This is the accessible text file for CG Presentation number GAO-07-1273CG entitled 'Fiscal Stewardship and Health Care Transformation' which was released on September 28, 2007. 

United States Government Accountability Office:
GAO: 

Fiscal Stewardship and Health Care Transformation:

The Honorable David M. Walker: 
Comptroller General of the United States:  

Aging Revolution Summit: 
Wesley Enhanced Living: 
Philadelphia, PA:  

September 27, 2007:  

Composition of Federal Spending:  

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There are three pie charts, containing the following compositions of spending by category: 

Year: 1966;
Defense: 43%;
Social Security: 15%; 
Medicare and Medicaid: 1%; 
Net Interest: 7%; 
All Other: 34%. 

Year: 1986;
Defense: 28%;
Social Security: 20%; 
Medicare and Medicaid: 10%; 
Net Interest: 14%; 
All Other: 29%. 

Year: 2006;
Defense: 20%;
Social Security: 21%; 
Medicare and Medicaid: 19%; 
Net Interest: 9%; 
All Other: 32%. 

Source: Office of Management and Budget and the Department of the Treasury. 

Note: Numbers may not add to 100 percent due to rounding. 

[End of figure] 

Federal Spending for Mandatory and Discretionary Programs: 

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There are three pie charts, containing the following compositions of spending by category: 

Year: 1966;
Discretionary: 67%; 
Mandatory: 26%; 
Net Interest: 7%.  

Year: 1986;
Discretionary: 44%; 
Mandatory: 42%; 
Net Interest: 14%.  

Year: 2006;
Discretionary: 38%; 
Mandatory: 53%; 
Net Interest: 9%.  

Source: Office of Management and Budget.  

[End of figure]  

Table: Fiscal Year 2005 and 2006 Deficits and Net Operating Costs:  

On-Budget Deficit, Fiscal Year 2005 ($ Billion): (494);
On-Budget Deficit, Fiscal Year 2006 ($ Billion): (434); 

Unified Deficit[a], Fiscal Year 2005 ($ Billion): (318); 
Unified Deficit[a], Fiscal Year 2006 ($ Billion): (248); 

Net Operating Cost[b], Fiscal Year 2005 ($ Billion): (760); 
Net Operating Cost[b], Fiscal Year 2006 ($ Billion): (450);  

Sources: Office of Management and Budget and Department of the Treasury.  

[a] Includes $173 billion in Social Security surpluses for fiscal year 2005 and $185 billion for fiscal year 2006; $2 billion in Postal Service surpluses for fiscal year 2005 and $1 billion for fiscal year 2006.  

[b] Fiscal year 2005 and 2006 net operating cost figures reflect significant but opposite changes in certain actuarial costs. For example, changes in interest rates and other assumptions used to estimate future veterans’ compensation benefits increased net operating cost by $228 billion in 2005 and reduced net operating cost by $167 billion in 2006. Therefore, the net operating costs for fiscal years 2005 and 2006, exclusive of the effect of these actuarial cost fluctuations, were ($532) billion and ($617) billion, respectively.  

[End of table]  

Table: Major Fiscal Exposures ($ trillions): 

Explicit liabilities (Publicly held debt, Military & civilian pensions & retiree health, Other): 
2000: $6.9; 
2006: $10.4; 
Percent increase: 52. 

Commitments & contingencies (e.g., PBGC, undelivered orders):
2000: 0.5;
2006: 1.3
Percent increase: 140.  

Implicit exposures: 
2000: 13.0; (Future Social Security benefits: 3.8; Future Medicare Part A benefits: 2.7; Future Medicare Part B benefits: 6.5; Future Medicare Part D benefits: 0).
2006: 38.8; (Future Social Security benefits: 6.4; Future Medicare Part A benefits: 11.3; Future Medicare Part B benefits: 13.1; Future Medicare Part D benefits: 7.9).
Percent increase: 197.  

Total, 2000: $20.4; 
Total, 2006: $50.5; 
Percent increase: 147.  

Source: 2000 and 2006 Financial Report of the United States Government.  

Note: Totals and percent increases may not add due to rounding.Estimates for Social Security and Medicare are at present value as of January 1 of each year and all other data are as of September 30.  

[End of table] 

Table: How Big is Our Growing Fiscal Burden?  

This fiscal burden can be translated and compared as follows:  

Total major fiscal exposures: $50.5 trillion; 
Total household net worth[1]: $53.3 trillion; 
Burden/Net worth ratio: 95 percent. 

Burden[2]: 
Per person: $170,000; 
Per full-time worker: $400,000; 
Per household: $440,000. 

Income: 
Median household income[3]: $46,326; 
Disposable personal income per capita[4]: $31,519.  

Source: GAO analysis.  

Notes: (1) Federal Reserve Board, Flow of Funds Accounts, Table B.100, 2006:Q2 (Sept. 19, 2006); (2) Burdens are calculated using estimated total U.S. population as of 9/30/06, from the U.S. Census Bureau; full-time workers reported by the Bureau of Economic Analysis, in NIPA table 6.5D (Aug. 2, 2006); and households reported by the U.S. Census Bureau, in Income, Poverty, and Health Insurance Coverage in the United States: 2005(Aug. 2006); (3) U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2005(Aug. 2006); and (4) Bureau of Economic Analysis, Personal Income and Outlays: October 2006, table 2, (Nov. 30, 2006).  

[End of table] 

Potential Fiscal Outcomes Under Baseline Extended (January 2001); Revenues and Composition of Spending as a Share of GDP.  

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This is a line/stacked bar graph with one line (revenue) and four stacked bars containing four spending items (Net interest, Social Security, Medicare and Medicaid, and All other spending). The vertical axis represents Percent of GDP and the horizontal axis represents fiscal years 2005, 2015[a], 2030[a], and 2040[a]. 

Source: GAO’s January 2001 analysis.  

[a] All other spending is net of offsetting interest receipts.  

[End of graph]  

Potential Fiscal Outcomes Under Alternative Simulation; Revenues and 
Composition of Spending as a Share of GDP.  

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This is a line/stacked bar graph with one line (revenue) and four 
stacked bars containing four spending items (Net interest, Social 
Security, Medicare and Medicaid, and All other spending). The vertical 
axis represents Percent of GDP and the horizontal axis represents 
fiscal years 2006, 2015, 2030, and 2040.  

Source: GAO’s August 2007 analysis.  

Notes: AMT exemption amount is retained at the 2006 level through 2017 
and expiring tax provisions are extended. After 2017, revenue as a 
share of GDP returns to its historical level of 18.3 percent of GDP 
plus expected revenues from deferred taxes, i.e. taxes on withdrawals 
from retirement accounts. Medicare spending is based on the Trustees 
April 2007 projections adjusted for the Centers for Medicare and 
Medicaid Services alternative assumption that physician payments are 
not reduced as specified under current law. 

[End of graph] 

Social Security, Medicare, and Medicaid Spending as a Percent of GDP:  

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This is a line graph with three stacked lines (Social Security, Medicaid, and Medicare). The vertical axis represents Percent of GDP and the horizontal axis represents fiscal years 2000 through 2080.  

Source: GAO analysis based on data from the Office of the Chief Actuary, Social Security Administration, Office of the Actuary, Centers for Medicare and Medicaid Services, and the Congressional Budget Office.  

Notes: Social Security and Medicare projections based on the intermediate assumptions of the 2006 Trustees’ Reports. Medicaid projections based on CBO’s August 2006 short-term Medicaid estimates and CBO’s December 2005 long-term Medicaid projections under mid-range assumptions.  

[End of graph] 

Federal Tax Expenditures Exceeded Discretionary Spending for Half of the Last Decade:  

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This is a line graph with three lines (Mandatory spending; Sum of tax expenditure revenue loss estimates; and Discretionary spending). The vertical axis represents Dollars in billions (in real 2005 dollars) and the horizontal axis represents fiscal years 1982 through 2005.  

Source: GAO analysis of OMB budget reports on tax expenditures, fiscal years 1976-2007.  

Note: Summing tax expenditure estimates does not take into account interactions between individual provisions. Outlays associated with refundable tax credits are included in mandatory spending. 

[End of graph] 

Revenue Loss Estimates for the Largest Tax Expenditures Reported for Fiscal Year 2006:  

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This is a bar graph with the vertical axis representing Revenue loss estimates (dollars in billions) and the horizontal axis depicting bars indicating the amount of expenditures in six categories. 

Revenue loss estimate, Exclusion of employer contributions for medical insurance premiums and medical care: 187.5 (Treasury estimated income tax revenue losses: 125; Approximate payroll tax revenue losses: 62.5[A]; 

Revenue loss estimate, Deductability of mortgage interest on owner-occupied homes: 68.3;
Revenue loss estimate, Net exclusion of pension contributions and earnings: defined benefit plans: 49[A];
Revenue loss estimate, Capital gains except agriculture, timber, iron ore, and coal): 48.6; 
Revenue loss estimate, Deductability of nonbusiness states and local taxes other than on owner-occupied homes: 43.1; 
Revenue loss estimate, Net exclusion of pension contributions and earnings: 401(k) plans: 40.8[A].  

Source: GAO analysis of OMB, Analytical Perspectives, Budget of the United States Government, Fiscal Year 2008.  

[A] The value of employer-provided health insurance is excluded from Medicare and Social Security payroll taxes. Some researchers have estimated that payroll tax revenue losses amounted to more than half of the income tax revenue losses in 2004, and we use this estimate for 2006. The research we are aware of dealt only with health care, therefore the 50 percent figure may not apply to other items that are excluded from otherwise applicable income and payroll taxes. 

[End of graph] 

Current Fiscal Policy Is Unsustainable:  

* The “Status Quo”is Not an Option: 
- We face large and growing structural deficits largely due to known demographic trends and rising health care costs. 
- GAO’s simulations show that balancing the budget in 2040 could require actions as large as: 
* Cutting total federal spending by 60 percent or; 
* Raising federal taxes to 2 times today's level. 
* Faster Economic Growth Can Help, but It Cannot Solve the Problem: 
- Closing the current long-term fiscal gap based on reasonable assumptions would require real average annual economic growth in the double digit range every year for the next 75 years. 
- During the 1990s, the economy grew at an average 3.2 percent per year. 
- As a result, we cannot simply grow our way out of this problem. Tough choices will be required.  

The Way Forward: A Three-Pronged Approach: 

1. Improve Financial Reporting, Public Education, and Performance Metrics. 
2. Strengthen Budget and Legislative Processes and Controls. 
3. Fundamentally Reexamine & Transform for the 21st Century (i.e., entitlement programs, other spending, and tax policy).  

Solutions Require Active Involvement from both the Executive and Legislative Branches.  

Key National Indicators:  

* What: A portfolio of economic, social, and environmental outcome-
based measures that could be used to help assess the nation’s and other 
governmental jurisdictions’ position and progress; 
* Who: Many countries and several states, regions, and localities have 
already undertaken related initiatives (e.g., Australia, New Zealand, 
Canada, United Kingdom, Oregon, Silicon Valley (California) and 
Boston); 
* Why: Development of such a portfolio of indicators could have a 
number of possible benefits, including; 
- Serving as a framework for related strategic planning efforts; 
- Enhancing performance and accountability reporting; 
- Informing public policy decisions, including much needed baseline 
reviews of existing government policies, programs, functions, and 
activities; 
- Facilitating public education and debate as well as an informed 
electorate; 
* Way Forward: Consortium of key players housed by the National 
Academies domestically and related efforts by the OECD and others 
internationally.  

Key National Indicators: Where the United States Ranks: 

The United States may be the only superpower, but compared to most 
other OECD countries on selected key economic, social, and 
environmental indicators, on average, the U.S. ranks 16 out of 28. 

OECD Categories for Key Indicators (2006 OECD Factbook): 

* Population/Migration;
* Energy;
* Environment;
* Labor Market;
* Education;
* Public Finance;
* Science & Tech.;
* Quality of Life;
* Macroeconomic Trends;
* Economic Globalization
* Prices.  

Demographic Trends Pose Challenges for Employers and Workers:  

* The combination of increasing life expectancy and declining birth rates is expected to reduce the number of workers per retiree, a trend that will strain the finances of national pension and health programs and may affect productivity and economic growth.  

* The impending retirement of the baby boom generation and slower labor force growth will result in the loss of many experienced workers and possible skill gaps in certain occupations.  

* Many older workers face the possibility of less secure retirements. While longer life spans have increased the number of years individuals spend in retirement, pension plans have increasingly shifted financial and longevity risk to individuals and health care costs have risen rapidly.  

* The increasing ratio of the elderly to younger workers will place added pressure on public benefits such as Social Security and Medicare, both of which face long-term financial problems.  

Aged Population as a Share of Total U.S. Population Will Continue to Increase:  

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This is a line graph with one line (population aged 65 and over) with the vertical axis representing percent of total population from 0 to 25 percent and the horizontal axis representing years 1950 through 2075.  

Source: Office of the Chief Actuary, Social Security Administration.  

Note: Projections based on the intermediate assumptions of the 2007 Trustees’ Reports. 

[End of graph].  

U.S. Labor Force Growth Will Continue to Decline: 

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This is a line graph with one line (decline of labor force growth) with the vertical axis representing percentage change (five-year average) from 0 to 3 percent, and the horizontal axis representing years 1970 through 2080.  

Source: GAO analysis of data from the Office of the Chief Actuary, Social Security Administration.  

Note: Percentage change is calculated as a centered 5-year moving average of projections based on the intermediate assumptions of the 2007 Trustees Reports.  

[End of graph] 

Personal Savings Rate Became Negative in 2006:  

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This is a line graph with one line (personal savings rate) with the vertical axis representing percent of disposable income (from -2.0 to 12.0), and the horizontal axis representing years 1960 through 2005.  

Source: Bureau of Economic Analysis, Department of Commerce.  

[End of graph]  

Key Obstacles to Engaging and Retaining Older Workers:  

* Some employers’ perceptions about the cost of hiring and retaining older workers are a key obstacle in older workers’ continued employment; 
* Total compensation and training costs were seen as primary concerns; * Workplace age discrimination, the mismatch of workers’ skills and availability of jobs because of changes in the economy, as well as the need to keep skills up to date, are all challenges facing older workers; 
* There is a more limited pool of interested workers because of financial incentives to retire as soon as possible, workers’ desire to retire or change careers, and some jobs’ requirements that make continued work unappealing or unfeasible because of health issues; 
* Legal and regulatory requirements hinder hiring and retaining older workers.  

Working Longer May Help Address the Challenges of an Aging Population:  

* Impact on the Economy; 
- Larger labor force; 
- Additional economic growth.  

* Impact on the Federal Budget; 
- Additional tax revenue; 
- Reduced expenditures: Social Security & Medicare.  

* Impact on Individuals; 
- Enhanced retirement security and quality of life.  

The Importance of Seasoned Workers:  

Seasoned workers are our nation’s most underutilized asset. This must change for their sake and the sake of our country.  

Key Elements for Economic Security in Retirement:  

* Adequate retirement income:
- Savings; 
- Social Security; 
- Pensions; 
- Earnings from continued employment (e.g., part-time).  

* Affordable health care: 
- Medicare; 
- Retiree health care.  

* Long-term care (a hybrid).  

* Major Players: 
- Employers; 
- Government; 
- Individuals; 
- Family; 
- Community.  

Social Security and Medicare’s Hospital Insurance Trust Funds Face Cash Deficits:  

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This is a bar graph with vertical bars representing the Medicare HI Cash Flow and Social Security Cash Flow for each fiscal year. The bars indicate a Medicare HI cash deficit beginning in 2007 and a Social Security cash deficit in 2017. The vertical axis of the graph depicts billions of 2007 dollars from -900 to +200. The horizontal axis depicts fiscal years from 2005 through 2040.  

Source: GAO analysis of data from the Office of the Chief Actuary, Social Security Administration and Office of the Actuary, Centers for Medicare and Medicaid Services.  

Note: Projections based on the intermediate assumptions of the 2007 Trustees’ Reports. The CPI is used to adjust from current to constant dollars.  

[End of graph]  

Key Dates Highlight Long Term Challenges of the Social Security System:  

OASI:
Date: 2009;
Event: Cash surplus begins to decline;
Date: 2018;
Event: Annual benefit costs exceed cash revenue from taxes; 
Date: 2028; 
Event: Trust fund ceases to grow because even taxes plus interest fall short of benefits; 
Date: 2042; 
Event: Trust fund exhausted.  

DI:
Date: 2005;
Event: Annual benefit costs exceed cash revenue from taxes; 
Date: 2013; 
Event: Trust fund ceases to grow because even taxes plus interest fall short of benefits; 
Date: 2026; 
Event: Trust fund exhausted.  

OASDI:
Date: 2009;
Event: Cash surplus begins to decline;
Date: 2017;
Event: Annual benefit costs exceed cash revenue from taxes; 
Date: 2027; 
Event: Trust fund ceases to grow because even taxes plus interest fall short of benefits; 
Date: 2041; 
Event: Trust fund exhausted.  

Source: Social Security Administration, The 2007 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Disability Insurance Trust Funds(Washington, DC: April 2007).  

[End of table]  

Possible Way Forward on Social Security Reform:  

Make little or no changes to those who are near retirement or already retired and make a number of adjustments that would affect younger workers:  

* Phase-in an increase in the normal retirement age and index it to life expectancy; 
* Consider phasing-in an increase in the early retirement age and index it to life expectancy with a modified disability access provision; 
* Modify income replacement and/or indexing formulas for middle and upper income earners; 
* Strengthen the minimum benefit; 
* Consider a modest adjustment to the COLA formula; 
* Increase the taxable wage base, if necessary; 
* Consider supplemental individual accounts and mandatory individual savings on a payroll deduction basis (e.g., a minimum 2 percent payroll contribution and a program designed much like the Federal Thrift Savings Plan with a real trust fund and real investments).  

Issues to Consider in Examining Our Health Care System:  

* The public needs to be educated about the differences between wants, needs, affordability, and sustainability at both the individual and aggregate level.  

* Ideally, health care reform proposals will: 
- Align Incentives for providers and consumers to make prudent decisions about the use of medical services; 
- Foster Transparency with respect to the value and costs of care, and; 
- Ensure Accountability from insurers and providers to meet standards for appropriate use and quality;  

* Ultimately, we need to address four key dimensions: access, cost, quality,and personal responsibility.  

Key Dates Highlight Long Term Challenges of the Medicare Program:  

Date: 2007;
Event: Medicare Part A outlays exceed cash income
Date: 2007; 
Event: Estimated trigger date for “Medicare funding warning;”
Date: 2013; 
Event: Projected date that annual “general revenue funding” for Part B will exceed 45 percent of total Medicare outlays;
Date: 2019; 
Event: Part A trust fund exhausted, annual income sufficient to pay about 80% of promised Part A benefits. 

Source: 2007 Annual Report of The Boards of Trustees of the The Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds(Washington, DC, April 2007). 

Number of Non-elderly Uninsured Americans, 1999-2006:  

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This is a bar graph of the number of non-elderly uninsured Americans with 
the vertical axis representing population in millions from 0 to 50 and the 
horizontal axis representing years 1999 through 2006.  

Year: 1999;
Non-elderly Uninsured Americans: 38.8.  

Year: 2000;
Non-elderly Uninsured Americans: 38.4.  

Year: 2001;
Non-elderly Uninsured Americans: 39.8.  

Year: 2002;
Non-elderly Uninsured Americans: 42.0.  

Year: 2003;
Non-elderly Uninsured Americans: 43.4.  

Year: 2004;
Non-elderly Uninsured Americans: 43.5.  

Year: 2005;
Non-elderly Uninsured Americans: 44.8.  

Year: 2006;
Non-elderly Uninsured Americans: 47.0.  

Source: U.S. Census Bureau, Current Population Survey, 2000-2007 Annual 
Social and Economic Supplements.  

Notes: Estimates for 1999-2005 were revised to reflect the results of a 
change to the survey process that assigns insurance coverage to dependents.  

[End of graph] 

Growth in Health Care Spending: Health Care Spending as a Percentage of GDP:  

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This is a bar graph of the percent of health care spending as a percentage 
of GDP with the vertical axis representing percent from 0 to 25 and the 
horizontal axis representing years 1975, 1985, 1995, 2005, and 2015.  



Year: 1975;
Health care spending: 8.1.  

Year: 1985;
Health care spending: 10.4.  

Year: 1995;
Health care spending: 13.7.  

Year: 2005;
Health care spending: 16.0.  

Year: 2015;
Health care spending: 19.2.  

Source: The Centers for Medicare & Medicaid Services, Office of the Actuary.  

Note: The figure for 2015 is projected.  

[End of graph]  

Growth in Health Care Spending: Health Care Spending as a Percentage of GDP: Cumulative Growth in Real Health Care Spending Per Capita and Real GDP Per Capita, 1960-2005: 

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This is a line graph with two lines (Real health care spending per capita and Real GDP per capita) with the vertical axis representing percentage from 0 to 800 and the horizontal axis representing years 1960 through 2005. The Real health care spending per capita line indicates an average annual growth rate of 4.9%, and the Real GDP per capita line indicates an annual growth rate of 2.3%.  

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services, Office of the Actuary, and the Bureau of Economic Analysis.  

Note: The most current data available on health care spending per capita are for 2005.  

[End of graph]  

Where the United States Ranks on Selected Health Outcome Indicators:  

Outcome: Life expectancy at birth (U.S. = 77.8 years in 2004);
Rank: 23 out of 30 in 2004. 

Outcome: Infant Mortality (U.S. = 6.8 deaths in 2004); 
Rank: 26 out of 30 in 2004.  

Outcome: Potential Years of Life Lost( U.S. = 5,066 in 2002); 
Rank: 23 out of 26 in 2002.  

Source: OECD Health Data 2006 and 2007.  

Notes: Data are the most recent available for all countries. Life expectancy at birth for the total population is estimated by the OECD Secretariat for all countries, as the unweighted average of the life expectancy of men and women. Infant mortality is measured as the number of deaths per 1,000 live births. Potential years of life lost (PYLL) is the sum of the years of life lost prior to age 70, given current age-specific death rates (e.g., a death at 5 years of age is counted as 65 years of PYLL).  

[End of table] 

Selected Potential Health Care Reform Approaches:  

Reform Approach: Revise the government’s payment systems and leverage its purchasing authority to foster value-based purchasing for health care products and services; 
Short-term action: [check];
Long-term action: [empty]. 

Reform Approach: Consider additional flexibility for states to serve as models for possible health care reforms; 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Consider limiting direct advertising and allowing limited importation of prescription drugs; 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Foster more transparency in connection with health care costs and outcomes; 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Create incentives that encourage physicians to utilize prescription drugs and other health care products and services economically and efficiently. 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Foster the use of information technology to increase consistency, transparency, and accountability in health care; 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Encourage case management approaches for people with chronic and expensive conditions to improve the quality and efficiency of care delivered and avoid inappropriate care. 
Short-term action: [check];
Long-term action: [empty].  

Reform Approach: Reexamine the design and operational structure of the nation’s health care entitlement programs—Medicare and Medicaid, including exploring more income-related approaches; 
Short-term action: [check];
Long-term action: [check]. 

Reform Approach: Revise certain federal tax preferences for health care to encourage more efficient use of health care products and services; 
Short-term action: [check];
Long-term action: [check]. 

Reform Approach: Foster more preventative care and wellness services and capabilities, including fighting obesity and encouraging better nutrition; 
Short-term action: [check];
Long-term action: [check]. 

Reform Approach: Promote more personal responsibility in connection with health care; 
Short-term action: [check];
Long-term action: [check]. 

Reform Approach: Limit spending growth for government-sponsored health care programs (e.g., percentage of the budget and/or economy); 
Short-term action: [empty]; 
Long-term action: [check]. 

Reform Approach: Develop a core set of basic and essential services. Create insurance pools for alternative levels of coverage, as necessary; 
Short-term action: [empty]; 
Long-term action: [check]. 

Reform Approach: Develop a set of evidence-based national practice standards to help avoid unnecessary care, improve outcomes, and reduce litigation; 
Short-term action: [empty]; 
Long-term action: [check]. 

Reform Approach: Pursue multinational approaches to investing in health care R&D; 
Short-term action: [empty]; 
Long-term action: [check]. 

[End of table] 

Three Key Illnesses:  

* Myopia; 
* Tunnel Vision; 
* Self-Centeredness.  

Four National Deficits:  

* Budget; 
* Balance of Payments; 
* Savings; 
* Leadership.  

Five Leadership Attributes Needed for These Challenging and Changing Times:  

* Courage; 
* Integrity; 
* Creativity: 
* Stewardship: 
* Partnership.  

[End of presentation] 

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