Transcripts For CSPAN2 Book Discussion On Americas Bitter Pill 20150221

[inaudible conversations] i and coowner of politics and prose. On behalf thank you for coming out this evening. We at politics and prose and georgetown, George Washington University First time i made that slip but anyway, we have worked together a number of years to put those events together and i thank the staff that helped make tonights event possible. I want to thank all of you for supporting such talks. Like many other independent bookstores, facing a challenging marketplace but we are actually doing quite well in large part due to the many Jerry Bledsoe and book readers in washington and you remain committed to bringing the great author, grade book events to the washington area. A few issues remain critical to both our individual health and the nations wellbeing in this country yet few issues are as rife with controversy and misinformation. We are fortunate this evening to have with us and accomplished journalist and media entrepreneur, steven brill, who has made his focus over the last few years to sort fact from fiction and get the truth behind the Affordable Care act and the American Health care system today. Steve has a long history of taking on big subjects through journalism. Shortly after graduating from Yale Law School in the 70s the American Lawyer to cover the business of law firms and lawyers and also wrote a book on the teamsters. In 1991 he founded courttv. In the wake of the 9 11 attack he wont a sweeping account of coping with the tragedy in a book titled caster how america confronted the september twelfth 0. A piece he did for the new yorker and lead to a book on Public Education called class warfare, inside the fight to fix americas pools, steve is continued not just to write but to create organizations that promote great journalism. But decade ago he donated 1 million to establish a Journalism Initiative to teach and provide Career Guidance to students interested in journalism and he continues himself to teach at yale and in 2009 he and other investors set of journalism on line to develop online a platform for newspapers and magazines. His latest book grew out of a revealing 24,000 word article on the exorbitant cost of medical care that he did for Time Magazine. An article that for the first time in times history took up the entire feature section of the magazine. The ps won the National Magazine award for public interest. In his new book America Jerry neal 18, he explored how the Health System involved. And how it shaped the Affordable Care act and what remains to improve Health Coverage and especially contain costs. The book has much to offer for those interested in how we got to where we are it is very consumer friendly and useful to people trying to understand their own Health Care Bills. Steve himself when reporting completing the book went through open heart surgery. Bent even he given all his research, had trouble making sense of the medical bills that he received. Now steve will be in conversation with c emanual who had insider role in the battle to enact obamacare, special revise their on Health Policy to the o and b director but the cancer specialist, zeke is now vice provost at the university of pennsylvania where he heads medical ethics and Health Policy. He has written his own book about the Health Care System titled reinventing American Healthcare, and is mentioned several dozen times in steves book where he is portrayed as shallow and we say not meek and mild about what he thinks. Ladies and gentlemen please join me in welcoming steven brill and z. Emanual [applause] thank you. One note. The introduction made it sound like i had the open heart surgery to complete my book. I wont go that far. You dont believe in self experimentation . No. It is a pleasure to interview you. You spoke once in the process of your writing of the book for about an hour i recall. Alzheimers early. I want to ask you why you wrote the book and in particular a large part of the book is about those sorts of fighting over the passage of the a c a, reclaiming, the fixing of the web site, and the question i get is did all that matter . Lots of peoples they you shouldnt book the sausage of making kills someone the we learn from that sausagemaking . At the core we learn why the sausage is the way it is. For a while i have been looking for a book to write about what i perceive is the challenges facing our governments, the dysfunction of washington and it struck me that looking at how a dysfunctional washington attempts to reform, quote the most dysfunctional aspects of the economy would probably produce a fun story. A fun story. What lessons fun is watching people like you write a angry memos to their colleagues, this doesnt do enough to control costs saying we cant be doing that, people writing angry memos back to you. The whole process is important because at the end of the day what this book reminds us or tells us is in this day and age what comes out of washington, for any major law to come out of washington, it comes out because the powers that be in washington let it. That is not a profound statement until you start to define who the powers that be are. What you see is the Health Care Industry spends four times as much as the next biggest lobby in washington, the militaryindustrial complex. As you and your colleagues on the Economics Team and the omb team realize if you want to Reform Health care you can spread coverage. That is good but you cant touch costs, you cant touch toward reform. You cant touch the things that make it so expensive. We will get back to that. The fact that there are so many Interest Groups that surprising . Healthcare when we were reforming it was almost 18 of gdp, the biggest single sector of the entire economy affecting everybody. Isnt everybody in there fighting . There are a lot of things that arent surprising intellectually but when you get into them as a journalist and tell their story in detail involving real people, you understand it really differently. The Time Magazine article, before i wrote that it was not revelation to anyone in this country that health care was really expensive. Was a bit of a revelation that nonprofit hospitals were charging 77 for a box of dr. Oz hills and that is why was so expensive. By providing detailed and explaining how it happened, what is not surprising to people on a general intellectual level becomes important understandable to people and ultimately it gets them to do something about it. One of the things you just mentioned, some people think you have an out for hospitals in your book. I am sitting here because about hospital. The book seems to portray them as villainous. That is the difficulty in writing about health care. One thing i try to train my journalism students to do, nothing is black and white. This object is the ultimate example. If the people who work in hospitals to poor whites of the antebellum south do gods work. It is hard to see them as villains and i dont. It is not like when they wake up in the morning theyre going to work in an office and making video porn. They are caring for the ill. But i think, this is something i learned when i started writing about lawyers along time ago, when you give people even good people doing good things unaccountable 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, charge the prices they do ultimately because they can. The sisters of mercy in the midwest, hires batteries and bill collectors and they sue people into bankruptcy for 77 pitts not because they are evil people but it just seems to have evolved that way. They wake up one morning, or a journalist weeks, up one morning, you are suing people into bankruptcy. That doesnt sound all that merciful. What was the most surprising story about the passage of lower Affordable Care act that came out of your reporting besides my angry memos . It is a counterintuitive thing if you just sort of you are from outside washington, subscribe to the cliche and to the category of not everything is black and white staff people from i talked to who did so much to write this law. On the republican side and democratic side. I assure you. Had a lot to do with the provisions and you wrote it including the Debt Collection traditions. My point, the revolving door image of washington with staffers working on the hill and they go lobby and go back to the hill and lobbying is an evil thing and they are evil if they do that. The people who work day and night on this bill and the white house including you, they cared about it and honest and did the work. It is the best they could do under the constraints of the system. And they are so incompetent when it came to governing. And not just talking about a website. And the people who warned them early on, you got to bring someone from the inside. This is the most complicated ecommerce effort ever undertaken and it is almost as if the nuts and bolts of governing were below the petter grade and that is really surprising. I cant to be an ivy league kind of person. It must be really small and these people went it came to nuts and bolts of implementing a law were just clueless. The best kind of journalism is one that defies expectations. So we on the east coast tend to think of silicone valley as a bunch of selfish, clueless people. These people who came in and rescued the website, first of all they volunteered to do it for free. The hardest reporting i had to do was for them to allow me to use their name. They didnt want publixcity. They wanted to do it fix and one said i am an engineering and love to fix thing and i am fixing something that is really important. So that was a bit of a surprise. It made me feel good. These were really good people. One of them has been hired as you know by the whitehouse to Fix Technology programs across the federal government. I have not done any reporting on this but maybe he feels like he is a prisoner in an iranian jail. I sort of also knew but it was surprising was how terrible the Government Contracting system is in. They promise to win contracts and specialize in explaining why it wasnt their fault. Did you figure out i mean i think one of the things those of us who read the book want to know is did you figure out how to solve that problem . That is a problem i could see clearly serving in the government if you look at the tech stuff and sites they do it is all a disaster. Diagnose and cure here. I have this dream article i want to write one day and i keep waiting for the Washington Post to do this is a daily report of outstanding government contracts, how much they are overdue, and behind schedule. With a top a ranking system. Why do you think that is inherent in the system . Because democracies tend to work best in situations where there is a crisis is everybody is watching. The government contract to secure the border during the Bush Administration with cameras and other things they gave bowing half a billion and they had to rip it off because every time a bird went over the border an alarm was going off. Arent they Illegal Immigrants . The lockede contract to built cutters and some of the stuff on the deck wasnt waterproof and they said they didnt tell us to be waterproof. If that got attention all of the time it might be fixed. And the other problem is and you know this it is really hard to get good people to serve in the government. In appointed positions they have to have Financial Disclosures and even at lower levels it is hard to attract good people because they dont get rewarded and i am not talking about mun eoney but not like they do in the best industries where if they do a good job they get promoted over somebody else who has been there longer. You sound people focused instead of institution focused. My sense on the government is they have too many institutions. There is an Inspector General for every department. They have the institutions. They just dont have it at the senior level including the president a sense that this is really part of government. This is part of the execution part. This is part of being elected president , especially if you are a democrat and you want to convince the world there is a role for government then you have to make government work. I want to ask you about two people in particular. One of the people who i think doesnt get enough credit for getting the bill through and passed is nancy pelosi. Watt do you think . That is right. The only way the bill was going to happen as you know and i recount in the book is if the house agreed to go with the senate bill that was passed. The first time this was mentioned she said my members will never agree with this and by the next day she said maybe and by the third day she was ad adamant and whipped it through in a way that is unusual. There is one theme in the book where she calls a member of her caucus i am a junior democrat from somewhere and he said i dont know if i can do it and she looked at him and said thanks for nothing. I got you here. Get out of here. And the guy changed his mind the next day. I think you are right. She deserves a lot of credit. And the president deserves a lot of credit. There were a lot of time most of his closest advisors except for vicepresident jarred, said to him you should give this up including your brother on two different occasions and he kept going and what he told me was he kept going because like all of the other candidates he was running to people on the campaign trail that had horrible stories of woe even if they had insurance. And it moved him. And plus the staff on the economic side your side of the house, was telling him part of the fixing the economy was fixing health care. That didnt work out because you didnt get the cost control you wanted. So you just praised the president. What do you think his role especially on the implementation after the passage . I have to make it clear i think he deserves as Much Negative criticism for the roll out. He just didnt manage the government. Just the thought that you can be president of the United States this is your single most important legislative initiative and you know it is complicated to launch the website, and he really never did anything other than have people show him screen shots and his chief of staff was so out of the loop that the night before the disaster of the october 1 launch he calls to friends saying wait until tomorrow morning we will knock your socks off. He was right but didnt want to be right. Your assessment of valerie jarred isnt charitable. I dont think it is uncharitable. I admire her for her up accounted power. She bucked up the president and reinforced his determination to push ahead with the bill during all of the those different junctures and she played a public role and recruited famous people to sign hem up. It is a mixed picture with her. So i want to switch gears for a second. You were heavily criticized by malcolm graph and one way of reading his report was you are an impostor. That is not how i read it. If you read it he is not the best writer in the world so most people couldnt get to the fifth page. I guarantee you none of us got there. Some of us got there. What do you think his mistake is . One of the things he says he is not an expert in this area . That is for sure but leaving that aside, he does this dichotomy if you remember between michael and bob and he says this. He says if woodward and burn stein wrote the story of how the institution of the whitehouse corrupted Richard Nixon. And i would bet you if you asked bob he would say it is vice versa that nixon corrupted the whitehouse. His whole model falls apart there. And by the way what that has to do with my book i am trying to figure that out. He said i dont rely enough on the private marketplace. And then mentions a book by a guy gold hill who is a terrific guy and wrote a book where he praises the marketplace and the lead blurb on the jacket of the book is from malcolm when i found out after i read the review because it wasnt in the review. I just disagree with that. And i think you do too. And this is the substance and the point i disagree that Hilary Clinton Clinton Health care is a Consumer Product equivalent to other products. You dont wake up and say you will wander down to the emergency room and if you dont like it you will check out another one. It is isnt like buying a cellphone and going to apple or verizon. You cannot decide either to stick with what you have and not buy a cellphone. But the fundamental thing with health care is i learned this on a gurney myself and when you are sick, and you know this with the thousands of patients you have treated, when you are sick you are not thinking about money. People dont ask how much is that blood test going to cost. What happened to you, maybe you can tell the audience how did your experience of open heart surgery at columbia affect your perception of the Health Care System becausesides the fact you think three trillion is okay to spend. I dont think three trillion is okay to spend. I am just pulling your chain. I am disappointed because the way i prepared for this discussion and going to my index and looking up your name. So far so good. So lets go to this. The last day of enrollment in the exchanges, march 31 i was having a routine checkup. And my doctor took this side of my wrist for pulse and this side and for some reason i guess you probably know, he said that sounds a little strange. He listened to my heart and said i think you ought to have a sonogram. And i am obsessed with Health Care Bills and this is a new doctor my wife and i just met he is a fabulous cardiologist giving me a check up. But he said you need an mri and i said we use three times per capita more than any other country and now i am getting one. But the mri showed a bubble on my heart. I go back to the doctor and he said to me and my wife he explains, you have this bubble and in my case it is big enough there is a 17 chance at any given time in any given here it can burst. And i said how often does the conversation continue and he said or you could have surgery. And he said i have this business trip to make so two days later i am in the hospital. When you are writing and book and just thinking about how am i going to write this it is all you think about. So i end up in the hospital a couple nights later and i think i am dreaming. I said how could i be in a hospital. And i cannot tell the difference between reality and a dream. And then i notice as i explained in the first chapter that i think my heart is coming through my chest. The nurse tells me i am okay. And then i have a dream the 3. 58 million of year ceo is there and i am being wheeled into the operating room for the surgery and someone welldressed is standing there saying wait we know why you are here we know who you are, you are not having this surgery, you are just going undercover and i said i swear the doctor said i have to have this surgery. I will not complain about your charge master. If you want to sell me six boxes of Girl Scout Cookies i will buy them in advance and do anything you say. What did the bock teach me . Book it taught me if someone asked me what i thought about my hospital bill it would be like asking ms. Lincoln what she thought of the playing. How much was the hospital bill . 190,000. Does that include the surgeon fee . No. This is in new york. As you know there is no correlation between cost and quality. I didnt say anything about the quality just the price. Okay. Here is the really interesting thing. When hospitals give out other bills they do something called a charge master and that is where the 7 for the gauze pads. Some hospitals charge 20 for a mucus control device. That is what it says on the bill which is a box of tissues. If you get a detailed hospital bill you will see this. Mine was 190,000 including 371 for patient education which happened the afternoon of my surgery. Let me tell you the afternoon of my surgery after i got out of the operating room i wasnt being educated about anything. I was gone. When i get the Insurance Company explanation of benefits i found out the Insurance Company only got an 8 discount. And that is because hospitals today, if they are big hospitals, they are basically four our five Hospital Systems in new york and you cannot bill insurance unless those systems are in your network and they know it. So the idea that discount off of the charge master was only 8 was stunning because during my timeTime Magazine article i was seeing 4050 percent and more routine the discount might be deeper. The other thing is i learned first hand what i knew and that was the system is crazy and dysfunctional. And after i got home i get two or three days later i get 36 letters from United Health care. 36 different things. One Prescription Drug here. This test here. 36 different things. First of all tells you about the efficiency of the system that was 36 letters and not all put together. I am figure this is great and i am home and i cannot do anything and i can dig into these things since i am the leading expert now in hospital bills. The third one i open up with and my wife is standing there and she is a real lawyer and generally a lot smarter than i am and we are looking at this and it says bills. Amount paid by Insurance Company 0. Amount you owe 154. 20. I look at that and i am looking at the codes and she can not figure it out either. It turns out before i got into the hospital i scheduled an interview with the ceo of United Health care at their Head Quarters in minnesota. So once i could travel i went out there and interviewed him about the lobbying over the bill and how it could affect the industry and his thoughts on hospital consolidation and all of that good stuff. And when i was finished i took the benefits list out of jacket and i said would you mind explaining to this. I have read and read it but i cannot understand it. And he takes it to Vice President of the Corporate Affairs who is sitting there and i can see him figure out what his next job is going to be. He is a very smart and nice guy. And looks at it and looks at it and looks up at me and says i could sit here all day and i could not tell you what that means. I have no idea why they sent it to you. And i said arent you they . The point of this is that is definitely the most common communication to consumers in the biggest industry in what is thought to be the most vibrant, free marketing economy on the planet. Explanations of benefits. We all get them. United health care send out tens of thousands of them and we think we are stupid because we dont understand it but the Vice President doesnt understand it. How can you have a system like this . The answer is you can and that comes back to a system being unaccountable and doing what they want. This guy isnt a bad guy. He didnt make it like this on purpose although some think they do. He was surprised. I want to conclude with a couple questions. The first one is your solution which i would say in the Health Policy community has been totally ridiculed and laughed off the platform. That makes me feel good because all of the Health Care Policies have governor a good job. Some have done a reasonable job. Maybe you can explain your solution and why you think it is the right solution. It would be the right solution if we could go back to 1984 when employers were allowed to give insurance is a sing sink singlepayer system. What i tried to do was look across the landscape and said what is happening. And what is happening is that large Hospital Systems are consolidating and buying other hospitals and doctor practices and clinics and labs. And that is seeing in a lot of the Reform Community as a bad or threatening thing because no competition. You have want to go Health Insurance in new haven connecticut if you dont have yale new haven in your system you are not selling Health Insurance. So the idea obamacare wants six Insurance Companies negotiating with the hospital instead of two or three is absurd. If they have six to play off that is easier than one or two. So i looked at that and said why dont we let them do that. These are not bad people. Toby cosgrove who runs the clinic is a respectable guy and why it is bad he want to take over a hospital in ohio when you have people from all ovthe world flying into his hospital. My solution to price control on drugs and tort reform is to allow the Hospital Systems to expand the way they want to but once they do that regulate them like monopolies. Regulate their profit margins, their practices, and the salary of the ceo even if you have to. And the benefit of the that in theory is if the Cleveland Clinic is dominating health care in ohio the Cleveland Clinic can sell their own Health Insurance because i can give Toby Cosgrove my 8 10,000 a year and say keep me healthy. You have walkin clinics, hospitals, doctor practices and you say you keep me healthy and i am holding you accountable. You have to make sure the hospital which is now appear Insurance Company, doesnt skimp on care just the way we wish we had regulations that make Insurance Companies not skimp on the care they approve. If you did that the hospital would have no incentive to over test or over treat me because the bills for the testing and overtreating would be going through the insurance owned by the hospital so they would be billing themselves. So it is the ultimate Accountable Care solution and bundle practice. You say it has been ridiculed. I think the option of big monopolies have been ridiculed. In new york there would be three or four or five and they would commitpete. When you see a billboard now that is meant to give more more leverage with the Insurance Company. They are not appealing to me directly because it is my employer who is buying the insurance sending me there. This makes the competition leaner. The only place you would have monopolies is where you do like in yale connecticut. My idea is terrible and makes no sense if the regulation doesnt come with it. So far what we have to is the fast developing companies fastly becoming four Hospital Systems, and cleveland is becoming one, we should acknowledge this instead of turning it to our advantage saying that is what you are. Most people think the regulator becomes captured when the tension seizes and they are worried that is going to happen here. You yourself started out talking about the fact that people spend a lot of money in washington. The idea probably comes idea the category of Winston Church churchills definition of democracy is the least bad system. You cannot think of another one that is realistic. The second to last thing i want to talk about is your claim about cost control. You have gone out a lot and said the bill failed on cost control and i certainly among others think we didnt do enough but the fact the bill passed over the last five years the cost is flat the percentage of gdp is flat medicare and medicaid is going down and the fact we didnt do enough doesnt mean we didnt do a good job inadvertentally. You said cost went down but you meant the cost increase is down no in medicare and medicaid medicaid not cost generally . On a per person bases medicare and medicaid have been going down. I am talking about Health Care Cost generally and not counting the medicaid and medicare. You also said in the last five years the data you are talking about the most recent is 2013 before the Health Care Exchanges existed so it is nice thought but has nothing to do with obamacare. That i totally disagree with. Obamacare started on march 2010. So the idea that parts of obamacare didnt come into affect until 2013 is not grounding here. Many parts of the cost control did come into play. Lets go to that now. The best way to look at this is at a read the actual law and look there for places that even report to do something with cost. There are a couple examples. Hospital readmission penalty for medicare even though the penalty is much luer than you argue it should be. It is meaning full because it focuses hospitals on that issue. There is a penalty for higher than average infection rates i dont know if that does much for cost but it does something for good care. Once you get past there you have a long way to go. Nothing to control the price of drugs. Nothing in there much to your furry that does anything for tort reform. I would not say nothing. We have been through this . Want to do it governor. There is nothing in there that does anything to control the price of drugs. The socalled comparatives affectiveness panel that was put in place effectiveness and said there would be public airing of drugs and treatments and comparing the cost is so looking that peter urzag who wrote i missed the boat on cost control wrote a vicious letter in bloomberg saying exactly what i just said. That the comparative effect is 0. And you agreed with this. I am happy to stand by that. And i know, iigate a really good education reading your emails, and your colleagues emails on the comic and management side of the house, saying this ask predicting this wasnt going to do it. If it has done it it may be fairy dust out there but the rose n there is noidatey that says it did it. Has the rate of increase gone down some . Yes, it has. But you cannot point to evidence of it having to do with the bill and the core drivers of cost in this country are hospital bills. Nothing controls hospital bills. There is an encouragement of bundle payments and that has had mixed results but that is good. It calls atens to it. And i quote a hospital ce 0 saying that. At the core, and you know because you were banging the table about this you and Larry Summers and other people you were wild i know it is hard to describe you as angry or loosing your temperature. I never get angry or lose my temperature. Right. I would say it is true from my perspective having worked on the bill woe didnt do enough. But i think it turns out to be true we did enough to effect the system. It has changed the system. Yesterday i was in Miami Book Fair talking with a guy who said he sits on the board of an organization where doctors try to cordordinate the care for everyone. And this changed everything. On a friday afternoon if a patient came in before we send them to the emergency room. And now we see them and not try to submit them and we made 4 million saving money last year. So i agree with you. I felt we didnt do enough could have done more, and i still think we could do more. But that is divinity than what effect the bill has had and i think it is has a psychological effect and kept cost flat. It has been a major factor. Lets not argue about it. Last thing i want to say is you called me in the book the brassest of the emanuals. You are trying hard to make me a liar tonight. I cannot believe you. When some of my relatives read that they said he doesnt know what the blank he is talking about. And that was my parents. One of my brothers said he never talks to me, how would i know. And the other one was very upset he wasnt the brassist. All three of us thought it should be inverted. We will have audience questions. Thank you very much for being patient and listening to us. We have a mike here and if you would come up to the mike. Not all at once. Tell us who you are and hi, good evening i am michele and i will take it quick. The american system is like the metro system here in washington. It is terminal. On a serious note i have 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 their child and adolescent mental Health System. Due to family aging, i am back what is the question . I want to thank the author for speaking sanity to a mad and brainwashed society. That is one of the best questions i have ever gut gotten. We have serious, serious problems. And until the society overcomes its denial and disassociation with reality that we have the most broken system in the industrial world and i would like your comment on this. Is this society, talking about anything and everything that was founded on private material monetary obtainment. It is the only society in Human History that thinks it is all about the private and not the collective. And i am working with mentally all right. We are going to ask steve to talk about this. Juvenile delinquiants and i am trying to get help for a child to not hurt the community but because of the burrocracy i cannot. What did you learn about the mental Health System and how the bill might affect Mental Health . Not enough. You didnt learn enough or there wasnt enough in the bill . I didnt learn enough. And i have a terrible thing where i will not try to wing an answer. I was talking to doctors and they were saying here is the scenario they have a patient, they are seeing them in their office and say i need to do a procedure or test you have but i cannot do it in my office but need to do it in a hospital that is the only place i can do that around here. But the patient go out of the hospital less than 30 days ago so the hospital doesnt get back do them because they are not going to get paid. How do we fix that problem . You want to go on that . I have not heard that. Maybe i didnt under your question. If they are not going to get reimbursed for the test they dont want to bring them in for anything else. The penalty on readmission doesnt penalize hospitals for every readmission within 30 days. It penalizes them for having than higher rates of readmission and there are good times to have admission that doesnt penalize. Correct. If it is a necessary readmission. It is the ones where it was a readmission. Like if you got in a car wreck after getting out the hospital you could not be charged for that. I resent us being lumped with hospitals. We are employees in that hospital under the gun of administration and dont feel empowered anymore to change the hospital. I agree. In fact i should have said it on the stage and i say it repeatedly in the book but the only people in the Health Care Industry who are not lining the gravy train are the doctors and the nurses. It is just true. Unless some doctor is working out a scheme where they have a clinic and they are referring patients to the clinic that is something. But doctors of all of the problems i see in health care the incomes of doctors and nurses are not among them. My name is donald. I have been trying to communicate and i have been unable to do so. I have some paperwork i would like to give you. Sure. This is the way these subpoenas also you have been allusive. He has to come to where where you are. Tell us who you are. Craig glazer. I want one of you to speak to the congressional process and looking back and looking back at how it might have been handled ditched ohio and the roles of republicans and was there a chance for a bipartisan deal every . And a little bit of the worst. I think the problem the republicans had with obamacare was it was the republican plan. Obamacare is a slightly more active version of something Richard Nixon proposed in the 70s heading off of ted kennedys proposal. On 2009 inauguration night, a republican consultant convened a onsultant convened a onsultant convened a onsultant convened a dinner meeting of leading republican s s leading republican s s s ns in the house and then the democrats threw in the towel on the more progressive reforms and said lets do the thing romney did and give Everybody Health care and have the government pay for it and not do anything to cut the prices. Can there be a more chamber of commerce plan than one that says the government is going to pay to inject millions of new customers into the private, overpriced system we had. And that is the republicans role in this. Thinking i am a reporter and i dont mean to take sides but that is a fact. The democratic side was they had been trying to do health care since the 1940s. Originally the unions were against it because once the labor board allowed employers to provide health care as a substiitute for wage increases which were not allowed the unions latched on to that and that was key negotiating tool and recruiting tool; they offered Health Insurance. So that cut off this huge voter crowd of anyone employed by a Large Company and their families. And president johnson cut off another group by insuring people who retire from their jobs dont chose medicare. The thing that is not exercised enough about this reform is this is a reform that is Income Redistribution and i think that is a good thing for a minority of people in this country. 2030 million who dont have health care at their job or are not in medicare. It take as lot of courage for a president to do that in this day and age. And i think part of the political blow back is that. We have time for two more questions. Yup. Great. Two more. Good evening. I am courtney mosely. I was wondering if you two gentlemen could entertain one or two of these hypotheticals. Only if it takes less than 30 seconds how would you imagine the conversation would be different if tom dashal was nominated secretary of health and Human Services or ted kennedy had the job. I dont want to sound too commercial but these were covered in the book. If he had been there, i think it is okay to argue, and you would probably agree, the way the law was implemented would be different. You would have had someone who understand the burrocracy and had the president s ear as much as valerie jarred does. I think it would have been different and it created a real vacuum and you saw what we got. The other hypothetical was if ted kennedy had lived and i dont think the result world war ii have been different. He did two things that were meaningful after he died. One was he got governor patrick to appoint someone to the senate and they passed a law and everyone thought it was going to save that seat for the democrats but that didnt work out. And he wrote president obama a letter and honoredis wife brought to the president after the senator died. And he read a lot of it the joint session of congress that he addressed after the summer of 2009. And a lot of democrats in congress and it was one of the things that moved president obama to keep going. Last question. That is a lot of pressure. I am an economic student here at George Washington university. I have a question about your prescription to the solution to the problem. I heard a lot in your answer about government regulations of hospitals and Insurance Companies. I was hoping you could clarify because at the beginning of the show or 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 nuts and bolts of government down to a science yet, and i presume these people would be the ones in charge. I was referring to the Obama Administration and government. This is regulation at the state level of hospitals. Most Health Care Regulation of at least the institutional part of it is done at the state level. But you ask a good question. Why do i have so much confidence these regulators could do this when their government officials cant even launch a website. That is a really good point. Again, i think my alternative as bad as it is better than the alternatives out there. The most likely one is we do nothing except keep the law we have we limp around and the cost keep going up. It is one of those slow moving crisis we are going through like Climate Change the cost keep going up and as if the climate deniers or people that dont think the cost are going up and it is like Infrastructure Investment. I am holding my tongue steve. Not much longer. I think we have seen our government doesnt do much unless there is a crisis and the people rise up and their power becomes more important than the lobbyist. So an example, there was a bridge that came down in cincinnati last week we have been talking about Infrastructure Investment for how many years and everyone knes we need it. If 15 bridges came down on the same day that would have been a crisis and that would have made the top of the news. And in two weeks we would have an infrastructure bill. Health care, the cost of health care is that kind of crisis. But sooner or later as your deductibles keep going up and your copay. Every year the Hr Department at every employer has a meeting saying your deductible is going up your copay on drugs is going up and there are differences and now they say is because of obamacare. It has nothing to do with obamacare. It has been happening for 15 years. Sooner or later it will become intolerable for families without Health Insurance. And the cost that the government has to pay is going to become just as in tolerable. Thank you, all. Thank you. It was fun. [applause] every weekend booktv offers programming focused on nonfiction authors and books. Keep watching more here and watch past programs online at our website. Looking back although it was never explained to me in this way, he taught me the spirit of the greek idea of honor and doing the right thing even when ones own interest or ones own life is imperil. Growing up while i never felt anything but australian there were two stories about the Second World War and greece i kept close to my heart. The first was in 1940 when italys Prime Minister asked the greek Prime Minister for free passage through greece. And on the spot at 3 oclock in the morning, without hesitation he said no. It was a spirited defiance and quite incredible when considering how vastly outnumbered the greeks were by the italians