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hello i'm hogue levins and we're here at
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the
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wharton school video studio and today
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our guest is dr
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ezekiel emanuel who's a vice provost of
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the university of pennsylvania
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and formerly he was an advisor to the
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white house and he is one of the
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architects of the affordable care act
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dr emmanuel thanks for being with us
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it's great pleasure
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and today we're here to talk about your
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brand new book
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correct and let me start at the
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beginning the very cover and the title
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of this is
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reinventing american health care and the
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subtitle
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is how the affordable care act will
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improve our terribly complex
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blatantly unjust outrageously expensive
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grossly inefficient error-prone system
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and my question is were you at all
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concerned
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that that that subtitle is somewhat
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confrontational
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uh it's somewhat absolute were you
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concerned at all that it might turn off
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some of the readers that you would
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otherwise be able to influence
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well i do think that the description
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there the complexity the inefficiency
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the expensive error-prone
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system are well accepted we did
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before the affordable care act have that
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kind of system
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that was terribly expensive and
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inefficient had a lot of people
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uninsured i do think that the affordable
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care act is going to make a big dent in
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each one of those
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and i make that argument uh in the book
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although i should say the book is not
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just an argument about the affordable
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care act it's
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sort of tries to educate people about
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the health care system how various
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parties get paid
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how insurance came about in the united
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states
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all the efforts over hundreds of uh 100
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years of trying to reform it
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how the affordable care act got passed
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what's in the affordable care act
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and then i do make predictions about the
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future so it's not just about the aca
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okay and in the book you take the
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congressional budget office
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to test you talk about the tyranny of
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the cbo
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and you say that although the
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congressional budget office scores are
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objective and nonpartisan
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they are frequently wrong and you talk
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about the bias and how it can create
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real harm by placing roadblocks for
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important and worthy legislation
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and you cite instances of from three
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decades of wrong
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cbo estimates so my question is
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how did the cbo scoring impede the aca
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uh and if there had not been cba scoring
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how would the aca be different
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so first of all i also say that we need
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an umpire
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i i recognize that the role the cbo the
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congressional budget office plays is
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absolutely essential
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you have to have someone who's going to
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objectively assess a bill
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but i also indicate as you point out
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that they have an institutional bias
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they're always willing to say discount
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savings
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and assess higher costs than
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you might because if they're wrong
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things don't cost as much
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or they save more than they anticipated
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they think there's no harm done to the
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system and part of what i wanted to
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point out is
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there is harm done to the system because
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good ideas
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that might have saved they say no it's
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really
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not going to save or it's only going to
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save a little or it might even cost
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they may be wrong on that and inhibit a
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lot of good ideas from coming forward
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and i do cite the
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over three decades from the 80s the 90s
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and the 2000s cases
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of major healthcare legislation where
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they simply have underestimated the
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savings
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uh that could be achieved the part d
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the uh medicare drug benefit is an
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excellent example their their cost
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estimate was 40
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too high that makes a very big
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difference in
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setting policy especially when every uh
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politician is constantly asking
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how does it score which means does it
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save money and
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there are a lot of programs that we
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wanted to put in to
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uh the affordable care act that didn't
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score or didn't score as much
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as the cbo would say and that means that
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you know when you're bargaining you
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don't retain them as
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uh uh for the bargain because you know
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it's not that expendable or you can't
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get as much savings from them
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and then there are you know i think i
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point out in the book lots of things
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where
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there's no precedent so they just guess
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and
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i'm not again i didn't want to fault
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them i did want to
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just indicate how it creates a certain
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kind of mindset
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everyone thinks they have this model
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which really does predict the future
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well they have a model that doesn't
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predict the future terribly well
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and uh to constantly be trying to guess
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what they're going to score it
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i think inhibits a lot more creative
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policy thinking than we might otherwise
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get
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of the elements uh for the potential
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elements for the ac that didn't score
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you know which one was the most
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important one you thought should be in
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and you regret it wasn't uh in general
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and this is separate from scoring in
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general the thing i'm most frustrated by
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is that we didn't have more
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payment reform in the bill because i do
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think that's a very important
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element to get us off the fee for
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service system which encourages
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using more services and of particular
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types that are
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highly paid to a system that doesn't
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encourage people just using services but
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actually keeping
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patients healthy keeping them out of the
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hospital
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i think that's a very important switch
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and again this is a case where i think
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the cbo scoring was less
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favorable to those changes the other
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thing i would say is that the cbo
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scoring
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tends to evaluate each individual change
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as opposed to putting them all together
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and for i think many changes a complete
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change uh that involves you know i.t
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uh disease management uh identifying
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high-risk people
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uh putting in place interventions uh
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those haven't been regularly and
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rigorously tested and so the cbo doesn't
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really have an idea about or doesn't
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think it can
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actually estimate with reliability
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savings but a lot of places have seen
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those changes give you a sort of
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directional savings
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and a a pretty good savings and
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but you know it doesn't meet cbo
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standards for including in their model
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and i think that kind of sort of
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experimentation doesn't get highly
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ranked
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nonetheless i recognize the important
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role of the cbo i don't
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we can't work without it in washington
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but i do think we all
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we and including the cbo ought to
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recognize the biases and flaws and try
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to figure out ways to counteract them
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okay in your in your frequent tv
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appearances
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and your interviews in other media at
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least the ones i've watched and the ones
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i've read
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uh over the last couple of years you've
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been uh you've been perceived to be a
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staunch
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supporter of the obama administration
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obviously
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and the aca parts of this book which are
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pretty critical seem uh to have a
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totally different tone is this a
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dramatic departure for you to be
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so critical of of internal white house
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management procedures now
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as opposed to the stance you took
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publicly in the past well i think
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a lot of people have tried to pigeonhole
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me in point of fact when the
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exchange went bad i had a pretty
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detailed
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critique in the new york times pretty
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public about what i think they needed to
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do to
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solve the problem uh including appoint a
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ceo they haven't done that
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you know and so i do think i've tried to
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be balanced in
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what has gone wrong and what has gone
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right you know
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i've actually been pretty out in the
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open i think it gets drowned out by the
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fact that i do think in general this
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the aca has been a big step in the right
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direction and
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is catalyzing positive change but there
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are plenty of things
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uh especially around the execution that
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i think could have gone uh better
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i i am disappointed we still don't have
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menu labeling
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uh regulations i have been disappointed
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about
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uh pcori the patient-centered outcome
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research institute not being aggressive
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enough and i think i've been actually
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pretty
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upfront about that but you know not
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everyone
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notices all the nuances of an academic
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and i think that's uh you know i am
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generally quite positive i think the
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bill did address
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many of the problems we had in the
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system and i've often said it's not a
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perfect bill in a democracy you can't
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expect
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a perfect a plus bill you're going to
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get
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compromises and that policy makers would
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prefer not to be there
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but politics dictates that they are
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you mention uh the ceo issue and in the
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part of the book that's a post-mortem
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inside the white house of what went
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wrong managerially
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it's sort of inside baseball but you can
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can explain a little bit about
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why a different kind of ceo might have
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made a difference in the way that
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healthcare.gov uh went bad
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so um i think you need to
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view the exchanges and the federal
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exchanges as a
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e-commerce site we should not view it as
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a
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program in the government like the va
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benefits
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it is much more analogous to say
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amazon or other e-commerce sites
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and in that regard it needs to be run
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like an e-commerce site not like a
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government program issuing regulations
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and that typically will require a ceo
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it'll require us
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a highly talented staff it'll require
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constant tweaking
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of the exchanges the rules how you want
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to
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show people what their options are and
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educate them and i've been pretty
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upfront about that i was upfront about
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that beginning in 2010
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that i thought this was necessary for
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proper execution
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and i think if you look at the
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successful state exchanges like
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connecticut like california
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they've had that structure where they've
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had someone typically
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with insurance uh company experience
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or running an exchange uh being able to
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collect the right team
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and basically every morning get up
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thinking about how are we gonna make
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this
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better how are we gonna work with our
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suppliers the insurance companies
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how are we going to work with our
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customers to make sure they're having
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the right experience
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or that we can adjust what we're doing
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to make it better for them
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i think that's the proper way to run
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this thing again on the idea that this
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is more an e-commerce site
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than this is a government program back
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then did anyone actually say to
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nancy ann deparla we should have a ceo
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of this type
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and why did she elect to go first of all
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i don't think it was her decision
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i think this was a a decision inside uh
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the white house um and i can't tell you
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why they uh didn't go that route i mean
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i have as i mentioned in the book
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there was you know political
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considerations
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they had the administration uh we had
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been criticized about having too many
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czars of this and czars of that
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and they were worried about uh
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additional criticism but i think as
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has become clear over time uh getting
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the exchanges right was
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critical politically and even if you
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took short-term uh
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criticism for appointing a ceo and
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creating this
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structure that would run it like a
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business
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i think in the long term it was clearly
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not optimal
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to fail to do that in the book uh on
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that point uh you write though
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in a very positive way there is no
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reason to despair or give up on health
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care reform itself
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as many high technologies have shown it
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is possible to bounce back from flawed
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website rollouts
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but this is only possible if relentless
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focus on execution
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becomes a reality so the question is
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today
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has the white house changed and is it
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relentlessly executing this correctly
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well uh clearly when they appointed uh
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jeff science to
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uh uh i guess the word the correct word
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is rescue the
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uh exchange in websites uh he was uh
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focused uh the recent steve bill article
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does show that they really work 24 7
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they got a really
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top flight team uh and i think that
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lesson uh
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should not be lost on them that that's
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really what you need
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uh when you launch and you know let's
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remember twitter was not a flawless
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launch
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lots of other companies have had
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problems with launching their website
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that have come back to be very
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successful
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and i certainly hope that the white
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house is paying attention to that okay
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back to a subject you mentioned payment
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reform and in the book you have a
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section on that
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and the whole issue of switching from a
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you know a four
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fee payment service to a more episodic
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one
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i've gone to any number of seminars and
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conferences this is a constant subject
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subject
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but i haven't been to any where anyone
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actually presents a plan
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to achieve that and there seems to be a
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great deal of confusion
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inertia no one knows what to do how do
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you take a
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four billion dollar a year urban health
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care
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network and completely unbuild its
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revenue systems at the same time you
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build
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something else that's not exactly
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defined how well first of all i do think
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in i believe it's chapter 12 of my book
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i do talk about healthcare health reform
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2.0 and i do have a chapter about
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or a section there about uh getting more
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uh alternative payment models to fee for
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service and i do have a very
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uh plan actually
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so i do think that there is a plan uh i
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would suggest that there are three or
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four steps that would be very important
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to this
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and as you point out you're not going to
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get for example the university of
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pennsylvania
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overnight to be able to go from feast
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for service to alternative payment
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models
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but the approach therefore is well let's
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give it a guide pla path but all agree
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that at the end of some predefined
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time period i say a decade so
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2022 is my time point by 2022
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75 or 80 pick a number is off fee for
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service
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and that gives everyone sufficient
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planning time and ability to shift
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then you pick particular areas where you
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think
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you can move off the fee-for-service
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system quickly
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and allow the hospitals and health
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systems to experiment
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so as i say in the book step one is we
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have had a
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recent medicare experience called the
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ace demonstration
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the acute care episodes which pays
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bundled payment
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for cardiac procedures and orthopedic
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procedures
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stents cardiac
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catheterizations cabbages coronary
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bypasses
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pacemaker placement hips and knees you
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give the
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institutions and surgeons a bundle
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payment
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that has shown to save some money and
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improve quality of care
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that's a place to start very defined
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i as i point out in the book the bundle
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used by medicare in the demonstration
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wasn't
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perfect and we'd like to try an
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experiment to expand it to include
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shared decision making at the start so
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every patient undergoing these
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procedures
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is given an information sheet or a video
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to see whether they want in or out and
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then it includes rehabilitation
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after the procedure as well as a
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guarantee
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for up to six months that anything that
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goes wrong say with the hip replacement
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is going to be covered free of charge
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that
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you can phase in pretty quickly because
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we have evidence it works
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then you take another area like cancer
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and i think cancer is a very good area
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because we have a lot of guidelines we
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have a lot of agreement
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on how patients should be treated and
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begin to identify
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very high volume high cost cancers that
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can be bundled
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and this i think provides you a a path
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way forward to move off the fee for
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service system into a system where
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people
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are not paid to do more but to do higher
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quality care
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efficiently and that i think is a plan
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that can take us to 2022 and shifting a
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lot of payments off
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the fee for service system and i think
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that's a great
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plan in theory and i guess the question
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is within the aca
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how do you actually get hospital systems
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to begin
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to do this well first of all first of
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all the aca one of the i do think one of
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the
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smart provisions we put in was the
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secretary of health and human services
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has the authority without getting
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additional legislation
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to nationalize to take a a experiment a
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demonstration project that has shown to
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either save money
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and or improve quality and nationalize
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it across
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medicare she doesn't need to go to the
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hospital she can say
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all right in two years we're going to
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start paying this way and
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give them two years to figure out how
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they're going to do it
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let's remember we have a lot of really
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smart people running these health
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systems including the university of
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pennsylvania
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you tell them what the rules are they
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will adapt to those rules i have no
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doubt about it
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and they just want those rules i mean
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one of the things that's true
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as i go around the country is they feel
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like
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a lot of doctors and health systems feel
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like they're caught in two boats
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at the same time which is they're paid
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fee for service and everyone is telling
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them
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oh you've got to improve the quality of
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your care you've got to become more
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efficient
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and yet they're not being paid to do
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those things and they would i think
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in general prefer to be paid to do that
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so they wouldn't lose money
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while trying to improve the quality of
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their system okay
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and in the payment section you also get
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into graduate medical education
00:17:37
10 billion dollars from medicare every
00:17:39
year and
00:17:40
i can't remember whether your word was
00:17:42
useless but essentially
00:17:43
uh it's not being tracked or assessed
00:17:46
assessed well how it's being used right
00:17:48
you indicate that the students coming
00:17:50
out are simply not prepared for modern
00:17:52
day
00:17:53
digitally based team-oriented care
00:17:56
right what's the answer to that how do
00:17:58
you change that you say it must be
00:18:00
changed what are the changes do you
00:18:02
think that
00:18:03
well again in the book i i think we make
00:18:05
pretty clear
00:18:06
during medical school first we ought to
00:18:08
shorten medical school
00:18:10
second we ought to have some focus on
00:18:12
training people
00:18:14
in team-based care training people in
00:18:16
digital medicine as you
00:18:17
point out how do you work with
00:18:21
various wireless monitors at home or
00:18:23
wireless compliance devices at home
00:18:26
that people need to be trained for that
00:18:27
we also need to train them in the
00:18:29
outpatient setting
00:18:30
right now if you're uh in medical school
00:18:33
and interned resident
00:18:34
the vast majority of your time 90 plus
00:18:37
percent of your time is spent
00:18:38
treating patients in a hospital whereas
00:18:40
in the new system
00:18:42
much less time much fewer patients are
00:18:44
going to be in the hospital doctors
00:18:45
are going to spend much less time
00:18:47
treating patients in the hospital and
00:18:48
yet that's how we train them
00:18:50
so we need to emphasize you now have to
00:18:52
provide half the training outside of a
00:18:54
hospital
00:18:54
that's complicated i recognize it and
00:18:56
again this isn't a change that can
00:18:58
happen overnight but you have to give
00:19:00
deadlines
00:19:00
otherwise no one's going to have an
00:19:02
incentive to change their system
00:19:04
and i think those kind of changes in
00:19:06
addition i think i mentioned in the book
00:19:08
that we need to train doctors much more
00:19:11
in management
00:19:13
change management how do you actually
00:19:14
manage change
00:19:16
negotiations because they're constantly
00:19:18
negotiating whether with their
00:19:20
colleagues or their patients
00:19:21
or payers we need to train them in
00:19:24
strategic planning
00:19:25
how to use data how to implement changes
00:19:28
so i think
00:19:29
there's a lot uh that needs to be done
00:19:32
to change the medical education we've
00:19:34
had i mean
00:19:35
one of the ironies is medical education
00:19:37
really
00:19:38
took the structure it has today 100
00:19:40
years ago with the flexner report
00:19:42
medical system has changed a lot the
00:19:44
kinds of treatments we're
00:19:46
giving to patients have changed a lot
00:19:47
you would think medical education should
00:19:49
change more than it has
00:19:52
okay uh one of the in in your book you
00:19:55
go through various trends as you look
00:19:57
forward and bravely
00:19:58
make predictions about what's going to
00:20:00
happen and you say this is a brave
00:20:02
you know brave test i recognize the
00:20:04
stupidity of making tradition
00:20:06
predictions mostly because phil tetlock
00:20:08
is a professor here at the wharton
00:20:10
school
00:20:10
uh and at the university of pennsylvania
00:20:12
and he's written a whole book about how
00:20:14
dangerous it is for experts to make
00:20:16
opinion
00:20:16
make predictions so i recognize it's
00:20:19
it's difficult
00:20:20
but i also recognize it's essential all
00:20:22
of us are making predictions about the
00:20:24
future whether you're running a hospital
00:20:26
whether you're a doctor or an investor
00:20:29
you're making predictions about how the
00:20:31
future is going to evolve
00:20:32
and i thought well i've got a lot of
00:20:34
experience knowledge i'll make some
00:20:35
predictions
00:20:36
and again i've learned from phil tetlock
00:20:38
that you've got to be very specific
00:20:41
what exactly quantitatively is the
00:20:42
prediction if there's a quantitative
00:20:44
prediction
00:20:45
and give a specific date so i try to be
00:20:47
as rigorous
00:20:48
as possible and i know that i might be
00:20:51
held up to laughter and
00:20:55
insult if my predictions turn out to be
00:20:57
wrong
00:20:58
one of those predictions is that in the
00:21:00
next six years
00:21:01
at least a thousand hospitals across the
00:21:04
country will close
00:21:05
and within that you you suggest that the
00:21:08
community either
00:21:09
that part of the community that works at
00:21:11
those hospitals or the patients who use
00:21:13
those hospitals
00:21:14
that they should not fight this can you
00:21:16
explain that more why
00:21:17
why would we want to see a thousand
00:21:19
hospitals close and
00:21:21
just sort of just let it happen uh first
00:21:24
of all
00:21:25
uh the hospital occupancy rate
00:21:28
uh in the united states is now under 70
00:21:32
that means uh there are lots of beds
00:21:34
that are not being occupied
00:21:36
and a lot of the hot there are a number
00:21:38
of hospitals under 50 percent
00:21:40
and they are not necessarily shouldn't
00:21:44
necessarily be there
00:21:45
take vermont for a population 400 000
00:21:47
people they have 11 hospitals that's
00:21:49
just
00:21:49
unnecessary second a lot of these
00:21:52
hospitals
00:21:53
uh as i mentioned we're one of the
00:21:55
reasons we're going to see
00:21:56
hospitals close is because a lot of care
00:21:58
that hitherto had been delivered in
00:22:00
hospitals
00:22:01
can be more effectively and at less cost
00:22:04
delivered at home or in other settings
00:22:08
there's no reason to go into a hospital
00:22:09
for example for a colonoscopy
00:22:12
you can do it in outpatient setting at a
00:22:13
cheaper rate and with the same kind of
00:22:16
quality
00:22:16
many patients who we used to admit to
00:22:18
the hospital for example for
00:22:20
exacerbations of
00:22:22
of emphysema or congestive heart failure
00:22:24
can be treated just as well
00:22:26
at home so we'll see that shift well if
00:22:28
you treat people at home
00:22:29
the nurses as i think i make clear in
00:22:32
the book who were once working the halls
00:22:33
are now going to be
00:22:34
visiting patients at home they're not
00:22:36
going to be unemployed if the main
00:22:38
worry about closing a hospital is
00:22:40
employment
00:22:41
you know will lose important high-paying
00:22:43
jobs
00:22:45
we're going to shift those jobs to other
00:22:47
services in the health care
00:22:48
industry while i'm a cost control hawk
00:22:52
you might say when it comes to health
00:22:54
care i am also a realist we are not
00:22:56
taking a system that now is spending
00:22:58
2.9 trillion dollars on health care and
00:23:01
going to reduce that to 2.6 trillion the
00:23:03
only question is
00:23:04
how fast or slow does it go up from 2.9
00:23:07
trillion to 3.2 3.3 trillion
00:23:10
and to the extent that it's on the
00:23:11
upward slope that means
00:23:13
more people are going to be employed in
00:23:14
the healthcare system more services are
00:23:16
going to be delivered
00:23:17
and therefore i think when we close
00:23:19
hospitals we shouldn't look as if
00:23:21
all of that's going away it's going to
00:23:22
be redeployed in other areas
00:23:24
people who were coming into this
00:23:26
hospital aren't suddenly not going to
00:23:27
need health care services
00:23:29
they're going to need them in a
00:23:30
different way in different facilities
00:23:33
or maybe at home and that's going to be
00:23:35
i think if you're worried about the
00:23:36
employment part
00:23:38
going to employ plenty of people and i
00:23:40
think again
00:23:42
is going to be better for patients and
00:23:44
we should remember
00:23:45
the main goal of a health care system is
00:23:47
not employment the main goal of a health
00:23:48
care system is keeping the population
00:23:50
healthy
00:23:51
okay and one uh one of the last
00:23:53
questions we're talking about
00:23:55
updating the law and in in the book
00:23:57
you're talking about
00:23:58
the aca is an enormous thing it'll make
00:24:01
significant changes
00:24:03
uh eve even as it will need further
00:24:05
modifications and revisions
00:24:07
and uh just the other day um we had
00:24:10
andrew dreyfus
00:24:11
from massachusetts come and he and
00:24:14
others
00:24:14
talked about how in massachusetts since
00:24:16
the law was passed in 2006.
00:24:18
it's been significantly amended six
00:24:21
different times
00:24:22
and they anticipate an ongoing endless
00:24:24
amendments
00:24:25
because of corrections because of
00:24:27
unintended consequences etc
00:24:30
the aca is is one it never made it
00:24:33
through conference
00:24:34
now it's like a non-dynamic law what do
00:24:37
you see
00:24:38
happening as this non-changeable law
00:24:41
pushes forward and can't be corrected is
00:24:44
that
00:24:45
sufficient to the aca or where
00:24:47
is that going to go
00:24:49
uh it seems in the poison atmosphere of
00:24:52
washington
00:24:53
it's unlikely that it will be amended is
00:24:56
that
00:24:57
so i think i think what andrew dreifus
00:24:59
says is right
00:25:00
healthcare i think the opening line of
00:25:02
my disclaimer is healthcare is dynamic
00:25:04
and we similarly need policies and laws
00:25:07
and regulations relative to healthcare
00:25:10
to be dynamic and to respond
00:25:12
as the system evolves as flaws are found
00:25:16
and ironically if you talk to people in
00:25:18
washington who when they're not engaged
00:25:20
in the partisan battle
00:25:22
there's a lot of agreement about the
00:25:23
kinds of changes they want to be put
00:25:25
into place but we're locked into this
00:25:26
uh what seems to be an endless uh battle
00:25:29
over the soul of the aca
00:25:32
i actually believe that's unfortunate i
00:25:34
think almost everyone no matter whether
00:25:36
you're republican or democrat believes
00:25:38
it's unfortunate
00:25:39
and i think that we're probably going to
00:25:41
fight two more elections on the aca the
00:25:43
2014 election and maybe the 2016
00:25:46
presidential election and then hopefully
00:25:49
uh my hope is that we'll be able to get
00:25:51
all right it's the law of the land uh
00:25:54
let's
00:25:54
deal with uh the problems and let's see
00:25:56
if we can improve things
00:25:58
i will say my uh best hope on that
00:26:01
regard is before i went on to
00:26:03
on tv last night with bill o'reilly uh
00:26:06
he said to me
00:26:07
look i don't want to talk about the aca
00:26:08
it is the law of the land it's coming
00:26:10
into being i want to talk about
00:26:11
responses to it and for in for example
00:26:13
how doctors are responding or not
00:26:15
responding and don't want to participate
00:26:17
in the aca and i uh took that as uh wow
00:26:21
that's uh revealing and you know i wish
00:26:24
you would say it on the air
00:26:25
because that i think would change the
00:26:28
discussion and allow us to move forward
00:26:30
but i can tell you i've talked to a
00:26:31
number of staffers of republican
00:26:33
senators and congressmen and they
00:26:35
recognize and actually have a lot of
00:26:37
agreement with the things
00:26:39
i want to propose i think you know when
00:26:40
i talk to conservative
00:26:42
uh health policy experts there's a lot
00:26:45
of overlaps 60 70 percent overlap
00:26:47
between my views and their views
00:26:49
and i think we could actually make a lot
00:26:51
of progress if we put the ideology
00:26:53
behind us and try to
00:26:54
improve the health care system in this
00:26:57
country
00:26:58
and you know again i was
00:27:01
involved in passage in enacting the aca
00:27:03
and
00:27:04
helping to design various provisions um
00:27:06
i recognize it's flawed it's not a
00:27:08
perfect bill as i said before it's it's
00:27:09
not enable you're not going to get
00:27:11
perfection in a democracy
00:27:12
and it needs to be constantly healthcare
00:27:15
system needs to be constantly tweaked
00:27:17
the idea that we do it once and for all
00:27:19
that is just false and looking down the
00:27:22
same road
00:27:23
in the book you talk about how the aca
00:27:27
has been a great achievement for
00:27:28
president obama at the same time it has
00:27:30
wounded him politically really badly
00:27:32
and you also say that you think down the
00:27:35
road
00:27:36
that history will actually look back at
00:27:38
him and smile tell us how and why
00:27:40
i not not many people are are
00:27:44
students of american history but let's
00:27:47
take a pause and a little diversion to
00:27:49
answer your question
00:27:50
harry truman when he was actually
00:27:51
president was not very popular
00:27:54
some people don't uh don't fully
00:27:55
remember but the 1948
00:27:58
in that year he was more or less written
00:27:59
off everyone was sure he was not going
00:28:01
to be re-elected
00:28:03
even the chicago tribune on election day
00:28:05
published you know dewey defeats truman
00:28:07
uh so here's a guy who is not very
00:28:10
popular and a lot of the things he did
00:28:12
integrate the army drop the bombs on
00:28:14
hiroshima
00:28:15
the marshall plan nato
00:28:19
the cold war were at the time you know
00:28:23
he wasn't popular for integrating the
00:28:24
army the marshall plan barely passed the
00:28:26
senate
00:28:27
he had to call the marshall plan instead
00:28:28
of the truman plan to get it to pass
00:28:31
uh very you know not very popular
00:28:33
president
00:28:34
now we lionize harry truman and we think
00:28:36
he's like the greatest
00:28:38
you know he's a near great president
00:28:39
behind uh washington lincoln and rose
00:28:42
franklin roosevelt he stands with people
00:28:44
like teddy roosevelt
00:28:45
uh and others as a near great president
00:28:48
well
00:28:49
i think that the affordable care act is
00:28:51
going to play the same way
00:28:52
once it plays out once it begins to
00:28:54
transform the system if
00:28:55
in fact you know even half my
00:28:57
predictions are true it gets healthcare
00:28:58
inflation down to gdp
00:29:00
uh it transforms the delivery so we're
00:29:02
really taking care of the
00:29:04
chronically ill and the mentally ill
00:29:07
you will see people say wow this really
00:29:10
did
00:29:10
make a very positive move in the system
00:29:13
it was a very important
00:29:14
change it's going to take a decade to
00:29:16
see those effects
00:29:18
i believe again because we're dealing
00:29:19
with such a big
00:29:21
part of the economy such a complex part
00:29:24
of the
00:29:25
economy i would also say i think i
00:29:28
say this very clearly in the book the
00:29:30
wounds
00:29:31
that politically have been suffered
00:29:33
because of the aca
00:29:35
are a result of bad communications about
00:29:37
the aca what's in it what it means for
00:29:39
the average
00:29:40
person and the bad implementation of the
00:29:43
exchanges
00:29:44
neither of which were inherent or
00:29:46
necessary
00:29:47
both were in as i say in the book
00:29:49
somewhat self-inflicted we didn't
00:29:51
the obama administration didn't do a
00:29:54
particularly stand-up job either
00:29:56
of communicating around it or
00:29:59
executing and i think there's nothing
00:30:02
inherent or necessary
00:30:04
in the aca being viewed as negatively as
00:30:07
it is
00:30:08
today it could have been different a
00:30:11
perfect ending dr emmanuel thanks for
00:30:13
being with us and good luck with your
00:30:14
book
00:30:14
thank you very much
00:30:39
you
