Those go hi good to see you again. Tell us why he wrote this book. Guest as they say in the acknowledgments a reporter from the New York Times called me up when she was switched over from Foreign Affairs to Public Health and i talked to her about the American Health care system and explained to her the American Health care system and she wanted to know if we could meet for tea. I thought thats a bit ridiculous. You cant explain the Health Care System and an hour. When it be nice if there were 250 page book i could give to someone and that would explain the system. When a lookout there there is no such book and i always figure if youre a tenured or Faster Health policy person its beneath you to write a book explaining the system and if you arent untenured trying to get tenure you figure if you read this book you will never get tenure because the tenured peeper people will. Once i got into writing the book i began to think it sets the platform for whats going to happen. Why dont i start making predictions about the future from what i now and all the people i have talked to and i had been trained well enough because one of my colleagues has done a lot of research about forecasting and making predictions and warned that it was a bad idea because mostly experts dont do so well. Nonetheless we all have to make predictions whether we are running hospitals for our investors. I did my best on the predictions. Host a lot of people know you as one of the architects of the aca the Affordable Care act otherwise known as obamacare is but before we talk about that how did you meet and get to become an architect . What was your path and let star with medical school. Guest is pretty circuitous. I was in medical school and not very happy about what i saw around medical school that we were failing in one of the most frustrating aspects of it is when i was working in the emergency room as a student and seeing we took care of the patient who had say Heart Failure or difficulty breathing, admitted to the hospital and he worked hard to make sure that patient was dried out and the excess fluid was taken down and everything ws tuned perfectly discharge the patient home and inevitably he or she came back six, seven, 10 days later and we had to do it over again and we were not following i remember a patient that was in the hospital for six weeks with end up bacterial end up card itis. It was extremely frustrating. I did a ph. D. In political theory at harvard thinking that i would some of this was the value of the Health Care System so i worked on endoflife care and the physician patient relationship and i came to the nih annual worked on Research Ethics and the end i was seeing the end after seven years seeing the end of that i decided i should turn my attention to resource allocation and the Health Care System. I had the good fortune of teaming up with a Prominent Health economist from stanford. When everyone at Health Policy was depressed about there would be no conference of reform we were thinking what would a conference of form we would want to have and we developed a voucherbased system. That got me into thinking more about Health Policy. Then when president obama one the appointed peter orszag as the office of management and budget i knew peter from a lot of conferences and meetings and i emailed him and i said peter do you need a doctor to work on healthcarhealthcar e reform . We talk that afternoon and worked out an arrangement where i would work at omb assisting. Host as far as the problems with the aca which you devote perhaps the first half of the book to that you set out to fix collectively can you outline those . Guest the American Healthcarhealthcar e system as they say in the subtitle is terribly complex. Host lets read this. How the Affordable Care act will improve our terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system. Guest right, so i think the Health Care System in 2008 in 2009 before we reformed it were all those things incredibly complex trying to explain to people just how its paid for through insurance and medicare and medicaid and it takes about 40 pages. I dont even go into all the details. Then you explain how doctors are paid and how are hospitals are paid and what the incentive structure is what the regulation for drugs is, for devices. All of that is incredibly complex and we were doing well. I any metric, 50 p. 50 Million People were uninsured. Some of our greatest Academics Centers are fantastic but pretty uneven. We have millions of people with high Blood Pressure not hard to diagnose and not hard to treat. We know that increases your risk of stroke and Heart Disease and shortens life. That is full in the system. Before we pass the Affordable Care act one and people 20 people got a hospitalacquired infection 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. I think you know anyone of them them would be good enough and i dont think there was a republican or democrat in the world in 2008 or nine who understood the system who would say oh no its great. Really by 2008, 2009 almost everyone agreed we had a system that was broken and needed repair. The question was is what kind of repair . Host you explain that very clearly. The Health Care System is a daunting enterprise and incredibly unclear and whats also interesting in the beginning of history and i guess you could go way back lets start with nixon and work our way up to clinton. Guest well one of the surprises i decided lets give people a feel for how long we have been trying to change the system. It does go back to 1912 but one of the surprises to me is to uncover how engage republicans werent Health Care Reform in 1945 at the governor of california at that time earl warren a republican pretty conservative proposed conference of Health Care Reform for california and came within one vote of getting it passed in california. And he had gotten sick and said we really need to protect people from a cost of getting sick. When nixon got elected in 1946 the congress one of his first legislative ills he introduced was it till about conference of Health Care Reform and heres the crazy thing. If i describe it to you you will say was he one of the architect . He wanted to give people subsidies based upon their income so they could go and buy private insurance to cover themselves. The government would provide those subsidies. Sounds a lot like obamacare to me. He proposed that in the late 1940s and then when he was running for president in 1960 against john kennedy there was a big debate both republicans and democrats trying to figure out how to get the people left out of the employerbased insurance, poor people especially the elderly, how to get them insurance. He reintroduces idea of subsidies where people could buy private insurance and then when he gets to be president in 1973 and 74 he he negotiates with ted kennedy and the senate and wilbur mills in the house about how to come together on a comprehensive Health Care Reform bill and they were this close to a bill that they could agree to and then a typical washington, as typical washington scandals broke out. Wilbur mills with a fanny fox scandal where an exotic dancer falls into the tidal basin is or stop the chairmanship of the ways means committee. Watergate overtakes nixon and it all goes poof. We also need to say that liberals and unions at that time did not want to have a deal that would have private insurance continue. They wanted singlepayers and they were resistant to making a deal with nixon and they withheld their support. So you have accommodation of scandals which mainly put the kabash on this bipartisan agreement with the unions and liberals opposing it. For 20 years after that until bill clinton we didnt have another reform and clinton comes in and wants a marketbased reform, proposes his Health Security act and unfortunately there are lots of other things. Overtook single focus on it. He had to pass a tax increase. They have been off the bill. By the time all the rest of the stage was clear for health care opposition had gained and had defeated the bill. He didnt get one bill passed out of committee. Health care reform is dead for 15 more years until 2008 and the system become so onerous we needed reform and thats why i called the passage of the Affordable Care act and this will be the framework for the next 20, the 30, 40, 50 years. Host well i think it might be fair to say that the most interesting part of the book of course is the fact that you were there at the revolution. In addition to the runup when you do devote a good portion of the book to that its very Good Foundation again and when i showed this to people they go where is that part . The chapter is eight through the rest of it that when you talk about your own observations and insights as someone who really was there and you he specifically talked about in the quoting here the complex interplay between policy and politics and Interest Groups and if you would elaborate on that and maybe focus on lets start with malpractice. That was one of the more easy ones to understand. Guest yeah and it does illustrate that is not nearly as simple as people lay it out to be. Going into reform i would have thought getting malpractice reform there was a reasonable chance of it. First of all we should also be modest in the expectatiexpectati on so malpractice is something regulated at the state level and not regulated at the federal level sub putting malpractice reform in a federal piece of legislation is not going to solve the problem. You cant force states in the federal government to do malpractice in this way so we provide incentives but we had a very good combination of arrangements that made it look likely. The president himself was more about practice reform. He had articles in the new england earl of medicine coauthored with Hillary Clinton before he advocated for malpractice reform. He thought this was an important issue. There were two doctors in the white house myself and bob cochair. Both of us thought malpractice reform is a good thing to do. There were other senior advisers Larry Summers and peter orszag who thought malpractice could encourage quality care and could encourage doctors to focus on quality. We had a good arrangement. We studied a number of options and as i tell it in the look we had laid out nine different options the pros and cons a detailed memo. One day in the summer of 2009 is we are putting various things together i go to my brothers office which i tended to do towards the end of the day and ron wants a piece of information about analysis of Insurance Options and i was reporting back to him and in his usual way he says so what else are you suing suing doing seek . He basically said they asked word showed up. We are not doing that and he explained to me why we are not doing it. When the ama whatever they say in public they come in to my office and were talking about what they need out of this bill and we are cutting the sausage of legislation. They never talk about malpractice. All they ever talk about is basically held medicare pays doctors and they want that fixed so doctors can get more money. They never mention malpractice. Im not doing malpractice because malpractice will require we have to effect often the democratic base. By the way no republicans are coming to negotiate. If they came as a part of the negotiation for our our support with the malpractice we would have done it but that wasnt the case. Here you had 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 the republicans werent interested. People say a oh no but thats the way it wound up. If either the doctors had said all right we understand about payment but heres malpractice and we have to have something on malpractice or we will negotiate with here and here are the things we needed to build it would have happened. Thats not the way it a lot up and nonetheless the president had two elements of malpractice one in midseptember speech to the joint session of congress where he said look we have a private program and we are going to make grants available to improve Patient Safety through malpractice reform and made grants available of more than 100 million in the Affordable Care act could take the provision of 10607 if i remember correctly that says we will give grants to states to reform them are pat theyre malpractice law and study to see how it affects cost of malpractice insurance. President obama marketed the malpractice reform and did two pieces of pilot programs on malpractice reform more than anyone else. You cant say he was not committed to it. I am disappointed but the main Interest Groups and politicians who needed to support support it werent there in the cause. Host as a clinician of malpractice interests me a lot and to pursue it a little bit more you had a very interestiinteresti ng fact here supported by several studies which i admit i didnt know which is most people who really are big air adults do and the vast majority of malpractice lawsuits are frivolous so your preferred approach as i recall was a safe harbor kind of strategy. Say a little bit about that. Guest again one of the things i point out in the book when i catalogued the problem with Health Care System is no one should be happy with the malpractice system whether you are doctor a patient the hospital or a lawyer. Its broken. It doesnt do anything is supposed to do to incentivize doctors compensate patients who are afflicted and to make sure its done efficientefficiently without overhead costs. It doesnt do any of that. There is not a single metric that would measure it where it succeeds. Patients as well as doctors should want reforms. Some people lets m. We save and put a short statute of limitations on it so people cant sue. I dont like those. In some ways they harmed the victim of malpractice. Our fewest lets use malpractice as an incentive to improve the quality of care and make doctors adhere to guidelines we agree on so we basically tried to think of the program that would do that it may call this safe harbor. If doctors adhere to guidelines for the treatment of the patient they are resumed, is a presumption which could be rebutted their presumed to be innocent. This way doctors say the patient comes in with simple head trauma and the guideline says dont do a ct scan but to protect my bottom i do a ct scan. In the safe harbors is no if you follow the guideline you would via the safe harbor and you would be presumed to be innocent. That seems to be the way to go. It incentivizes using the electronic record and thats exactly what we want doctors to do. We prefer that. Are there other alternatives . Yes. The university of michigan has pioneered the say you are sorry which easily identifies a problem it is up to the patient propose to them a simple solution according to a set schedule. If you have a medication error here is what we are going to do and that is substantially reduce the number of lawsuits in reduced payments. It has reduced the time to resolve it so that looks promising but again we dont have enough research. Host thanks. Lets move on to the actual aca here. As january 1 rolled around and things went into effect and some stuff went right in some stuff went wrong. Talk a little bit about what went right and then we will talk about what went wrong and how it was fixed. Guest first of all the Affordable Care act is very unfair to say it just came on line. The fact is right after passage in march of 2010 lots of things came on line. Many people should remember although they might have already forgotten the idea that young adults up to age 26 can stay on their parents plan. That came on line by September September 2010 and Many Insurance Companies made it effective before within six months of passage. Similarly there has been a revision to encourage hospitals to reduce their readmission rate patients on medicare who are discharged from the hospital theres a 20 chance they will be returned to the hospital within 30 days. We created a program to incentivize hospitals to worry about what happens patients when they leave the hospital. That went into effect within a few months. The patientcentered Outcome Research institute went into effect quickly after the bill. We didnt wait until october 1 of 2013 to open exchanges for the Affordable Care act to be implemented. A lot of those provisions went into effect in some of them are very successful. Some of them we were disappointed and to be perfectly plumb. It has been quite timid and we have been trying to push that to undertake more comparative studies. Host is that in the hhs . Guest no, its an independent private notforprofit funded by an assessment on all insured people the board is dominated by the gao the Government Accountability office so its independent and not part of the government. Host