The first time i made that. They helped make tonights event possible. I also want to thank all of you for supporting such talks like many other independent bookstores. We are facing a challenging marketplace but we are doing quite well in large part due to the avid book readers here in washington and we remain committed to bringing a great author and great book event. A few issues remain critical to our individual health and the nations wellbeing as a state of healthcare in this country. And yet a few issues are as bright and controversy and misinformation. We are fortunate this evening to have with us and accomplished journalist and media entrepreneur who has made it his focus the past few years to sort fact from fiction and get to the truth behind the Affordable Care act and the American Healthcare system today. Steve of course has a long history of taking on big subjects through journalism. Shortly after graduating from law school in the mid1970s he launched the American Lawyer to cover the business of law firms and lawyers and also wrote a book on the teamsters in 1991 and founder of court tv. She wrote a sweeping account of coping in the tragedy. The pc led to the book on the Public Education called class warfare inside the fight to fix americas schools that was critical of the teachers unions. Steve has continued not just to write but to create organizations that promote great journalism. Nearly a decade ago he donated a Million Dollars to establish the journalism initiatives at yale to teach and provide Career Guidance to students interested in journalism and he continues himself to teach at yale. And in 2009, he and others to set up Journalism Online to deliver the Online Platform for newspapers and magazines. His latest book put out the revealing 24,000 word article on the exorbitant cost of vehicle care that he did for time magazine. An article that for the first time in times history took up the entire section of the magazine. The piece won a National Magazine award for public interest. In his new book americas bitter pill, he goes further in exploring how the Health Insurance system evolved, how the specialinterest shaped the Affordable Care act and what remains to be done to improve improve Health Care Coverage and especially to contain cost. The book is much to offer for those that are interested in how we got to where we are is also very consumer friendly and useful to people trying to understand their own healthcare bills. When completing his reporting for the book he ended up going through open heart surgery. And even he committed in all of his research, had trouble making sense of the medical bills that he received. Steve will be in conversation with a sikh emmanuelle who had a role in the special adviser on Health Policy to the omb director. A cancer specialist committees now a vice provost where he heads the department of medical ethics and Health Policy. He is within his own book about the Healthcare System titled reinventing American Healthcare and he has mentioned several dozen times in the book where he is portrayed as not my old about what he thinks. So, ladies and gentlemen, please join me in welcoming stephen and seek. [applause] the introduction made it sound like i had the open heart surgery to sell my book. Book. You dont believe in self experimentation . [laughter] it is a great pleasure to interview you. We spoke a lot more than that. I want to ask why you wrote the book and in particular a large part of the book is about sort of fighting over the passage of the aca reclaiming the fixing of the website and i guess the question that i have is did all that matter backs. What did you learn from that . 40 while id been looking for a book to write about what i perceived as the challenges facing the government and the dysfunction of washington and it struck me looking at how they attempt to reform the aspect of the economy would probably produce, and it did. The whole process i think at the end of the day what this book reminds us of four tells us is in this day of age but comes out of washington for any war. That isnt a terribly profound statement unless you start to define the powers that be and what you see is the Healthcare Industry spends four and a half times as much as the next biggest lobby in washington, the militaryindustrial complex. So as you and your colleagues on the team realize that if you want to Reform Health care you can spread coverage. Thats good. But you cant touch the cost or the tort reform. You cant touch the kind of things that make it so expensive. We will get back to that question. But in some sense at the time it was almost 18 of gdp. The biggest Single Center of the entire economy affecting everybody. Is everybody fighting over what you would expect quick it was surprising intellectually. But, when you get into them as a journalist and tell the story in detail involving real people you understand the Magazine Article before i wrote that it wasnt a revelation to anyone in this country. His health if healthcare was really expensive. It was a bit of a revelation that nonprofit hospitals were charging 77 for a box of clothes and that was expensive. By providing detail and explaining how it happened, what isnt surprising to people on the general level becomes important to people. One of the things you mentioned some people think that you have it out for hospitals in your book im sitting here in front of the hospital. The book seems to portray them as a villain. That is the difficulty of writing about health care. One thing i try to train my journalism students to do is to understand that nothing is black and white. And this subject is the ultimate example. The people that work at hospitals do gods work. It is hard to see them as villains. Its not like when they wake up in the morning youre going to work in the office and make a video. They are caring for the ill. This is something i started writing a long time ago that when you give people even good people good things on accountable power for a long time, they abuse it and hospitals charge what they do and make the profits that they do while they are having the annual Charity Dinner and think of themselves as wonderful charitable institutions. They charge the prices they do and ultimately because they can. They hired bill collectors and they sue people into bankruptcy not because they are evil people but because people involved that way. When you wake up one morning or maybe a journalist wakes them up and you see people into bankruptcy. What is the most surprising story about the Affordable Care act that came out of the reporting besides the memo . It was counterintuitive if you subscribe to the cliche and not everything is black and white. The staff people i talked to who did so much to write this law a republican wrote that law i assure you. They had a lot to do with the good traditions and. Com clued in data collection. My point is the revolving door image of the staffers and other work on the hill when they lobby and go back to the hill and it is an easy thing to the people that work day and night on capitol hill and in the white house including you really worked on something because they cared about it, they were honest and they did the work. Its the best work they could do under the system so that is a bit counterintuitive. What was also surprising to me is you could have so many smart people on the staff in the white house and ultimately they were just so incompetent when it came to the revisionary. Im not just talking about the website which is obvious. And you were one of the people but warned them early on. This is the most complicated effort ever undertaken and they just were not into governing. Its almost as if the nuts and bolts of governing or just below their pay grade. And thats really so crazy because i am an ivy league kind of snob. They must be really smart. And these people when it came to the nuts and bolts of implementing these were just clueless. For me i think one of the great pieces of reporting in the book is about the disastrous website and then it is resurrection with the socalled technical search. What do you find surprising about that . The best kind of journalism is journalism that defies cliches and expectations. So, on the east coast we tend to think of it as selfish, clueless narcissistic people. These people that came in and rescued the website first he volunteered to do it for free. The hardest part that i had to do was for them to allow me to use their name. They didnt want any publicity. They just wanted to fix it and one of them told me im an engineer and i love to fix things and in this case i am fixing something thats really important so that was a bit of a surprise. V. s were really good people. One of them had been hired as you know by the white house in the fixed Technology Program across the government. I i havent done any reporting on this but maybe he feels like hes a prisoner in a jail because one of the things i sort of knew what was surprising is how terrible the Government Contracting system is. These people specialize in making promises to win the contracts and then specialize in explaining why its not their fault. Its connected you figure out did you figure out how to solve that problem lacks if you look at all of the stuff the government does it is pretty much all a disaster. The i had a dream and i kept waiting for the washington post. You have a page of outstanding government contracts and how much they are overdue and how much they are behind schedule and how much the cost is overwritten if you have the rankings that are changed every week. Why do you think that is inherent in the system . They tend to work best in the situations when there is a crisis and everybody is watching. The government contract would secure the borders for example during the Bush Administration with cameras and stuff like that. They gave i writing half a billion or a Million Dollars. Every time a bird even flew over the border there were helicopters coming in and who would have thought that . I remember writing about it and it turns out some of the stuff wasnt waterproof. They didnt tell us to be waterproof. If thats got a lot of attention it might be fixed but another problem and you know this as well as anyone, is that it is really hard to get good people to serve in the government. In Employment Positions they have to run with all kinds of Financial Disclosures and conflict checks and all of that. But even at the lower level it is still really hard to attract good people because they dont get rewarded, and im not talking about money but they do not get rewarded in the way they do and a lot of the industries where if they did a good job they get promoted over somebody else who has been there for longer. Your diagnosis sounds like is people focused. My sense of government contract they have the institutions. They have too many institutions. The elaborate procurement regulations, inspector generals for every department. They had the institutions, they just dont have them at the senior level the sense that this is part of government and being elected president especially if you are a democrat and want to convince the world that this is a good role for the government you have to make the government work. I want to ask about two people in particular. One of the people that i think does not get enough credit, and i might be biased in getting the bill through the passage is nancy pelosi. What do you think . Thats right. After Martha Coakley decided to take a vacation and what the senate race in massachusetts, the only way that it was going to happen is if the house agreed to go with the senate bill and the first time this was mentioned she said my members will never agree to that and maybe we do need to do that and by the third day she was just adamant and i think thats fair. And i know i say in the book is in a way that is really unusual but there is a scene in the book where she calls a member of the caucus and he says i dont know if i can do it and she looks at him and says thanks for nothing. I got you here. And he changes his mind the next day. I think youre right she deserves a lot of credit and the president deserves a lot of credit. There are a lot of times that most of the closest advisers except for the Vice President [laughter] we will get to that in a second. That was the next question. They said you should give this up. Im including your brother on two different occasions. He kept going and what he told me as he kept going because like all the other candidates he kept running into people in the campaign trail that had these terrible tales even if they had insurance they had lousy insurance, the kind that you didnt get to keep ones obamacare past. Plus, the staff on the economic side was telling him that part of the economy was fixing health care. That didnt work out because you dont get the cost controls that you want that also kept him going. What do you think that his role especially on the implementation after the passage . I think that he deserves as much credit to the implementation as he deserves positive credit he just didnt manage the government. He could be president of the united states, it is the single most important legislative initiative. You know it is complicated to launch the website. Anybody could figure that out. He really never did anything other than have people show static screen shots, and his chief of staff was so out of the loop at the night before, he calls around to the friends saying wait until tomorrow morning we are going to knock your socks off. He was right. [laughter] your assessment of Valerie Jarrett was not charitable. I admire her for having that accountable power. Thats not in the way that you think i often say that she kept the president going on this and reinforced his determination to push ahead with the bill during the different junctures where it looked like it was just going down the tube. We played a public role with the press on the tv appearance. If you are a real journalist is in a mixed picture. I want to switch gears for a second. You were heavily criticized by Malcolm Gladwell. One way of reading his review in the new yorker is that youre an imposter. [laughter] but it didnt end well. Most people hes not the best writer in the world. Thats where it was bad for me and i guarantee no one got it. What do you think his mistake is . One of the things he said hes not an expert in this area. Thats for sure. He does this dichotomy as you will recall. She writes about the people and institutions and he actually said they wrote the story of how the institution of the white house corrupted Richard Nixon. I would bet if you asked bob woodward he would say that it is vice versa. So his whole motto falls apart and what that has to do with my book i am still trying to figure that out. What he said about the book is that i dont rely enough on the private marketplace. Then he mentioned a book by someone whos a turkic guy and wrote a thoughtful book in which he espouses the private marketplace and the jacket is from his friend Malcolm Gladwell i just disagreed with it and i think you did, too mac. This is the substantive part of healthcare is a Consumer Product in the marketplace. You dont wake up one morning and say im going to wander down to the emergency room to see what they have on sale and check it out and if i dont like it i will go across the street. In some ways buying a smartphone you can go to the Consumer Reports and figure out which one is the best one. You can also decide i think i will stick with the one i have i dont want to buy a smartphone. The fundamental thing about healthcare come and i knew this intellectually when you are sick with thousands of patients to see your thought thinking of money. Told the audience that havent read the book that happened and how did your experience with open surgery at columbia change your perception and the Health Care System and the fact that you think 3 trillion is okay to spend. I dont think that is okay. The way that i prepared for this discussion because i was trying to think of things you would want to discuss iran to my index and i looked up your name. [laughter] dot last day of enrollment in the Exchange Last year march 31 was having a routine checkup and by doctor checked this site and decide and used his stethoscope and then im thinking to myself, remember i am obsessed with Health Care Bills and this is a new doctor that my wife and i had just gotten who was just giving me a routine annual checkup. He says you really need to get an mri. We used three times per capita as any other country because it showed this bubble on my heart and i go back to the doctor a day later and he says you have this bubble and in my case it is big enough so there that there is a 17 chance that at any given time in any year you can burst. He said i have this thing ive got to do in europe or a business trip i have to make. So two days later im in the hospital but it was just bizarre because when you are in first and writing a book in the middle of the reporting and thinking about all this away into the hospital and i think im dreaming. How can i be in the hospital . And i cant sort of tell can sort of tell the difference between reality and a dream. Then i noticed as i explained in the first chapter that i think my heart is coming through my chest and id have to say making it the nurse tells me im okay and then i have a dream that the ceo of the hospital 3. 58 million im being wheeled into the operating room for my surgery. Very welldressed someone making 3. 5 million a year with bnp standing there saying wait. We know why youre here. We know who you are. Youre not having the surgery you are just going undercover. [laughter] and i said no i swear. He said i have to have this surgery. I wont complain about the charge just let me have it. If you want to sell me six boxes of goods i will buy them right now and i will do anything you say. And so this dream was mixed in with reality that what did do they teach me, its taught me asking my hospital bill with asking mrs. Lincoln if she prayed. How much was your hospital bill but hundred 90,000. Does that include the surgeon fee or not . No. Now here is the really interesting thing. As you know there is no correlation between the cost. I didnt say anything about about the quality just the price. Here is the really interesting thing. When hospitals gave a good bill thats where you see some hospitals charge 20 for a mucus control device, thats what it says on the bill, which is a box of tissues. [laughter] mine was 190,000 including some 371 i think it was for the patient education which happened the afternoon of the surgery. Let me tell you the afternoon of the surgery when i got out of the operating room i wasnt educated on anything. So then when i get the Insurance Companies the benefit i find out they only got an 8 discount off of it. Thats because hospitals today if they are big hospitals and new york presbyterian is the merger of new york and presbyterian they are basically four or five Hospital Systems in new york and you cant sell insurance unless the systems are in the network. The discount on the charge was only 8 which was stunning to me because i was doing my time Magazine Article seeing discount from 40 50 . If it was something more routine, the discount might have been deeper. The other thing about that i learned again again sort of firsthand what i knew which is that the system is unaccountable and crazy and dysfunctional. After i got home, i cant two or three days later 36 firstclass envelopes from the United Healthcare by Health Insurance company and its 36 different explanations of benefits. The same benefit of . 36 different things. One Prescription Drug here. 36 different things. First it tells you something about the efficiency of the system that was 36 different envelopes. So im thinking this is great. Thats when the leading expert on the benefits and the third one i open up is my wife is sitting there with me and she is a real lawyer and shes generally just a lot smarter than im. I am. So we are looking at this thing and it says im out dear. Amount paid by Insurance Company, zero. Amount you owe 154. I cant figure this out, i give it to her she cant figure it out. As it turns out, i had scheduled an interview with the ceo at the headquarters in minnesota. So as soon as i was able to travel a couple weeks later i went and interviewed about the lobbying over the bill and over obamacare and how it was going to affect the hospital consolidation and all that good stuff. And when i was finished, i said i took the explanation of benefits out and i said do me a favor if you could explain this to me i read it and i just couldnt understand it. So he takes it to the executive Vice President which is that a 100 billiondollar company sitting there and at that moment i can see that hes trying to figure out what his next job is going to be. He is a very smart guy in the industry. I could sit here all day and i cant tell you what that means. The point of that is it is arguably while it is definitely the most common communication to consumers in the biggest industry it was thought to be the most vibrant while working economy on the planet explanation of benefits. United healthcare, there are tens of millions every year. We in this room dont understand it but the ceo of the company doesnt understand it. How can that be, how can you have a system like that . This comes back to my first point when the system is unaccountable they can basically do what they want. They think that the Insurance Companies do make it unintelligible but hes kind of surprised. The first question is your solution which i would say that didnt help the policy community that has been totally ridiculed and laughed off of the platform. They have done such a good job up until now. Some of us think we have done a reasonable job. So tell us why you think that this is the right solution. The healthcare policy would be the right solution if you go back to 1943 and change when employers were allowed to get insurance. I am a singlepayer system. We can all argue that is the right solution and say that we want it but we would like it could be christmas too. Its not going to happen. What i try to do i looked across the landscape and i said what is happening and what is happening is that large Hospital Systems are consolidating and buying other hospitals and doctors practices and clinics and it is a that is a pretty bad or threatening thing because there is no competition. If you want Health Insurance in new haven connecticut, if you dont have it in your system and you are not selling Health Insurance, the idea that obamacare would encourage that there would be six Insurance Companies in new haven negotiating instead of two or three is kind of absurd because if they are in the system and they have six they can play off against each other it is easier if they have one or two. So i looked at that and i said why dont they do this do that kind of these are not bad people why do you take over when you are flying in from all over the world to go to the hospital . So in addition to the price controls is to allow the Hospital Systems. If they are monopolies and they regulate them and the Profit Margins by regulate the practices and even though salaries of the ceos and the benefit of that is at the Cleveland Clinic is now dominating healthcare in ohio the Cleveland Clinic can sell its own Health Insurance. If we have 10,000 a year for my family to see you keep me healthy. You have Walking Centers urgent care centers, hospitals, doctors practices. So here he is venting to us you keep me healthy im going to walk you accountable. One of the regulations is you have to have the ombudsman essay it is now an Insurance Company so they dont skimp on care the way we wished we had regulations that make Insurance Companies skimp out on the care that they approved. But if you did that come of the hospital would have no incentive to go for test were over treat me because the bill in the testing and over trading would be going to the hospital so they would be building themselves. So that is the ultimate accountable to organization. Its the ultimate bundle. You say that its been ridiculed. I think what has been ridiculed as the notion of the big monopolies in the clinic in ohio and all of new york taken over by columbia. Thats what i said. New york four xxray for washington it would be three or four or five and they compete. Now when you see one on the west side of the highway that billboard is meant to give them more leverage and its not to me directly because its my employer buying insurance thats going to send me there so this would make the competition cleaner. The only place you have monopolies is when you do have to monopolies. But there is a monopoly or an oligarchy by idea is terrible and makes no sense if the regulation doesnt come with it so far what we have today is we have the oligopolies that are fast developing for the Hospital Systems and new haven has become one and the cleveland has become another. We should acknowledge it and turn it to our advantage by saying okay now we are going to treat you that way. What happens is the regulator becomes captured. You your self started out talking about the fact that it comes into the category of Winston Churchills definition of democracy. You cant think of a better one that is realistic underlined that is realistic. And even though whats realistic. The last thing id want to talk about for the second to last think is the claim about the cost reform. You have gone out a lot and decided that the bill has failed on the cost control and i certainly among others think that we didnt do enough but the fact is that since the bill has passed for the last five years the costs have been Vice President of the gdp is flat and onto per person basis in medicare and medicaid actually gone down, so whatever the fact that we didnt do enough doesnt mean we didnt do a hell of a good job inadvertently. Lets unpack what you said. First costs have gone down. You rate the cost increase that has gone down. Medicare and medicaid per person. On a per person basis, medicare and medicaid have actually gone down. On the healthcare cost generally lets get to what else you said. You said in the last five years the data that you were talking about that was recent is 2013 before the Healthcare Exchange even existed. So it is a nice thought but its nothing to do with obamacare. First, that i dont totally disagree with because of obamacare started on march 23, 2010. The exchanges are not the only part of obamacare. So the idea that parts of obamacare didnt come into effect until 2013 whatever you are referring to were not returned in march of 2010 having been written yet as you know. So now the best way to look at this is to read the law and look for places that even purport to do something of cost. There are a couple of examples. The Hospital Readmissions penalty for medicare even though the county is much lower than you argued that it should be. It is meaningful because it focuses hospitals on that issue. Theres a penalty for higher than average infection rates. I dont know if that does ashford cost behind sure that it does something for good care. Once you get past that you have a long way to go into there in there is nothing that controls the price of the drugs. Weve already been through this. Do you want to do that again . Connected there is nothing in there that does anything to control the price of drugs. The socalled comparative Effectiveness Panel that was put in place so that at least there could be a public airing of the drugs and treatments and devices that would compare their effectiveness to the cost is so lacking that peter or zagat is wrote i missed the boat on cost control wrote a very vicious editorial in bloomberg about a year ago saying exactly what i just said with the comparative effectiveness. And you agreed and they may have even coauthored as far as i know. I got a really good education reading your emails and your colleagues emails on the economics and management side of the house saying all this and predicting so there may be some very best out there but there isnt even any data that says that its done. Has the latest increase gone down some . There is no evidence. You cant point to any evidence that it has anything to this has anything to do with the core drivers of cost in this country nothing that controls hospital bills. There is an encouragement of the bundled payments added that have had mixed results. But thats good. It calls attention to it. So at the core as you know because you were the one with a bunch of other people it is hard to describe you as angry or losing your temper i never do. I would say it is true from my perspective having worked on the bill we didnt do enough but i think that it also turns out to be true that we did enough to effect the system. I will give you an anecdote. I was in miami talking with a guy that had a very complex draft. He said they try to coordinate the care for everyone and he said that Accountable Care organization completely changed how we do things to be on a friday read on a friday afternoon if a patient came in before we send them to the urgency room. Now we actually see the patient and try not to admit them to the him to the hospital. Last year we made 4 billion because we saved money and its changed how we practice. So i agree with you i thought we didnt do enough and we could have done more. But that is different of what effect the bill has had and i think its had a bigger psychological effects of van it has kept the cost flat for five years now. Its not been the only, but its been a major factor. Last thing i want to say is that you called me brash. When some of my relatives read that they said he doesnt know what hes talking about. And that was my parents. [laughter] the other one was very upset. [laughter] one dot a. That does all three of us thought that it ought to be injured. We will have audience questions now. Thank you for being patient and listening to us. [applause] we have a microphone here and if you would come up not all at once. Tell us who you are. And questions, not answers. My name is michelle and i will meet this very clear and succinct. I have had the american system like the natural system here in washington. Its terminal. And on a serious note i spent half of my adult life receiving health care from three different European Countries and in the case of the uk also was employed in the child wasnt until Health System due to family aging. Whats the question . I want to thank the author for bringing this back to the society. This is the best question ive got. I do hear what youre saying but i want to share with you. We have Serious Problems and until they overcome their denial can overcome that his association with reality that we have probably one of the most broken systems in the industrialized world and even coaster rica acknowledged but i think the premise is and i would like your comment on this. In this society if you talk about anything and everything founded on private material, monetary of attainment the only society in Human History that thinks its all about the private and not the collective. We are going to ask steve to talk about that. We spent two weeks trying to get health care for a child. Im trying to prevent causing harm to this community here but because of the bureaucracy which the government no longer has a monopoly on so i just wanted to point out you didnt learn enough or not enough in the bill . I had a terrible habit as a reporter. I was talking to some doctors and they were saying that they have a patient seeing them in their office and they say i need it to do a procedure with you but i cant do it in my office and i need to do that in a hospital. Thats the only place i could do that around here. But the patient got out of the hospital less than 30 days ago so the hospital doesnt get back to them and answer whether or not they can schedule but because they are not going to get paid very to read how do at how do we fix the problem . I havent heard that particular problem. Maybe i didnt understand the question. We dont want to bring them in for anything. And then they cant get the care that they need. The penalty on the readmission doesnt penalize every readmission. It penalizes them for having a higher than average mission and theres all kind of good missions that do not penalize kurt . The if it is a necessary recognition, it is the unnecessary ones related to the diagnosis. So you have this chart and then for instance you got in a car accident they couldnt say that it was a readmission. So i and the elephant in the room. I am an academic physician and i resent us being lumped with hospitals. We are employees in the hospital under the guns of the administration and do not feel empowered any more to change the hospital. I agree. I should have said it on stage. I say it repeatedly in the book about the only people in the Healthcare Industry who are not riding the gravy train our doctors and nurses. Doctors, of all of the problems we see in healthcare they are not among them. Ive been trying to communicate with you. This is the way that the subpoena works. [laughter] is one of you could speak a little bit to the congressional process have that might have been handled differently in the role of the republicans and was there a chance for a bipartisan deal ever . The problem that they had with obamacare is that it was the republican plan. Its a slightly more conservative version of something Richard Nixon composed in the 70s to head off a ted kennedy proposal. He was in a pollster and republican consultant and convened a dinner meeting of leading republicans in the house and senate and the subject of the dinner meeting was held we stop the Obama Administration and the topic was healthcare into the problem they had was then by throwing the towel on the progressive reforms they said we will give everybody healthcare and they wont do anything to cut the prices. Can there be a chamber of commerce plan that says the government is going to pay to inject millions of new customers into the private overpriced system that we have. So the next role in this and i dont mean to take sides but that is trust the fact of what happened. They had been trying to do health care since the 1940s. Originally the unions were because once the labor board allowed allowed to be employers to provide health care as a substitute for getting the wage increases were not allowed during world war ii, the unions etched onto that and it became the key negotiating tool and a recruiting tool that they offered for Health Insurance. So that sort of cut off this huge constituency from ever worrying about health care reform. That constituency being anybody that was employed by the relatively Large Company and their family. And then president johnson cut off another constituency by ensuring people that retire. So the democrats basically kind of threw in the towel much to their credit. What what isnt emphasized enough about the reform is it as an Income Redistribution program which i think is a good thing for the minority of people in this country, 20, 30 million who dont have health care or jobs or who are in the care and it takes a lot of courage for a president to do that in this day and age and i think that as a part of the political blowback. We have time for two more questions. Good evening. I was wondering if you could entertain more than two hypotheticals as it relates pinnacle made it takes less than 30 seconds. How would you imagine we that we would be having a different conversation tonight if tom daschle has been nominated for secretary of health and Human Services and ted kennedy have lived . He created a real vacuum and use always done in the other hypothetical was of ted kennedy had lived i dont think the result would have been different but i will tell you this, ted kennedy did two things that were really meaningful after he died. He did two things that were meaningful after he died. One was a god governor patrick to appoint someone to the senate and they passed a law which everyone thought was going going to save betsy for the democrats but it didnt work out. The second thing he did was he wrote to president obama a letter. It was on his deathbed and his wife brought it to the president after the senator died and he read a lot of it at the joint session of congress that he addressed after the summer of 2009. And it was quite persuasive to a lot of the democrats in congress and more important it was really one of the things that move president obama to keep going. Last question. Thats a lot of pressure. Im an economics student at George Washington university and i have a question about your prescription to the solution of the problem. I heard a lot in your answer about government regulation of hospitals and Insurance Companies and i was hoping you could clarify because at the beginning of the show, the discussion, the lecture at the beginning of the lecture you were talking about your experience embedded among the lawmakers and the powers that be and you were talking about how they dont seem to have the and bolts of government down to a science yet. I presume those people would be the ones who are in charge. Thats a really good question. I was referring to the Obama Administrations federal government. This would be regulation at the state level of hospitals. Most Health Care Regulation at least the institutional part or at least a lot of it is done at the state level but you ask a very good question why do i have so much confidence that these regulators could do this when the government officials can even launch a web site. Thats a really good point. Again i think my alternative is mine is better than the alternatives that are out there. The most likely alternative out there today as we do nothing except keep the law we have and we limp along. Costs keep going up and the problem is its one of those slowmoving crises that we are going through here like climate change. The costs keep going up and with the climate deniers and there are some who think costs are going up. [laughter] is sort of like an Infrastructure Investment. Not much longer. I think we have seen in the last x number of years that our government doesnt do much of anything unless theres a crisis and the people rise up in one way or another and their power becomes more important than the lobbyists. So for example to take one example i will close with this. There was a bridge they came down in cincinnati last week and we have been talking about Infrastructure Investment for how many years and everyone knows we need it that nobody will do anything about it. If god for bid 15 bridges had come down the same day which as i understand it with arpa structures entirely possible that would have been a crisis that would have made the top of the news and in two weeks we would have infrastructure bill. The cost of health care is that kind of crisis but sooner or later as your deductibles keep going up in your Insurance Plan and your copays coming every year now the h. R. Department of every employer has a meeting that says your debacle is going up insurance is going up and your copay on drugs is going up. The only differences now they say its all because of obamacare. It has nothing to do is obamacare. That isnt happening for 15 years. Sooner or later thats going to become intolerable for families even with Health Insurance and that cost as reflected in the subsidies the government has to pay for people going to the exchanges to get insurance is going to become just as intolerable. Thank you all. [applause] booktv continues now. Toby harnden toby harnden recounts a british battalions efforts to prevent the taliban from seizing a province of afghanistan while awaiting the arrival of u. S. Marines in 2009. Mr. Harnden discusses his book with dan lamothe National Security reporter for the washington post. Its about an hour. Host toby thanks for joining me today on after words. I am dan lamothe and i run a military blog checkpoint with the washington post. The bureau chief for the sunday times of london toby harnden talking about about his book dead men risen which has just been released in the united states. About a unit traveling through afghanistan in 2009, a welsh unit that saw quite a bit of combat. Topia was hoping off the top he could explain about the title of the book. Its a very striking title. Guest dead men risen is a statement and a poem. Its not a very famous poem but a Company Commander killed in action in june 2009 is mother had sent him out a collection of First World War i poems that he sees the misphrased dead men risen because his company was an amalgam of bits of other companies so all these men thrown together