-pager and I like the bullets because that's the way people with whom I associate read.

I'm more inclined to do that than more of a prose kind of 10-pager so to speak. The focus groups hopefully will help us come to a conclusion on that. I'm comfortable with the tone and I have liked the language of both the 10-pager and the 25-pager. Not because I read it -- not because I wrote it but because I read it and feel it helps us move along. It's not exactly how I would write it but that's a given. It's not going to be exactly how anybody else here would write it either. I hope we can come to a report that will not be too far off actually what we have and what, at least, some of the comments that have been submitted. And that we'll have the initiatives clearly indicated as potential consideration by people who read the report. Other comments before we adjourn?

MR. HANSEN: I won't be here this afternoon either, Randy. The 10-pager I didn't look at that close. I just told Therese on page three some of the suggestions there I thought were weak but they can deal with that this afternoon.

VICE CHAIR MCLAUGHLIN: That's the same problem as in the long report.

MR. HANSEN: We talked about the long report.

VICE CHAIR MCLAUGHLIN: Exactly. It's the same list so the same problem.


MS. STEHR: I do have one question. If we do devote the afternoon to working on the shorter documents, we just did have a discussion and suggested that the bulleted documents might serve our purposes on October 6th. I think what I heard was then we wanted to print something that was more engaging with graphics.

CHAIRMAN JOHNSON: That's my point in responding to that. I believe that what we have can be printed and be used as a short-term, shorter, briefer report.

MS. VANDYKE: And we will put graphics into that. Like I said earlier, at this point that document doesn't have it because what we need to do is get it to the point where everyone is in agreement on the text before we can start designing it.

VICE CHAIR MCLAUGHLIN: I understand if that is a different format which I think we talked about yesterday when you weren't here. It's a different format than having something like this where you open it up and you see it like that. This has graphics but it's different --

MS. VANDYKE: That's what we're trying to get to.

VICE CHAIR MCLAUGHLIN: -- than a list of bullet items where you open the story boards as it were.

MS. VANDYKE: That's what we're trying to get to but we've got to agree on the text before we can put it into graphics.

CHAIRMAN JOHNSON: Again, the focus groups will tell us whether that is effective or not and we'll have a chance to --

VICE CHAIR MCLAUGHLIN: But our focus group is going to see something like this to see whether or not it's effective.

MS. VANDYKE: The focus groups right now are seeing this.


MS. VANDYKE: They are seeing the 10-pager as you have it text only. We are talking about language in that. Then they are looking at the 25-pager as it is now which is not designed, it's only text.

CHAIRMAN JOHNSON: Are we ready to adjourn for the morning then and reconvene at 12:30?

PARTICIPANT: 12:30 or 1:00. It said 1:00 originally. When do you want us back?

CHAIRMAN JOHNSON: What time would you like to reconvene?

MR. GROB: At your convenience. I just need food.

CHAIRMAN JOHNSON: Okay. Catherine will reconvene us all.

(Whereupon, off the record for lunch to reconvene at 12:30 p.m.)


12:30 p.m.

VICE CHAIR MCLAUGHLIN: I think we have everybody. Okay. We have a couple of things we have to do this afternoon. Aaron did ask me just now if we can try to stay on a fairly tight line because he does want at least a short meeting of the community meeting committee. We have to keep things on track.

The other thing is that Dottie did want Andy to have the chance to show us the website so we are going to do that as well. It won't take very long. We saw it yesterday. It did not take very long. As we get into this, if we need a bright spot, we'll ask Andy to show us the website because I will reveal to you already that the communications committee was very excited about it so it's something that is going in the right direction and we are making lots of progress which we may need that boost in the arm in a little bit.


MS. TAPLIN: Everyone is here except Aaron. Can I just make an announcement about getting to Frank's tonight?


MS. TAPLIN: We are supposed to meet in the lobby of the hotel at 6:30 and all will be revealed.

PARTICIPANT: Black tie, right?


MS. TAPLIN: Black tie and white socks.

VICE CHAIR MCLAUGHLIN: Okay. Since we are going to talk about the report, I would like the three of you guys to come up to the table because at lunch it was quite clear that we have some questions about the report. If Randy's desires are met, you guys are going to be incorporating comments later today and tomorrow. It would be great if we start that right now. Also, just one second, Deb. If you can keep --

PARTICIPANT: This is Chris.

VICE CHAIR MCLAUGHLIN: You know why? Because I was looking at Deb. I was. I was looking at Deb. Chris, can you let me finish one second? I want somebody to make sure to take good notes. I don't know whether Caroline is the best note taker.

MS. TAPLIN: I don't have my laptop with me.


MR. ROCK: This is actually on the public record.

VICE CHAIR MCLAUGHLIN: I understand but I meant for the staff to then make changes. We need really good notes so that Jill and Craig know what to look up. That's what I meant, Andy. I know you're taking notes of the general conversation. I thought Tish and Kristen were coming but I guess they're not?

PARTICIPANT: Tish left. She had a flight to take.

VICE CHAIR MCLAUGHLIN: I see. Okay. I guess we won't get her expert advice then. Several people had proved this out yesterday because Dottie had asked me to and asked me to bring it. Montye had looked at it. Aaron asked to look at it this morning and so I copied over my fun key just to have it up here to have a start.

What we need to do is come up with an idea of what we want the short report to look like and what the content will be. We are going to get feedback from the focus groups sometimes tomorrow according to Tish about the version that they put together with the bullet items. It was brought to my attention that we may have to make a decision.

Before we start going through all those bullet items, make a decision about what style we as a working group want. We heard from Randy and -- oh, I forgot. You had your hand up. I'm sorry. I forgot, Jennifer.

MS. WRIGHT: I'm not upset -- upset or not upset that he's not here but I did hear Randy say that he was uncomfortable because he wouldn't be here this afternoon for the discussions.


MS. WRIGHT: I just want to make sure I'm not wasting all of our time or any of us are wasting our time this afternoon with whatever we suggest to Randy and then he says no, he doesn't like it. I think what is decided here this afternoon we have decided as a group and that he as the Chair doesn't go back then and change it and say, no, it's not satisfactory to him because I'll walk out now.

I guess what I'm saying is if we come up with ideas and this is what we like by the end of the day, then this is what we as a group stick to and it's not, "I sort of like it and I sort of don't. If we did this it would be all right."


MS. BAZOS: In that light I also think that at the end of this meeting we should then see where we are and really decide if we do think we can get the product that we are talking about agreed on for the October 6th meeting which kind of says the same thing.

If we go one way and then we are going to get a day or something to look at it, if it's wrong, I think we all need -- not wrong but if it's considerably changed, then I think we need to agree to forget October 6th and spend more time at it until we get it the way we want it.

VICE CHAIR MCLAUGHLIN: I'm not sure we can, in fact, make that decision. I think Randy would come back and say -- I think that is probably when he would overrule, Dottie.

MS. BAZOS: The October 6th you mean?


MS. WRIGHT: But if you're telling me everything is good --

VICE CHAIR MCLAUGHLIN: I don't know, Chris.

MS. WRIGHT: -- then we should just meet in our separate focus groups. There would be nothing accomplished today.

VICE CHAIR MCLAUGHLIN: I do not know. I think it's a legitimate point.

PARTICIPANT: So what don't you know?

VICE CHAIR MCLAUGHLIN: Whether, in fact, let's say -- where I was headed, Chris, was that some people were saying instead of putting up the Edelman 10-pager and wordsmithing, changing, approving, disapproving, if that's not the base that we want but instead we want a base more like this, why not start here and edit this and come to agreement on this? That is right totally what Chris was just saying. Randy may come back and say, "You spent three hours making this look like what you wanted but I don't find it acceptable because I wanted bullet items." So I think Chris' point, I hadn't thought about it but it's a good point.

MS. HUGHES: Maybe I misunderstood because I thought her point was that we were going to all stick together on whatever we decided on in the room. Am I wrong?

VICE CHAIR MCLAUGHLIN: We'll try to come to an agreement but are we going to try to come -- okay. We could play it safe and make changes at the margin and look at the Edelman report and just tweak it, make minor changes with confidence that Randy would probably be willing to accept it unless we put in something really outrageous that he disagrees with. Just like Pat was talking about her constituents and he has his constituents which are the HR folks. He doesn't want anything in there that his HR people won't say, "Randy, I can't believe you let that go through." So we have to be aware that he has those constraints just like all of us do. One way is to play it relatively safe, though, Therese.

What some people are talking to me about is let's see about doing something that is really very different. I think Chris' point is well taken that Randy may come back and say, "I'm sorry. I just don't find this acceptable."

MS. HUGHES: I would like to just add to the conversation this. The Edelman product is going to -- the 10-pager as we have it is going to focus groups.


MS. HUGHES: Now, and we're going to come back with opinions and comments on it.


MS. HUGHES: And there is validity, in my opinion, for us to look at it and to make the changes and to see where it is because it has moved into another arena and I think that if we are going to get any type of compromise at the table in terms of sign-off, that we need to see how many people want to go with your report the way it is and start with that as the basis and how many people want to go with the Edelman.

VICE CHAIR MCLAUGHLIN: I would rather call this the Salt Lake City report than my report. It's not Cathy's report. Jill Bernstein and the summer interns and the four members of the report committee put together.

MS. HUGHES: Okay, Catherine, I --

VICE CHAIR MCLAUGHLIN: It happens to be on my thumb key.

MS. HUGHES: Okay. I'm sorry I used the words "your report." I think that the report that is put up here we need to decide first what we are going to look at.

VICE CHAIR MCLAUGHLIN: Great. That's where I was headed.

MS. HUGHES: Because I think --

VICE CHAIR MCLAUGHLIN: That's exactly where I was headed.

MS. HUGHES: Okay. Because I think the fact that it's going to the focus group is going to give us more information.

VICE CHAIR MCLAUGHLIN: I understand. Let me make a comment about that. It is a very strategic move to send a place strategies and pieces of a strategy and then ask for opinion midstream and then people are reluctant to change where you're going. It is, in fact, the case that the focus group is going to be looking at the Edelman report tonight. Right? We have been told Monday or Tuesday that maybe they wouldn't do the focus groups, or yesterday afternoon. It became quite clear that they are going ahead and doing the focus groups based on the Edelman report. All right? However, in economics there is this concept that we talk about as subcost. Right? Sometimes you put into place something and down the line you realize that we don't want to keep throwing good money after bad.

We don't want to keep going that way. Instead of saying, "Oh, but we have..." you say, "Let's say where we are now and where do we want to go from here?" and look at the marginal benefit and the marginal cost of going from here.

MS. HUGHES: I understand that.

VICE CHAIR MCLAUGHLIN: I totally understand the value of the focus group's responses to the Edelman report but if we don't like the Edelman report, I don't think we should feel like we have to go with it just because that's the one that we'll get focus group response to.

MS. HUGHES: Okay. I guess I don't think that we have to go to it just because it went to the focus groups.


MS. HUGHES: I don't think we've discussed the short report.


MS. HUGHES: I don't know how people -- I can't say I like this or I like this.


MS. HUGHES: I like the format of this. I don't like the format of this.


MS. HUGHES: We haven't discussed it so if we are going to start with this --

VICE CHAIR MCLAUGHLIN: We're not. I just put this up because we don't have copies of this. We have copies of Edelman short report. All I was going to do, Therese, is flash this up on the screen so that you guys could see what that is. Then we would have a conversation and say which do we want to do?

Do we want to say, "Okay, that's fine but we're not going there. This is what we have and let's work on it or not." That's all I was going to do. I was not going to go page by page and discuss this.

MS. BAZOS: I think we need to keep in mind there are two things to think about. One, give content. The other is presentation. They are totally different. Let's just not mix them up.

VICE CHAIR MCLAUGHLIN: I'm talking about presentation, not content.

MS. BAZOS: Catherine is talking about presentation. I think what happened was when Edelman sat there they said -- they looked at Catherine's report and went, "That's where we're going but we want to get the content right first." As I understand, you're putting this up to remind us what the presentation might be.

There was a discussion about whether the presentation should be bullets or something more graphic. Then we've got to get into the content and the content is -- we've got content from the 25-pager. We've got content from the 10-pager. We've got content from here. That is where I'm hoping we'll have some really lively discussion.

VICE CHAIR MCLAUGHLIN: Let's take 30 seconds, which is all I want to do, to remind people of the different stories so it's not just the look. It's also how you are telling the story. In this case remember there was that but then there was this thing. This is a very different beginning is all I'm saying, Therese. I just want to say do we want to stick with this or do we want to have it be gone.

Again, this is a different way. This is not bullet items. Now, I'm not asking you to look at the content here. That wasn't what I was going to do. Just say opening it up to be a story board like this, a two pager, is very different than the 8.5 by 11 flipping of pages. The both have their advantages. They both have their disadvantages. I'm just saying it does do something different.

This way you get equal amount of space to each of the three because each set of two pages. In their version you can have this much on quality, this much on access, this much on cost. That is one of the advantages. This way, you know, you are sort of stuck with the two pages per each one of the three topics. Then the very solution.

This is what I tried to tell Randy. We already had solutions. We just had them organized differently, worded differently. We had ideas over there and the statutes and coverage. We say these have been proposed. We just did it differently. That's all I want to do is say, all right, that's one way to do it where the construction does, in fact, change how the story is and how it's told. I don't care how we spend the rest of our time now thinking about what we want to do in the content. I would just say remind us what that looked like. That's all I wanted to do.

MS. BAZOS: Can I ask a question, though?


MS. BAZOS: If we agreed on a content, if we agree on 100 bullets framed in a certain way, couldn't that content then be portrayed --

VICE CHAIR MCLAUGHLIN: Within the distribution constraint.

MS. BAZOS: Yes, within that constraint but also in a bulleted report?

VICE CHAIR MCLAUGHLIN: It can be small bullets that are there instead of small paragraphs.

MS. BAZOS: No, I'm not saying within -- I'm saying couldn't it be -- Randy was -- at least, that's how I understood it, concerned about people who are reading things in a certain way.


MS. BAZOS: Bullet format, something that looks more like a report.


MS. BAZOS: We are trying to get something that jumps off the grocery store shelf to someone. If the content is the same, if we all agree on the content, then couldn't we have both? I mean, I just don't understand why it's an either/or. Then we can decide which one is ready for the 6th.

VICE CHAIR MCLAUGHLIN: None of our communications people are here. I think the either/or is that we have to decide what we are going to have on December -- why do I keep doing this? -- October 6th and what we are going to settle our money printing and having translated and, you know --

MS. BAZOS: Braille.

VICE CHAIR MCLAUGHLIN: I don't think we're going there.

DR. BAUMEISTER: I'll never forget many years ago there when Time and Life were the two big magazines. There had been some article in Time magazine that somebody had just really objected to and they wrote this stinging letter to the editor of Time. He said they read both magazines and they had become convinced that Life was a magazine for people who could think but didn't take time to read, and that Time was for people who could read but didn't have time to think.


DR. BAUMEISTER: I'm not sure. I remember we discussed all this before and I've been sort of here and yon today and stayed out of this because I got sort of -- if I opened my mouth again I would accuse the PR people of selling soap and that didn't go over well. I remember we were going to write a long report and it was going to be a scholarly treatise on health care. Then we were going to put together a comic book.


DR. BAUMEISTER: Sort of classic comics of health care that you could understand in a homeless shelter down in Burnside. That has totally evolved now that the short from is for Robert Pear and for other notables who read things very quickly when they are standing on the train. Is that right? The short form has become a way of informing the intelligentsia who are in a hurry.

VICE CHAIR MCLAUGHLIN: I think as articulated this morning, and I'm happy for anybody to jump in and tell me I didn't hear it right or I'm not recollecting it right, that the short form is now being seen for the press, for the staff, the Hill staff.

DR. BAUMEISTER: The upshot of that is that nobody can read the long form which I think is really an error. I think that's a grievous mistake. I think academics are going to read the long form. I think deans of medical schools will read the long form. I think that benefits managers, if they have a brain, will read the long form. I think leaders of medical societies, leaders of advocacy groups will read the long form.

VICE CHAIR MCLAUGHLIN: And that doesn't have to be snappy to get them to read it.

DR. BAUMEISTER: I think I can read this thing in about an hour, you know, and understand it. I think most people can and most people will. This stuff is on everybody's minds and I don't think you have to dumb it down. I don't know, that's just --

VICE CHAIR MCLAUGHLIN: I mean, Dottie's comment was sort of what I was asking this morning and I don't think I got a really clear response from Connie and Tish who was following up on Therese's comment about needing something for the Hill staff and whatever. I said is what we have on October 6th -- I did it. Major breakthrough -- October 6th, can that be like a four or five-page bullet thing with no graphics, no people's faces, nothing. Just be the fact sheet kind of thing that they are used to.

DR. BAUMEISTER: Bare bones.

VICE CHAIR MCLAUGHLIN: And it's not mass printed. It's not colorful and that we have a different thing that is cartoony colorful that will be mass produced. George has been talking to Costco and Target and all these different places. It's not mass produced, Dottie, but it's like, you know, a five-page version of this.

MS. BAZOS: I think that's a compromise. It's a good compromise.

VICE CHAIR MCLAUGHLIN: But I'm not sure that meets the PR side of it of yawn, yawn, who cares? I mean, wasn't that the response that they gave me sort of this morning of just having a summary, a bullet summary of the long report? We might as well not have it. Wasn't that right, George? Isn't that sort of the response that we got?

MR. GROB: Yes. Basically what I took it to be was that we should distribute something that we can call a report on the event. That is just the usual papers won't cut it that way.

VICE CHAIR MCLAUGHLIN: One of the things I need to point out is that the long report, as Frank said, the 25-pager that is now going up to 50 pages, the long report is the Health Report to the American People. We made a decision for a variety of reasons two months ago because Larry Patton pointed out to us that there was no money in the appropriation for us to do the report.

That was a legislative mix-up. Fine, fine, fine. Whatever. We didn't get that other money so the thing that's titled the Health Report to the American People can't be some fancy slick production. It can be on the website as a scholarly report that is factually accurate. If that is the case, this thing that is 25 pages, call the 25-pager report, we are legislatively mandated to include a long list of things. All right?

Jill and Caroline and I sat back in June and did a matrix where we went through that long list of things and made sure that if anyone ever questions us, we can sit down and show them where we addressed everyone of them. There was a long list in that statute of items to be covered in the Health Report to the American People. We will never get that in either this or this.

The fact of the matter is the report that we have to have October 6th almost by definition has to be the long report that is on the web because that is the only one where if we are ever questioned we can say we did not get -- we did not use the money. We did not use all this money for it. Right?

We just did it with existing stuff. We didn't do new stuff. We didn't focus group it. We could stand by that if the IG office ever gets us. Right? And, two, that we can say we've covered every single thing that is in the statute. The 25-pager is the only one that is statutorily correct and is defensible and we will not get into trouble.

DR. BAUMEISTER: I agree with that.

VICE CHAIR MCLAUGHLIN: So October 6th the Health Report to the American People has to be some version of that 25-pager and it cannot be colorful, snappy, mass produced. It cannot or we could be in trouble.

MR. GROB: I doubt that we would be but I do agree with everything you're saying.

MS. BAZOS: I think we are talking about

-- we have this 10-pager that Randy seems to like the format. This is what people read and that type of thing. This is actually -- Pat just gave me the word -- this is like an executive summary of the 25-pager.


MR. GROB: It is.

MS. BAZOS: I don't understand why we can't have this on the 6th and say, "In addition, we have created a report that looks like this for anyone who doesn't read this kind of thing." I don't understand. And the one that we are going to make a thousand million copies of is going to be the one that the average person on the street would pick up. I don't understand why we need to spend -- I just don't want to spend the next two hours deciding that. If we agree on content, then we could do both.

VICE CHAIR MCLAUGHLIN: George, are we in trouble if on October -- I have to really think about it to say it -- October 6th, we say, "We've got this 25-pager, which is actually 50 pages, but never mind. We call it the 25-pager. It's the Health Report to the American People. We were mandated to do it and, boy, we did.

It's scholarly and accurate and we are really proud of it. It tells you where the money comes from and where the money goes, what it buys, who uses it. We did all the stuff we were supposed to do. Aren't we great. Boy, it's up there and we hope a lot of you will read it because we hope you'll learn stuff," and blah, blah, blah, blah, blah, blah, blah, blah.

Boy, it's up there and we can print copies for the press that show up knowing that they won't read it that instant but maybe they will read it later. Then if we have the executive summary, the bulleted items, so that it's reader friendly for staffers and Robert Pears and all this kind of stuff, and we then talk about committee meetings and the website and dialogue and shake hands and listen to people and key pads and questions, is that enough or do you still feel as though we have to have something like this that is mass produced?

MR. GROB: I'll give you may answer but remember it's an opinion. I think that -- I'm going to use the word graphics now to distinguish it from graphs, although it is a combination just as yours is. The patina of it as well as the graphs contribute to that.

What I understood and it's something I believe, too, and is also what I thought that I was hearing, is that it would be appropriate for us to have a document which is very report like in its format that would then be this but it's not just like pages because there would be a cover to it.

Maybe as well some kind of -- I'm guessing but if you look at the slide show and they have the page across the top. Something that gives it a style that, in fact, does look like the executive summaries that are often made available for reports. That would be very important to have. That would be the kind of thing that you could -- that would be a good handout to give to people.

VICE CHAIR MCLAUGHLIN: So you would have maybe 100 copies of it.

MR. GROB: Whatever you would need that would be available. Yes, then you have something that you could give to the members of the committees. That is something that you -- I think the thought was you do have to have a report like document that you are giving away and so the idea of converting is not to your initial concept which I feel very warm to.

I've always told you that, Catherine. But that there is this other crowd of people who think in terms of, "Well, where is that report?" I think it goes beyond the Congressional staffers. I do think there are professional people throughout the country that would appreciate having a document that looks like that.

VICE CHAIR MCLAUGHLIN: With little bullets.

MR. GROB: Well, again, yes.

VICE CHAIR MCLAUGHLIN: I'm sorry. I didn't mean the bullets were small. I meant little short one sentence as opposed to Frank saying it takes you one hour to read the 25-pager.

MR. GROB: Yes. I think that people usually appreciate that. I have never been to any place where an important report was issued that they didn't primarily traffic in the 10-page version of it that looks like the report.


MR. GROB: I would say that would be -- I would say for the people I deal with which, again, is not the country that you all deal with but at the levels of the interest groups that it would almost be regarded as impolite if you didn't have something to give them.

VICE CHAIR MCLAUGHLIN: Right. But that is not what the focus group -- the participants are not those people from what she said. The focus group that they are doing are the everyday people that -- I'm not holding this up as the thing but that we wanted it to be more engaging but not an executive summary.

MR. GROB: But I would say, and I want to assure you this is your meeting and I want to be of service so I'm just going to give you my best honest answer. I would say these kind of reports do have an even broader following than the professional staff. There's many people that will read it and can understand it. I do see a bit of ambivalence because of what you're saying in terms of who the focus groups are.

I think a professional looking report could, in fact, be used for any people, particularly in the style that this report is given. Again, I think that there was a point to say that people Evans and Lopus were attempting to reach all Medicare beneficiaries throughout the country and that this style is the kind of style that they were required to use for that purpose.

VICE CHAIR MCLAUGHLIN: Because if you're invited it's not to the staffers. That's not executive summary. But then the second page, and I think that's what Dottie is alluding to, once you get to the second page, the rest of it is executive summary.

MS. BAZOS: I don't know why we can't make an executive summary for the 6th and then work on a document that we'll get back from Edelman, feedback from this. We have other language and graphics. I mean, we have always said that we want to make this available to everyone so what I'm hearing is, "Hey, there's a bunch of people who want bulleted reports," so we do an executive summary that is full of bullets and a couple of graphs, whatever it is.

Period, done, finished and everybody is happy. In addition we do a 10-pager that's got graphics that jumps off the grocery store shelf. And I think we should do a three -- you know, this thing that I think of as a trifold for people who just go, "Whoa. They want to hear from me?" Third grade language, whatever it takes.

I mean, isn't that what we said we would do? We are making the rules. I don't understand why we get so -- let's make them to work. That's what I think. I don't think -- I think if we agree -- my point is if we agree on the content, then you can put it into any of those formats. I think what this group has not done is agreed on the content.

VICE CHAIR MCLAUGHLIN: So should we start with the executive summary piece and agree to the content?

MS. BAZOS: I would like to suggest that we start with the executive summary.

PARTICIPANT: So we're up to three reports now. Is that right? We have the long form and the executive summary and the comic book.

MS. BAZOS: But you know what? You do that. I mean, there's one report. There's one report. We're up to one report. We said we would put it in formats for anyone anywhere.

MS. HUGHES: I have to agree with Dottie. We need to look at content and then the content can go in many forms. If we are willing to translate it into Spanish and other languages, we need to be willing to look at the fact that we need it at different levels for other people.

I'm not married to the idea that we just need a 10-pager and a 25-pager. I think that we need to look at the content and move forward and then get all of us in agreement on content and then come up with an executive summary to come out ahead of the report.

VICE CHAIR MCLAUGHLIN: This bullet one -- let me call it the bullet one.

MS. HUGHES: We'll call it the executive summary.

VICE CHAIR MCLAUGHLIN: Yeah, it is an executive summary. Okay. The executive summary then, the first page and the last page probably are going to be very different from what they are now. That's the only reason why I'm waffling on that. Then on the content, are we going to accept the general order of things that are already in the long report? Dottie is saying there is only one report.

It is just presented in different lengths and different languages where language is not just Spanish version, it's English, which is Therese's point. That's okay. One of the things that Randy and George were pointing out in a conversation I had a couple of weeks ago was that means that, for example, if the 25-pager is cost, quality access, this has to be cost, quality and access. The trifold has to be cost, quality and access. Do we want to say that first before we start going page by page?

MS. BAZOS: That's a good starting point. Let's start there.

VICE CHAIR MCLAUGHLIN: Okay. Whew. First I want to say are we in agreement and that is okay with us. I didn't hear -- oh, we're not.

MS. BAZOS: I just want to talk about it for a minute because in the report we do talk about cost, quality and access.

VICE CHAIR MCLAUGHLIN: Right. Remember it used to QCC and people said QCC is not the way to go so we changed it to cost, quality and access.

MS. BAZOS: What happened to where does the money come from and where does the money go? Cost, quality and access issues.

VICE CHAIR MCLAUGHLIN: Right. But you want a layer before that. Is that what you're saying?


VICE CHAIR MCLAUGHLIN: Okay. But once you do the layer before it, that system thing before it, you're okay with cost, quality, access because Pat and a couple of you were saying, "I want access first." Are we okay as a group sticking with cost, quality, access? Let me see a show of hands if that is okay.

MS. MARYLAND: Are you saying in that order?


MS. MARYLAND: I'm willing to concede.

VICE CHAIR MCLAUGHLIN: I concede it, too. I wanted coverage first but I conceded that one weeks ago. Okay. Randy has asked us all to compromise. He has asked us to meet him half way. All right? We just all compromised. Let there be a record we have all compromised. Many of us did not want cost, quality, and access.

PARTICIPANT: Could we make sure we're talking about those are the issues, that is not the system?


MS. BAZOS: Thank you.

VICE CHAIR MCLAUGHLIN: Those are the issues. We are okay with it going cost, quality, access which I know will make George very happy because that is what the long report is and to switch it around would be a whole other rewrite so I think we're okay.

We'll keep that in mind that for the executive summary and the cartoon -- no, the comic book and the trifold cost, quality, access. Okay. Later before that there were some people who wanted something about the system.

MS. BAZOS: I want something about the system and then I want where the money goes and where it comes from.

VICE CHAIR MCLAUGHLIN: Okay. All right. So where do we start now? Do we look at the actual cost, quality, and access that has been here and see how we want to change that content?

MS. BAZOS: I think we have to address the fact and make a decision on whether the questions are going in the report or not. Not exactly which questions.

VICE CHAIR MCLAUGHLIN: Okay. That's the ending part. You are absolutely right. I hadn't gone there yet. You're right.

MS. BAZOS: But I thought it might

drive --

VICE CHAIR MCLAUGHLIN: You're right. Here is the deal. I think -- we talked a little bit about this at lunch so I was just going to share that because a little group of us had this discussion at lunch. Having questions as a question -- do we have the questions again? I think most of us say yes. It's just what level of questions.

At a minimum it was suggested that we have the four questions from the statute that we were asked to ask the public. I think fitting again our statutory requirements, I think we do need to say, "We have been asked to ask you guys, the American public, what sources do you want, how do you want them financed delivered." We don't use the exact wording I don't think but we have to somehow bring those four questions. Can we agree that we have to have that in all the different reports at a minimum.

MS. HUGHES: I would just like to throw something in here and I'm sorry but the four questions are under community meetings. The four questions are not in the law and the report.

VICE CHAIR MCLAUGHLIN: That's correct. That is absolutely correct.

MS. HUGHES: I'm just putting this out on the table.

VICE CHAIR MCLAUGHLIN: That's absolutely correct.

MS. HUGHES: Neither of these are required in the report.

VICE CHAIR MCLAUGHLIN: That's right. That's why I'm asking do we want to do it. We don't have a choice of whether we say some things.

MS. HUGHES: I think that for the report we have to include at least the things that we talk about.

VICE CHAIR MCLAUGHLIN: Right. Right now they are in the long report.

MS. HUGHES: Right now the four questions are in the long report.

VICE CHAIR MCLAUGHLIN: Some of them got dropped?

MS. HUGHES: Probably.


MS. HUGHES: Wait a sec. The questions do not have to be in the report. That's what I just said.

VICE CHAIR MCLAUGHLIN: I know. That's why I was asking, Therese. I didn't ask do you think we should put in blah, blah, blah if it's in the statute because we don't have a choice but we do have a choice about the questions.

MS. HUGHES: Just so that's on the table so we know legally where we're coming from and this is how we have to word it.



MS. BAZOS: Then we could separate our thinking in the report and then the packaging of the report.

VICE CHAIR MCLAUGHLIN: We don't have to have the questions in the 25-pager.

MS. BAZOS: We don't?

VICE CHAIR MCLAUGHLIN: We don't have to have them in any of them.

MS. BAZOS: That's what I'm saying.

VICE CHAIR MCLAUGHLIN: What you're saying is we don't really have to have them in the 25-pager.

MS. BAZOS: What I am saying, and I do want to finish it, so we've got the 25-pager and then we have this executive summary. Then we have our cartoon. Somewhere I think what we wanted to do was to package at least the cartoon or something as a call to action.

VICE CHAIR MCLAUGHLIN: Right. That's where I think you have to have some kind of questions.

MS. BAZOS: And I think maybe what we should do is tie the questions to the -- I mean, as an additional thought is we could say talk about the report one way and then talk about how they get packaged. The one that gets packaged as a call to action gets questions.

We don't have to decide which questions but they get questions so they are exciting or whatever. Then even in the executive summary or the report there can be a piece that says, "And we are going to ask questions."


MS. BAZOS: They are going to be focused around blah, blah, blah.

VICE CHAIR MCLAUGHLIN: I think that the executive summary and the long report can at the end say we are mandated to enter into a dialogue, blah, blah, blah, blah, blah, and ask the American public. We can talk about tone.

MS. BAZOS: So there's the report and then there's how you package it.


MS. BAZOS: And maybe separating the question piece into the packaging helps us think through that issue.

VICE CHAIR MCLAUGHLIN: For the thing that is mass produced I think the questions have to be part of it because -- same with the trifold because there's not going to be a packet of things. There's just going to be that thing.

MS. BAZOS: I don't mean package it physically. I mean like --

VICE CHAIR MCLAUGHLIN: Okay. Got it. I gotcha.

MS. BAZOS: The thinking around how you're going to end this kind of thing.

MS. MARYLAND: But the questions are key to all of your materials because what we have to do is a call to action. We have to get a call to action. To read the report with nothing following that will then lead us into the community meetings, the only way you can do this is through your questions, the call to action.

MS. FEDERER: Just going on what Dottie said, if you go to the actual physical packaging, and this also goes with what you said, Pat. It would be very simple to do a cover page that would go on every version of the report that would say we are going to be having these community meetings.

We are going to be asking these four questions and then have a sentence that says, "Call to Action." Just have that be a standard cover page that lists the four questions. It's a call to action and says we are going to be engaging citizens as a cover to every version of the report. Actually it's easy to do as an inside cover, cover page.

MS. BAZOS: Actually, when I was talking about packaging I was really thinking about we have the report and we all agree on content of the report. Get that over with. Then we think about what are we actually going to use this particular report for and think about how it should be packaged. For example, for the grocery store report, something that people can pick up, we need to think about that needs to be packaged as a call to action for the average citizen to read it and respond and get to our website. For the executive summary, how is that sort of --


MS. WRIGHT: Am I confused? Edelman's is a public relations firm period?


MS. WRIGHT: They are not a communications and they are not a marketing?

PARTICIPANT: They do everything. It's a big global --

MS. WRIGHT: Okay. I think we're spinning our wheels here because I'm not an expert in communication and marketing but I'm going to them and saying, "I need a 25-page report to talk to the doctors and PhDs and economic geeks, I need a simpler report to hit these workers, and I need a comic book version.


MS. WRIGHT: We tell them what we want and they come back to us with examples.


MS. WRIGHT: We're sitting here, I feel, trying to battle out what we need and what we look like.

VICE CHAIR MCLAUGHLIN: I think how that will happen is they were told that the 25-pager is not for the Ph.D.s and the docs and the econ geeks. They were told to make a 25-pager for everybody. Right? Robert Pear, Hill staff. I think they gave us what they were told to give us.

MS. HUGHES: I don't think so. I thought the executive summary was for Robert Pear and the Hill staff. I really did.

VICE CHAIR MCLAUGHLIN: No, because you're invited to become part of the historic discussion. We are not inviting Robert Pear to be part of our historic discussion. Well, we are but -- and you need to take part because as a consumer I think --

MR. GROB: I want to be of service to you but I recognize I'm not a member so I would invite some guidance from you as to how much you would like me to pipe in to clarify things.

VICE CHAIR MCLAUGHLIN: You can raise your hand like everybody else.

VICE CHAIR MCLAUGHLIN: You can raise your hand like everybody else, George.

MR. GROB: Okay. I just wanted to be sure. I understand that distinction and I don't want to violate it but if it would be helpful for you for me to clarify things that happened or were intended to, it might be useful.

Therese, I do have one for what you are talking about right now. I can tell you I don't think that our instructions need to be as specific as people are saying right now. I think we said to them that we needed a 25-pager but while that did serve the purpose of the deep research that we did, it also had to be interesting and readable.

We didn't need to say just because something was more of an academic background that it didn't need to be interesting to even make that readable. I think that's what they responded to. I gave them, and I think you ought to know, you had provided me, Catherine, you know, whatever version you had of this at the time.


MR. GROB: I provided that to them. I provided other documents like that. We need another version of the report that will bear more traffic that can be used in a much broader setting. We didn't say it would be the national news writers. We just said we need another version that will tell the story and can be used in many settings so we would like your advice about that.

They did have these various versions and they then said, "If you need to reach many people, this is how we would advocate that you write it," and then gave it to the person who for better or worse did that for reaching 30 million Medicare beneficiaries.

VICE CHAIR MCLAUGHLIN: So this was not put out as an executive summary.

MR. GROB: No. It was just another version of the report.

MS. HUGHES: That was just the recommendation.

VICE CHAIR MCLAUGHLIN: Right, right, right. No, I'm saying Therese that this was not written for Robert Pear.

MS. HUGHES: No, I know. I understood that.

VICE CHAIR MCLAUGHLIN: All right. What several people here are recommending is that we change this to something written for Robert Pear and the HR people and busy executives who don't have time to read the long report, but that it is still written for basically the college graduate who is real interested in it but doesn't have enough time to read the whole report. We then have a different document that is written at high school level and that is more engaging. I mean, that is what some people are saying. Am I right? Did I summarize this correctly?

MR. GROB: I think people are saying it's not what Edelman gave us.


MR. GROB: Thank you.

VICE CHAIR MCLAUGHLIN: But I think what Edelman did give us can fit that need with a different beginning and ending. Or do you think this beginning is still okay?

MS. HUGHES: I think that -- I think that, like you started out saying, we need to mirror the big report so we've got the cost, quality, and access part. If we are starting out the large report with the "you're invited," then I think we need to mirror that.

VICE CHAIR MCLAUGHLIN: Is that how the large report starts off?

MS. HUGHES: No, but we agreed that however it started the first paragraph -- the first page needed reworking. I think that one of the concepts should be if we keep, like Dottie suggested, everything put together, then we need to keep a format a certain way.

VICE CHAIR MCLAUGHLIN: Do we start with a snapshot?

MS. HUGHES: If we start with snapshot, then we should start this one with snapshot.

VICE CHAIR MCLAUGHLIN: No. They've got, "How would you make health care work for all Americans?"

MS. BAZOS: I'm getting myself totally confused here.

MR. GROB: Could I add something?


MR. GROB: The report that you have is not the one that I gave to Edelman. There is a change I would like to show you.

VICE CHAIR MCLAUGHLIN: What do you mean gave to Edelman? You mean today?

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: Oh, that you gave Edelman today.

MR. GROB: Yeah, for the focus groups.

VICE CHAIR MCLAUGHLIN: Little one or big one?

MR. GROB: The little one.

VICE CHAIR MCLAUGHLIN: Little one. That would be great.

MR. GROB: Just so we're all on the same page. I'll tell you just briefly, as I pass it out, what I did to it from the version that you had gotten earlier. One is we did request them to do some graphics and their response was to put three graphs in knowing that's not enough and so there are three graphs in this.

The other thing is that I told you we received the comments from the two members, the two senators. I did adapt the language for them. They are very minor changes in the beginning. It's what I told you they were and I had received that comment.

Finally, Catherine, you will be happy to know that I now talk about the 45 percent of adults.


MR. GROB: Fifty-five percent of adults, yeah. Whatever the phrase is. I copied it from your memo. Basically I absorbed the comments that I had received. I thought it was easier now not to explain later the version that you have. You might want to put a mark on it so you know this is the one.

VICE CHAIR MCLAUGHLIN: Okay. We need to get some work done, guys. Okay. We need to make a decision and I think it may be easiest to deal with the cost, quality, access piece of it and then work out. If we start at page 2, cost, quality, and access.

I don't know about you guys but I would like some -- I didn't think Pat's story fit here and I don't think it made any sense for here.

MS. MARYLAND: I agree.

VICE CHAIR MCLAUGHLIN: And I also think if this is, in fact, becoming the executive summary, I don't think we should have any of the story quotes in here.

MS. BAZOS: But then I've got to say we've got to separate now because I do make mistakes -- sorry, George, which probably will confuse everybody.


MS. BAZOS: If Edelman wrote this for the average citizen, then perhaps what we need to do is review this document as though it were going to go into the comic book and then think about --

VICE CHAIR MCLAUGHLIN: Why can't we review it for the comic book later but review it for the product for October 6 now?


VICE CHAIR MCLAUGHLIN: We need to have that done.

MS. BAZOS: Will that make sense?

VICE CHAIR MCLAUGHLIN: We need to have that done.

DR. BAUMEISTER: This is going to become the executive summary?


MS. BAZOS: Okay. That would make sense.

VICE CHAIR MCLAUGHLIN: I agree. We can get the comic book later. So I think the story goes out. Agreement? Okay. Moving right along.

PARTICIPANT: You're saying that all the stories go out?

VICE CHAIR MCLAUGHLIN: I would recommend all the stories go out. You don't usually get executive summaries with stories.

MS. HUGHES: This is not relevant to the section but some of the stories are relevant.

MS. BAZOS: I don't think that all the stories should go out.

VICE CHAIR MCLAUGHLIN: Let's look at them one at a time.

MS. HUGHES: I think Pat's doesn't belong.

VICE CHAIR MCLAUGHLIN: It definitely doesn't belong.

MS. HUGHES: So Pat's needs to come out. The reason I think we need to have the stories in is because it makes it a little more personal.

DR. BAUMEISTER: I would take them out. I wouldn't leave them in the executive summary. I would leave them in the comic book.

VICE CHAIR MCLAUGHLIN: Me, too. And in the -- yeah, I totally agree.

MR. GROB: Whatever you recommend here I would give you the reason why they are in there. When you all responded to the last report, the most common comment was that you wanted to put the stories back in.

DR. BAUMEISTER: Can we change our mind?

MR. GROB: No, that's okay.

VICE CHAIR MCLAUGHLIN: I think they want the stories in the comic book, George. They still want stories in the comic book.

MR. GROB: They followed our request.

VICE CHAIR MCLAUGHLIN: I understand. Definitely Pat's goes out. We can make that decision. It does not belong here.

MS. HUGHES: It does not belong here. I agree.

VICE CHAIR MCLAUGHLIN: All right. So we have this definitions of cost, quality, and access. That is what the focus group is going to give us responses to of whether they understand that. I think we should wait and hear from the focus group for definitions. Does that make sense?

What about the sentence right before it, Dottie? You were saying that you felt you should offer changes. "Our health care system is complicated to understand but much easier if we think of how well it works in terms of three basic ideas." If you could think of a different -- that is part of your point, that you don't want people thinking these three things are the system.

MS. BAZOS: These, I think, are the issues of the health system.

VICE CHAIR MCLAUGHLIN: I'm saying do you want that sentence rewritten to make that clearer?

MS. BAZOS: And we are looking at this for the executive summary?


MS. BAZOS: For the executive summary, if this were to be the executive summary, I would have just the paragraph that said something about the fact that our system is extremely complex. We have a fragmented service and payment system, blah, blah.

VICE CHAIR MCLAUGHLIN: That's going to come in the part before this, right? Or do you want it right here?

MS. BAZOS: Oh, okay. We're just doing cost, quality, and access. Okay. Just say this has got to be rewritten to say this is an issue.

VICE CHAIR MCLAUGHLIN: Okay. These are basic ideas.

MS. BAZOS: That's what leads you to think about system, right?

VICE CHAIR MCLAUGHLIN: Right. Take out all that part and say it's much easier if we focus on three issues.

MS. BAZOS: But it's not much easier. It's not much easier. This is about issues.

VICE CHAIR MCLAUGHLIN: Okay. The staff will come up with some language to run by us.

MS. BAZOS: It's the issues that are complicated.


MS. BAZOS: I mean, the system is complicated but we're talking about issues.

VICE CHAIR MCLAUGHLIN: Right. Okay. So there are big problems that need new thinking and creative solutions. This is the one that Joe talked about before he left. Those are his final words on the short report. This has the same problems that Richard and I had with them in the long report.

MR. GROB: On the amendment I made to reflect it the best I could in the short version is the paragraph that follows it.


MR. GROB: Page 4. That was my attempt.

VICE CHAIR MCLAUGHLIN: Those three sentences?

MR. GROB: Yes. It was the idea to say that a few of them are easy to do. Some will prove themselves. We have some hard work cut out. That was an attempt to in a general way accommodate the idea that nothing is settled yet.

DR. BAUMEISTER: That was Richard's --

MR. GROB: That was Richard's point.

VICE CHAIR MCLAUGHLIN: But it hasn't been run by us.

MR. GROB: No. I just wanted to let you know.

VICE CHAIR MCLAUGHLIN: Right. That's what I'm saying. Richard hasn't seen those three sentences --

MR. GROB: That's correct.

VICE CHAIR MCLAUGHLIN: -- and said, "Yep, that does it for me."

MS. BAZOS: This goes at the end of the report.

VICE CHAIR MCLAUGHLIN: I agree. I think it belongs at the end.

MS. BAZOS: First we introduce those three terms.

VICE CHAIR MCLAUGHLIN: And then we go somewhere else. I agree, Dottie.

MR. GROB: I'm having a hard time following you. The whole thing about there are big problems?

VICE CHAIR MCLAUGHLIN: That whole thing gets moved and start, "In health care everything is related to everything else."

MS. BAZOS: Except we say we've got three major issues, cost, quality, and access.

VICE CHAIR MCLAUGHLIN: And then we say, "In health care everything is related to everything else. Cost, quality, and access are not independent of each other. Our health care system is a lot like our natural environment." Right? That's what I think we're saying. Move that whole section, "There are big problems," somewhere after we talk about cost, quality, and access.

MS. CONLAN: And that kind of pays acknowledgement to your idea of the system. We are going to focus on those three ideas but knowing that those issues are not isolated. They fit together in this ecosystem. Then what we are going to do is look at each one separately in the next part. I think that brings up your idea of the system.

MS. BAZOS: It reinforces it.


MS. CONLAN: It would go right after the issues which are mentioned, just three. Then it puts them in the context that these aren't three isolated things. They work in unison and there is a ripple effect throughout this ecosystem. Then we go on and discuss each one individually.

MS. HUGHES: Can I make a suggestion?


MS. HUGHES: I would like to suggest that this part, the largest part of page 3, and the bullet and the paragraph on the top of page 4 go into page 10 after No. 4. The reason is, well, we're talking about it being at the end.


MS. HUGHES: Mentioned at the end. Then it goes into, "Congratulations. You have mastered three important concepts." And that's the end. It needs to -- if we are going to follow what you suggested, Dottie, that this was at the end in the large report, then we need to put it here in the smaller report.


MS. HUGHES: I'm just saying let's remove this and put it here after the third bullet on No. 4 on page 10.

MR. GROB: Clarification. On page 4 there is a part that is going to be moved including, "In health care everything --


VICE CHAIR MCLAUGHLIN: No, no, no. It's just that section.

MR. GROB: I wasn't clear. Okay.

VICE CHAIR MCLAUGHLIN: And we can argue later whether it goes before congratulations, after congratulations, how it's done. It's going to be on page 10.

MS. HUGHES: After No. 4.

VICE CHAIR MCLAUGHLIN: Okay. So, "In health care everything is related to everything else."

MS. BAZOS: Then it comes back around, "What are the facts within the issues?" Then you are going to examine --


MS. BAZOS: That makes more sense that way.

VICE CHAIR MCLAUGHLIN: Are people okay with what it says or did you want more system stuff in there, Dottie? I think it's probably okay given what this section is supposed to deal with.

MS. HUGHES: I would like to say this. Not everybody understands our system and I am aware of that, but people know that if they need care they have to go somewhere. I think that if we pepper throughout the system when we're talking about three specific issues that we are hoping will grab them, we're going to have problems.

VICE CHAIR MCLAUGHLIN: Oh, I just meant in this section is it okay that we are just focusing on these three issues.

MS. HUGHES: I guess I'm supporting you by saying that I think that we need to do that.

MS. BAZOS: The only thing I would ask in this is we say that cost, quality, and access can support each other and fail each other. Then our examples, unless I'm not reading them correctly, are all about failing. There is the notion that you could improve quality and decrease cost. Some people are thinking about that.

There is the notion that you could ration care that you don't need and have better health outcomes. You don't really call it rationing but pay for performance is a type of rationing. You no longer get the surgery that doesn't improve outcome. You begin to think about decreasing the number of days you spend in ICU, end-of-life care.

VICE CHAIR MCLAUGHLIN: After we say "poor quality care," blah, blah, blah, etc., we could say "on the other hand" or "in reverse" or "in contrast" or "at the same time" and we could give a positive example.

MS. BAZOS: And then I think we need a statement that says when we think about reform or when we think about something, I mean something to wrap it up so we need to always be cognizant that they are interrelated because of the unintended consequences of fiddling over here and what we get over there.

VICE CHAIR MCLAUGHLIN: The next paragraph we can adjust to that. I think, staff, if you could come up with a one-sentence example of a positive reinforcement between the three, then the next paragraph then does this, Dottie.

MS. BAZOS: I don't think it's true that we can't have our cake and eat it, too, because in some places we do.

VICE CHAIR MCLAUGHLIN: I understand what you're saying but it gives the point that we have to be careful. I'm saying this is where we could add. This is where I think we should add a sentence for your point that any change to any one of these things, you have to be aware of the fact that you are going to affect the other. It could be positive or negative.

MS. BAZOS: Cake throws us off here.

VICE CHAIR MCLAUGHLIN: Cake throw us off. MS. BAZOS: "You can't have your cake and eat it, too" I think would be very dangerous to say.

VICE CHAIR MCLAUGHLIN: Let them eat cake.

MS. BAZOS: It's on page 4. "It's one reason why the choices you have to make are so tough. You can't have your cake and eat it, too." That just does not make sense.

VICE CHAIR MCLAUGHLIN: Okay. So we need another sentence, you guys, about the fact that -- not unintended consequences, I don't think, but just somewhere on those lines and that they can be positive or negative but we have to understand that any change that we make to any one of these --

MS. BAZOS: "You can't have you cake and eat it, too" means you've got to ration care. They are saying either/or. I'm saying it's not always either/or.

VICE CHAIR MCLAUGHLIN: Right. Dottie, the staff is going to try to come up with a sentence or two that talks about positive or negative unintended consequences. You always have to be aware of that when you are recommending changes in anything.

MS. BAZOS: And what Pat says kind of wraps it around. Maybe it's not true. You're the accountant.

MS. MARYLAND: With limited resources.

MS. BAZOS: It's almost like if you thought about just using the resources we have and improving the system. I know you can go there but it's kind of like what they are trying to say is with limited resources if you wanted to fix one piece or the other you're going to end up with tradeoffs.

DR. BAUMEISTER: Do you want us to add that in there or not?

MS. BAZOS: No. We're asking. We're trying to figure out a way to kind of wrap this and maybe that's not the right --

VICE CHAIR MCLAUGHLIN: I think at the end when we talk about different initiatives. The staff did offer some language in the longer report that no one of them is looking at the whole system. We could add that none of the initiatives that are already out there are trying to fix the whole system.

MS. BERNSTEIN: Although what we added do involve quality and efficiency and some payment stuff and some access stuff. Some of them in multiple parts.

VICE CHAIR MCLAUGHLIN: Exactly. But that none of them do and remind people that we have to be aware that one could affect the other. Then what was the third thing you just said that I thought was good that they should put there at the end? Oh, shoot. What did you say, Dottie?

MS. BAZOS: About wrapping it around limited --

VICE CHAIR MCLAUGHLIN: Oh. And that if we are going to recognize the fact that a lot more money is not going to be thrown into the health care system, we have to understand that we have to start thinking about ways that are either win/win or that if it's win/loss what losses are we willing to take to get those wins.

MS. BAZOS: Win/win sounds good. We've got to have some win/wins in there.

VICE CHAIR MCLAUGHLIN: That's upbeat and also getting to the stuff that you and Joe and others are saying let's think about this as a system and not all the little piecemeal things. And also Wyden and Hatch both said, "1.7 trillion we ought to be able to do it."

MS. BAZOS: Yeah, and that's what communities are saying. They are saying, "Look, we're not going to give you more money." That's what the guy from Salt Lake City said. "Don't ruin my piece by fiddling with something else." I think we need to --

VICE CHAIR MCLAUGHLIN: So that might be a nice setup of the initiatives, the list of initiatives. That might be a good way to set it up. And then to also say, "And now this what we're going to do. We're going to come out and talk to you guys and say --

MS. BAZOS: What do you think.


MS. CONLAN: I think if you use limited resources, that's going to --

VICE CHAIR MCLAUGHLIN: We can't use that.

MS. MARYLAND: If you say that, then it's going to reinforce the fears that are already out there.

MS. BAZOS: But it gets to --

MS. CONLAN: Just the more intelligent design of "Here's the money we've got. How can we use it?"

VICE CHAIR MCLAUGHLIN: Oh, yeah. You can't use that phrase.

MS. CONLAN: But that's what I'm trying to say. We have what we have.

VICE CHAIR MCLAUGHLIN: We can't go there. Chris already left. She's abandoned us. We can't go there.

MS. CONLAN: We have what we have and we can work together but not using limited resources.

MS. MARYLAND: Unlimited resources.


MS. MARYLAND: That's the positive way of saying it. The only pet peeve I have here is, "There are no silver bullets." Silver bullets are used to kill vampires. I don't like that.

VICE CHAIR MCLAUGHLIN: Meanwhile, back at the ranch. Okay. We're making progress.

MS. MARYLAND: I like Chris' story. You can't beat a dead horse.

VICE CHAIR MCLAUGHLIN: I asked her to make sure it was accurate, $80,000.

MS. MARYLAND: Where is Chris anyway?

VICE CHAIR MCLAUGHLIN: She abandoned us.

PARTICIPANT: She had to take a phone call.


MS. BAZOS: The only thing I didn't like about her story is she says -- I don't know if I'm reading it wrong -- that, "The 20 percent of the bill that I would have had to pay." Did she pay it?

VICE CHAIR MCLAUGHLIN: Well, that's what I have always asked her to be -- this is what was from a transcript that Caroline --

MS. BAZOS: My question is if she didn't pay it and it got absorbed. I mean, I want to know did she pay it. Did she have to pay that much money.

VICE CHAIR MCLAUGHLIN: It might be that they had complimentary insurance.

MS. CONLAN: I think that's it. I think she got it waived.

VICE CHAIR MCLAUGHLIN: Complimentary insurance, coordination of benefits kind of thing so they didn't have to pay it but she is saying -- I don't know.

MS. CONLAN: This isn't a fact or an issue.

DR. BAUMEISTER: The stories aren't going in, right? We decided no stories were going in?

MS. CONLAN: You and I did but other people didn't agree with us, Frank.

DR. BAUMEISTER: Can we vote again?

VICE CHAIR MCLAUGHLIN: She thinks the stories should be out, too. It's not a fact or an issue.

MS. CONLAN: Begin by asking what are the facts, what are the issues. Then the next little thing is that a fact or an issue.

MS. MARYLAND: I see what you're saying. That's a good point.

VICE CHAIR MCLAUGHLIN: Say that again, Montye.

DR. BAUMEISTER: The wording of this report, with all due respect, in their infinite wisdom the whole complex is changed here if this report is going to go to benefits managers who can't read.

PARTICIPANT: They are going to skip that part.

VICE CHAIR MCLAUGHLIN: It's true. Montye is right, they are not going to read that.

MS. CONLAN: They are not going to read that. It's not a fact or an issue anyway.

DR. BAUMEISTER: It's like it's directed to an elementary school student.

PARTICIPANT: But that's what they wrote it for. That's what George is saying.

VICE CHAIR MCLAUGHLIN: George clarified that for us.

DR. BAUMEISTER: I understand that but --

VICE CHAIR MCLAUGHLIN: They tried to get this report to show too many focuses.

DR. BAUMEISTER: But we now have a different audience.

PARTICIPANT: That's what I was saying.

VICE CHAIR MCLAUGHLIN: Exactly. That's what I said, too.

DR. BAUMEISTER: So "citizens like you" sounds like a civics class, you know.

PARTICIPANT: We're not on that part. We're on page 4.

DR. BAUMEISTER: I understand that but it's the whole --

VICE CHAIR MCLAUGHLIN: He's a speed reader. He's a speed reader.

DR. BAUMEISTER: The whole format is so infantile for a benefits manager or from an editor of a newspaper to cram through 10 pages.

VICE CHAIR MCLAUGHLIN: It's getting down. It's going. We're cutting it, Frank.

PARTICIPANT: But I think Frank's overall comment is quite good.

VICE CHAIR MCLAUGHLIN: This is how I started off by saying "you're invited" is not what our beginning is going to be.

MS. MARYLAND: The audience has changed.

DR. BAUMEISTER: "You need to take part." Children of the world, you know.

MS. BAZOS: That was my question. Can we edit this? George, you can help me. You thought we could. We talked about the executive summary. Can we make -- is it a waste of our time to try to make this an executive summary or do we take the 25-pager and make an executive summary and rewrite -- agree on this so it goes into the more graphic.

MR. GROB: I think you all have to decide what you want to produce. I'll just tell you what the intention was. The intention was to reach a broad audience.

MS. BAZOS: Right, and we still want to do that but in a different report.

MR. GROB: But then you would want to write a different report. This one was intended for a broad audience.

MS. BAZOS: It was done at the 6th grade level. It was intentionally done at the middle school level. He told me that specifically today.

MR. GROB: The standard they used was the kind of material for Medicare beneficiaries. They were required to meet that grade level and this is the style that they used for that purpose. If they want to reach a broad level, this is the way they have to write for it. That is their belief and that is the contract they had with CMS to do it for the Medicare program. That's what they wrote because we asked them to write a document that could reach a broad audience. MS. BAZOS: So if we are going to review this document, I think we should review it and agree on it as something that would reach a broad audience. For example, something that would go into the comic book. That's what I said. I didn't know that we could -- I thought it would be difficult to review this as though it were going to be an executive summary because it's not written as an executive summary.

MR. GROB: My opinion is it's a very different style of writing. You'll have to start from scratch if you're going to do that. I think it's simply a document that is a version that could be made available to many people.

VICE CHAIR MCLAUGHLIN: Remember that what we were supposed to do is talk about content.

MR. GROB: Right.

DR. BAUMEISTER: So this will be focused as the graphic health care for dummies.


MR. GROB: What I heard her say is something in between, that when we settled on content this would be published in a more graphical way than it is now. Rather, it would be the one that would sort of -- I think that, Catherine, what you said. We ought to go there, too. I couldn't tell whether this was going there or whether there was going to be another one that would go there or some combination

VICE CHAIR MCLAUGHLIN: I think she thought this was going there. I think what she meant by that was not to do the two-pager but to have one page but they were going to put some graphics in it but it was still going to be bullets.

MR. GROB: Something like that, yes.

VICE CHAIR MCLAUGHLIN: That's what I thought.

MR. GROB: I think that's correct.

VICE CHAIR MCLAUGHLIN: It was going to be colorful like this but the content was going to be this exactly. Exactly.

MS. MARYLAND: Are we comfortable handing something like this out October 6th to the group that is going to be there in Washington, D.C.? This is not appropriate for that audience we're talking about. We're talking about editors, newspapers, members of Congress and staff.

MR. GROB: If I were to hand in those two, what I would do is the night before I would hit the print button on my website, take it down to Kinko’s and run a hundred copies of it and give it to them. I

MS. HUGHES: I would agree with you on that. I guess the thing that I'm aware of, as I'm sure we all are, is that if -- I hate to say this but, you know, I'm just going to say it anyhow. If Randy felt this was okay for his -- what do you call these people, HR people?

DR. BAUMEISTER: I'm glad they're not coming to dinner.

MS. HUGHES: I agree.

VICE CHAIR MCLAUGHLIN: He said he liked the tone and the style.

MS. HUGHES: He said he liked this for his HR people. He said he liked this for them, the short one.

VICE CHAIR MCLAUGHLIN: He liked the bullet format.

MS. HUGHES: He liked this for his people. I'm just saying.

MS. BAZOS: George, we're going through this exercise. I mean, that's why I do feel frustrated. We're going like around the barn because we want to actually come to agreement and get a product. We would like to compromise with Randy who I think he said he liked this but a lot of us don't. Help us understand. Now I'm thoroughly confused about what it is we are trying to do.

DR. BAUMEISTER: We're no longer on the three reports. We're back to two reports.

PARTICIPANT: We forgot about the executive summary. George says that when all the dignitaries show up for the press conference, he will give them copies of the 50-pager.

MS. BAZOS: George, you've been in meetings with Randy and I'll ask you will he be happy with that do you think? I mean, I'm asking you to guess.

MR. GROB: Randy always felt strongly that the 50 -- that had to be available to people. What he reacted to today wasn't his desire to not do that but could it be printed in time and I said no. On the schedule we're on now --

PARTICIPANT: The 50-pager?

MR. GROB: I said that it could not be printed.

VICE CHAIR MCLAUGHLIN: The 50-pager isn't going to be printed.

MR. GROB: No. She's asking what Randy was thinking.


but --

MR. GROB: What I'm saying is that Randy's desire all the time was that we would issue a complimentary copy of the 50-page report --

VICE CHAIR MCLAUGHLIN: To the attendees.

MR. GROB: -- to the attendees and the reporters and this kind of thing because they are accustomed to getting reports like that and absorbing it. His reaction this morning about not doing that was in response to my answer to his question that I don't think we can print it in time. I think we can get it on the web but I don't think we can get it printed.

VICE CHAIR MCLAUGHLIN: Print it the day before.

MR. GROB: The printing we were talking about was the style layout, the report that looks more professional in style.

DR. BAUMEISTER: A bound copy.

VICE CHAIR MCLAUGHLIN: A bound copy. Oh. And that's what he wanted. He wanted like a bound copy of the 50-pager.

PARTICIPANT: And George told him no.

MR. GROB: I told him that I could not promise that I could get it here and then have GPO convert it to that format.

VICE CHAIR MCLAUGHLIN: All right. I'm with you.

MR. GROB: That's why he kept asking.

VICE CHAIR MCLAUGHLIN: We're only going to do like 100 of those.

MR. GROB: He was going to do more, maybe 500. There are many members of Congress and things of this nature.


MR. GROB: Yeah, of whatever it would take.


MR. GROB: Yes, the heavyweight one. That's why he kept asking Tish now, "Can we have a successful event if we don't hand that out on that day?" You suggested it could come later. A week later we'll do that. He kept asking but he was skeptical.

VICE CHAIR MCLAUGHLIN: We were talking across each other. I was thinking about this a week later, the lightweight.

MR. GROB: So basically he reluctantly went along with the idea that it would be sufficient to stick it on the thing. Tish's answer was, "That's okay as long as you have something else."

VICE CHAIR MCLAUGHLIN: Right. Which is what we are now trying to talk about.

MR. GROB: It kind of looks like a report.

VICE CHAIR MCLAUGHLIN: Right. That's what we're now talking about.

MS. BAZOS: No, no, no. No, it's not.


MS. BAZOS: But --


MS. BAZOS: What are we talking about?

VICE CHAIR MCLAUGHLIN: Okay. Here was why I had my hand up.

MR. GROB: The young lady with her hand up.

VICE CHAIR MCLAUGHLIN: Thank you. The staff who are going to do all this work, remember, had a sidebar with me that they can create an executive summary by taking the heavyweight, you know, this afternoon, tomorrow morning, and you cut and paste and make an executive summary where you actually use the same titles, the same words. How many of us think the staff ought to do this?

MR. GROB: I can't promise you I can do that. My experience with executive summaries is you just don't snip things up.

VICE CHAIR MCLAUGHLIN: No, but we just meant instead of working on this where Frank was saying this was written -- what did somebody say, 6th grade? -- middle school level and working from the middle school level why not work from the 50-pager which was written at a more appropriate level for an executive summary.

MR. GROB: Okay. Again, you can do what you want.


MR. GROB: I'm just saying that --

VICE CHAIR MCLAUGHLIN: Chris, I'm doing that on purpose. I know it's not --

MS. STEHR: George was just saying he could go to Kinko's the night before and print out the whole 50-page one. Okay. Then let's take -- so that goes into the press packet.


MS. STEHR: Okay. Then let's take -- so that goes into the press packet.


MS. STEHR: Then we do this one as the simple version, the one that is going to go to everybody so that both examples are in the press packet. Does that make sense?

VICE CHAIR MCLAUGHLIN: But we don't have it ready to be the comic book one that goes to everybody.

MS. STEHR: Okay. We won't have that ready.

MR. GROB: I think what she told me she could have ready was a version of this that had a graphic look to it. I'm telling you what she said and then you can decide what you want. She used the slide show as an example of the kind of graphic look that this one could have. Something about like that. That could be done in time.

VICE CHAIR MCLAUGHLIN: I understand but that's why I started this off two hours ago that will not be this.

MR. GROB: Right.

VICE CHAIR MCLAUGHLIN: And we would not be starting off with our stories and boxes. It would not be an open-up storyboard. It would still be something like this that is a page at a time but has like a slide show with a little border across the top.

MR. GROB: That's correct.

VICE CHAIR MCLAUGHLIN: And it's bullets. It's very different. It doesn't mean it's wrong. I'm just saying --

MS. HUGHES: I guess I --


MS. HUGHES: Thank you.

VICE CHAIR MCLAUGHLIN: The lovely lady from the west.

MS. HUGHES: I guess -- everything has so many layers I guess I think that because we have to be fluid and because I would like to continue on this, on going through it to see how things are, and I would like, I mean, me personally, my idea for doing it is that even though this would not be the executive summary I would choose to present to everybody, but since our chair is comfortable with it, not meaning we can't change parts of it and things like that but --

VICE CHAIR MCLAUGHLIN: How would you see Robert Pear responding or Susan Denser respond to this? What story would she write?

MS. HUGHES: I don't think that -- rather, I do think that they would look at it as two different audiences. I think that it's appropriate to look at, like I said, for different audiences. I think they would look at it for different audiences.

MR. GROB: I think the way you would do Robert Pear is you would have a meeting with him and you would sit down and say, "Here's where we are. We got this report. Here's a copy for you. Now, we've prepared another report to reach a broader audience. Here's a copy." And he would see that's what it is.

MS. HUGHES: Right. And I think Susan would do the same thing, Catherine.

VICE CHAIR MCLAUGHLIN: But then we don't have an executive summary.

MS. HUGHES: I just want to say if Randy wants to call this an executive summary --

VICE CHAIR MCLAUGHLIN: But then this also then becomes -- do we ever do the comic book version or is this the comic book version?

MR. GROB: I understood Tish to say that she still wanted to get where you were at.

MS. HUGHES: I agree.

VICE CHAIR MCLAUGHLIN: But that was, I think, like a two or three page --

MR. GROB: Actually, I think she was impressed with that. She thought we can get there but we can't get there by October 6th but we ought to try to get there. Randy also suggested to her that by October 6th that there be a trifold or a three-page, a more easily printable broadcast version. I saw the look on her face, "Okay, boss. Yes, I think we can do that."

VICE CHAIR MCLAUGHLIN: The trifold will not have stories. The trifold will not have all those graphs.

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: I mean, it won't.

MR. GROB: Again, I'm just saying that she reacted to that in my opinion like it would be a hard road to get that ready by October 6th. That's sort of what I heard personally.

PARTICIPANT: She kind of wanted to give you a yes answer.

MR. GROB: Yes. She's working for us. Whether she can do it or not, could she make it happen, yes, I think so. But I would agree with you, Catherine, that is not --

PARTICIPANT: She's trying to sweeten you up.


MR. GROB: I'm happy to let that happen, you know.

VICE CHAIR MCLAUGHLIN: I believe in bribes. I'm a mom, remember?

MS. BAZOS: I just want to go back. What do we need for October 6th? I think we need to make a decision. We are reviewing this for the wrong purpose. This is not an executive summary. If we are going to do an executive summary, I would like to suggest that the staff do it. The question is does it make any sense to try to do an executive summary to have that bound on October 6th?

MR. GROB: I don't think I can do it.

MS. BAZOS: Okay. Then that's fair. That's good. Let's can the idea of an executive summary.

MR. GROB: Right.

MS. BAZOS: Then let's -- of course, we have to ask. That's what I would suggest. Then I would suggest if we are going to review this -- oh, thank God -- we'll review this as it was written for content for a broader version, the graphical document. Then we argue about what the graphics look like and whether they are little boxes and that kind of thing after.

MR. GROB: She said if we get the content right, then you can bring it to design but you can't bring it to design until we get the content right. Again, I want to be careful to understand that I am trying to describe what I think people said. I don't want to advocate any particular thing. I'm just trying to describe what happened.

I think this was intended to be a report for a broad audience. I think their consideration was given to also prepare one along the lines of what Cathy worked on, possibly a three-pager or trifold or something, other means to reach people. The question is what can we achieve by October 6th. What can we get done. We can do the 50-pager but we can't stylize it. We don't have time for that but we can get it on the Internet.

This one we could stylize as a somewhat professional looking document with some graphical aspects to it so it looks kind of nice. That still doesn't turn it into what Catherine has been advocating. I think that many of us relate to one and would like to see happen. I heard her say, "We should get there but we can't get there by October 6th.

And the question that Randy was asking her is would that do it. She said, "Yes. It's okay if you have your document on the Internet but you've got to give them something that does look like it's something of a report-like document." She said, "With this one we could do it."

VICE CHAIR MCLAUGHLIN: We're going to have the 50-pager. The 50-pager is a report-like document. I understand that you don't think we can get it pretty and bound and printed.

MR. GROB: Right.

VICE CHAIR MCLAUGHLIN: It can be done. Sorry but it can be. The other thing is that I'm sorry but I do think that in the next two weeks, which is what we have, the staff could come up with a serviceable executive summary-like thing.

MS. STEHR: We have to come up with a press summary anyhow and the press package is going to have to have written at the Robert Pear level, a two-page thing inside that says what the report says because you have to do that and the Robert Pear level is not the 6th grade level.

VICE CHAIR MCLAUGHLIN: No. Definitely not.

MR. GROB: Clarification.

VICE CHAIR MCLAUGHLIN: No. Wait until I finish.

MR. GROB: Go ahead.

VICE CHAIR MCLAUGHLIN: Then the question is do we also have this as it now stands ready for October 6th knowing that we are not going to -- we really are not going to have this by October 6th. It's just not going to happen. We are not going to have the participant's discussion guide, get the dialogue started, that is inviting, welcoming, etc. This is supposed to be -- this is what Edelman saw at the middle school level participant's guide. I think we need to decide is it worth having us spend another minute, which is Chris' point two hours ago, another minute on this? Will it be used?

MS. HUGHES: I would like to respond.


MS. HUGHES: I want to say this out front because a number of people have asked me exactly what it is I'm trying to do. I'm trying to -- there's a lion in the cave and the lion's paws hurt and I'm just trying to make a bridge so that what the lion is handling can come together with what the rest of the people can handle.

I think there is some validity. I think there is a great deal of validity to going through this because if it pulls the thorn out of the lion's paw and we can go forward on other things, then I think we should do it because I think we should do it.

VICE CHAIR MCLAUGHLIN: Here's what I'm asking. It's one thing to print 100 of these with the minor changes we've made. Just minor. In other words, stay with this style, have it be a participant's guide, "You're invited," middle school level which includes 6th grade -- middle school level, print 100 of them, 500. Okay, 500, not even -- you know, hand them out but make no pretense that this is what we're going to print 10,000 copies of over the next four months.

MS. HUGHES: I think -- okay. I'll take it one step further. I think if we were to do this today and come up with an approval of it, we have given Randy something that he wants except that there would only be 400 or 500 printed and that we read this at the discussion of the warmer piece and the more friendly piece and we unite on that as well.

I don't think it has to be an either/or today and that's what I'm advocating for. I understand that -- I know you can say it's the framing of the question and we are down the road and what's the sum cost. Well, I would take the risk to work through this to get it approved so that it meets all the criteria that you academics know, that is comfortable for me, that is comfortable for the other people, and then focus on this warmer piece and have equal unity behind it as well as is behind this.

I just think that for us to look at changing everything at this point in the game the lion is going to roar. It's not that it's wrong that the lion roars but you don't always have to meet lions head on.

VICE CHAIR MCLAUGHLIN: She's saying Randy is a lion and he's got a thorn in his paw because we don't like this.

MS. BAZOS: He just wants to have the meeting on October 6th.

VICE CHAIR MCLAUGHLIN: No, I think he likes this. He really likes this. This is his style.

MS. HUGHES: This is what he likes, Dottie. Really. If he's comfortable with this, this is what he likes.

VICE CHAIR MCLAUGHLIN: My issue is, Therese, and I'll play Joe's point, this is the working group. This is not Randy's group. It's not Randy's product. It's the working group product. Yesterday there was little support from the working group for this.

MS. HUGHES: I don't remember that. I didn't read it. I don't think -- I didn't think we discussed this yesterday.


MS. HUGHES: I like what you have. I think what you have is going to appeal to a lot of people.

VICE CHAIR MCLAUGHLIN: Well, but clearly not the Randys.

MS. HUGHES: Right.

VICE CHAIR MCLAUGHLIN: This is what is going to appeal to the Randys.

MS. HUGHES: Right.

VICE CHAIR MCLAUGHLIN: His constituency.

MS. HUGHES: Right.

MR. GROB: Again, a clarification. I think Randy likes it because Randy has throughout his career helped produce brochures that goes to employees and to others that are enrolled in things, as well as to his peers at the higher executive levels.

I think --

VICE CHAIR MCLAUGHLIN: How about benefit design?

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: As Richard reminded us when we heard Chet, we are not about benefit design.

MR. GROB: I'm just saying in terms of a writing style for broad distribution. Could I answer your question about the executive summary since you asked me? If by executive summary you meant like the two or three-pager, yes.

VICE CHAIR MCLAUGHLIN: That's what I meant.

MR. GROB: I thought you were talking about the 10-page executive summary. That I don't think I could do.

VICE CHAIR MCLAUGHLIN: When Tish was here I was saying why can't we have this press packet like a three-page bullet thing.

MR. GROB: Again, this is your decision, but her response was that you need to have something that is report like in its general appearance.

VICE CHAIR MCLAUGHLIN: We do. We have a 50-pager.

MR. GROB: No, something else. Something that looks like a professional report that is stylized with graphics that could reach a broad audience. You have to have something like that. That was her answer to Randy's question as to whether you could get by with only having the 50-pager on the web. You've got to have something you can give out that looks professional.

MS. BAZOS: Let me ask you, George. If we then took this document that Randy likes as a way to talk about the content and ready to go forward and have October 6th as a way to meet a lot of people needs. If we review this and agreed on the content and put it together as a document written at the 6th grade level, what would we call it?

MR. GROB: I don't think you need to have this discussion. I think you can call it anything you want.

MS. BAZOS: I'm not trying to be difficult.

PARTICIPANT: Report in brief.

MS. BAZOS: Report in brief?

VICE CHAIR MCLAUGHLIN: This is a report in brief written at the 6th grade level.

MS. BAZOS: But why would we -- I'm just curious.

VICE CHAIR MCLAUGHLIN: Because it starts off, "You're invited," you know. That is not a report in brief. A report in brief will get rid of the first page and a half and I think the last page and a half. Then it would be a report in brief. Instead of executive summary it would be a middle school summary.

MS. BAZOS: My question is what would we say it was for? It's not for the press because it's not at their level. You know, is it a call to action to the American people? We know it's not the comic book. It's not the executive summary. My question is if we were to spend more time on it and agree on it and develop it, what is it and what would we use it for?

MR. GROB: You would use it for a broad audience as you would use it as a basis as a way of showing that you are trying to engage citizens of the United States in a way --

VICE CHAIR MCLAUGHLIN: It is the substantive for the comic book. Let's be honest, George.

MR. GROB: It's today's substitute.

VICE CHAIR MCLAUGHLIN: It is a substitute for the comic book. That's what this is being pitched as.

MS. BAZOS: I understand that but if we --

MR. GROB: That can be produced by October 6th.

MS. BAZOS: Okay. So we need to know what we are looking at it for and what it would be and

then --

VICE CHAIR MCLAUGHLIN: And what do we tell the people who show up? We say this is what -- this is our substitute for the comic book.

MS. HUGHES: I think as we just said in the press packet we have the heavy, the executive summary. Then we just show this as one of the means we are doing outreach with and just leave it at that.

MS. MARYLAND: I think it's a call to action to the citizens in this country. That's what it is.


MS. MARYLAND: If you look at the beginning of this, I mean, the first thing it states on page 1 is, "You need to take part because you are a consumer, taxpayer, citizen."

VICE CHAIR MCLAUGHLIN: Exactly. The audience of this is not the press, it's not the Hill staff, it's not the Robert Pears.

MR. GROB: You are revealing on the day we are now in touch with the citizenry of the United States.

VICE CHAIR MCLAUGHLIN: Right. And what we were saying, George, is some of us don't think -- I'm not proud of this. Randy kept talking about yesterday we wanted to be proud of this. I'm not proud of this as our call to action to the American people. All right? That is beyond factual accuracy. I'm just saying I'm not excited about this at all. It leaves me cold. Right? But if the group decides this is what we want as our call to action, I'm not going to say no.

I will give you all my little comments about things I think are inaccurate or misleading but I never meant to suggest that I'm holding out for this. I am not. I just thing this is -- I would be much more excited about this format as a call to action than this. I don't really care if we add little pictures to the top. I just don't think that is going to change what this is.

Now, Randy likes what it is. That's fine. As Randy said this morning, this is not the first time he and I have disagreed and it may be the last time but it is not likely. That's fine. I believe in a democratic process and I don't give a tinker's damn if he's the lion. I believe in a democratic process.

This is the working group report and if the majority of the members of the working group like this call to action, then let's go for it and let's just work on tweaking wording here and there for accuracy so that when they get back with the focus group we have all the data, as Therese said, and then let's stop wasting our damn time which is Chris' point.

I'm not interested in wasting anymore of my time. I've wasted a lot of time in the last five months. Quite frankly, I'm not interested in wasting anymore time. George, quite frankly, you're digging in your heels and you are trying to shove this down our throat.

I understand you're trying to do your job and you are trying to make a deadline and that's fine but if that's the agenda and you and Randy are going to shove this down our throats, then fine. Let's just see what there is in here that we can not accept and stop all this wasting of time about style, presentation, and everything else because it ain't getting us anywhere.

MR. GROB: I would like to reply to that.

VICE CHAIR MCLAUGHLIN: I'm drinking water and not Coke and I'm still agitated.

MR. GROB: I generally am pretty reticent about any implied criticisms of myself or any one questioning my motives, but when I hear something I think is a personal affront, I would like to take the opportunity to do it.

I am not Randy's partner in trying to shove anything down anybody's throat. I just would like to establish that. I'm trying to be of service here. I do believe this is correct but, like you, I appreciate, Catherine, the first time I saw your written comments --

VICE CHAIR MCLAUGHLIN: Let's forget this. Let's talk about this.

MR. GROB: That would be fine. I just wanted to clarify the remark. I did take that as a personal affront and I would like to correct it.

VICE CHAIR MCLAUGHLIN: I didn't mean it as a personal affront that you are partners. I just meant that I think you and Randy both agree that this is the way to go. That's what I meant by it, not that you are partners, but that you both agree this is the way to go. You got the product from Edelman that you think is appropriate and that this is the way to go.

MR. GROB: I would agree with that.

VICE CHAIR MCLAUGHLIN: That's all I meant.

MR. GROB: Okay.

MS. CONLAN: I'm afraid to say anything. I don't want you to pounce on me.

VICE CHAIR MCLAUGHLIN: I would never pounce on you.

MS. CONLAN: Is it possible that --

VICE CHAIR MCLAUGHLIN: I only pounce on the big guys like George. We have lions and we have George of the Jungle. I mean, you know.

MS. CONLAN: Is it possible that we could have different paths and different calls to action?

VICE CHAIR MCLAUGHLIN: It's possible but down the line we might get this.

MS. CONLAN: Why does it have to be one? Why is it mutually exclusive with other calls to action?

VICE CHAIR MCLAUGHLIN: It's what we have now.

MS. BAZOS: I think the problem is that we have a deadline. Come on, guys. That's the problem. Let's decide do we want to go for October 6th or not? Personally, I think that is the decision before we get to anything else. If we want to go to October 6th we are paying Edelman very big bucks. What do you need? You have to have the big report. It has to be on the web and you have to have something to hand out. We've got to have something to hand out. If we can't agree on what we're going to hand out, then we are not going to go to October 6th. We've got to change the date. Let's just decide that and then maybe right after we decide that, decide are we going to have a temporary thing? Is this going to be --

VICE CHAIR MCLAUGHLIN: I think, Dottie, that was part of my point. I don't get the feeling that either George or Randy are recommending this be a temporary thing. I think they are recommending that this be our call to action at the middle school level.

MS. BAZOS: But let's just decide is the problem is the question. I guess it is, George. Maybe you can help. Maybe the focus groups will do it all. It's too bad the focus groups don't have -- you know, it really is too bad. It's kind of very difficult. I think we need a couple of things, content, but it is too bad we don't have something in graphic form because it's very hard to see what it might look like. If we had to have a call to action for October 6th, I guess the question is does that exclude having other products down the line.

MR. GROB: It doesn't.

MS. BAZOS: That's what I'm saying.

VICE CHAIR MCLAUGHLIN: That's what I'm saying. We can see it as part of the process. Exactly.

MS. CONLAN: And you said from the very beginning we were going to reach different audiences in different ways.

VICE CHAIR MCLAUGHLIN: Right. But these are both geared toward 6th grade. That's all I'm saying.

MS. CONLAN: Okay. So we have 6th graders in two different ways. Not every 6th grader is the same.

MS. MARYLAND: Obviously not every executive is the same. Some executives don't have time. They want the bullet summary.

MS. CONLAN: Hey, this is what he likes. But George just said they could do a three-page executive summary so there's another form.

MS. MARYLAND: I am concerned. I will agree to that. Fine, if this is the document you want to use, that's great, but for October 6th handing it out to -- I wouldn't hand this out to any of the constituents that I deal with. I just wouldn't.

MS. BAZOS: This was my original question. Would you hand it out as describing this as what is going to be handed out to people at the 6th grade level or however you are going to describe it?

MR. GROB: Could I ask you all a favor again? It has come up several times. I will give you my advice. It's advice I would give Randy. Randy doesn't always agree with the advice that I give him. This is my advice. It's not anyone else's advice but my advice and you are the ones that have to decide what to do with it.

I believe that on October 6th if we do not have a presentation that shows that we are trying very much to engage the public of the entire United States and we have only something that is like the 50-page report and the press kit and the little executive summary, we will bomb out. I said that before. We will bomb out.

However, we do have within our near reach some exciting things, I think, that will engage people. I think we have the website which already has had 5,000 people call it up and want to speak to us and a better one coming. I think the slide show is a good basis, too.

I think that this is a good thing to reach out to people with because of its format and because of the language that's in it, because of the language style. I think it does speak to our trying to reach them. It also has disadvantage. It can be completed by October 6th but the other ones can't be.

If we want to have our document along with the others that can be part of this package, this is achievable. I have all along advocated that there are so many different people out there that we probably do need to have coming out a variety of products.

I've been a great supporter all along of the kind of approach that Catherine took but I again say that we can put together a total package that will be available on October 6th if we work our way through this. This is my advice to you all. This is not Randy speaking. This is not someone trying to shove anything down your throat. It's my advice to you.

MS. WRIGHT: I think for someone with as many years of experience as George has, we should heed his advice. He's the guy who has been in it all these years and I haven't.

VICE CHAIR MCLAUGHLIN: George, with a due respect, has not been trying to reach the American people. He's been in the federal government writing reports for the Hill and for certain constituencies but not mass middle schoolers to try to do a call to action. We keep being told this is historic. It has never been done before. None of us have experience in this, Chris, including George.

MS. WRIGHT: That's what we've hired the communication and marketing firm for. We are still sitting here an hour later trying to figure it out when I said this is what we've hired the communication and marketing firm for.

VICE CHAIR MCLAUGHLIN: But I think the problem with this is we don't agree on the content.

MS. WRIGHT: Then we need to stop right now because we're not going to agree and there are six of us missing. If we want a consensus, there's not six of us here.


PARTICIPANT: We are going to print, what did we say, 100 copies of this, George?

MR. GROB: Well, maybe 400 or 500 for the first time and then we'll see how much we would use it after that.

PARTICIPANT: Can we print 400 or 500 copies of that, too?

PARTICIPANT: Not by October 6th.

MS. BAZOS: What George is saying is we can't get that done by October 6th.

PARTICIPANT: But as that is could we? I'm not talking about the new tabloid form that you're talking about with the two-page thing but just like that.

VICE CHAIR MCLAUGHLIN: I don't think Randy would accept that.



MS. HUGHES: I would like to suggest that we look at that to go to the community meetings. I don't know if that's possible but I really think that something like that going to the community meetings is going to be more to our advantage than this is. I do think that a lot of people will read this. I do think that a lot of people will like this.

I can't give you a percentage but I think a lot will. This is my preference and my preference is at the community meetings. I would like to suggest that we have that available at some point for a minimum of half the community meetings so that it can be worked on to get that.

DR. BAUMEISTER: Explain to me what we're going to show up with on October 6th, George?

MR. GROB: We would be unveiling the website.

DR. BAUMEISTER: Go through the scenario. I need a visual here. Is there a podium?

MR. GROB: There would be a Senate meeting room and about 80 people could go in there. There would be members of the press invited and possibly others. We are still working on who those might be. It would be, though, primarily in the form of a press conference and it would feature the two senators making statements.

It would probably feature some footage of David Walker with support on this. It would feature presentations made by members, particularly talking about the report, the 50-page report. It would feature the opening of the website. It would feature the availability of the --

DR. BAUMEISTER: That would be shown on a screen?

MR. GROB: We are thinking of that, right. We are featuring the availability of the 50-page report. We would be showing that we are trying to engage the American public in a variety of different formats. They would see that we have the slide show. They would see that we have this. They would see the tone of the different values.

They would see that some are written inside, some are written more to the public. They would see there's a variety of ways to do it. We would be telling people that we are this committee. We are open for business. We want to talk to people and we have an initial series of documents that would do that.

DR. BAUMEISTER: And then there would be questions?

MR. GROB: Probably from the press. The time of the event could be probably an hour at the most. Most press conferences are half hour but I think we would have --

DR. BAUMEISTER: This would be in the packet as an example.

MR. GROB: It would be featured --

DR. BAUMEISTER: As an example.

MR. GROB: -- of how we are trying to communicate with the public.

DR. BAUMEISTER: This is how we are reaching out.

MR. GROB: As one way. That's correct.

DR. BAUMEISTER: Your tired, poor, and huddled masses.

MR. GROB: Exactly.

VICE CHAIR MCLAUGHLIN: But if there's 500 copies, it's more than just that day. It's going to be distributed to a lot of people.

MR. GROB: Yes, that's right.

DR. BAUMEISTER: And this can be changed later on. Is that right?

MR. GROB: Sure.

DR. BAUMEISTER: It's just show business.

MR. GROB: It's a start. No, it's a start. It is a document that would be used.

DR. BAUMEISTER: Sure. Here's what we've got.

MR. GROB: Other documents would follow for different events. Other versions.

DR. BAUMEISTER: And Andy will be back there trying to show the website on the big screen.

MR. GROB: We actually had talked about having the senators go up there and turn it on and actually answer some questions. We don't know whether they will go along with that but that would be the kind of idea that we have in mind.

PARTICIPANT: It seems to me that the basic difference between the two documents, and correct me if I'm wrong --

DR. BAUMEISTER: This is important.

PARTICIPANT: What's that?

DR. BAUMEISTER: That this is an example in the packet and they are not going to read it to educate themselves. They are going to read it to see how we are trying to reach out to the public. If Robert Pear reads it, Robert Pear is not going to get a Ph.D. in health care from this. All he's going to say is, "Hey, they've done a pretty good job in reaching out to the public." Is that right?

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: Do you think Robert Pear will think this is a good job of reaching out to the public?

DR. BAUMEISTER: I don't know but it changes the whole way I look at it.

VICE CHAIR MCLAUGHLIN: I think it's naive to think that it's only going to be put in a packet and not read by anybody and be seen as an example of how we are going to reach all the public. I think it is going to be used --

MR. GROB: I agree with that.

VICE CHAIR MCLAUGHLIN: -- as a way to reach out to the public. It actually is, in fact, going to be mass produced and distributed.

DR. BAUMEISTER: But it's not going to be used by those 80 people who are there at that coming out.

VICE CHAIR MCLAUGHLIN: There won't be anything that is used by them because the 50-page is not going to be ready.

MR. GROB: It will be in the wings.

DR. BAUMEISTER: They will use the experience of having been there.

MR. GROB: Most of those people would rather not get it. They would rather go to the web and pull it down.


VICE CHAIR MCLAUGHLIN: You said we have to have a report that we hand out.

MR. GROB: A report-like document and I think this satisfies -- Tish's answer was that this would satisfy that purpose.

MS. FEDERER: I know Dottie is not here.

MS. BAZOS: I am here.

MS. FEDERER: I mean Connie. Connie is not here but from her communication standpoint we are saying on this date that we are reaching out to the American public to invite them to be part of something that has never been done before which is try to do something about the problems we are facing in health care.

To help them join that discussion, we have written this little report to help you get involved in the discussion. I think that is where Frank's distinction is really important because this is an example of one of the ways that we are inviting Americans to get informed enough to join this dialogue and participate.

We can be announcing that we are coming out with other reports. We're doing this and doing that but here is an example of a way that we are going to allow every individual American to get informed enough to join this big important discussion.

PARTICIPANT: But Catherine is looking beyond that day, right?

MR. GROB: Yes. I think we all are.

DR. BAUMEISTER: I think under those circumstances that's fine.

MS. HUGHES: I'm certainly looking beyond this.

PARTICIPANT: Why can't we have that as one example? If we are going to have one example here, why can't we have one example there?

DR. BAUMEISTER: Why can't we have them both?


PARTICIPANT: When we looked at this we didn't like it initially.

VICE CHAIR MCLAUGHLIN: It had garish huge colors on the back.

PARTICIPANT: And we couldn't read it.

DR. BAUMEISTER: We got it because the Government Printing Office wasn't equipped to deal with graphics of that complexity. That's what we were told.

VICE CHAIR MCLAUGHLIN: I did it. I did this on my little lap top. It's very complex.

PARTICIPANT: Catherine, other than the layout --

DR. BAUMEISTER: That's what was said, though. That's what Michael O'Grady said. We could have some other agency work it up and make it more --

VICE CHAIR MCLAUGHLIN: That's what Michael O'Grady recommended, that we hire a company other than GPO who could do really snappy nice graphics.

DR. BAUMEISTER: Because GPO had the colors overlapped.

VICE CHAIR MCLAUGHLIN: Exactly. That we have that company do the focus groups and everything else and make sure it's legible and attractive and it captures people.

PARTICIPANT: But the question for me is what is the difference in the content in these two documents? Can you describe it?

VICE CHAIR MCLAUGHLIN: It's a lot. First of all, we picked different facts to highlight. Second, that has a lot of the facts presented in graphical form or bar graph form so that you see the whole range of numbers.

DR. BAUMEISTER: But are they the same facts?

VICE CHAIR MCLAUGHLIN: No. That's what I'm saying. They come from the same 50-page document, right? But we selected some different facts and because that has the graphs and bar graphs, etc., taking up a lot of the space, it doesn't just pick out one number or two numbers. It gives you all the numbers and the ages or whatever so that if you want, you get more numbers. Then it has text boxes where it gives you factoids.

DR. BAUMEISTER: Can't you just adjust them so the numbers are the same?


DR. BAUMEISTER: I mean, look at one and if they don't match, just make them match. What's so difficult about that? Turn bullets into the pictures and say, "Here's two ways that we are going to reach out to you."

VICE CHAIR MCLAUGHLIN: The bullets can become like the text boxes but it can't become like the graphs. The bullets can become like a text box or vice versa. Here.

DR. BAUMEISTER: You may not want to come back here.

VICE CHAIR MCLAUGHLIN: I actually think we ought to talk about the actual content of this one. I basically have given up, thrown in the towel. Right? Let's feed the lion and make sure this is accurate. Some people weren't happy about some of the content and had comments. Right? Then there's the issue should we do this at all or should we just wait for the focus group?

MR. GROB: The answer to that, if I could again offer, was that I think Tish said she wanted to make sure that we were comfortable with the content. If you wait for the focus group, you'll have their comments and you'll still have this document. Their comments will be of a general nature. If there are things that are troubling here --

VICE CHAIR MCLAUGHLIN: So far, just to recap for you, we have made the decision to move, "There are big problems that need new thinking," that whole section to the end of the report and to keep it cost, quality, and access so that it's in the same order as the big report, not to change the order of the issues.

And to ask the staff to change the language from implying that those are the three components of the system and instead make it clear these are three issues that we are addressing and giving people information about because they need attention. Right?

Then we also had language about how it all fits together, some positive examples, not just negative examples of how they interrelate. We removed Pat story. It's staying within the context of this document. We know longer are going to change this to an executive summary. We are not going to change the language.

We are not going to make it Robert Pear, another language. We are going to keep it middle school language level and we are going to keep it as a participant's guide that starts off, "You're invited," as opposed to the more executive summary of the facts. I think that's where we've ended up.

MS. BAZOS: But why have you dismissed that?

VICE CHAIR MCLAUGHLIN: Just being realistic. It's just not going to happen. Maybe it will happen in a few months but it's not going to happen.

MS. BAZOS: These are the only graphs that are going to go in?

MR. GROB: We don't know.

VICE CHAIR MCLAUGHLIN: But to keep it short, there can't be many more graphs.

MS. BAZOS: You know, the 10 pages is an arbitrary thing.

VICE CHAIR MCLAUGHLIN: But I think it's the reality, Dottie, that people aren't going to read much more than 10 pages. Right? Deb and I talked about this. We don't think they are even going to read these 10 pages. Pat was saying she's not going to show this to her constituents. They won't read it either. I think it is betwixt and between.

PARTICIPANT: They will read the 50-page report because that is the very nature of what they do.

VICE CHAIR MCLAUGHLIN: Exactly. This one the language level is insulting to a certain group. The way it's presented is not engaging enough for the people who have a 6th grade reading level. That's what Rosy was saying.

None of the people she's talking to at a 6th grade reading level are going to read this. With all due respect, I just don't think -- I understand why this was done and everything else but I don't think it's going to be useful for either audience but that's just me. Let's move on.


MR. ROCK: I had another thought to throw into this mix. You could actually use this document without characterizing it with a title as such. You could actually -- I was just looking at the beginning of this again.

Actually just have at the beginning of it and say, "An invitation to the citizens of the United States." That could be the introduction. And then what follows in a sense is kind of like this is a way to help you start thinking and get into it a little bit without having to say all this.

You basically are giving people 10 pages as a place that they start. You could even think of it, if you did that, that it's something that is for the press kit if it's more palatable that way to think of it in those terms.

That makes sense because why are we here? In other words, what is the press event about? They are kicking us off or getting us started. Then we give you the escape of is it an executive summary, is it a report in brief, or is it an X, Y, Z kind of thing.

DR. BAUMEISTER: If you did that, wouldn't you take it out of second person and quit talking about you and talk about citizens or people or my beloved or whatever rather than say, "To become part of...citizens like you..." Knock that out. "...get to tell what you like, they like, and don't like. We hope citizens will be a part of..." "That's why it's not another one of those," etc. "Citizens need to take part because as consumers they..." That would make it more -- I don't know.

PARTICIPANT: Is October 6th start the dialogue day?


PARTICIPANT: So can this be the invitation to start the dialogue?

MS. BERNSTEIN: A sidebar down here that emerged was -- it happened at lunch, too, is you are trying to do two different things in this document which I think is part of the problem. Doing this call to action and PR, engage the people, get them all excited thing.

We are doing, "Here are the basic facts about the health care system that 6th graders should be able to understand" thing. I was wondering if they could be two separate pamphlets? Basically you've got your call to action in the front of the folder and right behind it for anybody you want to give this to in your family here's a thing that maybe it will be helpful. You can cross reference them somehow.

You could say, "In the pamphlet we've got a little folder attached that gives you some of the basic facts that we'll be talking about at the community meetings." All the PR stuff that Edelman is good at is in the Edelman thing which is the call to action. This is the first time in the history of the universe that we ever talked about health reform or anybody has asked your opinion. The second part is, "Here are the basic facts about the health care system."

VICE CHAIR MCLAUGHLIN: We'll have the lies and the facts. I'm being facetious.

MS. BERNSTEIN: I'm clearly pretty good at that myself. Part of the problem is that when you mix the two things, that's when we get uncomfortable. Basically in the long report we came to the conclusion that Edelman couldn't deal with the inside chapters very well because every time they dummied it down they made it wrong. We spent endless hours going back and forth in the middle chapters which weren't the problem chapters.


MS. BERNSTEIN: The problems were the beginning and the end which is the Edelman stuff.


MS. BERNSTEIN: What I'm thinking is, at least in the stuff for the average people, we need to separate them a little bit more. I don't know if that will work either. I don't think it's hard to do. They clearly have been written by different animals anyhow if you look at the reports, especially the long report. The front and back don't match the middle and that happened for the last three iterations.

MS. BAZOS: That's an excellent insight because one of the things that I really did not like about this is it's just issues and it doesn't -- you take out these creative solutions and put them in the back in an appendix and we have to talk about those. I don't think the questions are at 6th grade level. We've got to talk about those. The rest of it is pretty thin.

VICE CHAIR MCLAUGHLIN: It is really thin.

MS. BAZOS: It's really thin. I'm trying in my mind to compare it to what you did here. I think the difference that Catherine is trying to articulate with this and why she's married to this is because you really do get a better sense of the story very quickly. Although I would say it's a little hard to tell which box to go to first or second, you know, with all due respect.

VICE CHAIR MCLAUGHLIN: Ecosystem. Lilly pods.

MS. BAZOS: If we were to think about what Jill said, if we were to take the Edelman call to action and we had a call to action, three-pager, two-pager, whatever it took, there is a big problem. And then we had a document and we did -- Catherine, could you -- I'm going to end this because I'm tired but could you take this and this and could we develop something for citizens using both together?

VICE CHAIR MCLAUGHLIN: I agree with Chris. I think this is a waste of our time. I think we made be able to talk about this down the line, down the lane in the future, whatever the express is. Right now I think we have to talk about whatever is going to go in the packet.

I think we can talk about separating this into a primer written at the 6th grade level and then take out the front and the back and make it the call to action but then it's not really a participant's guide anymore. I think the reason why they did this is they were mimicking what George and I saw in Maine which was a participant's guide which had a lot of facts about the situation in Maine followed by the very specific questions that they designed that day to address.

MS. BAZOS: It was very different.

VICE CHAIR MCLAUGHLIN: Exactly. This is trying to do that but we're not setting up a five-hour day and we're trying to describe a lot more. I think that is where they got this idea of merging the two. I don't know whether they'll work separate. As Chris has pointed out, I'm not the PR expert. I don't know whether they'll work as two separate documents. I think about what Therese says, you know, going out to Randy's constituency and going out to whatever.

MS. BERNSTEIN: But when we actually do these meetings there really will be something, a guide or a piece of -- a packet of paper --

VICE CHAIR MCLAUGHLIN: For the 10 meetings.

MS. BERNSTEIN: -- for the meetings. That's a participant's guide.

VICE CHAIR MCLAUGHLIN: Right. My guess is that you thought it was going to be adjusted to this.

MR. GROB: I never liked the title. Again, I'll give you my opinion. I never liked calling it a participant's guide. I just thought that it was a document that would speak to a broad audience. I thought that narrowed it too much and I would take that off and give it some other title.

MS. TAPLIN: But I do think it was our intent to give it to the people developing the participant's guide as raw material for that.

MR. GROB: Right. It would save a step because it would have to go through this process. Again, I just would like to make this comment. Any attempt at this point to start from scratch to develop some other document simply cannot be done.

There are no hours left. Tomorrow we will be engaged in a meeting. That will end at 2:30. We have staff that can work at something but if I were to write to you now a three-page document, a two-page document, a 10-page document, I would have to vet it with all of you. You would not like many of the phrases that I use.

We would then sit around and once again say, "Why did you pick this fact rather than that fact? Why did you put this first rather than second?" We would all be then meeting until midnight having a meeting on that three-page document instead of this document. The clock is simply out on this.

The idea of original writing right now, there isn't anybody who has any time to do original writing while we simultaneously try to get this through the vetting process. It just isn't possible. The question that I was asked is what can be done by October 6th? We ended up here. That was an answer that I gave that could be done.

MS. MARYLAND: We take this document and add a little bit more substance to it.

MR. GROB: I think the idea would be if someone now could suggest what that would be, we could go through this and say what the content was that we wanted. Yes, we can do a little bit of that because Jill and Craig are here. They can work tomorrow on this and the other report.

VICE CHAIR MCLAUGHLIN: I'm not sure why you want more substance to this.

MS. MARYLAND: It won't be any prettier.

VICE CHAIR MCLAUGHLIN: I guess, Pat, the reason I'm saying that goes back to what I said five minutes ago. If it's going to go to something other than the middle school level, then this is the thing Frank pointed out. The language isn't right. If the language is the 6th grade level, then this is already too long. It already has too much in it.

It should be cut, I think, by quite a bit. If we are going to make it more substantial, then the language has to change. George is right, we don't have time. It's just one of those unfortunate things that what has happened in the last month has led to a product that some of us aren't happy about but now it's too late is what we're hearing. It's too late.

MS. MARYLAND: Call it something else then.

MR. GROB: I would call it something else.

VICE CHAIR MCLAUGHLIN: Call it something else.

MS. MARYLAND: Yes, please.

MR. GROB: A call to action. That makes sense to me.

MS. MARYLAND: Invitation to the citizens of this country. Let's call it something that is not a report.

MR. GROB: Yeah, I would agree.

VICE CHAIR MCLAUGHLIN: No, it's not a report.

MR. GROB: An invitation. We have to work on a phrase like that, an invitation, because that is what it is. It is an invitation.

MS. MARYLAND: I guess can we at least come to some agreement that we call it something else and it will be acceptable with the modifications that were recommended?

VICE CHAIR MCLAUGHLIN: Were there other modifications?

MS. MARYLAND: Well, the movement of the one section.


MS. MARYLAND: The movement of the one section.

MR. GROB: I've been taking notes of the changes you were talking about. Those are easy to make.

VICE CHAIR MCLAUGHLIN: So the key facts. Do people think those are the key facts? Were there specifics that people wanted to talk about?

PARTICIPANT: None of us have read it.

VICE CHAIR MCLAUGHLIN: It's just the same, I think.

George, what's changed besides the addition of those three sentences on page 4?

MR. GROB: The wording before the change you can see for yourself what they were. They were more to --

VICE CHAIR MCLAUGHLIN: What about the key facts? Are they all the same?

MR. GROB: As far as I know. I did correct one or two that you suggested but other than that I did not attempt to change any key facts.

VICE CHAIR MCLAUGHLIN: So the key facts are the same.

MR. GROB: Right.

VICE CHAIR MCLAUGHLIN: Page 4 you added three sentences.

MR. GROB: Yes.

VICE CHAIR MCLAUGHLIN: All right. Then the questions are different. Is that it?

MR. GROB: Yes.

PARTICIPANT: Are the questions different?

MR. GROB: The wording of some of the questions as reported that Senator Wyden had suggested to bring them more down to earth.

VICE CHAIR MCLAUGHLIN: Is that the what's important? Oh, no. The questions that begin on page 10.

MR. GROB: I think it doesn't matter in the sense that you either like the questions or you don't. I can figure that out.

MS. STEHR: I can tell you which ones.


MS. STEHR: The one that jumps out at me page 10 in the new report under cost. "Health care benefits are now tax free to workers under an employer plan. Do you believe this should be changed so as to create an incentive for everyone to try to contain cost while promoting personal responsibility?"

I don't like the language of that at all. It's horrible. I think the original line, "Should some or all of the health insurance premiums that employers pay for their employees be considered income and be subject to federal taxes?" That question sounds better because this one is like suggesting that's what has to be done. I do not like the question.

MR. GROB: Which one?

MS. STEHR: The second one.

VICE CHAIR MCLAUGHLIN: It's also mixing two things. It's mixing two things. This question on page 10 was not in the old one. It didn't say anything about personal responsibility. It didn't say anything about containing cost.

MR. GROB: So let me make sure I get the notes. So on page 10 the question -- which question again?

DR. BAUMEISTER: No. 2 under cost.

MR. GROB: Okay.

PARTICIPANT: You are absolutely right. That is not an answerable questions.

MS. BAZOS: I have a suggestion. I would just like to say this. I just think proposing these questions at this point just like writing a new document is going to be impossible. I don't think we are going to agree on the questions. I would like to take them out. I would like to say that, "We are legislated to focus on four questions. These are the big four questions. We will be developing questions after that and you'll get them when we have a community meeting."

VICE CHAIR MCLAUGHLIN: That is one approach that I brought up an hour and a half ago saying at a minimum -- as Therese correctly pointed out, we are not required to include any questions at all in any of these reports. I think we all agree now that I don't think this is a report. That is what Pat stated quite strongly.

This is not a report. It's not a report in brief. It's not a short report. It's not a report. A report doesn't say, "We need you." I mean, that's what Uncle Sam says, "We need you." Okay. That's just not what this is. We are statute free on this. There's nothing telling us what has to be in it. We're not required to include anything in this. We are totally free to decide and the same with the questions. I agree with you, Dottie, we can decide whether or not we want to ask any questions and if we do, what kinds of questions. Now, the PR aspect of this, which George talked about and Tish talked about this morning, the PR is saying, "We want your involvement."

Certainly on the website they wanted questions then after this press event for people to be able to go on the website and there's questions ready for them to answer. Before we have questions on the website that people are going to answer, it's possible that in this all we have to say is, "We've been instructed by the statute to ask people the following four questions. Please go to our website to see some of the ways we are trying to get input from you on those four general questions." That is one strategy.

PARTICIPANT: Do we ask them to suggest questions?

DR. BAUMEISTER: I think the level at which this document is written is a much more -- what do I want to say? The questions are more complex.

VICE CHAIR MCLAUGHLIN: They are not 6th grade level. That's for damn sure.

DR. BAUMEISTER: The document is written simplistically and the questions are written by a Ph.D. economist that have conferences.

VICE CHAIR MCLAUGHLIN: How much of the Government promo on paper. I mean, that is something that there are Ph.D.s all over trying to talk about that. Is it a public good? What are the externalities? These are very complicated questions.

MS. MARYLAND: I think the four questions we should have in there. The basic four questions I think should be there.

DR. BAUMEISTER: In the legislative.

MS. MARYLAND: Yes. And no more than that.

MR. GROB: Could I make a slight change to that? If you want to go that way, what I would recommend would be to ask those four questions and then to ask the last three that are on here as well.

MS. BAZOS: Those are the general ones. And on that day for the web if we haven't vetted the questions by then, George, we could have those three on the web to begin with.

DR. BAUMEISTER: The basic four and the added three. Seven is a lucky number.

VICE CHAIR MCLAUGHLIN: Do we have agreement on that?

ALL: Yes.


MR. ROCK: Could I just confirm something you're all saying?


MR. ROCK: Are you all agreeing on that second half of what Dottie said that it has implications for the web and what neighborhood America is doing for us. Do we put the four questions on law and those last three on the web as well?

MR. GROB: My view is that everyone has said when we start deciding what questions we ask we are getting into some pretty heavy dealings among ourselves. If we don't have the opportunity to have that kind of dealing or comfort level, then I think it does drive you where you're suggesting. Again, those four questions --

MR. ROCK: Until we have that conversation.

MR. GROB: Exactly. That's correct.

PARTICIPANT: We are going to put the same thing on the big report?

MR. GROB: Yes, I think they should be the same.

PARTICIPANT: And on the slide show.

VICE CHAIR MCLAUGHLIN: What about the key facts? Are people okay with the key facts? These are the ones that were not changed.

PARTICIPANT: Can we change the ones that are wrong?

VICE CHAIR MCLAUGHLIN: Yes, we can certainly change the ones that are wrong. Supposedly these are ones that some of you already looked at on the plane.

PARTICIPANT: But they didn't make all the changes.

MR. GROB: There should be to the extent that any of the facts that are inconsistent with the report, they should be corrected.

PARTICIPANT: There are a couple of things that didn't get -- I mean, you sent notes how to correct them and they corrected them but they are not correct.

MR. GROB: They can be fixed easily. They should be totally compatible.

DR. BAUMEISTER: We had already decided somehow or another that cost would be listed first. Is that right? Rather than access.

VICE CHAIR MCLAUGHLIN: Also, I mean, there are certain wording things. This gets to the point that Jill said. You can't expect Kristen, who has never worked on health before in her life apparently, to understand the nuances. As she tried to make this language friendlier, she loses some of it.

An example is page 6, the third point, that says, "Older Americans use more health care than younger people. During the first half of your life you might spend only about one-fifth of the money." You may spend nothing or you may spend 100 percent. It all depends on what your insurance is and everything else. Again, it sounds like a pedantic difference but as it's currently stated it's wrong.

MR. GROB: Can you help me find that again?

VICE CHAIR MCLAUGHLIN: Jill and I have worked through this language so many times, George. I'm sorry to sound impatient but we keep explaining to people that it may be the cost of the care you received or the expenses incurred because of but it's not what you as an individual spend.

MR. GROB: It should be corrected.

DR. BAUMEISTER: Does it have to be in there at all?

VICE CHAIR MCLAUGHLIN: I don't know, Frank. I'm just saying somebody said -- Montye said to me, "Catherine, did you find things?" I was using this as an example, "Yes, I found things in here that because of wording changes they are no longer accurate."

MS. HUGHES: Is it my turn?


MS. HUGHES: I would like to say that this should be in there because it says -- otherwise, if focuses on those of us who have chronic conditions and that really is totally unfair. I mean, it really is totally unfair. The bullet, the second bullet, it says, "Managing these illnesses can be expensive." Let's get real. It is expensive. It is expensive.

VICE CHAIR MCLAUGHLIN: No, it's not always. I mean, I'm allergic to cats. Managing that chronic illness is not expensive.

DR. BAUMEISTER: Couldn't it be rewritten, though, so it's not quite so damning to old people and people with chronic diseases?

MS. HUGHES: I would like it rewritten but I think we need to have some balance because if you only have the first two parts, then, you know, those of us --

MR. GROB: My suggestion on handling that, because I was thinking about that, is that we all use -- we all use more care when -- we don't all but to put it in we as opposed to those old people.

VICE CHAIR MCLAUGHLIN: Those old people.

MR. GROB: I think that's what the objection is, that we are somehow --

DR. BAUMEISTER: Yeah. I mean, it says nothing about crack babies. Crack babies are quite young and they cost a lot of money.

VICE CHAIR MCLAUGHLIN: We have some language in the big report and why it was not followed here is a mystery to me.

DR. BAUMEISTER: I don't know why it was left there.

VICE CHAIR MCLAUGHLIN: I think, Frank, the original purpose of it, right? The original purpose of having that kind of information in the report back in Salt Lake City days was -- the way we tried to phrase it was to try to say, "We are all in this together."

DR. BAUMEISTER: It can be written better than that then.

VICE CHAIR MCLAUGHLIN: That's how we originally had it. We all are going to use health care at some point. We are all going to dip into the well at some point. We are all going to count on that pool of money that all of us contribute to sometime in our life. That is exactly how we had it written.

MS. STEHR: It also came out of the language in the law that talked about --

VICE CHAIR MCLAUGHLIN: Exactly. Some of the things we were required to have in the official report which this is not. We don't have to have it in this report.

MR. GROB: Are you saying in your big report you do have the wording of this?

VICE CHAIR MCLAUGHLIN: We did. God knows what it is now but we did.

MS. STEHR: I really can't cancel it that easy without hurting our credibility.

DR. BAUMEISTER: What's the word to use, the alternative wording there?

MS. STEHR: "At different periods in our lives we need more or less medical care. Both the cost of the care we receive and our ability to pay for it changes over the course of our lives. Young adults ages 19 to 39 are less likely..." Is that the one? That was what I started reading. "... are less likely to have insurance whereas young children and the elderly are more likely to be covered in part because of access to public insurance. Many factors includes both the health care expenses for a family as well as the insurance coverage they have for those expenses."

VICE CHAIR MCLAUGHLIN: So that's the coverage but the beginning waxes and wanes.

MR. GROB: To me this is simple. Jill and her magic will find the appropriate language and insert it here.

DR. BAUMEISTER: This kind of points fingers at old people and chronically ill people. We're all in it together.

VICE CHAIR MCLAUGHLIN: That's how our original thing is written, we are all in this together.

MS. BERNSTEIN: Catherine, the other point we are trying to make it got mixed up. One is we are all in it together. The other is most of our health care money is actually spent on people who are actually sick.

VICE CHAIR MCLAUGHLIN: I know, and need it.

MS. BERNSTEIN: And need it which is what you need to understand when you start to talk about consumer-driven health care.


MS. BERNSTEIN: Actually putting the burden on individuals who are sick is probably not a good idea. That got lost.

MS. HUGHES: Can we go to page 7?

DR. BAUMEISTER: We're not through with 6.

MS. HUGHES: That's what I'm asking.

DR. BAUMEISTER: We're talking about lifestyle decisions. We don't mention booze. We don't mention smoking. We don't mention substance abuse. We don't mention any of the others.

VICE CHAIR MCLAUGHLIN: We just say obesity and exercise.

DR. BAUMEISTER: We talk about obesity.


MS. BERNSTEIN: It would be easy to put in about substance abuse, smoking, lots of other things that also affect our health if that's what people want.

MR. GROB: Your choice is either to broaden it out or to eliminate it. Either broaden it out to other risky things. I think it should be broadened out. I don't like the idea of picking on the obese.

VICE CHAIR MCLAUGHLIN: You know the one that is just by orders of magnitude more expensive than any of the others is drunk driving. Much more expensive than alcohol, plain alcohol consumption, tons more expensive than obesity, tons more expensive than smoking because, I hate to say it, smokers die so young that they end up saving us money because they don't collect social security and Medicare and pensions.

I'm sorry but that's just the statistical thing. We are hoping you're not in that category but that's a statistical thing. The one that ends up being unbelievably expensive for society is drunk driving and that is because they kill innocent people.

MS. BAZOS: It might be nice if we said our lifestyle decisions affect cost and quality of life.

MS. HUGHES: And then use drunk driving.

MS. BAZOS: It does affect your quality of life and the literature does say that.

DR. BAUMEISTER: Lifestyle decisions affect our health and, consequently, the cost of health care.

MS. CONLAN: Remember how you wanted something to balance the negative in terms of the system?

VICE CHAIR MCLAUGHLIN: Don't call on us.

MS. CONLAN: If we're going to say lifestyle decisions affect cost and quality of life, can we balance out those poor people with chronic diseases who can save money by --



VICE CHAIR MCLAUGHLIN: We've lost it down here, Montye. Don't count on us to be upbeat.

MS. CONLAN: -- managing their disease through things like exercise and all of that?

MS. BAZOS: The only thing, Montye, about saying that, I'll tell you, is in the 1970s the Canadian Minister looked at why people were dying in his country and decided that a lot of reasons people were dying were for preventable reasons. In the 1970s if you go back and look at what happened is we got these books about jogging and books about exercises. All the focus about saving cost and improving health the onus was put on the individual.

I'm not saying the individual shouldn't participate and get some skin in the game, but later research has really shown that what you can do about your -- what all of us can do about our health habits is influenced by our social environment and physical environment where we live. It's not as simple as saying to someone, "Get out and exercise." Maybe I'm 70 years old and I can't walk around the block because I'm afraid of violence.

VICE CHAIR MCLAUGHLIN: Exactly. You go outside your door and you might be shot.

MS. BAZOS: You might be shot. Maybe you can manage your health care because you can read. I'm just saying that it's just not that simple and I want to be really careful about our language that we don't go back to pointing the finger at individuals like it's their fault, it's their responsibility. It's like cost shifting. This is just blame shifting.

MS. HUGHES: That's right. I agree.

MR. GROB: The think the idea here is to eliminate or go for broaden.

PARTICIPANT: It's both but which one to do?

MR. GROB: I think people said broaden.

PARTICIPANT: I think it should be broadened. Drunk driving. Let's get the drunk drivers.

MS. WRIGHT: And also change because it says this means they are at a higher risk? They could be at a higher risk.

MR. GROB: That's fine.

MS. MARYLAND: Could I ask the chair, we were to close by 4:00 today so it's 4:00.


MS. MARYLAND: Do we want to come to some conclusion about the report?


MS. MARYLAND: Can we see the webpage because that would be a nice uplifting --

VICE CHAIR MCLAUGHLIN: See how positive I'm being? Yes. Yes. Andy, can you go to the website now? As he's doing that, I think it's incumbent upon each of us to send an e-mail to George, and it can be copied to everybody, if on the way home or tonight or tomorrow you see a key fact or something that you really find inappropriate, inaccurate, misleading, chime in, but basically what we've done is reorder that one piece.

We want some cautionary language added -- the three sentences aren't quite enough for me -- about those different options. We ask for additional language from staff on a couple of key pieces. We have asked for some facts to be changed. We want this to be called something other than report, report in brief.

MR. GROB: It will be an invitation to something.

VICE CHAIR MCLAUGHLIN: It's going to be designed as something else. We want the questions taken out and have four plus three, right?

PARTICIPANT: So we are taking out cost, quality, and access.

VICE CHAIR MCLAUGHLIN: We're taking out the questions at the end and we're just having the four plus three questions. We understand that this is going to become our middle school level reaching out to people about who we are and what we're doing.

PARTICIPANT: First draft.


MR. GROB: It's going to be ready on October 6th.

VICE CHAIR MCLAUGHLIN: I don't think it's a first draft.

MR. GROB: The other documents we use for meetings, for other things, for other purposes.

MS. BAZOS: We also decided to take out Pat's story.


PARTICIPANT: All stories.

VICE CHAIR MCLAUGHLIN: We're taking out all stories. Once we decided what the purpose of this was, we voted to take out all stories.

MS. BAZOS: The stories go out. We are not calling it a participant's guide so the first bullet goes out. We'll have to rewrite that section. Please join in. What are we doing with -- what are we doing with the "here is the big problem" thing? We moved it to the end but we never talked about the content of that.

MS. HUGHES: I think the suggestion should be to forward it to George.

VICE CHAIR MCLAUGHLIN: I agree. In particular given that we are going to be seeing responses from the focus group and we'll see whether they have anything on the problems, the ideas, but I think there is some language that is consistent with Richard's and my concerns on the big report and the language for that that we'll share. We're all going to see another version of this tomorrow night or whatever.

MR. GROB: The schedule would be --

VICE CHAIR MCLAUGHLIN: Because we get the focus group response at noon tomorrow or --

MR. GROB: We'll all be meeting for the big event tomorrow. Right?


MR. GROB: But Jill and Craig will be behind the scenes.

VICE CHAIR MCLAUGHLIN: At noon tomorrow you get the focus group stuff and then we have until next Wednesday to look at our they incorporated those comments and get specific feedback. Basically we are doing this style. Also in the packet is going to be the website. The only thing that we are going to hand out to them is this --

MR. GROB: Hand out to them?

VICE CHAIR MCLAUGHLIN: We are not going to give them a report. We are just going to give them this.

MR. GROB: That's correct.

MS. HUGHES: And the executive summary.


MS. HUGHES: Oh, the big report?

PARTICIPANT: No there's going to be a press conference.

MR. GROB: Well, I said I could. We can ask about that. The times they are a changing. I talked to Kevin Murray and no one does that anymore. The people like the report but they would just rather go to the web. Don't bother me with all that paper. It's a different day today. He said all you really need --

MS. HUGHES: A lot of them that I've seen they just do a summary.

MR. GROB: He said, "Look, don't waste your money. Just print a brochure, trifold.

VICE CHAIR MCLAUGHLIN: Okay. Any, are you ready?

MS. TAPLIN: Can I ask one just to make absolutely clear that in terms of the questions that are in this report, the long report, on the web and --

VICE CHAIR MCLAUGHLIN: Right. Those questions are no longer in there.

MS. TAPLIN: Right. The only questions and they are the same in -- oh, in the slide show, and all four things are the four and three.


PARTICIPANT: In the big report?

MS. HUGHES: The big report as well.

VICE CHAIR MCLAUGHLIN: It's four and three.

MS. HUGHES: Four and three.

VICE CHAIR MCLAUGHLIN: In this to-be-named document four and three.

MS. HUGHES: Website?

VICE CHAIR MCLAUGHLIN: As of now on the website four and three. We haven't even started talking about this list of questions you gave us. Slide show, four and three.

MS. TAPLIN: I just wanted to be clear.


MS. TAPLIN: Eventually there will be four more on the website.

VICE CHAIR MCLAUGHLIN: Four more on the website.

PARTICIPANT: And at the community meeting.

VICE CHAIR MCLAUGHLIN: One of the things that we talked about at community meetings is do we want the same questions as the focal point for the community meeting or do we want to target?

MS. HUGHES: No, we want to target.

VICE CHAIR MCLAUGHLIN: That was one of the things we talked about ages ago. Okay.

PARTICIPANT: Nice website effect.

WEBSITE: There are some serious problems in our health care systems that need your attention. The President and Congress have asked the Citizens' Health Care Working Group to make recommendations that will result in health care that works for all Americans.

We face some tough choices. What health care benefits and services should be provided? How do Americans want health care delivered? How should health care be financed? What tradeoffs are we willing to make in how we pay for the services we want, how those services reach us, and how we give high quality care? There has been enough talk about the problems. Now is the time for action. To help make health care work for all Americans, we need to hear from you.

Your input will be used to prepare a citizens' roadmap that the President will respond to and that Congress will hold hearings on. Help us find solutions that will lead to health care that works for all Americans. Make your voice and your preferences known.


PARTICIPANT: Let's go some place. Take us on a little tour.

MR. ROCK: This is where the report will be. It's blank right now so we won't go there. This is whatever we call the next document.

PARTICIPANT: Let's skip the report stuff.

MR. ROCK: The slide show they were actually able to put up, the one that you saw. Loading is an issue, PowerPoints and things. Fifty-five slides is a big document.

VICE CHAIR MCLAUGHLIN: Doesn't the Health Report to the American People have to be the 50-pager, not the slide show?

PARTICIPANT: That's not called the Health Report to the American people.

VICE CHAIR MCLAUGHLIN: Oh, I thought he clicked on the Health Report to the American People.

PARTICIPANT: He clicked on slide show.


MR. ROCK: Those are the slides. You have to run it yourself once it comes up the way it is right now. We won't go through all 55 of those. It's the same show that you saw. It needs to be shorter if we do it there. That was the one about health care. Then we actually have the webcast that was done in Boston.

DR. BAUMEISTER: Is there any way we can delete that?

MS. MARYLAND: I had to leave for that.

PARTICIPANT: It's too long.

MS. MARYLAND: Oh, is it controversial?

MR. ROCK: Some of these went out after I actually was leaving for the plane.

(Phone ringing.)

VICE CHAIR MCLAUGHLIN: Oh, an interesting citizen is calling.

MR. ROCK: It's probably Randy.

MS. FEDERER: Speaking of people participating, tomorrow we will have representatives from the Association of Health Care Journalists and four of the local TV stations have it on their books to attend. Just so you will know while this is loading, we will have more people hopefully watching us tomorrow.

MR. ROCK: We have to come back to that because it's not working right now.

MS. BAZOS: Location of meetings. That could be a map Catherine said. This is all changeable internally.

PARTICIPANT: It would be nice as a map.

MS. BAZOS: We can put red blinking lights on where we are today and where we're going, blue for tomorrow.

MR. ROCK: This is Dottie's slide.

MS. BAZOS: That's my slide?

MR. ROCK: I don't know why this is coming up so big here. We'll leave that up there is you will agree with everything else, Dottie.

MS. BAZOS: You can't buy me off that easily. George, if you offered me ice cream I might consider it.

MR. ROCK: It's not the right size. I'm not sure why it's so large. Upcoming events. We have to populate these things.

VICE CHAIR MCLAUGHLIN: Fill in things. Anything that exist just fill them in.

MR. ROCK: Press kit. These things are also have to be filled in. This is the media center. Then this is where we put things about the meetings and the hearings we've had under the resources category as well as other things. Kind of a reading room for people looking for Federal Registers, agendas.

MR. GROB: What was that topic list, Andy? The one that was right above that.

MR. ROCK: Resources?

MR. GROB: Yes.

MR. ROCK: Topic index. This is a preliminary, you know, taking things we've done and then grouping.

MR. GROB: And then you can click on every one of them and then it brings up a PowerPoint show?

MR. ROCK: Yes.

MR. GROB: That is really good, Andy.


MR. ROCK: Again, I'll have to see whether they fit inside the screen. They do.

MR. GROB: That's really excellent. Excellent. There's a lot of information already there. That really is excellent.

MS. BAZOS: You know the difference in that really, George, really is that in this there is no more information in here than the other one but this one because it's a story you don't have to account for everything that is missing. I know we can't go anywhere but I just wanted -- I've been trying to grapple with why am I more satisfied with this.

MR. GROB: Because there are different people in the room. Some people like a implies b, b implies c, a is true, therefore, c is true. Other people like to say, "Let's talk. This is what I value more important. Could we talk?" People are simply different so some people will relate to that and other people will relate to the bullets because we are all different.

I'll repeat there are none of us in this room who haven't felt warm to what Catherine has tried to do. I'll repeat, there are none of us in this room who haven't felt warm to what Catherine has tried to do. We hope it will be successful. There are other people who prefer to talk like this so we'll do what we can now and do more later.

MS. BAZOS: I would feel better, though, if we could make a commitment to put something together like this for those people who prefer it. Can we make a commitment to do that?

MR. GROB: I think we can but not by October 6th.

MS. BAZOS: No. I agree.

DR. BAUMEISTER: For the community meetings, you mean?


MR. GROB: Sure. I think many of us are strongly committed to that.

MR. ROCK: Keep me informed of the time and place for divisions and organizations. Basically these are listservs and we are trying to make them simple. Tell a friend would be to get your e-mail address and friend's name. Then this box needs to be bigger.

We actually did this as a preliminary thing. Start writing the note so they could change it and then they could just go ahead and send it as an easy way to pass it on. The logo on all these actually takes you home. It takes you to the home page by clicking the logo. Then we have the public comment section.

PARTICIPANT: It worked yesterday.

MR. ROCK: Yes, it worked yesterday. They may be making modifications on it.

MR. GROB: What does it do?

MR. ROCK: It takes you to the questionnaire. It will take you to the seven questions.

MR. GROB: Actually for those you could just have seven buttons to choose. You said earlier some people will answer one question.

MR. ROCK: This is actually attached to our current website. It's not live now. Technically it is live but it's under demo so you don't know it's there and you won't go looking for it. This gives you two options here, CDC database of stuff by state.

PARTICIPANT: Andy, why are there three colors?

MR. ROCK: Why are there three colors? Good question. I don't know.


PARTICIPANT: Each, central, west.

PARTICIPANT: But it's not time zones?

PARTICIPANT: No, it's not time zones.

MR. ROCK: Good question. I don't know the answer to that.

PARTICIPANT: That would be interesting to find out.

MR. ROCK: Then you have a link to the state health facts which is Kaiser who did an interface page for us that we still have on our site. It has the states. It has a lot of data. Lots of individual facts, teen birth rate. All of these windows you just close out the window and you're back. Well, it was supposed to go back.

MS. BAZOS: Actually, the slide show people are saying it's a little long. It's a good educational tool but you might want to think about, George, is to shorten it.

MR. GROB: Yes, I could do that.

MS. BAZOS: A short one for download but a long one for -- you know, some people would learn through --

MR. GROB: I just feel that we are --

PARTICIPANT: That's not true.

MR. GROB: -- going to be engaged for another --

VICE CHAIR MCLAUGHLIN: I think we're finished. Thank you very much, Andy. Thank you, Don, for your wonderful stewardship of this project. You and Andy made a great team and we are very grateful to you for it.

MS. FEDERER: And when it's live use the Tell a Friend feature. Everybody use the Tell a Friend feature when this website goes live.

VICE CHAIR MCLAUGHLIN: My daughter will send it to every one of her friends.

MS. FEDERER: Yes, in 7th grade. You click on Tell a Friend and a box will pop up where you can put in anybody's e-mail address and it will be from you to whoever you send it to and you can type in, "I thought you might want to check out this website." You can send it to whoever you want.

(Whereupon, the meeting was adjourned.)