Evening with a discussion of health care in a conversation with andrew slavitt, mike leavitt and congressman Joseph Crowley. I think you can get republicans and democrats to in congress to agree on three things. Rose right. The first is the fee for Service System is at the heart of the problem. The second is coordinated care is going to be better than uncoordinated care. The third is whatever we do about this has got to be scorable so we can show that its reducing the cost curve. And if you could just build on those three items, you could take it a long ways to finding a solution. Rose the future of the attorney general and the future of health care when we continue. Rose we begin this evening with politics. President trump continues to fuel speculation that he will fire attorney general scweftion. Earlier Jeff Sessions. Earlier today the president said he was very disappointed in Jeff Sessions. He referred to the attorney general as beleaguered and weak and suggested ousting sessions may be part of larger strategy to fire special Council Robert mueller. A Senate Committee moved to begin debate on the g. O. P. Health care bill after Vice President pence broke the time senator john mccain addressed the chairman for a vote since the First Time Since his brain cancer diagnosis. Our deliberations today, not just the debates but the exercise of all our responsibilities, exercising government policies, appropriating funds to implement, exercising our advice and consent rule are often livelily and interesting. They can be sincere and principled, but they are more partisan, more tribal more at a time than at anytime that i can remember. Our deliberations can still be important and useful, but i think we would all agree they havent been overburdened by greatness lately. And right now, they arent producing much for the American People. Both sides have let this happen. Lets leave the history of who shot first to the historians. I suspect they will fnd we all conspired in our decline either by deliberate actions or neglect. Weve all played some role in it. Certainly i have. Sometimes ive let my passion rule my reason. Sometimes i made it harder to find Common Ground because of something harsh i said to a colleague. Sometimes ive wanted to win more for the sake of winning than to achieve a contested policy. Incremental progress, compromises that each side criticize but also accept, just plain muddling through to chip away at problems and keep our enemies from doing our worst isnt glamorous or exciting. It doesnt feel like a political triumph, but its usually the most we can expect from our system of government, operating in a country as diverse and quarrelsome and free as ours. Rose joining me from washington, jonathan swan. He is a National Political reporter for axios. Here with me in new york is peter beinart, editor at the atlantic and contributor to cnn. His latest article for the magazine is called why trump might fire Robert Mueller. Pleased to have both of them on this program. Let me begin with Jeff Sessions. What is the latest on that, jontsen . We are in such a dysfunctional situation. Im getting calls from sources in the Justice Department asking me if Jeff Sessions is going to get fired, when is he going to get fired. I dont know. Ive referred them to Donald Trumps tweets. This is this psych to drama playing out. No one is certain what he will do. Roll the tape forward a bit, if he tries to do a recess appointment, theres been speculation donald trump would try to replace sessions in the august recess which would allow him to sneak around the senate oven medication process. Chuck schumer did a speech on the senate floor and he said were not going to let you do that, theyre not going to allow the recess to happen. So donald trump is left without good options here. Rose you ask, peter, why is donald trump doing this other than the recuse and he hates the russian probe. I guess the other answer is he is donald trump. Hes a bully and hes a cruel man. This is a cruel thing to do. I dont agree with Jeff Sessions politics at all. But Jeff Sessions has been deeply loyal to donald trump. He stuck his neck out from the beginning. Rose first among the established politicians. He risked something to support donald trump. Hes been very loyal to donald trump. A lot of people watched that and said this is the way donald trump treats people who have been deeply loyal to him and tried to serve his agenda. Sessions is a leader in the trump agenda. Its selfdefeating but also someone who doesnt act with honor in his dealings with other people. Rose you wonder why the president , if in fact he was so angry about it simply wouldnt go to Jeff Sessions and say, you know, ive got to make a change . Well, if you go back to the 19 you know, 90s, 80s when Donald Trumps love affairs were playing out in the new york tabloids, you know, sometimes it was the gossip columnists who found out before ivan nay trump that donald trump was having a liaison or elements of this affair were playing out through the tabloids. So its not out of character for donald trump to broadcast decisions about people who are even more intimate than a loyal cabinet secretary through the media. Rose there is a story that sessions, and i can imagine this is true, tried to resign or went in and offered his resignation. Yes, thats accurate. He did. It wasnt as quite as dramatic as has been reported. Sessions basically said to him, you know, if you feel that its the right thing to do and, you know, im happy to resign, it was very much out of a sense of honor. Although ive talked to people who were close to sessions and they say that since this resignation that hes really enjoying the job and doesnt want to leave, but even they wonder how much longer he can sort of withstand the public humiliation of the president of the United States publicly criticizing him. Rose tweeting it. Yes, it does seem unsustainable. Rose do you think the president will try to fire Robert Mueller . If i had to bet on it, yes, i do. I think that he is obsessed with the probe thats going on at the moment and, particularly now that the probe seems to be veering into his based on the public reporting into business dealings, i suspect, based on some of the conversations ive had with people around donald trump, that that is the third rail and if it does head in that direction, i mean, i definitely dont rule out the idea that he could try to fire mueller. Rose do you believe that, too . I do. Donald trump was not willing to release his tax returns in order to protect that privacy during the Campaign Even though it hurt him to some degree. I think donald trump probably figures mueller is trying to get me, maybe donald trump knows mueller will find things and its better for him to have this crisis happen now before mueller discloses all of that rather than when mueller does. Rose he has the right to fire him, or does the Deputy Attorney general have to fire him because he appointed him . Its very legally murky here how trump would do it. First of all, the special counsel is not a law, its just a regulation. Some people suggest trump could simply rescind the special counsel regulation on his own authority. Its also possible he might have to keep firing people down into the Justice Department rose like the saturday night massacre of nixon . It seems murky enough that donald trump can do it and it will be fought out in the courts and he will bet republicans as they have on almost Everything Else will ultimately enough of them stand by him. Trump has a good record of creating facts on the ground. He just does things. Trooper times during the campaign where republicans said we think this is awful. Remember when he went after judge curiel, paul ryan called it racist, basically. He didnt do anything that actually blocked trumps path. Beyond saying we disagree with this and think mueller was a good guy, what are they willing to do in conjunction with democrats. Rose and what can they do . Presumably they could try to pass a law to appoint mueller again, for instance. Rose a congressional act rather than president ial act. Right. Rose or executive branch act. We dont know. If his rating remains over 40 we dont know where it would go if he fired mueller. If hes still popular among republicans, republicans will think twice of going against to him. Rose thats like what happened when republicans went to Barry Goldwater and said you have to go. People stuck with nixon for a long time. Rose after the Supreme Court spoke. Right. Rose back to mueller, because thats central, there is also talk that the secretary of state thinks about or at least trr sources saying that he is not happy and is considering whether hes in the right place. I cant speak to his head space. What i can speak to is the very real tensions is probably too soft a word between Rex Tillerson and particularly his chief of staff margaret in the white house. There have been huge clashes over staff. We saw that blow out into the press. A meeting where Rex Tillerson exploded at the head of president ial personnel. There have been huge clashes over stuff. What im also hearing from sources in the room is Rex Tillersons voice on Foreign Policy and to the extent it encroaches on National Security is really not a very powerful voice in this administration. Donald trump listens to james mattis more than anyone else. Probably more than anyone else in his entire cabinet. When it comes to that group of people, try to influence the president on Foreign Policy, Rex Tillerson has, you know, waning influence. Rose whos on whos side inside the white house about firing sessions, about maybe leading to the firing of mueller . I dont know if anyone in the white house who is agitating for donald trump to fire Jeff Sessions. In fact, there have been a number of meetings where i have been told that everyone in the room has been kind of trying in their various tactical ways to get him to calm down and offer a vote of confidence. Rose what do you know about that . Anything . I think there is an interesting difference in the comey situation. The reporting suggests Jared Kushner actually pushed for comeys firing. Thats true. So i think it would be interesting to see what happens in the family because i could imagine this is not based on reporting. That you could imagine a situation in which the Mueller Investigation has the potential not just to hurt donald trump but the people in his family, to hurt donald trump, jr. , Jared Kushner and ivanka trump, if he starts moving into business dealings with russia. So you can imagine a situation where the family members would have quite an incentive to stop that investigation before it uncovers things that could potentially cause them tremendous problems. Rose its hard, the shifting factions within the white house or what we know about them from the reporting because theyre not united on s said to be opposed to theon hiring of the new communications chief. Right. Rose according to the reports ive read, i mean, whereas others who you think would not necessarily even have an opinion were in favor of it. Right. Thats true. I mean, one of the one of the key dynamics at the moment is that steve bannon and Reince Priebus, the chief of staff, have become allies of convenience in a feud against Jared Kushner and ivanka trump. That is probably, in terms of the hottest conflicts in the white house, thats probably right up at the top, and jared and ivanka distrust Reince Priebus, they think hes incomp at the present time and want him out of the job. The extent to which steve bannon sees jared and i ivanka aas personal and ideological enemies, he wants to protect Reince Priebus which is ironic since a few months ago they were not best buddies. Rose it is indeed. Jonathan, great to have you. Pleasure. Rose peter, as always. Thank you. Rose we turn from politics to legislation, as the senate moves to debate whether to repeal the Affordable Care act. Healthcare remains as complex and divisive issue as ever. At the core central questions, how to cut Health Care Costs while improving quality and access, and what role should government play in the lives of americans. Last year i appeared on stage with three men who grappled with the questions. Andrew slavitt administrator of centers for medicare and medicade services. Mike leavitt republican governor of utah from 1990 to 2003, and secretary of health and Human Services under george w. Bush. And congressman Joseph Crowley is chairmannen of the Democratic Caucus, representing new yorks 14th district. Here is the conversation about health care. Whats happened to us . Why has health care been something that has become paramount for the president , president obama to pass, and paramount for President Trump to try to repeal is this. I think, charlie, in referring to me as a politician, that in and of itself connotes negativity. Rose i dont mean it that way. I know you dont mean it that way. Thats not how its perceived. Oftentimes, when that happens, we referre we prefer to be rd to as elected officials. laughter but the nobility of politics and being involved in public debate on polls issues is a noble thing and ought to be. Many would look back to a great deal of the changes and going back to tip oneal would say the worst thing to happen to washington, d. C. Was the jet airplane because people no longer stayed. Getaway day was today. We were on the 2 00 shuttle, loaded with members of Congress Going back to new york and everyone was flying out. So that was a contributing factor. You know, in this modern world of needing to be back home with the constituency all the time, the postgingrich years where many looked to what transpired during that time period where it was really frowned upon to be in washington, to bring your families there and ill suggest more things that radically influenced or changed things in the way washington works and for the better i argue. The removl of money in politics. For instance, lobbyists can no longer take members of congress to dinner. Thats probably a good thing. Whats lost is the linkage between democrats and republicans. People would take everyone out. Weve lost that social connectivity and thats not going to come back. Its frowned on to take trips. If youre a marginal member of the house of representatives and member of congress and worried about election, you will not go on the trip. Afghanistan may be the only place you can go and get away with it. Everythings fair game. Rose mike . I would point to three or four things. The first, the country is fundamentally divide in our view of what role we want government to pra play in our lives. Its hard to devote just that much interest to that question unless you have Something Like health care thats so personal where you can use that as the means of doing it, and i think there is a basic division in our philosophy. Second thing i would point to is the combination of technology and politics. Our ability now to use precision in reapportionment, to literally carve districts that are winnable on both sides has eroded the middle to the point it is virtually nonexistent. There may be 20 districts now that are swing districts, and all the of the money and focus is on those and everyone else is safe. And i think that has created an enormous difficulty. The third is that i think the math has changed. It used to be, when you ran for office, your goal was to get 50 or to hold your base and to erode enough of the middle, you could get 50 plus one. Now the discovery is there is enough apathy in the mid that you can get enough votes on the extremes on either side to win an election and, therefore, people have begun to, in essence, just focus on their base. So they talk to themselves. And i think the media has discovered that thats true and, therefore, they now speak to their own cohort. Its msnbc vs. Fox, its the wall street journal vs. The new york times. Very little is devoted to the middle. Lastly, i would say there is been a dramatic federalization of many of the most intensely personal issues that were originally intended to be battled out at the state level, and we have now made them national issues, where its very difficult to resolve matters where those differences of opinions and difference in values make difficult decisions. If you have to have it the same everywhere, you cant get to a conclusion. Many of the issues like education and health care and others that typically would have been dealt with at the local level have become federal issues. Rose andy . I think weve got two different world but i dont think its democrat versus republican world, i think its a washington versus real world. I think the perspective we have in washington is i think the republicans are largely still living in 2016. In 2016, talking about obamacare was goal. It won them a number of elections. It was easy to criticize. For all the policy gains, certainly as we sat there ie 2016, it wasnt a political success, i think president obama has said that, and they find themselves in 2017 not necessarily fully prepared to govern, and i think those that have been brave enough to two home and face their districts and not many have have learned that in 2017, its not about Obamacare Repeal and replace, its about what do i have today versus what are you trying to do. Rose and what are you trying to take away. What you are trying to take away. Thats a fundamentally different equation and i think some are waking up to it, many arent. Whats interesting, you go into the real world, and ive gone out and been part of town hauls and across the country, the thing i find very striking is if you say to people, it doesnt matter whether youre a trump supporter, an obama supporter, whether you voted for hillary, doesnt matter who you voted for, you have a rooting interest in your healthcare and shouldnt have to declare because all of a sudden in this country, how we feel about our healthcare has somehow gotten tied into how we have to describe our politics. I think ironically and where theres some hope is i actually believe healthcare is one of the issues that can unit us because it is something that can transcend politics if we get past the issues in washington. I think theres a great, great hope in the rest of the world that in the rest of the country that people will put the politics to the side more than any other issue, and no matter what party theyre in, they will find them out of step with what people are looking for now if they dont. Rose has the failure of politics and the collapse of the senate and repeal and Everything Else they have thought about trying led to a general awareness that weve got to find a different way . Is their mindset moving in that direction . My sense, is among the rank and file members, some yes. Among the leadership, not so much. And i think i think the white house clearly isnt going to give this up. I think if were in round d, were going to see e, f and g before this thing gets through, and were not yet at a point where the leadership and the congress who i think are getting weary of this are willing to stand up to the white house and say, you know what . Maybe we ought to step back or go for something smaller or try a bipartisan approach. That dynamic doesnt yet exist within the majority party, with all due respect to the majority party, and their relationship with the white house. Rose hard to do that after seven years youve campaigned about all the evils of obamacare. I would also tend to agree with that. Also, from the democratic side of the aisle, theres a bit of divide between the leadership and membership as well. As weve seen this week with the new dems working together with the tuesday Group Meeting in some unnumbered room somewhere in the capitol, and that kind of resonates back and people are, like, were not quite ready to do that yet, and that comes from the standpoint were not ready to negotiate with republicans on the future of health care until they stop the effort to repeal. As you say, the sevenplus Year Movement to repeal. Once we feel thats over, i think we can go back. I think there are things we can do to work and bolster what we have accomplished so far. Rose do you think thats a possibility, mike, that there will be a moment in which an assessment at some time that we cant have everything we want so we better try to figure out to get something . The difficulty with great slogans is people remember them. Repeal and replace is memorable. It reminds me of read my lips, no more taxes. And i continue to believe were going to see a piece of legislation. The imperative is simply too strong for the republicans for them not to come up with something. I think, if their aspiration was this, it will likely be this ia bit optimistic, not about the politics of the day, but i think you have to step back aways and say this is not we are arguing about the here and now. The reality is we are in this country moving toward what i think may become a uniquely American Healthcare system that will not be proposed by either party but will essentially be the sum total that those two extremes battling will ultimately lead us to. I think were 25 yearars into a 40year transformation that isnt being driven by politics alone thats really being guided by economics. I find it highly unusual and strange that we have been through an election in 2016 when the economic deficit was never a mention. Were going through a debate now on what is 20 of the entire economy and there is virtually no conversation about the impact this is having on our economic sustainability. But i think thats the invisible hand that ultimately is going to guide this and that economics is going to shape this substantially more in time than politics. Rose when you look at the future beyond what youre saying at some point it will work its way through and finally people will wake up and say weve got to do something different, where will was it a mistake not to start with infrastructure and get some kind of coalition, some kind of working together between democrats and republicans on something at the beginning of this congress . My feeling is the executive orders that have come from the white house in the last six months but primarily in the early stages in january and february were very debilitating towards creating a positive relationship with the Democratic Caucus in the house or the senate. For me, as i mentioned, or was mentioned before, my districts right across the river, the east river in queens, and i represent Jackson Heights and woodside, astorous, sunny side, corona, i have some of the most diverse places in the entire world. The change in i. C. E. Procedures, the dappa withdrawal, my constituency feels under duress every day when i. C. E. Agents are standing outside the courthouse in Queens County because to have the the Human Trafficking case, that sends shock waves throughout my constituency and makes it very difficult to work with this president. Doesnt mean in a bipartisan way with congress. I can decipher that. But it makes it very difficult to work with the president on anything, quite frankly. I worked i didnt agree with george bush on just about anything. Thats not really true. I did agree with many things, but i worked closely with him, for instance, on the indian civilian Nuclear Transfer deal. I became one of the lead democrats, i was at the bill signing between four people standing between condi rice and the president when he signed the bill because i believed it was in the best interest to work in a bipartisan way. I was sent to work with the indians because it was a bipartisan bill. I dont see the opportunity to work in that way now with this president because there has not been any form of an olive branch. It was really incumbent on him because he did win because their party controlled everything that if were to work with them, there needs to be this olive branch. The discussion about how democrats are to blame because we cant get the Health Care Bill passed, were doing what we can to preserve the Affordable Care act but weve never been asked to the table, to begin with. As long as their goal is to undermine the Affordable Care act, its not giving us a starting point. I am not here as a partisan, but could i just say this is how it always is. You look back, when the Affordable Care act was passed, there was drama like this every week for a long time. Would they get the 60th vote . How would the things turn out in massachusetts . It was a cliffhanger all the time. We started off this year, i dont care if they had taken the water bill, infrastructure bill, tax cut, the same thing would have happened. The Freedom Caucus had to demonstrate nothing would have happened in Congress Unless they were there and they would have walked away no matter what the bill was. Donald trump and paul ryan could not allow that to occur. They had to show they could walk awe way, too, and, so, they did. Lo and behold, two or three weeks later they all got back together and there was an announcement were going to vote. Same thing now. Two senators announce it, write the obituary, this is over, throw in the towel, Mitch Mcconnell is the guy that throws it, oh, looks like were stuck with obamacare. Not for a minute. Hes back there working to put this together. This is just the way a messy, political democracy works. This is a negotiation and people are looking for leverage and, you know, they may not pass anything. I think they will, but it wont happen neatly and cleanly and for the first time. Rose will it happen before the 2018 election . I think, personally, if its going to happen, the best opportunity we were talking about this earlier, theyve got this reconciliation vehicle, and if, in fact, that is truly going to expire, i think the pressure is on for them to get it done between now and september 30t september 30th. Rose and as a supporter of a. C. A. , what did it get right and wrong in terms of concept and execution . Well, look, i think the things it got right everybody in this room knows and i dont think we need to belabor. We could talk about all the people that got covered, but i will tell you that whats more important about the 20 Million People who got covered is what it means to their daily lives. You know, i had the privilege of getting letters and emails from people getting coverage for the first time and one of the ones i recall is a woman who described how she came home from work one day and her middle School Daughter was there and she said to her daughter, you can join the gymnastics team, and her daughter leapt into her arms and started to cry and said, but mom, could have been telling me three years i cant join the gymnastics team, and she said, yeah, mommy has insurance now. And what is important to me about that story is its so ordinary, but it represents the link that i think health care plays with our connection to the middle class. And we changed the compact in this country to say doesnt matter what your income level or your health status, youre entitled to Affordable Access to care. Did we get it perfectly right . No. Did we get about 70 right . Thats about right. Rose what did you get wrong . You get a bunch of people who get help from the government, through medicaid or insurance exchanges. If you get insurance through your employer you get a tax subsidy, same with medicare or the v. A. But if youre in the middle class and buying insurance on your own you dont get access to the subsidy. We left out the middle class. A political scientist would probably say that wasnt the smartest political move. The affordability burden, people are more or less protected fra, unless theyre in the middle class and i think that needs to be fixed. Rose do you think it made a difference in the 2016 elections . I think it did. Rose might have been the difference . Look, i would say there are probably three or four of the differences. Rose yeah. And any one of them might have changed the outcome, might not have, but, certainly, this was something that the obamacare became something that and i think this is another thing that wasnt executed well, that the republicans defined better than the democrats, and they defined it basically as everything you didnt like about the Healthcare System call it obamacare. If your doctor moved his office a block away, that was probably obamacare, if someone cut your hours, that was probably obamacare. And it wasnt until it was something other than obamacare that that reality got right. I dont blame anybody but ourselves for not making sure that the pieces, the Patient Protection pieces people very much value were not properly associated with so the democrats have to look at themselves and the republicans have to look at themselves, too. If they look over the last seven years at the Supreme Court court cases, denying Medicaid Expansion to 3 Million People which drove up rates for everybody else, at defunding the Rate Stabilization fund that would have kept rates lower, everybody has a little mud on their hands and i think the bottom line is the country cant afford for one side to be able to blame the other any longer. I would agree with this in terms of lessons learned. One thing that is an absolute certain in politics is that, whenever a party who has been out of regains it, they always overreach. Barack obama was elected president. They have been out of power for a time. They reached to a point they excluded republicans, and we ended up with a bill with no republican votes at all. We now see donald trump and the republicans take power. They make exactly the same mistake. They overreach. You end up with a partisan debate. The solutions here are not that complicated, and were arguing actually about words a lot. Is this going to be repeal and replace or is this going to be repair . The reality is there are a lot of areas where there is Common Ground rose but nobody is using the word repair. To be fair, there is a lot more than words going on. If they wanted to have the debate on repeal and replace, the American Public found out it was about defunding medicaid and a tax break for the wealthy, 80 of the bill. If they had gone with repeal and replace, focused on decreases deductibles and reducing premiums, looking at essential benefits and state lines, h. S. A. S, i think we would be in a very different spot. But youre making my argument and that is that if you could get republicans if they didnt overreach, if we could have a serious conversation about solving the problem yep. You could get there. But heres again, back to your first question. Took me a while in washington to figure this out but washington, congressman tell me if im wrong about this, but a lot of it is how do you virtually preparing for the next election and controlling the news cycle today because it will help you prepare for the next election, because that other team will not do anything right. They will always be wrong, but we will always do it right, so lets not do anything until we have power, and we just go back and forth. Again, i go back to the argument that a lot of this is were discussing now issues at a federal level and having to deal with everything being bun way as opposed to allow ago little more flexibility in states. I would think there is truth in terms of the precedent that was set during the Obama Administration that didnt exist during the bush administration. I said before my one example. There were a myriad of issues, there was bipartisanship in moving through the house and senate during the bush administration, and in fact the response to the attack on 9 11, a lot of things that happened that was done in a very bipartisan way. But clearly this notion of sitting back and doing nothing and letting them flail happened during the Obama Administration. Were not going to help this man get reelected. Something about Mitch Mcconnell. Now the issue is on the other foot. I would suggest, though, as i said, its the tone thats set, i think from the top, about the body politic of our country and how were going to move forward, that what has been set about this president at least in my years in Public Service is unprecedented. Its making it very difficult for people who want to work in a biparents way to do that. Rose Silicon Valley uses the word disruption a lot. Do we need some new ideas in health care that will disrupt the Health Care System that we have. Is this i would argue we have an idea, an its the change in the payment structure away from fee for service to value, an my colleagues here can comment on it, but its a big idea. Its the biggest change thats happened in 50 years in health care but its very hard, an it isnt something that you can just embrace as an idea and then execute. Its going to take a long time to doit. I think that change is supported by the way by both parties. There is agreement on it. The issue is how do you execute on it. And this goes back to what i was suggesting. I think our hope is for economics to disrupt this, not for politics to disrupt it. Rose what do you mean by economics in this case . I think that if we can begin to focus on the fact that we have an economic imper tuff that we share to solve this problem because you look at other countries whether its in europe or even in south america, you see economies that were disrupted by the debt problem were working toward, and if you look at what is driving that problem, it is healthcare. And if we dont we have a shared problem, at someponent it will become a some point, it will become acute enough that the economics will override politics. Rose but we have deadlock and gridlock on Budgeting Issues in congress. Look at the difference in tarp and when we had the economic crisis. Congress came together in a matter of weeks it was ugly. But it happened. And an unfortunate fact of political life is, in the democracy we live in today, it takes crisis to get the politics to move, and i think, at some point in time, were just waiting for a gentle heart attack that might get us to change our appetite. Rose if were not at that crisis, when will we be there. It could happen quickly. Wanto talk about the imperative to help people. At least moral imperative. The Affordable Care act recognized the moral imperative to help people who could not cover insurance. We have a dilemma between our sense of compassion and this new sense of Global Economic dispassion that is saying if people give us money for bonds, they want it back at some point in time, and that collision between our sense of compassion and our sense of economic dispassion thats now pushing, thats ultimately whats going to drive, i think, this new system, and the reason i think there is purpose in being somewhat optimistic. Let me put the two pieces together and focus on the disruption that i think we need. I mean, we have we do not have a problem in this country with the 67yearold white jogger with two fit bits. Thats not going to bankrupt the Healthcare System. That person gets good care. The problem we have is the woman who lives two bust stops away from the Dialysis Center and probably two blocks away from the nearest Grocery Store and if she misses the bus in between, she goes into kidney failure, spends 100 days in the hospital, and people with chronic conditions and all kinds of social, behavioral, mental, nutrition and other issues is what drives our cost in our system, and weve all seen those charts comparing ourselves to orthocountries which show we spend a lot more and get a lot less. What we dont always show is the reverse chart which is other countries figured out if you invest in primary care, in mental health, in social determinates of health, you focus on the people that are difficult to treat and take care of, people with chronic conditions, until we make that investment and really fundamentally understand that investment, we are going to be going down the same track, absent politics, and thats where the compassion and economics actually meet. Can i add to that . I think andy is right in terms of the disrupting factor. The ever evolving nature of health care goes beyond the contact of the physical itself, but does the person have the ability to get to that office . What are the Living Conditions . So is health care now moving towards assistance in terms of how people afford their rent or their housing as a means of fitness or wellnis . These are questions. But i think, in essence, in coming back to the politics of it, how i perceive it is my republican colleagues were damned if they didnt but more damned if they do. I think thats part of the difficulty theyre in now because of their Political Base and the expectation they would have done this. And where i think youre right, governor, i think in some respects the overwhelming pressure to get again to that political goal is very powerful. The political goal dr. Of repealing. But thats what i said, if we move into 2017, i think well look at this differently. Rose 2017 and 2018. Im not even talking about the political side. Im talking about the reality on the ground that every single poll is saying exactly what the republicans dont they theyre saying if theyre living in 2016 where they were living in a world where they can cash in on repealing obamacare. Rose was there a sense of change with a new appreciation of medicaid that took place in this debate, did the republicans understand the political axiom that if you give benefits to people, its very hard to take them back is this. I think there is a widelyheld aspiration in this country that spans republican an democrat for people to have access to affordable insurance. Rose right. That is not a dispute. The issue is what role will government play, and thats what happens in medicaid. In medicaid it becomes a question of is medicaid a way in which we can help those in economic need or is medicaid programmed to expand the number of people who are insured . There is a lot of difference of opinion in congress about that, and once they figured out medicaid would be the program that was clearly designed for one, but its been expanded to another, so its not about whether we want people to have insurance, its are we going to use medicaid as a means of paying remember why, it scored better. Cant dispute that. Rose apart from politics, and its hard to be apart from politics, what do most people, most smart people, whether its doctors, whether its hospitals, whether its academia, whether its pharmaceutical companies, what do they agree on . I believe there is a wideheld aspiration for people to have insurance. Rose right. I think theres an agreement rose for everybody to have insurance. I think you can get republicans and democrats even in congress to agree on three things. Rose right. The first is that the fee for Service System is at the heart of the problem. The second is that coordinated care is going to be better than uncoordinated care, and the third is whatever we do about this has got to be scorable, so that we can show that its reducing the cost curve. And if you could just build on those three items, you could take it a long ways to finding a solution, and i would just make this point, both parties are West Virginia got this problem where every party that loses power gets it and overreaches and it flops again and were just going back and forth. I think there is a moment in time when somebody is for whatever reason and under whatever motivation going to craft something thats bipartisan and whoevers in power when that happens will govern for an extended period of time. Rose you really believe that. I do. Rose somebody will come up with a formula you spoke about the magic moment. Rose right. It may be that again, you look back at when we had an economic crisis, you look at 9 11, there will be some moment where there is a catalyst for that kind of activity and, when it happens, i think it will beta thats correct to the American People and they will reward politically whoever did it. Its certainly everybodys hope. Look, i think, generally speaking, if you talk to democratic policy people, the first thing out of their mouths is how do we cover more people. Rose right. And if you talk to republican policy people, generally speaking theyre going to want to talk about the sustainability of the system, the cost of making sure that were not paying too much. I think democrats could do better to talk more about cost. Rose and republicans more about access . Well, republicans can do better not to use cost as a fig leaf for other things because i think some of the cost rhetoric, when there is people that are serious about it and there are people that use it as really a ways to say were actually just going to, you know, curtail the federal budget, were going to do this whether its to do tax breaks or whatever it is. So both parties, i think now, in between that, i think you probably have some portion of the Republican Caucus that agrees about coverage, but when i try to remind people back in the real world and you can tell me if im getting this wrong is that we expect and believe that each of our congressmen and women and senators are policy experts at every topic and that they know health care as well as we do and people ask me all the time why dont people recognize x, y and z . I say the reason is 50 of the guys in congress in 2009, they were selling automobiles and now theyve got to have expertise in russia, health care, transportation and, so, they get the talking points when they go home to their districts and they may have policy staff or may not have access to Health Policy staff. So leadership is more and more important. The leadership in the congress is more and more important. I think with the current leadership in the senate on the majority side right now, you know, its harder to see our way there. So, again, i think one of the things that people are yearning for, and i understand what the debate, is there are some people who dont believe that thats a conversation that we can allow states to have individually because they might come up with slightly different solutions. But in my mind, long term, there is a lot of this will have to be solved in the laboratories of democracy an states as opposed to trying to have 535 people trying to figure out the solution for everybody. Coming back to something you said initially and i think whether its about access to health care or the mandate that everyone will be covered, everyone will try to cover in some way or another and primarily its about access in terms of the philosophy from the other side whereas we have come from the philosophy of more of mandate, that they must be a part of it. Signing thats part of the issue, whether we can actually come to some agreement in terms of that. The other is in terms of applying and i agree with you on this end applying every area of the country to the other. Ive, you know, been par e been in part of the negotiation on the Affordable Care act, and part of my colleagues around minnesota and the cleveland clinic, the mayo clinic, this is how it should work. It should work that way if most people had access to some form of insurance, limited exposure to medicaid. As opposed to what happens in the big city of new york where there is more exposure to people with medicaid, less have access to insurance, you have the undocumented communities that have no access to insurance. So i recognize there are differences to the region that issue. Most importantly its whether you afford to provide access to insurance or about the mandate and thats where the rubber meets the road. Its a very good way to say we have different philosophies in our country about what the role of government should be. Rose you come back to the role of government a number of times because you believe its the fundamental question that separates an opinion on health care. I do. Rose so, therefore, can you imagine ever that america would want a singlepayer system . I dont think well go there. I will just say to the congressmen, i think there are a lot of states in this country who would initiate, pass and execute an individual mandate. I think well struggle to get that done and have it actually executed countrywide. It would be a fascinating thing to see how states that did that, how it worked out by comparison to rose but does that go to fundamental opposition to people, you know, how they see government . I think thats right. There is ling them there is a pretty stable turf the right people can work out between those two ideas because i dont think theyre diametrically opposed. I think the smart people would say make sure we have guardrails. Argue over the guardrails. Now the current legislation says give states money but dont require them to spend it on lowincome people. Rose guardrails are what in this case . To give you an example, in the senate legislation, states can apply for waiver, take all the money going for tax credits to lowincome people, they can spend it on whatever they want. They dont have to spend it on health care. Rose can they spend it on tax cuts . On anything they like. So i think you find a lot of people, not just democrats, very uncomfortable with that. But if you said, look, let the states meet a goal and the goal is to figure out ways to treat a they spend that money withong that population and furthering the cause, let them go to down in all the ways as long as we can measure it and learn from it. Im in complete agreement. End of story. Lets have dinner. Exactly. Rose thank you very much. Thank the panel. Thank you very much. applause rose for more about this program and earlier episodes, visit us online at pbs. Org and charlierose. Com. 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