host: thanks for being with us. later we will talk about health care with a physician and writer. we will also have the decision about what is best for the u.s. economy. bob cusack is with us to talk about politics in the wake of reelection bids. we will begin with a corollary to that. there were two articles talking about the u.s. senate.

one talks about the great summit of the 1960's and 1970's and elements it is not so great anymore. in "the washington times" -- a profound loss of retirement and death of senator kennedy on expertise. with all this discussion we would ask your view of the u.s. senate. i want to show you a little more of those two articles to set the stage. if you are one of the armchair historians in the audience who knows about senate history and would like to add your thoughts about the senate of currenearlis we welcome that. as well as your thoughts as current watchers.

here is the op-ed piece in today's "the new york times." he's working on a book. he looks at that time. as the heyday of the senate. in the 1960's and 1970's the great senate occupied a unique place in our country. he writes the little changed in 1980 where the election was more than just a change of party control. gone was the senate that had been experienced, progressive, and bipartisan.

the decline has only accelerated. we would like to hear your view. first we would like to get an update on what is happening on the ground in yemen. the foreign correspondent here raghavan is with us by phone this morning. he will tell us what he has been observing. guest: good morning. host: how long have you been there? guest: 43 weeks. host: tell us about the changes you have observed? guest: the biggest was last year with the attempted bombing. -- i have been here for three weeks. we have had to deal with those

who have arrived this week. what we are seeing now is the intensified crackdown on suspected al qaeda militants. there have been two major air strikes backed by the u.s. on suspected hideouts. there have also been several raids in recentñr days been of e government is taking a proactive role in trying to tackle them. host: are you able to judge any reaction to them on the street to the intensity of an increased presence of the police and other actions? guest: not really in the capital. it is life as normal. last year the u.s. embassy was attacked with a car bomb. there has always been a good enough -- a security here in the capital.

it cannot tell much difference. host: there must be some conversation having in coffee shops. any idea what the public sentiment is? guest: most are focused on the civil war in the north or the secessionist movement in the south. that is more the topic of discussion then what has happened in detroit or four could. host: i'm asking because our papers here in the states have a number of articles suggesting the challenges to win the hearts and minds in yemen that the u.s. has too over to presence or coa backlash. could you add credence to that theory? guest: sure, there is a sense among the young men citizens that perhaps the u.s. is intervening a little too much.

there has always been a heavy dose of anti u.s. sentiment here. especially towards u.s. policies for iraq and afghanistan. yemen sent thousands of fighters to afghanistan and iraq and other countries to fight against non-muslims. there is a good amount of antipathy to american policies here. the concerns on the part of the government is they do not want to be perceived as being a puppet of america or too weak to handle al qaeda on its own. you c in the local press here that the government is trying to publicly downplayed this relationship to the u.s. for instance today i was at a press conference with a dr., the deputy prime minister in charge

of security and defense and he clearly sent a message that human does not want any u.s. troops on its territory. host: well, thank you. i know the situation is in flux. we appreciate your update. the country for the past two weeks has gone to all of america's front pages. we look forward to three more in the weeks ahead. he is the foreign correspondent for "the washington post." let's turn back to the discussion about the u.s. senate. life here is another headline. they looking at a loss of senator joe biden to the vice presidency and the announcement by those will not seek reelection, and the death of senator kennedy. it is looking at the years of seniority that they brought to the senate. hess, a longtime washington fixtures said in the old days

the loss of experience and seniority might have mattered more. some the use of today's senate compared to the senate of old. we would like to hear your comparisons. let's begin with a call from alexandria, va. by trolls on the

republican line. caller: i loved your show. i am a big fan of the senate. i am very much in line with james madison's view that the senate is the saucer into which legislation is poured into cool. he was discussing with thomas jefferson the senate and ow legislation move rather slowly through the senate, and he said that is a good exercise and why the senate is designed to be where legislation is cooled, massage, stroked and works as a midwife. host: do you still think of functions that way? caller: very much so. host: are you pleased with the way it has been working this year? caller: yes.

some of of the road rules likely to end filibusters seem arcane and silly, but they are designed by the senate, not the constitution. the 60-vote, and the three senators present voting are designed by the senate with good reason. host: next is rob in new york city. what your thoughts about the senate and help functions today compared to the senate of past decades? caller: dysfunctional. host: why do you said that? caller: there is no bipartisanship whatsoever. this health-care business, not one republican vote. watch retiring connecticut senator chris dodd to go through the revolving door in the suddenly pop up when your or couple of years from now as a

lobbyist for the hartford from connecticut. it is the same old. lastly, my final thought and then i will hang up and listen to more commons. for example, with the healthcare, it is medicare and medicaid going bankrupt. if you brought in as the private insurers are able to jury began bring in healthy individuals to medicare -- are able to bring in and cherry pick healthy individuals -- perhaps a sliding scale -- it could bring healthy individuals paying full premiums into medicare to balance out the expenses we have now to pay for 65 and over.

as you get older more medical bills. i would be interested to see c- span have some accountant or actuarial come in to run the numbers that exist for the private health insurers and have them make their profits. how to make medicare at a fee. host: banks, we will go at this point because we will have an hour-long later on health care. today concerning the senate, your view, the independent line from anderson, indiana. caller: it is truly disgusting after the display of the health care fiasco you have seen. the conservative an element is tearing up the fabric of democracy. after watching the sonia sotomayor confirmation hearings you have a 99 white guys who

question people's patriotism if they have any anglo-saxon heritage and any pride in it. but that we were supposed to be a melting pot. with this conservative movement with the next retiring justice -- barack obama will feel somewhat reluctant to appoint anyone but a white person. i know he does not have the gumption to elect a black person. we have seen how he has kowtowed to pressure from the racist, radical right. the senate itself is being used as a mechanism to make a mockery of democracy lately. the senators hold out for special gift for health care. host: thanks for your comments. more from this op-ed pieces.

the senate's fall was as swift as it was surprising. here is a message by twitter. what are your thoughts? next is a call from new orleans on the democrats' line. caller: i have been watching the senate for a while now. they are dysfunctional. i completely agree with the earlier caller. i was watching last night and i think it has been reduced to about 100 people -- host: hear

the paper says that bipartisanship will be a victim of a loss of long serving senators. both houses have become increasingly partisan. we are asking your view of the senate. passed on the republican line is next. caller: ok. this is pat from kentucky. i would like to express my opinion about the senate, but i will be very critical. but it is not really about the senate, but about our people. i just took a 4,000 mile trip on a greyhound bus across country. host: why did you do that? caller: for christmas, the holiday.

i noticed in my travels that our people are not very virtuous, not considered. as a matter of fact they are obstinate and belligerent. washington told jefferson that a government without virtue and is no government. people without a virtue have no government. so, really our senate in my view is what is holding all this together. there really believe that with the president and his administration -- you know, they are avowed socialists, communists. the senate is trying to keep our people in the state of democracy.

a socialist is a totalitarian. they don't even believe in democracy. host: you are saying that that is your view of this current administration? caller: i'm beginning to believe that, yes. i will give you my background. my mother had my twin sisters when she was 40 years old when we were placed in a government project. i worked hard to help to raise them. i got two master's degrees. faugh of course commended mr. doing all that. i see it from both perspectives. from being very, very poor, to having some sort of life in our society. -- of course, it made me very sick doing all that. host: next is a north carolina, larry, on the independent line. caller: yes, like the other

caller said, i think they are very dysfunctional. i think the problem is -- we live back with the government we started 200 years ago. but those guys there for six years and you can get them out. whinnied term limits. if not, then the american people need to come together. we cannot get them out even with the voting system. we only vote for a certain amount each time. there is one way to get them out if we want to claim them all out. that is to come together, get everybody to commenit -- registered voters that they will vote early. then we could it early vote with enough people. we could know the outcome before.

i know that there are some good ones, but there's no way to clean them out unless you clean them all out. from what i hear on c-span and think both parties are really disgusted with the signatures. you can see on the last bill obama tried to get through that he is doing a good thing, but with the people he is working with -- even a lot of the democrats are not working with him. that was unheard of in the democratic party of old. you have read something before you begin the show concerning human. the kid's father who was on the plane -- his father was the richest man in yemen. host: your confusing the two stores. his father is a banker in nigeria. caller: yes, but at any rate he is very rich. he got on the airplane because he was rich. host: i will let you go.

we'll return to focus on the view of the u.s. senate. the next caller is a route from washington, d.c. caller: you have to bear with me but i have seen a deterioration of the senate since the 1980's. we had the rise of the so-called republican think tanks. they were essentially propaganda machines. they had a one-liners for the masses. the wealthy paid a majority of texas -- well, the majority made at the majority of the money. it is simple think. we had reagan -- an actor. then we had huge tax cuts on the wealthy. we had a distribution of wealth toward the top 1%. we had consolidation of the media at that time overseen by the republicans.

we have gone from 60 entities down to only 6 entities controlled. we have the war in tone-liner competitions and now we have the al gore election where we have only one senator say they have a public this. it is a stunning. when you look at what happened in florida concerning the elections by the bush family. then we had the false flag 9/11 attack. it was brought about by the bush administration. immediately after which we have a complete dismantling of the bill of rights with habeas corpus -- host: please caller: wrap up we're not to the point where we're just waiting for the next event. we have essentially lost our

democracy. the stupid tv watchers after of the world federation wrestlers will sit back and watch the whole thing away. host: bob from twitter says -- the author today does think it has deteriorated since the middle of next is winter haven, fla. -- james, on the republican line. caller: i think the senate is doing real well, able to stop this legislation. i am a jim demint republican. once we get this out of office

we will have our own health care bill. host: next on the democrats' line from eagle river, wisconsin. caller: i want to wish everyone a happy new year. i think both sides are bought and paid for by big business and not being. they don't have the people's interest of heart anymore. i think we have to start public financing of our voting, elections. it is the only way to get the corporate interests out of the government. we have to stop and think about lobbying. we have people lobbying our government from other governments for their interests. our government is not answerable to anything the people want any more. yes, i think the senate needs some kind of overhaul.

there are people in there who say one thing and turn their back and do entirely different thing. it is showing now after the health care so much that we cannot trust our own government anymore. thank you. i'll listen to any other comments. host: our discussion was precipitated by commons of the two senators who said it will not seek reelection. we will be soon joined by bob cusack of the hill to talk about 2010 election prospects. steve, hilton head, south carolina on the republican line. caller: the democrats elected for less leaders to run and develop this whole policy. why don't the moderates come together to join a third party?

stop this animosity in difficulty. secondly, you guys do excellent journalism. many of your guests stammer. don't you screen them? sometimes the callers do that too. we need to get to the point where there is stability. -- civility. here is a message by twitter from doug. the next comment comes from ohio on the independent line. caller: yes, i believe congress should have term limits. the go in their rich and sit

there and get richer and the themselves pay raises. that is not right. host: "the philadelphia inquirer" lead editorial joins the discussion concerning the healthcare debate. here is the headline. they say that c-span and other media were able to cover this. the access should not be shutdown now that the final product is nearly at hand. washington, d.c. on the democrats' line -- alvin. caller: i think there should be a three-term limit. they come in with ideas of, helping of but when they get in there with big business it all goes out the window. host: american hero, a message for twitter.

osage city, kan. on the republican line. caller: good morning. but republicans were in the majority through the 1960's and 1970's until ronald reagan -- host: you mean the democrats were in the majority? caller: yes. and the republicans had to play along. as soon as the republicans got control, the democrats -- that is one the divide it took place. once the democrats were out everything went to pot. host: democrats retirement added burden to obama. health care raises voter anger -- that is the view of this paper. we would like to hear from you.

martinsburg, west virginia on the independent line. caller: thank you. the biggest thing i think that people are missing the boat on -- people do not like the, congress the, but they never say that they don't like their congressmen or senators. that is the issue. when i vote for people here in virginia, if there will get kickbacks to the state of will put them in a matter of-. other states may not like it, but there's nothing they can do about it. they need to repeal or do whatever to the constitution to get people out. whether that be term limits are some health where there is a majority. because when other states have

reason to be able to oust someone else in another state, maybe there would be doing what is better for all the people, not just those in their state. host: another piece that echoes from the past in today's paper. faugh a political science professor at rutgers -- this piece -- america was politically rancorous during fdr's time. laura tells us on the order to get money out of politics. the last call on this is from louisville, ky on the democrat'' line. caller: the problem with a lot

of it is you have a bunch of movie stars in politics any more just like in sports. everyone is on tv, getting in front of the camera, making that the point of reference. back in the 1960's and 1970's you were fortunate if you knew your own senator by face. now with the 24/7 fox news, msnbc news pitting one against the other it makes four end of the chair real -- and makes for an adversarial atmosphere. host: did you then think that putting cameras on the senate floor to televise was a bad idea? caller: no, not at all. it is not the venue of c-span that is concerning. it plays a bit of a part, but generally you can look at people doing their jobs that way. the other things like when you go on your channel of msnbc, or

fox -- dunno about cnn. the situation where people keep talking about term limits, i think that is a terrible idea. if you think it is bad now, if you have a situation with term limits attached to these people where they know they only have a short amount of time, can you imagine the deals that will make of lobbyists then? you have a situation where you have to go back into the private sector which shows you nothing and you are not guaranteed a job. you will make all the deals to possibly can. term limits in my opinion is about the worst idea anyone could possibly have if you

intend to stop some of the corruption and bad dealing going on. host: we appreciative. we'll take a break and return with bob cusack to continue this discussion but more tactically about the 2010 elections. whether or not the democrats can maintain their 60-seat hold on the house. ♪ >> in fed we trust -- on fed

chairman ben bernanke and will be placed after the collapse of 2008. he will discuss his book with alice rivlin. part of this weekend's booktv on c-span2. >> the new c-span video library is a new video archive. from barack obama to ronald reagan, and everyone in between. it is fast and free. >> saturday president obama as ambassador at large for global women's issues talks about supreme court justice ruth ginsburg and the changing role of women in the law and the rights of women around the law. >> i am always concerned about the potential for an unintended

consequences of the new regulations. they act as a tax. when you regulate something you tend to get less of it. this weekend, republican fcc commissioner on efforts to create a national broadband plan among other things. "washington journal" continues. host: bob cusack is the managing editor of the hill. he is here to talk with you about his and his reporters' view of the party's chances of the 2010 elections coming up. i want to show you in the audience about what the morning headlines look like. the democrats may not be enjoying them this morning. and inside it says it determines

pre-sage challenges for democrats in the midterm. here it says they add a burden for obama. this is from "the washington journal." retirement adds twist midterm -- usa today. in "the new york times" -- democrats become wary after two senators decide to retire. there is the headline view of reporters -- what is yours? guest: it is a nuanced situation where you have the retirement of senator chris dodd which had been rumored for weeks. he denied it. it helps democrats. now that they are favored to retain that seat -- now they are favored to retain the seat. the announcement of dorgin was a total surprise. his seat in the red state of north dakota was expected to

stay in the democratic camp as long as the governor was not going to run. when the announcement was made a changed landscape. now the seed is likely to change hands. in last year in the senate -- back then that would have said the landscape of how the senate will change is probably not that significant. over the past year republican recruitment has been solid. we have seen at the president's approval number step. no one is talking about democrats losing their majority -- they would have to lose 11 seats. it is not likely. are they looking at losses for 2010, though? they are. karl rove has said between four and six seats. other independent analysts have said between two and five.

host: for some who did not follow its a closely how many senate elections are their next year? guest: 37. host19 by democrats, 18 by republicans. it has changed because of replacements. as far as competitive seats, seats that could go either way -- on the democratic side we're looking at nine. on the republican side, five. it can change at a moment's notice. those numbers are in play right now. host: have you been able to list those who have announced retirement? guest: as far as democrats, dorgin and dodd for the first elected. there have been many appointments such as gillibrand. but the two were the first elected.

martinez retired earlier. he was replaced by lemieu who is not running again. it will be competitive in florida. meeks will run against either rubio provide conservatives and the republican party against crist, the governor of florida who is still considered the favorite. the bulls have tightened their. many close races coming down the stretch for november. host: we will give you the phone numbers and would like to have you join us in the discussion. if you lived in a state with a senate race we would like to hear about what you have been reading and what your thoughts are as the election of your purchase. will move on to the house and a little, but we're beginning with

discussion about the senate. bill ritter of colorado -- parties are all claiming that their prospects. let's begin with spokane, washington and richard on the democrats' line. do you have a question or comment about the elections? caller: i think they should all be retired. nothing are doing anything but getting their own agenda taking care of. host: maybe we can parlay that comment into one about the mood of voters of this year? guest: if you look of the numbers republicans are certainly feeling better about themselves after being crushed in 2008, but their poll numbers have not significantly improved as a party. that is a concern for some republican strategists who know

that there is an anti-incumbency mood in the country right now. it could put off some republicans. unlike the last two elections where democrats were generally safe for 2006, that could be different. for 2010 a lot of members could be thrown out. most are expected to be democrats because they are the ruling party, but that does not inoculate republicans enough some in the house and some in the senate are facing difficult primaries. host: "the boston globe" is the largest is deeper in new england. here's the front page from yesterday. -- the largest paper in new england. it says that blumenthal is quickly becoming the front

runner. all across the country -- here is that l.a. times -- dodd was tied to the economy and his connections to the financial industry turn into liabilities. guest: it was a very difficult decision for him. he has been thinking about it for a long time. in his speech yesterday mentioned he lost his good friend ted kennedy and his sister recently. he has also battled cancer over the summer. to his credit he also edged knowledge to was in the toughest political shape of his career. he said all that factored into his decision to decide to retire. an interesting anecdote -- on christmas eve he went to arlington cemetery to kennedy's burial site and thought about it. he soon made the call after the holidays that he would step aside. host: dennis is watching in fort

washington, maryland. are you there? let me move on to kevin in hartford, conn. caller: if the healthcare bill is such a great bill then these democrats would not be dropping like flies. they would stand up and be proud. instead of doing this in secrecy. not transparent as they promised. they 1 because of republican incompetence, and now they're doing a lot of the same. the democrats are now doing the healthcare bill and a similar fashion behind closed doors. what is the difference? they are both correct. they should be able to go up and be proud of the healthcare bill.

that is why they're dropping out. host: i hear both parties talking about the benefits of health care for their constituencies. that is one view. can you tell us the other? guest: democrats acknowledged that they will have to sell the bill. it would have a conference or allowed c-span cameras in. a lot of times the final decisions by either parties are made behind closed doors. some of the polling is a bit shaky. one concern from democrats is the basis not very happy with the fact that the public option is basically dead. the republican base for the first time since 2004 is really fired up. democrats have a significant

fund-raising advantages in the house. but right now they're playing defense. host: the hill has on its website congress law. -- blog. they have assembled a lot of abuse from a well-known people. fifth -- a lot of views. 12 democratic house members and 13 republican house members have decided to retire. six republican senate members and two democratic members have decided to retire. it looks like the retirement tied is still running against the republicans? guest: the announced retirement of a democrat, brown, -- republicans said it could take the sea. it will be an uphill climb. the mood will be different this

year. the numbers are not exactly lining up as republicans are saying as far as this massive discrepancy. if you look at numbers and pulling and independent analysts, in the house-certainly house budget losses for democrats. in the senate may be a handful of democratic losses. host: let's move on to the numbers in the house. all seats are up for reelection, but how many are competitive? guest: a fair amount. the house as a little more difficult to gauge than the senate because many candidates have not gotten in the race. that is what's rnc michael steele got in trouble about a little yesterday because he told the fox show he did not think that the house republicans could win the house back. he retracted a little. some candidates have not yet gotten in. if you get charlie cook's

analysis of there are more republicans in tough races. host: what is the majority? guest: 256 democrats and 176 are so republicans. the amount of pick ups will have to be about 40. when you look back to 2006 the democrats picked up 30. for 2008 it was 24. larger waves then the democrats had will be difficult to do. republicans say will probably take a couple of cycles. host: in fact, charlie cook, we just referenced in his analysis of the house currently -- democrats have 38 seats listed as tossups and democrats have a 11 similarly. the next is bowling green, ky

. caller: it amazes me that any of these individuals will pass bills that have never read. it makes washington summit the big circus run by a bunch of clowns. host: do you generally vote? caller: yes, i do. i voted for the individuals who think would do the best job. unfortunately, the individual who runs against the present senator, he was colored to say the least. [unintelligible] you do not have a lot of choice. any more it seems like that is the way it is. they cannot find anyone credible

to run against an incumbent. they pass bills like nafta which took thousands of jobs. unemployment is high now. the passing the bills you have not even read it to me is crazy. host: anything from kentucky you would like to add? guest: there are many people frustrated with the gridlock. democrats are. they have even said, floated as liberal bloggers -- that the number for the filibuster should be dropped from 60 to 55. thought so that things can get done. we saw this a few years back when republicans did the attempted nuclear option.

there is frustration over bottleneck. people say that this was supposed to be the president to change the tone. like bush obama has struggled to do that. host: here is an obvious agenda. is the tea party affect influencing retirement in congress? guest: i think the jury still out on that movement. it is one of the things that campaign analysts will watch closely, and so do we republicans on capitol hill like the enthusiasm of the tea party base, but also know it is not necessarily a republican movement. it is a conservative movement. if you are not conservative enough, then potentially u r target.

they want to harness the enthusiasm, but are struggling with how to deal with it. for democrats, yes, they little threatened. host: you have an article -- into policy six and new voting man. guest: this will be the first election since she was elected top house democrat issue will not go toe to toe with and george w. bush. she battled the president at that time. she lost in 2004, but then his low approval ratings helped her to become speaker in 2006 and expand in 2008. she is very good. she said she was in campaign mode last month. she is very good at a defining her opponent. but will be her opponent on the republican side this time? certainly it george bush's

policies will bebu involved willt who is the face of the republican party? do you talk about george w. bush and his policies? or more conservative lending rods like dick cheney and sarah palin? she did it when she labeled the health insurance companies' ads villain-- as villains. host: stay on your note about it also being a problem for republicans. some are invoking 1994 when there was a big republican sweep in the house as a possibility for this year. the difference is that they had newt gingrich who organized candidates. is there a leader who is organizing candidates around a message for republicans this year? guest: not yet.

michael steele suggested the other day that there will be some type of document -- not a contract with america, but some type of document to define the republican party. is it him or john boehner or mitch mcconnell? is it john mccain who has a record number of twitter followers? is it sarah palin? they do not have one clear leader. for 2005 after senator tom-0 and senator kerry lost, then the democrats did not have a face either. it did not hurt them for 2006. host: daytona beach. caller: good morning. host: you have a big senate race coming up in florida. caller: yes, we do. independent intellectuals

understand with regards to the history --the senate of the country began under the rule of law that no one is above the law. over the past 200 years society has evolved into different groups of people. the senate reflects them. when the majority get into power the bring forth their agenda here regardless of the law. instead of advocating for health care, although law and first get the amendment. most intellectuals i know -- that is where my interest is is looking more for the principles of people. i just view the senate as a reflection of people. over the past 200 years we have

gone from believing in principles and freedom and capitalism into a bunch of collective different groups of people who want to fight over our little bread crumbs that are important to whatever specific. specific to me the congress and senate just reflect that. host: ed harkinit harkens back e discussion that we had about ira schapiro saying that the senate was at its best back in the 1960's and 1970's. that color reflects the same type of the crown -- the center of the break down concerning coalitions in society. guest: it is interesting to see frustration from some of the older members of the senate. the senate is older as far as

its history and who is in it. senator chris dodd went to the senate floor before the holidays at to chastise the newer members for their behavior he did not name names, but most of the newer members are democrats. he could have referred to senator jim demint, a thorn in the side of democrats. al franken has also robbed people the wrong way. he went on and on about newer members and said they really need to understand what the chamber is all about. host: should you have done about retirements. but on the same page there's another "gop struggles to capitalize."

you have some new polls out. what are they telling you? guest: there was a recent poll, how you identify yourself as a democrat has dipped considerably over the past year. republican members and polls are still struggling. the problem for house republicans is -- you don't have much power when you are in the minority in the house. republican leaders are trying to make the case that they can win back the house. we will either get close or make significant strides. a lot of these guys have been in power. they have been chairman. now they have very little power and it is frustrating to them. host: the newly times" has --

"the new york times" has the story about bart starr pack. his position on abortion does not reflect that. -- bart stupak. guest: what stupak did on the health care reform debate which is still ongoing was quite remarkable. i rare foreperson -- i think it was rare for a person not a committee chairman. he formed enough collisions where nancy pelosi knew that she needed to get as many votes as she could. without him and a lot of the people he got it would not have passed. stupak got his amendment on the

floor. 240 democrats voted for his abortion amendment which is a lot more conservative than the senate language. it is interesting because nancy pelosi is very pro-choice. harry reid is pro-life in the senate. but the bill is kind of flipped. what stupak this remarkable, and he has gotten older. at first he said he would not vote for the healthcare bill unless he got an amendment. then when his amendment passed to says it will not vote for any health-care bill without the language that he put there. that was pretty remarkable. host: let me add a little more. here is a photograph of him. for now as he considers his return to washington he is canvassing his district.

he is trying to pass the health care overhaul. he predicts the legislation will ultimately collapsed for reasons apart from abortion. he will be blamed anyway, he is sure. he says "i'm sure in the last guy that the president wants to see." tammy on the democrats' line, fla. caller: thank you for c-span. we have some good senators like nelson. that man is for the people. in a few weeks i will visit washington.

lemieu's office when i called them -- at get any return phone calls or insight. faughalan is stepping them. that seed will be open. they say that our governor will run for senator. he is a good man and has done a lot for florida. -- that seat will be open when alan is stepping down. host: she is interested in financial reform legislation which is senator dodd's committee. a number of analysis pieces. here is one. . .

he can just get down to legislating. he has a very good relationship with the ranking member, senator shelby. but the issue is, that consumer protection agency does not have -- will not have 60 votes and if it is going to pass the senate and think it could be something similar to the public option, where it they get it through the

senate they will have to hash out the differences in conference. host: texas, richard, republican. caller: my comment is i feel if this republic is going to be saved, we just about have to repeal the 17th amendment just like real -- we repealed 18th prohibition amendment. the senate was designed to represent the state. it was not ever designed to represent popular -- that was the whole point. they did not want philadelphia, new york, boston people to run the country so that had a senate that was representing the state. and we've got some many senators who are not going back, and -- not doing that. it is creating a mess. it is given the governor's a mission of possible. just my opinion. host: let's show the front page

of "the denver post." governor ritter is not going to be seeking reelection. the headline on the story -- guest: very interesting. can salazar, former senator from colorado -- ken salazar. there are rumors about attorney general but more focus on the interior. he ultimately accepted the job at interior. a very difficult decision for him. he made good inroads in the senate. alternately took that job and now democrats are trying to retain that seat. he is the big name coming up now that ritter is not going to seek reelection. he would be considered the favorite also -- as the denver mayor, could also step in -- and republicans, former congressman scott mcinnis and another

former congressman could make a play. but richard was suffering from low approval ratings and many people thought that if he ran he would have lost. host: republicans are suggested -- suggest king -- suggesting they would capture state houses. guest: the reason why it is so significant is because of the senate. the state legislatures and governors races. i think you will see a lot more federal money or money that usually goes to federal campaign committees going to the states because it is so vital and people on both sides already have keep people watching the senses because it is so important. host: we got a lot of long time politics watchers the people -- explain why the census matters and by the government has a role in it? guest: when they send out a

census and they are already starting for 2010, starting to get organized for that, basically the more people in district did -- different districts get more money. as populations grow and wayne, also congressional seats either get added to their districts get merged. it becomes fascinating for political watchers because in a certain state, a lot of the population drops, then you have a lot of match ups of democratic incumbent against democratic incumbent or republican incumbent against republican incumbent and a half to face off. as far as to who draws the line as far as who decides what states will do more and how the districts are going to be drawn, a lot go to state water -- legislatures and governors office. a lot have independent commissions, but as we saw with tom delay in 2004, working with the republican governor and

texas legislature basically redrew the districts. it challenged by democrats legally. republicans won. because of that, republicans pick up seats in 2004 elections and had it not been redrawn that we democrats would have picked up -- host: talking about salazar. it is headlined -- this headline. in politicians speak, what does it translate to? guest: when we heard that he was joining the cabinet -- and we had sources saying that, we also asked him. we heard he was going to go to interior. he ducked and denied and ultimately went there.

i think he is certainly weighing it. i wouldn't be surprised to see him get it. host: long beach, new york. you are here with bob cusack. guest: it is exasperated. i used to have a great deal of respect for the senate. i'm on the independent line. by nature i am conservative -- or its -- libertarian type person. i was watching or hatch giving a tour of the building and he went to the president's room with these marble statues and said this is where we come and meet with our lobbyists, and he realized what he said and he said, constituents. there and lies the problems. they did not send all the jobs overseas, a great manufacturing jobs -- they did this hand in glove, democrat and republican together. when they are working bipartisan i know we are in big trouble. we are about to get stomped

because they are not acting in our interest. these closed-door meetings with the health care, are you people upset? are you going to flush home and say something about that? i'm sorry. host: you don't have to be sorry. that is why -- why as the meetings to be opened. we had a conversation on a program yesterday morning's so we have in fact it something about that. and giving for the caller? guest: there is some frustration. the obama administration promised major change. and not only the meetings, democrats and democrats about what will be on the final bill, but this white house is very pragmatic. they know how to count votes and they struck deals with lobbyists, with drug companies on the health care bill knowing if the drug industry was against them, it would be very difficult to get the bill through. but it thrust -- frustrates a

lot of people. a lot of people on the left is asking, this is not the change we voted for. host: yesterday congressional leaders met at the white house. the speaker said sometimes there is an agreement but sometimes we approach the built differently. >> telephone call, avondale, arizona. jim on the democrats' line. caller: regardless the retirement situation -- it might be a blessing. i don't know who has the poll's of the regular voters out there -- republican, democrat, independent. most people are pretty of all discussed it with the congress and the senate. however the incumbent is, i feel

sorry for him -- it seems like people will vote for whoever the opposition is regardless of affiliation. the entire of the stuff. the people don't represent us any more. they don't represent the people anymore. it even goes down into the local elections, communities where people are going to advance this discussed. host: another call about voter sentiment. guest: one of the things to remember is in these al-maliki times -- you look back six, eight, 10 years, the difference in the house and senate, did go up three, four, five seats -- really 2006 with this the biggest wave since 1994 and

another wave in 2008. in these volatile times, failing economy, high unemployment, two wars -- now 2010, another wave is expected. the thing to think about is while incumbents in congress as an institution i never really popular, a lot of people like their local congressman. if you are going to beat your local congressman or senator you have to raise your money, so you can go on television, you have to have a good staff and a lot of people that run and launched these bids. if they don't have that, they are not going to win. host: you have a story in "of the hill." -- "the hill." why are committee chairmanships

important? why should people follow the detailed down to this level? guest: because they will decide what is in the bills of jurisdiction. if you look at the health care bill, senate finance committee, chairman max baucus is more conservative than most democrats and he crafted a bill that even some democrats on his panel would not crazy about the end up voting for it. whoever heads the committee is usually the one crafting the bills and setting the agenda for the committee. generally working with house and senate leadership. whoever gets the gavel basically has a ton more power than the second ranking person. if committee chairman does not help the votes, -- you have seen jostling over the last year, a lot of committee chains -- chairs have changed.

it also depends on elections as far as who gets the chairmanship's and what kind of ratios -- how many democrats, how many republicans. host: connecticut, charles, republican line. good morning. caller: mr. bob cusack was speaking before about republicans getting behind some faith that was obvious. i watched the senate a great deal on c-span. the one man who impresses me the most when he is speaking on the floor is tom coburn. i'm wondering what mr. cusack's viewpoint of tom coburn as a leader in the republican party. i will hang up. guest: he is definitely very popular among the republican base. he usually votes fairly conservative on almost all issues. he is a friend of actually the

of the president, they have good working relationships but ideologically are very different. he did vote for the bailout, which raised some eyebrows but republicans are happy he is running again. he is now in his first term -- his second term, that will be it for him. in six years plus he will be leading the senate. it -- leaving the senate. but he also republicans the wrong way because he blocks their bills, whether appropriations or earmarks. he was a big backer of senator mccain because of his anti earmarked position. he is definitely a voice in the republican party but because he will basically be in his last term next year it will be interesting to see woody does in -- when he leaves. he is a doctor. in a go home. host: a question about the florida senate race --

as opposed to charlie crist, the governor. guest: there definitely were some splits in that we saw in the republican primary when it came down to mitt romney and john mccain, and there were some splits about who is on what side. and i believe -- i believe mccain contributed to rubio. but charlie crist is basically a mccain guy and because charlie crist back the stimulus, which mccain had not, that is something that really hampered him. rubio, who is just viewed as an up-and-coming star, newt gingrich had said a lot of good things about him over the years. really closing in but that image of charlie crist hugging obama and then charlie crist recently saying he really didn't back the stimulus has hurt his political standing. but charlie crist is still a

very shrewd politician. anyone who counts and out could be foolish. host: washington, pennsylvania. paul on the republican line. caller: i would like to make a comment on the 2010 elections. i don't think there are going to be any presidential coattails. i certainly hope we can include arlen specter in that retirement party. i'm always amazed, mr. cusack, people like you, will have such a wealth of information -- i guess it is your job -- but it is good to hear people like you because we get to know a little bit more about what is going on besides watching c-span. lastly, i would like to say, i will harkened back to gerald ford's speech. i think the national nightmare was starting. i don't think it was over. and i would like to say something that i know this may

not be very popular, but when the democrats decided to destroy richard nixon because he did something that democrats do all the time, we left ourselves open to all of what has happened since then. i will hang up and you can tell me what you think about what i have to say. host: thank you so much. let us start with his comments about senator specter. charlie cook in his political report put senator arlen specter's seat firmly in a tossup. guest: fascinating race. it started up where it look like when arlen specter was a republican he was going to face up against pat toomey in the republican primary and a lot of republicans privately said, well, we don't want pat toomey to run because he can't win general, and now are inspected changes parties and now, specter is battling congressman joe sestak in the race -- that race is looking to find joe sestak,

he is a favored to win the primary -- host: who is favored to win? >> arlen specter. he is up in the polls but that may change because a lot of people are frustrating with arlen specter, both on the left and right. but the matchup of pat toomey and arlen specter, if it is that, is going to be fascinating. these guys went at it in 2004 and the republican primary. arlen specter barely beat pat toomey. these guys are not friendly toward one another. that could be a fascinating race. polls have shown pat toomey has made up some ground and recently he said he backed actually the nomination of sonia sotomayor, which is gonna surprise because he is a conservative and most conservatives rejected her. some people viewed that as a move to the middle. host: twitter -- guest: absolutely. if you are an incumbent, once you get here you are favored to stay here.

freshmen are told, if it is your first term you of the bulls -- most the honorable you will ever be. -- the most vulnerable you will ever be. host: we will take a break. in the next segment we will talk about the economy and get two views.

>> richard holbrooke is the u.s. special representative to afghanistan and pakistan. he will be visiting those countries next week and meeting with leaders. today he will talk about obama administration policy in the region at the brookings institution, live coverage at 2:30 p.m. eastern on c-span2. "in fed we trust," on fed chairman ben bernanke and his role after the economic collapse in 2008. he will discuss this book with alice rivlin, former federal reserve vice chair and first director of congressional budget office. >> the new c-span video library is a digital archive of c-span's programming, from barack obama

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just create a 5 to 8 minute video on one of our country's great strengths or a challenger country is facing. it must incorporate c-span programming and show varying points of view. winning entries will be shown on c-span. don't wait another minute. go to a student'scam.org. >>host: during our next segmente will be talked about the economy. we have two voices. kevin hassett, economic policy studies director at the american enterprise institute. lawrence mishel from economic policy institute. both are phd and spent a lot of time helping to influence the policy debate over economic issues. and once to start, so people know where you are coming from with the philosophical question for both of you. would you explain to people your view, given the state of our

economy and the financial markets, your view of government spending in this time of recession and a corollary, are you concerned about the increase in the federal debt? let me start there and that will define where you are coming from. guest: i'm absolutely concerned about the increase in the federal debt. you should not run a surplus in a recession but even if you include stimulus and calculations government spending is 25% side -- exclude stimulus in cancellations government spending is 25% higher and it assumptive with the fix in the next few years and fix may be either tax increases or reductions in spending that might put a damper on the recovery. host: lawrence mishel? hawaii guest: i think the major problem in front of us is the fact we have very unemployment and it will stay high for some time. air response to a financial crisis and policies that were overly reliant on markets

without enough government regulation. the fact that we have a very high fiscal deficit right now is almost totally do two things. when you have a huge recession, not enough taxpayers paying money and money we spend a session -- and the savaging of the revenue base by the bush administration in the last administration. so, we will get the deficit under control as we get jobs, and so the real problem right now is getting people jobs. host: let's turn to jobs. a question for both of you. what is the government's role in job formation? guest: might be right now, when you have a private sector that is totally -- my view right now, when you have a private sector totally dead and monetary policy at full blast and we still not getting very robust growth, not getting very good job growth and unemployment declining, you actually do need the government to step in and do more to help

generate jobs. they can do that in very simple ways. some is providing fiscal relief to state and local governments, allowing them to preserve their jobs, preserve their purchasing and create jobs. we have infrastructure spending. the government can do direct job creation. he have to provide ample relief to the unemployed. so they are out there protected from recession but also spending. i think we can do a lot more to generate jobs in the next year doing that kind of program. host: kevin hassett? guest: i think everybody will be reattached to the work force because the private sector is growing. the public sector is already large. while the government can do things in the short run to help us out, may be building a bridge over here and in planning folks, the real problem is the government needs to think about what is going to do to create incentives for people to the jobs in the u.s.. there are a lot of policy changes i think are necessary for the job climate.

i think the top two is one that maybe larry and i agree on, i think we need to change our unemployment insurance program so firms have an incentive to share jobs with people rather than laying them off. right now to get unemployment insurance, a sort of have to separate you from employment. if, on the other hand, i can reduce your hours 20% and your salary and have the government fill in some of the whole, maybe you could spread the pain out amongst more people and not actually separate people from the labor force. number two, we have to understand why it is people are not creating plants in the u.s. they're much. i think we have a lot of policies that are out of whack with the rest of the world. in particular, corporate tax. the second-highest on earth. in many states, the highest on earth. firms are rationally looking offshore where taxes are lower. those are the two big ones. host: d.c. corporate taxes and impediment to job creation? guest: that is not what is going on right now.

it is insufficient demand. we have too much supply, way over capacity of firms to produce. many more people who want to work are not working. the problem is not the fact that there is not an incentive for people to produce. the problem is consumers have cut back because they lost a lot of wealth in the housing market and the stock market and employers, corporations are not investing because there are no consumers for their product or not sufficient. i don't see the corporate tax rate -- kevin cites the numbers but these and that the effective tax rates. we diminish the role of corporate taxation and our economy for very many decades, and i don't see that as a problem whatsoever. host: phone numbers, if you would like to join into the discussion --

host: the big story en "usa today," it affects of recessions been felt for generations in society. do you see this in this recession, and if so, how? guest: it is really an urgent policy issue that congress has to address and has been lax getting going. the fact is, if you take someone and separate them from the workforce for a while, that does permanent damage to their career, if you think about the kids coming out of college having a hard time, or folks who lost their job a year ago and have failed to find anything yet. if you separate from the labor force for a year or two, you are going to add a hard time getting back in. you are going to be the to do it, but it really does do serious damage. i think the fact we have not done something like create a work sharing program is really going to cause a lot of harm. i think it should be an urgent thing for congress to address beginning of next year, to think

about what will we do -- long term unemployment was really not a problem like it is not going all the way back to the great depression. the great depression, you remember in movies and things they had, hoboes, people were just a different part of subsiding that exist in little bit but it might expand tragically now. long-term unemployment is something that needs to be addressed. guest: susan, i think that is a very important point, the fact that recession does permanent scarring to people and productive capacity. you hear a lot of concern about the debt, as if this is going to hurt our children and grandchildren and the fact is, not doing anything about jobs and getting out of recession is also going to be hurting the future a lot. we are not getting the investment, you do not get the innovation. it even has a substantial impact on children in school. school problems has much to do

with -- at home and what their parents going through. parental stress, loss of income, higher poverty. the 10% unemployment rate that we now have and will be seeing will lead to 50% poverty rate for african-american children. this is going to substantially hurt their education progress, and this is going to start a generation of kids. guest: just to put it in perspective, i did a calculation a while ago that if we had taken the stimulus money -- i do not want to talk about what that the stimulus was smart for stupid. i think there were a lot of good things. but if you took the stimulus money and hired people -- people at the median wage you could've committed 20 million jobs. this is an urgent time. just giving people jobs is not a crazy thing to do. we could, once again, bill pass in national parks and so on. but i think affixing unemployment insurance and the government instead of trying to create jobs, juicing economy

here and there, are giving refunds also security, i think instead of doing that the government should consider, such a big problem, creating jobs. host: our first call is from missouri. ron on the republican line. caller: i first have a comment and question and i would like your guests to attend to answer it. the biggest problem as i see with the economy in this country and what has happened to it is the lack of integrity through the entire population, from the oval office to the janitor cleaning up. everybody seems to want something for nothing and the work ethic is just about disappeared in this country. or the good work ethic. more to the point, one of the biggest problems in this society seems to be there are so many non-productive jobs getting fantastic pay. for instance, both the guests

this morning on this program, it appears that they sit in an office and administrative over a group of people that is nothing but make policy decisions or review policy decisions as opposed to the way it was years -- a few years back where our best and brightest are actually doing something productive. both of you, i've heard this morning, proposed more government intervention. with the policies of congress and the administration right now, the future is such an unknown because you don't know what the taxes accord today, you don't know what the liabilities are going to be, it is impossible for any reasonable mind to figure out in the future what your costs are going today, whether or not you could possibly even hire someone.

so everything going on, from extended unemployment to higher taxes for health care just makes jobs innovation or new jobs and impossibility for any of japan or businessman. host: thank you for your call? guest: i think ron raises import issues. first, let me say, i will speak for myself but larry is a very productive guy and, in fact, he brought this book over here that they produce every year which is the state of working america and folks run out to the stores to buy that every year when it comes out because it is filled with useful facts so he is producing a product people want, not just sitting in his office and thinking about policy. i honestly do think the caller is on to something, that while we can think about stuff the government can do better, we need to remember ultimately it is the private sector that will

create jobs. we have to understand if the private-sector is not writing jobs, why it is. high tax rates are a big issue right now the government needs to do more to address those issues. guest: i take umbrage at the notion that a major problem facing america is that people are slackers. when we have 15 million people unemployed desperately looking for work, and private sector firms laying off and insufficient policies to generate jobs. right now there is something like six people unemployed for every job opening. so i think the idea of that there are a bunch of slackers out there is repugnant. i believe that kevin is a very productive person as well. host: of the point about

uncertainty. guest: i think there is a lot of exaggeration. we have major problems that have not been attended to for 30 years. and we have major crises in front of us. of course there is going to be a lot of uncertainty and we have to do major changes. we have to address climate change. we have a health care system that is broken. we have a retirement system that needs fixing. there are many things that need changing, so we have to do that and i don't think that is the main impediment to job growth. host: ai tweets us -- guest: the real economic burden -- first, an act of a lot of people over 65 are working really hard right now, to -- actually a lot of people over 65 are working really hard right now, not just collecting government checks. of the government checks the collector things they earn over a lifetime contributing to

social security and medicare. to think of them as a burden. we did not want to put people on an iceberg and float them out to sea. but the problem is those programs are not doing well financially in the long run and they need to be adjusted. congress keeps putting it off. i think the health bill does not really do a good job putting medicare and medicaid on sound footing in the future, and ultimately as we keep running up our debt, world investors will say, why should i buy this u.s. government stuff? they keep avoiding their big problems. the problem of aging is a big part. host: sandy is on the democrat'' line in stockton, california. caller: thank you for c-span. i'm wondering what both of you gentlemen think is the role that nafta, our current laws that allow employers to offshore

living wage jobs that would be high paying jobs, out of the united states with a tax break given to them by we, the taxpayers, to ship our jobs overseas to country's mood don't have the same labor laws and safety laws and to also don't have to pay -- or don't have the increased cost of new products or health care costs, increasing the costs of their products. how do we as a country come to terms with the way that we have

structured our business laws, trade laws. how does that impact where we are now? i believe it is damaged us. i sincerely believe that the ability for employers, multinationals, to seek out the country with the lowest cost in terms of production -- not that americans are not producing. we are producing at a stellar rate. we are producing more with less. host: @ thank you. at this point we will stop because we understand your question and we will start with lawrence mishel. guest: sandy, i think you are onto something that is important, and the large trade deficits we have had and the

erosion of manufacturing has been a major blow to the middle class in this country, a major problem. i think there has been far too much indifference to this problem and i think it can be addressed. i think we need an industrial strategy to try to focus on making sure that we have a healthy manufacturing sector. we talk a lot about alternative energy and green jobs. we have to make sure we actually produced it in the united states and provide employment. based on these policies. and we have to have trade policies that stick up for the american worker. so, i did you are onto something. guest: i think that we can't shut off our borders to trade. the bonds are there are many products in sandy's like that she really enjoys -- maybe a car that was made abroad or a television. the fact is, right now our tax code encourages firms to locate

activity offshore, just as sandy said. if i locate my profits overseas and sell back into the u.s., i have a much lower tax rate than if i eat produce it in the u.s. the problem is, if you say let's not let them do that and make sure they have to produce it in the u.s. to sell in the u.s., you run into the problem cutting up to you plan -- u.s. market thing to want to have the mayor, imports from other countries, and you run the risk of having a u.s. firm disappear altogether and foreign firms can take over the market because they have the tax advantage. the average oecd country pays a 10% lower tax rate than a u.s. manufacturing firms, and that 10% rate difference in a big deal and it is a cost for u.s. firms and something we have to address. right now as the economy starts to expand, if you are a firm that has a hot product you would almost be crazy to build a new plant in the u.s. and locate the activity here because of you located offshore your profits would be a lot higher and it is

something we need to fix. host: dollar policy. could you both comment on your views on the administration's approach to dollar valuation? guest: i think if you have a big deficit, which is something caused by a lot of things, a lot of things larry and i agree -- the dollar will be weak. people were rigged that probably we will try to inflate our way out of the debt, and so on. i think the fact the dollar has been weak is not a surprise. host: would have been the pluses and minuses? guest: of the plus is it makes it easier for our products to compete and you see movement and the right direction. the minuses -- we put ourselves in a tough situation if we want to continue to borrow a lot of money from farmers because they give us money, they buy dollars to do it and get dollars back

and of the dollars are worth a lot less, a much higher interest rate. that is going to be, i think, a big factor this year. president obama, i think, is promising behind-the-scenes that the state of the union will talk a lot about deficit reduction. i think if we don't make a serious, credible effort of long run deficit reduction, then of the weak dollar could really put a lot of strain on the fiscal situation. people would really demand higher interest rate to buy u.s. assets. guest: i think it is a good thing the dollar is weaker than a year ago and i think it needs to ask the fall in value further pared i think we have had a strong dollar policy that basically is serving the financial sector's ability to buy assets abroad cheaply, and at the expense of people who want to produce things to export, and at the expense of people suffering from greater import competition. i think you have to address forthrightly the manipulation of

the exchange rate by the chinese, which is essentially helping them to grab a part of our manufacturing sector. host: our next call for our two guests, portsmouth, new hampshire, john on the independent line. caller: how is everyone today, all right? that's nice. i have a question. the and how long ago it was where we didn't have a deficit -- do you know how long ago it was when we didn't have a deficit, the country was running and positive question of guest: we were forecasting surpluses a little as about a decade ago and i think there was a surplus inherited by president bush when he took over the white house proposed cut in the annual budget. but as opposed to national debt? guest: the national debt has been going back almost to second world war, it could be that we have to go back to the revolutionary war.

the was a time when chairman greenspan was giving speeches about his concern that the surplus was so large that we might retire the debt and people would not have treasuries to invest in. i think treasuries have been around as long as anyone can remember. guest: only because greenspan was trying to make the case for tax cuts for george bush. there is no problem with the national debt. everyone who owns a home has a debt. there is nothing wrong with debt. it is a question of is it manageable, if you are borrowing money, would you using it for? it is true, we had a large annual surplus in the latter years of the clinton administration and at that figure away. host: john, what is your point answering the question? caller: do you think we can pull out of this debt somehow? guest: yes. host: john, we lost the transmission. guest: absolutely we can pull

out of this. in fact, there is good literature on how to do it. one of the interesting things about the recent history of europe is that there have been a lot of countries that started as eastern bloc countries with a terrible fiscal situations who had to get the houses in order in order to join the eu. so they went through some pretty radical policy changes to fix the fiscal situation and generally found it could have a great deal of success if they followed the kind of recipe that relied more on consumption taxes like value added and reduced government spending. i think there is a precedent for giving the house in order. whether the u.s. has the will to do what any time soon is the question. host: this viewer by twitter -- guest: weren't the bush tax cuts wise thing to do and fairly structured?

i think the fairly structured thing -- for me, i don't think they were wise at the time. i argued against the bush tax cuts as mccain's adviser in the 2000 campaign. but the reason why i did not like them as an economist might be different from the reason the person sending the tweet. i did not like them because they wasted a lot of money on things that would have no economic effect. if you are worried about the marriage penalty, were read about the child credit, then what your doing is maybe redistribution policy but it is not actually changing incentive -- people will not go out and have a kid because of the child credit. i thought they were poorly designed at the outset because they were very costly and a lot of the cost was on stuff that cannot have economic impact. i think if you are going to cut tax rates, then people on the

top of the income distribution are going to get a bigger dollar reduction. i think the proportionate reduction was about even across the board if we go back and look at those. so, i am not as concerned about some of the sound bites about how the rich got this percentage of the tax cut and so on because they pay a large percent of taxes. guest: i think the experience of the bush tax cut should settle the date as to whether we get economic growth because with several major rounds of tax cuts, reducing taxes on capital gains and dividends and focused on high end tax cuts and we have the weakest growth rate cut -- a record, employment growth, of any business cycle since world war ii during the bush administration and so of that were really such a great recipe we would have done a lot better, so in retrospect when not only have given away a lot of revenue that we needed and we really did not get great economic bang for the buck. host: new orleans, frank, a

republican line. caller: good morning. two quick questions. several economics people and people in general are worried about spending and i think that they are saying that that was one of the reasons we had the deficit and had problems. would you comment on whether or not the bailout of gm and some of these other companies where there are several jobs online and several jobs behind those jobs on the line, was that a wise spending move in terms of committing the money to something that is of economic value? you know incurrent -- incurring some deficits, was that a wise spending will versus saving those jobs? my second question has to do with -- income inequality in a sense that most of the people

who are working now or who are out of jobs now, if they get a job they have to accept a low- wage because they are not getting a job back in their own field. but when the jobs do come back, which is quite a ways down the road, the argument from the other side may be, you have to accept a low wage because we are now competitive, now in a global economy and somebody in china or india is getting one third of your wage so you must accept a lower wage. that in itself a sort of institutionalize a new way to level that was different than we used to have and sort of establish income inequality again because i don't think a higher level folks are going to change their salaries. host: thanks. let us start with your second question because there is a good job thing -- jumping off point about what is happening to wages and the economy.

guest: i do think that helping out the auto companies with a good idea because we saved 3 million jobs from that. and i do think one of the major issues facing this country was the fact we had wage growth that is not good enough and there was too much downward pressure on wages -- one of the things we had as a problem causing this financial crisis is we grow based on people on borrowing and based on inflated asset baubles and the stock market and housing. what we really need to do is have growth based on people earning good wages and spending it. wages have not kept up with productivity growth. people are producing more. they don't get their fair share. if we don't fix that i don't think we will have stable, robust growth into the future. so, to me, that is a really fun answered policy question that needs to be addressed as we get out of this recession. ihost: income inequality.

guest: ultimately we cannot dictate higher wages to firms. we have to create the conditions that make them, one, invest in things that promote productivity and, two, make sure the labor market is tight enough so productivity has impact on the wage. i think the g-8 and bailout and the auto bailout's generally was a terrible idea -- gm bailout was a terrible idea and a waste of taxpayers' money. it was extremely political. i think a big union donors to the democrats were put in front in the bankruptcy process in a historical unprecedented. i view it as just a partisan political maneuver that did not save jobs at all because if these firms were forced through the bankruptcy process that would have probably reorganized at the normal bankruptcy process. host: chattanooga.

kathy on the democrats' line. caller: i'm disabled and i worked enough to draw the $20 more than someone who did not work at all during their life. my biggest thing is, i think tennessee was a jump off the state with reagan -- with bush, trying to start their own medicaid program. what ended up happening is everybody that did not have children or was not disabled got kicked off -- is what was called. i heard the other day that he got $7 million grant for housing but nobody knows where it went and a couple of days later i heard $17 million was allotted to help rebuild housing in -- i don't know if it was where a

tsunami hit war in iran. our section 8 has 4000 people waiting on the waiting list of there is no money. the people on the waiting list has no money to get section 8 vouchers to find safe housing. host: kathy, thanks. i will pick up from there. for me, that question really is on priorities on government spending. people at home waiting for affordable housing as money is going overseas. guest: i am concerned about priorities, too. and i think we need to be a lot smarter than what we have been in thinking about how do we help the people that right now who are at risk of being long term unemployed, how do we give firm's incentives to locate here so people have good jobs here, and less on the issues that have driven politics for the last decade. i think there is gonna of a tit-

for-tat between parties where we are always for that, always against that and we get washington, i think, flooded with partisan disputes over things that are not the urgent problems of the day and that needs to be changed. jon scott i think priorities are such where people want -- guest: i think priorities are people want people to have section 8 vouchers. but polls show the american people think the government spends a lot more money abroad than it does, basically i think less than 1% of the total budget. host: excluding wars. guest: but in terms of transfers to assistance abroad. i think we spent a lot on wars, too much. but, you know, and nothing that is what is really draining the money from being able to do section 8 housing. i would note that any time there

are bills going through congress, they throw money and business tax cuts. we just had another $30 billion or so last november and december, which is going to be very ineffective to do anything to generate jobs. but there seems to be a bipartisan agreement. host: we have about five minutes left. i want to go to a real core issue, asset valuation of real estate. as you suggested, many people's wealth was based on what they felt was the ever increasing value of their house. since that bubble has burst, it seems as though policy toward restoring real-estate values, where we keep seeing signs valuations are going down. how is this cycle going to end up and where will people and up with their real-estate holdings, which was the major source of wealth? guest: of that is a good question. i think that we are going to continue to see realistic housing values fall in many places of the country -- real

estate values fall, they were at an inflated level and the need to be restored in another way. we need to do something to try to preserve people in their houses -- nine host: not necessarily the value of the house. guest: i don't think keeping the housing values from falling is a long run solution to this. it got out of whack and it will have to restore itself. we have to make sure people don't get thrown out of their housing. it will take sacrifice from banks as well as people, as well as the policies to keep people in their homes. but it will not be keeping housing be used where they are now on getting back to where there were two years ago. guest: if you go back to the early 1800's, jerry the single -- jeremy siegel did an analysis estimating rate of return realistic going back to the

1800's and it turns out it is approximately zero. historically there have been homes and busts throughout american history. i think one of the reasons is, when prices start to go up, people start to build and expand into vacant areas and the u.s. has been blessed with lots of land and it has been pretty easy to do that. the fact is historic leap has been something that has not been a great investment compared to other things. in part, diggs supply response to -- you cannot drive around d.c. without seeing supply response. highways are completely covered with condos all the way out to dulles airport. what it means is we experience something what you have seen many times we for and we should not expect a rapid recovery because this is what real estate does. host: hollywood, florida. knacks on the line. independent. caller: my comment is toward mr.

hassett, along the lines of the reason why our corporations, multinationals, tend to locate of short, we have the highest tax rate, corporate tax rate in the world which really is a nominal tax rate by the time you figure in all of the tax shelters, accounting games, deductions, etc., they bring in, it has come out in the past that some of our most profitable corporations pay a very tiny percentage toward taxes. so this argument that our high corporate tax rate is driving our business is off shore is a fallacy. guest: no, max, actual your facts are 100% correct that we have a high tax rate and low taxes relative to profits for firms. but the thing is the mechanism that firms use to reduce their u.s. tax liability is to locate

the profits offshore. what they will do is put a subsidiary and a place like ireland and that subsidiary will sell intermediate goods to the parents back in the u.s. at a really high price of the profits will end up sitting over there in ireland and the u.s. activity -- will not pay much tax. it is true that the tax revenue we get out of the system is relatively small, it is because those games are played, but it is those games better costing u.s. jobs because in order to play games yet to locate over in ireland so you can transfer profits to them. host: fullerton, california, helen on the republican line. caller: i read of bernanke has said that he compares the great depression with our recent great recession, and by comparing the stock market bust in 1928 and 1929 was subprime mortgage bus and easy credit bust. what we are going through economically is worse than it

was in the great depression for the simple fact that the trend has been for the last 30 years has been to outsource our business and industry. how are we supposed to economically recovered if we outsource most of our jobs that will stimulate our economy, and over 30 years ago my father worked in the steel mills out here in california and my mother was unskilled labor, working in factories. caller: my question is -- well, not my question, but my observation is it will be a lot harder to recover from this economic crisis that was back in the 1920's. host: we are out of time to read is she correct that it will be a

lot harder this time around to get out of this? guest: we are in a really deep hole. what she is talking about is my concern, that we have had a war on " good jobs for 30 years, and we need to make it a centerpiece of the economic policy, a great jobs that people can support a family with. it is not just enough to make productivity growth. we have had lots of productivity growth. 80% productivity growth over the last two or three decades, workers pay up 5% or 6%. that is really not the answer. we have to find what works for working people that provide some good jobs, good benefits, a good retirement, i wages. we need to have strong unions and a strong minimum wage and a much better health care system. guest: i think that the united states can do a lot better, but

we need to remember that there is reason for hope, that we have had a lot of recessions, from the second world war, and the recessions have been deeper, we've tended to recover faster and stronger. it could be that the economy has moderated, and will take a lot tend to recover, will be is proven, -- will be disapproving, just as having our recent recession and was proven by recent events. gdp will grow something like 4%. if we get 4% growth in the fourth quarter, that is the kind of thing we need to start to get a job creation again. we can list all the bad things and leave people depressed as they start their days. the thing to remember is that we recover from the other recessions -- and we recovered from the great depression, for goodness sakes, and we will recover from this one, too. host: kevin hassett at the american enterprise institute

and lawrence mishel of the economic policy institute. we'll talk about health care during our final segment with someone with an inside view of the profession. we'll be right back. >> richard holbrooke is the u.s. special representative to afghanistan and pakistan, and will be visiting those two

countries next week and meeting with leaders. today he will talk about obama administration policy in the region. that is at the brookings institution. that is at 2:30 eastern on c- span2. "in fed we trust," from david wessel, on ben bernanke. he will discuss his book with alice rivlin part of this weekend's book tv on c-span2. >> this c-span video library is a digital archive of c-span programming from barack obama to ronald reagan and everyone in between. now available to you. it is fast and free. try it out at cspanvideo.org. >> "washington journal"

continues. host: we will introduce you to our final guest, dr. atul gawande, a surgeon, and has been involved in the policy on health care for a decade and have now. he has written a number of books, and his latest book is called "the checklist manifesto." will talk to him about all that this morning. during the clinton years, he served as a senior health policy adviser during the campaign and in the white house from 1992 to 1993, and you can reach him on a fairly regular basis in "the new yorker." when did you make the decision that in addition to practicing, you would also be involved in health care policy? guest: i tried to avoid being a doctor for awhile. the son of two indian doctors, you will naturally become a doctor yourself, and i wanted to push against my own inevitable path. during that time, i did a

master's in politics and policy and came to washington and work for jim cooper, a conservative democrat from tennessee. i worked on the al gore campaign for president way back in 1988. in 1992, i came back from medical school, which was the thing i kept falling back to, because i did not like depending on working for other people to figure out how to -- what i really think and how i can contribute. host: let's get to the 30,000- foot in 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 -- how much it costs us to get, and how many people don't have access. guest: in many ways, we have amazing, cutting edge of health care. we have access to unbelievable technologies, unbelievably well trained people. the same time, you can find

some really abysmal health care, with a lack of access in poor communities, cities and neighborhoods, and that is a stark contrast and a major problem we are struggling with. the second major problem we are struggling with is that the pieces don't fit together for any of us. the thing we are struggling with in health reform -- we have focused on the insurance hassles and insurance organization, but we've missed the point that the deepest struggle is with the complexity. science has given us 13,000 diagnoses that we have identified as problems that the human body can sustain, 13,000 ways that the human body can fail, and out of the last century, 6000 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 costs once and for all? the reality is that in order to organize care more effectively, we know we had a fundamental problems. doctors don't work together. we are fragmented. the incentive system where we are paid piecemeal, fee-for- service, has led to be small care -- to piecemeal care, has

led to overtreatment in certain sectors, undertreatment and others, and his treatment, mistakes and a carrot that happens all 2 ft. -- mistreatement, mistakes and get that happens all too frequently. host: have you come to a conclusion about what is moving along the track on capitol hill? guest: you know, might litmus test is are there tools here -- we have clinicians working with patients, be able to use to make the care better for our local communities. the 15% of our patients who come in the door and don't have coverage -- that is a constant clinical battle. i'm a cancer surgeon. . i spent years struggling with what we are going to do with chemotherapy or radiation

treatments for people who cannot afford them. when massachusetts passed this plan a couple of years ago, it suddenly disappeared as an issue. we still have our struggles with some cost aspects for the patient, but the coverage part is there. the second part is that we really have not as a community of clinicians worked on how to make care more consistent, more reliable, and less wasteful. for the first time, i'm hearing people in our conventions, our meetings, and in our hospital organizations trying to figure out -- if the bill passes, there is a lot in here to push us in the right direction. i'm hearing discussions i have never heard before about what we should do to get our costs down. host: we would like to invite you to take part in this conversation. many of you involved in health care debate. we have been talking about it is not here. as congress goes back to work, and opportunity for you to

get engaged in discussion with dr. atul gawande. one last question before calls -- let me ask you to tell us your views about the implications of the aging baby boomer generation, both on the kinds of care people will be seeking, and the countries ability to pay for it. guest: the one we people are voicing about the health care bill is that covering the 45 million people, where are you going to get a primary-care doctors? the larger issue is that over the next 15 years or so, the population over 65 is going to double, which means that the number of breast cancers, calling cancers, heart attacks are going to nearly double. our work force for managing this problem is not going to get bigger. 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 are thinking, let us hire

more, spend more, and there is every sign that we can make it safer, higher-quality care and organize themselves better in ways that we can handle that problem without expecting 50% of americans to become doctors. host: how does that get implemented? how does that break into the system as an idea? guest: let me give you a small example. assthma care -- asthma care -- i was at a children's hospital recently, and they implemented checklists, a counter intuitive idea for experts. if out about a half a dozen things that the major happen for each patient, and they found that you tackle things like having calls to keep them on inhalers and so on. the rates fell over 80% to guess what their number one revenue source was? asthma admissions for children's

hospitals. under reform, you say, but let us take for a package of care will be paid for results, rather than just extra money every time you bring a kid into a hospital. we are seeing hospitals talk about how to organize care so that we actually become more efficient, and get better results for people. it is going to be a real turn in how we think about ourselves as doctors and nurses and others working on problems. it is the kinds of experiments that we have to be taking seriously. host: buffalo, missouri, the democrats' line, you are on the air. caller: good morning, susan . doc, what i want to talk to about, and susan, too -- senator coburn was on your show about a

month or two ago, and he was talking about running all of these tests that he knew was unnecessary, but he had to do it for his liability, whatever. now, is that not waste, fraud, and abuse? if i would do something like that, i would be in jail. i know of doctors that do this. i am 63, i am in the va system. they control my blood pressure and everything. it is not cost me a dime. i could be on medicare, but i chose not to do it. i've been with the va since i got out of the service in 1971. but why are all of these tests being run? and i know it costs money. host: thank you. in fact, testing has been a regular theme of your sthe is 1 "new yorker" article with

the headline, "testing, testing." guest: your caller hit the button on one of the issues driving the process, the malpractice system, which is driven in ways -- let me give you an example -- headaches. one community tried to look at how many ct scans and cedar rapids, iowa, they were doing for people. they did 50,000 cds dance for a population of 300,000 people a year. all of us know this is not necessary. 10,000 of them were for had ct scans, and only a tiny number of them turn out to be abnormalities. many of them were just takes. some of it is fear of malpractice. we have not really established what our process is, the

appropriate guidelines for care for handling the headache so that we can do it the right weight. we have tens of thousands of unnecessary ct scans that are causing more harm, because we have radiation exposure, and we're seeing increases in cancer likely to appear over the next 10 to 15 years. this situation is not going to be solved entirely by malpractice reform. one frustration is that we're not seeing that as part of the components of the package. but it is out of meeting the communities to begin looking at the numbers and find ways to drive down the use of these scams, and we've found ways to do it even without malpractice changes that is able to drive high-quality, low-cost care. host: is malpractice the primary driver, the scenario you

mentioned earlier? guest: i've looked at communities and in texas where there was not practice reform, and after substantial and malpractice reform, -- it there was malpractice reform, after substantial malpractice reform, there was not a significant reduction of costs. when community spent twice as much money for health care as the other, and you what you saw was that home care agencies and others that have cropped up to take advantage of the insurance system, and use of relief fragmented, disorganized care, where doctors had -- you saw really fragmented, disorganized care, where doctors had not organized to make sure we get good care up front. even more, you sought two to three times as much surgery in the population. we are rarely doing surgery just to protect ourselves from the

malpractice suit. instead, you have gray zones. you have someone with a gallbladder attack. the textbooks say that you wait, but when you make no money, watching and you make some money -- no money watching and you make some money doing the operation, there is that tension between those needs and the business needs. host: good morning, scott. caller: good morning. i have a question about efficiency and automation. is it possible that we could -- i know that there's a lot of advancements in surgery and things, and is it possible that we have a loss of the jobs because our medical system gets so efficient, like what happened

in industry of working-class people, fabrics, automotive, woods, and things like that? is that a possibility that could happen? guest: it is. it is actually -- the move towards are being more efficient -- we could have lots of people digging ditches and we could hire more people to dig ditches and fill them up again, but if they are not providing value, it is not help our economy. in a similar way, in health care, if we are moving more and more into that sector of the economy, it means we are not able to grow and other parts of the economy. the places we are going, we are far from a world where we are about -- one of the striking things is that in this recession, health care is one industry where it has continued

to grow in employment. we have expanded spending in health care over 130% over the last 10 years, and a lot of it has been in middlemen in the system, without necessarily getting you more time with your doctor. that is one of the bizarre parts here. it is why, unexpectedly even for me, i wrote a book about check lists in health care, because solving these problems is really about these things -- we will be much more disciplined and organized about how we design care. i designed with my team a surgical checklist with the world health organization that is a two-minute check to make sure there are 19 things you get right in every operation. i was stunned to see in two out of three cases before we brought it in, patients had one of those keep life saving steps missing. we implemented it in eight hospitals, and we saw in 8000 patients we produce a major complication rates by more than 35% -- reduced major

complication rates by more than 35%. we don't work on these kinds of organizational problems in medicine, partly because of the incentives, and partly because we as experts don't think of these as the kinds of problems to work on. host: next question is from illinois, andy on our republicans' line. caller: first, i want to chastise most of the colors. seems like all of them call you up and ask, how are you feeling this morning? you know, you answer it wants at 6:00 in the morning and you don't have to answer any more, i don't think. anyway, the reason we have the best health care and the world is that we spend so much on it, and we spend it the wrong way. what we should do is specialized -- when i need a gallon of milk, i go buy a gallon of milk at the best price for my money.

when i break my leg, you know, i don't know what is the best value i can go for my money. what we need to do is promote the capitalism in health care and get it away from the insurance model. i'm so tired of everybody saying we need to have coverage. well, and no, we don't need coverage. what we need to do is no where to go -- that is to know where to go to get quality care at the best price for our money. host: let me interrupt for a second and poke around the edges of your analogy. with the milk, you want milk. but you don't necessarily know you of broken your leg when you of fallen. the first step is getting the diagnosis. caller: exactly. we have got the internet. i'm actually writing a book on how to fix all of this, and i

know how to fix the health care system in the country, and in a way, is it completely opposite of what they're doing in congress. it is to unleash the specialization -- several economic principles -- specialization, supply and demand -- we need to have the supply of health care professionals much greater, train them in a free or nearly free clinics, where people are means tested and have a copiague, electronic medical records for every american -- several points to be killed to go into here. -- too detailed to go into here. guest: he is onto something that is right. we have a figure to be really transparent about where the choices are in men -- a failure to be really transparent about where the choices are in medicine. one of the fascinating about the

bill is efforts to create and use for this. i think until towards of competition here is that we want organizations -- i think the real choice of competition here is that what organizations to be accountable for the standard of your health care and deployment, whether it is vertically integrated models of health care that we're seeing in places like the mayo clinic -- i am part of a system that is trying to move in this direction in boston. but the systems are about is saying to people that we will provide the full package of services, even the complications, and we will work to ensure that they are higher quality at lower cost. the bill offers a world where we will have competing insurers in exchanges that are driving in the direction of giving people more choices like these. but the second part of it is that we have not been willing to be as transparent about our results, or the work on these

organizational problems. and so might sense of the here is -- my sense of it here is that what is a desire to sweep away the old system, drop a new one on everyone, but the reality is that we have to build from where we are today, and it is taking steps forward, including the ideas of really driving our reform process in the direction we have got. half of the 2000-page bill is about coverage and insurance plans, but the other half are experiments and changing the way we a for health care and make it more transparent. host: the doctors latest book is available right now, and you also have a web site. guest: www.gawande.com. host: what will people find there? guest: two information about the books, but

also the research we do with the world health organization, deploying these to surgery and childbirth and beyond. host: our next call, patricia. caller: hi, susan, dr. gawande. . i'm retiring nurse. i want to mention two issues that i find would be helpful for reforming the health-care system. one of them is -- you had a guest on -- susan, i don't know if you are the moderator at the time -- but it was either from johns hopkins or the mayo clinic, and he confessed that there were no standards of practice for high-risk surgeries in hospitals. that astounded me. i feel that that really, you

know, is a tremendous race towards tort reform. i think it is necessary to have standards of practice in hospitals where they perform high-risk surgeries. it is the fault of the physician and hospital, they should pay out a patient who suffered -- the family of the patient who died, or the patient that has long term negative results. this would reduce tort reform immensely, as far as i'm concerned. secondly, i want to talk about primary-care physicians. i know that president obama is pushing for a primary-care physicians to increase the help in rural areas, especially. however, i go to a primary-care physician, and i like him very much -- however, i had an experience with the drug they

put me on when i was under chemo, and that increased my blood pressure. host: patricia, with all apologies, we have a lot of colors. -- callers. caller: i'm sorry. when they found out my kidney tests will become the primary care physician did not listen to me. host: what is the point about primary-care physicians? caller: the point is that i was sent to other physicians, and multiple tests were done, and this to me was a waste, and medicare and private insurance had to pay for all this waste. all i am trying to say is that if you are going to put primary- care physicians in, you have to teach them to know what they are doing rather than to rely on specialists to get the answers. host: great, thank you. we have a la -- a lot of callers

waiting. guest: what she is describing is the world. struggling with in edmonson. -- had the world we are struggling with in madison. we cannot know it all. we have been unwilling to admit that. we've been trained to get the idea that it is all going to be in our head, and we have not developed the systems in the place that can change that. it is why i ended up writing on something as mundane as developing a checklist across madison. we look at the aviation world and how they handle themselves, the skyscraper world, and we found the the first principle of successful conditions of complexity is for experts to admit to themselves that they are fallible, that they will fail at times, it will not remember everything, and then to build in those standards of practice, the checks on the half-dozen things that we should just never forget, that we check

before you even go out the door. it runs against our expert in stings. becoming expert is about the idea that we don't use checklist 30 am smart enough to know that -- that we do not use checklists. i'm smart enough to know what i do, that is for low status people. but as they use them, saving errors over and over, i started using checklists. i thought that at harvard, you know, we know we're doing. i have not gotten through a week without finding that our checks are catching problems of the sort that she is describing. complexity has gone beyond our individual capabilities, but we have tools that can improve our quality while saving our costs. host: california, mark, independent life. -- line.

caller: i'm wondering what his views are on how the media has covered the medical malpractice issue, and unnecessary surgeries that are being done, unnecessary tests. constantly, the press is representing this and repeating statements from some of those involved, which implies to the public that these are tests or surgeries that are done because of the risk of medical malpractice, when in fact performed the surgery is probably the most risky thing you can do. it is absurd to make this claim to the public on a regular basis. the press, of course, is getting at enormous amounts of advertising -- you can see these full-page advertisements from hospitals, and when you get hit by a car on the street, you are going to go to the hospital. you do not need to see full page advertisements in your newspaper. but $70,000 cash money coming to the newspaper every day, every day at the full-page advertisement appears in the newspaper for lasik surgery,

different kinds of advertising, different methods of pumping money into the news media to corrupt the news media, and the bribes paid -- host: we get the point, thank you. guest: it is hard for me to lay the blame at the news media ' here. i did research on what the malpractice cost drivers are, and it is about 3% of our increased cost coming from malpractice. see how much money is coming from the practice system? others are pointing out that it is only a small part of our overall cost drivers here. there are multiple drivers. the striking thing is that it has to do with -- yes, someone hears about the practice, it bought about our disorganization in our care, a lot about the way we pay for care on a piecemeal basis.

it has to do with the sheer complexity and technology of our care, and wanting to be sure that we have access to the right technologies. here is a heartening thing i would point out -- that we have about 1/3 of our communities that are providing higher-than- average quality with lower-than- average costs. moving our communities to embrace what those kinds of practices are at the medical front lines is likely to be the place where we will get the most bang for the buck and actually make a difference. with our economy struggling because our wages are being diverted over to the health-care benefit costs, we all have run into this wall, and it is why reform keeps pushing ahead, even though it is so complex and gives us all these headaches and worry about where it can go. it is because if we do not act, we -- will find well, we are already finding ourselves in deep trouble.

it is hard for me to blame the news media on that one. host: we are having a discussion on health care and the delivery mechanisms in this country with atul gawande. next call is from alabama, linda on the republicans' line. caller: good morning. i have two questions and i will try to make them brief. he sounds like a very nice doctor that i am listening to. the first question is, my husband and was rushed to the emergency room in 2009. my son said that he had no strength, could not stand. after nine and a half hours in the er, the doctor came in and its stated, "i believe your father has suffered a stroke, there is nothing we can do for him." my son says, "what can i do? i cannot get him home. my father is greatly il." he said, "if you want a question my diagnosis, i have a

form you can fill out to take a discharge and go of my recommendation." my son to get rid -- my son did that. my entire family from central kentucky drove seven hours to get to birmingham. they did nothing to it did not come into the room, -- they did nothing. they did not come into the room. he needed to go to the bathroom, and we assisted him. three weeks later, the same scenario. my son called me, and i said, " you called 911, you call them now." they got there, my husband, since august 19, has been in birmingham, alabama, and they did not do a simple test on him. he had pneumoniae. it turned into respiratory failure. at dr. -- that dr. got in my

face and my son's face saying, "it will not dispute what i as a medical professional have told you." we had come to realize that there were two deaths last year in the hospital from pneumonia undiagnosed. he got a bill for that one day, $18,000. guest: the kind of story you are telling gets at the heart of many issues we are struggling with. look, first of all, if you have a stroke, you don't necessarily know, but with slurred speech and not moving one side of your body, a family member needs to called 911 right away. 60% of the strokes in our country are treated in completely or inappropriately in our hospitals. we want to say is that hospital or that dr..

for the most part, what i find is that unbelievably hard working people, unbelievably trained, but pushed against the limits of the complexity of delivering -- things i say we are fooled by penicillin, where we thought that most medical treatment in the 21st century, an injection that would make an infection go away, make a stroke away, make a cardiac problem go away. the reality is that it has been much more complex than that. the pneumoniae you talk about -- 40% of newmont yet in our hospital -- of pneumonia in our hospitals are treated it incomplete or inappropriately. not because people are not smart, but we are fragmented in our care. you experienced a drop in communication between one person coming on shift it and the next person where we have not gone forward is embracing ideas that are, in some other industries -- as professionals,

we see mistakes by lawyers, we see mistakes in foreign intelligence failures. the common issue is what the public feels about what the philosophers called ineptitude. our biggest struggles are no blogger with ignorance, although there are areas of scientific -- no longer with a difference, although there are areas of scientific ignorance. the solutions will come with doing ourselves from focusing on individual experts to thinking of ourselves as teams that have to have discipline, standards, and most critically, effective kinds of checks on ourselves that can aid the expert to be more effective than they were. host: taxes come mark on the democrats' line. -- texas, a month on the democrats' line. caller: i think doctors prescribed pharmaceutical drugs way to much.

the to be the last option. -- i think it to be the last option. second, i want a public health care option. i'm self-employed and i have had terrible health insurance my whole life. and i am healthy, so i am lucky on that. those are my questions. host: let's start with prescribing too many drugs. guest: we have a clear areas of undertreatment, and clear areas of overtreatment and mistreatment. drugs are often not given a four key conditions, especially preventive care, drugs liked saturn's for people who who have high coronary at risk, not offered as consistently as they should read it in other instances we are -- as they should. in other instances we are over- prescribing drugs.

do we have complete let the experts locally run things without any sense of feedback or information on it? we are on the way to carving a path between these two. of course we do not want on manned control. what we want ouare tools, better statistics and information about how well we're doing with the producing overtreatment and undertreatment, having that information --with reduecing or overtreatment and undertreatment, having that information available by county. that information is critically needed. and then what comes in behind that is the sense that doctors will check for themselves. i had a patient who led an onset

of depression and went to her doctor, and they tried and i to present medication after its anti-depressant medication to -- they tried anti-depressant medication after an anti- depressant medication. they realized years later that they had forgotten to check a hormone levels. the problem was not too many or too little drugs. the problem was that they missed the basic check along the way once she got the thyroid -- along the way. once she got the thyroid hormone, within two weeks she was better. host: how'd you feel about drug advertisement? guest: i'm conflicted. i feel they are largely unproductive spending. the reason they spend money on the advertisements is that the surveys show that 80 percent of the time, when they come up with the advertisement, they get the drug prescribed to them.

trying to argue out of it just takes too long. what we really need, though -- i have no idea concerning the legal issues -- what it reflects is that we have a value to the payment for things, drugs, tests, things that i do, without valuing the time that the doctors spent with people, where you can talk through what is the best problem here and how to best take care of it. doctors time is actually now cheaper than many of the technologies we have, and we have undervalued that critical he main component. it is not just doctors treated as respect -- not just doctors. it is nurse practitioners, people who can get the right care in the right time in the right ways. host: kentucky, good morning to you. caller: this bombardment of

high-profile drugs and things like that -- you have a lot patients who go to the doctors it or something they have seen on tv, and is not necessarily something that they really suffer from, because they had one of the symptoms. also, what about the drugs for minor afflictions -- with a lot of the drugs from one of the actions, they have severe side effects. is something that the -- with a lot of the drug some minor afflictions, they have severe side effects. it is something that the fda is getting on top of. guest: when a patient comes to see me with a particular treatment they want, they want to surgery potentially or a drug. if it is completely unindicated, that is an easy call.

the hard part is that when people are responding to an advertisement or just when a patient comes in and has a fever for one day, and the temptation is to prescribe an antibiotic when in certain circumstances, a cold is much more likely. over-prescription has led to massive resistance to the antibiotics that we are using. we want to be able to push back and say that in this circumstance, we should not use an antibiotic. but under the temperatures and the production model of the medical world, it is often easier for physicians just not to battle writing a prescription or an mri scan or sometimes during an operation. understanding how we can make systems that recognize -- we don't even measure how much overtreatment there is, identifying the places where we can work on it, and working with communities towards making sure that the mix of care patients get is much more suited to what

their problems are and what their needs are. host: this message here -- how challenging has it been to incorporate that into use in major practices and hospitals and that sort of thing? guest: on the one hand, we have pockets where we have done it and we have seen improvements each time we have done it, but it really has to be clinicians who are willing to embrace it. there is a huge difference between good checklist approaches and that checklists are purchased -- bad checklist approach is. if they are poorly designed and they take way too long, a doctor cannot use them at the bedside, or find them on helpful. when we put in our approach for surgical care we found a greater than 1/3 reduction in publications -- in complications

-- the u.s. has only had a 20% of hospitals moving with this idea. partly it is because we are all working as solo agents and are not used to getting together as an organization. host: with a national health- care system where that is easier to implement -- guest: that is right. people are more organized in many ways. the other component of it is that everywhere, experts are resistant to these kinds of ideas but we don't like having checks. when we surveyed teams after the implemented the checklist, in the beginning, they did not like at the end, 80% like it, but we still at 20% who hated it, said it was excess paperwork, too much time, "i hate this."

then we ask, if you work the patient in the operation, but would you want the checklist to be part of the care? over 90% said yes. host: next call. caller: doctor, when you do surgery on someone, you get compensated for your costs, and rightfully so. as the materials surrounding the surgery, gauze and whatever medical supplies you need, at today's surpass what you charge for surgery? and lobbyists in congress -- to what is the hospital administrator obligated to buy these products at high cost that really influenced the way out insurance pays off and the way the patient pays off? have a wonderful day, folks.

guest: thank you for the question. under the current structure, i get paid one fee, the anesthesiologist gets paid one fee. at a hospital gets paid a fee, including what incorporate the cost of the gauze and everything else. an interesting phenomenon is that the person who decides whether we use the disposable equipment, the $1,000 item, is the surgeon. i remember going into a case just a couple of weeks ago where we found that we had wasted about five dozen dollars worth of stock. first of all, -- about $5,000 worth of stock to first call, i tried to find out how much that's tough cost. -- that stuff costs. the second thing is that i did not really notice it until i started writing about these issues. each of us are so separated in

responsibility is that we never looked at the whole system of care where we say, let's do this operation in the most efficient way possible with the best quality results, working together as a team. we do that at my hospital in the sense of organizing ourselves, taking ideas from other places, trying interesting things, thinking of ourselves as that kind of organization, moving in that direction. that is new to us. that is something of a surprise, but it is the way we have to move in the future. the fascinating thing to me is that as the incentives of the health reform package are moving through an materializing and people are seeing what they are, for the first time i'm hearing that the conversations in our conference rooms in meetings where we say, ok, how could we as large groups of people, surgeons working with anesthesiologists, primary physicians and others, make it so that we have a package of

care that is smarter and less costly? host: i want to show you a few of the headlines regarding healthcare in the morning newspapers today. from "the washington times," "pelosi sees democrats close on health care." stories about the use of the excise tax on high-cost insurance, the difference between the house and senate. and "the new york times," "obama urges excise tax on high-cost insurance." in "the washington post," "experts remain skeptical of taxing health benefits." finally come in "the wall street journal," it david wessel writes about the lessons of medicare part d.

finally, from a local perspective, this goes back to the discussion about access. "the miami herald" as a story about "the jackson halts dialysis of poor patients." they cannot afford it anymore. guest: the striking thing to me is that we are becoming aware of these kinds of situations. it has been a common at -- it is fascinating to me that it that is finally a front-page piece of news, because the point at which we have been turning people away from care, struggling to figure out how to get coverage for people when they have dialysis, cancer troubles, has been an underlying current in our experience for a while. host: the chief executive of the jackson held system --

health system is quoted as saying that the decision was not taken lightly. but they can get the treatment in the emergency room. guest: a way that happens is that when you have a kidney failure, you can function for all while, and then after a week or two, you become so sick that you were at death's door, you go to the emergency room and get emergency dialysis, but what you really need is dialysis in two or three-time-per-week basis in order to survive. it is an appalling kind of situation for a country like ours, which has, as one of the callers noted, amazing capability and technology and care. but the fundamental commitment is one at that, if pelosi is right and we are as close to changing that as possible, we underestimate the ways that that

represents a significant change for the health of the country. host: minneapolis, you are on. caller: i have a question for dr. -- host: gawande. caller: what is your take on people who are living with hiv and aids, and health care -- you know, how they plan on cutting -- i hear they plan on cutting medicare part d are doing something with medicare part d. hiv and aids have come a long way since the 1980's. but now that they are cutting

medicare part d, what is your take on that? thank you. guest: the h.i.v.-aids patient care is a nice microcosm for thinking about what is happening in corporate medicare part -- what is happening in care. but why wouldn't hiv or aids patient qualify for medicare -- would and hiv or aids patient qualify for medicare, given that they are on disability for the most part? we have turned into a deadly illness into a chronic one -- turned it from a deadly all this into a chronic one that people can live with and be healthy with. but getting insurance coverage, if you are self-employed or needing individual coverage, the pre-existing conditions make it said these patients cannot get coverage -- so that these

patients cannot get coverage. the only way they get coverage is if they filed disability and no longer work anymore because of their illness. they don't get treatment, they get ill, they file for disability, and we're in this town about where we lose the productivity of a significant part -- of the in this round about where we is the productivity of a significant -- lose the productivity of a significant part of the population. we could have a larger population of people that could really moved back into being productive in the lives as possible and have the advantages of the science so that they can also help contribute to economic recovery. host: just a few minutes left with dr. atul gawande pre confine him on the internet, and his book about -- with dr. atul gawande. you can find him on the internet, and his book is in

stores. caller: good morning, susan, and dr. gawande how will health-care reform might affect the time i spend with my doctor? will they be able to check on the basic things, or will this be quicker than normal? secondly, correct me if i'm wrong, but is malpractice insurance driving our costs up, or is it just a red herring? guest: let me ask a question about physicians and then come to the second one. -- answer the question about physicians and then come to the second one. two years ago, massachusetts took an approach similar to the new reform package, offering it for people who do not have access to insurance or for whom insurance is too expensive. if your income is very low, it can even be free. it has capped the cost at about

8% of income, and it has allowed people a choice of plans. we had 12% of those who have insurance, only 2% who have insurance. the striking thing is, for most of us in the clinical world, for all of our other patients, we have not noticed a difference at all. i am a cancer surgeon, and i have not seen a patient with insurance coverage problems like we used have in two years. it has been an amazing thing. it can affect physicians in the sense that we are starting to embark with this package on experiments to deal with how we deal with costs. that means struggle at the local level, but for us to be thinking about what can i offer a package, can i join with colleagues in the hospital so that we can change the way we organize our care? it is an opportunity, and it is also one that we will find hard.

malpractice reform i have been in favor of. i am not in favor of taps, but instead moving towards a kind of no fault of practice insurance system. but as a driver of costs, it is one, but it is about 3% of the increase in costs from the studies that i've been part of and that others have been able to do. it falls in between. it is not quite a red herring to talk about malpractice reform, because it is available to us, and as long as we are being fair and accounting for the costs for patients who we harm. at the same time, it is far from the be-all and an ego-a -- and end-all. texas had a strong malpractice reform in this, and did not improve the cost structure there. host: next call.

caller: good morning, susan, and dr.. the doctor seems like eight very common sensical kind of fellow. is it necessary to achieve all the reforms we talking about, to create an entirely new branch of the federal government to compensate for this? guest: it i don't have the easy answer to that question. there is a bunch of the functions we have to have agreed although i am someone who would have liked to have seen a government insurance option as a backstop around the country, and the plan does not have that. the private insurance plans that would be offered -- even there, resorting to a world where we want to have private insurance, we want to have a structure of insurance exchanges that can make it so that you have