The head of the Mayo Clinic since 2003, Dr. Denis Cortese has charged into the growing national debate on health-care reform, recently making his case before the National Press Club in Washington, D.C. His prognosis for an ailing system? Grim, but a cure is possible. The 64-year-old pulmonary-medicine specialist spoke with Star Tribune editorial writer Jill Burcum and offered up these observations and recommendations:

THE HEALTH-CARE SYSTEM: CRISIS OR NOT?

To the extent that people say the system is broken, I would reject that as a too-simple thought. There is no system.

So let's design one. The fatal problem that all of our people in Washington have -- and many people have in the country: They've come to believe that the system is "broken.'' That's like saying, 'I've got a broken car.' And you're going to go out and you're going to fix it. And you go in the garage and you find out, 'Oh, I forgot. I don't have a car.' You can't fix something that doesn't exist. Nobody ever designed this to be a system. Nobody's ever sat down to say here's where we want to be in the future. That's what we're trying to do. We're trying to get across the message that we've got things that aren't working. Yes, we have a catastrophe coming at us. It's not a crisis yet. But it will be. It's a crisis because we know it will be when Medicare hits. We're going to go bankrupt. Medicare is orders of magnitude more of a significant financial problem for this country than Social Security is, and it's coming in the next four, five years. Big-time, with all the people retiring. Seeing that and looking at it should be actually a releasing truth because we're gonna have a major crisis, number one, and number two, we don't have a system. We should say, OK, let's go design a system. Let's start from scratch and create one with a patient at the center.

THE PROBLEM WITH HEALTH INSURANCE

One of the problems we have in this country, that interferes with doing with what I'm talking about ... is the way insurance is structured in this country. We have a public and private insurance system in this country. ... When you're under 65, you're in the private system. When you're over 65, you're now in the public system. Now what does that mean?

That means the insurance companies don't have a real incentive to keep you as healthy as you could be. ... Example: You get diabetes when you're 50. Insurance companies and your employers right now ... will give you as much care or as little care as they can get away with. There's no incentive for them to invest more in keeping you really, really healthy because when you get all your complications from diabetes, you'll get them when you're 70, 75. Complications occur 20 years later. Then it's all Medicare's problem.

We need to have insurance companies get their reward for keeping you healthy ... invest when you're younger, so at later years, they get a return on their investment by keeping you out of the hospital. Which is, after all, what you want. We need to get it all aligned so the insurance companies, by giving you health and wellness -- they get a reward. The providers giving you health and wellness and chronic management -- they get a reward. That's what I mean by putting the patient at the center. It's a total different change in the way you would structure this, and that's what we're espousing as we look toward what the future can maybe look and feel like.

MANDATES AND HEALTH COVERAGE

I think we've already answered the question about mandates. All the people who work and get a paycheck in this country are buying health care for other people. It's your Medicare deduction.

I don't remember that we were given a choice about that. That was mandated. ... We're telling people you've got to buy insurance for other people. We've never said you gotta buy your own. Now, you tell me if that makes any sense?

I know and I understand that mandates won't mean everybody will be insured. There's still going to be people, just like there are in the automobile industry, who don't buy insurance. I understand that. But there should be an expectation that people are contributing to their insurance. It ought to be mandated, and there ought to be a penalty if they don't participate.

REFORM: PIPE DREAM OR REALITY?

It's going to happen. It's actually going to happen. President Kennedy said we're going to the moon in 10 years. He had no idea how that was going to happen. He gave no details. He just said, 'I want to be on the moon in 10 years.' There was no NASA, no infrastructure ... no aerospace industry, there was nothing at that point. This is a hugely talented country that responded to the president's desire. The government stepped up by helping to create a NASA agency. Notice Congress didn't run NASA ... private industry responded. Why? Because they put dollars on the table and said we'll pay you for that value. Yes, there was fraud and abuse and everything else ... but the combination was a true public-private partnership driving towards a vision. Without Congress changing the vision by micromanaging the vision level, why, we got there.

A REALISTIC TIME FRAME

I'm not saying this can be done overnight. Everything I've described to you is what I envision a system in the United States to look like 20 years from now.

THE PRESIDENT'S ROLE

It has to be the president, because nobody else will do it. ... It has to be run like any other initiative. This is like going to war. Congress can't wage war. The president is the one [who] has to wage health and has got to drive this from the position of holding people accountable, that we're moving in a certain direction. Congress is accountable to individual constituents, and those constituents will be any lobbying people. That is not the way to get this done. Look where we are today based on what we've been doing in the past.

MCCAIN, CLINTON, OBAMA: CANDIDATES FOR CHANGE?

The big hope ... is all three candidates at least have health care in their top five priorities. They're all saying something needs to be done. Each one of them has an element that makes sense. Two of them are saying everybody should have insurance. One says it ought to mandated, one says it shouldn't be, but they're saying there ought to be choice. Nobody is saying a single-payer system. Instead, it ought to be a public-private partnership. That's commonality. ... So when I look at the compilation of all three of them, they're all moving in the right direction ... but none of them are talking about changes to the delivery system, a learning system of health care, generating value, individualized medicine, integrated/coordinated care. Nobody I have heard of is talking about system-engineering in health care to redesign the way we provide care. Nobody's talking about the vision. I have some hope that at least whoever is elected will have health care as one of their top five areas, that they're paying attention to it. Just having that is an accomplishment, and if they would speak about it and then let others come forward with ideas, [that] gives me hope that we'll get there. I know we will get there, because if we don't do anything now, when Medicare hits by the year 2012, 13, 14 or 15, we'll have a burning platform. Then, we'll have to change.