[inaudible conversations] i and coowner of politics and prose. On behalf thank you for coming out this evening. We at politics and prose and georgetown, George WashingtonUniversity First time i made that slip but anyway, we have worked together a number of years to put those events together and i thank the staff that helped make tonights event possible. I want to thank all of you for supporting such talks. Like many other independent bookstores, facing a challenging marketplace but we are actually doing quite well in large part due to the many Jerry Bledsoe and book readers in washington and you remain committed to bringing the great author, grade book events to the washington area. A few issues remain critical to both our individual health and the nations wellbeing in this country yet few issues are as rife with controversy and misinformation. We are fortunate this evening to have with us and accomplished journalist and media entrepreneur, steven brill, who has made his focus over the last few years to sort fact from fiction and get the truth behind the Affordable Care act and the American Health care system today. Steve has a long history of taking on big subjects through journalism. Shortly after graduating from Yale Law School in the 70s the American Lawyer to cover the business of law firms and lawyers and also wrote a book on the teamsters. In 1991 he founded courttv. In the wake of the 9 11 attack he wont a sweeping account of coping with the tragedy in a book titled caster how america confronted the september twelfth 0. A piece he did for the new yorker and lead to a book on Public Education called class warfare, inside the fight to fix americas pools, steve is continued not just to write but to create organizations that promote great journalism. But decade ago he donated 1 million to establish a Journalism Initiative to teach and provide Career Guidance to students interested in journalism and he continues himself to teach at yale and in 2009 he and other investors set of journalism on line to develop online a platform for newspapers and magazines. His latest book grew out of a revealing 24,000 word article on the exorbitant cost of medical care that he did for Time Magazine. An article that for the first time in times history took up the entire feature section of the magazine. The ps won the National Magazine award for public interest. In his new book America Jerry neal 18, he explored how the Health System involved. And how it shaped the Affordable Care act and what remains to improve Health Coverage and especially contain costs. The book has much to offer for those interested in how we got to where we are it is very consumer friendly and useful to people trying to understand their own Health Care Bills. Steve himself when reporting completing the book went through open heart surgery. Bent even he given all his research, had trouble making sense of the medical bills that he received. Now steve will be in conversation with c emanual who had insider role in the battle to enact obamacare, special revise their on Health Policy to the o and b director but the cancer specialist, zeke is now vice provost at the university of pennsylvania where he heads medical ethics and Health Policy. He has written his own book about the Health Care System titled reinventing American Healthcare, and is mentioned several dozen times in steves book where he is portrayed as shallow and we say not meek and mild about what he thinks. Ladies and gentlemen please join me in welcoming steven brill and z. Emanual [applause] thank you. One note. The introduction made it sound like i had the open heart surgery to complete my book. I wont go that far. You dont believe in self experimentation . No. It is a pleasure to interview you. You spoke once in the process of your writing of the book for about an hour i recall. Alzheimers early. I want to ask you why you wrote the book and in particular a large part of the book is about those sorts of fighting over the passage of the a c a, reclaiming, the fixing of the web site, and the question i get is did all that matter . Lots of peoples they you shouldnt book the sausage of making kills someone the we learn from that sausagemaking . At the core we learn why the sausage is the way it is. For a while i have been looking for a book to write about what i perceive is the challenges facing our governments, the dysfunction of washington and it struck me that looking at how a dysfunctional washington attempts to reform, quote the most dysfunctional aspects of the economy would probably produce a fun story. A fun story. What lessons fun is watching people like you write a angry memos to their colleagues, this doesnt do enough to control costs saying we cant be doing that, people writing angry memos back to you. The whole process is important because at the end of the day what this book reminds us or tells us is in this day and age what comes out of washington, for any major law to come out of washington, it comes out because the powers that be in washington let it. That is not a profound statement until you start to define who the powers that be are. What you see is the Health Care Industry spends four times as much as the next biggest lobby in washington, the militaryindustrial complex. As you and your colleagues on the Economics Team and the omb team realize if you want to Reform Health care you can spread coverage. That is good but you cant touch costs, you cant touch toward reform. You cant touch the things that make it so expensive. We will get back to that. The fact that there are so many Interest Groups that surprising . Healthcare when we were reforming it was almost 18 of gdp, the biggest single sector of the entire economy affecting everybody. Isnt everybody in there fighting . There are a lot of things that arent surprising intellectually but when you get into them as a journalist and tell their story in detail involving real people, you understand it really differently. The Time Magazine article, before i wrote that it was not revelation to anyone in this country that health care was really expensive. Was a bit of a revelation that nonprofit hospitals were charging 77 for a box of dr. Oz hills and that is why was so expensive. By providing detailed and explaining how it happened, what is not surprising to people on a general intellectual level becomes important understandable to people and ultimately it gets them to do something about it. One of the things you just mentioned, some people think you have an out for hospitals in your book. I am sitting here because about hospital. The book seems to portray them as villainous. That is the difficulty in writing about health care. One thing i try to train my journalism students to do, nothing is black and white. This object is the ultimate example. If the people who work in hospitals to poor whites of the antebellum south do gods work. It is hard to see them as villains and i dont. It is not like when they wake up in the morning theyre going to work in an office and making video porn. They are caring for the ill. But i think, this is something i learned when i started writing about lawyers along time ago, when you give people even good people doing good things unaccountable power for a long time they abuse it and hospitals charge what they do and make the profits that they do while they are having the annual Charity Dinner and think of themselves as wonderful charitable institutions, charge the prices they do ultimately because they can. The sisters of mercy in the midwest, hires batteries and bill collectors and they sue people into bankruptcy for 77 pitts not because they are evil people but it just seems to have evolved that way. They wake up one morning, or a journalist weeks, up one morning, you are suing people into bankruptcy. That doesnt sound all that merciful. What was the most surprising story about the passage of lower Affordable Care act that came out of your reporting besides my angry memos . It is a counterintuitive thing if you just sort of you are from outside washington, subscribe to the cliche and to the category of not everything is black and white staff people from i talked to who did so much to write this law. On the republican side and democratic side. I assure you. Had a lot to do with the provisions and you wrote it including the Debt Collection traditions. My point, the revolving door image of washington with staffers working on the hill and they go lobby and go back to the hill and lobbying is an evil thing and they are evil if they do that. The people who work day and night on this bill and the white house including you, they cared about it and honest and did the work. It is the best they could do under the constraints of the system. And they are so incompetent when it came to governing. And not just talking about a website. And the people who warned them early on, you got to bring someone from the inside. This is the most complicated ecommerce effort ever undertaken and it is almost as if the nuts and bolts of governing were below the petter grade and that is really surprising. I cant to be an ivy league kind of person. It must be really small and these people went it came to nuts and bolts of implementing a law were just clueless. The best kind of journalism is one that defies expectations. So we on the east coast tend to think of silicone valley as a bunch of selfish, clueless people. These people who came in and rescued the website, first of all they volunteered to do it for free. The hardest reporting i had to do was for them to allow me to use their name. They didnt want publixcity. They wanted to do it fix and one said i am an engineering and love to fix thing and i am fixing something that is really important. So that was a bit of a surprise. It made me feel good. These were really good people. One of them has been hired as you know by the whitehouse to Fix Technology programs across the federal government. I have not done any reporting on this but maybe he feels like he is a prisoner in an iranian jail. I sort of also knew but it was surprising was how terrible the Government Contracting system is in. They promise to win contracts and specialize in explaining why it wasnt their fault. Did you figure out i mean i think one of the things those of us who read the book want to know is did you figure out how to solve that problem . That is a problem i could see clearly serving in the government if you look at the tech stuff and sites they do it is all a disaster. Diagnose and cure here. I have this dream article i want to write one day and i keep waiting for the Washington Post to do this is a daily report of outstanding government contracts, how much they are overdue, and behind schedule. With a top a ranking system. Why do you think that is inherent in the system . Because democracies tend to work best in situations where there is a crisis is everybody is watching. The government contract to secure the border during the Bush Administration with cameras and other things they gave bowing half a billion and they had to rip it off because every time a bird went over the border an alarm was going off. Arent they Illegal Immigrants . The lockede contract to built cutters and some of the stuff on the deck wasnt waterproof and they said they didnt tell us to be waterproof. If that got attention all of the time it might be fixed. And the other problem is and you know this it is really hard to get good people to serve in the government. In appointed positions they have to have Financial Disclosures and even at lower levels it is hard to attract good people because they dont get rewarded and i am not talking about mun eoney but not like they do in the best industries where if they do a good job they get promoted over somebody else who has been there longer. You sound people focused instead of institution focused. My sense on the government is they have too many institutions. There is an Inspector General for every department. They have the institutions. They just dont have it at the senior level including the president a sense that this is really part of government. This is part of the execution part. This is part of being elected president , especially if you are a democrat and you want to convince the world there is a role for government then you have to make government work. I want to ask you about two people in particular. One of the people who i think doesnt get enough credit for getting the bill through and passed is nancy pelosi. Watt do you think . That is right. The only way the bill was going to happen as you know and i recount in the book is if the house agreed to go with the senate bill that was passed. The first time this was mentioned she said my members will never agree with this and by the next day she said maybe and by the third day she was ad adamant and whipped it through in a way that is unusual. There is one theme in the book where she calls a member of her caucus i am a junior democrat from somewhere and he said i dont know if i can do it and she looked at him and said thanks for nothing. I got you here. Get out of here. And the guy changed his mind the next day. I think you are right. She deserves a lot of credit. And the president deserves a lot of credit. There were a lot of time most of his closest advisors except for vicepresident jarred, said to him you should give this up including your brother on two different occasions and he kept going and what he told me was he kept going because like all of the other candidates he was running to people on the campaign trail that had horrible stories of woe even if they had insurance. And it moved him. And plus the staff on the economic side your side of the house, was telling him part of the fixing the economy was fixing health care. That didnt work out because you didnt get the cost control you wanted. So you just praised the president. What do you think his role especially on the implementation after the passage . I have to make it clear i think he deserves as Much Negative criticism for the roll out. He just didnt manage the government. Just the thought that you can be president of the United States this is your single most important legislative initiative and you know it is complicated to launch the website, and he really never did anything other than have people show him screen shots and his chief of staff was so out of the loop that the night before the disaster of the october 1 launch he calls to friends saying wait until tomorrow morning we will knock your socks off. He was right but didnt want to be right. Your assessment of valerie jarred isnt charitable. I dont think it is uncharitable. I admire her for her up accounted power. She bucked up the president and reinforced his determination to push ahead with the bill during all of the those different junctures and she played a public role and recruited famous people to sign hem up. It is a mixed picture with her. So i want to switch gears for a second. You were heavily criticized by malcolm graph and one way of reading his report was you are an impostor. That is not how i read it. If you read it he is not the best writer in the world so most people couldnt get to the fifth page. I guarantee you none of us got there. Some of us got there. What do you think his mistake is . One of the things he says he is not an expert in this area . That is for sure but leaving that aside, he does this dichotomy if you remember between michael and bob and he says this. He says if woodward and burn stein wrote the story of how the institution of the whitehouse corrupted Richard Nixon. And i would bet you if you asked bob he would say it is vice versa that nixon corrupted the whitehouse. His whole model falls apart there. And by the way what that has to do with my book i am trying to figure that out. He said i dont rely enough on the private marketplace. And then mentions a book by a guy gold hill who is a terrific guy and wrote a book where he praises the marketplace and the lead blurb on the jacket of the book is from malcolm when i found out after i read the review because it wasnt in the review. I just disagree with that. And i think you do too. And this is the substance and the point i disagree that Hilary ClintonClinton Health care is a Consumer Product equivalent to other products. You dont wake up and say you will wander down to the emergency room and if you dont like it you will check out another one. It is isnt like buying a cellphone and going to apple or verizon. You cannot decide either to stick with what you have and not buy a cellphone. But the fundamental thing with health care is i learned this on a gurney myself and when you are sick, and you know this with the thousands of patients you have treated, when you are sick you are not thinking about money. People dont ask how much is that blood test going to cost. What happened to you, maybe you can tell the audience how did your experience of open heart surgery at columbia affect your perception of the Health Care System becausesides the fact you think three trillion is okay to spend. I dont think three trillion is okay to spend. I am just pulling your chain. I am disappointed because the way i prepared for this discussion and going to my index and looking up your name. So far so good. So lets go to this. The last day of enrollment in the exchanges, march 31 i was having a routine checkup. And my doctor took this side of my wri