Q Also I'm looking towards my future with career options and opportunities and I don't want inflation to skyrocket by just adding this to the national debt. So I'm wondering how we can avoid both of those scenarios. (Applause.)

THE PRESIDENT: Right, it's a great question. First of all, I said I won't sign a bill that adds to the deficit or the national debt. Okay? So this will have to be paid for. That, by the way, is in contrast to the prescription drug bill that was passed that cost hundreds of billions of dollars, by the previous administration and previous Congress, that was not paid for at all, and that was a major contributor to our current national debt.

That's why you will forgive me if sometimes I chuckle a little bit when I hear all these folks saying, "oh, big-spending Obama" -- when I'm proposing something that will be paid for and they signed into law something that wasn't, and they had no problem with it. Same people, same folks. And they say with a straight face how we've got to be fiscally responsible. (Applause.)

Now, having said that, paying for it is not simple. I don't want to pretend that it is. By definition, if we're helping people who currently don't have health insurance, that's going to cost some money. It's been estimated to cost somewhere between, let's say, $800 billion and a trillion dollars over 10 years. Now, it's important that we're talking about over 10 years because sometimes the number "trillion" gets thrown out there and everybody think it's a trillion dollars a year -- gosh, that -- how are we going to do that? So it's about a hundred billion dollars a year to cover everybody and to implement some of the insurance reforms that we're talking about.

About two-thirds of those costs we can cover by eliminating the inefficiencies that I already mentioned. So I already talked about $177 billion worth of subsidies to the insurance companies. Let's take that money, let's put it in the kitty. There's about $500 billion to $600 billion over 10 years that can be saved without cutting benefits for people who are currently receiving Medicare, actually making the system more efficient over time.

That does still leave, though, anywhere from $300 billion to $400 billion over 10 years, or $30 billion to $40 billion a year. That does have to be paid for, and we will need new sources of revenue to pay for it. And I've made a proposal that would -- I want to just be very clear -- the proposal, my preferred approach to this would have been to take people like myself who make more than $250,000 a year, and limit the itemized deductions that we can take to the same level as middle-class folks can take them. (Applause.)

Right now, the average person -- the average middle-class family, they're in the 28-percent tax bracket, and so they basically can itemize, take a deduction that is about 28 percent. I can take -- since I'm in a much higher tax bracket, I can take a much bigger deduction. And so as a consequence, if I give a charitable gift, I get a bigger break from Uncle Sam than you do.

So what I've said is let's just even it out. That would actually raise sufficient money. Now, that was my preferred way of paying for it. Members of Congress have had different ideas. And we are still exploring these ideas.

By the time that we actually have a bill that is set, that is reconciled between House and Senate and is voted on, it will be very clear what those ideas are. My belief is, is that it should not burden people who make $250,000 a year or less.

And I think that's the commitment that I made, the pledge that I made when I was up here running in New Hampshire, folks. So I don't want anybody saying somehow that I'm pulling the bait- and-switch here. I said very specifically I thought we should roll back Bush tax cuts and use them to pay for health insurance. That's what I'm intending to do. All right? (Applause.)

Okay, I've only got time for a couple more questions. Somebody here who has a concern about health care that has not been raised, or is skeptical and suspicious and wants to make sure that -- because I don't want people thinking I just have a bunch of plants in here. All right, so I've got one right here -- and then I'll ask the guy with two hands up because he must really have a burning question. (Laughter.)

All right, go ahead.

Q Thank you, Mr. President. I've worked in the medical field for about 18 years and seen a lot of changes over those 18 years. I currently work here at the high school as a paraprofessional. I have a little, you know, couple questions about the universal insurance program, which, if I understand you correctly, President Obama, you seek to cover 50 million new people over and above the amount of people that are currently getting health care at this moment.

THE PRESIDENT: It will probably -- I just want to be honest here. There are about 46 million people who are uninsured. And under the proposals that we have, even if you have an individual mandate, probably only about 37-38 million, so somewhere in that ballpark.

Q Okay, I'm off a little bit. (Laughter.)

THE PRESIDENT: No, no, I just wanted to make sure I wasn't over-selling my plan here.

Q That's okay, Mr. President. (Laughter.)

THE PRESIDENT: She's okay --

Q He winked at me. (Laughter.) My concern is for where are we going to get the doctors and nurses to cover these? Right now I know that there's a really -- people are not going to school to become teachers to teach the nursing staffs. Doctors have huge capacities; some of them are leaving private to go to administrative positions because of the caseload that they're being made to hold. I really do feel that there will be more demand with this universal health care and no added supply. I also understand that it was to be taken from Medicare, about $500 billion -- correct me if I'm wrong on that.

THE PRESIDENT: I just said that.

Q Okay. Also, you know, I'm very, very concerned about the elderly. I don't know if this is also correct, but I understand that a federal health board will sit in judgment of medical procedures and protocols to impose guidelines on all providers -- when to withhold certain types of care -- like, what is the point you get to when we say, I'm sorry that this cannot happen. Thank you very much for letting me ask those questions, Mr. President.

THE PRESIDENT: Of course. Well, first of all, I already mentioned that we would be taking savings out of Medicare that are currently going to insurance subsidies, for example. So that is absolutely true.

I just want to be clear, again: Seniors who are listening here, this does not affect your benefits. This is not money going to you to pay for your benefits; this is money that is subsidizing folks who don't need it. So that's point number one.

Point number two: In terms of these expert health panels -- well, this goes to the point about "death panels" -- that's what folks are calling them. The idea is actually pretty straightforward, which is if we've got a panel of experts, health experts, doctors, who can provide guidelines to doctors and patients about what procedures work best in what situations, and find ways to reduce, for example, the number of tests that people take -- these aren't going to be forced on people, but they will help guide how the delivery system works so that you are getting higher-quality care. And it turns out that oftentimes higher-quality care actually costs less.

So let me just take the example of testing. Right now, a lot of Medicare patients -- you have something wrong with you, you go to your doctor, doctor checks up on you, maybe he takes -- has a test, he administers a test. You go back home, you get the results, the doctor calls you and says, okay, now you got to go to this specialist. Then you have to take another trip to the specialist. The specialist doesn't have the first test, so he does his own test. Then maybe you've got to, when you go to the hospital, you've got to take a third test.

Now, each time taxpayers, under Medicare, are paying for that test. So for a panel of experts to say, why don't we have all the specialists and the doctors communicating after the first test and let's have electronic medical records so that we can forward the results of that first test to the others -- (applause) -- that's a sensible thing to do. That is a sensible thing to do.

So we want -- if I'm a customer, if I'm a consumer and I know that I'm overpaying $6,000 for anything else, I would immediately want the best deal. But for some reason, in health care, we continue to put up with getting a bad deal. We ™re paying $6,000 more than any other advanced country and we're not healthier for it -- $6,000 per person more, per year. That doesn ™t make any sense. So there's got to be a lot of waste in the system. And the idea is to have doctors, nurses, medical experts look for it.

Now, the last question that you asked is very important and I don't have a simple solution to this. If you look at the makeup of the medical profession right now, we have constant nurses shortages and we have severe shortages of primary care physicians. Primary care physicians, ideally family physicians, they should be the front lines of the medical profession in encouraging prevention and wellness. (Applause.) But the problem is, is that primary care physicians, they make a lot less money than specialists --

AUDIENCE MEMBER: And nurse practitioners.

THE PRESIDENT: And nurse practitioners, too. (Applause.) And nurses, you've got a whole other issue which you already raised, which is the fact that not only are nurses not paid as well as they should, but you also have -- nursing professors are paid even worse than nurses. So as a consequence, you don't have enough professors to teach nursing, which means that's part of the reason why you've got such a shortage of nurses.

So we are going to be taking steps, as part of reform, to deal with expanding primary care physicians and our nursing corps. On the doctors' front, one of the things we can do is to reimburse doctors who are providing preventive care and not just the surgeon who provides care after somebody is sick. (Applause.) Nothing against surgeons. I want surgeons -- I don't want to be getting a bunch of letters from surgeons now. I'm not dissing surgeons here. (Laughter.)

All I'm saying is let's take the example of something like diabetes, one of --- a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family -- if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 -- immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money. (Applause.)

So changing reimbursement rates will help. The other thing that will really help both nurses and doctors, helping pay for medical education for those who are willing to go into primary care. And that's something that we already started to do under the Recovery Act, and we want to do more of that under health care reform. (Applause.)

All right, last question, last question right here. This is a skeptic, right?

Q I am a skeptic.

THE PRESIDENT: Good.

Q Thank you, Mr. President, for coming to Portsmouth. My name is Michael Layon (ph). I'm from Derry, New Hampshire, District 1 in the congressional district. I'm one of the people that turned myself in on the White House Web page the other day for being a skeptic of this bill. I'm proud to have done so.

THE PRESIDENT: Before you ask this question, just because you referred to it, can I just say this is another example of how the media ends up just completing distorting what's taken place. What we've said is that if somebody has -- if you get an e-mail from somebody that says, for example, "Obamacare is creating a death panel," forward us the e-mail and we will answer the question that's raised in the e-mail. Suddenly, on some of these news outlets, this is being portrayed as "Obama collecting an enemies list." (Laughter.)

Now, come on, guys. You know, here I am trying to be responsive to questions that are being raised out there --

Q And appreciate it. (Applause.)

THE PRESIDENT: And I just want to be clear that all we're trying to do is answer questions.

All right, go ahead.

Q So my question is for you, and I know in the White House the stand which you're on has often been referred to as the bully pulpit. Why have you not used the bully pulpit to chastise Congress for having two systems of health care -- one for all of us, and one for them? (Applause.)

THE PRESIDENT: Well, look, first of all, if we don't have health care reform, the gap between what Congress gets and what ordinary Americans get will continue to be as wide as it is right now. And you are absolutely right -- I don't think Carol or Paul would deny they've got a pretty good deal. They've got a pretty good deal. I mean, the fact is, is that they are part -- by the way, I want you to know, though, their deal is no better than the janitor who cleans their offices; because they are part of a federal health care employee plan, it is a huge pool. So you've got millions of people who are part of the pool, which means they've got enormous leverage with the insurance companies, right? So they can negotiate the same way that a big Fortune 500 company can negotiate, and that drives down their costs -- they get a better deal.

Now, what happens is, those members of Congress -- and when I was a senator, same situation -- I could, at the beginning of the year, look at a menu of a variety of different health care options, most of them -- these are all private plans or they could be non-for-profit, Blue Cross Blue Shield, or Aetna, or what have you -- they would have these plans that were offered. And then we would then select what plan worked best for us.

But there were certain requirements -- if you wanted to sell insurance to federal employees there were certain things you had to do. You had to cover certain illnesses. You couldn't exclude for preexisting conditions. I mean, there were a lot of rules that had been negotiated by the federal government for those workers.

Now, guess what. That's exactly what we want to do with health care reform. (Applause.) We want to make sure that you are getting that same kind of option. That's what the health exchange is all about, is that you -- just like a member of Congress -- can go and choose the plan that's right for you. You don't have to. If you've got health care that you like, you don't have to use it.

So for example, for a while, Michelle, my wife, worked at the University of Chicago Hospital. She really liked her coverage that she was getting through the University of Chicago Hospital, so I did not have to use the federal employee plan. But I had that option available.

The same is true for you. Nobody is going to force you to be part of that plan. But if you look at it and you say, you know what, this is a good deal and I've got more leverage because maybe I'm a small business or maybe I'm self-employed, or maybe I'm like Lori and nobody will take me because of a preexisting condition, and now suddenly got these rules set up -- why wouldn't I want to take advantage of that?

Now, there are legitimate concerns about the cost of the program, so I understand if you just think no matter what, no matter how good the program is, you don't think that we should be paying at all for additional people to be covered, then you're probably going to be against health care reform and I can't persuade you. There are legitimate concerns about the public option -- the gentleman who raised his hand. I think it's a good idea, but I understand some people just philosophically think that if you set up a public option, that that will drive public insurance out -- or private insurers out. I think that's a legitimate concern. I disagree with it, but that's a legitimate debate to have.

But I want everybody to understand, though, the status quo is not working for you. (Applause.) The status quo is not working for you. And if we can set up a system, which I believe we can, that gives you options, just like members of Congress has options; that gives a little bit of help to people who currently are working hard every day but they don't have health care insurance on the job; and most importantly, if we can make sure that you, all of you who have insurance, which is probably 80 or 90 percent of you, that you are not going to be dropped because of a preexisting condition, or because you lose your job, or because you change your job -- that you're actually going to get what you paid for, that you're not going to find out when you're sick that you got cheated, that you're not going to hit a lifetime cap where you thought you were paying for insurance but after a certain amount suddenly you're paying out of pocket and bankrupting yourself and your family -- if we can set up a system that gives you some security, that's worth a lot.

And this is the best chance we've ever had to do that. But we're all going to have to come together, we're going to have to make it happen. I am confident we can do so, but I'm going to need your help, New Hampshire.

Thank you very much, everybody. God bless you. (Applause.)

This article is republished with kind permission from our friends at The Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery of in-depth coverage of health policy developments, debates and discussions. The Daily Health Policy Report is published for Kaisernetwork, a free service of The Henry J. Kaiser Family Foundation. 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.