>> history, as you know, is much more than politics and social issues. it is >> we should not lot things into categories. it is all part of the same thing. >> harriet beecher stowe, john singer sargent, thomas jefferson, henry adams. tonight on "q&a", part one of two weeks with david mccullough. at 8:00 on c-span.

>> we are pleased to welcome the administrator of the centers for medicare and medicaid. he is responsible for obese sitting and $800 billion federal budget. -- for overseeing and $800 billion federal budget picture >> thanks for being here. he has proposed to transform the program quite dramatically and in the process to save quite a bit of money. when you listen to budget debates in washington, one thing that becomes clear is the only way to really cut money is to cut money. that is something his plan does

effectively on that score. what is wrong with that? >> we share the problems and are trying to tackle, which is that health care needs to become sustainable in this country. there are two ways to do that. anybody can do that. you cut a budget. this plan does so quite effectively. we will be in deeper and deeper trouble of that were true both free. there is an alternative to that, to make health care better. that is the strategy i am very much more committed to. there is nothing proposed by paul ryan that improves care. that is the way to make it sustainable. >> one of the things they

representative ryan's plan does did they id shows that it seniors are empowered in choosing their own health insurance that they will help to drive better care. they will help drive lower cost. isn't that the way the market works in this country? >> the great way of being involved with the medicare program is to work for seniors for them. we are unified voice on behalf of the beneficiaries. vouchers would erode steadily over time. i think medicare is paying 68% of care for the beneficiaries. over time, that balladur, entirely inadequate, it will get down to 35% of the cost. there will be those who will not be able to afford insurance and not be covered. i think that that would be a very bad thing for our nation. >> and we have an alternative.

>> one thing interesting about seniors, medicare has been trying to do more care coordination with different attempts over the years. we have not quite gotten there. the latest regulation that we got a got some push back from well-known clinics, may go. what people are wondering, what makes you believe that you will be able to achieve what you are saying here? >> we have done it over time. medicare has been a steadily improving program. better benefits, much more texture but medicare advantage, d we have parts drug coverage over time. it is a tough time. american healthcare has never faced a more difficult passage then and now faces. we have a care system, not just

medicare. it is a player, but as the person with chronic illness, they will often described dropped balls, they do not know where to go, the specialists is not talking to the primary care doctor. the end up back in the hospital. a system is quite fragmented and driven by this payment system which is the more that you do, the more that you get paid. we need a system that says the better that you do for your patience, the more that you get paid. reoriented from this ferry wasteful and fragmented the point. medicare can do that. we are totally allied with the private sector here. every important funder of health care once the health-care system to improve just as medicare does. i am optimistic about what is possible for us as a nation. didn't you get the sense that you're very optimistic about

making this work. how do you sell that message to the public, which is wary of the government being in charge of anything right now. and this is an easily demonized process. it is very he isn't to say that medicare is taking the reins and say that you are rationing. how you plan to overcome those obstacles. >> there are things being sold about a government takeover of health care, that those of us who want health care to be improved are taking things away from them. from the very people that are trying to cut medicare and medicaid. people know what good care is like. you are now on, you're taken

care of over time, the system is coordinated around you. we just need to tell the story more more. i think results matter. i think the public is smart and if they cared does not improve, and it will if we stick with the affordable care act, they will experience more seamless care. the parts of the affordable care act covering kids under 26, seniors getting rebate checks for their part d costs. the growing momentum we have for putting insurance companies under more scrutiny so they cannot take away coverage. all of these are improvements under way now. the public will realize how much better this system is over time. >> can i talk about how the program has changed course marked undoubtedly is different from 1966. the benefits are different, certainly the way that medicare pays is different. but it is also true that in nearly half a century of federal government oversight, it has not succeeded in two important things.

number one, medicare costs are still growing substantially more quickly than the economy. number two, that fragmented system that you described in which people and doctors do not communicate has persisted in medicare for 46 years now. why should the public, when it hears you and the president say do not worry, we will make it better and give you a more efficient, higher quality health care system, why should they believe that the federal government can do now which it has not been able to do for close to half a century? >> we are not at the health care system we want and need, i agree with you. but those problems are not medicare problems, they are health care system problems. we need the country to make healthcare better. we are part of a larger set of issues. i am not sure i agree with the premise that there have not been improvements.

medicare was established and did not cover preventive services. some were added over time. now with the affordable care act, seniors will have access to this at no cost of them. it is the key to the system that we want. the addition of drug coverage, a big advance. i think medicare has gotten better but there are a lot of problems that have been there for a long time. we are in a turning point in this country. are we willing to improve the health care system at the level we really need to? the really good news is that we have examples of success. we know when it goes right. i continue hospitals around the country that have no infections, places that have reduced pressure ulcers and 95%. paces bill that places that treat patients at home.

bringing excellence to scale is a great opportunity now. we have not had that level of opportunity at this scale before. i am excited about that. >> we had been hearing for decades about fraud and abuse. if we open up our phone lines here, we could get story after story of their own personal lives or the ft said. -- where they see it. what resources does your age is in need to tackle that aspect of the program? >> i share with you how shocking it is fraud and abuse far beyond what i understood before came here. we know it is there. it is a tiny minority of the hospitals and clinicians that engage in this. most go to work and do the right thing and they are well within the bounds of ethics and law. an important minority spall the

peril for the west. i am more aware of how pervasive it is and it tends of billions of dollars. it affects all payers and all of the patients who get hurt that way. the affordable care ad put in our hands tremendous new tools for dealing with fraud and abuse. i now have four deputy administrators and one is the center for program integrity, his full-time job is to work on the fraud and abuse and errors in the work of health care and make sure that we're protecting beneficiaries. when that occurs, it helps everybody. some one is pretending that they are getting care and they are not, that is a terrible thing for the individual. they're stealing money out of the public treasury and out of the taxpayer pocket book. the good news is that we know what to do. we have a lot of great enforcement. we are working closely with the department of justice and the fbi and local and state law-

enforcement agencies. we have recovered billions of dollars already from very diligent enforcement of stuff that no one should tolerate. beyond that, we're doing something more important. you can prevent fraud if you are smart about it. we had a regulation which allows us to screen high risk providers in high-risk areas and make sure they do not have a criminal background, that they deserve the public's trust. preventing an upstream is just as important. >> for all the doctors watching today, there is a strong concern with the payments system, the dock fix. it is built into the budget for the federal government come of these gigantic cuts for doctors. what are you hearing? are you confident that will be

tackled this year? and you have a point person on capitol hill for this issue? or are they going to do what they are going to do annual take any agreement that they can reach? >> i have practiced for 20 years and i have immense respect for the work force in this country. we are really blessed with people that want to do the right thing. it is so important to give the resources and encouragement that they need to do the right thing. holding a sword of damocles over the doctors, the massive cut in their paid, how we dealt with the unsustainable rates. it cannot be done except with partnership in congress. we're committed to work with congress to get it fixed.

in the president's budget, there is a two-year fixed. but it is a big problem and we need to work on it together. we're committed to a solution i think the long run solution is the same as i said before, making care better. we're in this pickle overall because health care became unsustainable from the way that it uses resources. by improving care, we can get out of this box. >> there was always been a problem in measuring the budgetary affect in proving quality and efficiency. but it takes on an additional urgency, given the fact that medicare and the social security trusties' provided their estimate of how soon the main health trust fund will go in. given that, doesn't the administration need to be a bit more explicit about coming up

with ways that will actually 100% guaranteed save money as opposed to delivering a promise that is unmeasurable of this point? >> it has to be delivered. it is hard to be secure about the estimates of what can happen if we improve care. they are doing their job as they need to do. i am confident about the ability to reduce costs. and i have seen it happen. when a hospital is able to reduce some infections to 0%, which some hospitals have been done for five years running. it is an infection you get from catheters. those are extremely expensive, tens of thousands of dollars when someone gets one of those dangerous infections. when that in fishing goes away, that is a tiny example. and we have those examples. and hospitals are showing a

return on investment. i have seen a seven to one in a hospital when a patient care gets better. when the infection does not occur. a payment does not always a line with that. that savings minute of the hospital, something needs to be fixed. so that the hospitals can share and not be placed in financial penalties as they improve care. we need to work on that and the affordable care has that medical homes and other forms of payment which allow that kind of benefit to everyone when we make this care improved. let me tell you, i've no doubt whatsoever about the immense promise of improvement of care for saving money. and we need to improve it and let the actuary and the cbo say, it did work. that is my job. theveryone knows you're medicare boss, but you're also

the medicaid costs. in the right and budget, everyone talks about medicare saves a lot of money, but such as reforming medicaid. there is a lot of concern about medicaid advocates that it is going to be difficult for democrats if they are unlikely to do anything with medicare, to not cut medicaid's substantially. just today we saw the national group of state legislatures bipartisan say there is this effort, technical, but basically more spending. they are all for the republican plan to give them more flexibility to not do that. does that create pressure on the administration in on democrats -- and on democrats to cut medicaid? >> the pressure is on medicaid, very severe. my heart is closer to medicaid

and medicare. i've taken care of inner-city kids who depended heavily on medicaid support to get through illnesses. it is crucially important. the states are under enormous budgetary pressure right now. it is a very important area. we are as committed to improving the medicaid system as medicare. and the same kind of improvements in care that help reduce costs in medicare will do so and medicaid -- in factions in real admissions affect that as well. but the dual eligibles, eligible for both medicare and medicaid because they have chronic illnesses and behavioral disturbances that make them very vulnerable and very ill. $350 of expenditure goes into care of these 9.2 million people in our country. 40% of medicaid is for the dual eligibles.

they get lost, too. if we could get that correct, states would save money, but that would save money, patients would save money, and health status would improve. there will be a tremendous amount of change. we're committed to partnership with the states. we have to protect the beneficiaries. there are areas where we cannot allow the states to withdraw coverage and benefits for people. but we're committed to working state by state. we have medicaid action teams out in states right now working to customize responses that will help the state get through it. it is a tough time. we know that. but we cannot give up on term for the short run game. >> that is a follow-up question. you sound very thoughtful, but they're people that want results now.

how are you going to not cut medicaid substantially? >> that will stand by that beneficiary and looked for efficiencies that allow the cost of all. every day i go to work thinking not just about the trouble we're having with the budgets and the cost, but the people, the people out there who depend on this federal/state partnership, to protect their help and their well-being. the kind of country all are is not going to abandon those people. we're going to do everything that we can and find a way to make better care for them. >> what do you do with the state's in implementing the new health care law in general? there are a growing number of state leaders from one party primarily with who were quite resistant to implementing the new health care law and are more suspicious of the federal

government telling states what they can do in their medicaid programs. rather than diminishing, that resistance is intensifying. how do you deal with that? >> must be patient and stay at the table. it does not matter what party leads it, they are still our partner and we need to work through the cancers with these people. there are some no go areas. moving toward block grants is not an except the one way to provide the benefits. it would do away with the partnership that we have. what if another flu epidemic hits? i do not think it is good for those states, even though they think it is is, but it does not mean that we have all the answers. we just issued $15 million planning grants to states a weaker to ago to help plan care for the tools. -- duals.

and it is a state-by-state issued. we are not a cookie cutter country. we are committed to dialogue. >> in social security, there has been an acceptance that the age of eligibility has to rise. why is this still 65 for medicare? >> i can answer your question from the viewpoint of congress. >> from the health care perspective, would that help with the quality of care for americans? >> i think the quality of care at that the system gives our seniors, i think we should keep it. this idea that when you hit that age, and then you're part of a national investment in your well being, if you have contributed and you get the benefit. i think we should stay as close to that as we can. the policy of balls to come up

with a more creative solution, i am sure i will work with it. >> there has been some discussion of trying to get higher income medicare beneficiaries to pay more. part of the program in medicare part b, there is a requirement for higher premiums. that is not the case for part eight. can you envision a scenario in which there would be some? >> probably too speculative for me right now. i like the system we are in right now. we are all in it and committed to it. i know that creates a dynamic of of commitment on the part of seniors that is very good for us now. in that context, i know we can make progress. given the current way that we handle eligibility for medicare, you still have tremendous potential for health care improvement. >> are you limited in what you can say, but are you hearing

any sign of all the senate republicans are warming up to you? >> i'm enjoying any interaction i have with congress. i cannot tell you how much i have learned from interactions with senators and representatives on both sides of the aisle. right now the way i view my own position is that it is day-by- day. it is an amazing opportunity that i have with my colleagues with cms to work on one of the most important challenges for our country, to make healthcare better. i'm so grateful to have this opportunity. >> your referenced you surprised that they love all -- the difference between your practice and running the medicaid and medicare system. what did you learn from the inside? >> the confidence of the federal work force has been a

major learning for me. i did not know what it would be like. my agency has over 4000 people in it, wonderful people. i was the public could understand how many people go into work every morning to make the public lives better. they could be doing other things with their time. i'm blown away by the confidence in the commitment and the willingness of these people. i have decided cms to decided are around the three part goals. we are not an insurance company. we are a group of people in our country try to make care better for 100 billion people. they rise to the case and so well. >> to sum up, you talked about your view of the long term. but your future is in doubt. health reform is in the courts and we do not know what happened. how confident are you all the long-term plans are not going to result in nothing?

>> i am 100% confident of success. i know that this is going to work. we have a crisis in our country. republicans, democrats, payers, providers, we are all in the same boat. it is time to come together and i see that happening, i really do. yes, there are wrinkles and debates and complaints. but we are really on track now. and i have a lot of confidence in this country that we will get to the right place. it may not happen in one year but it will happen in my lifetime. >> if you could fix one thing without any interference from anybody else, what would it be? >> tempo. i would go faster. we are at a pace now we think about three years now from now. my whole senses of readiness. we know what to do in this country and make care say.

we know how to make chronic care excellent. we know what i prevention looks like. we know so much. maybe it is my metabolism but i say let's do it now. whenever i see a deadline that is three years away, i think three months away. but we are on the right track. >> thank you for being our guest this week. we're back with the reporters. gentlemen, we just talked to dr. berwick. what is different about the crisis level this time that might force some accommodation among the very different sides of the medicare-medicaid debate? >> i think we have seen -- we have seen two very different proposals. three things going on.

medicare is an open-ended entitlement program. it is too costly right now and not enough money going in. the republicans on one side saying, for the most part, go the private sector and see if the markets can work this out. and of the democrats saying, long-term improvements, quality of care, and the question they're being, is the government capable of doing that and does the public have any appetite to trust the private sector? these are very different approaches. i am not sure there is any accommodation. >> is the outcome unknowable? >> i think it is informed by a level of urgency. it may be somewhat different than in the past. there is not a huge amounts of time to actually come up with something.

but he is right, the two sides are very far apart. at the moment. did in the sense of urgency, the program running out of money, the current trustees estimate 2025? that the medicare system will run out. what does that look like? what would happen when the medicare insurance program is out of money. >> when it runs out of money, they do not stop paying. there is still money coming in from taxes. but they paid last. if the medicare hospital insurance trust fund starts running into the red, those choices would be, he could stop paying one group of providers and we're going to pay hospitals, or we will cut everybody down 80%. >> they will continue to run up the dead. >> they cannot run of the debt from the trust fund. they could potentially borrow it from somewhere else. but they would ep