Q    Thank you.  I’m the practice manager at an ophthalmology（眼科学） practice at the Eye Center of Columbus, downtown（市中心区） .  It is a great facility that the city of Columbus helped us get in place.  There are over 30 ophthalmologists providing specialty care in separate practices, a state-of-the-art ambulatory（流动的，走动的） surgery center.  We see tens of thousands of patients a year.  And I think we do a very efficient job of providing quality care, over 300 people employed.  So I’m kind of on both sides of health care.

And when I started working for this practice 25 years ago, we are now getting reimbursed one-third of what we got paid for  -- I’m just going to pick cataract（白内障） surgery -- yet our operating costs continue to go up.  My boss is kind enough to provide health care costs entirely for all of his employees.  How does he continue to do that when Medicare continues to reduce what they're paying, and there’s the threat of more cuts coming and the private insurance companies follow suit（跟着做） ?

THE PRESIDENT:  Well, it’s a great question.  And let me talk about Medicare generally.  Medicare I think is one of the cornerstones of our social safety net.  The basic idea is, you’ve been working all your life, you retire; just like you’ve got Social Security that you can count on, you’ve also got health care that you can count on and you’re not going to go bankrupt just because you get sick.

But in the same way that Social Security has to be tweaked（扭，拧） because the population is getting older, we’ve got to refresh and renew Medicare to make sure that it’s going to be there for the next generation, as well.  And the key problems are not just that more people as they retire are going to be part of Medicare.  The big problem is just health care inflation generally.  The costs of health care keep on skyrocketing.

Now, the way we’ve been dealing with it, which I think is the wrong way to deal with, is basically under-reimbursing our providers.  The right way to deal with it is to work with the providers to figure out how can we make the system less wasteful, more efficient overall.  And that way we’re paying -- your boss, if he’s spending a dollar on care, he’s getting reimbursed（偿还，赔偿） a dollar.  But we’re also making sure that the care he’s providing is exactly what the person needs, and high quality for a better price.

And that’s part of what health care reform was all about.  I’ll just give you a couple examples.  One of the things that we were doing in Medicare was we were giving tens of billions of dollars of subsidies（补贴，津贴） to insurance companies under the Medicare Advantage plan, even though that plan wasn’t shown to make seniors any healthier than regular old Medicare.

So we said, all right, we’re not going to end Medicare Advantage, but we are going to have some competitive bidding and we’re going to force the insurance companies to show us, well, what exactly -- what value are you adding?  How are you helping to make these seniors healthier?  And if you’re not helping, then you shouldn’t be getting paid.  We should be giving that money to the doctor and the nurse and the other people who are actually providing care, not the insurance companies.

Well, there was a lot of hue and cry about this, but it was absolutely the right thing to do -- because now we just found out -- the actuaries（精算师） for Medicare said the changes we’ve already made have extended the life of the Medicare trust fund for another 12 years -- which is, by the way, the longest it’s ever been extended as a consequence of a reform effort.

So we’ve made Medicare stronger just with some of the changes that we’ve already made.  But you’re absolutely right that we’re going to have to keep on making these changes to continue to make it stronger.  And that will affect not just Medicare; it will affect the entire health care system.

Because there’s no doctor out there who doesn’t see Medicare as the $800 gorilla.  If Medicare is saying you’ve got to improve your quality and efficiency, then they will because they’ve got a lot of Medicare patients.  But they also have a lot of regular patients.  So hospitals, doctors, everybody starts getting more efficient as Medicare gets more efficient.  The key is making sure that we’re not just cutting benefits.

And, frankly, this is an argument that I have with my friends in the Republican Party sometimes.  One big change that some of them have advocated is to voucherize the Medicare system. You basically -- instead of once you have Medicare, you knowing that you can take that and go get care anywhere you want, we would just give you -- all right, here is whatever it is, $6,000 or $7,000 or whatever.  You go shop and figure out what kind of best deal you can get.

The problem is, is that if Medicare costs -- if health care costs keep on going up but your voucher（收据，证人） doesn’t keep on going up, you’re going to be in trouble.  And suddenly, you’ve got seniors who find themselves way short of what they need in terms of providing care.

We’ve got to change how the health care system actually operates.  And that means more prevention -- more preventive care.  It means better -- that we reimburse（偿还，赔偿） people for checkups. It means we reimburse doctors when they’re consulting with people on things like smoking cessation（停止，中止） and weight control and exercise.

There are a whole bunch of things that can make us healthier, reduce our costs overall.  But unfortunately, the system doesn’t incentivize（鼓励，激励） them right now.  We need to change that.

Anybody have any last burning question?  That was technically the last question.  But this has to be like one that you’re just, man, I really need an answer for.