Taylor Stratton Elementary School
Nashville, Tennessee

1:36 P.M. CDT

THE PRESIDENT:  Hello, everybody!  (Applause.)  Everybody, have a seat.  Have a seat.  Well, it’s good to be back in Nashville.  (Applause.)  I like Nashville.  I don’t know if you noticed, I come back here quite a bit.  (Laughter.)

First of all, can everybody please give Kelly a big round of applause?  (Applause.)  In addition to being wonderful and somewhat feisty spirit, as I have learned, she also has the distinction of possibly being the first person ever to be picked up at her house by a presidential motorcade.  (Laughter.)  Which I thought was pretty cool.  Well, it turned out it was so close to the school, so we said, well, we might as well just swing by and get her.  (Laughter.)

I want to thank the school for hosting us here today, because I know it’s a lot of work when we come into town.  Very much appreciate everybody who was involved in that.  You have a great Mayor, Karl Dean, who’s here, so please give Karl a big round of applause.  (Applause.)  There he is with his beautiful family right there.  Family, stand up.  Family, come on.  There’s his family — yay!  (Applause.)  You can’t imagine what a family has to put up with when you’re in public service.  So we really appreciate all of them.

Kelly already mentioned him, but he is somebody who is what you want out of a member of Congress.  He works hard.  He calls it like he sees them.  He’s willing to do courageous stuff even when it’s not popular.  He is a gentleman, one of my favorite people — Jim Cooper.  (Applause.)

Also here is somebody who knows health care well, was a health care professional, a doctor and executive, and knows a little bit about politics because he used to be the former Majority Leader.  When I first came in, in fact, he and I had a chance to work together on a number of things, and he’s been a terrific advocate on behalf of health care for a lot of people — Mr. Bill Frist.  (Applause.)

So, with that, I think I’m going to take off my jacket, get a little more relaxed here.  Part of the reason we came to Tennessee — in addition to me just liking Nashville and liking the state, generally, is that Tennessee has a history of innovation when it comes to health care, doing some very creative stuff — health care professionals, doctors, nurses, hospitals and executives working alongside nonprofits and the public sector to make sure that people are getting the very best health care they can, and also being able to control costs in a sensible way.
And thanks to the Affordable Care Act and the efforts of people like Jim who took some very tough votes, we now have about 166,000 Tennesseans who have health care who didn’t have it before.  Folks like Kelly.  (Applause.)

In addition to the people who are able to buy health insurance through the exchanges, through the marketplaces that were set up through the Affordable Care Act, I think it’s important to remember that everybody who has health insurance benefitted and continues to benefit from this law — even though a lot of folks don’t know it.

So if you have health insurance through the job, you’re able to keep your child on health insurance up until they’re 26 years old because of this law.  (Applause.)  And that’s provided millions of young people across the country with health insurance who may not have had it before.  And that’s especially important as young people are transitioning, getting their first job — they may not always get a job that has full benefits, and this way they’re able to make sure that they stay healthy.

In addition, if you’re a senior citizen, or somebody who’s disabled, it turns out that you are getting discounts on your prescription drugs that you may not have noticed but are saving you potentially hundreds or even thousands of dollars.  And there are millions of people across the country who are benefitting.  That is because of this law.

If you don’t fall under those categories and you’re just somebody who’s got health insurance on the job, you now are protected, so that if you, let’s say, lost that job, or decided to move to a job or just start your own business, you can’t be prohibited from getting health insurance because of a preexisting condition.  That’s a protection that everybody is benefitting from as a consequence of this law.  (Applause.)

If you’re a woman, you can’t be charged just for being a woman as a consequence of this law.  (Applause.)  Last I checked, that’s about over half of the population, so that’s a pretty large constituency.  You’re able to get free preventive care, including mammograms, as a consequence of this law, on your insurance.

So there are a whole host of things that fall under the Affordable Care Act that are benefitting 100 million, 150 million people.  They just may not be aware of it.  But what it’s done is it’s made health care stronger, more secure, and more reliable in America.  You don’t always notice that until you need it — the way Kelly needed it.  And that peace of mind, that understanding that if you get sick you’re not going to lose your job — or you’re not going to lose your house, you’re not going to lose all your savings, that you’re going to be able to get quality care — that is extraordinarily important.

I’ve said before, the scariest day of my life was when Sasha was three months old — my daughter — and she got meningitis.  And the only reason we knew was because we had a great primary care physician and we were able to rush to an emergency room and the doctors and nurses did extraordinary work.  And I was feeling helpless in that situation, but I thought, what would happen if I was in the same situation and I didn’t have health care, and I didn’t have a primary care physician to call in the middle of the night because we noticed she wasn’t crying the same way she usually cried?  Because of the law we passed, there are parents who just aren’t going to have to face that.  And that’s priceless.

Now, the good news is that, contrary to some of the expectations, not only has the law worked better than we expected, not only are 16 million people now getting health insurance that didn’t have it before, not only do we now have the lowest uninsured rate since we started tracking people and how much health insurance they had, but it’s actually ended up costing less than people expected.  And health care costs have been held — the inflation on health care costs have actually proved to be the lowest — since the Affordable Care Act passed  — in the last 50 years.  So we’re actually seeing less health care inflation.

And part of the reason is because the law also encouraged health care providers and doctors, nurses, hospitals to start thinking more creatively about how can we get a better bang for our health care dollar.  How can we make sure that rather than spending a lot of money on unnecessary tests or readmissions, we’re encouraging really high-quality care that’s good for the patient but also good for health care spending.

And this is another area where Tennessee actually has been really innovative.  In fact, it won a $65 million grant for state innovation, where you’ve got hospitals and doctors and nurses and not-for-profits and other groups working together to figure out how can we, for example, identify potential diabetes patients early, make sure that they’re getting healthy quicker, preventing some of the worst elements of it.  And even though it might involve a little extra spending on the front end, it turns out it saves hundreds of thousands of dollars on the back end; improves quality of life, improves quality of care, cuts costs, which is good for our economy, good for patients, and good for America.

So I’m feeling pretty good about how health care is going.  (Applause.)  And the thing I’ve never lost sight of, though, is that this is about people.  This is not about politics, it’s not about Washington.  It’s about families and loved ones, and the struggle and the fear that comes about when you have a serious illness and knowing that you’ve got not just your own family, but also a community that has your back.

And you heard Kelly talk about her story.  Sitting right next to Kelly is a wonderful woman named Natoma Canfield, who came down with me today.  She’s from Ohio, and she wrote a letter to me, pretty similar to Kelly’s, back in — five years ago, so back in 2010, when we were still in the middle of this fight to try to get health care that’s affordable for everybody.  And Natoma had been diagnosed with cancer, had beat it back, then was buying health insurance on the individual market and it turned out that the costs were just skyrocketing so high that she just couldn’t afford it anymore.

And she wrote to me a passionate letter about why we needed to get this done.  And I would always refer back to her letter whenever things got a little bleak and Congress wasn’t behaving as sensibly as Jim Cooper behaves.  (Laughter.)  And when we finally signed that bill, I had Natoma’s letter framed with the pen that I signed the bill with — one of the pen’s that I signed the bill with — just to remind me that this wasn’t about politics, this was about people.

And so I’m so glad Natoma is here, but I’m also glad that all of you are here.  And part of what I’m hoping is that with the Supreme Court case now behind us, what we can do is — (applause) — I’m hoping that what we can do is now focus on how we can make it even better.  Because it’s not as if we’ve solved all the problems in our health care system.  America still spends more on health care than any other advanced nation and our outcomes aren’t particularly better.

And so we know there’s still a lot of waste in the system.  We know that the quality of care isn’t always where it needs to be.  And so my hope is, is that on a bipartisan basis, in places like Tennessee, but all across the country, we can now focus on what have we learned.  What’s working?  What’s not working?  Are there further improvements we can make to improve quality?  Are there more ways we can encourage people to get preventive care so that they don’t get sick in the first place, so that we have a actual health care system instead of a disease care system?  Are there ways that we can do better to provide the support we need for outstanding primary care physicians and nurses, who oftentimes are coming out of school loaded up with debt and aren’t always getting the support that they need and aren’t always able to practice the way they want to practice?

There are huge areas of improvement and, frankly, there’s still a lot of people who aren’t insured.  Part of the design of the Affordable Care Act was that some people were going to buy health care on the marketplace; in some cases, we were going to allow states to expand their coverage through individualized programs in their states.  I think because of politics, not all states have taken advantage of the options that are out there.  Our hope is, is that more of them do.

We still have to sign a bunch of people up.  We’ve covered now about a third of the people who weren’t covered before this law passed, but that means there’s still two-thirds out there who still need some help and they’re still going to the emergency room at the last minute when something goes wrong.

And so we want to educate people.  We want to listen to folks.  We want to hear good ideas from all sources.  We want to think about this in a practical, American way instead of a partisan, political way.  And if we do that, then I think there’s still great strides to be made.

So I want to thank all of you for being here.  And with that, I’m just going to open it up for a bunch of questions.  And you can ask me about anything, but probably you should ask me a couple of questions about health care.  (Laughter.)  I’m also willing to talk about the women’s soccer team and how we’re going to beat whoever it is we’re playing up in Canada.  (Applause.)  I can talk about the NBA free agency.  (Laughter.)  I can talk about the Predators and hockey. (Applause.)  And I can talk about other things other than sports.  (Laughter.)

But the way we’re going to do this is we’re just going to — this is very casual.  I’m just going to call on folks.  The only rules I’m going to lay down are when you raise your hand, if you can wait — are there microphones in the audience?  So wait for a microphone so we can all hear you.  And I’d like you to introduce yourself.  And I’m going to try to make sure that we go boy, girl, boy, girl, so that it’s even.  (Laughter.)  Okay?  All right.

We’re going to start with this young lady right here in front.  You’ve got a microphone right here.  So remember to introduce yourself.  Go ahead and hand her the mic.  Sometimes we tell our folks to hang onto the mic because people keep it for too long.  (Laughter.)  But this looks like a pretty well-behaved group, so go ahead and hand them the mic.

Q    I am a Tennessee volunteer enrolling people in the Affordable Care Act.

THE PRESIDENT:  Thank you.

Q    Thank you.  (Applause.)  We live in a city with a lot of health care companies and a lot of great medical facilities who can take advantage of some of the things you mentioned.  What do you think ordinary people — people who are volunteers, or ordinary citizens can do to help make our health care system and our health insurance system better?

THE PRESIDENT:  Well, first of all, I want to thank you for volunteering, because so much of our challenge these first couple of years as we’ve gotten this started was just getting people information, because there was so much misinformation out there.
So, for example, a lot of people don’t know that through the exchange, through the Affordable Care Act exchange plan, there is enormous choice of plans.  And Tennessee actually has benefitted from some of the widest range of choices of just about any state. I think there are 70 options to choose from for people throughout the state.  And about 80 percent of people who are purchasing health insurance through these exchanges because they’re getting federal subsidies, they’re spending less than 100 bucks a month for good, quality care.  And that’s true nationwide.

So part of our goal here is just to give people good information.  And in fairness to folks, look, before I started tackling this whole health care thing, when I got a job I didn’t really pay attention to health care benefits.  You go to the job, and somebody from HR hands you a form and says, here, fill this out, and they tell you, well, you need to choose from two or three plans, and you kind of ask them, all right, well, what do you think?  (Laughter.)  They tell you, well, that one is pretty good, and you sign up for it.  Most of us don’t spend a lot of time thinking about health insurance until we get sick, unfortunately.

So getting people information, I think that’s something that is really helpful when it comes from neighbors, friends, coworkers, your church — because you have more trust.  Sometimes people don’t always trust what they see on television, especially on something that became sort of a political football.

I think the other thing is for citizens to share their stories of how it’s helped them not only with their friends, neighbors, coworkers, but also with their state legislators and with their governor, and writing letters and letting them know that this is helping people, it makes a difference — so that they then recognize that this is an important need and it’s worthy of support.

And then you’ve also got to take care of yourself.  But you look really good, so you’re obviously — (laughter) — getting exercise and eating right, and getting regular checkups and all that good stuff.  Because that’s helpful, as well.  That’s part of how we keep costs down, is making sure people are well-informed about what it takes to live a healthy life.

Great question, though.

All right, it’s a gentleman’s turn.  This guy right down here.  You’ve got a good-looking beard.  All right, hold on a second.  Let’s get the mic — like I said, you can just pass it down to him.

Q    It is an honor and a privilege to be here, Mr. President.  I live in Pikeville, Tennessee.  It’s about 50 miles north of Chattanooga.  And I’m here representing the 280,000 people that is uninsurable in the state of Tennessee with the Insure Tennessee Act.  And what we need is — we got no insurance.  We can’t get no insurance.  We don’t make enough to pay for insurance, but still yet we make too much to get a subsidy insurance.  And I would like to know if you are aware of this, or is there anything that — movements or acts that you can make on the part of our problem here?

THE PRESIDENT:  Well, first of all, I appreciate your comments.  There is something that can be done, but it’s going to be at the state level.  And I think that it’s important for state legislators to get together and find a uniquely Tennessee solution to the problem.

But understand, the way the law was set up was that states would have the option of expanding existing programs like Medicaid, and then you’d also have people who were buying health insurance on the marketplace and getting subsidies.  And the point you’re making is that if the state hasn’t taken action on one part of the program, then even with the good work that’s being done for people who are getting subsidies and purchasing insurance, you’re still leaving a bunch of folks out.  And here in Tennessee, that’s probably a couple hundred thousand people who could benefit if we really focused on how to fix it.

Now, as I said before, Tennessee has a history of bipartisan, smart, state-specific efforts to expand health insurance.  And I don’t expect that what’s good for Tennessee is automatically going to be the same as what’s good for California or what’s good for my home state of Illinois.  But given the strong history of innovation in health care in Tennessee and given the high quality of doctors and hospitals and nurses and networks that are here, you all should be able to find a solution.  And the federal government is there to help and to work with those states that are ready to get going.

I will tell you the states that have taken full advantage of all the federal options available, they have an even lower uninsured rate, and a healthier population, and more people signing up for the options that are available than those states that have not taken full advantage of those options.  And that’s just a fact.  And it is unfortunate that getting this done got so political.  Washington is kind of a crazy place.  But that doesn’t mean every place has got to be crazy.  (Laughter and applause.)  So I’d like to see some good sense spring forth from the great state of Tennessee, see if we can get this thing done. (Applause.)

All right.  Yes, right there.  Go ahead.

Q    Thank you so much for being here today and sharing with us.  I’m from St. Thomas Health and one of the administrators.  So the work that’s already been done, the exchange, we know we have work to do with expansion.  What would you envision are the next steps that we need to take in health care in general for our country?

THE PRESIDENT:  The areas where I think we can still make the biggest difference, in addition to making sure everybody is signed up for the options that they have, is to really think more about the delivery system of health care.  And this can get real complicated because we got a complicated health care system.  But I can boil it down maybe into layman’s terms.

Right now we spend too much money on the wrong things and not enough money on the right things.  So health care generally is very expensive in this country.  But if you look at how that money is spent, we don’t give enough incentives to health care providers to really focus just on the patient and the quality of care.  First of all, there’s way too much bureaucracy.  There’s way too much paperwork.  That wears out the patient.  It wears out the doctor.  It wears out the nurses.  They don’t like it.

The second problem is that because of the way that we’ve designed the payment system in health care, historically what happened was that, let’s say, a hospital or a doctor had a patient come in, says, I’ve got diabetes or I have I think maybe diabetes.  The hospital or the doctor would get paid to amputate the leg of a patient, but they wouldn’t get reimbursed if they just hired somebody to monitor whether that individual was taking their medicines on a regular basis and monitoring their eating habits, right?  So what ends up happening is, is that you don’t end up helping the patient who might have kept their leg if they were keeping up a regular regiment of looking after themselves.

The doctors don’t feel good about that.  The nurses don’t feel good about it.  But they just don’t have time because of the economics of the health care system.  So one of the things that we’re trying to do across the board — and Tennessee is actually doing some good innovation on this — is let’s reimburse people for the outcomes and the quality of care that people are getting.

So instead of — when that patient comes in, instead of worrying about just, okay, I’m going to bill for this test and I’m going to bill for this surgery, let’s tell them, if that person ends up having a good outcome, then you’re going to get reimbursed.  And the better the outcome, maybe the bigger the reimbursement.

And now it may turn out that it’s a good deal for the doctor to spend an extra half an hour with the patient very carefully going over the medicine they should be getting.  Or the hospital may say, you know what, we’re going to sign you up for a health club and make sure that you’re getting some regular exercise, or we’re going to reimburse you for a smoking-cessation program — and suddenly all that produces a better result.

But we’ve got to make sure that we’ve got a payment system that follows that logic of patient-centered care.  And as I said before, we’re already seeing that happening.  Part of the reason that we’ve actually seen health care costs slow — the inflation of health care slow is because folks are starting to get reimbursed in different ways, and health care groups are starting to organize themselves to focus on the quality of care as opposed to the amount of care.

If we can do that, see, what that does is it — first of all, it frees up resources.  It’s not good for anybody when health care costs go up because not only does the federal government have to pay more, the state of Tennessee has to pay more.  That means there’s less money left over for doctors, nurses, for health education.  It means higher premiums for the patients.  But it also means that if we’re saying — if we just cut 2 percent or 3 percent on the cost of health care, that’s hundreds of billions of dollars that we can now spend on something else.  We can spend that on education.  We can spend that on job training programs.  We can spend that on fixing some potholes.  And it can improve everybody’s quality of life.

So that I think is the area that we’re going to be spending a lot of focus and a lot time, in addition to making sure that people are able to sign up for the care that they need.  Because I want to emphasize, there are still too many people out there who haven’t signed up or can’t sign up for the health care that’s available to them.  And if we can clear away some of the politics, that will help, as well.

Good.  Gentleman, right here.

Q    Good afternoon, Mr. President.  My name is Eric Brown from Nashville, Tennessee.  I work for the Children’s Defense Fund and a small, local congregation here.  My question is more for veterans when it comes to health care.  I have a family member who’s a veteran.  She would like to have a female doctor. She’s been rejected about two or three times.  So I just wanted to hear more of your thoughts on that — how to help her to get the health care that she needs, but also have the safety that she needs for it as well.

THE PRESIDENT:  Okay.  Well, as most of you know, the VA system is an entirely separate health care system from the private sector health care systems that most of us use.

Here’s the basic principle:  If somebody is wearing our — the uniform of the armed services of this country and sacrificing and putting themselves in harm’s way to protect us, we’ve got to give them good health care when they come home.  (Applause.)  We’ve got to make sure that they get the very best.

Now, the good news is that the overwhelming majority of veterans are very satisfied with the health care they receive once they get into the system.  The bad news is that because a lot of the processing and systems in the VA system are outdated, sometimes it’s taking a long time for folks to get into the system, to get an appointment, to make sure that they’ve got a doctor that they’re comfortable with.  There are areas where there are still shortages — for example, in mental health, with a lot of folks coming back with PTSD — there haven’t been, historically, enough mental health services provided for our veterans.

So my Secretary of Veterans Affairs, Bob McDonald, who is a former — who’s a veteran himself, but also a former CEO of Procter & Gamble, so knows about big companies and big operations — he’s really been doing a good job in revamping how the VA system is organized generally.  It’s going to take some time.  It’s still not where it needs to be.

With respect to your — was it your sister, in particular?

Q    Mother-in-law.

THE PRESIDENT:  Your mother-in-law, in particular — we’ll get your name and your mother-in-law’s name, and we’ll find out what exactly the issue is.  But generally speaking, we’ve actually made an investment in women’s health care in the VA system, reflecting the fact that we now have extraordinary women who are serving in the armed services, and the health care needs of women are not always going to be the same as the health care needs of men.  And so we’ve actually been trying to boost the kinds of specialties and training that are needed to provide health care to women — our women veterans, and we’ve been expanding that.

And that’s something I’m very proud of.  We’ve made a significant inroad in that area.  Tell her thanks for her service.

All right, it’s a young lady’s turn.  Go ahead.  I’ll go here, and — don’t worry, I think I’ll be able to catch everybody.  Go ahead.  But she does have an Obama pin on, so I thought I’d — (laughter) — I figured I had to give her a little props for that.

Q    Thank you.  And thank you, Mr. President, for coming to Tennessee.  And my name is Brenda Gilmore.  I’m a member of the Tennessee General Assembly in the House.  And there are a number of members that are here, so I just wanted you to know that we support you.  We believe that health care is the right thing for everybody, and especially for Tennesseans.

And I wanted to ask you, with your background also being a state senator —

THE PRESIDENT:  State legislator.

Q    — do you have some strategies that you could share with us — (laughter) — that we could encourage our Governor to stay on the journey and to continue to find solutions to present Insure Tennessee, and to bring some of our colleagues over on the other side so that we can take the politics out of it and help them to understand how important this is to the quality of life for Tennesseans?  (Applause.)

THE PRESIDENT:  Well, I don’t presume to know as much as you do about Tennessee politics, so I will leave the expert advice to folks like Jim Cooper maybe.

But here’s the one thing I do know, is that elected officials respond to public opinion.  I think one of the challenges that we’ve had throughout this fight has been that there’s been a lot of misinformation out there.  And so if you stopped the average Tennessean on the street and you asked them, do you support making sure that insurance companies can’t bar you from getting health insurance because of a preexisting condition, eight out of 10 of them would say, absolutely, I support that.  Overwhelming majority of Republicans would support it just as much as Democrats did.

Now, if you asked them, did you know the Affordable Care Act is what is guaranteeing you don’t get blocked from getting health insurance with a preexisting condition, you’d get an argument with at least half those folks — “no, that’s not what it’s doing.”  So part of it is just providing people good information. That’s really important.  And if ordinary folks feel it’s important, then usually elected officials start responding.

I think the other thing to emphasize, which I know you’re already doing, is recognizing that not every state is the same, and that the truth is, is that there are a lot of different ways that states are approaching this problem.  And if everybody will just acknowledge that people should get health insurance, that they should be able to get affordable care when they need it — if that much is acknowledged, that base principle, then you can say to them, okay, here’s our ideas for how to do it, what are your ideas?  And people can come up with good ideas of their own.

I will say this.  People tend to forget that the Affordable Care Act model, with health care exchanges and buying on the — in the marketplace, and getting subsidies from the federal government — that was originally a model that was embraced by Republicans before I embraced it.  It’s the model that Mitt Romney signed into law in Massachusetts.  It’s the model that conservative organizations like Heritage Foundation thought were a good idea.

So my hope is that maybe now we can return to a constructive conversation about — if folks have better ideas, you should accept them.  My general rule is I have no pride of authorship here.  I just want to make sure Kelly has got health insurance and I want to make sure that Thelma has got health insurance, and I want to make sure this gentleman gets health insurance.  And if there’s a better way of doing it, let me know.

But it turns out that it’s hard.  (Laughter.)  So it’s got to be an idea that actually works.  It can’t be an idea that sounds good, but then doesn’t work.  That’s the only danger.  So if somebody tells you that, well, we’re going to prohibit insurance companies from barring you from getting health insurance if you’ve got a preexisting condition — which is popular — but we’re going to allow people not to get health insurance if they don’t feel like it, then the truth is that doesn’t work.  And the reason it doesn’t work is, if you think about it, if you knew that the insurance company couldn’t prevent you from getting health insurance once you were sick, you wouldn’t pay all those premiums until you got sick.  And then you’d go to your health insurance company and say, there’s a law you got to sell me health insurance — and you’d save a whole lot of money, but, of course, the whole insurance system would collapse.  It wouldn’t work.

So there are just some basic things that — basic realities about the health care system that have to be taken into account. But I think you should be open to other ideas.  Like I said, look, I didn’t mind stealing ideas from Mitt Romney.  (Laughter.) But the bottom line is:  What works?  What works?  And if Republican legislators have better ideas, they should present them.  But they have to be realistic.  They have to be meaningful.  (Applause.)

Okay.  The gentleman right here in the glasses.  Right here.  Yes.

Q    Thank you, Mr. President.  I work with Family and Children Service.  I am versed in the health care system and I help people enroll in the marketplace.  And I want to thank you so much on behalf of the many people I’ve been helping, especially the most vulnerable immigrant people, to get affordable health insurance.  We really thank you very much.

Also, I just want to ask you if you have any plans to expand the Affordable Care Act for sick migrant people, especially the people who don’t have enough documents in this country but they still live and work here for a long time.  Thank you.

THE PRESIDENT:  Well, we were very clear that the Affordable Care Act did not apply to people who are not here legally.  And that’s the law.  So that’s another example of — there’s a lot of misinformation about this.  The law says that if you are undocumented, if you’re not here legally, you can’t benefit from subsidies and the program that we’ve set up.

The real answer to your question is why don’t we have immigration reform so that people who’ve been here a long time who are otherwise law-abiding citizens, who oftentimes have children who are U.S. citizens, who are contributing to the society and are willing to pay their dues, pay taxes, get a background check — why don’t we give them a pathway so they can be legal.  (Applause.)  If we do that — if we reform the immigration system, which is all broken, then this problem that you just mentioned takes care of itself.

I mean, look, we should not be encouraging illegal immigration.  What we should be doing is setting up a smart, legal immigration system that doesn’t separate families, but does focus on making sure that people who are dangerous, people who are gang-bangers or criminals — that we’re deporting them as quickly as possible, that we’re focusing our resources there; that we’re focusing on a strong border.  We’ve made improvements on all those fronts, but we could be doing even more if we had immigration reform.

And we almost got that done.  We had a bipartisan bill come through the Senate that was very smart and was well-crafted.  It wasn’t exactly what I wanted, but it was a good compromise among a lot of different ideas.  The House of Representatives declined to call it to a vote, even though I think we had a majority of members of the House of Representatives who would be willing to vote for it.

I’ve taken some administrative actions to try to improve the system.  For example, us not deporting some young person who grew up here and been here since they were three or four or five years old, brought here by their parents, hasn’t done anything wrong, are going to school with our kids, or friends with our kids, and suddenly — in some cases, they didn’t even know that they weren’t citizens — and then they’re 18 years old and suddenly they can’t get a college scholarship because it turns out they don’t have the legal documents.

And I said, administratively, that’s not who we are to just send those kids back.  In some cases, they’ve never been to the country that their parents are from, don’t speak the language.  What do you mean we’re going to send them back?  Some of them serving in our military.

So we’ve done a lot administratively.  Ultimately, though, to really find a full solution to the problem we’re going to have to get congressional action.  And I suspect this will be a topic of conversation during the upcoming presidential campaign.

I should note by the way that Michelle is very happy that I cannot run.  (Laughter.)  That is good for the health care of our family.  (Laughter.)

Yes, go ahead.

Q    Thank you, Mr. President.  Marian Hurst from Mount Juliet, Tennessee.  And thanks to the ACA, I was able to retire and still get health insurance.  My question is, what are your thoughts on how to now manage the premiums?  I don’t know if you’re aware that BlueCross BlueShield of Tennessee has announced a significant increase after the one that they gave from 2014 to 2015.

THE PRESIDENT:  Well, keep in mind that the Affordable Care Act was designed so that there’s competition.  And folks in Tennessee benefitted over these last two years not only of a lot of healthy competition — more insurers came in offering plans than just about any other place — it was really impressive — but Tennessee’s premiums were also substantially lower than a lot of other states, and have been over the last couple of years.  The insurance companies now have come in requesting higher premiums.

The good news for people of Tennessee is this has to be reviewed and approved by the insurance commission.  And if — last year is a good example.  Last year there were a number of states where the insurance companies came in requesting significant spikes in premiums.  And there were a lot stories in the newspaper, just like there are this year, about, oh, premiums are skyrocketing and this is going to be terrible and all that.  When all the dust settled and the commissioners who were empowered to review these rates forced insurance companies to justify what they were seeking, what you discovered was, is that the rates actually didn’t go up as much as people thought.

So I think the key for Tennessee is just making sure that the insurance commissioner does their job in not just passively reviewing the rates, but really asking, okay, what is it that you are looking for here?  Why would you need very high premiums?  And my expectation is, is that they’ll come in significantly lower than what’s being requested.

But I think that this emphasizes the need for us to not let our foot off the gas when it comes to the delivery system reforms that I talked about earlier.  Because part of what’s happening in terms of health care costs is that as technology changes, and there are more cures for more diseases, people utilize them more. And if we aren’t smart about how we spend our health care dollars, if we want everything right away even if it’s not shown to be particularly effective, then that shoots up health care costs and ultimately premiums are going to keep on going up.

So we’ve got to think more carefully about this.  The best example of this, by the way, is prescription drugs.  The biggest spike in health care costs is around prescription drugs.  Now, some of this is just because drugs have gotten better and people are able to now deal with cholesterol or deal with other chronic problems through a drug regimen.  And that’s a good thing.  We should be happy about that.  But when you’ve got a situation where the brand-name drug costs 100 bucks a pill and the generic drug costs 10 bucks a pill, and the generic has been shown to be just as effective as the brand name, it’s good for all of us as consumers to make sure that we’re generally using the generic drug when we can.

And a lot of times — sometimes we’re very insistent because we’ve seen some fancy ad on TV — people are running around looking happy.  (Laughter.)  Until they read that thing about:  “This may cause serious side effects.”  (Laughter.)  Diarrhea, migraines.  (Laughter.)  I always laugh at those ads.  (Laughter.)

But a lot of times, because of the advertising, you’ll have somebody come into their doctor and say, well, I want X because I saw a TV ad, and if the doctor says, well, actually Y works just as well and is a lot cheaper — a lot of times, people’s attitude is no, no, no, I want X.  And if the system is set up where you’re getting X, then that means your premiums are going to go up.  If you want your premiums to stay low, then you have got to base your decisions on your doctor — you want your doctors and your nurses basing decisions on science and what’s proven as opposed to what’s being advertised.

And that’s just one example of how we’ve got to make sure that we continue to save money in the system.  Because if costs keep on going up and everybody wants everything and is not smart about how we’re spending out health care dollars, then, yes, premiums are going to end up going up too high.  But stay on your insurance commissioner, pay attention to what they’re doing.

Okay.  I got time for one more — but I’m going to take two.  (Laughter.)  Yes, sir, this gentlemen right here.

Q    I’m Walter Davis, and I’m a director of the Tennessee Health Care Campaign, which does both enrollment and advocating for Governor Haslam’s Insure Tennessee.  It’s wonderful to hear the success stories here.  But here in the South, we need help from the government and from supportive institutions to talk about the people being left behind.  And I want to make sure you meet Davy Crockett before you leave today.

THE PRESIDENT:  Is this Davy right here?

Q    Right there.

THE PRESIDENT:  Okay.

Q    Over there with the Tennessee Justice Center.  There are important stories about the people who are left out because of decisions by legislators.  And we love the legislators that are with us, both parties, but the other legislators need to meet people in the gap.

THE PRESIDENT:  Okay.  Well, you know what, I think this is like a handoff to Davy here.  (Laughter.)  So we’ll get you the mic here, Davy.  Hold on one second.  Is your name really Davy Crockett?

Q    Yes.

THE PRESIDENT:  That’s a cool name.  (Laughter.)  But you don’t have that beaver cap.  (Laughter.)

Q    I’ve got one at the house.

THE PRESIDENT:  You do?  (Laughter.)

Q    Yeah.

THE PRESIDENT:  Okay.  All right.

Q    My name is James Davy Crockett.  And I live in Bulls Gap, Tennessee.  And I want to know — I’ve been turned down four times for Social Security.  Is there anything that you can do to maybe push it through or something?  (Laughter.)  I mean, I have been turned down and I’d like to be able to get some help.

THE PRESIDENT:  All right.  Well, here, I’ll tell you what. Here’s the thing, Davy, I don’t run the Social Security Administration.  It’s the law.  But here’s one thing that does happen.  If I ask a question, I tend to get an answer pretty quick.  So what we’re going to do is we’re going to get your information, Davy, and I’ll make sure the Social Security Administrator takes a look at it and expedites it.  All right?  (Applause.)

Q    Thank you.

THE PRESIDENT:  Okay, thank you.

Davy Crockett!  (Applause.)  You all remember that TV show? Actually, a lot of people are too young here.  (Starts to sing)  Davy, Davy Crockett.  (Laughter.)  I loved that.

Right here.  This young lady is going to get the last question, because she wrote me a letter, and when people tell their stories that reminds me of why I’m doing what I’m doing.

Q    Thank you Mr. President.   My name is Margaret Mackatee (ph) and I’m a retired teacher and school administrator for 38 years in the great state of Ohio.  And I moved to Tennessee to be with my son and my grandchildren.  And my grandson, Patrick, said to say hi to you.

THE PRESIDENT:  Tell Patrick I said hey.  (Laughter.)

Q    Yes, sir.  The letter I wrote was after watching you make a speech to college students.  And at the time, it was after the fact of the death of my son.  And being off of health care  immediately after he graduated from Wright State University, and through the process of his illness and his death, how it affected me economically, and paying COBRA and shots.

And in the context of being a school administrator, as hard as that might have been to me, it was worse for my kids at school, going through much the same thing or worse, with no support system like I had, especially as we went through the economic downturn in the country.  And being a high school principal and watching my kids be homeless and transient and mobile, and much harder to grab ahold of.  And they would be into crime or stealing or whatever for survival on the streets.  And they would show up at school, or they’d get off the bus and come down and say, “Doctor Mackatee (ph), I need to go to the clinic because I’m sick.”

And so our little school clinics became their health care. And sometimes even their parents would come and say, hey, can your nurse check us out.  And at one time, we had one nurse for seven schools.

And so, in terms of people that are lost in the shuffle — especially at the secondary level — transient, homeless children — we had a huge population of homeless children and they kept my head on straight through the grief I felt in our family because they’re so compelling.  They don’t let — teenagers don’t let you sit around and whine.  They pull you forward into life.

And my concern for the school systems in this country is for the massive health care issues that walk in the doors of school systems who don’t have nursing care, who don’t have clinics that are staffed, who don’t have the resources.  And many of the teachers in America take care of the kids out of their pocket.  School cooks feed children — slip them a little bit.  I know for a fact that many of my kids only ate with confidence at school.  That’s one of the reasons I love Mrs. Obama and her notion of — (applause) — of decent school lunch.

I can remember walking into a school system and the lunch they served was a little piece of cheese, a little short pasty breadstick and a tiny little tomato sauce cup.  And that was lunch until Mrs. Obama brought focus to what was being served to our children.

So the kids in the country who are homeless and deprived and transient — as soon as a kid gets 15 or 16, it’s hard to — they come and they show up once in a while, or they go off and they bounce from home to home, or buddy to buddy, or situation to situation.  They’re the ones that I’m worried about falling through the cracks.

And I’m worried about our school system and the focus that we spend more time and effort trying to get what we used to call in Ohio “butts in seats to take tests,” instead of seeing to their health care needs and their mental health care needs and support needs, so that we can wholly educate a child in the United States of America.  (Applause.)

THE PRESIDENT:  That’s a great comment.  Well, first of all, Margaret, we’re so grateful for you sharing your personal story, because it reminds us of the goodness and generosity of the American people, when somebody like Margaret is going through her own pain but she’s thinking about people other than herself and her family.  That kind of spirit is to be found all across the country.  It’s not unique to one party.  It’s not unique to one region.  There are good people like Margaret everywhere.

A couple of points I’d just pick up on that you’ve mentioned.  Number one — when we talk about the health care system, we have to just remind ourselves of the economic impact of the health care system on families.  It’s not just feeling bad.  Obviously, when you’re sick, your most important concern is getting well.  But what is also true is, is that when you get sick and you don’t have health insurance, then that is draining your resources for other things.

Bankruptcy because of medical expenses is a huge portion of the bankruptcies in America.  When families lose their house, or a parent has to stop working because of an untreated illness, or they miss too many days at work because they can never go to a doctor and then lose their job or lose incomes from those days they don’t work — that can send a household into a spiral.  And then, once a household starts breaking down because they lose a home, or they lose a car, or they lose a job, now, suddenly, you start having people in shelters, and people on the streets.  And that then affects kids and then their capacity to learn.  And you then create cycles of problems that are much harder for people to pull out of.

So part of the reason that it’s important for us to get this health care issue right is so that people have at least a stable base from which to then focus on all the other issues that they’ve got to focus on in their lives.  And if we can, as I said before, continue to do a better job of providing high-quality care to everybody, but in a more efficient way, then that will free up resources so that, for example, we can address the underfunding of schools, and we can make sure that we are having additional resources inside the schools for things like mental health.

The number of under-diagnosed young people who end up getting in trouble or dropping out of school just because they didn’t get the same health care services that better-off families get, it’s substantial.  And once they’ve dropped out, you lose them.  And then they end up in the criminal justice system.  And we then end up paying for their incarceration instead of them paying taxes because they’re able to get a good job and support a family.  And those cycles can build.

One of the most challenging things as President for me is to try to get folks to recognize that investments in people oftentimes save us money over the long term, even if it looks like it costs money in the short term.  And we make this mistake over and over again.

You mentioned school lunches, for example.  We know that children’s grades and test scores tend to go down at the end of the month, on average, in low-income communities.  All right, well, why is that?  It’s because food stamps start running out at the end of the month and kids are hungry and they’re not focused.

Now, it may look smart for us to restrict those benefits, except if even half of those kids end up doing better in school, and didn’t drop out, and were able to get a job, the society would be much wealthier.  If we are focused on mental health services, then we could cut down on the crime rate.  If we invest in early childhood education, we know there are improved outcomes that save the society money as a whole.

And let’s face it, part of what prevents us from making those investments in the short term is, is that we’ve gone through some tough times.  The middle class feels strapped.  People’s incomes and wages haven’t gone up — even after the recovery where we dug ourselves out of the crisis.  We still have growing inequality where a huge amount of the increase in income is still going to folks at the very top.  And so if you’re a middle-class person, and you’re already struggling and things are tight, then sometimes you feel like, well, why am I going to pay more taxes to help folks at the bottom?  Right?  That’s, I think, the mentality that a lot of folks have.  And it’s understandable.

But part of what I’ve been trying to argue — and I know Jim tries to do it, as well — is to recognize that we don’t have to choose between middle-class families working hard and trying to get ahead and low-income families who are working hard and trying to get ahead — if those of us who’ve been extremely blessed are just a little more open-hearted about how we can help everybody. (Applause.)

And I would like us to just reflect the generosity of spirit that Margaret expresses, because if we all had that generosity of spirit, if we all look at every child as a member of our family, if we think of everybody as part of a single community, then we can solve a lot of these problems.  And it won’t end up costing us more money, we won’t necessarily have to pay more taxes, we’ll just be spending it in different ways.

In some ways, health care is a good metaphor for a lot of the problems we have.  We spend things on stuff we don’t need and we neglect the things we do, and we don’t end up healthier as a result.

Well, that’s not just true for the health care system; that’s true for our economy.  We waste a lot of money on stuff we don’t need.  And we under-invest in those things that will make sure that we have a healthy society.  And politics oftentimes gets in the way.  And part of what I’ve tried to encourage my own Democratic Party to do is to recognize that not all the money that we spend at the federal level is smart, and some of it — some programs don’t work and we should end those when they don’t work, and be honest about what’s working and what’s not.

But part of what I’ve also tried to do is to say to the Republican Party:  Open your hearts and think about the people here in Tennessee who are working hard, are struggling, and just need a little bit of help.  And if we give them that help, it’s going to pay off over the long term.  This will be a stronger state.  Employment will be higher.  Folks will be paying taxes.  Everybody is going to prosper.

We’re all in this together.  That’s what I believe.  When America is together and we have a certain generosity of spirit, even if we’re hard-headed about making sure stuff works right and we’re not wasting money, but we’re doing what is needed to give everybody a shot in life, that’s when America grows.  That’s when we prosper.

I know that’s what you believe, too, Margaret.  You showed it in your own life.  We appreciate you very much.

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

END
2:44 P.M. CDT