line will take this part you take that and we will live happily ever after. ..

>> host: good to see you again. >> guest: nice to be here. >> host: tell us what you wrote to the book. >> as i say given the depth knowledge of it as a reporter from "the new york times" switched over from foreign affairs to public health and said i talk to her about the american health care system that is the bit ridiculous. and wouldn't it be nice if

there was the 250 page book to give to someone to explain the system? there is no such book and i figure is as a tenured a professor it is believed you to write the book that explains the system and if you try to get tenure you figure if you write e will never get a. so i wanted to fill the void and once i got into writing the book i said it sets the platform for what will happen why don't i start making predictions about the future from what i know and the people i have talked to and i have been trained well enough. he has done a lot of research to make predictions because moseley experts don't do so well but we all have to make predictions so i did my best.

>> peopled know you as one of the architects of obamacare but before we talk about that how did you become the architect? what was your path? start with medical school. >> it was pretty circuitous. i was a medical school not very happy that we were failing and one of the most frustrating aspects is when i would work in the emergency room as a student we would take care of a patient who had heart failure admitted to the hospital we worked hard to make sure that patient was dried out with excess fluid fluid, right medication but then you send the patient told and inevitably they become back 61 dash 610 days later we were not following

up and i remember one patient was in the hospital six weeks with bacteria but literally two weeks later with the same problem and it was extremely frustrating. i went to duke of a phd in political theory at harvard thinking that some of this was the value of the health care system so i worked on the end of life care, a position patient relationship then i came to the nih with research ethics and because i would see the end of that after seven years i sheltered by a detention to resource allocation i had the good luck to hook up with an economist from stanford when everyone was depressed there will be no reform we were thinking what would comprehensive reform we would have?

we developed a voucher based system and that got me thinking into health policy then win president obama won a and appointed peter or sag at omb i knew him from a lot of conferences and meetings i e-mail them and said you need help and he sublets talk and rework dowdy a range and i would work at omb assisting. >> host: aside from the problems of that a cia that you set out to fix collectively can you outline those? >> the american health care system is incredibly complex as the subtitle says. >> host: let's read it. how the affordable care act will improve our terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system" .

>> guest: right. the health care system before we before.was incredibly complex still trying to explain to people how it is paid for through insurance through medicare and medicaid it takes 40 pages and i don't go into all the details. then explained how doctors are paid, hospitals are paid, and sentence structure, regulation it is incredibly complex. we were not doing that by any metric. 50 million uninsured, some great academic centers are fantastic outstanding quality but not even in millions who have high blood pressure not hard to diagnose or treat either not diagnosed or inadequately treated and we know with a stroke or heart disease one before we pass the affordable care act week at

the hospital acquired infection. the and the cost with the economy to make the state's trade-off between medicaid and education making individuals get health insurance lots of reasons to change the system and i explain all of those anyone would be a good enough justification but i don't think there was a republican or a democrat who really understood the system who would say it is great. by 2008 almost everyone agreed we had a system that was broken and needed repair but the question is what kind of repair? >> host: you explain that very clearly. the health care system is a daunting enterprise and what

is interesting is the history but start with nixon working our way up to clinton. [laughter] >> guest: one of the surprises i decided let's give people a feel how long we try to change the system but one surprise to me is to uncover, engaged republicans were in 1945. the governor of california california, comprehensive health care reform and within one vote to get it passed and he had gotten sick we really need to protect people from the cost of getting sick. when nixon was elected one of the first in the legislative bills he introduced was a bill about comprehensive health care reform. if i describe it you would

think did he write obamacare? he wanted to give people subsidies based on income so they could buy private insurance to cover themselves. the government would provide subsidies. that sounds like obamacare. he proposed that the late 40's and when he was running for president against kennedy there was of big debate trying to figure out how to get those people left out of the employer system insurance. he reintroduced the idea of subsidies of private insurance then when he gets to be president he is negotiating with ted kennedy about how to come together on a comprehensive health care reform bill than they were this close that they could agree to send with

typical washington region and there was a scandal. with the and exotic consider he is disgraced and forced off the chairmanship and watergate's overtakes and it goes away. also liberals and unions at that time did not want to have the deal they wanted single payer lint they've withheld their support. there is a combination of scandals which put the cabochon the bipartisan agreement and over 20 years until bill clinton we did not have another reform then clinton comes and wants a market-based reform to propose the health security act and unfortunately there

are other things that overtook the focus. pass the tax increase the nafta bill and i the time the stage was clear for health care the bill was defeated you did not even get one bill passed out of committee. for 15 more years it had become so onerous that is what i called up passage of the affordable care act this is the framework for the next 50 years. >> host: did might be fair to say the most interesting part of the book is you were there at the revolution and in addition to the run up

the good portion of the book to that again chapter eight to 3-d rest of that but your own observations and insight of someone who was there and do specifically talk about the complex interplay between policy politics and interest groups. if you would elaborate on that and focus with malpractice? that is one of the more easy ones. [laughter] >> it does illustrate not nearly as simple as people play it out to be. >> getting malpractice reform was a reasonable chance. first of all, we should be modest with the expectation and going in that day is regulated at the state level

not federal level. so putting malpractice reform in federal legislation will not solve the problem. you cannot force the states to do malpractice. but we had the book -- a good combination of president himself had written an article in the "new england journal of medicine" before he declared malpractice reform and thought this was an important issue. there were two doctors both of us thought it was a good thing to do. other senior advisers who thought it could encourage quality care to focus on quality. we had a good arrangement to study the options and as i tell it to in the book with

the pros and cons in a detailed memo one day in 2009 i go into my brother's office that i produce at the end of the day and that's all and he wants of peace of information i was reporting bacchant in his usual way she said what else are you doing? i explained malpractice and he said the f word. shut up. we're not doing that and he explained why. when the ama says the public they come into my office what they beat out of this bill and they never talk about malpractice but how medicare pays doctors they

never mention malpractice i am not doing malpractice because that will require we have to defend the democratic base and i did not know to do that. by the way the republicans come to negotiate. efface said that we would have done it but it was not the case. here you have a situation where on policy grounds it was for malpractice reform but in the interest groups and the republicans were not interested. but that is the way it wind up if doctors had said we'd understand pavement or the republicans said we will negotiate it would have happened but it is not the

way it lined up but he had two elements in the joint session of congress we have the pilot program and to improve patient safety of more than $100 billion sandy affordable care act has a provision if i remember correctly that says we will give grants to states to reform malpractice law with the cost of health care. >> more committed to malpractice reform than any president did have to pieces more than anyone else you cannot say he was not committed that we did not get more comprehensive

reform. i was disappointed but made interest groups and politicians needed to support it. >> host: what interests me a lot is an interesting fact which i agree i did not know that those who are the victims don't sue and the vast majority of malpractice lawsuits are frivolous. so your preferred approach is the safe harbor. that is interesting. >> guest: one of the things i point out in the book cataloging the problem is no one should be happy with the malpractice suit with doctor or patient hospital or lawyers. it is broken.

it does not incentivize doctors to not make the error or without overhead. it decided to that. there is not a single metric it fails on every store so patients as well as doctors should want reform. some people say cap how much we pay with a short statute of limitations i don't like those. they harm the victim of malpractice. our view is you sat as an incentive so page tried to have a problem.

and it could be rebutted and presume to be interested. the patient comes in with head trauma don't to the ct scan and but i protect myself if you follow the guidelines you would be a safe harbor. imprisoned to be innocent. it incentivizing using the electronic record that is what we want doctors to do. are there other alternatives? yes. i don't think we have enough research to say the university of michigan has pioneered this that is easily identifying a problem and a simple solution according to a set schedule

week high as a laceration here is what we will pay you and s has substantially had a number of lawsuits and reduced the time to resolve the case so that looks promising. >> host: let's move on to the actual casey a. thinks we're into effect some things went right to and wrong and how that could be fixed up. the affordable care act is more than just the exchange it is unfair just to say a cable online. right after passage so many people should remember if they already had forgotten

young adults came on line by september and many made it effective within six months of a package unabashed of passage patients on medicare there is a 20 percent chance they will return to roots of hospital and so they were about to that there is continuity of care. the research institute went into effect pretty quickly. we did not wait until october 1st with the opening of the exchange's blood of those were successful with those

provisions some of those are disappointed to be blunt i don't think the outcome research institute has been sufficiently progressive it has been quite timid and we have tried to push them. >> host: hhs? >> and independent private not for profits for all injured people nominated by a the edge diego and independent not part of the government. that is subject to political winds it has through 2019 and unfortunately has not undertaken in the right to comparative effectiveness research they spend a lot of

time for dissemination and getting that basic information whether we give this kind of treatment surgery compared to medical treatment for an illness they have not done enough of that's nevertheless but me mention one other program the partnership for patients in 2010 was in the effort to reduce hospital acquired conditions. and the major program the total number fell of 9% and rorer importantly and they

have gone down by 50% with infections it shows what can be done. >> host: you were very transparent with the web site. could do you think at this time it is considered to be the loser in the environment right now? what can we do about that? >> the american public the execution of federal exchange people accused of word fiasco and there really was. i eighth tried hundreds of times and many people were

frustrated and it did not have to me that way but connecticut's it succeeded. california did moderately well. i think it was not properly managed when you have a reasonable competent team come together to fix it. >> host: why did that take so long? you refreshingly were transparent about the dynamics with managerial skill and health insurance experience. >> i cannot explain the resistance but if you looked have spent a good but

connecticut has a health insurance executive has a quasi private derangement the same thing to understand the insurance needs in the marketplace also with managerial experience how do we make the exchange better how they operate to give the right to information? that there is a good experience in a reasonable amount of time and they run it like amazon. that is what we need to aspire to. maybe a not to right out of

the box to become amazon overnight it has been out there for nearly two decades but we need to have the relentless focus managing the e-commerce web site we're riding a government program. you have to attract customers and make sure they are satisfied a very different mentality. i just hope that is the mentality that takes over. the american public will show love shopping for insurance. >> host: we will see if there lint can catch up. >> but now this is the way we would consult sandy don't

have to reinvent the wheel some of them signed up for the exchange to say we will put in place that would be good as well. >> that makes sense and. >> this is one of the more sensitive parts one of the core beliefs that the public should be able to trust what he said but if you like your doctor you can keep them in premiums will go down by 2500 per year. those did not come to fruition. you want to debate that but the public perception weekend agree it is in violation in the polls

reflect that. if you go back again? >> first of all, in this important public perception and it is he was not telling the truth. the president in dealing with him and how does that square with what we said in speeches? he takes the idea of what he's just say of the notion you can keep your health insurance plan and people say no that was violated. i know ibm is in the minority but i was on the inside but there is nothing it with the affordable care act that says you have to

blow people off you keep the same plan we want to get out but to say individuals are buying insurance we're kidding a lot of the market. is it is true they responded to that but insurance companies decided but there is no lion that says you must cancel this plan. as you point out the public thinks so right now to explain the benefits of the affordable care act we need to be quite honest.

implementation of a complex bill and change of the american health care system will be bumpy. not just a bet of roses. put that on the table but second to the better is a system that will be much better with access to insurance and care with cost of the whole experience and on each metric we already had success and will continue. to get to the last point everybody will save $2,500 it is against the background greater than the growth of the economy and the cbo

pointed out there a lot lower than we have calculated. inflation has come down. part of that is the recession and weather will turn now to me 2500 by the end of the decade, of the will see but it is the case let me give you a concrete example. medicare beneficiaries with part b have in fact, not dollars but of relatively flat. with the last few years have remained flat they are not paying more year after year

but the same. my fisa to the white house says you need a strategic campaign to explain to the american public how the law has done it even going back to 2009 it is not that complicated. and we save pretty clearly fit to self-inflicted wounds that were a problem as a comprehensive communications strategy never executed of the law to the best of our abilities. >> i know that you have a day job. >> i vice president of global initiatives with

medical ethics and health policy at university of pennsylvania. >> host: but just fantasizing would you go back if you were called to help tie up the loose ends? >> filled with those cnn air rose and slanderous attacks on dr. death to create a death panel. all of which were shown to be totally false. to improve the system for the american public how frustrating it is when you are a doctor you're frustrated given the skills

that one of the things i could do was think of policies that have the likelihood of people think my skills that could help and no wings the down sides of the government servant even when they are false. that is minor and improving the system that is something that will last for generations. one of the things that motivates me is the american health care system is so expensive, so much money influences our debt. one of the things that constantly motivates me is i care about future generations but to reduce health care costs because

what drives the long-term debt? high health care cost high medicaid cost so getting it under control freeze up resources to pay down the federal debt is one of the reason i am motivated to do everything i can to improve the american health care system. >> host: is said to loved working in the white house revolutionary was the word but what was the average day like? >>. >> meeting with peter orr said. >> early on we met regularly

been a kid more civilized but then the work on what you are working on whether some provision or a pleasure to work, the let's move initiative also a global health issues then get the end of the day. this an adult working in n a white house is the uncertainty that the important thing can happen to sit down and work on that unpredictability to control your schedule is the worst aspect at a very high level. most of the psychology researchers the key elements will control your environment looking at

policy development that control completely disappears and that was the most frustrating. the lack of control but can i make a big difference? can now push in the right direction? that is a deep honor to have that impact. >> speaking of the right direction march 31st is the time. >> march 31st is the end of open enrollment. >> i know that you and others have said the exchanges need to spread around primarily through the

enrollment of younger and healthier people and is incredibly important the estimated need for involvement was between five and 7 million. where are we now? >> here we are early march the numbers that are when we called have people enrolled the end has the high bobby and rework the deadline. my best guess between five and five and a half million at the moment we are 27% percentage did are likely to increase the most sifting of the offense is below the and what was predicted or expected but enough young

people that the risk pool is probably going to be okay. we will not see a rate shock but i don't think anyone can be happy to miss the target. between the end of march and october 1st business is another opportunity to improve the web site to advertise and educate and get them involved. and the 10 for a do they have insurance and the notion it is there obligation if they don't have it they will pay a penalty.

my own personal views that the estimate by a the cbo by the end of the decade will have many more than the 25 or 30 million day estimate. >> host: a few weeks ago of a new health care proposal on the block that coburn. [laughter] has the alternative to the a.c. a. if that were round in 2009 to you think the trajectory? >> i think people with c-span only remember there was the hatch proposal because no one else out there the day after was announced it disappeared part of the reason is it is a proposal that is bad for

the average american. i did a column in "the new york times" to take their proposal in the 28% income-tax bracket that means $1,500 in additional taxes you have to pay not what most americans want to do. is not a good deal for the average american. this is what i cannot get. the core of the obamacare proposal to have a marketplace to compete in 40 years people will have subsidies to decide which insurance product they've won that its best with their needs to have the incentive it sounds very bipartisan

and market oriented. i think what happened is the democrat said we can live with the idea. we may want a public option but we can live with that marketplace orientation. but some brace that and republicans say originally at was our plan there is no plan that makes sense to address the issues altogether. republicans have painted themselves into a corner they have no coherent plan whether the latest patch coburn plan does not work because the republican plan that does work is called the affordable care act. >> host: my colleagues that 8e i.

[laughter] >> one of your colleagues come to my class and he did not have the alternative plan it turns out he wanted to tweak a round obamacare i think that is the true plan. is market oriented with subsidies to cannot afford to buy. i think republicans ought to except it lets try to make it better. right now we know things could be done. >> host: enumerate some of those. >> i have a chapter.

>> host: the megatrends? >> guest: the chapter before. >> i would like to raise the cigarette tax $0.50. we know if you raise the cost of a package of cigarettes you can get their predictable decline in smoking. everyone wants to have fewer people spoke. >> host: can smokers be susceptible to a 50% increase? >> $0.50. >> is there a penalty of a premium? >> the ability to charge people 50 percent more if they are smokers but that is so dumb they ended does not help. but we know from behavioral economics that has to be immediate. raid drill that would

decrease by 3%. everyone should agree andrew that is one of the most harmful things. seconds one of the most important things for cost control and increasingly doctors and hospitals want a change of pavement so i propose there is a set of things called bundled payments to put those associated with one medical treatment like bypass surgery into one payment to measure the quality in attitude good quality of care they can share in the savings. we have programs ready to go it will experiment like cancer care.

third, competitive bidding. part of the affordable care act is a proposal of the marketplace for oxygen equipment, hospital beds, wheelchairs', walker's it is better the marketplace set the price. does anyone believe the government is setting prices? to the affordable care act has that to be rolled out by 2016 headed a lot of money to not do the co pay. why don't we expand that? we can begin next year. we could expand the services things that are commodities and i propose let's have a

business group that oversees wouldn't you love to have this from the head of acquisitions? those understand maximizing quality. those that would be quickly implemented to improve quality. >> getting to predictions you had an article about how you see insurance companies evolving. >> the first megatrends is insurance companies as we know them. there is no better line for a politician and to get applause i often think sometimes it is fair or not fair we are indiscriminate

but with the most favorite part as far as the public is concerned with dash concerned it will force them to evolve. why do i say that. we have a health system whether the cleveland clinic with the mass general or brigham hospital our hospital system has a growing number of affiliated hospitals that can take care of patients in the doctor's office in a skilled nursing facility and soon they'll offer the products of the exchange managing the money to provide the care. with integrated delivery system competing

head-to-head with insurance companies to take the profits to roll into the operations of a lower-cost plan with brand recognition of hospitals and doctors. how will insurance companies respond by integrating delivery systems to take the premium and pay the doctor to deliver the care as well. i note some early examples. boyle point once a system called care more that provide insurance to seniors as part of the medicare managed care but at a very high level saving 20 percent off the usual payments that high-cost

or high-quality low-cost i am shepard wellpoint tries to figure out the secret sauce. similarly they have now employed 5,000 doctors. we will see the hospitals with the delivery system to provide care in the traditional insurance company goes the way of the dinosaur. that is where i think the insurance companies are going. >>. >> but accountable care? >> accountable care

organizations are part of the intermediate species of the health care system because they are a bit like the neanderthal is. with the risk-management function when you add that they are integrated with the delivery system to integrate care over the entire continuum for the skilled a nursing facility. that is rarely begin to increase. >> host: one of the ideas is making information available to consumers. granted it is challenging enough which parameters but how they even understand them if they are well

measured how do you envision that working? >> the idea of transparency definitely is key to the future and right now we know we don't have transparency and we don't know how much will that colonoscopy going to cost? for the mri? or the insurance company will pay that will come especially as they say to people here is a reasonable high-quality price something that churches more will pay the differential. and i getting good quality? that is what we've want to know to measure that quality

is a little more challenging. we don't have the best metrics across the board but not which that will be the challenge can we solve the problem? a matchup of data and i think a lot of money to be made to develop the quality metrics you will see a lot of smart people working to develop as they become public companies to make the system more efficient. once people know what good quality is then i have to believe they will respond to those incentives.

>> host: actually we only have five more minutes but it is very interesting. hispanic you mentioned the insurance companies the vip care for the chronically ill that is a challenge. >> host: 10% uses two-thirds of the dollars that is the quality and the cost for every health care system figures out we will focus on those with chronic illness. from what i can see the expense can be cut by 20 percent once they got a

system in place attending to people at home prevented from getting sec it turns out to almost everyone agrees is the group of health economist is in mental house. the depressed patients the severely anxious patients to sue their anxiety. >> host: we know how to treat the severe mental ill in conjunction with the civil system there is a lot to be done. >> i agree. by the end of the decade the system will begin to focus on mental health you will have parity because people realize that is the way to improve the quality of care.

>> host: and the emergence of digital images and? >> we will see more wireless monitors take a pitcher of our dash they did not see you but can diagnose if you need medical attention to monitor the of glucose every day. that is very common by the end of the decade. >> host: i will mention the other two but with the employer sponsored health insurance and finally transformation of the information's been met by a frustrated that medical education is basically the same from 100 years ago and i don't think it has kept up in any dimension. retake too long.

we could train them in three years to do a more efficient job so when i was a trade he to become a cancer doctor one year of clinical work taking care of breast cancer and leukemia with two years of research. you don't need a three-year trading if all you give people as one year of clinical care. you don't have to train everybody in research. we need to have more management turning how to work in teams that is with nurses sanders practitioners dieticians, a physical therapist similarly when you are a resident all the time

is in the hospital but the future is not in hospital but at home or nursing facilities this will be a comprehensive revolution where we trained people and what we are educating them about i see that happening again. and hast not been changed radically but over the next decade pelosi of big change. >> host: thank you very much. . .