In his last State of the Nation speech as president, Dmitry Medvedev outlined several steps to simplify Russian election rules and give voters more power.

The promises come just two days ahead of the next big demonstrations in Moscow.

Thousands of people are expected to protest Sunday against alleged fraud in the parliamentary elections earlier this month.

Anchor Lisa Mullins speaks to Julia Ioffe, Foreign Policy magazine Moscow correspondent, about the unrest in Russia ahead of a big opposition rally planned for Saturday.

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The text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

Lisa Mullins: I’m Lisa Mullins and this is The World, a coproduction of the BBC World Service, PRI and WGBH in Boston. Today, Russia’s president tried to soothe tensions in the country with a promise of reform. In his last state of the nation speech as president, Dmitry Medvedev outlined several steps to simplify Russian election rules and to give voters more power. The promises come just two days ahead of the next big election demonstrations in Moscow. Tens of thousands of people are expected to attend the protests Saturday against alleged fraud in the last Russian elections earlier this month. Julia Ioffe is Foreign Policy magazine’s Moscow correspondent. Is what Dmitry Medvedev said today likely to placate anybody, especially as it comes just as this big protest is happening on Saturday?

Julia Ioffe: You know, I don’t think it’s going to placate anybody really because since September 24 when he and Prime Minister Vladimir Putin announced that they would simply switch jobs come March, Medvedev has been seen as a very weak figure, as an extremely lame duck. And the reforms are seen as too little too late. The fact that the dim elections have already passed, it’s been almost a month, and there won’t be another set of elections for another five years, so that coupled with the fact that it’s coming from the mouth of a very weak political figure that nobody really takes seriously doesn’t instill much hope.

Mullins: So here we have a weakened president. We have someone also who has been somewhat on the fringe of popular culture of social media in Russia, who seems to be gaining in popularity; this is a man named Alexei Navalny, who was released after 15 days in jail. This happened yesterday when he was released. He has been blogging against the government and in doing so he’s really captured the limelight. How come?

Ioffe: Navalny is a very talented politician. He’s also the only competent effective promising, viable figure that the opposition has. The reason that so many people have come out to protest, the reason that United Russia could barely garner 50 percent of the vote even with massive fraud, a lot of that has to do with the grassroots work that he’s been doing over the past year in cultivating the image of United Russia as a party of crooks and thieves, which is a phrase he coined.

Mullins: This is Medvedev’s party.

Ioffe: Yes, this Medvedev’s and it was created to support Putin.

Mullins: So does that mean that Navalny is a politician, a possible opposition leader because this is a man who is popular, but he has many detractors who say he’s a nationalist, and for them being a nationalist is synonymous with being a skinhead or a fascist. What does he stand for?

Ioffe: Navalny’s main issue is fighting corruption, which takes up most of his time mostly because there’s so very much of it in Russia because it’s becoming not just a thing that greases the wheels in an ineffective system, but something that hobbles the system, slows it down. Another issue is the abuse of power and privilege — things like VIP sirens on official cars that allow the cars that have them to circumvent all traffic laws, which often causes deadly accidents which are then covered up, and the police help in the coverup. Another issue is dealing with migration. Russia has the second largest migrant population in the world after the US. The rate at which Russia, especially Moscow has seen the influx of migrants from former Soviet republics in central Asia, from Russian republics in the north caucuses has been really big. So this is an actual issue that needs dealing with. The problem is in dealing with them Navalny often finds himself speaking alongside the more radical and actually more racist figures. And I think Navalny underestimated the size of his natural constituency, which is the middle class, the white collar workers, what is called in Russia the office plankton. And I think by reaching out to the nationalists, which is very organized, very anti-Kremlin group, even though it’s a very motley group, think he was trying to expand his electoral base. And doing so however, he has alienated many of the more natural constituency which is again, lawyers, doctors, accountants, consultant, designers, journalists, etc.

Mullins: So would there be, just to help us understand what that all amounts to in terms of maybe our concept of politics, what does it mean?

Ioffe: Here’s the thing: Russian liberals are not European liberals or even American liberals. Russians are far more conservative on the whole than their European counterparts. And Navalny is the classic Russian liberal, which on the American spectrum would put him somewhere in the kind of moderate Republican territory. If it’s any kind of barometer, in the 2008 election, observing it from Russia, they told me he supported McCain rather than Obama.

Mullins: So on Saturday then to what extent can you expect that Medvedev and Putin will be watching and even counting the numbers of people who show up at this protest? What’s at stake for them?

Ioffe: Well, there’s nothing at stake for Medvedev because Medvedev is a political nonentity. I think Putin will be waiting to see how many people come out and to see if the very small concessions mostly in words that he’s made over the last two weeks will have been enough to ease up pressure on the system without him having to concede too much power. As for Navalny, if people don’t fall back asleep after the March presidential elections I think you can expect to hear much more from him and maybe even see him as the next president of Russia.

Mullins: Julia Ioffe, Moscow correspondent for Foreign Policy magazine, thank you.

Ioffe: Thanks so much.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

Protesters in Egypt (Flickr image: Al Jazeera)

Egypt remains in ferment. The Egyptian military has created a committee to amend the country’s constitution and has formed a caretaker government. Some said it’s time to wait and see what the armed forces will deliver. But protest organizers said they need to keep pressure on the military to move towards real reforms.

This week, about fifty bank workers gathered in front of their bank’s headquarters in Cairo.

They called on top bank officials by name, chanting: ‘Why are you hiding!?’

The workers wanted the bank chairman’s resignation, and salary raises. They said if their demands aren’t met they’ll go on strike next week. So far, despite warning from the military, there have been strikes by workers at textile factories, the Suez Canal, electrical companies, and the Cairo airport.

And this Friday, once again, large demonstrations are planned in Tahrir Square and elsewhere. That’s because protest organizers believe the revolution is far from other.

Mubarak cronies

The interim government is made up in large part of cronies of former president Hosni Mubarak. And protesters don’t trust them.

“We stress our demands for a speedy formation of a government made up of independent figures and technocrats who are qualified to run the country until an elected government is formed,” said, Ahmad Naguib, who spoke for the protest organizers at a press conference this week. “We stress the need to quickly purge all state institutions of the former regime. Those corrupt figures should be held accountable.”

“Purging” state institutions isn’t easy, though.

Sabah Hamamou is a reporter at Al Ahram, Egypt’s flagship state newspaper. While her newspaper was strenuously supporting former President Mubarak, she was posting home-made videos of violence against protesters to her blog and even sleeping in Tahrir Square.

After President Mubarak resigned, all government newspapers, from one day to the next, came out in support of the revolution.

But at a recent editorial meeting, Hamamou and a few of her younger colleagues confronted management.

“They were talking about the revolution and blah blah blah,” Hamamou said. “So after they finished I stand and told them, with all respect for these senior colleagues, none of these people at this table right now slept in Tahrir or participated in Tahrir, so please stop ignoring us, you’ve been doing that for whole decades. Give us a chance to be part of this.”

The reaction, she said, was explosive. Her editors first shushed and then yelled at her. Some colleagues took her side.

“It was very chaotic,” Hamamou said. “Another colleague of mine got really angry and said: ‘I’ve been working in this place here for 16 years and nobody knows me because I’m not allowed even to publish freely my articles if I want to publish it as it is.’ I raised my voice as well. There was, I don’t know how to put it in English, lots of feeling in it. We are very angry, people in their thirties, early forties. Because it’s our own revolution,” Hamamou said.

Hamamou is circulating a petition calling for the CEOs and editors of state newspapers to resign; for new, objective editorial guidelines; and for a more equitable pay scale. But her outspokenness has made her the target of reprisals, she said. Someone circulated an anonymous letter in her office accusing her of being an opportunist who benefitted from the old regime.

Changing too fast?

Meanwhile, some believe you can only expect so much change, so fast.

Farouq ElBaz is a renowned Egyptian-American scientist. He supported the protests and came back to Cairo recently for a round of meetings with both youth groups and government officials. He said after every revolution world-wide, throughout history, there is a period of imbalance.”

“And people that don’t know what will happen,” ElBaz. “And the people who were crushed by the revolution would like to come back.”

But ElBaz is optimistic. He said the current caretaker government is a necessary step.

“Yes they were part of the system,” ElBaz. “But all of Egypt was part of the system. Where will you get people?” he asked. “You can’t import people to do this. And they know where they stand. And they know someone is watching.

“So all their mandate is we are going to keep the boat floating and we’re not going to go in any direction. We’ll just keep it afloat. We’ll just keep it waiting here for the new passengers to come and take it out.”

But many of those new passengers are clamouring to board now.

Interactive map of Middle East and North Africa protests

Ursula Lindsey on The World:
• The women of Tahrir Square
• Protest chants as musical soundtrack
• More of Ursula Lindsey’s stories

• Q&A: US healthcare reform
• On The World: Living with American health care

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This text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

MARCO WERMAN:  The last piece of the health care reform law is now on its way to President Obama.  He’s expected to sign it next week.  The law’s main purpose is to extend health care coverage to millions of uninsured Americans.  Non-Americans who are here illegally are still out of luck.  Here’s The World’s Alex Gallafent on what that could mean for the nation’s health care system.

ALEX GALLAFENT:  Health care plus immigration equals political combustion.  Indeed, undocumented immigrants are not covered by the health care reform bill.  But even without Joe Wilson-style interjections, the fact remains that the problems of health care and immigration are related.  So says Ira Mehlman.

IRA MEHLMAN:  The growth of immigration in the United States over the past several decades has had a direct impact on the growth of the medically uninsured in the United States.

GALLAFENT: Mehlman is with the Federation for American Immigration Reform, a group devoted to capping immigration levels and stopping illegal immigration.  He says it’s correct that he health care reform bill doesn’t extend coverage to illegal immigrants.

MEHLMAN: Number one, it is costly to the tax payers.  Number two it bestows recognition and benefits on people who should not be in the country in the first place.

GALLAFENT: But in a place like New York City, thousands of undocumented immigrants are a present and immediate concern.  Alan Aviles should know, he’s President of the city’s Health and Hospitals Corporation.  He runs a network of 11 hospitals in the city, including six level one trauma centers.

ALAN AVILES:  So in New York City we have an estimated 500,000 undocumented immigrants.  The New York City public hospital system, which is the largest in the nation, has been the principal safety net for new immigrant communities across New York for decades.

GALLAFENT: That hospital system treated about 450,000 uninsured patients last year.  Aviles says a very large percentage of that number were undocumented, or illegal immigrants.  They didn’t have insurance, but they needed care, and so they went, more often than not, to places like this.  Emergency rooms.  The problem for Aviles, he says, is that the health care reform bill funds expanded coverage for Americans partly by limiting federal funding for public hospitals like his.

AVILES: And this is being done under the assumption that the uninsured that we currently serve will largely become insured and that will replace those dollars that are now being taken off the table.  But the reality in urban centers like New York, particularly gateway cities like New York, who have so many undocumented immigrants among the city’s residents, that will not necessarily play out as predicted.

GALLAFENT: So Aviles is concerned about a funding gap.  Less money from the federal government and not much more money from newly insured patients.  Aviles is especially galled by the fact that undocumented immigrants, many of whom do work and pay taxes, won’t be able to buy insurance from the new government run exchange, even at full cost.  When they’re sick, someone, somewhere is still going to have to pay for their care.  Aviles says there is a glimmer of hope.  The federal government might end up taking less money away from states with large numbers of illegal immigrants, keeping those emergency rooms going.  But that wouldn’t amount to a real fix, says Ira Mehlman at the Federation for American Immigration Reform.  Cities like New York, he says, should be doing more to limit illegal immigration in the first place.

MEHLMAN: We shouldn’t be dealing with this at the emergency room door.  We should be dealing with this far earlier in the process by seeing to it that fewer and fewer people come and remain in the United States illegally, and therefore draw less on our vital social services.

GALLAFENT: That means immigration reform.  And for Sonal Ambegaokar it could be an opportunity to deal with unfinished health care business.  She’s health policy attorney with the National Immigration Law Center.

SONAL AMBEGAOKAR:  So right now, newly arrived legal immigrants, immigrants who have their green card, have to wait 5 years before they can be eligible to enroll in what we call the Medicaid program, which serves the lowest income folks.

GALLAFENT: Maybe that’s fair, maybe that’s unfair.  At the very least Ambegaokar hopes it will be considered as lawmakers turn to immigration.  New York hospital administrator Alan Aviles also sees immigration reform as a necessary step in expanding health care.  If undocumented immigrants are allowed to earn citizenship, he says, health benefits will follow.  Now that doesn’t square with Ira Mehlman, although he is hoping for a sober discussion on what all agree is an emotive topic.

MEHLMAN: Respecting people and understanding why they come here doesn’t mean that we should not enforce laws, that doesn’t mean that we shouldn’t set restrictions.  We need to be able to deal with immigration policy just like we deal with any other public policy in the United States.

GALLAFENT: Given the tone of the recent health care debate, that should be fun.  For The World, I’m Alex Gallafent in New York.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

• BBC coverage
• Reporting US health care reform abroad
• Health coverage on The World

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This text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

MARCO WERMAN:  Democracy here in the U.S. can be a messy business.  The health care reform debate is but the latest example.  Today President Obama held a televised ceremony to sign the health care overhaul bill into law.  Mr. Obama told lawmakers and others at the White House that the bill marked the start of a new season for the country.

PRESIDENT BARACK OBAMA:  Here in this country we shape our own destiny.  That is what we do.  That is who we are.  That is what makes us the United States of America.  And we have now just enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care.  And it is an extraordinary achievement that has happened because of all of you and all the advocates all across the country.  So thank you.  Thank you.  God bless you and may God bless the United States of America.

WERMAN: The rest of the world has been watching closely and we’ve been bringing you a variety of international perspectives on the U.S. health care debate.  Today we get that from Justin Webb.  He was based in the U.S. for the BBC for eight years before moving back to Britain last year.  Webb now anchors the BBC’s main morning news radio broadcast, the Today Programme.

JUSTIN WEBB:  The big picture viewed from here in Europe is that America has taken a really important step, not towards a British style NHS, but a step in the direction of every American has a right having some kind of health coverage.  And that to really the rest of the rich world to be honest, but certainly to Europe, just looks to most people including senior conservatives here in the U.K., and I was talking to one the other day, it just looks like America joining the normal world as it were.

WERMAN: And for you Justin, issues of health care came right into the spotlight of your life just before Christmas in 2008.  You were living in Washington at the time and your son Sam got ill.  What happened?

WEBB: He was diagnosed with Type I diabetes, which is a horrible life-threatening illness.  It’s not brought on by any kind of lifestyle thing, it’s an auto-immune disease actually that just comes in youngsters and lots of people will know people with it if not have experience of it themselves.  And it was fascinating for us once we sort of got over the shock and the sadness about it all, to see how the American health care system coped and then really not much more than six months later to move back to Britain and see how the British system coped.  And as you’d expect there are strengths in each.  I think in a way, people in each country don’t fully understand the strengths of the other country.  That’s what I brought away from this.  So in the United States we were very well treated.  Sam was wonderfully well treated.  He had access to fantastic medicine and fantastic technology as an insulin pump that was made available very quickly under the American system.  Now there are all sorts of co-pays and things, it’s not as if it was free and our insurance certainly paid a lot of money, but we were well insured, so everything went rather well. So that was the situation in America.  We came back to Britain and lo and behold everything’s free.  You know, the test strips, a lot of people with Type II diabetes will know what I’m talking about now.  There’s test strips that you test your blood with.  You go to a British doctor and you say I’d like some more please and they say yes, how many?  And they just give them to you.  To be honest, it was an extraordinary sort of change.  I was really used to the American system where everything is accounted for and paid for by someone and quite often by you.  So here in Britain all these thing are handed out, but, although the medicine is just as good, and there’s no question in my mind that Sam is as well treated as he is here in America, I have to say that the technology, in particular that pump that pumps insulin into him is a very state of the art thing.  It is not, at the moment, available in the U.K., the particular pump that Sam uses.  And that is, at least in part because, the pump makers can make money in America and they can’t make it under the British NHS.

WERMAN: I’m wondering when you went back to the U.K., how much health care actually kind of showed up in your calculations about getting back to the U.K .and finding something that was perhaps better?

WEBB: Well that’s an interesting thing.  We would not have moved back here for the health care.  There’s no question at all that we were perfectly happy in America and we were well insured and had no prospect of losing it.  But I have to say that my son would be in the category of those people who would go along to a health insurer in years to come, and he wants to be a film director in Hollywood at the moment, he’s 10 years old so he can still have those dreams, what would he do for health insurance had the Obama bill not passed?  Now of course, American health insurance companies would have turned him down because he has a serious pre-existing condition.  If that genuinely does change, which it seems that it is going to now, then that for someone like my son, is a major plus.  It means that for him there is a possibility of working on either side of the Atlantic.  Of course it just means for American as well, and for everyone who has a pre-existing condition, it’s a greater freedom for that group of people.

WERMAN: The BBC’s Justin Webb, thanks very much for sharing your views and experiences with us.  I greatly appreciate it.

WEBB: Pleasure.  Nice to talk to you.

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• Gregor Peter Schmitz: “US Health Care – Good for America, Bad for the World?”
• BBC coverage
• Video of President Obama’s reaction
• Health coverage on The World

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This text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

DAVID BARON:  Passage of President Obama’s health care overhaul made headlines around the globe.  The foreign reports who covered the debate and last night’s vote, include the Washington Bureau Chief for the Toronto Star, Mitch Potter, and Gregor Schmitz, he’s the U.S. Correspondent for German’s news magazine, Der Spiegel.  Both are in Washington.  Mitch Potter, to you first, how are Canadians reading the story of health care reform in America today?

MITCH POTTER:  Well it’s a bit of a paradox.  Canadians have been fascinated by this all along.  On one hand I think Canadians in large part are sort of cheering on Americans.  It in a sense validates the system we have.  We know that what President Obama has brought forward here is not a Canadian style system, but it’s moving in that direction and I think Canadians feel validated by the fact that the United States is moving in our direction, if you will.

BARON:  Right, well it would be interesting to point out that among some groups, Canada has been a bit of a punching bag.  People have said this is what we don’t want to become.  We don’t want Canada’s health care system.

POTTER: It’s true and it’s really been a political piñata.  Time and again the Canadian system has been cherry picked with isolate horror stories being conflated into something to scare away Americans.  And that, truly, has annoyed Canadians.  A lot of Canadians have taken offense as they have watched this play out.

BARON: Now Gregor Schmitz, you had an opinion piece in Der Spiegel today and the headline reads “U.S. Health Care Good for America, Bad for the World”.  Now what do you mean by that?

GREGOR SCHMITZ:  Well I think if you look at the more recent debates you see there is a real risk that Obama might become a one issue President.  And I think if you look more closely at his speeches over the past weeks or months, there was basically no reference to other conflicts, or say other challenges, let’s say Afghanistan, even though soldiers are fighting there increasingly there now in recent weeks or months.

BARON: Because he’s been so wrapped up in health care.

SCHMITZ: Exactly he has been so wrapped up in health care and I don’t think anyone has predicted for this to drag out for so long.  So I think there is a real risk.  If you look at other parts of the world, particularly Europe, they are becoming a little disillusioned by a lack of interest.  He had to cancel the trip to Asia which I think was understandable in the context of the health care debate.  But still, it sent a signal to the rest of the world that this is the most important issue to us, understandably, and we don’t really care about the other challenges.  So I think there is a real risk for him to become a one issue President.

BARON: Well something I would like both of you to address is the way that Barack Obama is perceived around the world.  We know that when he was elected President in 2008 he was extremely popular in other countries.  How popular is Barack Obama in your countries now and I wonder to what extent have people in your countries been cheering on health care reform in the U.S. because they wanted to see President Obama succeed.  Mitch Potter, let’s start with you from Canada.

POTTER: Well I think that’s largely the case with Canadians.  There’s a recognition that we may not have a force in this health care fight, but if anybody is looking to see an Obama administration assert itself on other foreign files, they recognize that he needs a victory.  You can debate the wisdom of whether to have invested do much political capital to make health care his signature project was the right thing to do, but imagine how politically ham strung he would be in trying to pursue the rest of his agenda if this had all fallen apart on him and he would be approaching these mid-term elections with absolutely nothing to show for this first period of his Presidency.

BARON: But bottom line he is still popular in Canada?

POTTER: Definitely.

BARON: And in Germany Gregor Schmitz?  What is President Obama’s approval rating over there these days?

SCHMITZ: It probably has slipped from 99% to 97%.  I think overall he is still very popular in Europe and I think it is true in this regard when you look at health care that it is not about Obama.  It is about America.  Mitch has already alluded to that.  Europeans are cheering on the Americans because for them it’s just beyond imagination that the richest country on earth hasn’t been able, for so long, to provide basic health care coverage to every citizen.  So for Europeans that is more of a moral issue.  Frankly, they just don’t get it.  And I think on this specific issue, Obama is getting a pass.  I think they look at Washington and they basically blame the Republicans for blocking everything.  But one thing that I think is missing in the European debate that makes it harder for us to explain the debates here in the U.S. is the fact that many Americans are actually happy with the health care system.  When Europeans look at the American health care system, they don’t fully understand that the people who are a part of the system now, who have coverage, who have insurance are often very happy with the way they are being treated and with their options.  So I think that is something we need to explain to our readers that these debates are so fierce because it is the question of whether they want to extend that coverage or an offer of more solidarity to other Americans and whether they want to include the people that are left out right now.

BARON: Well gentlemen I expect you didn’t get all that much sleep last night.  Thank you for coming in.  It was good to talk to you.  Mitch Potter is the Washington Bureau Chief for the Toronto Star, thank you Mitch.

POTTER: Thank you very much.

BARON: And Gregor Schmitz is U. S. Correspondent for Der Spiegel in Germany, thank you.

SCHMITZ: Thanks for having me.

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• Health Canada
• Foreign lessons in hospital efficiency

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This text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

JEB SHARP: I’m Jeb Sharp and this is The World.  This was a Canadian Broadcasting Corporation television broadcast from July, 1962.

NOLTON NASH:  Good evening, I’m Nolton Nash and this is another special report on the Saskatchewan Medicare fight.  A fight that has torn Saskatchewan apart in almost unbelievable bitterness and anger.

SHARP:  That summer, doctors in the Canadian prairie province of Saskatchewan, went on strike.  Their grievance?  A new government healthcare program.  It was the beginning of what was a long uphill battle to implement universal health care in Canada. Roy Romanow was Premier of Saskatchewan from 1991 to 2001.  He joins us from Saskatoon, Saskatchewan.  Roy Romanow, you Canadians have been through this uproar already.  Give us a sense of what the rhetoric was like back in Saskatchewan at the beginning.

ROY ROMANOW:  When we listened to the rhetoric going on in parts of the United States, that’s exactly the rhetoric that you heard in Saskatchewan, with the exception thankfully of any reference to violence, physical violence.  But the usual rhetoric, this was Socialism; this was introducing a plan whereby a government bureaucrat would be between you and your healthcare provider.  Freedom, you couldn’t afford it, the quality of healthcare descending and all of those things that are coming across in the United States of America.

SHARP:  Why were the doctors striking specifically?

ROMANOW:  The doctors felt very strongly that the program made them “employees” of a government plan and initially, the idea was to put them on a salaried basis as opposed to a fee for service basis and they argued that once you’re salaried, then by definition you’re an employee of the state.  In fact, the eventual solution came about as a result of the intervention of Lord Taylor from the UK House of Lords, who was brought in as a mediator and they negotiated an agreement whereby the provision on salary was removed but the battle raged on for a number of years after that.

SHARP:  I was going to say.  I mean, was the doctors’ argument about being salaried employees the main argument or was there a much stronger main thrust that was simply anti-government?

ROMANOW:  It was a stronger anti-government thrust, just the notion that a government would be the somehow arbitrator of the delivery of healthcare to people in Saskatchewan.  I attended several rallies and our rallies here were very large by Saskatchewan standards, eight, nine, ten thousand people, so it was a combination but mainly a combination of mainly the argument of politics and ideology and some flaming rhetoric attached to issues of healthcare and the quality of healthcare. The argument which tried to focus on the quality of healthcare was really the weakest and the least pronounced.  The most pronounced was essentially the scare tactics and of course the largest scare tactic was when all the doctors, with the exception I think of three or four, went on a province wide strike so we had no doctors and then we had to bring in UK doctors who rallied to the cause in a humanitarian way and very quickly were processed by the UK government and the Canadian government, in fairness to the Canadian federal government, to come to Saskatchewan to help break the strike.

SHARP:  I do want to help Americans understand what happened in Canada by talking a little bit about the man who drove the change in Canada to a universal healthcare system.  His name was Tommy Douglas.  Douglas was the Premier of Saskatchewan and he launched a campaign in the late nineteen forties to create what became Canadian Medicare. Here’s Tommy Douglas in an interview with the CBC in 1962, explaining why this new healthcare system was needed.

TOMMY DOUGLAS:  Most of these plans, in order to stay solvent, have to eliminate a great many groups of people because of age, because of chronic conditions, because of congenital illnesses, past medical histories and so on and these are precisely the people who need some kind of protection.

SHARP:  That was former Saskatchewan Premier Tommy Douglas speaking in 1962 so again there, you know, we’ve heard these arguments before but what’s it like to hear that old tape and think about what it means now, especially with regards to the United States as opposed to Saskatchewan?

ROMANOW:  Well, before I get to the United States, very briefly, hearing Tommy’s voice, I knew him, I was much younger of course.  Those of us who actually saw that debate and heard the oratory of Douglas and his successor, Woodrow Lloyd, this brings goose bumps because it was a very difficult period, bordering on civil disorder a bit in Saskatchewan but essentially, Douglas’ analysis then is dead right now.  I think Obama is going to be forced to adopt reforms limiting the insurance companies’ capacities to limit or to delist those kinds of people that Douglas identified as having illnesses which do not permit coverage.  That’s what I think the legislation will be aimed at, trying to rectify.  I don’t think it’ll work because there will still be a market system which will be involved in the process and there will be ways and means to get around it.  But this again speaks to the values.  If America could ever adopt an approach that healthcare is a social good, that there’s a communitarian value to this, then of course they would see the elimination, if not complete, largely those categories of people who have been denied, had been denied before Medicare in Saskatchewan and are being denied in the United States of America.

SHARP:  Roy Romanow, are you finding it quite excruciating to watch the debate unfold here from up north?

ROMANOW:  Well I am, actually.  I’ll give you one small anecdotal story.  I was in Ottawa, our capital city, oh four or five weeks ago at a congressional, joint congressional and Canadian conference on healthcare and primarily the American healthcare system.  And we had two representatives from Congress, both Republican and Democrats who were there and I, excruciating may not be the word but I certainly find it very befuddling to hear some of the language that is kicked around.

SHARP:  But why since you, you all went through very much the same thing up there.

ROMANOW:  Yes, I would have thought that you know, history’s a bit of a teacher, that we learn from other countries, the good things and avoid the bad things.  And we can adjust some of the good things to fit our own societies.

SHARP:  In 2004 there was a CBC poll to find the greatest Canadian and the winner was actually this Premier from Saskatchewan, Tommy Douglas, who championed healthcare.  Do you think he’s a hero?

ROMANOW:  He is a hero.  He really struck a nerve, implemented a great program.  He remains a Canadian hero.  Leadership is very important.  Douglas and Lloyd went through fire to implement the Medicare plan.  They were prepared to sacrifice their government and they had the authority of the parliamentary system to do so.  Obama needs to exhibit leadership and a determination to go through fire to have a reformed healthcare Medicare system in the United States.

SHARP:  Roy Romanow, great to have your perspective, thank you.

ROMANOW:  Thank you for inviting me.

SHARP:  Roy Romanow is the former Premier of Saskatchewan.  He’s now the chair of the Institute of Well Being Advisory Board.

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• BBC coverage
• The BBC’s Jonathan Beale analyzes the President’s speech
• Full text of the speech

• BBC coverage

Read the Transcript
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MARCO WERMAN: I’m Marco Werman. This is The World. President Obama today picked up where he left off last night in his push for healthcare reform.

BARACK OBAMA: I am confident the plan that we’ve put forward is the right plan for the American people. I continue to be open to suggestions and ideas from all quarters – house members, senate members, Democrats, Republicans, and outside groups. What we cannot do is stand pat. What we can’t do is accept a status quo that is bankrupting families, businesses, and our nation.

WERMAN: The president also said he accepted an apology from South Carolina Republican Joe Wilson. Last night the congressman heckled Mr. Obama. He yelled, “You lie” just as the president said that healthcare reforms would not apply to illegal immigrants. We’ll have more about that breach of protocol in a few minutes. First The World’s Matthew Bell has been doing some fact checking. He explores how Democratic healthcare plans would deal with immigrants – both legal and illegal.

MATTHEW BELL: Healthcare reform and illegal immigration – two contentious issues that when combined apparently got the best of Congressman Wilson. But he’s far from the first person in weeks to become animated over the suggestion that illegal immigrants might receive new benefits through healthcare reform. Questions about this notion came up during town hall meetings over the summer and at protests like this one during a presidential visit to New Hampshire last month.

PROTESTOR: They should be sent on the first bus one way back to where they came from. We don’t need illegals. Send them home with a bullet in their head the second time.

BELL: Last night president Obama attempted to put the issue to rest. He said the claim that reform efforts would provide insurance to illegal immigrants is false and that reforms he’s proposing would not apply to people here in the US illegally. But Steven Camerota isn’t buying it. He’s with the Center for Immigration Studies in Washington. The group advocates for stronger limits on all immigration into the US.

STEVEN CAMEROTA: What we have right now is analogous to a speed limit sign on a highway that the police have said they’re never going to patrol. So the sign is there – the law is there – but the enforcement provision is not.

BELL: Camerota says yes there is language in healthcare reform legislation being debated now that says illegal immigrants are not eligible for government subsidies but he says the legislation doesn’t include reasonable enforcement measures.

CAMEROTA: There’s a program called the save system which runs people’s names through databases to make sure that they’re entitled to the programs that they’re trying to sign up for. That provision [INDISCERNIBLE] left out of this bill and then when it was voted on in committee it was killed.

BELL: But advocates of the current reform efforts say it’s a work in progress and it’s not clear yet what kind of verification measures will be used to make sure that undocumented immigrants don’t receive benefits they’re not entitled too. The enforcement mechanisms used by government programs like Medicaid will stay in place and whatever new programs are created they will include a system for determining eligibility as well.

LEIGHTON KU: This is clearly is an example of where people are trying to raise a boogieman that does not exist.

BELL: Leighton Ku is a professor of health policy at George Washington University.

KU: It is true that the health reform bills that are being considered by congress and what the president is considering would not provide any federal subsidies for the undocumented. However one of the points that’s come up as a sticking point periodically in the senate was whether legal immigrants would be eligible to participate in the health insurance exchanges and to get some of the federal subsidies that were being considered as a way of making health insurance more affordable for low and moderate income people.

BELL: Ku says giving legal immigrants access to health insurance pools is probably good policy and good economics. As a group, immigrants tend to be younger and healthier and they use health services than native-born Americans. That means making health insurance to legal immigrants could actually lower health premiums for everyone. For The World I’m Matthew Bell.

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Read the Transcript
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MARCO WERMAN: The high cost of healthcare in America was addressed at length by the president last night. Mr. Obama argued there’s so much waste and abuse in the current health care system that making more efficient would provide a way to expand coverage to the nation’s uninsured. That’s a message Boston University professor, Eugene Litvak, has been promoting for years. Litvak is a Soviet-trained management consultant who now advises US hospitals on better ways to manage the flow of patients. The World’s Katy Clark has more.

KATY CLARK: Eugene Litvak is an unlikely prophet. He learned the art of efficient business operations in the notoriously inefficient Soviet Union. But Litvak says his outsider status helps him when it comes to addressing the inherent waste in America’s healthcare system.

EUGENE LITVAK: Many people who were born in this country believe the healthcare delivery system should not be even touched because it just was this way forever. I don’t have this baggage and many people just forgive me because believe that this guy is Russian, crazy; he just doesn’t know what he is doing.

CLARK: But Litvak does know what he’s doing. It’s called operations management or the art of meeting customer’s needs as efficiently as possible. Operations management is common in other industries – making cars for instance or making donuts – but it’s relatively new in hospitals. Litvak says running a hospital is a lot like running a restaurant.

LITVAK: If you want to increase customer throughput through the restaurant we have only three means to do that. The first one you would ask your diners to eat quickly and you would ask your waiter to serve them quickly. That’s the first option. Second option you build more restaurant tables so you make sure you accommodate more people. That’s how you improve access to your restaurant. And finally the third option that you make sure that your tables are not staying idle.

CLARK: The healthcare system has already implemented the first two options, reducing the length of a typical hospital stay for instance and adding more beds. Litvak says the third option, managing the flow of patients more efficiently, is the least tried. But he maintains it holds the most promise. Take what happened at Cincinnati Children’s Hospital. CEO Jim Anderson brought Litvak on as a consultant four years ago. Anderson was concerned about chronic delays and patient overcrowding.

JIM ANDERSON: He helped us understand the importance of surgical scheduling so that in our elective surgeries we schedule those in a much more even way throughout the week rather than have them peak at any particular time of the week in a very unregulated way.

CLARK: Litvak also suggested that Cincinnati Children set aside two operating rooms strictly for emergencies in order to minimize disruptions to scheduled surgeries. These days Cincinnati Children’s Hospital is doing more surgeries with the same resources and pulling in an additional $137 million in revenue. Jim Anderson is thrilled with the results but he says it wasn’t a simple process.

ANDERSON: Well it is hard work and it does go against the cultural norms of healthcare.

CLARK: Translation: Doctors don’t like to change their schedules around and administrators are loathed to antagonize doctors. That’s meant an uphill battle for Eugene Litvak. In 12 years of preaching efficiency Litvak and his colleagues have managed to get only a half dozen in the US to implement their ideas. Fighting an entrenched system though is nothing new to him. America’s healthcare bureaucracy reminds him of his life back in the Soviet Union.

LITVAK: Frequently having some conversations with decision makers I feel that if I can only replace English with Russian I would feel like I’m back home.

CLARK: But Litvak remains hopeful that hospitals will come around to his way of thinking especially if President Obama’s healthcare reform efforts succeed. Litvak believes if America is ever going to provide high quality healthcare to all its citizens, hospital administrators have to start thinking more like modern factory bosses and less like Soviet-era bureaucrats. For The World this is Katy Clark.

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Read the Transcript
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MARCO WERMAN: If you didn’t hear it last night here’s the moment Representative Joe Wilson interrupted President Obama during his speech to Congress. The president was countering accusations against his healthcare plan.

BARACK OBAMA: There are also those who claim that our reform efforts would insure illegal immigrants. This too is false. The reforms I am proposing would not apply to those who are here illegally.

JOE WILSON: You lie.

OBAMA: It’s not true.

WERMAN: We’ve already heard about the content of this debate but the tone of that exchange is generating a lot of heat. Politicians including Vice President Biden and Senator John McCain have said that such a breach of decorum has no place in the United States Congress. Here’s The World’s Alex Gallafent.

ALEX GALLAFENT: It didn’t take long for Congressman Wilson to offer an apology to President Obama. Today the president accepted it.

OBAMA: I’m a big believer that we all make mistakes. He apologized quickly and without equivocation and I’m appreciative of that. I do think that, as I said last night, we have to get to the point where we can have a conversation.

GALLAFENT: Forgive me Mr. President. The speech last night interrupted the conversation that’s dominated the news over the last couple of months. Raucous town hall meetings and the like. Now it wasn’t the speech of a member of Congress – a debater. This wasn’t in the style of say a British prime minister standing up in parliament and expecting flak from the backbenches. It was the head of state leaving the safe harbor of the executive branch behind and heading into the foreign waters of the legislature. All this reminded Elihu Katz of another political moment. Katz is a professor at the University of Pennsylvania’s Annenberg School of Communication. It was 1977. Egypt’s president, Anwar Sadat, made a historic visit to Israel’s parliament. Katz says Sadat went in armed only with rhetoric.

ELIHU KATZ: Their arrangement was that he would speak in Arabic and that Prime Minister Begin would then reply in Hebrew in the presence of the entire assembled parliament and it was a very dignified reverent occasion.

GALLAFENT: But Katz adds there was heckling just like there was last night. Though there the similarities end. The heckling in Israel was accompanied by a debate between Sadat and Begin – a conversation. A conversation was not the point of President Obama’s visit to Capital Hill last night. It’s not the point of presidential addresses generally. There, says Elihu Katz, conversations are held at a distance in the form of prepared responses and that explains, if not excuses, Congressman Wilson’s interjection.

KATZ: The outburst, while irreverent and unconventional, is not so hard to understand given that the opposition has no voice in the parliament at that moment on that ceremonial occasion.

GALLAFENT: And thus the ceremonial bubble was burst. In another country, say South Korea, things aren’t considered out of hand until punches are thrown. But in the rarefied air of the United States Congress all it takes is a couple of angry words. For The World I’m Alex Gallafent.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

• BBC coverage of the health care debate
• The Guardian newspaper: Is public healthcare in the UK as sick as rightwing America claims?
• Zack Cooper’s LSE profile