There is also incredible diversity in resources. Within New York state, for example, we have to plan for reform suitable to one of the world's largest and most complex cities, New York City, as well as for communities in the Adirondacks that are wilderness areas, with tiny towns that can be inaccessible for several months of the year.

There is also enormous diversity within New York state when it comes to supply. Even though overall we have 360 physicians per 100,000 population—which is a third more than the national average—there are communities within the state where the physician to population ratio is 30 or 40 per 100,000. Even in our heavily regulated state, we have an excess of hospital beds. Whereas our tough certificate-of-need (CON) process has kept occupancy rates in New York hospitals at 85 percent or better in the last seven or eight years, that occupancy rate is starting to drift downward and it is now in the mid-70s. We figure we have an excess of about 20 percent in our inpatient acute hospital beds, about 11,000 to be specific. The problem is far different in California where occupancy has averaged about 50 percent over the years. In comparison, occupancy in New York used to be 85 percent, but now it is in the 40s and heading south.

Traditions are also highly variable. As I mentioned, New York has a very strong tradition of regulation in the health care sector, and clearly we would choose a different route to health care reform, given our druthers, than a state that did not have such a tradition.

From that perspective my remarks may not be generalizable, especially given the caveats just outlined. In fact, to give away a little bit of my bottom line, I will say that we will have to come up with a blend of regulation, collaboration, and competition in order to achieve health care reform, and the recipe for that blend is very likely to differ from one part of the country to another and perhaps even within individual states. A strong argument can be made for varying reform agendas to deal with the diversity within states.

Now, to further give you my bias about this effort, I am going to assume that we more or less agree on the goals of health care reform and can start from that premise. There are three goals. Universal access to care is the first goal, and we should not be playing semantic games with the word universal. I mean something very specific by universal access. I do not mean access to insurance or the availability of insurance. I mean access to care with financial and nonfinancial barriers swept away. Every



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