Did you even get to become an architect . What was your path . Acerbic medical school. So i was in medical school and not very happy about what i saw around medical school that we were feeling at one of the most frustrating aspects when i would work in the emergency room as a student that we take care of this patient who had heart failure, difficulty breathing, we work hard to make sure the patient was what we called dried out to the excess fluid was taken down and everything was turned out perfectly. Inevitably, he or she came back six, seven, 10 days later and we had to do it all again and we were not following up one patient in the hospital for six weeks for back to endocarditis. Send the patient home in two weeks later back in and it was extremely frustrating. I also than what to do a phd in political theory at harvard, thinking that i would at some of this was sort of the values of the health commissions. So i worked on endoflife care, physicianpatient relationship for a while. Then i came to the nih and mark don research ethics. As i was seen the end of after seven years i decided i should turn my attention to resource allocation on the Health Care System and be a Prominent Health economist from stanford and whenever im in Health Policy is depressed about theres going to be no comprehensive reform were thinking over the comprehensive reform would want to have developed a voucherbased system and that got me into thinking much more about Health Policy and then when president obama won any appointed peter orszag as head of the office of management and budget, i knew peter from a lot of conferences and meetings can i email him and said peter, you need needed doctors who help on Health Care Reform. He said lets talk about what that an arrangement for a work at omb assisting. As far as the problems with the aca, which you do though perhaps the first half of the book to comment that you set out to fix, collectively, can you outline those . The american Health Care System as i say sub title is terribly complex. Are the Affordable Care act will improve her terribly complex, blake on just reinventing American Health care how the Affordable Care act will improve our terribly complex, blantly unjust, outrageously expensive, grossly inefficient, error prone system. The Health Care System and to does make him a thousand nine saw the same spirit is incredibly complex, still trying to explain to people was paid for through insurance, medicare, medicaid and takes about 40 pages. I dont even go into all the details. The next and how doctors are paid, hospitals are paid, with the incentive structure is, what the regulation for curt says, devices. All of that is incredibly complex. We were doing well. 50 Million People were uninsured. Yet uneven quality. Some academics are fantastic outstanding quality, that pretty uneven. Millions of people who have high blood pressure. Not hard to diagnose, not hurt to treat worried theyre not diagnosed or inadequately treated and we know that increases your risk of stroke, Heart Disease comest shortens your life. Before we pass the Affordable Care act, one in 20 people at a hospital acquired infection. Tens of thousands of people died and then there was the cost taking ever more of the economy, making states tradeoff between medicaid and education, making individuals get Health Insurance by keeping wages low. Lots of reasons to change the system and i explained all of those. Anyone of them would be good enough. Having all of them, i dont think theres a republican or democrat in the world in 2008 at 2009 who would say its great. Really by 2008, 2009, almost everyone agreed we had a system that was broken and needed repair. The question was what kind of repair. You explain that very, very clearly. The Health Care System is a daunting enterprise. Its incredibly clear. Whats interesting in the beginning is history, i guess you could go way back, but started mixing a worker with the clinton. Were no surprises as i decided to lets give people a feel for how long weve been trying to change the system. One of the surprises to me as to engage how republicans work in 1945 the governor of california at that time, earl warner, propose comprehensive Health Care Reform and he came within one vote of getting it passed in california and he had gotten sick and said we really need to protect people from the cost of getting sick. When nixon got a late date in 1946, one of his first legislative dose he introduced was a bill about comprehensive Health Care Reform. Heres the crazy thing if i describe it, no think man, did he write obamacare . Was he one of the architects . He wanted to give subsidies so that they could go and buy private insurance. The government would provide the subsidies. Sounds a lot like obamacare to me. He proposed that and when he was running for president in 1960 against john kennedy, there was a big day. Public and the democrats trying to figure out how to get people left out, poor people, especially the elderly, how to get them insurance. He reintroduced the idea is that it is for people to buy private insurance and when he gets president in 1973 and 74, hes negotiating as president with type kennedy in the senate and wilbur mills in the house about how to come together on a comprehensive Health Care Reform bill. They were this close to it though that they could agree to and in typical washington arrangement, scandals break out. Wilbur mills has learned exotic dancer falls into the tidal basin. He is forced up the chairmanship of the ways and means committee. Watergate overtakes nixon and it all goes poof. We actually need to say liberals and union at that time did not want to have a deal that would have private insurance continued. They wanted single payer and were resisted to making a deal with nixon and they withheld their support. If that a combination of scandals, which put the kibosh on this bipartisan agreement with the union and liberals opposing it. For 20 years, until bill clinton, we didnt have another reform. And then clinton comes in and wants a sort of marketbased reform, proposes his Health Security act and unfortunately there are lots of other things with a single focus on it. He had to pass a tax increase. They had the bill. At the time all the rest of the stage was clear for health care, opposition had gained and defeated the bill. We didnt get one bill passed out of committee. 15 more years until 2008 in the system had become so onerous we needed reform and thats when i called the passage of the Affordable Care a world historical act. It did take 100 years in america and this will be the framework for the next 20, 30, 40, 50 years. Well, i think it might be fair to say the most interesting part of the book of course is the fact you were there at the revolution. This is what he saw at the revolution. In addition to the run up when you devote a good portion of the book to that, it is a very Good Foundation again that when i showed this to people as they say where the steep part. Chapters eight through the rest of it where you talk about your own observations and insights as someone who really was very new specifically talk about the complex interplay between policy, politics and Interest Groups. If you would elaborate on that and maybe focus on, at least our bucknell park is because thats one of them are easy once to understand. It does illustrate that its not nearly as cool as people laid out to be. So going into reform, i wouldve thought getting malpractice reform was the regional country and reasonable chance. First of all companies should also be modest in the expectations going in. This is something regulated at the state level. Its not regulated at the federal level. Could malpractice reform legislation is not going to solve a problem. You cant force states to do this in this way so we could provide scientists another structure. We had a very good combination of arrangements that made it look likely. The president himself was for knockout this reform. He had written an article in the new england journal of medicine coauthored with Hillary Clinton before he declared for president , advocating for malpractice reform. He thought this was an important issue. There were two doctors in the white house. Myself about cochair. Both of us that malpractice reform is a good thing to do. Other senior advisers, Larry Summers and peter orszag thought it could encourage quality care, can encourage doctors to focus more on quality. So we had a good arrangement. We studied the number of options and as i tell it in the book, we have laid out nine different options and pros and cons. One day in the summer of 2009 as we are putting various things together, they go into their brothers office, which i tended to do to the end of the day if i went in at all and he wants some piece of information about an east affairs Insurance Options for me and i was supporting acts in and then in his usual place as to what else are you doing . I began to explain the malpractice and then he basically said password showed a period we are not doing that. He explained to me why we are not doing that. And the ama, with the same public, they are talking about what they need out of this bill and cutting the sausage of legislation. They never talk about malpractice. All they ever talk about is basically how medicare pays doctors. They want a fix of doctors can get my money. They never mention malpractice. I am not certain its because malpractice will require some of the Democratic Base and if i dont need to defend the Democratic Base to keep the doctors on board, im not going to do it. Either way, no republicans are coming to negotiate. If they said our support would be no pack is, we wouldnt have done it. But that wasnt the case. So here you have a situation where on policy grounds the white house was for malpractice reform and we had to buy some reasonable proposals. But the Interest Groups, the ama and the politicians, republicans perniciously. People say no, no, no, but thats the way it wind up if either the doctors had said already, we understand panic, but heres malpractice. We have to have something all malpractice republicans they will negotiate with you and heres the things we need in the bill, it wouldve happened. But thats not the way i find out. Nonetheless, the president had two elements of malpractice that he pushed. One in a september speech to the joint session of congress. He set the outcome was that a Pilot Program on Patient Safety and we are going to make grants available to improve Patient Safety through malpractice reform. More than 100 million. The Affordable Care act contains a provision i think 10607 if i can remember correctly that says we would give grants to states to reform their malpractice laws and study to and see how it affects care and cost of malpractice insurance and cost of health care. The president obama, more committed to malpractice reform than any president actually did two pieces of a Pilot Program on malpractice reform, more than anyone else. You can say he wasnt committed to it. We didnt get more comprehensive reform. Im disappointed, but main Interest Groups and politicians needed to support it with there in the clutch. As a clinician, this interests me a lot. Just to pursue it a little bit more, you have a very interesting fact here supported by several studies, which i admit that most people who really are the victims of arafats and the vast majority of malpractice lawsuits are herbalists. Your preferred approach as i recall was a safe harbor kind of strategy. Its a little bit about that. Its very interesting. One of the things i point out in the book is no one should be happy with the malpractice system. I dont care whether you are a doctor, patient, hospital, lawyers, its broken. It doesnt do anything is supposed to do, which is to incentivize stock durst not to create errors, comment a patients, and make sure its done efficiently without a lot of overhead cost, doesnt do any of that. Theres not a simple theres not a single metric unit of measure the malpractice system on where it actually succeeds. I think patients as well as top durst want to perform and some people want lets just cap how much we pay unless pretty short statute of limitations on some of. I dont like those. In some ways behind of the most good. Rv was let these this as an attentive to improve the quality of care, make doctors figure two guidelines, so we basically try to think of a program to recall safe harbor. If doctors adopt Electronic Health records and adhere to the guidelines for treatment of the patient, they are presented it is a presumption, which could be rebutted. They are presumed to be innocent. They say. Is it a patient comes in with simple head trauma you normally wouldnt do a ct scan. To protect my bottom from a lawsuit i do as he teased him. In the safe harbor says if you follow the guidelines of patient qualified, you would be in safe harbor and present to be innocent. That seems to be the way to go. Again, incentivizes using adhere to guidelines and thats exactly what we want to her studio. So we prefer that. Other other alternatives . Yes. I dont think we have enough research for the optimal system. The university of michigan has pioneered to say youre sorry, which is admitted to the patient, propose to them a simple solution according to a very sad schedule if the cosby laceration, heres what we are going to do. That has substantially reduced the number of lawsuits. Its reduced the payments. This reduced the time to read all of it in cases. So that looks promising. Again, we dont have enough research. Okay, thanks. Lets move on to the actual aca here. As january 1st rolled around and things went into effect and some stuff what writing some stuff went wrong. So talk a little bit about what we pride and then well talk about what went wrong and how that can be fixed. First of all, the Affordable Care act is more than just big changes. I think it is very unfair to say it just came online. The fact is right after passage in march 2010, lots of pain take my mind. Many people should remember, although they mightve forgotten the idea that young adults up to age 26 can stand their parents plan to effective on on monday september 2010 and Many Insurance Companies made it effect is before six months of passing you similarly, theres been a provision to encourage hospitals so patients on medicare or 20 theres a 20 chance of a return to the hospital within 30 days. They created a program in the Affordable Care act to actually worry about what happened when patients leave the hospital to make sure there is continuity of care. That went into effect. The patient better Outcome Research institute went into effect pretty quickly after the bill. So we didnt wait until october 1st, 2013 in the opening of the exchanges for the Affordable Care to be implemented. A lot of those provisions went into effect in some of them are very successful. Some of them were disappointed to be perfectly blunt. I dont think the Research Institute has been sufficiently progressive in the studies that have been quite timid and we been trying to push back to undertake more compared it 30s. Is that located at hhs or other universities . Independent, private, notforprofit funded by an assessment. The board is nominated to the gao, Government Accountability office so it is independent and not part of the government. Adiabatic correct. The basic idea would be subject to political winds. Is scott until 2019 and i think they unfortunately have not undertaken the right to compared the effectiveness research. They spent a lot of time worrying about the information and getting the basic information about which treatments work better, whether we ought to give this kind of treatment is surgery compared to medical treatment for a particular illness yet again, they havent done enough of that. Nonetheless, in the larger context, the bill is a remarkable impact. Let me mention one other program. The partnership for patients in 2010, what is called innovation is in an effort to reduce hospital acquired shows, errors, surgery on the wrong part of the body and threeyear major program, preliminary data are very, very encouraging. More important, the major problems like ventilator assisted infections are central infections have gone down by 15 . Thats a remarkable a private hospital and i think it shows you what can be done. You are very transparent in the book about a month the problems with the website and the rollout. So who do you think at this time, who would you consider so does the losers in the environment right now and what can we do about that . I think the American Public unfortunately execution on the exchanges, the federal exchanges was not implemented. I think people would use the word he asked go, disaster. It really was terrible. I tried hundreds of times and many other people were frustrated and it didnt have to be that way. The most important issue to me is look, we know it could have succeeded. California moderately well with the rollout. I think it wasnt properly managed. In outcome would just sigh zionists came in, we had a reasonably confident team to come together to fix. Shows you could fix it. Why do you think it took so long . Ui really, refreshingly transparent about the dynamic of t