time once again for community form and we're very lucky to have with us live in the studio this morning dory now story is the cord needing director of the northwest atlanta marine alliance prior to joining the alliance she served as the  interim chief operations officer for the healthy building network she serves on the executive committee of the national family farm coalition and granite state fish and is a former advisor to harvard's medical school center for health and global environment for fisheries articles appear regularly in the fisherman's voice and as well as a range of other publications and she is the keynote speaker at tonight's community alliance for global justice annual dinner taking place at university christian church you know as a thank you very much for coming in and spending time with us this morning thank you good morning it's great to be here thanks for having me start out tell us about your organization the northwest at atlantic marine alliance certain northwest atlantic marine alliance has been around for about eighteen years and the purpose of the organization of us to explore new ways of managing fisheries and organizing fisherman we felt that the old ways were in working we were losing ecosystems integrity we were losing coastal communities fisheries management had become and it still is a very top down approach to managing our fisheries and taking care of our ocean and on top of that at this mess is the fact that small scale medium scale community based fisherman have an ecological role to play while feeding us at the same time and so we felt it was a it was time to change that dynamic it was time to introduce a new way of organizing in fishing communities it was time to shake up the fishery management process and so we began to work in fishing communities at the time novel was actually created i worked for greenpeace as a fish fisheries and oceans campaigner so i watched the development of the organization over the span of years and when the position came up to be the coordinating director it seemed like the right place for me to be and stepped right in found ourselves in the midst of working with communities all over the world at this point on policy alternatives that support small scale medium scale family owned fishing operations that have the smallest ecological footprint and market opportunities that them and allow us to have our fish and eat it too because a lot of times we find that fisheries although we pretend to be killing them for the purpose of feeding people we don't talk about fisheries when it comes to what is a sustainable food system what does it take to look at fisheries through the lens of feeding people are we feeding people with it or are we really just supplying the all you can eat for ten ninety nine most of it go in the trash sort of a diet and so we wanted to really shake up not only fisheries policies but also the food system movements and conversations and make them realise that the only thing we eat that actually has the ward food in it is left out of our conversations all the time and when we do that we give a blank check to those who exploit the ocean to continue doing what they do there's a lot of lessons that we have learned from the land based food system that we feel are transferable to the marine base food system that can make that industry much more ecologically responsible and and the food that they provide much more accessible to those who need it most and not just those of us who already have options so what is community supported fisheries community support fisher is a model that we adopted obviously we still a lot of ideas i have to admit we looked at the land based food system and thought what helped the renaissance our family farms and small scale farms over the past thirty forty years since the farm crisis and industrialization of our farming and agribusiness takeover of our land what sparked the coming back of the family farms and skewness support agriculture played a big role it began to put people back in touch with where their land based food comes from it gave farmers the opportunity to start reconnecting with those who eat what they grow and raise and most importantly it help them accountable because now you're coming face to face with the people who are actually eating your food and that gives you that for a layer of responsibility and we had also heard that community support agriculture was leading to a higher price a better price getting farmers to actually get closer to getting to parity when it comes to meeting their cost of operations so we thought what if we replicate that model and created community supported fisheries and that was the first one we created was in two thousand and seven late two thousand and seven in port clyde maine and from there we kept adapting the model and creating more and more of them and today there are nearly fifty community supported fisheries around the world the last one we heard about actually i got an e mail a couple of days ago from someone in london u k wanting to set up a community supported fishery and wanted to have that support we have upside local catch dot org that people can go and put in their zip code and find the closest community supported fishery to them but what it's done more than anything else is we find the small and medium scale fishermen are really demoralized they have constantly been told they are doing it wrong and we felt what the the most important role community support fisheries have done is give them some hope give them some love back from their community that people do appreciate what you do and when it comes to fishing would rather see you succeed tysons or the caterpillars or the kind aggros or the industrial agribusiness model that's been taking over the fishing industry rapidly over the past couple of years a couple of decades so it really provided that spiritual uplifting that some of these this case you pick up your share of whatever fishermen caught in your area and one of the interesting thing about a community support fishery that more and more it's a challenge for a lot of folks because we're so used to eating half a dozen species and yet the majority of fishermen aren't just catching half a dozen species they're catching more than that the a b don't accept that into our diet and my opinion is if we've already killed it it's our responsibility to absorb it into our market system and so in new england for example on an average year there are over sixty species that come across docks in the new england region and yet the average chef knows about ten to twelve of them and so the benefit of a community support fisher is that mystery element of it you don't know what you're going to get for some consumers that's a challenge but for others it's an experience it's a something that they want to explore and see what are the other species that we are catching it is truly true that it takes an ecosystem to raise a fish and so there's a lot of other things that swim with the species that are popular and and they come up and then that's when they come to shore and fishermen get paid virtually nothing for them and in a community supported fishery they're actually getting paid a good price for those species which cost them this amount of money to catch them the popular ones but because there is no market there are often thrown it overboard that so i think it's our responsibility as eaters people who believe we should have access to seafood to also take responsibility for all the other species that come to shore and c s f gives people that experience so how do you encourage people to try out and consume the other forty five to fifty actually sees that they are normally go have had to get creative about that people are afraid there is a little bit of an unknown element what is it i'm eating i don't know this fish this fish looks grave that fish doesn't look wide enough for me that fish as the flesh is the friend so in new england we started these events because seafood throwdowns and we hold them at farmers markets they're cooking competitions and we invite local shops and we have a judges and we have an mc and and we focus on introducing people in those competitions to those species that they don't know so we can be mystified the process for them how do you clean a fish do you have to always fillet it no i actually don't know how to fly and i don't want to learn how to fly and so teach people how to stake a fish how to stuff a fish and and that the chefs when they arrive they can bring three of their favorite ingredients but when they get to the farmers market or the food festival rahal these events they're given revealed a secret locally caught seafood and we give them each twenty five dollars and they got to run around and buy the rest of their ingredients from that event so it also helps people know that this is not an out of reach thing here you can have a great meal and unknown species and have the ingredients come from your local farmers and your local vendors and this is easy to do so we wanted to really break it down literally for people and also those events give us about two hours of captive audience to talk about fisheries policies and what's happening and for fisherman to actually come and see that that people are excited about their cats and about what they do and they also happen to be fine we didn't want to when i when i got hired i thought you know as an activist most of my adult life the idea of tabling somewhere it just i just couldn't handle it and i thought what if we created something that was less passive and people couldn't help but come to the event and so we literally spend weeks around my kitchen table with our farmer's market manager in gloucester massachusetts and some other creative friends and we cooked up this idea obviously it's another idea we stole from food network and all these other cooking competitions but it seems to work in this case where people are introduced to things they don't know and at the same time you know i jokingly say there's a subversive idea of having the policy issues come into that conversation but it's a happy environment people are willing to learn because they're excited by the competition element of it and now they get to see the whole animal and that's another piece of a community supported fisheries or the educational pieces that we do we want people to know this is an animal that has a tail that has a head it has a body it's not just a identified food object i call it you know a filet on a on a piece of ice so it's really important for us to get back in touch with that and and show people how do you scale it has what is a look like and get comfortable with the fact that much like a chicken this thing is a real at a mall and you need to respect it and you need to also learn how to handle it and i saw with a video of you at one of the throwdowns you had pointed out that when you fillet a fish you're basically throwing away sixty percent of it is i right yeah there's the number an average of about sixty percent of the fish ends up on the cutting room floor and the some of the fish vendors and processors know what to do with that a lot of them that have  fish store for example or they make value out of things like chowder use a lot of those cuttings but most of the time they don't weigh in gloucester we have neptune's harvest that takes a lot of the waste and turns it into fertilizer so at least some of it is being used but most of the time it isn't and there's another standpoint if we're using the whole fish and we can reduce the amount of fish we waste that translates into less fish that we have to catch to feed the market so that's a really important element there's also the nutritional element and i cannot help but think that cooking the whole animal with all the connective tissue is all that all the things we take us supplements we get fish oil for god's sake you know we take a glucose simian and whatever shark fin seen event and supplements and those are all the things that are already in the animal so i think when we cook at all of those nutrients there's a holistic health care person in gloucester and i was talking to her about it and she said i kind of agree with you i can see how that would happen where you are the breakdown of all of those ends up in our in our diet and in our in our bodies and then there's another element which i think when we cook a chicken on a bone when you cook a lamb on a bone and much like the same the same scenario exists it tastes better in my opinion it's much more moist it's getting the full flavor so if you're eating seafood for the sake of the seafood and all the nutrients in the omega three s and the good fats that are in there cook at whole you know keep the bones on you don't feel like you always have to just have a full a it's really not that difficult to stake a fish or to cook is that a salmon steak people are used to but other adam was that we get from the sea to cook them whole or to cook them in some other way than just fillet it is foreign to a lot of people so put a little you know those little insert signs america's all the settled fishing port because i think people forget that there were people who lived here way before europeans arrived gloucester is an old fishing port that has gone through many immigrant populations that have dominated the fishing industry there the irish the the silly and the finnish and and from a political standpoint historically economically geographically it's sort of been the center of fishery policies controversy and that and also innovation i feel a lot of new ideas come out of gloucester but we often dismissed them because we think gloucester is one of those communities where exploitation runs high and so we tend to do something that i that i feel we need to let go of as paint the fishing industry with the with a broad brush we assume they're already p and we've decided to ignore the fisherman completely and lost touch with them and glasser is one of those communities that i feel has been mischaracterized for the for the greatest part not that everybody in gloucester is perfect but much like the rest of the fishing industry or any part of our economy or even human beings none of us are perfect but we look at potential and when i think about fisheries and seafood and and who's catching it i think on one hand i can trust the fisheries so the as i mentioned the tysons in the congress in the car gills and and the factory fishing operations on the other hand i can trust the fisheries to the equivalent of family farmers and people who are much more connected and for me it's a no brainer and that's the piece that i think we want people to walk away from is there is a part of the fishing industry that we need to support if we want to continue to happening to the ocean for sources of food sea salt sea weed whatever it is and there is a difference between people who fish and people who extract seafood and if we want to continue to eat seafood it's our responsibility to support the ones who fish and dismiss the extract hers so how much influence and business do the large industrial large corporations have there in production strategies as well fishery has happened based on much like you know make cars the cheapest way possible and then we realise while at what cost you know grow we at the cheapest way possible what cost does that come with you know when we applied that formula with agribusiness to our land we saw that grid ation of our soil we saw that predation of rural communities we saw the value of our food decrease and we started to realise cheap food comes at a really high price and the those who advocate for that low volume low value high volume economically efficient so called economically efficient fishing industry are dominating the political system they're dominating the market and marginalizing the small and medium scale fishing operations and so most of our work involves bringing other players into the field those who have paid attention to the breakdown that's happened in the banking system in the health care system in the educational system all these systems where the lowest cost of operation has entered the picture and then we saw we lost our money we got sicker we love our education that were dated we lost our homes and now we're seeing the same the same policies be applied to the ocean and i'm scratching my head thinking have we not learned anything so it's really important to know that those elements exist in gloucester in seattle and other fishing communities everywhere and  and we have to separate the two we have to realise that we need to isolate those who want to replicate the same is the we made on land on our backs in our housing and replicated on the water and support those who are coming up with new economic strategies new fishing opportunities new business models and really shifting fishing from that high volume low value operation to low volume high value operations that are respectful of the ecosystem which includes the communities that they live and and also feed well here in seattle we have a local local fisherman and icon connection who actually know and he has pointed out on and on in previous interviews that i mean it is a major battle just be able to sell fish from his boat at fisherman's terminal here in seattle is the same situation where they were situation i give you an example we have worked in the past few years with the city of boston much like many coast communities i was surprised to find their ordinances that prohibit the sale of seafood and in boston the city couldn't sell seafood on public property and or if you did it couldn't be when other foods were present so you couldn't have a fish vendor at a farmer local food festival we really pushed the city gently to reconsider and two years ago we celebrated the lifting of this ordinance seventy plus years boss in boston you couldn't buy local seafood on public property so we celebrated with six farmers markets in boston bringing local seafood two years ago last year it increased to nineteen farmer's market which for you guys here in seattle where you have seafood in your farmer's market you may be thinking what you could have seafood in your farmer's market in massachusetts and boston you know sort of the icon of seafood in the city but it took some struggle to actually change that ordinance in the outer banks of north carolina again another place where fishing is as a boy of life you couldn't sell seafood you couldn't have something other than a fish vendor that has a brick and mortar facility to be able to sell your catch portland maine similar thing so these ordinances in some cases were put into place to protect public health because they were concerned that seafood could spoil or people didn't know how to handle it but you know we handled that well for many years before and so part of me thinks is that really a public health issue or is it a way to for some folks to carve out the market and really dominated so i think in some communities there is an earnest concern about public health like boston so we were able to show them we're not going to kill anybody and we know the procedures and the fishermen we work with know how to keep fish safe and good condition and so that's why they left at the ordinance so i think it's we have it's a good example of how if we approach something not from protest but from opportunity and from possibility and work with them to show that people are interested in working out the challenges you can actually create change and i think pete has shown that in their business and others have in various parts of the coastal communities that we work with and we readily share those experiences with others who are facing similar challenges so they can left similar ordinances that really don't make any sense anymore are there any community supported fisheries here in the pacific northwest there are a couple but not very close to seattle  there's one that i just recently heard about in bellingham and i as i missed mentioning earlier there was a time when community support fishery numbers were small enough that i could rattle them off by name and who operates them what they catch but the numbers have grown and i'm getting old so the my memory isn't as good so luckily there are others who are keeping that information and i encourage people to go to the local cats dot org put in their zip code and find what's close to them having said that in vancouver  great family run operation and they have salmon they have crabs and probably other species that like i said i'm getting old i can remember further down south in oregon the porter for a resource team runs porter for seafood and there's another c gibraltar oregon but i challenge people in seattle to take it on see if you can create a community supported fishery and show your fisherman some love back and give them a fair price and introduce yourself to some new experiences this a community that i think would embrace such a concept what would be the best way for one to do that well they can certainly get in touch with us and through local cats dot org they can get in touch with the people who are matching that website we have actually community supported fishery resource of a business model in order for it to meet the ideals that we have come up with which is we hear a lot about triple bottom line businesses that are socially environmentally and economically sound and with community support fisheries we've added another bottom line which is food system because i said earlier we the food system conversations have exclude fisheries and we felt we needed to explicitly state that we're not just doing this to pay fishermen a fair price provide seafood to consumers at a fair price to have to be socially responsible and environmentally have a smallest footprint but to also make sure we have a healthy food system that includes our fisheries and so they can start with that resource skype they can start by sending an email through that local catch thought org and then take it from there and if they don't know a local fisherman if it's a fisherman who wants to start one would be happy to work with them if it's a community person who doesn't know where to even begin and wants to connect with fisherman we can probably put them in touch with some of the fishermen that we know as a start of the conversation it's not a model that works for every community we have over the years found that was a good start to the conversation of shifting the conversation actually and the dialogue but in some communities it doesn't work for a variety of reasons and but we also recognize that a community supported fishery even the biggest ones don't capture all of the fish that fishermen are catching so we wanted to be able to use that market on that conversation to create a bigger market and as a result a bigger change so since two thousand and ten we've actually been working with the health care sector we have a partner in health care without harm it's an international organization that works with hospitals and health care facilities and we've been working with them to shift the buying policies of the health care sector so they can also start including locally caught seafood into their into their cafeterias into patients meals and the significance of going beyond c s s and incorporating some of these large institutions is it's a huge shift it's a cheap game changer for fisherman to sell all of their catch at a fair price to an institution that appreciates them but the health care sector has the history of using their market muscle to change policy and so we're not just doing this work to push the food we're doing this work to change the mindset and then tap into that mindset to push for policies that are going to change the way we fish and the way we market fish and the way we eat fish four minutes left what is green seafood greasy food is a confusing term and there are so many certifications there are so many less than i feel the public is almost  ildered by them you know do i buy marine stewardship council do i use the red yellow green lusts and and i think for the public who wants to start thinking about all of these issues it's a good start to look at those less than to consider those the cations but it's also time to go deeper because those less than those certifications we're finding don't include some of the broader values we've come to realize are important when it comes to a healthy food system fair price slavery conditions in our food system the conditions of the community that fishing is happening and that diversity of species for example a lot of those sort of occasions unless the very single species base then we find that a fish that's on the green list two years later it's on the red list so we talk about applying your values instead of focusing on species or sort of occasions or less if you've decided that it matters who raises your chicken or your pig or grows your lettuce or what are the conditions of those workers are they getting paid a fair price how's the environment taken care of in that process if you've decided your values have farted your food travel that carbon footprint we are always talking about now when you start laying out your values when we began to lay out our values we realized that those lists were good enough to start with but we needed to go deeper we needed to start broadening our horizons and and so we encourage people to to stop thinking about which species and start thinking about how far they've come who is the fisherman if you can if somebody can tell you where that fish came from i would say don't buy it because we worked with one hospital in massachusetts for example and we didn't want to overwhelm them by saying you need to change everything today there are certain we want you to do one thing different ask your vendor the name of the boat they did the vendor wouldn't give him the name of the boat overnight they changed their vendor and went to a vendor who could tell them the name of the boat that's so important and it's small step but it's a really important one because then when you know the name of the body can tell us a small scale but a large scale bird industrial boat can i get to meet the fishermen even if you don't but at least you can get some personal risk relationships there even if it's on paper on your on your computer and that was important indicator for them that that lack of accountability lack of traceability of where their seafood was coming from was an indicator that they needed to change vendors and they did and fishing but actually out of gloucester is now one of the main hospital boston medical center and a few other community health centers have really been leading the work on shifting kent hospital in rhode island for example but the early adopter of this work i have to give them credit  health care and when landlocked hospital in burlington vermont they took the challenge right on and they began shifting their seafood policies to the extent that they could within their their limitations and they found just on one element their carbon footprint they found that the seafood that was considered sustainable was traveling fifteen thousand miles to get to them it was caught in the bering sea and factory fishing operations and by making the switch they immediately reduced within one year their carbon footprint other seafood from fifteen thousand to less than a thousand miles well with that we are out of time i want to thank you very much for coming and spending time with us this morning thanks for having me time once again for community forum and we are very lucky to have  live in the studio this morning dr philip caper dr philip caper has held professorships dartmouth medical school and the university of massachusetts medics medical school where he was also vice chancellor for health affairs chief  the medical staff and hospital director from one hundred seventy one to nine hundred seventy six he was a professional staff member of the united states senate labor and human resources subcommittee on health chaired by senator edward kennedy he is a founding member of the national academy of social insurance a founding board member of maine all care and a member of the national board of physicians for a national health program and he is a regular monthly columnist for the banner daily news maine's second largest paper where he writes about health policy dr kapor thank you very much for coming and spending time with us this morning well very happy to be here with sue start out tell us about the advantages of a universal single payer health care system over what we have now and we're working very hard to educate the public through community forums and through  newspaper columns and letters to the editor and op ed pieces and any other way we can get the word out so we're really into or a grassroots organizing at a local level which in maine which has only one point three million people is actually doable in the you can reach a large proportion of the population just by chipping away a little bit at a time at a community level so we're focus intently on improving our health care system and bringing more into line with what exists in most other wealthy countries which we don't have now and we'd like to see that ha so is the affordable care act not enough no it's not enough and you know i want to make very clear that i have tremendous admiration for the for the  political accomplishment it was difficult as you probably know if you've been following to get passed it passed them on a strictly partisan vote in the congress and it was it passed way very narrow margin extremely narrow margin so i think it was a great political accomplishment but as a piece of public policy i think it's pretty messy and people are finding out about that as they are now required to pay more attention to the health care system because most people are now required to have health coverage or pay a tax penalty if they don't have it so the one the best thing it's done i think is to destabilize your existing very dysfunctional system of health care and but beyond that it's it's pretty messy is way way way more complicated than it needs to be to get the job done if the objective is moving toward health care coverage for everybody and that complexity introduces first of all cost a great deal of money in many states of just poured a lot of money down the drain trying to set up exchanges for example oregon right next door is now abandon its efforts to to set up and their own exchange and there they're going with the federal exchange but in the meantime they spent about a half a billion dollars trying to set up their own exchange to go with a erroll exchange because they can't make theirs work and so the complexity is expensive not only in terms of the dollars it costs and the aggravation it brings to patients and doctors with all the complexity but also it is cost the great deal in terms of public support because most people in fact all say very few people really understand what's in the affordable care act it's too experienced way too complicated and with complexity if people don't understand it they won't support it so i think it's going to be impossible to ever generate a really broad based majority support for the affordable care act because people don't understand what's in it if we had simply expanded medicare for example to include everybody maybe incrementally over time you know lower the age of eligibility by one decade every couple years we would have had a program that i think would have been broadly popular with the public you know doctor when medicare was an act it is almost fifty years old now it was fifty years next year they were able to enroll nineteen million people in nine months using index cards as a way of collecting information no websites no computers because there were none but it was a simple when you checked one box if you wanted in or you didn't and that was the end of it no prior health history no who's your employer know what your income while all of that was gone because the universal program so most of the money that we pay into medicare actually goes for medical care much of the money in fact on almost half of it we pay into the affordable care act is going to go to a ministration of one sort or another you know checking people out deciding what network they belong to deciding what services they're covered for deciding how much out of pocket they pay all of that cost money and it's as far as medical care is concerned it's just good money going down the tube so we would like to see act greatly simplified and expanded to include everybody it's actually cheaper to cover everybody there is to spend a lot of money deciding who not to cover which is what we're doing now you know we want to make very p q the american trait we want to make sure nobody gets something they don't deserve however we define deserve so we spent a lot of time effort and money trying to figure out to make sure nobody's getting suddenly good things covers expands coverage for a lot of people it rains in some of the more the worst abuses of the commercial insurance industry it doesn't remove the incentives to continue funny ways to abuse of the customer by the corps which has covered so we'd view it as doing some good things but a long way from where we need to be so how do you see as going was a provision called the state innovation waiver provision authored by senator ron wyden of oregon and that essentially says if a state can improve on the federal on the affordable care act can do their individuals including the mandates on businesses including the tax penalty all that stuff goes away if a stay can do something better what it says and i think that's i think you're going to see quite a few states trying to do that when twenty seventeen rolls around when they had a little more experience with the affordable care act and more people recognize its shortcomings and one of the things we're doing in maine all care is to try to educate the public to that possibility and saying you know we can do better because in most wealthy countries their health care systems cover everybody i mean everybody who is a resident of that country they have better outcomes there was just a report issue last week or a couple weeks ago by the commonwealth one that shows that of twelve industrialized countries studied the united states is first in only one parameter and that is how much money was spent by a longshot we spent almost twice as much per person as of the other countries on average but we are almost dead last on most of the other measures of quality of access fairness and other things so we want to educate people we're there is possible to do things in a much better way to other countries get better outcomes cover everybody have systems are more popular with the politicians with patients in the general public and with the doctors that have ours and all by the way cost about half as much as ours is so you know you have to ask yourself what's wrong with this picture what are we doing that other countries are not doing that's resulting in a higher cost  poorer performance across the board so who is really making all the money in our current system is that the pharmaceutical companies well it's it's ironically i mean it's everybody but the people actually doing the work of providing health care there was an interesting article in time magazine about a little over a year ago by steven brill called bitter pill and he sort of deceptive much a hospital bills and asked you know where is all the money going much of the difference in spending is accounted for by higher prices here including doctor's fees i have to say but more importantly the corporate profits are much higher for example pharmaceuticals costs much more in this country than they do in any other wealthy country and that's because in other wealthy countries the government negotiates prices with the drug companies in this country we  can't do it even our public program medicare is prohibited from negotiating prices with the drug companies by the congress and so that's one issue the for the money is being made by the business people in health care the people who are now running the large health care delivery system the corporate executives the corporate shareholders are doing very well in the pharmaceutical industry in the medical device industry and in these large particular for profit the hospital system companies you know like cancer centers of america as a for profit on college eat chain and they're you know doing pretty well by  convincing people who have cancer to come in and you get a second opinion from them and they then prescribe expensive medicines which are very high margin medicines so in this country while we don't have good access to  primary care that is your family practice your pediatrician and whoever we have excellent access to profitable services so we have a lot of and our eyes in cat scans we have a lot of surgery centers we have a lot of  services that provide high profitability so we really have the money driven system and as a physician that bothers me a lot because medicine you know we take the hippocratic oath when we're sort of sworn into the medical profession and the hippocratic oath could boils down to put the patient first that's it that's the essence of the hippocratic oath do no harm but the patient first and unfortunately  doctors are now more and more becoming corporate employees there is a vanishingly small number of doctors are still in practice entirely on their own and when you're a corporate employees march to the orders the corporation and the corporations are run by business people who are looking at the bottom line which is what they that's what they do and so the doctors are now sort of caught between the demands of their corporate employers and their own hippocratic oath and it's causing a lot of heartburn on the part of many doctors and i think accounts for the high burnout rate among  nearing retirement age more and more other of them are just saying you know our best days in medicine are over let's just get out of it and that's a big that's a big problem so i think that you know the united states is unique in that it's the only wealthy country in the world where health care and medicine is considered be a business and that transition happened during the late seventy's and early eighty's it was given to jumpstart by the reagan  n when they you know all of a sudden it became ok to be rich there's no shame in being ratchet was a great thing to do and lots of doctors and others began taking getting m b a s and you were going to be businessmen what they didn't seem to understand at that time is the fundamental mission of a business any business is to create wealth for its owners that's it that's what they all have in common and that's what they should do and in fact that's what many of them are required to do by their state corporate charters you know maximize profitability by any and all legal means set but that shouldn't be in my view the primary mission of the  profession it interferes with the healing and it destroys trust by the patients in the healers you go to your doctor and thinks it all and you think all your is an a t m to them  actually impair the healing process because you won't trust healer you know medicine is still a relationship business it's not a business about technology we use technology but it is fundamentally a business about relationships and because of the financial pressures on physicians now we can't spend more than ten or fifteen minutes with a patient we have to turn patients over you know do volume to get the fees in and that itself really impairs our ability to do our job and that i guess is what was really the most as a physician about what's going on here so we have some fundamental underlying i call it the underlying pathology of our health care system you know it all the other stuff the large number of uninsured the high cost the spotty quality those are all symptoms the underlying pathology is treating medicine as a business and relying on commercial health insurers as a way of financing it because the health insurance companies if they're if they're for profit particularly if they're publicly traded and worried about their stock price is a bottom line business it's like a bank or a credit card company and that's what you know they may do health care services but their primary mission and the legal obligation is to maximize profit ability in that interferes with the healing mission of medicine and other healing professions so that sounds like a paradigm that's going to be tough to crack at the state level yes it is well i'm not so sure maybe actually be easier to state level in some states that at a national level because this is a pretty heterogeneous country you know texas and maine and washington state and oregon and california are very different cultures from one another and for example vermont has already passed a law saying we intend to go to a universal publicly financed health care system on a state level within four years and save set up a commission to say how do we get from here to there so they already have the political climate to to achieve this which is not the case in a place like alabama or texas for example taking oklahoma to take  examples so maybe that's why i think it's more more likely to happen on state level than on and in on a national level and i think once a few states have shown that they can do it and are getting better results everybody covered spending a lot less money i think it's going to catch on with that's the way it happened in canada canada started out in with scotch on one province and acting a universal health care system back in the in the mid sixty's and within ten years it had spread across the entire country and now it's essentially untouchable i mean no politician will admit they're trying to subvert the canadian system if they want to keep his job in parliament it's that popular with the public nobody is going to admit even though there are there are attempts to do it they're not they're calling him something else and part of that popularity i think is because in a universal system which is what we're advocating everybody has a stake in the same system in our country you have commercial insurance you have medicaid you have children's health insurance program medicare  the whole system is so fragmented that people don't have any common interest in a single system and i think that's a very important element for this political satang of sustainability  system and so we can end up with people fighting among themselves you know young people are many old people on the rich people are very the poor people and so on and i think that is a big cultural shift but it's what we have to do if for us if we really want to have a health care system that works in our health care system now doesn't work on of on many many levels too expensive it's too fragmented the ac a obamacare is is painfully unfair both in the way its benefits are distributed and in the way it's financed there are some people who are too poor to get any help there are some people who are too rich to get any help there are people who are in the middle for example in the states like maine refused to expand medicaid which was an important part of the affordable care act you can be too rich to get any to be on medicaid but too poor to qualify for help from the affordable care act there's a whole group of people that are very close to the poverty level they get no help at all while people wealthier than they are get federal subsidies for their health insurance  if you make more than about forty five thousand dollars a year you get no help from the real subsidies on the exchanges but you're continuing to pay taxes to subsidize health insurance for wealthy executives who are getting federal tax break because health insurance if it's linked to employment is tax exempt so you're paying taxes to make up for the taxes the wealthy employ the wealthy executives are not paying because they sticking with your state of maine so our what plans you have then for the short and medium term well we're working i have worked around politicians most of my career and i understand they cannot get too far ahead of their constituents in terms of their understanding of an issue if they want to keep their job so our focus is on changing the public environment and understanding this issue and we have  main legislature we actually got one through the legislature this past session to set up the first step in moving towards a single payer system in maine unfortunately it was vetoed by the governor or tea party governor and  and we're going to try to get something through the legislature failing that we have an initiative referendum process in maine so we can go directly to the public and we will do that if the legislature is unable to do the right thing and what would that first step entail it would set up what it would do it vermont it would set up a study the gets of actual information about how one approaches compares with another then one for mont did in what the bill we passed it would set up would require the legislature to fund three studies of three approaches one of them being a single payer approach and look at the cost look at the benefits look at where the money goes and come up with some information which  be used as a guide by the legislature to craft legislation actually creating a system that's what vermont did and they had they did their study they commissioned a study that was done by professor william sh university and they picked the single payer as being the best alternative but it that's followed about nine years of grassroots organizing so there was a lot of preparation of the public no vermont is even smaller than hundred thousand residents so that's pretty tiny place but they did a goose with they've sort of blase pathway we're following that with our one point three million people who were hoping to have the same result they did such a good job that the in the gubernatorial election back in about two thousand and ten or eleven they had competition among the democratic candidates for governor who was the most single payer who's  most a favor a single pair in peter shumlin ended up being the most a favor single payer he won the election and he was able to get the bill through their legislature and they're now going through the process of figuring out how we get from here to there now there's a big stumbling block has a big obstacle in that is that a publicly financed and controlled system is going to require a significant hike in taxes and you can call it whatever you want you can call premiums or contributions but their taxes let's face it and taxes are not very popular in the united states so when governor shumlin is asked is accused by his opponents of promoting the highest largest tax increase in the history of the state of maine he said well you know i don't look at it that way i look at it as a largest premium decrease it's ever been given to the people of vermont i'm sorry maine and  e is being successful in getting that message across people understand the total spending will go down even though some of it funded by taxes will go up here what you take home in your paycheck is going to go up because you're the taxes would be less and people are now paying through a combination of premiums out of pocket expenses and the other miscellaneous nasty surprises anybody who tries is a health care system is a store for so and people are now because of the complexity of affordable care act because when you find the once you buy a plan on the exchange you're still going to have a large alway thought out of pocket expenses associated that because the way they keep the premiums down is to increase the cost sharing at the time you use the services so your policy is fine as long as you don't try to use it for the city to try to use it you're in for a nasty surprise because you're going to be still left with large co insurance and deductibles out of pocket and you're going to find that some of the doctors and hospitals you've been used to using are not in the networks with the insurance companies  keep them out to try to keep their premiums low and it will be interesting to see how americans who love the idea of choice respond to that i mean i personally don't think anybody cares what who their insurance company is i think they care a lot about  providers are so when you go to the exchange to choose among insurance companies i think people are not are apathetic about really as you're his company is but they care a lot about whether their doctor is in the network or not and i think they're going to find that that's a trade off i'm not going to be willing to accept just about two minutes left so the a c a a will has protocols in there for vermont to make that leap that they're attempting to do it has  pretty provision i think a section of thirty thirty two state innovation waivers and they can get a waiver from the federal government to do their own thing as long as it's as least as good as and doesn't cost any more than the a c s and that's a pretty low bar given given what's going on and then all the money is flowing into the system that has nothing to do with medical care we should be able to do that pretty easily well with that we are unfortunately out of time i want to thank you