audience. thank you for joining us tonight. on behalf of harvard bookstore i am pleased to introduce this event present in the book the ten year were joined in conversation i hope you're hanging in there and thank you for joining us virtually for virtual events like this one harvard bookstore continues to bring authors and work to our community as well as a new digital community during these challenging times every week we will host events here and as always you can see the event schedule on our website at harvard.com / events. browse from home. this evening's discussion will conclude with questions. feel free to civic questions at any time during the talk by clicking on the q&a button at the bottom of the screen. in the chat i will purchase the link to purchase the tenure war. your purchases and financial contributions make events like tonight possible and independent bookstores thank you for showing up and tuning in with those incredible sellers we appreciate your support now and for always. and as you may have experience in virtual gatherings these last many months. technical issues may arise thank you in advance for your patience and understanding i'm pleased to introduce senate speaker. senior national correspondent and having to post. covering politics and policy. former senior editor of new york one - - the republic. he has won several journalism words with the association of healthcare journalist his previous book second was the harry chapin media word enough finalist the robert f kennedy book award among others the "washington post" called him one of the leading experts on coal policy in conversation tonight a senior fellow in governance studies at the brookings institution at georgetown university. the author of several books including the most recent one nation after trump and has many words including career achievement from the foundation. we will discuss jonathan's new book the tenure war covering the history of the affordable care act through interviews and e-mails and memos and primary sources on capitol hill and the white house. he argues the combatants didn't have knowledge and the preconceived notions clouded their judgment the book is definitely newsworthy so with writing that is lively and engaging detailed without being semantic investigative journalism at its best we are pleased to have them both here with us tonight the digital podium is yours. >> i say whatever is bad about the pandemic the first time people in my life tell me i meet yourself. [laughter] it's great to be here with jonathan and the harvard bookstore one of my favorite in the world harvard bookstore and an here in dc where i am politics and prose are two of the great bookstores in the country that really promote extraordinary conversation about civic topics and it is a joy to be with jonathan whom i met was 22 years old and edited something that i wrote and he was a really good editor then. this is a great book. i can do this. you don't have to do this you should go to the chat and pull down the lincoln order the book. it is really a great book. it is full of underlining's when the affordable care act was debated and passed they were really to people in the country you needed to read every day to know what was going on and one of them was jonathan. they cover this. it is called the ten year war and really this is his tenure war to write the book. he talked to everybody. i was surprised he didn't connect through ouija board to talk to truman who try to pass the healthcare law. it is a great book. let me just start with a question i said i would ask you. please send your questions in the chat. i will start to bring them in. let's do a shout out through healthcare and jonathan gruber who is a start the book. >> now he's a red sox fan so anyway welcome. please send us the question. let me ask the first question what changed your mind as you did this research and wrote the book? >> that's a great question. first of all i am blushing from the introduction to know people want to talk about the book that you should know that ej in addition to being a giant in political journalism was the kindest and nicest person you'll ever encounter i met him at 22 i met him just out of college i had no idea what was going on at a big convention and was the most unassuming and said hello. he is like that to everybody is a great journalist and brilliant everybody includes me but he is true. the highest compliment we can pay to my tribe. thank you. >> i write about policy and big ideas what should the healthcare system look like and how do you design that? and in politics, we're in the middle of the 30 year shift and the economy is changing with public opinion and is very much in line with the trend of political coverage we read people like nate silver reducing to numbers and predictions. i'm a big fan of nate silver don't get me wrong that's an important way to minimize politics and how the healthcare system is changing so much came down to individual people and how important that was to the outcome of the story. a person i talk about now is jean landrieu ^ who was an intellectual ^ for started working on healthcare with the clinton administration with the think tank ideas joining the obama administration if you don't pay attention to policy you have never heard of her. she had the encyclopedic knowledge of every know can cranny ^ that were so experienced and were so dedicated that's a big part of the story. if you want to know why it became law, because people like that was so dedicated and careful but why weren't republicans able to get across the line? they didn't have enough people like that. thought the staff level and elected officials. >> one of the things that is great about the book this isn't simply obama and clinton that all the way through those that were in the trenches coming alive in the book. >> i like how you went sequentially with the passage of medicare but we will stick with your people theme. i wrote down for names. i wrote on a fifth name clinton, romney, pelosi and obama and trump. in your account is how much the failure of clinton's efforts to get across the line caused everything on the advocates of universal coverage of how they should go about it. perhaps you can take clinton and romney and obama and tell the narrative. it is well told in the book. you can actually feel how we move as a country and how the policy world moves in that. >> what came up over and over again you are covering politics this whole time. the healthcare fight in 1983 and 1994, the clinton election was so excited because they had a block on the presidency. clinton was super young, he had that spirit coming in and will give an incredible speech before clinton then along - - before congress then clinton testifies in hillary clinton says she dazzles them and it seem like it would really come together in the nineties and then it collapses and it's a catastrophe. and left a deep scar on everybody working on healthcare reform. there was a sense so for years don't talk about healthcare. those advocates who been working on it for years and years they knew they would get another chance at winning get better on its own. but then obsessing what had gone wrong, how do we not make these mistakes again? and he spent years putting together a plan and a strategy with a singular focus to get past the failures with carter and truman going way back and they coalesce around the principles domestic people's insurance if they have it. don't do that. people run away they heard us work on plugging the whole. don't try to get in a big knockdown drag out fight, bring them to the table try to get a coalition's everybody can be united. they are just too powerful you cannot beat them. try to avoid looking like big government it is a fraction of what it was in the fifties and sixties. so then lo and behold in massachusetts dealing with medicaid funding, they pass a plan that fits the criteria republican governor mitt romney is signing it and scholars of the heritage foundation say we think this is a pretty good plan. the way to get to the liberal goal of universal coverage through conservative means. it did not disrupt or require huge tax increases like a lightbulb went off. interviewed obama without me even saying it i said how did you end up embracing this idea? he said we saw what happened in massachusetts. that inspired us people worked on it like john gruber. we thought that was the way to go. you have a situation consensus would look like something very similar. and then there was a sense from all the democrats even those that didn't love the massachusetts plan let's try it. >> let's talk jonathan stood question i will pull it in a moment and anonymous said am i chewing? know it is nicorette gum. it's a fair question. i will stop chewing. but with romney there is almost tragedy to romney in the issue when he ran for president. it was so striking the major achievement what plan in massachusetts any had to run away from it in 2012. so republicans just don't do healthcare and it causes problems and they try to repeal it. and then to do healthcare the most prominent left and went to brookings. >> i am a bit romney assesses because partly because of healthcare and he's from michigan and has family history here where his father was governor and a profile him a long time ago looking at his childhood. and his father george romney was an archetype of the old-school modern republican. but he got along with the labor unions really well and had a higher minimum wage and advocate for civil rights. the goldwater wing of the party in the sixties. romney's not a healthcare crusader by any stretch. he doesn't want to do universal healthcare when he gets into office. i don't get the impression that matters to him but it's a moral principle like it is with democrats he is however has a sense of leadership in public service is the romney family mantra do what is good for your country. and he is a problem solver coming up to the financial industry and consulting a really smart guy analytic reminded and gets into office. this is presented originally as a problem to solve. we spend money on charity care isn't there a better way to do this? the system is an efficient. and then the real impetus is move ahead on the plan that doesn't make them lose money on washington dc because washington doesn't change the coverage scheme. this is who romney is. there's a problem. i can solve it. give me the numbers. it made sense and it was logical to do. he's conservative there are conservative elements to it. the individual mandate he thought about it and sold it as individual responsibility. but he solving a problem. the official portrait in massachusetts two things are on the desk. a picture of his wife and a copy of the massachusetts healthcare law. he took great pride in it. then humans are president 2012. everybody hates him for it. he gave a very big speech at the university of michigan 1 mile away from where i live at the medical center explaining his position on healthcare it was a tortured explanation why he did this and why it made sense for the rest of the country. intellectually he is fit and thought about what he was saying but it made no sense. it was so obvious he was bending over backwards to renounce something that he that was a good idea but was instrumental to make it a lot of massachusetts and people are better off because of it. it was a shame. >> it was a shame and fascinating to watch him have to do that at the time. people should read the book to get the full story but that is available to you in the chat what unless the passage of the bill was you go through it and wonderful but not excessive detail first you have the endless negotiation to have republicans come on board. >> think it would like you to reflect the lessons we could take from that process. joe biden is taking a lot of lessons and some of them have to do with those fruitless efforts to get republicans to come on board then the house pass the bill the senate can even get one out and then they finally get the bill through congress and what happens massachusetts elect scott brown now they don't have 60 votes anymore telescope the whole story but the whole bill got a hold bad rap in part because the process to get it done was so long and ugly. reflect on that a bit. >> no question the negotiations hurt. this was the fear from emmanuel who was chief of staff desperate to move things along. number one, early on they made a decision they have to get 60 votes in the senate. the budget reconciliation process with just 50 votes. they felt they couldn't do that for a number of reasons. they had to get 60. in the beginning of 2009 it was 58 democrats. over the course the pick up tumor seats by the time they get to summer they have 60 been i have to keep them with conservative democrats you don't like the plant. it was a struggle. they were never going to do this in two or three months. it would always take some time and they thought it was absolutely necessary. as the year went on they said we need to do this on her own and instead do it by ourselves pull the plug on negotiating with the republicans providing get your right if they could get it through earlier it would be better. two things i learned in reporting and what has relevance for the future. first, we look back and think how ridiculous is it democrats thought they would get republicans? that was my attitude. i don't think anybody thought max baucus needed to wait that long to pull the negotiations. i did not know when is on the most was how much baucus in particular and other democrats believe they can pick up republicans. number one orin hatch in 2008, dispatched some of his aides to kennedy directly and quietly and said let's do a bill just me and you kennedy didn't think that but hatch wanted to do that i thank you would've got that was acceptable to democrats he was conservative but the interest was genuine. with a close relationship with kennedy with the children's health bill. and grassley had a weird relationship with baucus and he was expressing himself that made it sound like if he could get the yes he wanted to get to yes. that was surprising. interviewed perry read about this. this is the first time i spoke to him he is fascinating and terming an interesting i said don't you wish you could've moved to the train along faster? the one point he made he said if we moved faster pushing the conservative democrats didn't want to do it i'm not sure they would have been there at the end they had to get fully invested in the process. one of the reasons they were negotiating with republicans to convince conservative democrats they were trying to win republicans so they go back home to arkansas north carolina said we tried. by 2009 even conservative democrats are fed up with republicans. clearly you are not negotiating good faith when it came time to vote. reads that i tried my best every opportunity they wouldn't come along i need you now. the mental calculation was wrong and would have more relevance today if i'm a republican in arkansas my better off to have. bipartisan not good or a partisan bill >> you mean conservative democrat. >> yes. sorry. and talking about the covid relief bill, joe mansion from west virginia it doesn't look great voting with democrats in a republican state but it is worth it if it is a covid bill helping people in west virginia a lot more. that's a big lesson one passing on a bipartisan basis. >> this goes to jonathan gruber's point how much of a difference it could have made if not trying to be deficit neutral could 100 billion more made a real difference? my view less than 200 billion more could've made a big difference but was the train already out of the station and nothing mattered? >> yes for background come as the bill was being negotiated, it was agreed total spending cannot be more than $1 trillion over ten years. and in addition had to pay for itself. actually reducing the deficit. whatever went out the door had to come in. that had profound effects on how the program worked later on because the more money you spend, the more you help people giving the money to buy insurance the cheaper bill was then the less assistance they get and the more expensive their insurance would be john knows all about this because he was working up the model he was doing the modeling showing what happens if you spend extra money so what john is asking is if total spending was 900 billion over ten years, they spent an extra 100 million or 200 billion over $1 trillion and oh that's a lot of numbers for a zoom talk [laughter] it they spent were many in government spending wouldn't that be better? i think so and john gruber think so. but was there a way to do it politically? talking to the liberal democrats people that were working for waxman or liberal advocates, i would ask all the time if you could change one thing about the affordable care act is more money they said it's a politics issue you had forces that were compelling pushing in the direction of less spending and deficit reduction coming from conservative democrats the voting looked bad to the voters. some of that came from the white house. president obama firmly believed this was as much but was committed to the idea the main goal was to reduce the deficit. causing physical problems in the future and was advised by people who firmly believe that. peter or zach the most prevalent. he is spent years with healthcare delivery. these were not crazy notions there was a principal reason and political reason and once you got into the box to say had to reduce the deficit i quote in the book karen nelson the healthcare advisor to henry waxman like an extension of his brain. >> if you don't know he's one of the most legendary members of congress who passed an incredible number of bills very important to consumers and healthcare in a bunch of areas. >> he has fingerprints half of the welfare state and half of environmental protection he's a force of nature i don't think anyone in congress now is anywhere in his lead with that record. healthcare is a reform and karen nelson advisor most closely something along the lines that every time they got to the time to the end of negotiations increasing spending people that are be good to spend more money but you had to find it. you get it? take it from the drug industry? know then they fight they said are giving as much as they can give. what about this tax? arkansas or louisiana or north dakota and you go down the line and then there was no money. they did the proverbial look in the couch and they didn't have it. but i do believe had they not been committed to deficit reduction or such honesty they were rigorous. a lot of people advising the president why didn't you just fudge it a little bit? that is what washington does. i don't think jason furman would have let us do that. he actually teaches at harvard now very principled would have objected on the grounds we want to play by the rules. it's important to be honest in governing that's what obama believed there was a commitment to intellectual honesty that on the one hand is quite admirable but not politically useful. >> there are two questions about now that, of what you said. the fact the program could be structured with more generosity could make a big difference the way it worked with a little more money. what you think of the proposed changes of the reconciliation package likely to pass congress? they sound good to me and also related to the question the says please share your thoughts about what happens now with all the problems of the affordable care act especially with the hostility of republican states and exchanges that congress cannot fix those issues so the efforts to visit on - - to fix it and the other question. >> the biden administration made very clear they want to do. three big things have happened with the affordable care act one is efforts at sabotage they never did succeed in appeal but the trump administration can make small regulatory changes to change things like the formula of actuarial value which five only people know what i'm talking about everybody else falls asleep. it's a way to calculate how much are insurances. the trump administration turn the dial in one direction to make it less generation one - - less generous now they turn the dials back on around they are already doing it it'll take time they will do that. but now they can add the money back because the attitudes have changed. in the middle of covid relief in many flights out the door and in general, not only a crisis people don't pay as much attention and don't care about the thinking has changed along the economic establishment. we don't have to be so worried about deficits and there is an extreme version of that that you really don't have to i don't think the profession as a whole is there but there is a looser attitude if you're democrat we get in and inherit the big deficit republicans come in and blow it up with tax cuts we have to do the cleanup. we are sick of that. think they will be as profligate as republicans but they will not been over backwards either. it will change intellectual thinking and it turns out we do have this crisis so the covid relief bill has extra money to build a financial assistance for people who buy insurance on their own. if you buy coverage on your own it is called the massachusetts connector and through healthcare.gov you qualify for a tax credit but it is based on your income with four times the poverty line at $100,000 per year. everyone is already getting a discount get the bigger discount. so now it's only for two years and those kinds of changes with the biden administration is already working on we have a reasonably good tent chance and then you try to get change with winners and losers throwing money at it but the money, there are two questions could obama do a better job and indeed there is a vicious circle with a said obama care polls bad. don't talk about it. and then not until repeal don't have - - you don't know what you have till it's gone. there was a full-blown argument and in the question about single-payer so go through all of that. may did not do a good job of selling that. and then why the republicans failed to repeal it and it became popular again and then it flipped and the numbers became positive. >> they didn't do a great job of selling it. to be fair it's hard to sell it when you are in the process. they committed to the strategy to get the 60 votes. there are definitely moments so if we have one critique they did a bad job working with progressives and took them for granted. and then do a follow-up article. that's a complicated story on its own. but that really important moment of the aca debate when he gives a primetime press conference at the white house to explain. the middle of the summer. it's pulling badly. and gave long answers that were quite intelligent. and with that healthcare policy you are lost. in the last question of the night this is when the professor was arrested cambridge that's all the anybody wrote about in the pulling on the aca was the single biggest drop ever recorded in pulling right after that press conference because he was seen as racializing this. which to be fair people remember that incident. they did do a great job. is hard to sell but one really important part was the fact and then i also think nancy pelosi took a lot of grief for some that were shorthanded when it passes the point was voters don't know what was in the big complicated bill but then they realized what they had in the people who benefited not willing to give it up. that's why you have very conservative districts and hundreds of hundreds of people showing up to members of congress. i said at the time that was happening a lot of people didn't even know there was another democrat. now there are hundreds of people at the meetings so those that are affecting the laws popularity. let me read two questions that helps answer them something disappeared. hold on. i said you are supporter of single-payer in retrospect is that a better solution for better feasible in 2009 or anytime in the future? and those giving so much retail power was it necessary to get a good bill passed? but jonathan answer that they killed clinton care they didn't want it killed this time. and yes of the things could've happened maybe it wasn't such a priority with the individual mandate maybe the healthcare industry deserved more hostility and progressive supporters of reform a little more love. it's easy to imagine a substantially better version it's hard to imagine if it is substantially better version of the affordable health care act getting through congress was a great little passage single-payer and love to the industry. >>. >> if you started from scratch that would either be single-payer one of the other successful systems in europe and the right of citizenship and the government regulates prices and something like that. and then to use that have your load start. it is politically practically how you get there is much as long as i have been writing predictions so i feel confident to say that. in terms of second-guessing if you isolate those decisions you don't need to wait to september it's pretty clear that was going and then see the mandate and then the cadillac tax. in the way they treat insurance most believe drive up healthcare cost. that it is more complicated than you thought. there are reasons they did. and then to satisfy the congressional budget office to get the clean bill of health cbo says yes this will reduce the deficit which is something they had promised to do and that they needed to show to keep it together. if they haven't done the cadillac tax yes but you may have last the vote and you don't have any votes to lose. it barely passed. if anybody gets anything from the but how close it came to falling apart so many times. truman couldn't get it done. kennedy nixon couldn't get it done. clinton couldn't get it done. then pelosi and reid and bacchus and waxman and kennedy got this across the finish line. and what deserves our respect and you have to look at that picture is a whole. and then to do so much more but we got it done and it is huge. use the biden expression that a big bleeping dealer won't do too much second-guessing because they got it done. >> there is response one - - respect for jonathan out there. one big disappointment of the aca was opportunities americans with disabilities. and with democrats will do better this time around. >> i hope so. just to give background the class act as part of the affordable care act to do long-term care and services which are so important for people in nursing homes a disabilities. i would say whatever problem of the healthcare system generally, exist in the narrow category of long-term care only worse. that's the worst part of health care system. it's a hard thing to solve in other countries struggle with that also. it is complex there are modest things you can do along the way to fix it. i don't expect the biden administration to make healthcare a top priority outside of covid. the political capital they have i imagine they will go after the big ideas of infrastructure, climate change, before you see another run at healthcare. that may not be the worst thing because out of the spotlight there are a lot of republicans who will work on that if it doesn't get them in trouble with the voters back home. very conservative members of congress. it off it is a romney issue per se but imagine mitt romney were conservative members i remember a story about ted kennedy that he was so good at to build alliances this icon of american liberalism and could be a partner with anybody. there was a bill. it was stem cell research he was trying to get through. he ended up winning over as an ally, strom thurmond the segregationist no one in the senate floor opposite than thurmond that he had a granddaughter who had some kind of congenital disorder and he knew that. he could work that and appeal to the personal issue to get thurmond to support it. and help get it through congress. sometimes that's all hands on deck you need the lobbying in the big movement. sometimes it is off to the side sometimes that helps a little bit. >> we are just about on time can we have five more time on - - by more minutes? i just want to ask one question and read one section of the book. the short answer your phone rings. it is joe biden. he says jonathan i hear great things about your book. you had a great event at the harvard bookstore. i don't have time to read the whole book what can i learn from your reporting of this whole period of how i should govern now? what did you learn about the way american politics works given that context what would you tell joe biden besides saying it is a big blinking deal? >> i would be very surprised. politics has changed. biden gets this and right now we don't have a situation with a cooperative governing party on the right to have to be prepared to go on your own right away don't worry about the process what about the product don't be afraid of its democrats working with democrats. do it. so people like romney or murkowski is out there. but be prepared to act on your own. be bold. be quick. not just for biden, everybody. governing is hard. no reform pass the entire history was perfect none was close to perfect. it was a halting have to if you're an idealist or progressive thinking what you want the world to be like that this is your ideal and this is what you've got. and then to strive for the ideal to get what you can but at the end of the day and then that i can beget success and failure. i do with the liberal mindset looking at every single achievement half glass for versus glass half empty. >> i will be the final two paragraphs but i really did enjoy this book. i mean what i say. with the joe biden expression i mean that sincerely. woefully complete attempt to establish a basic right that already exist in most cases long existed in every other developed nation. and with that piece of legislation to pass inhofe a century and those that he may as well not nearly good enough but yet so much better than what came before it that is what change looks like. what a joy to be with you thank you for joining us tonight thank you for writing the book. >> thank you for all the kind words and for being here. this was such a fun conversation. thank you so much. >> thank you for joining us tonight everyone in the audience as well. please learn more about this book and their more of the tenure war here from cambridge massachusetts and harvard bookstore. please keep reading. be well