Transcripts For CSPAN Key Capitol Hill Hearings 20141230

People of low income africanamericans, hispanics are signing up with higher rates. Women are getting higher insurance rates than men. People in rural areas are enrolling with higher rates. Who are the people who did not have insurance before, who are the ones who were shut out before. Is also shows in large part the power of the medicaid elf pangs. Some states did not expand. Were saying theres a huge disparity between the states expanded and those that did not. If you are low income person in a state like minnesota, and you are likely to get insurance. If you are a low income person in a state like florida, your options are much more limited. Host in the piece you did, you break it down by race as well. 26 drops down to 16 . You can see, more whites or asians with Health Insurance. That is going down as well. Almost every group saw reductions in the rate of insurance. If you didnt have insurance there were other options available. Certainly, the groups that were most disadvantaged fall the most substantial gains and are starting to catch up. Host will go to cornelia. Caller hi, everybody. Basically, i believe that our entire medical system in america is broken. Obamacare is not helping. If it is making it worse. We need Health Savings plans ffrom the bottom up. Our pharmaceutical companies are in cahoots with fda. Talk about the militaryIndustrial Complex. We have a pharmaceutical Industrial Complex that is running our medical system in america. Guest the Pharmaceutical Company if you look at we have the biggest profit margin. To go to the broader issue there are a lot of people who are still unhappy with the functioning of the healthcare system. The Affordable Care act was never intended to fix everything with the healthcare system. It was intended to make a start. Mostly focused on coverage. Secondary focus on cost. Starting to give a push to a system that was changing he was anyway. There are still people who want to go far off in one direction, far off in another direction. If you look at the difficulty the congress has just passing the Affordable Care act it is difficult to imagine anything that would more drastically change the system. The system is on a path to reshaping itself. Its hard to know whether that is going to be better or worse or how much people will like it. Host this is a story that was tweeted out theres an obamacare rule saying that the government could reenroll you and obamacare, choosing your plan, dr. And coverage. Guest this shows the challenges that people have in implementing this law. Say you sign up for a plan in 2014. You take no action. You dont shop around or update your information. The government will reenroll you automatically in that plan. Obviously, you can go in and cancel. The goal is to keep people continuously insured. What we found the fear is that the plans that were really popular the first year are experiencing the highest increases in premiums. What the government has proposed is giving people a choice when he signed the first time you can say in advance, if i do nothing, i stay in the same plan, no matter how expensive it gets. Or, consumers can say, if i do nothing, i would rather stay in the cheapest plan. For people who pick that choice, they may end up with a different insurance play. It may not could have the doctors or drugs they had before. It would be an all matic process. I think is important to note that even if the government goes through with this people have a choice as to what default option exists. If youre the kind of person that wants to stay in the same plan, you wouldnt choose that. Also, everyone every year has option to go in during the open Enrollment Period and shop around. This would only apply to people who take no action. All evidence to suggest that people are better off going back and doing the hard work to shop for the better plan. The premiums are changing and other parts of their plans are changing too. People need to see what is best for them. Guest people can still change up until february 15. They will get a letter saying they are reenrolled in a plan. Or the plan does not exist anymore, you have been reenrolled in a similar plan to what you have. No matter why, you should go back and make sure. Maybe the premium is the same, but how much you pay for your drugs, or your doctor, that may have changed. You can always go back and look. You may want to go in and change. No matter what, it is good to go in and look at your plan. If youre in it now and youve been reenrolled, you have until february 15. Guest its important to say the proposal to change the switching mechanism, it is not final. It is just a suggestion that the government has put out. It may or may not become final. Host bob from virginia. Caller i hope santa claus was very good to you ladies. Basically i want your opinion on my opinion. I called in several months ago and made the same point. It seems that in this country we forgotten to be what its like to be a society the gentleman who called an earlier was talking about paying for Reconstructive Surgery individually, i cant build a road or a watcher sewage system and that sort of thing individually but as a society we can. I do not have any children, by do not mind paying my taxes towards the education of other peoples children. It just seems like we have forgotten what its like to be a society. I would like your opinion on that. Guest this is the whole concept of insurance. You think about Fire Insurance or car insurance, bad things only happen to a few people. If everybody pays in a little bit, you can afford to pay for the big amount for the bad things that happens. For health care, one of the problems is Everybody Needs some. That is why it is so expensive. There are very few people who never go to the doctor. Eventually everybody will need health care and health care is expensive. That has become the problem with Health Insurance. That was certainly the idea one of the big problems of for the Affordable Care act, was only people outside the system, there were not enough people inside the system to spread the cost. And, the people inside the system were paying for the people outside a system. Why not bring more people inside the system and have them pay something. Spread the insurance pool. That is basically the aca in a nutshell. Host what has happened to the cost of healthcare in this country since the aca. Guest this is actually a really interesting story. One of the goals of the Affordable Care act was to lower the cost of health care or slow down the increases. Anyone who pays the Health Insurance premium sees that it goes up every year. Its been a problem for the economy. The federal government pays for medicare and that gets more and more expensive. It is a real head when the premium or deductible goes up every year. A big goal of the law is to slow down that growth in health care costs. Wonderfully, costs have been going down since 2002. We now have a lot of years of data that show we are in an unprecedented slowdown in health care expenses. It is hard to give the Affordable Care act too much credit for that. It is possible that is making some contribution around the edges, i think it is more coincidence. There are a lot of other factors that explain what were seeing right now. I think there is a hope among people who wrote the law and those support it that there are things in the law that can help sustain that trend. It is a really important trend. The country really needs to get a handle on healthcare costs. Host lets talk about politics a bit. Here is a tweet from a republican in tennessee saying we will use every tool in the toolbox to end this destructive program. She has a link to the hills website. Thats the budget reconciliation. Whats in store when they return in january . Guest budget reconciliation is not obscure. Really they do it most years. Arcane maybe obscure, no. It is a piece of the budget process, the way budget process works, each house of Congress Passes a budget resolution. They get together. They come up with one resolution between the two houses and one of the things that budget resolution has many years, but not all years are whats call reconciliation instructions that require the tax writing committees, any committees that control mandatory spending to reconcile that spending to the budget. It has been used in previous years to do a lot of things that have to do with healthcare. Obviously with the tax code, those are big programs. One of the nice things in the senate is that it cannot be filibustered, and you only need 51 votes to get it. Host is it a mandate . Does did go anywhere if you put it in the reconciliation . Guest reconciliation is not a must pass bill in the way the spending bills dont get passed, the government gets shut down. If the resolution bill does not get passed, the government does not shut down. They passed two reconciliation bills in 1987, three months apart. So sometimes it can take them a long time to kind of get their act together. Its just a way to change the rules for mandatory spending program. But it does the big important thing is that you dont need a majority in the senate and it cant be filibustered. They are saying that since the Affordable Care act was passed with the reconciliation process, they can on passive with the same process. There are two problems with that. The a. C. A. Wasnt passed in the reconciliation process. The senate lost its 60th vote. When they passed the built Christmas Eve 1kwr69, they had 60 votes and senator scott brown was elected in massachusetts, they had 59. They basically used the reconciliation bill as a way to do a congress report. There are many things in the reconciliation bill that were not in the main law. The reconciliation bill must be budget related. I dont think if they wanted to. They could cause a lot of problems for the law but they couldnt repeal the law. The other thing is, if they can get to the house and the senate,the president would veto anything that would really undo the health law. The republicans may have some items they want to tinker around with, but a full scale assault seems unlikely. Host republican of georgia was our guest on newsmaker recently, we asked him about this process. You can watch the full thing on our website cspan. Org. He really wants the conference to decide. He said that the lawmakers will be getting together in their annual retreat and he will be listening to his colleagues before deciding. Host i think with the republicans want to do with the Affordable Care act is they have this big dilemma, if they take apart the most controversial and more unpopular things, that could make the law more popular. They do not want to do that. The things they could do is eliminating the medical device tax. There is democrat support for it. They do not want to maybe end up having a law that is more palatable or fixed. While president obama is in office, they cant repeal the whole thing. They are caught in a rock between a rock and a hard place. Host miles go ahead. Caller i am a republican, but since i have been watching obama in office our economy was on the brink of going off a cliff and now all of a sudden our economy is doing better and there are more people that are getting health coverage. Were a party of families, more or less, and values. What has happened to our society when we do not even want to take care of the poor, the kids, the families. Theres something wrong here. Host margot sangerkatz, part of the spending we have seen recently is triggered by people spending on healthcare. Guest healthcare is a really big part of our economy. Its pat of the reason why this law is so controversial. It is so huge. It is not a small thing on the margin. It is a lot of dollars that people spend, the government spends. It really matters for the Overall Health of the economy. Host congressman tweeting this out a new poll shows that the number of americans who say healthcare is personally unaffordable is skyrocketing under obamacare. Guest that is not true. There was a recent gallup poll and they asked people these questions is the amount of money you are spending affordable for healthcare. They basically, theres no change over the past few years. There are people who find it is unaffordable, but is not changing. Host jerry from chicago. Caller listen, i want to comment on one of the previous callers. I have medicare but not a supplement. I got an advantage plus plans through humana. I guess it depends on the state you are in. 8 for not enough, a minimum drug coverage to medicate. I just want to know, do not go for medicare b. You never need that. Secondly i am also a tax visor with a reputable tax firm. Last year we informed all the clients about the mandate. Next week, i will be in office calling all my clients to remind them to bring their 1095 form. They can determine whether you got to get the insurance. Im glad you ladies are out there to exthis to the callers in the country. It is very important. Thirdly, for a country like ours, it is hard it is not a free enterprise. I think there is something we can do. I wish people wouldnt be so hard on the president. Everybody is not a deadbeat in this country. I think there is something we can do. Host we will go to joe joan in maryland. Caller my husband and i went to our annual exam in december. I was expecting to get blood work the kind of exam that president bush had, they do blood work, they found he had a narrow artery, they put a stint in and now he is fine. We were given the sheet of paper to our medicare patients. The annual wellness visit is not the same as what many referred to as a yearly physical exam. Medicare does not cover the yearly physical exam. Medicare is specific as to whether it includes by the way, this is john hopkins physicians. What is included . Talking about your medical missile and risk factors with your dar. How do i know if youre not testing . Measuring your weight, height, and make a plan to keep you healthy based on what . So this was like to me a joke. Medicare will go bust according to the statistics ive read in 2026. Will we be put into the exchanges . What is the plan . Theres also a bipartisan agreement that the independent payment Advisory Board which is a ragsing plan. Nonphysicians will be making plans as to what you can have and what you cant have. Guest start with the last one. It does not exist yet, it is very controversial. Mostly does not exist because it was created to recommend ways to reduce medicare spending if it exceeds a certain threshold. We were talking how health care is growing at a historically low rate. Medicare spending is leading that historically low growth. Nothing is on the horizon that would trigger anything from that. One of the things it specifically says is that it may not recommend any rationing of care. They have to come up with other methods to finding ways to reduce medicare spending. There is a standoff over that. At the moment, does not matter because it is not being triggered. If i could go back a couple calls and talk of Medicare Advantage again. Something the caller was saying is something people should note. If you want to go into a Medicare Advantage plan bbasically a private plan that takes over for medicare. You do have to continue to pay your Medicare Part b premium because thats what basically pays for that private plan. I misspoke there is a guaranteed open enrollment, but only for certain plans. There may be some plans, if you drop your supplement, go into Medicare Advantage go back to Medicare Advantage, want a supplement, you may not be able to get back the one that you had. Host david from glench cove, new york. Caller i was just listening to the last caller. Are you saying that if you have a preexisting condition, you cannot get a plan . Host i do not think we said that. Guest the law says that if you go to the marketplace and you want to get Health Insurance your price will only be based on your age, where you live and what the income is. In the old days, Health Insurance could say, sorry, you have diabetes, no Health Insurance for you. Or, you could have it, but it would be paying two or three times as much as a healthy person, those days are over. Guest i think were talking specifically about the medigap plan. Host well go to kerry in south carolina, a democratic caller. Caller my husband had Health Insurance, he lost it. The employer couldnt afford it anymore. We said, okay. My husband is diabetic. We cannot afford that Affordable Care act because we worked a lot. I work over 60 hours per week. My husband works 50. We have four children. Three in college and one in high school. Because of that, on paper our Health Insurance would be almost 1500, only including two children. That is double my mortgage. We will take the penalty. We have to take the penalty. It is ridiculous. The fact that now my husband has no Health Insurance, we had blue cross blue shield. He is off his diabetes medicines because we cannot afford them. Believe it or not, he is doing better than when he was on medication. Guest im sorry for your situation. I assume that you have gone and tried to get someone to walk through it with you. Host where would she go to do that . Do you call . Guest on the website there is a place that says if you want to find local health, there are people who can walk through the options with you. Sometimes these people are trained, and they are better at parsing out where you might do the best. You have one Family Member who has a preexisting condition something expensive and you want to make sure you get a doctor or a particular drug and sort of work all that out. Host we have a couple more minutes here with our guests. Guest i think that highlights a group of people who are not very benefited by this law peoples incomes are high enough that they are not eligible for any kind of subsidy but not so much to pay 10,000 or 15 a year for Health Insurance. For people like this caller who maybe their family earns somewhere in the neighborhood of 100,000 a year, they have a mortgage and pay for their kids college tuition, the additional cost of Health Insurance may be a stretch. Host how may people are there in that situation . Guest i do not have an answer for that. Guest percentagewise, they are the smallest percent. We do not know in many cases why they do not have insurance. In fact, those who are in that threshold is very low. It is probably People Living in very expensive areas or people who have kids in college and people who have other expenses. Guest i spoke with one person who live in new york city they said our cost of living is really high, our rent is high, our child is in college. The full cost of premium is out of reach for us. There are not a lot of people in this situation. I think this law can make it hard to find insurance. Host it sounds like a lot what these people have to pay, when we hear from the people. We will go on to brian in michigan. Caller my question is i am between jobs now. My girlfriend has medicare she is on disability. I cannot afford it. I am in between jobs. It seems like this fee and everything the penalty is more of like just getting money more from the poor people than it is to help anything just like another tax. I would like to be able afford medicare or Health Insurance because i have issues, too i hate to get to see a doctor, but i cant afford the 300 a month. If i could do that i would be making a payment on a new car or something. Host thats our last phone call for the two of you. I want to end by asking you, what are you watching for next with the Affordable Care act as we head into 2015 . Guest i want to see how this Enrollment Period sort of winds up and what the republicans decide to do about their political, you know, issues, whether they want to make a show of opposing the whole law or try to address pieces of it. Host what about you . A lot more people are getting Health Insurance now. We dont know what their experience is going to be like with that insurance, whether they can get the care they want and afford it. I think thats going to be really important in the future. The other thing im going to be watching, what does this mean for peoples budgets and Financial Health . Are more people going into bankruptcy because of health care in the way they have in the past or provide people with some kind of financial crisis. Thats what we need to measure and see. Host to follow their reporting, go to Kaiser Health news. Org where julie is a Senior Correspondent there and you can follow her on twitter. Also margot, she writes for new york times, their Health Care Correspondent for the upshot which is a column that runs frequently. You can find her reporting on ny times. Com. Thank you both very much. Appreciate spending a good chunk of your money with us this morning and getting out appreciate it. At 8 00 eastern, remembering public figures who died this year starting with howard baker and a 2007 interview looking at his career in congress, at his time as chief of staff to Ronald Reagan. That tonight at 8 00 eastern time. During the holidays, were showing some of our q a interviews from over the last 10 years. Here is one from september of 2011. This week on q a Johns Hopkins University Brain surgeon dr. Alfredo quinoneshinojosa discusses his new book becoming dr. Q. Dr. Alfredo quinoneshinojosa, you write in your book that you were an illegal homeless immigrant farm worker illegal homeless immigrant farm worker and now youre a brain surgeon. How long ago were you a farmer . Thank you, brian. I think its a pretty comprehensive description. I came to the United States in 1987 and i talk about that on that recent book that we published. So a little bit over 20 years ago i was just came into this country with literally 63, 64 in my pocket. I spent 60 on my first tract land in l. A. X. With about 3 left and then found my way all the way out to Northern California where i began to work with the very same hands that now get to touch the human brain at one of the most prestigious institutions in the world which is Johns Hopkins. Do you remember the first time that you saw the brain . Can i remember the first time . Imagine, brian, i mean i was just a kid now that i look back. I started medical school at harvard when i was 26 years old. The sometimes people have asked me, did you know you were going to be a doctor . I said no. Did you know you were going to be a brain surgeon, i said no. How did i end up on this journey that i had lived for the past two decades . Sometimes things happen for a reason. I used to think that chance and good luck comes to anybody who wants it, but i began to realize that its not just that. It comes to those who look for it. One day i was walking in the hallways of Harvard Medical School and a very, very distinguished brain surgeon looked at me on a friday night at 11 00 p. M. And he asked me where are you going . Im going to the library to study. He said have you ever done brain surgery have you ever seen brain surgery . I said no. He said would you like to see brain surgery . I said i would love to. I was thinking this would happen in the future. I wrote that some my book. He says lets go right now. The next thing i know, i walk into this operating room and imagine the magic that i felt when i saw that beautiful brain on a patient that was awake, which incident alley what i do nowadays one of my specialties is doing brain surgery and taking out brain tumors out of patients who are awake. This is 1997 and i see the human brain pulsating with the beautiful rhythm in a patient that was awake dancing with the heart. And right there immediately right then, i was captivated and the idea was born as to whether or not one day i may be able to do the same thing. And here i am. How many times have you operated on a brain . By now imagine going through residencey, six years of 300 to 400 cases a year, now as an attending at john hopkins i do between 250 to 350 brain tumors a year. I have been there six years. You can imagine thousands of times i have seen the human brain. It doesnt how many times i do it. It doesnt how many times i see that brain, i still go back to the same feeling every time i peel back the duringa and i open it up, i see the human brain pulsating with such a beauty. It makes me wonder, you know, every patient, whether youre brown, whether youre black, whether youre hispanic, whether youre muslim, all our brains, once you peel back the dura, we all look the same. Whats the toughest part about being a brain surgeon . I think the toughest part about being a brain surgeon is the challenges that we face, the uncertainty that we face every day in the operating room sometimes no matter what you do, you can do the most perfect brain surgery, you can remove a whole tumor and at the end of the day, we still cannot defeat the Natural History of brain cancer for instance. I have so many patients that come nowadays from all over the world hoping that i can cure them from the most devastating disease that effects the human body which is brain cancer, no matter how much power, how much knowledge we have, we still cant defeat that disease. That to me is the most frustrating part of what i do is that i still have to go out and talk to the patients families and i got to look at them facetoface and say im very happy with the surgery that we have done yet i know this is only the first of many battles that you are going to fight with your loved ones. That feeling of knowing that no matter how much of an expert i am on the disease, i cant win the war. I may win a battle when i do the surgery, but at the end, the war is going to be fought by my patients and their families. That senator kennedy had . Deforming. G. B. M. You use those letters a lot in the book. When you see that and what do you see when you see that, is there any chance at all or what are the percentage today . Thank you brian. I can tell you. Every time i go into the operating room and i find myself in that dilemma of knowing that i am in front of this killer, this massive killer because it kills thousands and thousands of people every year, this type of cancer alone. Im not talking about any other cancer in the body. Im talking specifically the cancer that affects the brain. I go in and i know i am the underdog when im fighting that fight for my patients. My patients trust me with their life. So when i am in there, im like the special forces of brain surgery. I go in there with all of the passion, all of the knowledge, all of that energy that i have gathered from the patient and their families and my role is to go in and take as much as i can safely. Thats what i do a lot of times, i weigh to make sure i take as much as i can. The odds are against me making an incredible difference on that patients life at the end of the day because the bottom line is that the disease is devastating. At the end of the day, the disease keeps growing, the tumors keep growing but i never lose hope. Every patient i treat, every surgery i do specifically on that type of cancer, i always hope that this is going to be the patient that is going to defeat the disease and from that patient we will learn and make history for many other patients to come. I have that feeling in my heart every single time i enter that arena in the operating room. I have to. Otherwise i wouldnt be able to do what i do every day. Hope is the last thing. I hope i will ever lose. I dont want my patients to lose it either. You write a lot in your book about being an illegal. Yes. How did you come to the country illegally and then how did you become legal . So, its quite interesting. So you know that through the country, this country was built upon people who have come and immigrated to this country, some of them legally, some of them illegal legally. In my case, i came in with no documentation and no ability to get a job or education. When i first came into the United States in the late 1980s and i crossed the border between mexico and the United States and ended up coming into the San Joaquin Valley to work as a migrant farm worker, there was no challenge to find a job. There were not a lot of thousands of people trying to get the jobs of pulling weeds with the very same hands that im now doing brain surgery. I was pulling the weeds as you can imagine, pulling the weeds from the land that is doing all of the products, cauliflower corn, all of those kinds of things, my hands were bloody, i mean continuously being hurt. There were not a lot of people lining up. I came in and asked for a job and i immediately got a job. Eventually right around Ronald Reagan had the Immigration Reform that gave a working authorization specifically for people who had been in the United States for a certain amount of years and then there was a special legislation for people who came and worked as migrant farm workers. That legislation allowed you to have a working authorization. That was the first thing, and to pay taxes. Eventually that working authorization, you couldnt go back anywhere. You couldnt go back to your country, but it allowed you to work legally, pay taxes and eventually apply for a green shard which is eventually what i did. So the country was welcoming people like me who worked in the fields. It was a different time. I felt that i was given an opportunity, an opportunity to live the American Dream. It was quite interesting. We have talked about it. Times have changed. Our borders have gotten more strict. What i did back then wouldnt happen. I talk about this in the book. Nonetheless, the American Dream hasnt changed. Some peoples perception of how do a chief the American Dream may have evolved over time, but the American Dream is still the same foundation of hard work, people who are coming into the United States with the idea that they can work as hard as they can possibly can and still be able to put food on the table of their children and to be able to give the children an education. That was my dream back then. It was that simple. All i wanted to do was work hard enough so i would have food on the table of myself, my future children, my parents, and my siblings. That is exactly the journey that i took all the way from back then until where i am today. You quote your nurse is saying from a patient, is it true that the doctor is a dirty mexican . Isnt there another surgeon i can see . How often has that happened . It happened very, very often when i first came to Johns Hopkins in 2005. You realize i have been there for six years. We have been so blessed that i have raised in the academic rankings all the way to being nominated to a full professor at Johns Hopkins and people didnt know my background, they could see my skin color was different, they can detect a certain amount of accent in some ways and some could know about a little bit of my history, harvard and San Francisco training but they couldnt get over the fact that i was from a different country and i came from humble backgrounds. It happened a lot, to be honest with you. I always told my team that a lot of my patients who came to see me were not only suffering from biological diseases which is brain cancer, but they were also suffering from social diseases which is discrimination and sometimes seeing people for what they look and how they talk fully ignoring, not because i speak with an accent, that means that my brain works with an accent. It works as well as anybody else and we know that. So i told my team continuously, dont worry, they will come around. Every single one of those patients always came around. After surgery, when they decided to trust me with their lives, i would come in and talk to them. They would turn around and many times they would tell me or my assistants how sorry they felt for some of the comments. A distributed that to the disease, once again, the biological disease theyre dealing with the brain cancer that makes you think in ways that you really cant explain. It did happen. I didnt pay much anticipation to it to be honest with you. I turn all of that negative energy into positive energy. How do i do that . By doing research, by continuously making every single one of my patients part of history which is something to me ma is so simple that youll be surprised how many Brain Surgeons have either given up fighting against brain cancer or they have decided that they just want to go in and do their surgery every day and not necessarily fight the disease in the laboratory, which is something that i have done. Whats the point of operating on the brain and having the patient awake . A wonderful question, brian. So in fact i alluded to already in the discussion and there has been several people who have come into the operating room to see how i do this surgery. Im not the only one in the United States or the world. There are several surgeons around the world who do a beautiful job. The principle is simple. In our brain the left side the majority of us have dominance for speech on the left side right about right here we have the ability to produce the speech. Right around back here behind the ear we have the ability to understand language. Between these two areas, there are connections and thats how our brains interact. We understand and we produce language. So imagine if you have a tumor that is in this vicinity, many times these tumors if theyre the malignant brain cancer, can you tell the border between the tumor and the normal brain. The only way that you can do this is by mapping the brain and knowing where normal function lies and then you take your resection all the way to that border and leaving that border intact. So you have the act to take as much tumor as you can and leave behind the part of the brain that is necessary for language. How does the patient though not feel pain . Well, i have written about this and i have a wonderful patient that i used to talk to in the book actually who is a Sports Writer and he talked about, its difficult, its challenging to be there awake and knowing that someone else is up in your brain, you know, keeping you awake as theyre touching your brain and stuff. The truth is that the pain sensors are not in the brain surface. You can illicit memories, you can illicit painful memories, but there is no pain per se in the actual brain. The pain is in the scalp, the skin the pain is on the bone. The pain is on the part that coversed brain. Its called the dura mater. Its a small layer of issue. Its no different than the way we do to do dental work. As a matter of fact, many of our patients tell me when they undergo the surgery, it was more painful to have dental work than to have awake surgery. The difference is the psychological pressure. I tell you, its amazing, just about three weeks ago one of my patients, a young man, 15 years old, going to be featured in the john hopkins newsletter, he underwent an awake craneotomy with me. Talk about being a true hero. This young man was stronger than any patient that i have ever seen. He remained calm. He answered all the questions. Im asking him questions, theyre looking at pictures, theyre reading words, all this is going, they are working with me. We are working as a team and trying to eradicate their disease. They do a beautiful job. How long can a patient stay awake and have the brain open like that . It all depends. The surgeries range between an hour to sometimes up to three hours depending on the complexity of the tumor, depending on the size of the tumor, depending on how close they are, but they range. So they can be awake and sometimes i put them to sleep a little bit with a little bit of anesthesia, local anesthesia, i have a wonderful Anesthesia Team is crucial, they keep them nice and relaxed. When youre doing the most difficult of all brain surgeries, how many people are physically involved . Oh, my goodness imagine that. So yesterday i did a case, yesterday morning i did a case that lasted about 12 hours. And i was the captain of this team. And i had two e. N. T. Surgeons, i had two plastic surgeons and then i was leading a team of neurosurgeons obviously. Surgeons alone, we had about eight surgeons involved in this team. This is a patient that came from far away with a very complex tumor that we had to remove at the base of the skull. In addition to that, we have three anesthesiologists. In addition to that, we have about four nurses helping us circulate in the morning, four nurses in the afternoon, so all together i had a team of about 20 people and some of this is very, very complex cases that we do. If somebody had to pay out of pocket for that operation, do you have any idea how to describe the cost of it . Every now and then it does happen. You can imagine, i am at an incredible institution with an incredibly international reputation. At hopkins, we have people that come from all over the world. I would say that most of the time some of my patients that come from other parts of the world and have to pay cash, it ranges probably anywhere between 60,000 to depending on the complexity of the case up to several hundred thousand dollars and depending on how long they are in the hospital. As you can imagine, you know very well for people sometimes they come to the United States and choose to have their surgery because they want the best, and not necessarily because i lead a team, also because i am surrounded by an incredible amount of incredibly smart and dedicated physicians, nurses and everybody else that is involved taking care of the patient. Those are the ranges more or less for what i see. Whats the most difficult and you probably hate these kind of questions, but what is a very difficult operation, i mean i read in here about the skull, i mean the facing pulled down and all that, whats the most difficult situation you find yourself in . I would say the most difficult situation, brian, that i find myself is in those situations in which you are in the operating room, no matter what the case is, it could be a very complex brain tumor or it could be a simple brain tumor. But the difficulty is when something unexpected happens. About three weeks ago, i was doing a young man early 40s with a very large brain tumor soccer player, incredibly fit. As soon as i opened the tumor and i opened to begin to resect the tumor, there were small but very significant bleeders and it was just like you opened the gates and blood starts pouring out uncontrollably. The greatest challenge is you know that there is a fine line between life and death. Luckily, i remained calm. I kept my whole team calm and we were able to control the situation and that patient went home in two days. Imagine the pleasure that i had to know that. But i went home that night and i was still shocked, after that adrenaline comes down because youre in the middle of this and like i said, you are like the special forces. You have to lead a team. You got to keep everybody calm cool, and collected and make sure that you are paying attention to every single thing is going on, anesthesia, nurses, the people who are doing the neuromonitoring, my residents, everything, its almost as if time slows down and everything is moving around you and youre focused and everything is quiet and youre aware of everything that is going on and youre trying to save his life. I went home that night and i sit and my son david is having dinner and this is around 9 00 p. M. David, dad, how did your day go . It was a tough day. I had this patient, he had a tumor. I told him what happened with the blood. He asked me a question. He said, dad, how much blood do you think you could afford to lose before the patient dies . Thats when it hit me, not much. We had lost about six litters of blood. So we were this close to potentially losing him. In those cases are very, very emotionally and physically taxing for me. Did you have to go back the next day and do an operation . Yes i have to go back, the same day in the afternoon, i had to go back and do it all over again. Those are the challenges that we face. We never really talk about the emotional weight that these kind of situations carry on you and the amount of arrogance in somebody and i talk about this in the book. I am the first one to admit every day, i have to get up in the morning and tell myself i can do this. There is no one better to do this than i am. I have to believe that every time i go into the arena, into the operating room, i have someones life in my hand and i am fully capable of getting this patient in and out of the operating room because thats the trust that these patients have on me. I walk the fine line between confidence and arrogance. Lets back up to, i want to eventually get you to talk about what seems to be a metaphor in the book, you falling into the tanker. Lets back up from that. You have been how long at Johns Hopkins . Six years. Before that at the university of San Francisco and before that harvard for medical school. How long was your medical school . Four years and one year at Howard Hughes doing research investigation. Youre only 43. Go back then, beyond harvard, where were you in school before that . Before harvard i was at the university of california at berkeley, u. C. Berkeley and before that, you know, from 1988 to 1991, i was in a Small Community college in stockton, california Northern California right before i went to unfortunately c. Berkeley and right before that, i was working in the fields. How long did you work in the fields . I work in the fields to about a year and a half and then simultaneously as i was working, as i was studying english in Community College, i was working on the railroad. Lets go back before you jumped the fence. Yes. When did you fall into the tanker and why . So this is around this time. This is when i was in Community College learning english and i fell and i guess we have to set up the story because its a metaphor in many ways as to what its like to fight for your own life and what its like sometimes to give up control, all right. So right after i work in the fields, i am working in a Railroad Company and i was doing the most menial job that you can imagine. I started first cleaning tanks that carry fish oil. At the bottom there will be this fish lard that would accumulate. I would clean that. I advanced to cleaning tanks that carried Liquified Petroleum gas. Thats the story that we relate in the team, i am in a beautiful sunny Northern California day in the summer. I am working with one of my coworkers that i mention in the book pablo, and i am in charge of fixing this security box so the tanks wouldnt explode or wouldnt release all of the gases that they carry,ly quified petroleum gas, l. P. G. I am at the top of this 35,000 gallon tanker. I have a hole about this big and a big bolt falls into the tank. I tell my coworker im going to go down and get it, talking about arrogance. Thats in fact what happened and my friend goes to me, my coworker said are you crazy, no, well let it be. It will take a minute. I thought i was at the top physical shape in my life. I went down and as you can imagine, i didnt make it back up. I did try. I landed at the bottom of thisly quified Petroleum Tank and i realized there is no oxygen. I am with my whole equipment, you know, steel towed boots, big overyalls, a lot of tools i start dropping everything. I start grabbing this rope. I am about 18 feet right about the height of this, at the bottom and i start going up on this rope. If i start doing this and i relay that in the book my whole life starts flashing, just like when people talk about a neardeath experience. Im thinking to myself, oh, my gosh, i came to this country to fight for not only my life, but also to provide for my siblings and my parents. This is where im going to end up. Im not going to go without a fight and i started going up, going up, climbing that rope little by little with absolutely no oxygen in my lungs and i made it all the way up to the top and i grabbed pablos hand. Pablo relayed the story as to how when he saw in my face the agony, but also the strength i can almost crush his hand, he thought we were safe. He was asking for help. Right around that time my father comes because he was working on the railroad, the same place where i was working, comes up and he lands right on top of pablo at the moment that pablo couldnt hold me anymore because i completely lost consciousness. Pablo related a story right before i did this, i smiled and went down to the bottom of the tank. You fell all the way down. I fell all the way down completely unconscious. Then the whole incredible journey and work of a team, just like and led by a person that i mentioned in the book that subsequently died unfortunately when i was arrested with traumatic brain injury, he led this team and my own brotherinlaw went in not once not twice to save my life. He is an incredible story as to how they were able to get me out when i could have not only died, but the way they got out with a rope and no resources, we had nothing in this place and they got me out of there. The next thing i wake up the next time i wake up, im in a small hospital all right, in stockton california, and i am vomiting and i am completely strapped in one of those yellow stretchers my neck is protected. I know what traumatic brain injury and spinal brain injury, the way you have to protect it. The doctor is trying to examine me, they told me to relax. How do i relax i was vomiting, i had to move to the side, i was completely sick to my stomach. My father relays the story. They did all kinds of tests m. R. I. , i had been down there minutes with no oxygen. They thought i had a streak. I couldnt feel some of my hands. I was having a lot of side effects from thely quified Petroleum Tanks, the gas, not fluid, but the gas. I woke up a few hours later, my father came in and i see my father and my brother are crying when i talk about this story. A few hours went by and then i asked my father, you know, i noticed there were some young nurses taking care of me and my father knew that i was going to be ok when i asked my dad, dad, how does my hair look . [laughter] as you can imagine, the whole idea, the moment that i grabbed my coworker pablo, i had to, i knew that i had given it all i had and at this point it was symbolic of me when did you decide to tell the story . I decided to tell the story right around 2008 three john hopkins abc did a beautiful show on hopkins. I was in the first episode. And the last episode, i opened and closed the show. A lot of people were asking me already because i was a medical student. When i finished harvard and i had an article that made the cover of the boston globe, a lot of writers came to me and said wed love to write your story. And i was not ready. I was not mature yet. I came to hopkins, and i was not ready yet. I needed to climb the ladder of academic medicine. I needed to go from assistant professor to full repressor professor. Luckily, i have been nominated. Around that time, i realized that there was an incredible story to be told. Not just my story, but my interaction with so many people that had meant toward me me ntored me. I realized this was the American Dream and we were losing focus of what the American Dream is all about. I think the American Dream comes to the principle of hard work. And i wanted to tell the story of the underdog, the kid who came to the United States with nothing. And based on hard work mentorship and opportunities being given, and me taking those opportunities, i was able to show the world that you can still fulfill the American Dream. And that america is still the most people country in the world. Were you worried that some of your colleagues would think you are showboating . Of course it was worried. You always do. And it happens many times. Believe me, they would not give me promotions at hopkins based on this book alone. It has to be pure Peer Reviewed publications. We had our laboratory in nature magazine. It has to be based on grants from the government. I am one of the few Brain Surgeons in the United States that has funding from the National Institute of health. Alltime Million Dollars grants to study brain cancer. Thats how you get promoted. And thats how i said this is what going to do first before i release that story. I think john hopkins has a 1. 6 billion grant year that they get grants from the government. They are the number one hospital, for how many years now . Over 20 years now. What do they do with that money . You have to come in and see. It is all going back to research. I think that is what makes this place such an incredibly special place. We are constantly striving to make history with our patients. Not alone and not letting them do it, but as a team. We use all those resources to find new cures. We use those resources specifically for me. The lab of money i am getting and the money that many patients donate, we are using it so we can find a cure to fight the disease. So 20 years from now, we can say we are going to defeat your disease. And maybe future generations. You see whole Buildings Laboratory stash my laboratory is about 20 people. You can imagine, i have to pay their salaries and expenses. Money is constantly being put back into the economy so we can find cures for disease. Back to the basics of brain surgery. What is the average regular story that you hear of a patient that leads to brain surgery . Beautiful question. This is what i hear from patients. My patients and one of the reasons my practice is so successful is, first of all when patients come to see me they get access to everything in my team. Including my personal cell number in the event they have a emergency. But when i commonly here is that the moment that they got their diagnosis, and i write about this in my book, the moment they hear the diagnosis, it is like the whole world collapsed. One patient beautifully described it to me as if imagine you are driving in california. Highway five near bakersfield. A beautiful drive. Nice and quiet. You have the beautiful classical music. You have dac on. And something hits your car. And your whole world collapses. Turns over and over. You have no idea where it came from. That is how my patients describe their diagnosis of brain tumors. When first giving a diagnosis of brain tumor, they do not know whether the tumor is cancerous or noncancerous. There are many brain tumors that are not cancerous. At the moment they are given the diagnosis, all they know is we are giving the dinos diagnosis of brain tumor. That itself is a lifechanging experiment. There are thousands of americans living with brain or nervous system tumors. There are 130 different types of brain cancer. There are 124 that are malignant brain cancers. These are not only the primary brain tumors. But nowadays, as you can imagine, because we are get much better at treating cancers, we know lung cancer, Breast Cancer some of these tumors, they end up making it into the brain. The brain is like a sanctuary. It is a very privileged organ. Not only makes us different from other species, but drugs do not get so well into the brain. So we can cure cancers here, but many times, they make it into the brain. And that is obviously a devastating problem. Is why we have some new patients that and of having tumors in the brain. Cancerous tumors, not only the ones in the brain like senator kennedy. That was a tumor in the brain, but we have many others. What is the usual way you know you have a problem . This is the way. This is how their life is changed. Many times, patients present with a convulsion. They have a seizure. They have never been sick in their lives. One day they are doing something and they start having a convulsion or really bad headaches. Im not talking about small headaches that are solved with tylenol or aspirin. Im talking about headaches that keep getting worse. Im not talking about migraines. These are headaches that are getting worse and worse. And patients are taking a lot of medication. And suddenly they have a seizure or convulsion. They drop on the floor like a fish out of water. Does the best way to describe. They end up in the hospital with a scanner. Big lesion in their brain. That is how they end up, many of my patients, presenting. Lets a summary watching this has a convulsion and they want to get to you. What are the chances that they can get to you . They are very high. Anybody in the world. I have a webpage dedicated to me that people find. They find my email. My office information. There is information in my book. Anybody can send me an email from anywhere in the world. And i will make sure that either myself or one of my colleagues at hopkins will take care of it. I tell you, i can give up what i do today and go into a different job and make a lot more money. I am not cooler. Poor. In academic medicine, you do not make the sort of money you would make another jobs. I have gotten job offers. What i wanted to be part of history. I want to live the American Dream. I am thankful for what this country has done for me. Where your parents . San diego. How they living today . Much better. My brother and i helped them buy a house years back. My siblings and i. It is quite interesting you mention my parents, because my parents are beginning to realize what i do. As you can imagine, with a book coming out, even before the vote, my parents got a lot of requests for interviews, especially spanish television. They want to talk to my parents. They come from a humble background. They have one or two use of Elementary School and that was it. They are beginning to realize what my life is all about. For many years, they could not understand why, after i graduated from harvard, i was working 120 four 140 hours a week. They knew i was training to be who i am today. But obviously, they had a wonderful life. They can be very proud of not just me, but the rest of my siblings, that are working very hard to fulfill the American Dream. To dedicate a book to your deceased sister. How many other siblings are there . Were six of us total. Only five left. Where they . All over the United States. San diego and vegas area. Where did you meet your wife . I talk about that. A wonderful story. My wife, her first name is anna last name is peterson. She is absolutely brilliant. Witty. She is beautiful. When i was in Community College, learning english, read about the time i fell into the liquefied trolling tank, i was reevaluating my life. I had so much energy. I cannot relate to you. I would go for days without sleeping. Working all the time. I still had to do track and field. One day, i had an injury. I go into the zoning pool. The coach sends me into the morning. When i come out of the swimming pool, there is a young woman. I thought she was saying hello to someone else. But it was to me. I bolted the other way. I was so shy. I had seen this woman before. Two weeks prior, i was having lunch at college watching a coi pond. My english was so terrible. I bolted out of the place because i was so shy. It was the same woman. We didnt start dating until i was at uc berkeley. She saw the growth. She saw me when i had nothing. When i was going to Community College with steel toe boots, my jeans smelling like sulfur. Many of these days, i was shoveling sulfur. She has been my life partner. And gabby and elizabeth and david, how old are they . 10, 11 and a six years old. I know you have a picture. This is right around the time hopkins came out. I am proud of my children. I give full credit to anna, who has done a good job raising them with the principles of the American Dream. Had you going did you come close to getting aids . This is around the time in the Second Period of my life in uc San Francisco, training to become a brain surgeon. It was an incredible experience. Very humbling. Trying to help a patient. We are milking the knee of a patient that had a big collection of fluid. Another physician and i and our attempts to help the patient, we have a big meal needle. It was an Orthopedic Surgeon and myself. We had to do a lot of rotations before you went into becoming a brain surgeon. So we are doing this, and she has a big needle. And she loses control of this needle. We both get stuck with blood fluid. You can imagine. The same way i imagine i relate the news of brain tumors. My whole life collapsed. There was a case reported in San Francisco. The San Francisco general hospital, which had the first ward for aids patients in the United States, at that place, there was a patient that had converted from negative to positive. It was a Health Care Provider who also got stuck with a needle. I had to go into therapy. I dropped 17 pounds. I was vomiting. In some ways, several of our patients relate similar stories when they take chemotherapy to fighting cancer. That is how i had this incredible amount of respect for what they do. Because to a certain point, i did it for a month. Imagine our patients that do it for years at a time. Devastating. Like luckily, everything went well. There is a gap also, in between david and olivia. We had to protect ourselves. We do not know what was going to happen. I would go and get a result from my test. It was absolutely nerveracking. You can sense the amount of intense moments that my wife and i went through. Did you have a time where you are operating on somebody and was escorted on your blood sqwirted on that was at Johns Hopkins. I was trying to reconstruct a brain injury. I had protection. Special goggles and everything. Completely protected. Somehow, i hit a small little artery that sent blood perfectly located right above my eye right past my protection. Right into my eye. This was a young woman who had received a lot of blood transfusions. But it was so beautiful. The first thing that came out when i went to tell the family evident was fine, she wanted to make sure i was fine. That to me was so touching to know that i had her daughters light in my hands, and she was still concerned for the two of us. Evident was fine. There was a risk because of blood transfusions, but everything was fine. What is the worst thing that a family or patient does to a doctor . You know, i think it is a difficult question, obviously. I have had experiences where i think it is a relationship that you build with your patience. Expectations. Sometimes, patients come in with expectations that you are going to save their loved ones from brain cancer. And i have had a few patients like this. I think that the worst thing a family can do to a physician sometimes, that i have personally i cannot speak for other positions but for me one of the most devastating things is im the last one to give hope. But we reach a point in which we do things to patients that instead of helping them, i think are working against them. Once we reach the end of life, where we know that nothing is working and the disease continues to progress, the worst thing i have experienced from Family Members of a patient is their inability to realize that no matter what we do, things are not going to change. And they are willing to see their loved ones continue to suffer rather than deal with their own inabilities to cope with the fact that their loved ones are going to die. That breaks my heart. I meet with them and say please. This is not going to change. We need to help that patient may the transition. When in your professional training or life in Johns Hopkins have you sent to your self, i do not want to do what i see that dr. Doing . There have been a few occasions, obviously. Luckily, at places like hopkins, we are privileged to have some of the most brilliant decisions in the world physicians in the world. I would not say it happens as much as a resident. Not only in my discipline, but in other posts disciplines, doing things i considered to not be good for either the welfare of a patient, making decisions to continue treatment. Making decisions to stop treatment. Giving families false expectations. I think that is obviously something that i really deal strongly against. I tell myself, i would never do that. My goal in life is to be honest with patients. When i come out of the operating room, the first thing i do is say, this is what happened. This what we know. You know every single thing in my brain right now. You say in the book that one of the things you have changed is the patient no longer needs to have a relationship with their primary care doctor. You go around that rather than waste time explain that. One of the things i began to realize and has made my relationship with patients very strong is that sometimes, what we do as surgeons is we try to come in like the special forces. We go in and think about taking the tumor out. We tend to think that is it. When in reality, what i have been able to do with my team is take that tissue, work in the laboratory, and try to find a cure. Then i turned around and get the patients involved only in their own care, but also in being part of history. I consent with them so they can donate that tissue. That comes quickly from the institution. They feel part of history. My relationship with those patients continues to evolve beyond taking care of their tumor. I think that is a role that we can fulfill very well as Brain Surgeons. Especially the ones who specialize in brain tumors. I do not necessarily take away the role of a primary care physician, but i try to make it easier for them. Sometimes they feel frustrated because they do not have the specialty to deal with patients with brain cancer. And i do. I surround myself with people who do this all the time. Who know how to talk with patients. To deal with families that are upset, frustrated because loved ones are dying of brain cancer. I try to take the role of the primary care physician into my subspecialty. But i surround myself with a lot of people. When in your life did people start questioning whether or not you got into all these places because of affirmative action . I assume that has happened. Of course. It is never going to end. People will see this interview and wonder why it is that i am not there. Why their son is not the. He took a spot from someone else. I get this over and over. Writing this book is not going to be the exception. That is why i did not publish my stories. I needed to be ready for this. When hopkins came out, i got death threats, emails. People who hated me, people who loved me. People who missed the message. They think i have taken someone elses spot in medical school. That i have done that to someone else in the United States. They should be the brain surgeon in front of you doing this interview. That is never going to end. I think that is what makes this country most beautiful country that people can express their opinions. I do not agree with them. But i respect their opinions. As long as it does not affect my life or the life of my patients were the life of my family. I welcome it. Words come and go. But stays is ideas and what you do for people. How often his race and issue in your life . Every day. Every time i get a request for an interview, the possibility of doing something, people will say, we want to have this guy because he is famous mexican. No one else is like him. This is my agenda. I want to talk about my story. And what i do is a brain surgeon. There are things that i can do. But that plays a role every symbol day in my life, to be honest with you. I welcome it. I realized when i was in medical school that what size what i thought was a weakness, that i was a poor immigrant and now a brain surgeon, turned out to be the greatest strength of my life. The true definition of the American Dream. Take us through a day from the very beginning to the end. Take today. I got up at 5 00 a. M. To do this everyday . Everyday. I gather my thoughts and then i get up. I went for a run. I training for a Half Marathon in honor of my patients that are battling brain cancer. Im not going to lie, i am not completely imperfect shape in perfect shape. I went in, drove to my office. Made several phone calls. Came here to washington dc with you. Im going back to the operating room. Tonight, i get home around 8 00 p. M. Had dinner with my kids for 30 minutes. I receive about four or five calls throughout the night. I am always on call for my patients. Any patient that once to get a hold of me, they always have my phone. Sometimes they call the hospital because i need to get some rest at night. But i do that every single day. Seven days a week. 365 days a year. That is my level of energy. How much fatigue do you have . Im human. Of course i get tired. I tell people i get tired. Every morning when i get up, my body aches. I am sore because i have been training. But i think about the patients that are struggling everyday. As soon as i do that and get up it is like the world starts. I love to watch the sun coming out every morning. I love rainy days as well. Because it is part of life. So 10 years from now, based on what you watched happening in medicine, what do you think will be different about the art of brain surgery . I would say that, 10 years from now, we are going to see more personalized medicine. For instance, in my profession, in brain surgery, or a brain tumor, we take as much as we can, give the patient the more chemotherapy and radiation. What i envisioned 10 years from now is thanks to the workaround the world, we are going to say this tumor specifically response to this treatment. We are going to turn around and give personalized medicine to that patient. That is what i think will revolutionize our system. We cannot allow our country not to be able to do that. That is why feel so strongly that we need to support research. We still need to support those Creative Minds that are going to be able to help us live a long and healthy life. Looking back over your education, harvard, uc berkeley, what was your toughest time in your training . I would say that was undoubtedly being a resident. When i got stuck with the needle , working 120 or 140 hours, no question about it. Coming to hopkins as a young attending and having to face racism, that was a challenge. But working as a resident to train to become special forces little sleep, a lot of work, no money, no resources, not seeing my children that was undoubtedly some of the most challenging time i had to survive. The problem with hiv, the actual deal with the fact that San Francisco was a beautiful city but excruciatingly painful to live in because of how expensive it was. This is around the peak of the. Com companies in San Francisco. I talk about that in the book. Different challenges by the time i came to hawkins. Hopkins. I have incredible memories, but the ones that pay me the most are the ones that i would wake up and my kids were in my face and they were trying to play with me, and i was completely spent. You had a coauthor, ms. Reavis. How did you relate to her in this . Did she interview you . She is absolutely incredible. She has written several successful books. She was part of the team that wrote the pursuit of happyness. She has done an incredible amount of work. The moment i met her, the moment that we talked, i was with the publishers. They gather a lot of resources to be able to do this. She came in and spent time with me personally. She was with me in the hospital. In my laboratory, with my patients. She had multiple interviews with me. We worked through multiple drafts. It took about three years to complete this project. The name of the book is becoming dr. Q. My journey from migrant farm worker to brain surgeon. Alfredo quinoneshinojosa. Surgeon at john hopkins. Thank you for joining us. Thank you for having me. [captions Copyright National cable satellite corp. 2014] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] for a dvd copy of this program, call 18776727776. Programs are also available as cspan podcasts. Q and a is 10 years old. These interviews from the last decades are available on www. Cspan. Org. Among them, journalist april witt on a West Virginia man who won 1300 in the lottery and how it affected him and his community. And the president of the National Council of la crosse, jennifer ds. Search our Video Library at www. Cspan. Org. Tomorrow at 7 00 p. M. , nancy gibbs and Michael Duffy discuss the president s club. The worlds most exclusive fraternity. The history of private and public relationships dating back to herbert hoover. Tonight on cspan, we remember former members of congress who died this year. We start with howard baker, who was interviewed by Richard Norton smith. Then jim jeffers. When he changed Party Affiliations in 2001. And James Traficant addresses congress before a vote to dispel him from the body in 2002. Next from 2007 former senator howard baker talked about his career and his work in congress. Senator baker, who died this year at 88, was interviewed by historian Richard Norton smith for the dole institute. This is an hour. I would love to know the difference. My dad was in the house. I never was. The senate that you came into in 1967 how to that differ from the senate today . Honestly, i have avoided answering that question for a lot of reasons. One, because i try not to secondguess those who followed me. The other is, in all fairness, you do not know the senate there. You just do not know. You can lose it in a matter of weeks or months. The real touch, the real understanding of what the senate is like. I avoid trying to do that. I have always said it would appear from outside that things are tougher now than they were. More personal, more confrontational. But i cannot say that because im not there. Describe the senate that you walked into. The senate i walked into in 1967 was still a senate populated in large measure by the grand girls and dukes e arls and dukes. You had mansfield so many who had made a move mark for themselves in so many ways. I approached the matter as the youngest member of the senate at that time and the second most junior person in the senate. Mark at field was number 100. I was 99. The reason was mark stated that for two days to complete his term as governor. I jumped him by one day. As this day, we referred to each other as 99 and 100. I stood in awe of these people who had been there so long. Looking back on it, honestly, i must tell you that has a re tarding effect on a new center senator to jump into the mainstream. But i was pretty respectful. I remember when i made my maiden speech on the floor. Which all freshmen are destined to do. I went there excessively prepared. Carefully prepared. Not so on the floor. One democrat and my fatherinlaw, the republican leader, he was there out of curiosity. But i spoke for 40 minutes. And then i finished. And then derksen came over and said, perhaps in the future, you should guard against speaking more clearly than you think. That was my introduction to the senate. [laughter] that was the hazing of new members of the senate. Now, bob dole comes along a couple years later. Not much later, that is right. Did the younger members look out for still younger members . Not really. How were they brought into the fold . We all knew dole was. Many were surprised that he was elected. I was pleased he was elected. Got acquainted with him first off. And we established an early and pretty warm friendship in the beginning. But, no, the older members it was more like a sophomorefreshmen relationship than anything else. Sophomores are full of themselves, having gone through freshman year. Sort of the way it was. But the senate is all about standing seniority or age. Not very long before anyone is swimming in the same string. Stream. But in my time, they developed an early understanding that we were part of this group. We were part of the senate. That is something special. We do not understand what, but we know it is. That continued, i think, until i left. I am not sure it is so now. But i am not there and cannot say. You are saying there is institutional loyalty to the senate as a body . Almost. Not loyalty, as such, but a recognition. Not a family relationship. The commonality of interests and whatnot. There is little protecting your younger brother. [laughter] the Republican Caucus was different in 1967 through 1969. You had moderate liberal senators. That is right. How did that work . Very well. Can never dawned on me that it would not be that way. I was not surprised to find that their worse were significant numbers of liberal senators. An even greater number of moderate senators. And i would say that when i went there, the liberal and republican senators were probably the majority. But that gradually eroded. Began to go away in spades. By the time i left, moderate republicans were a vanishing breed. But that is not going to stay. If the twoparty system survives, as i think it will, because i see a resurgence of this complex of different points of view. And i think that is good. When dole arrived, did it rough edges . My sense is he was someone who was very much a man of his place. Of his culture. Of western kansas. Very conservative house voting record. How does that, over time, involved in the senate . You make an interesting point. Dole had a reputation. His reputation of being very tough, very republican. And i guess very conservative. Though i do not recall that was one of the hallmarks of his early career in the senate. And that began to wane. He established friendships and relationships in the senate. All those things, that previous image, began to be subsumed by his newer relationships. He fit in. He did not have trouble fitting in to the group. And he did it very easily and effectively. At some point in this interview, i want to tell you a true story about the republicans gaining control of the senate. And that was in 1980. And i was minority leader, about to be majority leader. We were full of enthusiasm. And late at night, as the results came in, i called, who is in kansas. I do not remember where in kansas. I said bob, we have the majority. You are going to be chairman of the finance committee. And he thought for a minute and said, who is going to tell russell law . I thought there were days that nobody told russell law. But that moves right into the role of chairman of the private committees of the senate. He did so effectively. That raises a question. I have heard him talk about the difference between the minority and all of a sudden, you realize that you have to govern. It is also, for someone like him , an opportunity to disprove doubters. That you are capable of doing. It is. It is really a remarkable transformation. Republicans had a big problem with that in the senate because they had not been the majority since 1954, 1956. There is not a Single Person in the Republican Caucus who has ever been a Committee Chairman at that time except strom thurmond, a democrat at the time. So it was a brandnew experience, a learning experience. High level of cooperation between members. But the sudden realization that not only we were the majority but we were responsible for the agenda, the timing, we can focus on what the country, or at least the senate would be concerned about, and just as important, what we are not going to do that is a big issue. Big deal. For while, i said the president will do that. Then, after a matter of weeks it was clear that the republican senate, majority in the senate had it not an equal role of the president , a significant role in setting the national agenda. I remember at the time we first gained the majority 1981, maybe even 1982, i think things were different. We thought of ourselves as equal partners with the white house. And we asserted those views. And we would visit with the president , leadership would, and we would invite the Vice President to policy luncheons on tuesday. Maybe it is just nostalgia and retrospection. But it seems to me there was a better understanding of the relationship between those branches at that time. That had existed for a long time, maybe ever. But it had a sobering effect on republicans in the majority. They suddenly realized this is our game. You get to run the show. We have to decide what to do. What not to do. What you said suggests that kind of relationship could only work because you had a president who would willing to buy into the. That is right. Maybe it would not have worked with anybody except reagan. What was it about reagan that made it work . I do not know. Except he never looked down on congress. He never ignored the senate. He was always willing and seemed to be anxious to hear what they had to say. It was a remarkable relationship. And the Republican Leadership dole as chairman of the finance committee, ted stevens me would meet regularly at the white house at the president s invitation. We would talk frankly about the agenda. I also seem to recall the candor between the congressional types and the white house was remarkable. I wonder if that is still so. It was certainly so with reagan. And may have been that reagans personality made that possible. Clearly not everyone agreed on the original tax cut, budget cut, package. That was reviewed by dole himself. You are a kindly person for not recovering recalling that when we went to the white house, the president outlined his plan. He was asked about it. The press said, we hear it, we understand it. But it is a riverboat gamble. I caught all sorts of hell about the. The truth of the matter is that is it it was a gamble. But it worked. Still on the list of things i should never have said. Dole agreed with you . We talked about it. Not before, but afterwards. In all fairness, i have to say a good hard about that evaluation of the message was based on what dole and i had talked about. But he was an important influential person, not only in the senate but to me. Because there is one thing you should know. I had a meeting with the committee of chairman at the leaders office. All the chairman of the standing committees. We invited one freshman to each meeting who, hopefully, just sat there. That was an extraordinarily important thing to me because it was an opportunity for a chairman to say what they have on their plate. What they wanted to do. But that is where i got insights into what was going on and what might go on. That is where i first came to have such a high regard for bob doles abilities as chairman of that committee. His analysis was good. But maybe even just as important, his presentation was lucid and prompt. It worked out well. What qualities make whole a successful chairman . I do not know. I was not a member of finance except as an ex officio member. It is undeniably so that personality has a lot to do with success or failure. Certainly for a Committee Chairman. Dole, from the very beginning, was a highly successful chairman. Not only with the administrative staff and providing for housekeeping details of the committee and also in terms of deciding the agenda of the senate. But the people respected his point of view. Not everyone agreed with his point of view, but they respected. I continue to. The 1981 tax cuts, budget cuts were, not that they were easy, but relatively easy. I imagine easier to pass then subsequent tax increases. In 1982, where you are basically trying to take the ornaments off the christmas tree. How did that happen . How to the white house feel about taking a step back . You know, by that time, a little of the luster had gone out of the Republican Leadership. They were flexing their muscles here and there. A long way of saying that there was controversy between the white house and the senate. The willingness to disagree with the president or the administration was greater. Even so, it was not a hostile relationship. And the fact that the white house and the representatives and the senate and our representatives would discuss these matters with great enthusiasm sometimes helped reduce prospect of controversy within the house and senate. One of the things were trying to get at is what it is that dole did behindthescenes that made him dole. Ive never really seen it spelled out. Beyond that, there is this whole question of what are the tools at their disposal of a majority leader to get desired results . The majority leader is not a statutory position. It is certainly not a constitutional position. It is a device created by the senate itself to create orderly and is and dispatch to the operations of the body. Im told that, early on, before majority leaders were designated, that the chairman of the finance committee or the chairman of the Appropriations Committee did that. By now, the majority leader is taking on special immunity opportunities. And responsibilities. But the power of the majority leader resides in two things. One is the tradition, the president that, in the case more than one senator seeking recognition on the floor, the chair is obligated to recognize the leader. Does not sound like much, but my friend, it is a lot. It means you get a chance to speak first. It means you have a chance, if you everything fails, to adjourn. Or try to reason with these people. As a powerful thing. The other is purely by example. I guess it goes back to the human condition that everybody has to lead. Everybody has to have a leader someplace. Even though it is not statutory or constitutional, that role falls to the majority leader. To agree, the minority leader. When i was minority leader as minority leader, there was a special opportunity to go across the aisle to mansfield or bob byrd and say, i know what you are doing. I am sympathetic. But that is not going to work. As long as you have enough to stop it, meeting at least 39 votes, or 44 votes, that you could stop it. Both leaders have an Important Role in recognizing the forms of both leaders but i was first elected majority leader, first one on the floor that day, the first thing i did was go over to bob byrd. I said bob, i will never know the rules and president of the senate the way you do. I will make you a deal. I will never surprise you if you do not surprise me. He said, let me think about it began back later this afternoon and said and we never did. I think that tradition is carried on. Dole adopted a position as well. It is a good step position, even if i did first abdicate it. The rules are set up so there is plenty of room for disagreement, plenty of room for controversy. And to do so without the framework of the organizations thinking up on your adversary. I wonder, did you learn something from watching your fatherinlaw . I am sure i did. He was a great man. He really was. And i am sure i did. But i would be hardpressed to the one thing i would say is that i have a big admiration for them. The relationship between fatherinlaw and soninlaw was potentially delicate. I have not really run the records, but i believe i may have been the only person in the senate that dirksen never asked to vote one way or the other. And i think that was in recognition and sensitivity of that relationship. But we discussed freely. I asked for his advice, which he gave freely. But you never tried to convince me. I do not think it was rebellion on my part, but an assertion of independence. It worked very well. How does this contrast with Lyndon Johnson in the 1950s . Kind of largerthanlife figure. All the things about johnson were true. It is interesting to me that dirksen and johnson were not only majority and minority leader but very close friends. And i think that facilitated the operations of congress and the senate, the fact that they could talk freely. And im sure agree and disagree freely. But what did i learn from dirksen . I will choose one thing to tell you. I remember i was grumpy about some foreign policy. I have forgotten what it was. I also remember i was traveling with who was it . A river golf abe rivikoff. We were in the middle east. Left in egypt. And we get on the plane. Approach the plane. And i made some smart remark about some item of administration policy. And we got on the plane. Rivikoff said, howard, i have discovered over the years if i have a criticism of the administration that i save until i get home, both i and the country are better off. [laughter] i always thought of that. Dirksen said the same thing. He said the president is arriving at andrews. I would like you to go with me to greet him. I said really, senator . I do not want to do that. He said, you should. And i did. He said the president is the embodiment of national sovereignty. He is returning from overseas. And we should be there to express our support. Not of his issues, necessarily or his positions, but his role as president. Or as turks would say, chief magistrate. Let me ask you. The whole relationship between dole and richard nixon, which is clearly typical, which mystified a lot of people, given the way dole was treated after that in 1972. I have often wondered, if there wasnt an element in their background that was common nixon, this scrappy kid who was not a natural, but through sheer work and effort made himself to be what he wasnt, obviously overcame economically, great odds, there was some kind of cultural identification that he had with nixon. Im sure he did. I never discussed that with dole. But i agree with every word you just said. Honestly, dole and nixon had that and other things in common. They are both and were, in nixons case, great patriots. I must tell you that i am thought of as being instrumental in the downfall of nixon does of my role on the watergate committee. But i continually had an admiration for nixon as president. In so many ways, he was a great center of the road, even moderate, president. But he made one fatal error. It is my private. Theory that he did not know about the breakin before it occurred, but he found out about it after it occurred. He was in california. His fatal error was that he he came back and instead of lining up those oaks and firing them on television, he decided to contain it. And that case, and i think in most cases, proves to be fatal. I do not know if nixon thought those thoughts or not, but i bet he did. It was a great loss. A great trauma to the country. Also a great talent in nixon but it was the right result because he made a fatal political mistake. As this unfolded, did you and your colleagues have a sense of astonishment at these revelations . Daily. Dole and i talked about. Dole is thought of as closer to nixon than i ever was. But i remember cloakroom conversations between us about that. And the amazement of the things that came out. Your both amazed . I am sure he was. I know i was. But they just called out one after the other. Did never ended. Terrible time. The tapes were you astonished when you heard tapes existed . Honestly, i think every president before him had had some sort of taping system. Kennedy did. Johnson i was not outraged at that. No. No, i wasnt. But it proved to be the ultimate downfall of richard nixon. I was interested to see now that Ronald Reagan diaries are being released, have been released but i am astonished Ronald Reagan kept that diary daily. I saw those diaries. He never let me read them except one case, but those diaries were written in longhand in leather bound books. They werent looseleaf books they were leather bound books and there were rows and rows and dozens of them. Some day, theyll all be published