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"The Floor of the U.S. Senate as the Operating Theater:
Is Transplanting Ideas Any Different From Transplanting Hearts?"
Remarks as delivered by William Frist, M.D.

U.S. senator from Tennessee and Senate majority leader
2003 recipient of the Woodrow Wilson Alumni Award

February 22, 2003

>> Coverage of Frist's speech

Thank you, Dean Slaughter. Let me say at the outset that it is an honor to be with you today, and to take a journey with you a little bit on some of my interests, and to really balance very much what I have to say on the previous speaker, Peter Bell, who I think captured -- really captured -- the challenges before us as an American people, but indeed an international people. It's a great pleasure for me to be here with my family, who Dean Slaughter so graciously recognized.

It was in August, just several months ago, that I had the distinct pleasure that many of you in the room have had -- and that is to load up my three boys, but especially this time Harrison and my wife, in August, and make that drive to Princeton as a new era for me in my relationship to Princeton as a Princeton parent. And to indeed drop Harrison off for his week at a freshman orientation program that many of you are familiar with now called Outdoor Action -- a program that today has 800 people participating.

When you come back to Princeton, you think -- all of us do it, and this is mainly alumni in the audience and students today -- you think of what the place was like when you were here. It dropped me back about 30 years when I and two other juniors and a senior took 13 students on what was the first Outdoor Action program. And to think that those 15 students now evolved into 800 students who spend a week together, [being] introduced to this wonderful place, helped put things in perspective. An idea whose time had come and you don't realize at the time. I'll speak about another idea whose time hit me about then -- but also the growth, the vitality, the assimilation of when one has an idea of gathering this wonderful community together in terms of alumni, in terms of faculty, in terms of students.

If you turn back actually from that time -- that was 30 years ago -- if you turn back about three months before that 1973 trip that we took, about three months before that in April of 1973, Marvin Bressler -- and many of you were taught by Professor Bressler -- issued a report by the Commission on the Future of the College. And in that report -- 1973, that's when I was a junior here -- it captured a lot of my experiences. And these big reports -- does anybody ever read them -- you never know, but I happened to glance through part of that report because, and I wrote it down, 1973 April, the report by the Commission on the Future of the College said, "Entering students arrive on campus as strangers in an unfamiliar universe." We all feel that. "Little in the institutional structure," -- speaking of Princeton -- "provided for the freshman and sophomore years exposes students to a sufficiently wide range of people, thoughts, values and lifestyles." 1973 -- we'd just gone co-ed, still sort of the entryway structures.

And the part of the report that really captured my imagination is this: in the report, it reads, "Parochialism is the enemy of education. And a well-appointed central facility which stands as an architectural testimony that Princeton is greater than the sum of its parts." All of a sudden light bulbs started going off. A building that included in 1973 -- this is after 200 years of not having such a facility -- "a building that included lounges, study areas, game rooms, a mail facility, dining and snack services, a coffee house" -- and, at that time, most of you know that we had a pub -- "a more authentic pub, might attract undergraduates who might otherwise not venture beyond their immediate circle." And the last sentence: "A widely utilized center would help create the spirit of common membership in the same community."

I mention that because it shows the importance of the family working together -- of alumni, faculty reports, especially undergraduates, thinking. Because out of that little seed, out of those sentences, which were imprinted in my mind, and after that was cultivated -- and it was effective in part because when I came here, I came from the South, none of my brothers or sisters were from here, I knew no alumni who had gone to Princeton, and I didn't know any other students at all who came to Princeton, nobody came from my school at the time, coming from the South -- and that lack of a sense of community -- and I remember because I was very homesick every night for that first year that I was here -- but that seed was planted, cultivated in part by being a young alumni trustee and hearing the trustees talk: "Someday were going to do this thing." But every time the student center or campus center would get to the top it would be pushed down below for some greater priority.

And then 10 years as a charter trustee in the 1990s and the cultivation of having Bill Bowen initially take my brother Tommy Frist, who, at the end of the day is responsible for this campus center here. But the reason, and so many of you are here as alumni, that Bill Bowen and Harold Shapiro literally walked, and my brother didn't go to school here, but for several hours and then days through this campus, painting a vision of what could be here, with that architectural testimony and the cultivation and the involvement of alumni, now we can come back, and many of you as alumni have been back to go to the campus center, that I think we can all be proud of. The students played a huge role, in terms of the structure of that center, in terms of the planning, in terms of the layout. I have to mention at least the architect, because this marriage of the past and the dynamic future, historic past, I think, is captured in that building. And the reality is not just a physical structure but a spiritual structure as well. It's where Princeton can really come together in an informal way, outside of the structure of classrooms, and as that Bressler commission report on the future of the college 30 years ago, that turned a little light bulb off in my mind that our University is, "greater than the sum of its parts."

Today I want to focus on public policy specifically. I want to talk about two issues, and Peter Bell's comment captured one of the two issues that I want to talk about. It's an issue that, in politics, when I go around the world and around this country, in every political campaign and even when I'm talking to the backwoods of Tennessee, I will talk about this issue, and Peter Bell captured it: the most devastating humanitarian crisis, your words, the most devastating humanitarian crisis of our times, and possibly of all times. Those are the words you just heard from Peter Bell, and I want to come back to that. I would also like to talk a bit about public policy on a domestic issue which affects every single one of you in this room -- every single one of you in this room -- and that is our health care security system for our seniors. But I'd be remiss if I didn't build a little bit on what Dean Slaughter said in her introduction. That is what Princeton made possible for me, as Majority Leader now of the United States Senate, and all of you know it's not a position that was a goal for me, it's not a position that I ran for.

In January of this year, just two months ago, or at the beginning of last month, the mahogany nameplate on the door in the most historic part of the Capitol, which is where the Majority Leader's office is, it's a mahogany nameplate in gold letters, they put my name as they put all Majority Leaders' names when you take over office, and it says, "William H. Frist, M.D." Now, you kind of laugh, and that's exactly what the political pundits in Washington say: "What is this 'M.D.' business?" The people in the newspaper, " 'M.D.', what's that have to do with being Majority Leader in the United States Senate?" It's interesting because it's done for a purpose and it's not just -- it was in my Senate office as well -- I did it there, to be honest with you, because my dad -- who died about five years ago -- when he came to my office he scratched his head and said, "Bill Frist, why did you give up being the greatest of all things, and that's a doctorate, to come to Washington, D.C.?" He said, "Put 'M.D.', you're a doctor, put 'M.D.' up there."

So that's the real reason, but, what it really says -- and it says what really Dean Slaughter captured -- the M.D. sends the signal of this concept of what I think has made our democracy great from the founding of this nation. And that is that we take real people who have had real jobs -- yes, jobs outside of government -- who bring the real experiences that Peter Bell talks about that you see -- that you feel -- by doing other things. And taking that for a period of time -- it could be a long time, it could be a short time -- in my mind, it's taking real people out of real jobs and allowing them to come and serve the country in the way, like I am today, in public service, and make one's contributions. It's called the citizen legislator concept, and what it really should send, I think, is that you don't have to be a career politician to engage in public service and to address the sort of issues that we talked about this morning. And that I'll talk about shortly.

It started with me here in Princeton University in this room for some classes, in Holder Hall, but best symbolized by the fact that I'd run from chemistry class in Frick over to the Woodrow Wilson bowl and study international relations, and then go back to Frick, or it might be Guyot in biology to learn about that little virus, that little tiny virus that's killing 23 million people. First of all, when I was here, it didn't exist. We didn't know it existed. That's how new this little 22 year old virus was that has killed 23 million people. Princeton allowed me, in fact, encouraged me to do both tracks, to do science -- basic science, medicine, health care -- and to do the international relations -- the economic policy, the exposure of social policy, and politics -- and to do them both, but also, to integrate them. It's confusing to people that William H. Frist, Majority Leader, M.D., can be merged together.

But at the end of the day, it allows me to address things with a perspective that's just different. It's different for Washington, D.C., and it's not better or worse, but it's different. It forces the conversation to a enter new realm where people talk bioterrorism and the threat to your lives, if right now you were exposed to smallpox or anthrax or the plague or botulinum. And that's where I've lived, and at the same time, I been in classified groupings of up to 12 or 15 nations in the world who have developed offensive biological weapons programs with those seven agents. I am blessed because my life has been spent in terms of studying the medicine, and the public policy, and the health care, and the threat that is before us: if 12 to 15 nations really have, which they have, developed the use of these weapons, and we are, not unprepared, but under-prepared as a nation. But we're getting there very quickly in terms of preparation.

Public policy, United States Senator, now Majority Leader -- is it different than being a heart surgeon, doing operations, doing transplants in the operating room? Not all that different. Both are healing, both involve patience, both involve taking calculated risks in terms of some boldness and some courage, both involve listening to that individual patient. If you don't listen to that patient coming through the door in a very objective way, there's no way to make the diagnosis -- absolutely no way to make the diagnosis.

Same thing in politics. You'll see, when I travel around the country, I'll spend a lot of time listening and taking notes. Well, I guess that started here, in places like Alexander Hall, and in Princeton. But both require listening. Both require accountability -- and that's key. When you see it play out in this tragedy at Duke, when a mistake is made, you're held accountable. And that surgeon stood up and has been held accountable. That happens in medicine every day, and you're held accountable when you transplant a heart or a lung, or you fix the heart in a young man or a young woman, you're accountable.

In politics, the accountability is not as natural as that. But my job, in many ways, is to reflect the accountability that must be instilled in politics broadly. Let me just add the other common thing of whether it's transplanting in the operating room or transplanting ideas on the floor of the United States Senate: it is a deep sense of humility -- a deep sense of humility in the sense that our lives are governed not just by coincidence, and our lives are not controlled just by chance, but that our lives are governed, in large part, by a divine providence.

The HIV virus, 23 million people -- unknown when I was at Princeton, unknown when I was at Harvard Medical School, unknown when I was an intern or my two years of residency. Really, we figured it out in 1983, and at that point in time, we had no earthly idea of the human travesty -- the human destruction -- that this tiny virus would cause. 42 million people, as Peter Bell mentioned, now have that virus today. Nine out of ten people don't know they have that virus today. Yet we have no cure, we have no vaccine. And for every one person that died in the last 20 years that we've known about this virus, for every one person that dies in the best of all worlds, even if we do everything right, two people will die. We can't rewrite the history books. For every one person who died, two people, in the best of all worlds, will die. Why? Because even if we discover a vaccine, that's not going to be for the 40 million people now, or the next 40 million people who don't get the vaccine. It will be for the people on down the line.

Africa. My love of Africa is real. I spend at least one trip a year there working with people with HIV/AIDS as part of the medical mission team. But it's not just an African problem. It's a problem that is rolling across the Caribbean, that is rolling across India, that is rolling across China. The fastest growing rate is indeed in yet another country, that is Russia. 23 million dead. 60 million people will more than likely die. 40 million in the next year. 40 million people have it today. What will the history books say when they look back upon 2003? Did we stand up? Or did we not?

In January of last year, I was walking through the slums of Arusha. And the slums have a connotation, in the United States, of being a bad part of town. The slums are just where people live in most of the world today. And we met with different people but the face of AIDS really came across to me through a woman by the name of Tabu. Tabu is 28 years old, walking through the slums, a mud hut about 8 feet by 8 feet, tin roof -- many of you have seen outside Nairobi, Arusha, and throughout Africa, the sort of slums I'm talking about. We went to see her, bright sun outside, dark inside this mud hut. But everything very clean. This 8 feet by 8 feet, she lives there with her 11 year old child -- but she's 28 years old. I couldn't see very much coming into the room, but I did see this big smile, and as I got closer I saw this sense of hope.

But then as I got a little closer, I saw somebody that is thin, that is wasted, that, in medicine, is what we call cachectic, that clearly was not going to live another year. Her two younger children she sent out two weeks before to live with her mother across the slums -- on the other side of the slums -- but pretty far, about a mile away, because she could physically no longer take good care of them. As she told me the story, she was embarrassed. She was embarrassed because this little virus was killing her in part; but in truth, it's because she had to send her children away because she physically could not take care of them. The next day she would leave her hut, because she couldn't live any longer there, to go join her mother. One week later, Tabu died.

I mention that story because it's the face of 40 million people around the world today. But really, more to paint that face because we know a lot about this little tiny virus. This is a little tiny virus -- the naked eye can't see it -- this is a little virus out there. We know a lot about it. Can't cure it, but we can treat it. We can prevent it. We can provide care, and we do know how to treat it today.

The key point to me is that only American leadership, only -- and this is not said out of arrogance, this is said out of many of the things that Peter Bell talked about -- we have to talk to the leaders of other countries and convince them, so that no matter how much we care, unless the leaders of other countries care as well, we really can't do very much. So, only American leadership can people like Tabu -- that face of AIDS -- truly hope for a fuller, happier, more productive life.

Have we responded as a nation up to now? Not terribly, not bad. I think we have a lot to be proud of as I look at what has been invested since I've been in the United States Senate. We started with about $150 million in 1999 and we've increased eight-fold to about $1.2 billion today -- and that's steady progress. But with the President's announcement the other day at the State of the Union, he catapulted onto the world stage not just the increase of $10 billion -- we spent $159 million five years ago and we've increased it up to about $1.2 billion -- he's talking about adding $15 billion. That's important. But what's even more important is the President of the United States -- speaking for you, speaking for the American people -- has demonstrated global leadership in opening the eyes of the world to the devastation, to this greatest humanitarian crisis of our times, and possibly of all times.

That is the hope Africa needs, the hope all people with HIV need -- people in India and China and Russia and around the world. If America does continue to summon our moral courage to lead the fight against HIV/AIDS, we will literally change the course of world history. Tens of millions of lives will be saved. But we will change the course of world history. All of a sudden you can figure out -- you get to see -- why the Majority Leader's sign indeed begins to make sense.

The most common question I get is, "Why in the world would you leave 20 years in the practice of medicine where you have the privilege, you are blessed, you've been given the tools by many of you what you support here at Princeton, and other higher education institutions that I've been to, you give that up to translate it into being a politician?" All of a sudden the healing process comes alive. The motivation -- not just for me -- but the motivation of public service comes alive. It's reflected and HIV's reflected: being a physician back in Tennessee where I operated, being a physician in Africa, where I do medical mission work, and now being a physician in the United States Senate. You see the HIV/AIDS, and that's why I wanted to build on what Peter Bell presented earlier today because it clicks, you see the importance of this broad approach to education.

Now I'm the Majority Leader of the United States Senate. What's the most common question I'm asked? It's very simple: "What is your greatest challenge?" I don't know yet, but let me tell you what I think it is. My answer is to compel the United States Congress to stretch our horizons -- and that's hard -- to address what is to me a very obvious growing imbalance between the policies, on the one hand, and the inevitable, immutable demographic shift caused by the aging of America's population. The imbalance may not be initially obvious, but in a few minutes, I want to be able to walk through and tell you why, when I said earlier it's important to each and every one of you in the room.

First of all, this demographic tidal wave -- the Baby Boom, the 1940s, after the war -- fertility rates went up. So, you really had fertility rates going up like this, and after the Baby Boom going up, and then coming down. That wave is moving through and hitting now retirement age -- 65 years of age. And that wave is going to hit starting about seven years from now. It's imminent and fast approaching. It is powerful -- much more powerful than previously imagined. Our policies don't reflect the realities of that Baby Boom. Our policy makers don't reflect that reality in the issues that we have heretofore addressed. There is what I refer to as a long-term leadership gap.

Politicians, for self-survival reasons, tend to think short-term. On average, your next election is two years away, probably about four years away. Senators run every six years, but we only have a third running every time. So, most of the people in Congress -- 535 people -- you have 435 running every two years and the senators, a third of them running two years from now. For self-survival, you're going to be thinking what your 6 million constituents in Tennessee think if you want to stay in office. I think people stay in office too long, by the way.

So you begin to understand. The politicians -- when I'm out and I'm in Tennessee, and I have a town meeting of people who come who care about the fact that 44 million people are uninsured in their community and they're coming to me -- it is hard to stretch them to be thinking about what happens in Southern Sudan, where I was in January. 2 million people dead. 5 million people displaced. "That's bad, but I came to hear you, Senator Frist, because I don't have health insurance and my child is sick." It's a stretch. A politician has to think short-term, but also think long-term.

Let me also add something which is not quite as apparent. It's more "inside baseball" and what happens in the United State Congress. Our Senate corporate institutional procedures are short-term. Our budgeting process is only five years. So when we start our budgeting process here in about a month, we look at what happens both to entitlements and to non-mandatory spending in a period of five years. Occasionally, we'll go out to 10 years. But the budgeting process, and all of our Senate rules, are written to focus on a five-year budget window.

The problem, what I just told you about this tidal wave of the Baby Boom coming through, which will affect every one of you, hits in seven years. Therefore, from the political standpoint, with people thinking too short-term, and from the overall standpoint of the rules, the institutional rules that have evolved over a couple hundred-year history in the United States Senate simply don't force you, don't encourage you, to look outside of that five-year window.

Thus, my challenge as Majority Leader is to pull the will of the United States Congress in a way that looks not just short-term, mid-term, but looks long-term. Long-term is not that long -- beginning in seven years. And that long-term vision is absolutely critical, and I'll tell you why. Because of this tidal wave of the Baby Boom -- this burst, this surge demographically driven in our population.

Let me just break it down to three different groups. Number one: those of you who happen to be grandparents, or say greater than 65 years of age, who come back to see a student who is here or come back for Alumni Day. You know better than anyone else why Medicare is important, because you saw before 1965 that we had a system in which there were obvious barriers to living healthier, and more productive, and longer lives. You're living longer, and you're living healthier. It's as simple as that. You have much better access to health care than before, when the program was enacted in 1965. This is the Medicare program -- the Medicare program takes care of about 30 million people, 35 million people today, seniors, and about 5 million individuals with disabilities. That's what our Medicare system is.

And you've saved costs that, before 1965, you actually had no protection from, that could be totally devastating to you and your family. In 1963, President Kennedy, as he was laying the road with the vision of Medicare said: "A proud and resourceful nation can no longer ask its people to live in constant fear of a serious illness for which adequate funds are not available. We owe the right of dignity in sickness as well as in health."

But the challenge we have is that the program was designed in 1965. And at that time, sickness was defined by acute, episodic illnesses going in the hospital. That's the way the system was designed. The system has not really changed very much since 1965. It has not incorporated preventive care or chronic disease management. As we live longer, there are more and more chronic diseases or long-term care. There are gaps in coverage -- or the one that's hot politically and the one you'll see me fighting about on the Senate floor is prescription drugs. Medicare itself has not changed very much. Health care delivery, science, medicine, molecular biology, genetics -- they've been changing like this and we have a system which has not adapted.

For those of you who are under 65 and not students -- why should you care? Because you are the ones who are paying today for your parents or your grandparents. The payroll tax is paid out the next day. There is no such a thing as a trust fund, really, not in the sense that you think of a trust fund. The money that comes in is the money that goes out. Your taxes are coming in, your taxes are expended. That works fine under relatively stable economic times. In truth, the economy is fairly stable, if you look over a hundred-year period, and if the demographics are relatively stable over time. But the problem is we have this imminent powerful surge unprecedented in the history of this country of this demographic of the aging of the population.

If you're under 65 today, you're part of this Baby Boom that is coming through. You'll hit the Medicare rolls in seven years. The number of people who will be on Medicare 30 years from now will go from 30 million people, double. It'll go from 40 million people up to about 77 million people. So over the next 30 years, the number of seniors will double. You'll go from about 12 percent of the population today to 22 percent of the population in 2030. You'll go from that much of the population to that much of the population.

Thus, if you're under 65, say you're 55, why should you be concerned? Be ready, if we don't do anything, to give up the benefits of Medicare today. Be ready if you have private health insurance today -- say an employer-sponsored plan -- be ready today to give up benefits like preventive care because there's none in Medicare. There is no stop-gap for catastrophic coverage in Medicare today. There are no annual physical exams in Medicare today. There are absolutely no prescription drugs on an outpatient basis in Medicare today. So when you hit 65, just be aware that you need to be ready for that. Medicare simply hasn't kept up with the overall delivery of health care today.

The last group in the room I'd like to talk to, those who are students or student-age. Why should students care today? Well, there are lots of reasons. First, and this is probably the last time I can say this to Harrison, because I told you so. But really, it's because in a few years, when you leave here four or five years from now, you'll be paying a payroll tax. Every month you'll take 7.65 percent of what you earn to support Social Security and Medicare. You think that's for you later. It's not. That money is being paid out right now. You'll pay that as long as you earn a paycheck. It that too high? Is that too low? I think people are pretty comfortable with it now. The problem is that it can't sustain the program long-term.

Part of the problem is that we're doubling the number of seniors -- we're going from 40 to 77 million people. That's bad enough. The real problem is because this was a Baby Boom coming through. The number of workers available to support each senior is going to be cut in half. It's going to go. Right now, four people are working to support one senior in this pay-as-you-go system. It's working O.K. because of the demographics. In 30 years, we'll only have 2.3 people. These 2.3 have to work twice as hard if you're going to be giving the senior these same benefits. Why? Because nothing changes in the system. It's just the demographics. So it's pretty clear: we have double the number of seniors. But for each one of those seniors, we have half the number of people working. Thus, the burden is twice as great for them to support a senior -- but really four times as great because they're having to support double the number of seniors as we go forward.

Life expectancy: I'll just add this as a fact. This is great -- this is what my business really is. Politics is what I'm doing for a period of my life, but what I really am is a physician. It started with my dad when I was a little boy and my brother, who's a physician, and my other brother, who's a physician. The goal of it really is to improve life and to make lives on an individual basis more fulfilling. And my thesis is that it is no different from what I do in the political arena now. But there are certain goals you measure. Over the next 30 years, we will increase life expectancy -- if you reach age 65 -- by another 10 percent. Pretty amazing. If you reach 65 years of age, we're going to increase the number of years you're going to live by 10 percent. It's the miracles of medicine and science and really what I've given my life for -- and many of you in the healthcare profession, and science, and research. On the other hand, it's a huge expense that we need to, in some way, be able to account for which, today, given our current policies, we don't. More seniors, seniors living longer and fewer workers to support each senior.

What's the urgency? Why act now? As an aside again, majority leader sounds good, and you are the leader of the majority caucus in the United States Senate. But people assume you've got a lot of power. They assume that you can just control the place. There is no power to it. You learn quickly that there's no power. But the one thing you do is control what is brought to the floor of the United States Senate. I have -- my position gives me -- the ability to decide what the United States Senate debates on the floor of that body, and thus what becomes legislation. So the priorities that you hear about are affected by my past. I talk about Africa, and I talk about the importance of our global community at the same time as Medicare.

But then you have to ask, "What's the sense of urgency? Why bring this issue to the floor now versus later?" The demographics are fixed. You can't move the goal posts. This is not something you can shift to the future. Politicians can't play with this one -- it is there.

Number two: health care delivery is complicated. All of you know it as you look at prescription bottles and you see different doctors and where medical records go -- what advances there are with taking gall bladders out today and knee operations non-invasively. Delivery is complicated today as we go forward because, if we're changing that system, we can't just say it's going to be changed and we'll have the system fixed. Very different than the sibling entitlement program. You have Medicare and Social Security -- the two big entitlement programs. Both are affected by demographics. Society Security is a piece of cake to fix.

I say that a little bit tongue in cheek. The reason I say that is that, actuarially, you just dial in the formulas. You can increase taxes, you can decrease taxes, you can cut the benefits -- you can just dial in the numbers because it's a formula. You have the same actuarial problems, the same formulas in health care. But you also have the intimacy of health care, the desire to want the very best health care for your wife if she gets cancer, or for your child who has leukemia. You're going to demand the very best. In America, we can, in many ways, deliver the very best. You've got that intimacy. Plus you have systems which have to adjust. If we truly want to integrate health care, and we have to take prescription drugs, and just like we did with hospitals back in 1965, physicians shortly thereafter. Preventive care is not there. Prescriptions aren't there. We have to integrate those into a health care delivery, not a nationalized system, but on individual care, where you can give people individual choice in the plans that they need. They can get the care they need in an integrated, coordinated way.

Thirdly, why aggressive now? If it's less abrupt -- again this goes back to the politics of it, and you've got millions of seniors in your district, and individual disabilities -- if you can sit down and talk to them in a non-panic atmosphere, seven years our or six years out, it takes a long time to put this system in. You can do it in a way that's less threatening. Imagine yourself: you might be living with your children and you're 85 years old, or in a nursing home, or in a community, and somebody comes in and says, "We're going to change your health care from what it is and do something else for you." It is scary. The unknown is scary. Thus, we'd have more time to both educate and talk through what is appropriate for our seniors -- less drastic, more time for the transition.

What do we need today in terms of health care security? Let me just say that my goal -- and I will outline hopefully what you'll see unfold, and I'm listening right now widely about what we should do -- but my goal is to really change the purpose of Medicare in terms of goal -- to improve it and expand it to giving seniors and individuals with disabilities health care security. If you're 85 years old, at the end of the day, you're sort of sitting there, and your biggest fear is that something catastrophic will happen, or you won't be able to get the care that you need, or you'll become a financial burden on your children or your grandchildren. So health care security, I think, is ultimately what we want to do.

Number two: if you ask seniors what that means, it means some pretty simple things. It means good preventive care, affordable prescription drugs, protection from these catastrophic events that will occur in their lives. I'm talking to all of you, because all of you are going to be in this situation. You want access, or reasonable access to the technology, or at least what other people are getting in the United States of America.

Now, I'm a physician, and I'm in a position to help bring up to date this program. I occupy a position that allows me to facilitate the debate. I don't pretend to have the answers as we go forward. But to address these issues in an objective, disciplined, focused and bipartisan way -- can we do it? I think we can. I think we have no chance to continue to guarantee health care security for you and our seniors unless we address it now, outside of a crisis situation, which we'll be in seven years.

Let me mention that the doctor-patient relationship is something that is important to me. It's important to me, again, because I grew up with it watching my dad and his patients, my brothers and their patients, and me and my patients. There's nothing more intimate, in terms of that relationship, in terms of coordination of care, in opening up and dealing with issues. That bond of trust between Medicare and America's seniors, to me, is very much like that doctor-patient relationship.

What do we need to do in terms of drugs? The President of the United States has said that the starting point can be $400 billion. That's to put into a program. But if we just add that to a program in a free for all -- I've just told you that the demographics are going to bring down the system unless we act. So to add a benefit that, people ask me, "How much is prescription drugs?" Prescription drugs is equally important to the hospital today. And it certainly will be five years from now in terms of your lives. Seniors over the next 10 years are going to spend $1.8 trillion on prescription drugs. That's how much they're going to actually spend. The overall federal budget is only $1.3 trillion.

We have an opportunity not just to add prescription drugs. We have an opportunity to integrate our health care system -- to integrate it in a way that seniors will have a better choice. They'll have a choice of integrated plans. They'll be able to have access to catastrophic care, preventive care, and prescription drugs. Private health care plans must compete in this model. We must capture the dynamic of the marketplace with very significant regulation to keep the playing fields fair by government for those 40 million people under Medicare, soon to be 80 million people.

The element of competition is important, because it allows integration into the system -- assimilation into the system of the very best health care delivery tools that we have today. It'll be a system of expanded choice. The federal government is not going to force a senior to leave a program that they have now. They can keep what they have now. But remember, I just told you, that if we offer similar to the type of health care that I get, the Federal Employees' Health Benefit Plan, I have the choice of fee-for-service, point-of-service, and other types of plans every year that I can enter. And every one of those plans includes prescription drugs. We need to make sure that we fix the system in the sense that we don't have physicians leaving Medicare as they are today because of unfair reimbursement procedures. We need to make sure the seniors who enroll in these plans and want additional benefits -- that they need to be able to pay a larger burden of those costs, something that's not been done in Medicare today. If you're very rich and very wealthy in Medicare today, you can't pay the cost today. The taxpayer has to pay those costs. We've also got to guarantee real protections for low-income seniors by providing very important, critical, additional subsidies and support for them.

At the end of the day, I don't know how the debate is going to work out. I can tell you it will be on the floor of the United States Senate. I hope it will be there in early March. It is clear to me that we can address it in a bipartisan way. I hope that we can keep it out of politics and recognize that, as leaders in the United States Senate and the United States Congress, we have a real responsibility to face this tidal wave -- this surge that is coming before us.

Let me close and simply say that I've taken the opportunity to talk about two challenges based, in part, because I think they both reflect my experience here at Princeton.

One is faced by our nation alone -- unique to our nation -- this demographic shift, peculiar to our nation, peculiar to our government, peculiar to the procedures that force us to look at short-term health care security. And the other is one faced by the world -- this deadly and destructive tidal wave, parallel to the demographics in many ways -- the HIV/AIDS virus.

These challenges paint really dark clouds on the horizon in many ways. And, when I put them together, people start scratching their heads and wondering what's going to happen to us. But considering their potential to do greater harm in the future, they are really just sort of a gathering storm that we have today.

We don't face challenges too often in this country until they become real crises. We have terrorism on our soil today. We're all going through a tough time. Nobody wants to go to war today. We know we are at war on terrorism today. It's a parallel that we struggle with, and that I struggle with, that the President of the United States struggles with. We know that there is a growing terrorist threat today. We know that our government probably failed to recognize that there was a growing terrorist threat over the last two decades to this country and internationally.

What if we acted not to keep a crisis from happening again, but to keep a crisis from happening in the first place? You see what that challenge is with health care. With guaranteeing health care security -- which is one of the most intimate, valuable, personal things in our lives. When you think about the HIV/AIDS virus, it's devastating that it's killed 23 million people. But when I tell you for sure it's going to kill, for every one in the past, two in the future. What we need -- not just me, I just facilitate -- it needs people such as you. It's not just the United States of America, but it is the world.

We the people of the United States of America -- although we like to think in many ways that we don't have a responsibility -- are indeed stewards of a great republic. We elect leaders to represent our interests, which are the interests of the greatest nation in the history of the world.

As I mentioned, the vision of our leaders is constrained by near-term forces, and that's my immediate challenge. But, when the people speak, the politicians and the public servants will listen. They will act, they will address those concerns, and, if compelled, they can address distant challenges before they become real crises.

So, in closing, I ask the Princeton family to continue to lift your eyes to the horizon and join me, and so many others, both in this room and in the Princeton community, to commit the will of this great, great nation to face the challenges of tomorrow. Yes, there are a few clouds, and we see them live under them every day. But in the distance, there is a future that is as bright and glorious and optimistic as our past. It's just a matter of each and every one of us seizing it today.

Thank you.

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