>> host: well, let's get to the 30,000-foot view of health care in the united states. will you give us your view of what kind of health care the american public has right now, and then let's talk about some of the other sides of how much it cost and how many people don't get access? >> guest: in many ways we have the making cutting edge health care and we have access to unbelievable technologies and unbelievably well trained people. at the same time you can find some really abysmal health care of with lack of access and poor communities right within our own cities and neighborhoods. and that stark contrast is a major problem we are struggling with. i would say the second major problem we are struggling with is that the pieces don't for a-- fit together for any of us. the thing we are struggling with the health reform, we have focused a lot on the insurance

hassles and the insurance organization that we have missed the point that the deepest struggle is with complexity. drugs, 4000 medical and surgical procedures. try to deploy it city by city, optimally, in the right time and my place for people. -- and right place for people. host: is there a big fix that is possible? guest: coverage, providing insurance to the white population of people who are missing dead, 45 million -- wide population of people who are missing it, 45 million, we have been battling over a period is a public coverage, a private coverage? which ever way, there actually is a solution. when it comes to quality and cost, this is more a management problem. you never fix it all at once. we have had this great frustration about the health care bill -- where is the master

plan for solving costsr >> but the reality is in order to organize care more effectively doctors don't work together, we are fragmented. the system where we are paid piecemeal, fee-for-service has led to piecemeal care with over treatment in certain sectors and under treatment of problems with primary care or mental health care gaps and mistreatment and mistakes that happen all too frequently. >> you have had some time in a broad areas of agreement agreement, have you come to a conclusion whether or not what is moving along the track taking us in the right direction? >> yes.

my litmus tests are there tools hear that we were key with patients can use to make her better in the committee's. ones that will mean that 50 percent of the patients that come in the door without coverage, that is a constant it clinical battle. i am a cancer surgeon. i spent years with struggling what we will do with chemotherapy or radiation treatments for people who could not afford them. when massachusetts passed a plan it is still the issue we still have struggles but some cost aspect but that coverage part is there but the second part is we really have not as a community of clinicians worked on how do we make care more consistent, reliable and less wasteful?

for the first time i am hearing net -- people in the conventions and meetings and hospital organizations trying to figure out if the bill passes there is a lot to push us in the right direction. i am hearing discussions i have never heard before about what we should do to get the costs down. >> host: we would like you to take part in this conversation we have been talking about it a lot but if the congress comes back with the opportunity for you to become is engaged with our guest, we will take your calls you could also send us a twitter message. tell us about your views of duplications of the aging baby boomer generation on the kinds of care seeking and the ability to pay for it. >> guest: one worry is covering 45 million people

will stage where will we get the primary-care doctors? but the population over 65 will double which means the number of breast cancer, colon cancer, heart attacks will nearly double. the work force for managing those problems will not get better. we have not been thinking through how we organize ourselves to handle a larger population of people with more complex needs and not as many people in the system. we think hire more and spend more and i think there is every sign we can make for higher quality care and organize better in ways to handle that problem without expecting 50 percent of americans to become doctors. >> host: how is that implemented and come out as an idea? >> one small example, as much care talking to a

children's hospital, they finally decided to organize themselves to make sure you get the right steps and a implemented a check list. that counter intuitive idea. there was half a dozen things they major happened for each patient they tackle things to make sure calls to keep them on and and tailor's their admission rates fell almost over 80% what was the number one revenue source? asman admissions and they were losing millions of dollars. under reform uc experiments that say let's pay a package of care for those great results rather than extra money for every time you bring your kid into the hospital. as we begin doing that we're seeing hospitals talk about how to organize care so we become more e efficient and get better results for people. it will be a real turn in

how we think of ourselves as doctors and nurses working on problems. but it is the kind of experiments we have to take seriously. >> host: buffalo missouri. you are on the air. >> caller: what i want to talk to you about, and susan, as senator kobren was on your show about a month to ago and he was talking about running all of these tests that he knew were unnecessary but he had to do it for his liability is that not waste fraud and abuse? if i were to do something like that i would be in jail. i know there are other doctors that do this. i am 63.

i am in the va system and they controlled my blood pressure and everything and does not cost me one time. i could be on medicare but i chose not to progress have been within the day since i have gotten out of the service in 71. but why are all of these test being run? i know it cost money. >> host: they do. testing and that has been a regular theme of yours with the regular habit -- article how to get to the point* where doctors, all on test that they say even are gold-plated? >> yes. your caller hit the button driving the process on the malpractice system which is driven in ways, an example. headaches. one community actually tried to look at how many ct scans

in cedar rapids speed 13 for a population of 300,000, we all know this is not necessary. 10,000 were forehead ct scans only a tiny number turned up any abnormal -- abnormality some of them were ordinary headaches. some of it was fear of malpractice and more significant is that we have not established what the process is or a proper a guideline for care for handling the headache so we can do it the right way. we have tens of thousands of unnecessary ct scans that are causing more harm because we have radiation exposure and seeing increases in cancer likely to appear at over the next 10 to 15 years. this situation is not solved entirely by

weil -- malpractice reform and one frustration is not seeing that as a component of the package but it is leading communities to look up the numbers and find ways to drive down the use of this defense. and communities are doing it even without malpractice changes and can drive higher-quality lower-cost care and avoid over treatment. >> host: is it malpractice or people make money off of the test? >> guest: one of the interesting things in june last year i looked at two communities in texas where there was malpractice reform and after substantial reform there has not been a dampening down of the cost. when you compare to communities or two counties on the border with similar health populations, one at committee spends twice as much as the other. use of business incentives

and home care agencies and others that have cropped up to take advantage of the insurance system and you saw fragmented disorganized care where doctors had not organized to make sure we're taking care of the good primary-care up front to avoid over testing. and two or three times as much surgery and that population. as a surgeon we are rarely doing the surgery just to protect from malpractice instead you have a patient with a gallbladder attack. do what it? to seek more attacks are taken out at the first? the textbooks says wage but when you make no money watching and do make some money and are significant dollars by doing the operation there is the tension between the patient -- business need and patient need and it plays out differently across

united states for. >> host: good morning on the independent line. >> caller: good morning. i have a question with the efficiency and automation. is it possible, i know that there are a lot of advances with surgery and things and is it possible we can have a loss of jobs because of our medical system gets so even should like what happened in the industry of working-class people fabrics, automotive, and things like that? is that a possibility that could happen? >> guest: it is. the move toward being more e efficient, we can have lots of people who dig ditches

and hire more people to dig ditches and fill them back up of there net providing value then it doesn't help the economy. and a similar way, if we are moving more and more of the labor force into that sector that means we're not able to grow 90 other forms. so the places that we're going we are far from the world, one of the striking things in this recession coming health care is the industry has continued to grow in employment. we have expanded spending in health care over 130% of the last 10 years and a lot of it is middlemen. without this nearly getting you more time with your doctor and that is a bizarre part. that is why ended unexpectedly even for me i wrote the check list because solving these problems is about saying we will be much

more disciplined and organized how we provide care. we design a surgical checklist with bud world health organization to make sure there are 19 things we get right in every operation and i was stunned to see to that of the cases patients had one of the key life-saving steps missing we implemented in eight hospitals and saw in 8,000 patients we wrote reduced the complication rate by more than 35% and the savings of this program which redeployed in eight massie than anything we would invest in it. but we all work on these organizational problems event -- in medicine because the incentives are at their end as experts we don't think of these as problems to work on. >> host: the republican nine you are on. >> caller: i went to

chastise the callers they ask you guys how you are feeling this morning for how you're doing? you answer at once at 6:00 in the morning and you don't have to answer it again. i think it is crazy. the reason we have the best health care is because we spend so much on it and we just spend it the wrong way. what we need to do is just specialize. when i need a gallon of milk i know where to buy it at the best price and best value for my money. but when i break my leg i don't know where is the best value? we need to promote the capitalism in health care. and get it away from the insurance model. i am tired of everybody saying we need to have coverage. no. we need to be able to know where to go to buy the

quality care at the best price for our money. >> host: i will interrupt with the end of your analogy with the milk. but you do not know necessarinecessari ly have broken your they could you have fallen but you have to get a diagnosis. >> caller: exactly. we have the internet we could go from i'm actually writing a book how to fix this and i know how to fix it and it is completely different than congress but it is to unleash the specialization come as several economic principles, specialization and supply and demand and we need to make the health care professionals much greater and train them is near the free clinics where people are means tested with a

co-pay. electronic medical records for every american and several points. >> host: we will pick it up from there. >> guest: he is onto something that is right. we have a failure to be transparent about where the choices are in medicine. one of the fascinating things about the bill is the effort to create these kinds of good news. i think the real choice of competition is we want organizations willing to be accountable for the full span of health care. whether vertigo eight -- vertically integrated models of places like the mayo clinic i am part of the system trying to move in this direction of the partner health care system.

this is being able to say we will provide the full package of services even the complications in we will work to ensure higher quality and lower cost and it offers a bill or we have competing insurers and exchanges that are driving in the direction of giving people more choices but the second part is we are not as willing to be transparent with the results are work on the problems my sense is new-line the desire to sweep away the old system in drop in me new-line but the reality is we have to build from where we are today and taking steps forward including the idea is ever the driving our reform process in the direction we

have the other half are experiments in changing the way we pay for health care make it more transparent. >> host: and the latest book "the checklist manifesto" is available and is that right now. >> my website is www.it gawande.com. >> we're developing ways and deploying them to reduce complications in surgery and childbirth and beyond. >> host: the jersey shore. >> caller: hello. i am a retired nurse practitioner i was in nursing over 50 years. i just wanted to discuss two issues i think would be

helpful for standard practice for reforming the health care system. one of them is that you have a guest on some months ago either from johns hopkins or the mayo clinic. and he confessed there were no standards of practice for high-risk surgeries and hospitals. that astounded me because i feel that really is a tremendous waste regarding tours reform for about nine believe it is necessary to have standards of practice in hospitals where they perform high-risk surgery is. it is the fault of the position that they should pay out all those who suffered a of the patient who died or if they have long term and negative results.

this would reduce tort reform immensely as far as i am concerned. second me talking about primary-care physicians i know president obama is pushing for primary-care physicians to increase the health of rural areas however i go to a private care physician and the like him very much to wherever i had an experience with a drug they put me on while under kilo. that raised my blood pressure. >> host: with all apologies please get your point*. >> caller: after they found out my kidney function test was elevated the primary-care physician did not listen to me. he said no.

>> host: what is the point*? >> caller: i was sent to other positions and multiple tests were done and it was a waste of medicare and my private insurance had to pay for all of the waste. if you put primary-care physicians then you have to teach them to know what they are doing rather than rely on specialist to get the answers. >> host: sorry to interrupt we have a lot of callers. >> guest: underline what she is describing is a world we struggle with in medicine. the average physician sees 300 or 500 new diagnosis per year and prescribes 400 drugs and we cannot know it all. we are unwilling to a mid negative and we have been trained to get the idea it is all in our heads and we have not developed the systems in our place that can change that. it is why i ended up writing

on something as mundane as developing the checklist across medicine and looked at the aviation world, the skyscraper world and found the first principle of making success under conditions of complexity for the experts to admit they are fallible and they will fail and will not remember everything. then build and the standards of practice. the checks of the half a dozen things we should never forget that you ever heard do before you go out the do. it is against our experts and stinks. it is the idea i am smart enough to know what i do but as we be in testing these tools and developing them and asking people to use them, they are saving errors over and over i started using a checklist for my own operations only because i

did not want to be a hypocrite introducing at other hospitals. and then i have not gotten through one week without finding that the checks are catching problems like the sort she is describing, the complexity has gone beyond individual capabilities. we have tools that can improve quality while saving cost. >> host: the independent line in california. >> caller: what is your view on the performance of the news media covering the medical malpractice issue which contributes to the cost of health care? and as far as the necessary procedures and surgery is being done in the end unnecessary test? the press presents this is repeating statements from some of those involved which is applied to the public that these tests or surgeries are done because

of risk of medical malpractice when in fact, performing surgery is the most riskiest thing you can do. it is absurd to claim this on a regular basis and the press gets the enormous advertising with full-page ads by the hospital of course, if you are hit by a car you will go to a hospital. but $70,000 cash comes into the niece day's newspaper every time the full-page ad for laser surgery or different kinds of advertising and rapids of pumping money into the it news media to corrupt them and their bribes paid to vice presidents. >> guest: it is hard to lay the blame at the news media's fee to i did some research what the cost drivers are and how much they contributed covet is 3%

of increased cost comes from meet park is. some say see how much money is coming for malpractice and others say it is only a small part of the overall cost drivers. there are multiple drivers and the striking thing is that it has to do with ps of the fears are of malpractice but a lot about disorganization in the care and the way we pay for care on a piecemeal basis and it has to do with the sheer complexity and wanting to be sure we have access to the right technologies. here is the heartening thing i would point* out. we have one-third of our committees providing higher than average quality with lower than average cost. in moving to reduce to embrace what those practices

are is likely to be the place you get the most bang for the buck. in our economy is struggling because our wages are being diverted to the health care benefit cost. we have run into a wall is why reform keeps pushing ahead even though it is all complex and worried about where it can go because if we don't act, we will find, we already find ourselves in deep trouble. it is hard for me to blame the news media on that one. >> host: we're having a discussion about health care and the delivery mechanism in this country and how we can improve it with atul gawande. the next call is from alabama on the republican line. >> caller: good morning. i have two questions and it sounds like a very nice dr.. the first question is my

husband was rushed to the emergency room august 2009 my son had -- said he had no strength after nine and a half hours the emergency room doctor stated i believe your father has suffered a stroke but he was going to discharge him because there is nothing we can do for him. my sense that i can i get him home. he said if you want to question my diagnosis and go above me i have a four you can fill out to go above my recommendation and my son did that. they admitted might x has been 2:00 a.m. and put him on the floor and then next day my son is a drove there on the advice he had suffered a stroke and they did nothing. the nurses did not take the by tolls and we assisted him

to the bathroom and they discharge him that afternoon and three weeks later my son called me same scenario and i said call 91. they got there and my ex-husband since august 19 has been at the downtown birmingham hospital they did not do a simple chest x-ray and he had ammonia. it turned into respiratory failure and they are fighting for his life. that dr. got in our face and said you will not dispute what i as a medical doctor professional have told you. you are going against me. have come to realize they were two deaths in that hospital from ammonia and diagnosed with a simple just x-ray. he got a bill for that one day $80,000. >> guest: that storey gets up the hearts of many issues

that i think we are all struggling with. if you have a stroke you do not necessarily know if it is slurred speech removing one side of the body a family member needs to call 911 right away us stroke has to be treated within 90 minutes. 60% of strokes and the country are treated incompletely or inappropriately in the hospital. we want to say it is that hospital or that dr.. for the most part what i find unbelievably hard-working people unbelievably trained the push against the limits of the complexity of delivery. we are fooled by penicillin were rethought most medical treatment would just be giving people an ejection to make the infection go away or a stroke go away or a cardiac problem go away bid has been much more complex than that.

that pneumonia, a 40% of a motive in the hospital are treated in appropriately were in complete the. not because people are not hardworking source march but we are fragmented in our care. you experience the drops in communication between one person coming on shift in the next and where we have not moved forward is in embracing ideas that are really in some other industries as professionals we see mistakes by lawyers and in foreign intelligence failures and that, the issue is what the public feels about what the philosopher recalls the institute. the big struggles are no longer of ignorance. we have knowledge of what to do but having a hard time employing it. the solutions will come from moving ourselves from

focusing on the individual experts to think of ourselves as a team to think of discipline standard in most critic the effective kind of checks on ourselves that can aid the expert to be more effective than they were. >> host: the democrat line >> caller: i have two things to say. doctors prescribe it pharmaceutical drive is way too much. i think it should be the last option. i am wanting a public health care option. i am self-employed and have had terrible health insurance my whole life. and i am healthy which i am lucky on that. those of my two questions. >> host: let's start with prescribing too many drugs 81 yes. we have clear evidence of under treatment and areas of clear over treatment and

those that are not given four key conditions drugs likes that tends for people who have high coronary artery disease risk are not offered as consistently as we should that yet in other instances beer over prescribing drugs. how do we get on top of these problems? do we have command and control with washington panels trying to drive things? do we have let the experts locally run things exactly as they want without any sense of feedback information? the reality is we're on our way to carve a path. of course, we don't want command and control because no one who was even 100 feet away from the doctor's office can know what the best steps are. what we want our tools like

better statistics and affirmation how will we are doing with over treatment and under treatment and having that information in a timely way. we do not tell people how well is ammonia or heart attacks being treated in your county? and that information is critically needed. then is the sense of what the doctors will check for themselves. i had a patient who had depression and went to the doctor and after anti-depressant medication could not find anything to work than realize 23 years later they had forgotten to check the thyroid hormone level. it was not too many or to the bill drugs but they've been stayed basic check along the way when she got the hormone she was better

in two weeks and she lost three years. >> host: to advocate continuation of drug advertisements? >> guest: hi again conflicted with my feeling. i think they are largely unproductive spending and the reason they spend money on advertisements is because the surveys show over 80% of the time when the patient comes in with an advertisement they get that drug because you have a 50 minute visit and trying to argue takes too long. but what we need i have no idea about the legal issues if you can be an it or not but it reflects we have valued the payments of the things and drugs and tests and the operations without valuing the time that a doctor spends with people that you can talk through what is the problem and how

do we best take care of it? doctors time is cheaper than the technologies and we have a undervalue that critical component. not just doctors but nurse practitioners and physician's assistants and them people who would get the right here at the right time without waste. >> host: the independent line. good morning. >> caller: i am wondering with the high profile of drugs what type of the fact doesn't have? patients to go to doctors hopper for something they see on tv and they don't suffer from is but because they have one of the symptoms. with these other drugs were minor inflections have pretty severe side effects. is that something the fda is getting on top of?

affecting people in adverse ways could have malpractice issues. >> guest: with a practice -- patient comes in the door with a treatment or a surgery or a drug, if it is completely un indicated that is easy. do you want to that blood pressure drug when your blood pressure is normal? the hard part is when people respond to an advertisement or fear a patient has had a fever for one day and the temptation is to prescribe and either via -- and the radical in in certain circumstances they cold as much more likely and it has led to massive resistance and bacterial resistance and we want to be able to push back and say in this circumstance we should not provide the antibiotic but under the time pressures and

a production model of the medical world it is easier for physicians not to battle it or order the mri or do an operation. and understanding how we can make systems that recognize, we don't even measure how much over treatment there is or to identify the places and work as communities to be sure the mix of care is much more suited to what their problems and their needs are. >> it seems that a computer check is a no-brainer. a high tech checklist. if that is what you are promoting then how do incorporate that into major practices and hospitals and that sort of thing? >> guest: we have pockets where we have done that and we see improvements each

time but has to be conditions to were willing to embrace it. there is a huge difference between good checklist approaches and bad. if they are poorly designed come away too long, then the doctor cannot use them and it finds them unhelpful. when we put in approach for surgical care after just a two-minute check, one of the reasons, the 21 countries adopted that the u.s. only has 20% of hospitals moving partly because we work as solo agents and not used to getting together as an organization and. >> host: as opposed to a national health care system? >> guest: that is right. a country like france implemented the save surgery checklist in all operating

rooms about one year ago. everywhere are broad experts are resistant to these ideas. we don't like to have a checklist when we survey teams after the employment that checklists. at the end they did not like it at the end they still like it by 20% still hated it that said mrs. excess paperwork, a waste of time and i do not like this than we asked them, if you were having an operation would you want that checklist to be part of your care? ninety-four% said yes. >> host: florida republican mind good morning. >> caller: good morning. i have two questions. when you go to a surgery on someone, you get compensated for your cost and rightfully so. to the materials that

surround the surgery being there gaza pad or medical supplies, do they surpass even what you charge for a surgery? and the second question, the lobbyist for the congress, to what with it is the hospital administrator to buy their products at the high cost that really influence the way an insurance pays off? have a wonderful day. >> guest: under the current structure i am paid one fee the anesthesiologist is paid one fee if there other specialists they are paid and the hospital paid of the including what would incorporate the cost of the cause and everything else. interesting phenomena of the person that decides if we open the disposable equipment or use that $1,000 item is the surgeon.

i remember going into a case a couple weeks ago where we found we wasted $500 worth of stock. i tried to find out how much does that cost? it took a week then i finally found the right person second of all the second striking thing is i had not noticed it until i wrote about these issues because each of us are says separated in our responsibilities we never looked at the whole system where we said let's do the operation in the most efficient way possible with the best quality results working together as a team. we do that in this sense of being clinically smart but reorganizing yourselves yourselves, take ideas from other places and think of ourselves as that kind of organization moving in that

direction is new to us. that is something of a surprise but that is the way we have to move in the future. as the incentives of the health reform package moving through our materializing, for the first time by a see that conversation in the conference rooms and meetings where they say how could we as larger groups of people, the surgeons working with the primary physicians and others make it so we have a package of care for people that are smarter? >> some of the headlines regarding health care today you can find them on line. from the policy page pelosi sees democrats close on health care. there are two stories about the use of the excise tax which is the difference between the house and the senate eise tax cut has met

resistance in the house. in "the washington post" experts remain skeptical of taxing healthabout how the costh that those are suggesting to support it. in the "wall street journal" david russell writes about the lessons of medicare part d including markets do the work but the prices denied to the predictable and programs never crossed what they predict. and from a local perspective , the "miami herald" has a front-page story about the jackson health system halting dialysis on the poor patience. facing life or death after they stop paying for treatment for the failing kidneys because they cannot afford it anymore. >> guest: the striking thing is we're becoming

aware of these situations. it has been common. it is finally a front-page piece of news because the points at which we have been turning people away from care struggling out how to get coverage whether it is dialysis come a comfort it -- cancer coverage has been under thee. >> host: the chief executive of jackson health system which stopped treatments at 175 patients said the decision was not taken lightly they can still get treated and the emergency room. so they go to the high cost emergency room. >> guest: that happens but when you have kidney failure you can function for a while but then after a week or two, and then you become so sick you are at death's door then you could go get emergency dialysis but what

you really need is dialysis on a three times per week basis or a daily basis to survive. it is an appalling situation for a country like ours that has amazing capability and technology and care but the fundamental commitment is one where pelosi is right we are close to changing that come a we underestimate the ways that represents a significant change for the health of the country. >> host: the democrat line minneapolis. >> caller: good morning. i have a question for dr. gawande. what is your take with people living with hiv/aids? and the health care and how

they plan on cutting medicare part d? i believe hiv/aids has come a long way. since 1980 but now that they cut medicare part d1 is your take on that? >> guest: hiv/aids patients care is a microcosm. medicare part d is not being cut said two different bills add additional money for pharmaceutical drug coverage but why would they qualify if they are on disability

under 65. what is fascinating the science has reached the point* we are able to keep people remarkably healthy and turn it from a deadly acute illness from a chronic one into one that people can be healthy and live on. but because of the inability to get insurance coverage if you are self-employed or needing to get individual coverage, the pre-existing conditions make it so patients can get coverage. the only way is if they actually filed for disability and no longer work anymore because of their illness. they don't get treatment then they get ill and file for disability then we are in the roundabout where we've lost the productivity where science is able to help them. the project is with the elimination of those pre-existing condition exclusions we can have a

larger population of people that we began to move back into being productive as possible and have the advantages of science so they can help contribute to our economic recovery. >> host: just a few minutes left with dr. gawande you can find his new book "the checklist manifesto" in your local bookstore but the next question arlington heights illinois independent line. >> caller: good morning. how is health care reform going to affect the time i spend with my doctor? will they be able to check on the basic things are well with the quicker than normal? second play, correct me if i am wrong but does not practice cost to rise if the health care cost up?

>> guest: i will answer the question first. under the guise of what has happened in massachusetts will reflect around the country. two years ago it took an approach similar to the reform package for people who don't have access or for whom it is too expensive the choice of plans and go to the web and if your income is very well, it can even be free. it has capped the cost at 8 percent of income and has allowed people a choice of plans we went from 12% down at 2% without insurance. the striking thing is for most of us in the clinical world, we have not noticed a difference at all. we just a notice renouncing a patient who has insurance coverage problems like we used to happen two years.

it is an amazing thing. it can affect positions in the sense we are starting to think about how we deal with cost. that means some struggle at the local level for us to think about can i offer a package price can i joined up with my colleagues and the hospital so we may change the way we have organized our care? and it is an opportunity and also one we will find hard. malpractice reform, i have been in favor of. i am not in favor of caps but a no-fault system but as a driver of cost, it is one but it is a driver of 3% of the increase in cost from the studies that i have been a part of and others have been able to do. it falls in between. it is not a red herring to

talk about malpractice reform because it is a lover available and as long as we are fair and account for the cost of patients who we harm. but at the same time, it is far from the be all and end all and texas had a strong malpractice reform that went into place and did not help to improve the cost picture. >> host: last call. republican mine. good morning. >> caller: good morning. i have a sample -- simple question. is it necessary to retrieve all of the reform say you talk about all of the things absolutely necessary and is it necessary to create an entirely new branch of the federal government to compensate? >> i do not have the easy answer to that question.

there are a bunch of functions we have to have and although i am someone who would like to have seen a government insurance option and as a backstop around the country that plan does not have that some of the private insurance plans that are offered, even their research team to a world to make sure it is private insurance that we have to have a structure called the insurance exchanges that can make it for a panel of options available if you have no insurance are access appeals that yes there are new rules for government and rules to get rid of pre-existing conditions with enforcement of those rules and then we have a substantial number with the

health care statistics with the cost really are and not knowing county by county how we do with heart attacks and of one is and surgical complications. that has to be more readily available. although i am very much in agreement that creating more government is a place where we can find ourselves hamstrung by bureaucracy but at the same time leaving the system to itself, we're watching collapse and not only people harmed by lack of care quality of care that is leading to economic troubles. >> host: thank you for spending an hour with the c-span audience today.

>> host: and the eighth pitch has a new book out entitled they killed off the dead. what new information has you found out about the assassination of president ink pen? >> i spent nine years i have tons of new information. the biggest is lincoln was

going from the old senate chamber where he witness the inauguration of his vice president. he went to the rotunda and a man burst from the crowd and the commissioner of public buildings seized him and the man insisted on his right to be there and they said maybe he is a new congressmen that lincoln was inaugurated but six weeks later he is shot and this man i found the letter and he said that was the face of the man that i restrained. john wilkes booth. >> host: can you find that photo online? >> guest: yes. >> host: you also talk a rubbery early-- utah also talk very early coming from springfield illinois with

1861 he was smuggled into washington had and his family then he found a new sources to corroborate 272 chart drop the beginning and the middle and the execution upham of the men. can you talk about their imprisonment and the results of the verdict? >> guest: the great granddaughter of their present governor and we became friendly and she showed me the day the "journal" and the private letters written to him and by him and the torture that i write about of the conspiratorial scumble hooded, shackled and sells 3 feet wide 70 long and individual cells. and they were howled like

this before they were charged two months before the verdicts came down. very, very vivid. >> host: a lot of new information in the book. thank you very much.

>> host: welcome to booktv "after words." we're talking to peniel joseph who has a very compelling book out dark-- bright nights from black power two barack obama. we'll come. >> guest: day here. >> host: tell me what the title means. that is intriguing. >> guest: the title refers to where black people have come from in this country really from the dark days of slavery, segregation and jim crow down to the first african-american