Transcripts For CSPAN2 Book Discussion On Americas Bitter Pi

Ever and every year it gets better and better. So were very happy that we made that choice. For more information on book to tvs visit to and a halfston, texas, and the many other cities visited by our local content vehicles go to cspan2. Org local content. Now more nonfiction authors and books on booktv. Steven brill, the founder of court tv, discusses the creation passage, and effectiveness of the Affordable Care act with dr. Ezekiel emanuel. [inaudible conversations] coopener of politics and prose, along with my wife. On behalf of the entire staff thank you for coming out this evening. We at politics and prose and George Washington university the first time i made that slip georgetown but anyway we and gw have worked together a number of years to put on author events together. And id like to thank the gw staff who helped make tonights event possible. I also want to thank all of you for supporting such talks. Like many other independent book stores p p is facing a challenging marketplace but were actually doing quite well in large part due to the many avid book readers here in washington, and we remain committed to bringing great authors and great book events to the washington area. Few issues remain as critical to both our individual health and the nations wellbeing as the state of health care in this country. And yet few issues are as rife with controversy and misinformation. Were fortunate this evening to have with us an accomplished journalist and media entrepreneur steven brill, who has made it his focus over the past few years to sort fact from fiction and get at the truth behind the Affordable Care act and the American Healthcare system today. Steve, of course, has long history of taking on big subjects through journalism. Shortly after graduate from Yale Law School in the mid19 ons he launched the American Lawyer to cover the business of law firms and lawyers, and he also wrote a book on the teamsters in 1991 he founded court tv. In the wake of the 9 11 attack head wrote a sweeping account in coping with tragedy in a bike titled after. How america confronted the september 12th era. Then a piece he did for the new yorker led to a become called class warfare. Inside the fight to fix americas schools that was critical of teacher unions. Steve has continued not just to write but to create organizations that promote great journalism. He continues himself to teach at yale. And in 2009, he and other investors set up Journalism Online to develop an online pay plat form 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 for the first time in time history took if the entire feature section of the magazine. The piece won the National Magazine award for public interest. In his new book, americas bitter pill steve explores how the system evolved and what remains to be done to improve Health Coverage and especially contain costs. While the book has much to offer for those interested in how we got to where we are, its also very consumer friendly and useful to people trying to understand their own healthcare bills. Steve himself, when complete his reporting for the book, went through open heart surgery, and even he, given all his research had trouble making sense of the medical bills that he received. Now, steve will be the conversation here with eseek emanuel, who had an insider role in the battle to enact obamacare, a special adviser on Health Policy to the onb director. A cancer specialist, he ills now a vice provost at the university of pennsylvania where he heads the department of medical ethics and Health Policy. He has written its own book reinventing American Health care and he is mentioned several dozen times in steves book. Where he is portrayed as, shall we say not meek and mild about what he thinks. So ladies and gentlemen, please join me in welcoming steven brill and zeke emanuel. [applause] thank you. The introduction made it sound like i had the open heart surgery to complete my book. Ill go pretty far but not that far. You dont believe in selfexperimentation . No. So, its a great pleasure to interview you. I think we spoke once in the process of your writing the book for about an hour if i recall correctly. No, we spoke a lot more than that. Host really. Guest yes. Host alzheimers early. I want guest i can call it up on my calendar if you want. To. Host i want to ask you why you wrote the book, and in particular a lot large part of the book is about the sort of fighting over the passage of the aca, the reclaiming of the the fixing of the web site and i guess the question i have is, did all that matter . We now have the law and doesnt lots of people say dont look at the sausage of making bills. What did we really learn from the sausagemaking. Guest i think at the core we learned why the sausage is the way it is, and for a while id been looking for a book to write about what i perceived as the challenges facing our government indeed the dysfunction of washington and it just struck me that looking at how a disfunctional washington attempts to reform, quoteunquote, the most dysfunctional speak of our economy, would probably produce a pretty fun story, and it did. Host so its a fun story. What lesson guest well, my idea of fun is watching orgies of lobbying watching people like you write angry memos to their colleagues in the white house about this doesnt do enough to control costs, you people insane in the we cant be doing that. People writing angry memos back to you. The whole process is important as fun as it is, because i think at the end of the day, what this book reminds us of or tells us is that 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 come out. Thats not a terribly profound statement until you start to define who the powers that be are, and what you see is that the Healthcare Industry spends four and a half times as much as the next biggest lobby in washington, the military industrial complex, so as you and your colleagues on the Economics Team and the onb team realize, if you want to Reform Health care, you can spread coverage, thats good but you cant touch costs. You cant touch tort reform. You cant touch the kinds of things that make so it expensive. People wont allow that. Host well get back to that question in some sense, steve is that is the fact that there are so many Interest Groups that surprising . After all, health care tet we were reforming it was 18 of gdp, the biggs singling sector of the entire economy affecting everybody. Isnt everybody in there fighting and fighting isnt at that what you expect . Guest not a lot of surprising things intellectually but when you get into them as a journal journalist and tell the story in n detail involving real people you understand it really differently. Just taking the Time Magazine article, before i wrote that, it was not a revelation to anyone in this country that health care was really expensive. It was a bit of a revelation that nonprofit hospitals were charging 77 for a box of gauze pads and thats part of why it was so expensive. So by providing detail and explaining how it happened what is not surprising to people on a general intellectual level becomes important to people becomes understandable to people, and ultimately one hopes as journalist pushes them to do something about it. Host one of the things you just mentioned about hospitals some people think that you really have it out for hospitals in your book. Guest i am sitting here because of a hospital. Host nonetheless, the book seems to portray them as villainous. You call them glutenous. Guest thats the difficulty of writing about health care. One of the things i try to train my journalism students to do is understand that nothing is black and white and this subject is the ultimate example. The people who work in hospitals do gods work. They save lives. They saved my life. It is hard to see them as villains and i dont. Its not like when they wake up in the morning, theyre going to work in an office and making video porn. Theyre caring for the ill. I think, though this is something i learned when i started writing about lawyers a long time ago when youve give people, even good people doing good things unaccountable power for a long time they abuse it, and hospitals charge a what they do and make the profits they do while theyre having the annual Charity Dinner and think of themselveses a wonderful charitable institution, the charge the prices they do ultimately because they can. The sisters of Mercy Hospital chain in the midwest, higher bat arrives bill collectors and sues people into bankruptcy for 77 gauze pads, not because theyre evil people but things just sort of evolve that way and they wake up one morning, or maybe a journalist wakes them up one morning and says youre suing people into bankruptcy. That doesnt sound all that merciful. Host what was the most surprising story about the passage of the Affordable Care act that came out of your reporting . Besides my angry memos. Guest anyone knows you, knows thats not surprising. Well it was counterintuitive if you just youre from outside washington and you subscribe to the crochet this comes under the category of not everything is black and white. The staff people who i talked to, who did so much to write this law, on the republican side and on the democratic side host a republican wrote that law. I assure you. Guest a lot of people on senator grassleys death had a lot do do with the good provisions in the law and you know, including the Debt Collection provision. But lets leave that aside. You could have so many smart old on this staff in the white house and they were just so incompetent when it came to government. Revisionary when it came to policy and im not just talking about the website, which is obvious. Youre one of the people who werent early on and says he got to bring someone for the side. From outside. Yeah outside. This is the most complicated ecommerce effort ever undertaken mhs vernon to government. Its almost as if the nuts and bolts of governing or just below the paid great unit that is really surprising because i tend to be an ideally kind of snob so i think anyone who would do yell or harvard, especially hell must be really smart. These people when it came to the nuts and bolts of implementing a law were just clueless. At least for me one of the great pieces of reporting in the book is about the disastrous website and its resurrection in two months with a bunch of tech geeks, the socalled text search. What do you find surprising about that . One of the things that was really surprising about the techs urge again, the best journalism is journalism that defies cliches and defies expectations. We on the east coast this is an overgeneralization, tend to think of Silicon Valley as a bunch of all fish, clueless narcissistic people. These people who came 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 names. They didnt want any publicity. They wanted to do it. They wanted to fix it and one of them told me im an engineer. I loved fix things and in this case im fixing something really important. So that was a bit of a surprise. They really made me feel good. These are really good people. One of them has now been hired by the white house to Fix Technology programs across the federal government. I havent done any reporting but it is either working out there maybe he feels like hes a prisoner in an iranian jail. One of the other things i sort of knew that surprised me was how terrible and incompetent the Government Contracting system is. These people by and large specializing in making win contracts and specialize in explaining why it is not their fault. Did you figure out i mean, one of the things, those of us who read the book want to know is did you figure out how to solve that problem . I have to say that is a problem serving in the government for the first time i could see pretty clearly. If you look at all the facts i that the government does, it is pretty much all a disaster. What is the diagnosis and cure . I keep waiting for the Washington Post to do it. They have done versions of this which is you just have a daily half of a page about standing government contract. How much they are overdue how much they are behind casual and how much the cost overruns and you have a ranking of the top 25 year the rankings change every week. Whitey think that is inherent in the system . You know democracy tends to work us in situations furthers the crisis in everybodys watching. You know, the government contract to secure the borders for example, during the Bush Administration but cameras and random stuff like that. They gave boeing Something Like half a billion or billion dollars and they had to rip out the whole thing because every time a bird flew over the border there were bombs going off, helicopters coming in. There is a lockheed contract. I remember writing about in my 9 11 book, to build new coast guard cutters it turns out some of the stuff on the deck wasnt waterproof and lockheed said they didnt tell us it had to be waterproof. So with that got a lot of attention all the time, it might be fixed. You know this as well as anyone if its really hard to get good people to serve in the government. They had to run up on my of all kinds of Financial Disclosures and conflict checks and all of that city for not lower levels it is though really hard to attract good people because they dont get rewarded yet im not talking about money, but they dont get rewarded the way they do in the blood of our best industries, where they do a good job, they could promote over somebody else who has been there longer. Your diagnosis sounds it is very much people focused at the posthumans additional and structural focus. That came across in the book. Im not an expert on this. They have all the institutions. They have procurement regulations. Inspector general for every department. They had the institutions. They just dont have it the most senior level, including the president , a sense that this is really part of government. This is part be elected president , especially if youre democrat and you want to convince the world that theres a really good role for government. Youve got to make government work. I want to ask you about two people in particular. One of the people i think you doesnt get enough credit for getting the bill through and actually its passage is nancy pelosi. What do you think . That is absolutely right. After Martha Coakley decided to watch the senate race in massachusetts the only way the bill was going to happen is that the house agreed to go with the senate bill, which at already then passed in the first time this is mentioned, she said theres no way were doing it. My members deny will never agree to that. By the next day she said a. B. We need to do it and by the third day, i think that is fair and i know when the book that she really put that thing through in a way that was really unusual. There is one scene in the book where she calls than some number of her caucus a junior democrat from somewhere and he says well i dont know if i can do it. Thanks to nothing. Get out of here. The guy changes his mind the next day. She deserves a lot of credit. They were a lot of times that is close this for most of his closest advisers come except for Vice President. [laughter] most of his advisers said to me should give this out. Including your brother on two different occasions. He kept going and what he told me was the cab going because like all the other candidates he ran to people on the campaign trail. He didnt get to keep ones past. Plus the staff on the economic side, your side of the house was telling part of fixing the economy was fixing health care. That didnt work out because he didnt get the cost controls you wanted, but that also kept them going. So you just praised the president. What do you think his role especially on the implementation after the passage . I made that clear. He deserves as Much Negative credit to the implementation as he deserves positive credit for getting the bill passed. He just didnt manage the government. This is still getting around it. Just the thought that the president of the United States is your single most legislative initiative, you know its complicated to launch the website. Anybody could figure that out. He really never did anything other than has people showed in static screenshot and his chief of staff was so out of the loop at the night before the disastrous october 1 launches he calls around to friend saying wait until tomorrow morning. We will knock your socks off. Well, he was right. So, youre a specimen is not shared. I dont think its uncharitable. I admire her for having the accountable power. But you are not charitable in the way she used to . I also say that she kept the president going on this. She reinforced his determination to push ahead with the bill to reynoldas different junctures when it looked like it was going down the tubes. She also played a public role with the press, radio appearances, recruiting celebrities to get people to signup. It is a mixed picture of her too. Everything if you are real journalist is a mixed picture. So, i want to switch gears for a second. Youre heavily criticized malcom gladwell. One way of reading his review in the new yorker is that you are an imposter. That isnt the way i read it. I was thrilled to get five pages in the new yorker. That didnt end well. A few radek most people couldnt get to it. The fish pages work out that for me and i guarantee no one got there. [laughter] some of us thought there. What do you think his mistake is . One of the things he says we will leave that aside. Does this dichotomy as you recall with Affordable Care<\/a> act with dr. Ezekiel emanuel. [inaudible conversations] coopener of politics and prose, along with my wife. On behalf of the entire staff thank you for coming out this evening. We at politics and prose and George Washington<\/a> university the first time i made that slip georgetown but anyway we and gw have worked together a number of years to put on author events together. And id like to thank the gw staff who helped make tonights event possible. I also want to thank all of you for supporting such talks. Like many other independent book stores p p is facing a challenging marketplace but were actually doing quite well in large part due to the many avid book readers here in washington, and we remain committed to bringing great authors and great book events to the washington area. Few issues remain as critical to both our individual health and the nations wellbeing as the state of health care in this country. And yet few issues are as rife with controversy and misinformation. Were fortunate this evening to have with us an accomplished journalist and media entrepreneur steven brill, who has made it his focus over the past few years to sort fact from fiction and get at the truth behind the Affordable Care<\/a> act and the American Healthcare<\/a> system today. Steve, of course, has long history of taking on big subjects through journalism. Shortly after graduate from Yale Law School<\/a> in the mid19 ons he launched the American Lawyer<\/a> to cover the business of law firms and lawyers, and he also wrote a book on the teamsters in 1991 he founded court tv. In the wake of the 9 11 attack head wrote a sweeping account in coping with tragedy in a bike titled after. How america confronted the september 12th era. Then a piece he did for the new yorker led to a become called class warfare. Inside the fight to fix americas schools that was critical of teacher unions. Steve has continued not just to write but to create organizations that promote great journalism. He continues himself to teach at yale. And in 2009, he and other investors set up Journalism Online<\/a> to develop an online pay plat form 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<\/a>, an article for the first time in time history took if the entire feature section of the magazine. The piece won the National Magazine<\/a> award for public interest. In his new book, americas bitter pill steve explores how the system evolved and what remains to be done to improve Health Coverage<\/a> and especially contain costs. While the book has much to offer for those interested in how we got to where we are, its also very consumer friendly and useful to people trying to understand their own healthcare bills. Steve himself, when complete his reporting for the book, went through open heart surgery, and even he, given all his research had trouble making sense of the medical bills that he received. Now, steve will be the conversation here with eseek emanuel, who had an insider role in the battle to enact obamacare, a special adviser on Health Policy<\/a> to the onb director. A cancer specialist, he ills now a vice provost at the university of pennsylvania where he heads the department of medical ethics and Health Policy<\/a>. He has written its own book reinventing American Health<\/a> care and he is mentioned several dozen times in steves book. Where he is portrayed as, shall we say not meek and mild about what he thinks. So ladies and gentlemen, please join me in welcoming steven brill and zeke emanuel. [applause] thank you. The introduction made it sound like i had the open heart surgery to complete my book. Ill go pretty far but not that far. You dont believe in selfexperimentation . No. So, its a great pleasure to interview you. I think we spoke once in the process of your writing the book for about an hour if i recall correctly. No, we spoke a lot more than that. Host really. Guest yes. Host alzheimers early. I want guest i can call it up on my calendar if you want. To. Host i want to ask you why you wrote the book, and in particular a lot large part of the book is about the sort of fighting over the passage of the aca, the reclaiming of the the fixing of the web site and i guess the question i have is, did all that matter . We now have the law and doesnt lots of people say dont look at the sausage of making bills. What did we really learn from the sausagemaking. Guest i think at the core we learned why the sausage is the way it is, and for a while id been looking for a book to write about what i perceived as the challenges facing our government indeed the dysfunction of washington and it just struck me that looking at how a disfunctional washington attempts to reform, quoteunquote, the most dysfunctional speak of our economy, would probably produce a pretty fun story, and it did. Host so its a fun story. What lesson guest well, my idea of fun is watching orgies of lobbying watching people like you write angry memos to their colleagues in the white house about this doesnt do enough to control costs, you people insane in the we cant be doing that. People writing angry memos back to you. The whole process is important as fun as it is, because i think at the end of the day, what this book reminds us of or tells us is that 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 come out. Thats not a terribly profound statement until you start to define who the powers that be are, and what you see is that the Healthcare Industry<\/a> spends four and a half times as much as the next biggest lobby in washington, the military industrial complex, so as you and your colleagues on the Economics Team<\/a> and the onb team realize, if you want to Reform Health<\/a> care, you can spread coverage, thats good but you cant touch costs. You cant touch tort reform. You cant touch the kinds of things that make so it expensive. People wont allow that. Host well get back to that question in some sense, steve is that is the fact that there are so many Interest Groups<\/a> that surprising . After all, health care tet we were reforming it was 18 of gdp, the biggs singling sector of the entire economy affecting everybody. Isnt everybody in there fighting and fighting isnt at that what you expect . Guest not a lot of surprising things intellectually but when you get into them as a journal journalist and tell the story in n detail involving real people you understand it really differently. Just taking the Time Magazine<\/a> article, before i wrote that, it was not a revelation to anyone in this country that health care was really expensive. It was a bit of a revelation that nonprofit hospitals were charging 77 for a box of gauze pads and thats part of why it was so expensive. So by providing detail and explaining how it happened what is not surprising to people on a general intellectual level becomes important to people becomes understandable to people, and ultimately one hopes as journalist pushes them to do something about it. Host one of the things you just mentioned about hospitals some people think that you really have it out for hospitals in your book. Guest i am sitting here because of a hospital. Host nonetheless, the book seems to portray them as villainous. You call them glutenous. Guest thats the difficulty of writing about health care. One of the things i try to train my journalism students to do is understand that nothing is black and white and this subject is the ultimate example. The people who work in hospitals do gods work. They save lives. They saved my life. It is hard to see them as villains and i dont. Its not like when they wake up in the morning, theyre going to work in an office and making video porn. Theyre caring for the ill. I think, though this is something i learned when i started writing about lawyers a long time ago when youve give people, even good people doing good things unaccountable power for a long time they abuse it, and hospitals charge a what they do and make the profits they do while theyre having the annual Charity Dinner<\/a> and think of themselveses a wonderful charitable institution, the charge the prices they do ultimately because they can. The sisters of Mercy Hospital<\/a> chain in the midwest, higher bat arrives bill collectors and sues people into bankruptcy for 77 gauze pads, not because theyre evil people but things just sort of evolve that way and they wake up one morning, or maybe a journalist wakes them up one morning and says youre suing people into bankruptcy. That doesnt sound all that merciful. Host what was the most surprising story about the passage of the Affordable Care<\/a> act that came out of your reporting . Besides my angry memos. Guest anyone knows you, knows thats not surprising. Well it was counterintuitive if you just youre from outside washington and you subscribe to the crochet this comes under the category of not everything is black and white. The staff people who i talked to, who did so much to write this law, on the republican side and on the democratic side host a republican wrote that law. I assure you. Guest a lot of people on senator grassleys death had a lot do do with the good provisions in the law and you know, including the Debt Collection<\/a> provision. But lets leave that aside. You could have so many smart old on this staff in the white house and they were just so incompetent when it came to government. Revisionary when it came to policy and im not just talking about the website, which is obvious. Youre one of the people who werent early on and says he got to bring someone for the side. From outside. Yeah outside. This is the most complicated ecommerce effort ever undertaken mhs vernon to government. Its almost as if the nuts and bolts of governing or just below the paid great unit that is really surprising because i tend to be an ideally kind of snob so i think anyone who would do yell or harvard, especially hell must be really smart. These people when it came to the nuts and bolts of implementing a law were just clueless. At least for me one of the great pieces of reporting in the book is about the disastrous website and its resurrection in two months with a bunch of tech geeks, the socalled text search. What do you find surprising about that . One of the things that was really surprising about the techs urge again, the best journalism is journalism that defies cliches and defies expectations. We on the east coast this is an overgeneralization, tend to think of Silicon Valley<\/a> as a bunch of all fish, clueless narcissistic people. These people who came 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 names. They didnt want any publicity. They wanted to do it. They wanted to fix it and one of them told me im an engineer. I loved fix things and in this case im fixing something really important. So that was a bit of a surprise. They really made me feel good. These are really good people. One of them has now been hired by the white house to Fix Technology<\/a> programs across the federal government. I havent done any reporting but it is either working out there maybe he feels like hes a prisoner in an iranian jail. One of the other things i sort of knew that surprised me was how terrible and incompetent the Government Contracting<\/a> system is. These people by and large specializing in making win contracts and specialize in explaining why it is not their fault. Did you figure out i mean, one of the things, those of us who read the book want to know is did you figure out how to solve that problem . I have to say that is a problem serving in the government for the first time i could see pretty clearly. If you look at all the facts i that the government does, it is pretty much all a disaster. What is the diagnosis and cure . I keep waiting for the Washington Post<\/a> to do it. They have done versions of this which is you just have a daily half of a page about standing government contract. How much they are overdue how much they are behind casual and how much the cost overruns and you have a ranking of the top 25 year the rankings change every week. Whitey think that is inherent in the system . You know democracy tends to work us in situations furthers the crisis in everybodys watching. You know, the government contract to secure the borders for example, during the Bush Administration<\/a> but cameras and random stuff like that. They gave boeing Something Like<\/a> half a billion or billion dollars and they had to rip out the whole thing because every time a bird flew over the border there were bombs going off, helicopters coming in. There is a lockheed contract. I remember writing about in my 9 11 book, to build new coast guard cutters it turns out some of the stuff on the deck wasnt waterproof and lockheed said they didnt tell us it had to be waterproof. So with that got a lot of attention all the time, it might be fixed. You know this as well as anyone if its really hard to get good people to serve in the government. They had to run up on my of all kinds of Financial Disclosures<\/a> and conflict checks and all of that city for not lower levels it is though really hard to attract good people because they dont get rewarded yet im not talking about money, but they dont get rewarded the way they do in the blood of our best industries, where they do a good job, they could promote over somebody else who has been there longer. Your diagnosis sounds it is very much people focused at the posthumans additional and structural focus. That came across in the book. Im not an expert on this. They have all the institutions. They have procurement regulations. Inspector general for every department. They had the institutions. They just dont have it the most senior level, including the president , a sense that this is really part of government. This is part be elected president , especially if youre democrat and you want to convince the world that theres a really good role for government. Youve got to make government work. I want to ask you about two people in particular. One of the people i think you doesnt get enough credit for getting the bill through and actually its passage is nancy pelosi. What do you think . That is absolutely right. After Martha Coakley<\/a> decided to watch the senate race in massachusetts the only way the bill was going to happen is that the house agreed to go with the senate bill, which at already then passed in the first time this is mentioned, she said theres no way were doing it. My members deny will never agree to that. By the next day she said a. B. We need to do it and by the third day, i think that is fair and i know when the book that she really put that thing through in a way that was really unusual. There is one scene in the book where she calls than some number of her caucus a junior democrat from somewhere and he says well i dont know if i can do it. Thanks to nothing. Get out of here. The guy changes his mind the next day. She deserves a lot of credit. They were a lot of times that is close this for most of his closest advisers come except for Vice President<\/a>. [laughter] most of his advisers said to me should give this out. Including your brother on two different occasions. He kept going and what he told me was the cab going because like all the other candidates he ran to people on the campaign trail. He didnt get to keep ones past. Plus the staff on the economic side, your side of the house was telling part of fixing the economy was fixing health care. That didnt work out because he didnt get the cost controls you wanted, but that also kept them going. So you just praised the president. What do you think his role especially on the implementation after the passage . I made that clear. He deserves as Much Negative<\/a> credit to the implementation as he deserves positive credit for getting the bill passed. He just didnt manage the government. This is still getting around it. Just the thought that the president of the United States<\/a> is your single most legislative initiative, you know its complicated to launch the website. Anybody could figure that out. He really never did anything other than has people showed in static screenshot and his chief of staff was so out of the loop at the night before the disastrous october 1 launches he calls around to friend saying wait until tomorrow morning. We will knock your socks off. Well, he was right. So, youre a specimen is not shared. I dont think its uncharitable. I admire her for having the accountable power. But you are not charitable in the way she used to . I also say that she kept the president going on this. She reinforced his determination to push ahead with the bill to reynoldas different junctures when it looked like it was going down the tubes. She also played a public role with the press, radio appearances, recruiting celebrities to get people to signup. It is a mixed picture of her too. Everything if you are real journalist is a mixed picture. So, i want to switch gears for a second. Youre heavily criticized malcom gladwell. One way of reading his review in the new yorker is that you are an imposter. That isnt the way i read it. I was thrilled to get five pages in the new yorker. That didnt end well. A few radek most people couldnt get to it. The fish pages work out that for me and i guarantee no one got there. [laughter] some of us thought there. What do you think his mistake is . One of the things he says we will leave that aside. Does this dichotomy as you recall with Michael Lewis<\/a> who writes about people and he actually says that woodward and bernstein wrote the story of how the institution of the white house corrupted Richard Nixon<\/a>. I will bet you if you asked bob woodward, he would say its actually vice versa bad mix incorrupt to duchenne of the white house. Bolcoms whole dichotomy falls apart. I am still trying to figure that out. What he said about the book was i dont rely enough on the private marketplace. And then he mentions a book by some guy who is a terrific guy and wrote a thoughtful, good book in which he espouses the private marketplace and in which the lead blurb on the jacket of the book is from his friend malcolm gladwell, which i found out after i read the review was the name. I disagree with that and i think you do too. This is the substantive point that health care is a Consumer Product<\/a> in the marketplace analogous to any other Consumer Product<\/a>s. You dont wake up one morning and say i think ill wander down to the emergency room is the what they have on sale. If i dont like about go across the street. Its not like i had a smartphone youve got a verizon, Consumer Reports<\/a> and figure out the best one. You can also decide its too expensive and ill stick with this one. The fundamental thing about health care and i sort of knew this intellectually and learned it when i ended up on a gurney myself. When you are sick thousands of patients he treated, when you are sick you are not thinking about money. People are not few while how much is that blood tests going to cost. So maybe tell the audience who havent read the book, what happened to you and how does your experience of openheart surgery at columbia back your perception of the Health Care System<\/a> besides the fact eating 3 trillion is okay to spend . You do know when im actually disappointed here the way i prepared for this discussion because that was trying to think of things you want to discuss if i went to my index and looked up your name. So far so good. So the last day of enrollment in the obama carry Exchange Last<\/a> year march 31. I was having a routine checkup and my doctor took the size of my wrist for a false and for some reason, i guess you probably know, it sounds a little strange. You ought to have a sonogram. If they did to myself, im obsessed with Health Care Bills<\/a> and open testing and this is a new doc or that my wife and i have just gotten was a fabulous cardiologist who is just giving me a routine checkup. You need to get an mri. The used three times as many as any other country. This mri showed this bubble on my heart. I go back to the doctor and tested a later and he says to me and my wife he explains that this bubble and in my case it is big enough so theres a 17 chance that any given time in any year they conversed and i said well how often does it continue after that . Youd be surprised. I have this business trip to make. It was just bizarre because again, when youre writing a book thats all you think about. I end up in the hospital a couple nights earlier. I think im dreaming. How can i be in the hospital. I cant tell the difference between reality and a dream. And then i notice i think my heart is coming through my chest. Im hallucinating and the nurse tells me im okay. The 3. 58 billion a year by the hospital, with obedient to the operating surgery. Very well dressed, someone they can 3. 58 million the year with e. Hes standing there in same way, we know why you are here. You are just going undercover. [laughter] said dr. Blumenthal said i have to have the surgery. I will complain about your charge message. Let me have it. If you want to sell me six boxes 77. A rather bright out. Ill do anything you say. So the dream was mixed in with reality. What did he teach me . It taught me that if someone you know asking what i thought about the hospital bill would be like asking mrs. Lincoln. Who cares. How much was your hospital bill . 190,000. Does that include the surgeons fee quite no. This is new york. As you know theres no correlation between cost. I didnt say anything about the quality. Just the choice. Heres the really interesting thing. When hospitals give out their bills, that is where you see 7 per gauze pads. Some hospitals charge all the things. So mine was 190000 including 7371 was for patient education, which happened the afternoon of my surgery. Let me tell you the afternoon of my surgery, i wasnt being educated about anything. I was god. So i see all this. When i get the Insurance Companies<\/a> explanation, i find that the Insurance Company<\/a> or they got an 8 discount off of that. That is because hospitals today is their big hospitals in new york presbyterian is the merger of new york and columbiapresbyterian, they are basically four or five Hospital System<\/a> in new york. You cant sell insurance unless those systems are in your network and they know it. Said the idea that discount was only 8 was stunning because i was doing my Time Magazine<\/a> article. As the discount of 40 50 . Had it been something more routine, the discount kind of been deeper. The other thing about that, first hand but i knew that the system was unaccountable and crazy as after i got home, i get it 36 firstclass envelopes from United Health<\/a> care. And its 36 different explanations. The same benefit. 36 different things. One prescription drugs here. Angioplasty here. 36 different things. First of all tells you something about the efficiency of the system with 36 different envelopes that he couldnt, got her bed, put them all together. I figure this is great. I can dig into these things because im the world leading expert in hospital bills and benefits. The third one i open up my wife is sitting there with me and shes actually have real voyeur. She is generally a lot harder than i am. We are looking at this thing and it says amount owed 0. Im not paid by Insurance Company<\/a>, 0. Amount you owe 154. 20. So i look at that and im looking at the code. I cant figure it out. I give it to her. As it turned out before it went into the hospital i scheduled an interview with the ceo of United Health<\/a> care at their headquarters in minnesota. As soon as i was able to travel come a couple weeks later i interviewed him about the lobbying over the bill and over Obama Karen Howe<\/a> is going to affect the industry and thoughts on hospital consolidation, all of that good stuff. I took the explanation and i said i wonder if you can do me a favor. Which you mind explaining to me . I read it and i just couldnt understand it. He takes that and the executive Vice President<\/a> for Corporate Affairs<\/a> of United Health<\/a> care which is 100 billion company sitting there and at the moment i can see hes trying to figure out what his next job is going to be. Its a very smart guy very nice guy, very wellregarded in the industry. Looks at it looks at it. And theyve accepted and says i can figure all day and i couldnt tell you. Ive no idea why they sent it to me. I said argue they . The point is that is definitely the most common communication to consumers in the biggest industry in what is thought to be the most vibrant while working freemarket economy on the planet. Explanation of benefits. United health care sends out tens of millions a year. We think we are pretty because we dont understand it but the company doesnt understand it. How can that be . How can you have a system like that . The answer is because you can because when a system is unaccountable they can basically do what they want. He didnt do liberally make that unintelligible. Although some people think Insurance Companies<\/a> to make it unintelligible. He was actually kind of surprised. So i want to conclude with a couple of questions. The first one is your solution which i would say in the Health Policy<\/a> community has been totally ridiculed and laughed off the platform. The Health Care Policy<\/a> community has done such a good job up to now. Some of us think weve done a reasonable job. Maybe you can explain your solution and why you think its the right solution. The Health Care Policy<\/a> usual solution which would be if we could go back to 1943 and change when employers were allowed to give insurance is a singlepayer system. We cannot argue that is the right solution and say we want it, but we would like it to be christmas, two. Its not going to happen. I looked across the landscape and i said what is happening . What is happening is the large Hospital System<\/a>s are consolidating. They are buying out the hospitals. Im not as practices. By including xm labs and that seems in the reformed Community Pretty<\/a> bad or threatening ring because theres no competition. If you want to sell Health Insurance<\/a> in new haven connecticut if you dont have any senior system, youre not selling Health Insurance<\/a>. The idea obamacare would encourage six Insurance Companies<\/a> in new haven negotiating instead of two or three if they have six that they can play off against each other, its a lot easier than one or two. So i looked at data and said why dont we let them do that . These are bad people. Toby cosgrove who runs the Cleveland Clinic<\/a> is like a great, highly respected guy appeared quiet is so bad he wants to take over all the health care when you have people flying in from all over the wrote to his hospital. So my solution in addition to tort reform which you can talk about in addition to price controls on drugs were the only country that doesnt do that is to allow the Hospital System<\/a> to expand the way they want to expand. Once they do that if their monopolies or oligopolies, regulate them is lake monopolies or oligopolies. Regulate Profit Margins<\/a> regulate practices even the salaries of the ceos if you have to. The benefit of added eerie is that the Cleveland Clinic<\/a> is now dominating health care in ohio the Cleveland Clinic<\/a> and sell its own Health Insurance<\/a> because i can give Toby Cosgrove<\/a> for 8000 a year for 10,000 a year for me and my family. Keep me healthy. You have a Urgent Care Centers<\/a> clinics, hospitals, doctors practices. You keep me healthy. Ill hold you accountable. One of the regulation since you have to make sure that the hospital, which is now also between Insurance Companies<\/a> skin on care just the way we wish we had regulations that make Insurance Companies<\/a> not skimp on the care they approve. But if you did that, the hospital would have known then to two over tester overstreet because the bills for the over treating would be going to the insurance hospital. It is the ultimate on the Accountable Care<\/a> organization. Its the ultimate bundle. You say its been radical. I think whats ridiculed as if it has big monopolies, Cleveland Clinic<\/a> in ohio and new york was taken over by columbia. Not what i said. New york for example for washington they would be three or four or five and they could compete. Now when you see a billboard on the westside highway this for cisco to nyu medical center,. Billboard is meant to give them more leverage. Theyre not appealing to me directly because my employer is buying insurance. So this would make the competition cleaner. The only place youd have monopolies is where you are the kind of do have monopolies. The weather is a monopoly or oligopoly, my idea is terrible in makes no sense if the regulation doesnt come with. So far what we have today is the oligopoly fast developing. New york is fast becoming or Hospital System<\/a>s. New haven has become one. Cleveland is becoming one. We should acknowledge it and turn it to our vantage jujitsu style by saying that is what you are an outlook treated that way. Most people think what happened to break a big industry industry is the regulator becomes captured and they are just worried this cannot happen here. You know what you yourselves started about talking the facts the idea probably comes under the category of Winston Churchills<\/a> definition of a democracy is the least bad system. You cant think of a better one that is realistic and you know from your scars what is realistic. Last thing i want to talk about of the second to last thing is your claim about cost control. Gone out of. The bills failed on cost control. I said i am anothers think we didnt do enough, but the fact costs have been the gdp is a per person basis. Medicaid is going down. The fact we didnt do enough doesnt mean we didnt do a of a good job in advert money. [laughter] well, lets unpack what you said your first of all what you meant was the rate of cost increase has gone down. In medicare and medicaid on a per person basis medicare and medicaid have actually gone down. Im talking about Health Care Costs<\/a> generally. Lets get to what else he said. In the last five years, the data youre talking about the most recent is 2013 before the Health Care Exchange<\/a> even existed. Its a nice thought but nothing to do with obamacare. First of all that i totally disagree with because obamacare started march 23rd 2010. The exchanges are not the only part of obamacare. So the idea that obamacare didnt come into effect whatever you are referring is that the past way is to look their workplaces that purport to do something. There are a couple of examples of the Hospital Readmissions<\/a> penalty of medicare even though the penalty is much lower than you should be. It is meaningful because it focuses on that issue. Higher than average infection rate. I dont know if that does much for cost. Im sure it do something for care. Once you get past their coming you have a long way to go. Nothing in rush to your carefree is go to him or him him him him or her socalled compared to effectiveness handle that was put in place to these therapies and public airing of drugs and treatment and devices that compare effectiveness is so lacking that peter orszag who actually wrote that i miss the boat on cost control to wrote a really vicious editorial and bloomberg about a year ago saying exactly what i just said that the comparing of the fact is zero to put it mildly. You agree. I think you maybe even coauthored it. So i am happy to stand by that. I got a really good education reading your emails and your colleagues and else on the economics and management side of the house saying all of this and predicting that this wasnt going to do it. So if its done that there may be some very best out there. Has the rate of increase gone down some . Yes, it has. There is no evidence. You cant point to any evidence that has anything to do with the built in the core drivers of cost in this country are hospital bills, feeforservice is coming up in the controls hospital bills. There is an encouragement of bundled payment and thats had mixed results. It calls attention to it and i quote faintly for calls attention. The core, as you know, because you are the one banging the table. You and orszag and Larry Summers<\/a> and a bunch of other people went wild here i know it is hard to describe u. S. And we are losing your temper. Has never been angrier this my temper. I would say it is true from my perspective having worked on the bill we didnt do enough. But it also turns out to be true that we did enough to affect the system. We didnt anticipate we would do this much, but it has changed the system. Yesterday was in miami talking about the god who has a big complex and he said i sit on the board of one of these Accountable Care<\/a> organizations where doctors take care of everyone. That Accountable Care<\/a> organization completely changes how we do things. The patient came in before. We send them to the emergency room. Now, we actually see the patient and not admit them to the hospital. Last year he made 4 million because we save Money Exchange<\/a> telegraph is. I agree with you i thought we didnt do enough in what could have done more and i still think we could have done more. But that is different than what effect that theyll actually had anything to qaeda figure psychological effect and it is actually kept by five years now. Is that you major factor. Not questioning that last thing i want to to say is a brash to say as he is as met with some of my relatives read that they had he doesnt know what the blank is talking about good how would he know. He was very upset that he wasnt the brashest. Is really hard. I guess it depends on the day. One guy who knows all three of us started out to be inverted. So were going to have audience questions now. Thank you for being patient and listening to us. Thank you. [applause] so we have the microphone here and if you are to the microphone, not all at once. Please tell us who you are. Hi, could you mean. My name is michelle london. Ill make this very quick and sustained. Ive had in a nutshell the american system is like the master system here in washington. It is terminal. On a serious note i spent half of my adult life receiving Health Care Three<\/a> different European Countries<\/a> and in the case of the u. K. Also was employed in their child adolescent and Mental Health<\/a> system. In the patient. I want to thank the author for speaking sanity to the mat and brainwash society. Thats one of the best questions i never caught. I do. I hear what youre saying. We have serious, serious problems. Until a society overcomes its denial, overcomes disassociation with reality, that we probably one of the most baroque systems and industrialized roles in costa rica even acknowledged. I would like your comments on this is this society come if you tack about anything and every day was founded on private materials monetary attainment. Is the only society in Human History<\/a> that thinks it is all about the private and not the collective. I am working with mentally i spent two weeks trying to work with the merit how to get health care for a child who im trying to prevent causing harm to this community, but because of the bureaucracy, the government no longer has a monopoly on. I want to point out the reason. Which is you learned about the Mental Health<\/a> system and how the bill might affect Mental Health<\/a> . Not enough. You didnt learn enough or not enough of the bill . I did turn enough. I have this terrible habit if i dont know an answer, i dont try to win one. I was talking to some doctors and everything i have a patient. They see them in their office and they say needs to do a procedure, a test to do, cant do it in my office and i need to do that in the hospital. Thats the only place i can do that around here. The patient got out of the hospital less than 30 days ago said the hospital doesnt get back an answer whether or not they can schedule that. How do we fix that problem . I havent heard that particular problem. Maybe i didnt understand your question. [inaudible] they cant get the care that they need. The readmissions and correct me if im wrong, it doesnt have every remission within or he days. It penalizes them for having higher than average rates of readmissions and it doesnt penalize, correct . Correct. If it is a necessary reignition, its the unnecessary one related to the original diagnosis. You got discharged in god for they got in a car accident. So im the elephant in the room. Im an academic position based in a hospital and i resent as being lumped with hospitals. We are employees in the hospital under the guns of administration and dont feel empowered many more to change the hospital. I agree. In fact, i should have cited onstage and i say repeatedly in the book that the only people in the Health Care Industry<\/a> who are riding the gravy train by the doctors and the nurses. Its just rude. Unless some doctors were some scheme reframed patient to the clinic. Doctors are aware of the problem i see in health care. The incomes of doctors and nurses are not among them. My name is donald. Ive been trying to communicate you have not been able to do so. Ive said paperwork id like to give you. This is the way the subpoena salazar. [laughter] youve been says. Theyve got to come to where you are. I wonder if you could speak wonder if you could speak a little bit to the congressional process and looking back sort of tie that mightve been handled differently. The role of the republicans. Is there a chance for a bipartisan deal . I think the problem the republicans had with obama cared was that it was the republican plan. Obama carries a flip remark server diversion of something Richard Nixon<\/a> proposed do not ask ted kennedy. On a not grecian knight 2009, frank luntz, a pollster and republican consultant convened a dinner meeting of leading republicans in the house and senate and the subject of the dinner meeting with how do we stop the about mr. Nation and topic a with health care. The problem they had was by then the democrats were throwing in the towel on the more progressive reforms and said he know, lets do this. Just keep old and have the government pay for it if they wont do anything to cut prices. So can there be a more chamber of commerce planned more chamber of commerce plan than one that says the government is going to pay to inject millions of new customers into the private system that we had. So the Republican School<\/a> and im a reporter. That is just a fact. A hack. Looking back. Again, they have been trying to do health care is the 1940s. Originally the unions were against it because once the war labor board allowed employers to provide health care for getting wage increases which would allow during world war ii that became a key negotiating tool and a Key Recruiting<\/a> tool. They offered Health Insurance<\/a>. So that sort of cut off this huge constituency from ever worrying about health care reform. The constituency been anyone who was employed by a relatively Large Company<\/a> and their families. President johnson was uninsured people who retired, which is medicare. The democrats basically threw in the towel much to their credit this is a reform that is really an Income Redistribution<\/a> program, which i think is a good ting. I dont think thats a dirty word here for the minority of people in this country 20 30 million who dont have health care at their jobs for who warrenton medicare. It takes a lot of courage for a president to do that in this day and age and i think thats part of the political blowback. We have time for two more questions. Rate two more. By name is courtney moseley. I was wondering if you two gentlemen could entertain more than two hypotheticals as it relates will make it takes less than 30 seconds. Halfway. How would you imagine we would have a different conversation tonight if tom daschle has been nominated secretary of his and ordered ted kennedy had lived. Well, i do want to sound too commercial, but those are covered in the book at some length. It is easier for me to imagine because i read it. If daschle had been there, it is arguable and you would probably agree with me that the way the law is implemented we wouldve had someone who understood the hhs the cohasset president arguably had the president either as much, maybe as valerie garrett. I just think it would have created a real document to say what we got. If ted kennedy had lived, i dont think the result wouldve been different. Ill say this. Ted kennedy did two things that were really meaningful after he died. He did two things that are meaningful after he died. One was he got governor patcher to appoint the senate and they pass the law, which everyone was going to say that seat for the democrats, but that didnt work out. The second thing he did was he wrote president obama a matter on his bad bad and brought it to the president. As we read a lot of the joint session of Congress City<\/a> addresses after the summer of 2009. It was quite persuasive of a lot of the democrats in congress. More important, it was one of the things for president obama to keep going. Thats a lot of pressure. Im an economics student here at George Washington<\/a> university. I heard a lot about government regulation of hospitals and Insurance Companies<\/a> and i was hoping you could clarify because at the beginning of the show you were talking about your experience embedded among the lawmakers and talking about the nuts and bolts is down to a science and i presume those people would be in charge. Thats a really good question. I was referring to the abundant evisceration tiered this to be regulation at the state level of hospitals, the most Health Care Regulation<\/a> of at least the institutional part of it. But usc very good question. By doing so much confidence for these regulators to do this when government officials can even launch a website . Thats a really good point. Again i think my alternative datasets might be most likely we do nothing except keep the law we have and that the costs keep going up and the problem is is one of those slowmoving crises that we are going through here like climate change. The costs keep going up. Theres even some people who dont didnt cost a going out. Sort of like infrastructure investment. Im holding my time steve. Not much longer. I think we have seen in the last x number of years that our government doesnt do much of anything unless theres a crisis in people rise up in one way or another and power becomes more important lobbies. I will close with this. There was a bridge that came down in cincinnati last week. Everybody sort of knows we need it. Nobody would do anything about it. God for bid 15 creatures had come down on the day which given the state of our infrastructure, that wouldve been a crisis in two weeks we have an infrastructure bill. The cost of health care is that kind of crisis. Or is rooted after both keep going up in your Insurance Plan<\/a> and copays, every year the h. R. Department has been meeting that says your deductible is going up, co. Insurance is going up. Your copay on drugs is going on. Now they say its all because of obamacare. Sooner or later is going to be even with Health Insurance<\/a> and that has the government has to pay envelope the gist is intolerable. Thank you all. [applause] now on booktv, a literary galveston, texas. During our stay galveston we spoke with casey green, coeditor of the book, three night of horrors which accounts a devastating storm that hit the city hundred","publisher":{"@type":"Organization","name":"archive.org","logo":{"@type":"ImageObject","width":"800","height":"600","url":"\/\/ia800209.us.archive.org\/33\/items\/CSPAN2_20150308_204500_Book_Discussion_on_Americas_Bitter_Pill\/CSPAN2_20150308_204500_Book_Discussion_on_Americas_Bitter_Pill.thumbs\/CSPAN2_20150308_204500_Book_Discussion_on_Americas_Bitter_Pill_000001.jpg"}},"autauthor":{"@type":"Organization"},"author":{"sameAs":"archive.org","name":"archive.org"}}],"coverageEndTime":"20240621T12:35:10+00:00"}