 My name is Mark Siegler and with Dr. Marshall Chen, Marshall, are you in the audience? Yeah, Marshall is up here. We've put this series of 28 lecture seminars together for the year. And on behalf of the McLean Center for Clinical Medical Ethics and the Bucksbaum Institute for Clinical Excellence, I welcome you to this, our 32nd annual seminar series. As you know, this year our focus is on the ethical issues in healthcare reform. In 2010, President Obama signed the Patient Protection and Affordable Care Act, the ACA into law. The ACA is unquestionably the greatest restructuring of the American healthcare system since Medicare and Medicaid in 1965. I was on the clinical wards as a medical student in 1965 when Medicare and Medicaid first became the law. We're delighted that this year's seminar series will bring together national, state and local experts to help us better understand how health reform and the ACA will shape the future of American healthcare. A number of our programs this year, eight in fact, beginning with today's lecture by David Axelrod, will be cosponsored with the Institute of Politics, this wonderful new institute that came to the University of Chicago in the last year directed by Mr. Axelrod. Next Wednesday, for example, on October 9, here in the same room at the same time, Dr. Mark McClellan, the former director of CMS, will talk about next steps for healthcare reform. And other speakers that the Institute of Politics is cosponsoring with us will include Austin Gouldsby, Dr. Elbert Wang, Nancy Ann DeParle, Dr. Bekara Kuker, Julie Hamos, and Neera Tandon. These lectures will be part of the larger series of 28 talks. We're particularly thrilled today to welcome David Axelrod to help us kick off the series. As I show on the first slide, we'd like this to be an off-the-record talk so that Mr. Axelrod can be as candid as possible. That would mean, if you please, no tweeting and no blogging from this event. Mr. Axelrod is a political strategist and the director of the new institute at Chicago. A graduate of the University of Chicago in 1976, he spent eight years as a reporter and columnist for the Chicago trip. I'm told he was the youngest columnist in their history. In 1992, Mr. Axelrod met Barack Obama and in 2004 joined his senatorial campaign and later served as senior advisor to Senator Obama during the presidential campaign in 2008. Mr. Axelrod then served in the White House as senior advisor to the president and in 2012 was again the senior strategist in Mr. Obama's reelection campaign. Following the 2012 campaign, David Axelrod turned his focus here to the University of Chicago and the Institute of Politics to help inspire and train in a non-partisan way the next generation of leaders. As director of the Institute of Politics, Mr. Axelrod oversees a wonderful team. I've worked with many of them for today's event. A team that brings leading practitioners and policymakers to campus to discuss wide-ranging issues to help us understand both our current political landscape and how we can best prepare the next generation to become effective global leaders. The Institute of Politics has three core programs at its center. A fellows program which brings political and policy practitioners to campus for an academic quarter. An internship and civic engagement program which provides paid opportunities for undergraduate students to get hands-on experience in public service and a speaker series of which we're part which brings eminent public speakers to campus to discuss current events, political life and policy issues that shape our world and communities. Please join me in giving the warmest welcome to David Axelrod. I want to first congratulate you on this series and on all the provocative programs that you've brought to this campus. I can't think of a more important series to have because of what you said, because of the importance of the Affordable Care Act. And I look forward to working with you during the course of this series. I also modesty forbade Dr. Siegler from mentioning that one of the splendid people who works with us at the IOP is his daughter Dylan, who is a force of nature as you might imagine and has coordinated our internship programs and has worked very closely with our students and is a great gift to us. So I thank you for that as well. And I thank all of you. I know that as we talk about the Affordable Care Act this year that many of you are going to be on the front lines of delivering on the Affordable Care Act, dealing with the changes that it brings and the opportunities that it offers. And I should say parenthetically because I see some of his colleagues here in the audience that I feel a special affinity for this institution because my father-in-law Richard Landau and endocrinologist was on the medical faculty here for 60 years. And so I have a familial tie to this institution. When people ask me about the Affordable Care Act, Obamacare, they often ask me, did we know it was going to be so difficult? And the answer is, hell yes. Absolutely. When you consider the history of health reform in this country, there have been presidents dating back 65 years trying to achieve universal health care and some of the reforms that are included in this law. Seven presidents tried, seven presidents failed. Bill Clinton had a huge majority for health reform back in the early 90s at the beginning and the bill never actually came for a vote on the floor because health reform is complicated. People's feelings about health reform and health care generally are complicated. So while there are real concerns about the cost of health care, you all know that we have the least efficient health care system among all the industrialized nations. We spend 17% of our GDP on health care. The next country down spends 11% and yet our outcomes are oftentimes worse. There's some recognition of that. People certainly feel the cost of health care. But there's also a real concern about losing control and choice within the health care system and this has made this a highly emotional, highly charged issue for a very long time. Senator Obama felt strongly that we had to act on health care. I was reading this morning, rereading his book, The Audacity of Hope and he made the case for why we needed to proceed on health reform and it had to do with two factors, runaway health care inflation which was approaching double digits year after year and the growing number of uninsured which was exacerbated by changes in the economy and he laid out in that book a plan that very much resembles the law that was passed. When he ran for president in the primaries health reform was a major issue. It was a big concern particularly to activists within the Democratic Party. He ran largely on the plan he laid out in that book and the truth is that he ran into significant criticism during the primary season for not going far enough. There were many people who wanted a single payer health care system. He didn't support as a candidate for president a mandate for adults. He supported a mandate for children. And still when we got to the general election and we started doing research with voters what we found was that just supporting health reform and the kind of plan that he had proposed made him highly vulnerable. It was a big concern of ours in the general election against John McCain when we had all the wind at our back. I mean people sometimes doubt that we had any concerns in that race but we really did and this was one of them because what we learned when we tested our plan and some of the attacks against it was that it concerned people and ran into these third rail issues that I mentioned earlier and so we actually ended up running nine ads on health care in the general election and they were all aimed at avoiding being attacked by McCain. It was aimed at obviating the advantage that he had and it was aimed at sort of placing us in the middle. McCain had supported a health care plan that would have fully taxed health care benefits. It didn't include insurance reforms. We knew that that made him vulnerable himself and so we tried to plant ourselves in the middle of the debate in the general election and I'll show you a couple of the ads that we ran which will give you a sense of what the politics were on this issue in 2008 as we were running for president. Tim, let's just show the first two. Two extremes, one in government run health care, higher taxes and the other insurance companies without rules benign numbers. Barack Obama says both extremes are wrong. His plan is to keep your employer paid coverage, keep your own doctor, pay on insurance companies to bring down costs. Cover pre-existing conditions and preventive care. A common sense of the change we need. So hold up for one second. So you can see that we, as I said, tried to plant ourselves in the middle. I can tell you this was an extremely effective ad. It was, again, from 20,000 feet it's easy to make the argument and people really embraced it and I can also tell you that there were folks who called him after the ad, people who were sympathetic to him. Senator Kennedy being one of them expressing some concern about the ad because of the way a position government run health care. But we felt we needed to do that in order to keep the issue from being exploited by McCain. Similarly, let's look at the second ad. And as I said, there were nine such ads. And as I said, there were nine such ads. It basically took the health care issue out of play and actually disadvantaged McCain. And then we were elected. And then the discussion became what do we do? The one thing that when all of this was going on wasn't entirely clear was just how profound the economic crisis we were about to enter would be. By the time mid-December rolled around we were having meetings in which our economic advisors were describing the potential of an economic crisis as deep as anything that we'd seen since the Great Depression. In fact, our economic advisors said there was a one in three chance that we could experience a second Great Depression which is something that you thought was relegated to history books. And so we became an economic triage unit trying to save the economy from pitching into a depression, trying to save the American auto industry, standing up the financial industry which was badly damaged. And none of this was very popular. When we were putting the Recovery Act together to kind of fill the hole in our economy with accelerated spending, one of the things the President said is I don't want to just spend money. I want to spend money for a purpose. One of the things that he insisted was included in the healthcare bill was healthcare IT. And this was an anticipation of health reform. It's something that he had written about. It was a crying need to tie our healthcare system together in such a way as to make records available, do away with duplicative tests, and make the system more efficient. So that was included in the healthcare. But the real question was do we proceed or do we not on the healthcare plan in the midst of all of everything else that we were facing? And we had a very, as they say in Washington, free and frank discussion about this. And there were strong arguments on both sides. There were the proponents of health reform who felt that this was the moment that he had made the commitment and that we had to move. And frankly, there were others on the political side, and I was one of them who had concerns about it. And let me just say at this point that this was a very difficult thing for me personally because I've interacted with the healthcare system in a very intensive way over the course of my life because in 1982 when my daughter was seven months old, we lived here in Hyde Park, my wife called me and said she had found the baby blue and limp in the crib at first she thought she had died. And then she saw this strange phenomenon of her arm going back and her eyes rolling back. She didn't know what was happening and she raised here to this medical center and we were told at first that it was probably a febrile seizure. She had had a cold and that it would pass. And a month later we were released and she was still having five to ten seizures a day. This was the beginning of a long nightmare for us. At the time I was a young newspaper reporter. My insurance wasn't particularly good and her medications were very expensive and we were among the Americans who almost went bankrupt as a result of gaps in the healthcare system. So I felt very passionately about this issue but my job was to provide political input to the president and it was frankly a daunting prospect to take this on in the midst of everything else. Thought the safer path might be to work on education reform which was a more unifying issue. And he listened to all the arguments and finally said what are we here for? Are we here to put our approval rating on the shelf and admire it? Are we here to spend it down and try and achieve something of lasting importance for the country? And he said I know this could be tough but I think we have to try. If we don't do it in the first two years it's probably not going to get done. It doesn't get done now. It is, you know, you have a real prospect of the healthcare system imploding governments, businesses and families dealing with this health inflation. More and more people uninsured. He said we got to try. And of course that's why I love the guy. I always say I like him so much because he listens to me so little. And so began the movement for the Affordable Care Act. And it was, the great challenge was that the focus was going to be on how we cover the uninsured and 85% of Americans had insurance. And so their assumption was that this was for someone else, not for them. Even though the Affordable Care Act included a very robust Patients' Bill of Rights prevents people from being thrown off their insurance if they hit caps, obviously the whole issue of pre-existing conditions allows kids to stay on their parents' health coverage until the age of 26. And there was a whole array of, you know, capped the amount of administrative and executive costs and executive pay insurance companies could take from premiums. All of this was positive for people who had insurance. But all the coverage was focused on covering 30 million uninsured Americans and the cost of such a program. And no matter how hard we tried to divert that discussion, that was what the debate was about. We had at the beginning the problem of a strategic decision that the Republican Party had made in the Congress that, as Senator McConnell said, we weren't going to give him any major victory on any issue because that would signify that he's figured out this whole bipartisanship thing. And they knew that was central to his message, and he said we weren't going to give him that. And there was very well-enforced party discipline. We had long talks with Republicans in the Senate. And the Affordable Care Act, in many of its principles, was predicated on plans that had been introduced by Republicans in the past. It was a market-oriented plan that involved building on the health care system as it existed, creating a, as we now see in the last couple of days, creating a marketplace in which people could buy private insurance at a price they could afford. So, and there were people still on the Republican side in the Senate who had worked on that issue and had supported such a proposal in the past. One of them sat in the President's office for two hours during the course of the discussions in 2009 and said, and the President said, well, we agree on 99% of this, can we, can you support this? And he said, well, now unless you can find another 10 Republicans to go with it, because I'm not going to stand out there by myself. And we ran into that problem repeatedly, but by the summer, some of the angst about health reform generally became popularized in the Tea Party movement. Some of the organized opposition leaped in. It became integrated in the, in the drive for, you know, for the Republican elections from 2010. So that, that became a complicating factor. We, we also, you know, when the President talked about healthcare as a candidate, he said, we're going to have a big negotiation and we're going to do it on C-SPAN. And I'm going to, you know, everybody will have a seat at the table. He said, I remember, because I heard this line a hundred times, he said, you know, I'll have the biggest chair, but everybody else will have a chair too. And, but the truth is that legislating something, anything, is more complicated than that and legislating something as complex as this proved to be far more complicated than that. And so we, we never achieved the level of transparency that, that had been promised. And there were, there's no doubt that there were deals and understandings made as there are around every piece of legislation. Some of them were people found obnoxious and the whole thing culminated at the end of 2009 and the special election in Massachusetts when Senator Kennedy died. It was the ultimate irony that the, the number one proponent of health reform in the Senate had passed away and his replacement ran promising to thwart health reform. And there was a lot of, there was a gen, the general sense was that people were reading last rights over the health reform bill. I see my old colleague from the White House, Susan Scherer here. She remembers that, I'm sure, very, very well. There was a lot of doom and gloom about it. But as was true throughout the whole process, the president was very resolute that he wasn't going to give up on this. In fact, in the middle of the healthcare debate, we had a meeting on a particularly difficult day and the president asked his legislative director, Phil Schalero, what he thought the chances of actually passing the bill were. And Phil said, well, it depends how lucky you feel, Mr. President. And the president just laughed and said, hey, I'm a black guy named Barack Obama and I'm president of the United States. He said, I feel lucky every day. But he, he, you know, every time someone wanted to throw in the towel, he refused to do it because he felt it was so important for the country in the future to pursue this. And he was, I went into his office in the summer of 2009 in the midst of all this madness. And, you know, I showed him polling that's, I said, look, you need to know we're taking water on, on this issue. And he said, you know, I know you're right, but I just got back from Green Bay, Wisconsin and I met a woman 36 years old. Has health insurance. She's married. She has children. Her husband works as well. But she has stage four breast cancer. Now she's reached the caps. And she's terrified that she's going to die and leave her family bankrupt. By now I felt his, we were standing in the Oval Office and I felt his hand in the small, my back leading me to the door. And he said, he said, that's not the country we believe in. So let's just keep fighting. And so after the Massachusetts race, there was a fair amount of opinion that this was not a doable thing. And he said, no, no, we're going to get this done. He said, but I think we should regroup. We've got a lot to do on the jobs issue. We're going to talk about that in the next three weeks. Meanwhile, we're going to put this back together. One of his insights was to try and recoup the transparency that had been lost by holding a marathon session at the Blair House with the Republican and Democratic members of Congress to talk about healthcare. It was a remarkable session, some of you may remember. I think it lasted seven hours. And the President just was in a colloquy with all of these members on healthcare, on television. And it was actually a pretty good moment for democracy. And then the bill passed. It was crafted in a, I think, a politically astute way in that the things that kicked in first were the health insurance reforms, children over 26, end of the caps, more coverage for Medicare prescription drugs for senior citizens, catastrophic sort of healthcare plans for people with preexisting conditions who ultimately would be covered when the exchanges kicked in. One thing I should do is back up and say, I missed a major point here. When we started talking in the winter of 2009 about whether we should go forward, our policy people made a strong case that we couldn't reduce costs without taxing at least some of the healthcare exemption to try and discourage these kind of Cadillac plans that were wasteful. And they also argued that we couldn't cover people with preexisting conditions unless everybody was in the system, hence the mandate. And, you know, he poked and prodded on this and he became convinced that that was the case as well. So those were the two most unpopular features of health reform, but they were also necessary to make it work and he incorporated them into the system. So, again, we implemented the most popular and, in many ways, the easiest parts of the Health Reform Act leading up to now. But it was always the case that, you know, this piece was going to be very complicated because you're setting up big markets that hadn't existed before. And, you know, we know and you could see yesterday, I mean, the good news about yesterday was that the demand was essential. The demand was overwhelming and even though there were glitches in the system, the notion that people aren't interested in health reform, I think, was rebuffed by the huge numbers of people who went on these sites. I want to show you a little bit of polling to say where we are now. You know, there is this, the Republican or the opposition mantra to health reform is that most Americans oppose it and it misses an important point. Let's, oh, about 14 to 16% of people who say they oppose health reform oppose it not because they think it goes too far but because they don't think it goes far enough. And when you add that to the people who support health reform, it's a majority. And for that reason, a majority of Americans want to make the law work. There is not a majority for this notion that we should scuttle the Affordable Care Act. So to the next slide. And here's the point I was making before. You can see that 54% opposed but in 16% say that the law didn't go far enough and these are mostly single payer people. Let's look at the next slide. And here you can see by 57 to 36, it says OIC, a fairly recent poll by more than a 20 point margin people want to make the law work. And what you hear from people is we know this isn't going to be perfect. We've got concerns about it but let's fix it as we move along rather than go backwards. People do not want to go backwards. There is obviously a partisan skew to this. And this has to do with the shutdown here but 44% of Republicans support cutting off funding and believe it's worth a shutdown. That's not true of independent voters or Democrats who are hugely opposed to that. But what's interesting is even within the Republican Party, among Tea Party Republicans, 64% say they want the law to fail among Tea Party Republicans who oppose the Affordable Care Act, 44% want Congress to make it work and 31%, non Tea Party, I'm sorry, Republicans, 44% want Congress to make it work and 31% want to make it fail. So there you see the divide within the Republican Party. What we have is the rewards in our political system have led to a kind of stasis that we have today because many of these Tea Party Republicans are aggregated in congressional districts that are homogenous, 80% of our congressional districts are not competitive and therefore the only thing that people fear are primaries within their own party. And so the strong activist Tea Party based within the Republican Party in these congressional districts give these members a sense that from a political standpoint for their own well-being that they should wage this relentless war on the Affordable Care Act. I don't know how the current standoff's going to resolve itself, just to save someone a question. Nor do I think that anyone in Washington really knows how it's going to end. I know the President feels strongly that he's not going to negotiate at the point of a gun and he's certainly not going to undermine the Affordable Care Act in order to sue for peace. So he's taken a fairly hard line. I see the Republican Party trying to find a way out, trying to find a pole to slide down to get out of what has become an awkward situation for them and the seriousness of it could get even greater if they tie, as some say they will, a delay of the Affordable Care Act, a delay of the mandate, which is you can understand the political logic behind them landing on that, to the impending vote on the debt ceiling and raising the debt ceiling because if we don't deal with that we will default on America's bills and plunge the world probably back into a recession. So that's a heavy threat to try and... But I think he feels strongly that if we set the precedent that you can extort those kinds of concessions, then you're creating the circumstances that will repeat themselves again and again and again. So I don't expect that he's going to yield on this point. So I don't know what's going to happen. What I strongly believe is that the Affordable Care Act, however, is going to... I think it is on its way. Many aspects of this act are now actually appreciated by the people who are benefiting from them. If any of you have kids who are under the age of 26, you know that. People who have hit their caps know that, seniors. I don't think the Congress is going to take that away. I think these exchanges are going to be bumpy because of the nature of starting something this ambitious from scratch. I think they're going to be bumpier in states where governors and legislatures have been committed to blocking the Affordable Care Act, and the federal government has had to move in to set up the exchanges. The irony of that, of course, is that many of those states are the states with the highest number of uninsured in the country. So it's kind of a shame for the people in those states. Texas, for example, just to choose one at random, has the largest number of uninsured in the country. I think it's now approaching 28%. So I don't know that all of them feel well-served by Senator Cruz when he filibusters against the Affordable Care Act. But I believe that the way this is structured with its largely self-sufficient independent funding mechanisms, the Affordable Care Act is going to move forward. And as we look at the ruckus around it, I took the opportunity to look back at some of the debate before other major social insurance programs, social security, Medicare, and it was really striking how some of the rhetoric, if not the tactics, were the same. So people calling social security Marxism. Ronald Reagan in 1961 said Medicare would be the end of freedom as we know it. And you don't hear, I don't hear any Tea Party Republicans saying that about Medicare today. Now we have people holding up signs saying keep the government's hands off of Medicare. Someone missed their civics class. So I believe that it's going to move forward. I think we're going to look back at five and ten years and certainly generations from now and applaud the decision that we made. I think it will encourage best practices. I think it certainly will mean that people who didn't get insurance could get insurance. And let me just end on that note because one of my most poignant memories, powerful memories of being in the White House was the night the Affordable Care Act passed. And a bunch of us, I don't know if Susan, if you were there, but were in the Roosevelt room at the White House, the team that worked on the bill, the president, the vice president as the final votes were being tallied in the House of Representatives. My office was nearby. And as the final votes came in, I found myself, I got up, went into my office, closed the door and wept. And it was surprising to me, you know. I mean, I'm a crier, but this was, but this sort of, I was surprised to be so overcome and I thought about it. I thought about why. And I realized it was because of the experience that we had when my daughter was young and the anguish that we felt worrying about whether we could afford to get her the care that she needed. And I knew that because of what we had done that in the future other families wouldn't have to suffer as that kind of anxiety or worse. And that made everything we were doing there real. You know, these things get covered as sort of who wins and who loses and who scores points and who positions for the next election. But there's real fundamental meaning to this for millions and millions of people. And I found the president and I still verklempt and I thanked him on behalf of all those families like mine who aren't going to have to go through that and he put his hand on my shoulder and said that's why we do the work. And that's why we do the work. And now you guys are going to have to do the work of helping us make it work. But I do believe that it is going to work. I think it's going to be bumpy. It's going to be noisy. It's going to be an issue in the next campaign although perhaps less of an issue than people think today. But I do believe that health reform and the Affordable Care Act is here to stay. And while there may be some changes along the way and there should be and there may be adjustments along the way in the main, the law that's in place is going to survive and I think it's going to prosper. So with that I'm happy to take any questions you might have. So I think that there is significant resistance to a single payer system. You know, I think if you were to, and this is me speaking, not for the President, I think if you were to start all over again and you were designing a system from scratch that that would be a logical place to begin. But we have a system that people are well invested in. And so I don't know, I don't want to predict that there's going to be that kind of full transition. But I do think that the numbers on support will change. I mean there were, the numbers on support on some of the previous social insurance programs were very mixed as well. And I think the numbers will change as the program becomes more familiar to people as the fears they have do not materialize. And as some of the benefits that accrue become more evident to them. Now whether in time the economics of medicine drive you in that direction, I don't, you guys would have a better sense of that. But I'm here to talk about politics as a political matter. I think we're a long way from that. Yes, I was in Washington on Monday and someone asked me what I was doing there and I said, I like to go where the inaction is. Look, I personally am a supporter of redistricting reform. I think that what they've done in California and some other states is the right way to go where you redistrict in ways that are nonpartisan and districts that are created are more diverse in terms of views. Part of it is a function of sort of geographic patterns of where people are settling so you get districts that become more homogenous. But I think that a lot of it has to do with political gerrymandering. And look, I'm a Democrat. In this state we've benefited from it. We squeezed out four extra seats after the redistricting here. In North Carolina it went the other way. So 53% of the vote was Democratic for Congress and Democrats got 27% of the seats. And I think it would be great to have redistricting reform. It's going to be hard to accomplish. Some states it can be done by initiative and I think voters will support that. The other thing to look at also now being done in California are what they call the jungle primary which doesn't sound like a solution to gridlock I guess but it really is which is everybody runs on the same ballot in the primary Republicans and Democrats in the top two finishers running. It could be two Democrats or two Republicans but it creates a market for moderation and I think that would be valuable. We're by the way going to do some programs this quarter at the IOP on the state of our democracy and some of these reforms and have some debate and discussion on that Amy Walters, one of our visiting fellows is an expert on Congress and congressional elections so I invite you and anyone to come over and join us for that. I was wondering about one of the public polling numbers you just showed with regards to how many people want the law to work and how many people want to stop funding for it and it seems like over the course of the past two and a half or three years the number of people who do not want it to work is like gradually increasing though like a small number but noticeable and the people who want to defund it actually is gradually increasing and I was just wondering if both sides are pushing for their opinions why is the side that wants Obamacare to work not being able to sway more public opinion especially when now some states have partially implemented it so we could argue that some folks are already seeing the benefits. First let me challenge a little bit challenge the initial premise because if you look at a lot of data what's striking isn't so much how the numbers have changed but how they've stayed the same the opposition has generally been within the same range the support has generally been within the same range that varies in some public polls but in credible polls that I see I've seen less rather than more variation but I think that the jury is out in the minds of many there's so little information first of all there's such a gap of information about the Affordable Care Act and so that's been one of the things I want to mention is that the opponents of the Affordable Care Act have on television until now outspent the proponents by five to one and so negative characterizations of the Affordable Care Act are much more prevalent obviously there's been a big effort on talk radio on the right and cable in this regard but I think that it's going to take time to implement this for people to see the impacts of it for attitudes to change about it one thing that's happened now is that the insurance industry realizes that they have skin in the game and they're spending more money they're spending serious money now advertising trying to get people to sign up for these pools because as you all know one of the tests for the Affordable Care Act and these exchanges are these markets broad enough and will younger healthier people sign up for these pools so as to hold down overall cost it is a fundamental mission to make that happen and the insurance industry is now advertising on the law probably going to help in some regard but I think ultimately it's going to take implementation to change those numbers and I counsel people not to get too wrapped up in polling in the short term on this but I am amused by the opponents who say well you know majority opposed the law because I also saw majority like 85% who thought we ought to have background checks for guns and that didn't seem to move then I feel bad about these folks who are standing they're standing and wanting to ask a question you better be a gentle question now that I took out the case for you I'll ask it very gently I came here because I was really interested in the title which was the ethics of health care reform and I'm a little bit disappointed that first of all the question of profit making in health care was not addressed at all and also the cost of health care which as we know of the health care in some of the other countries you mentioned you didn't mention by name they're not for profit health care so could you just address that a little bit? yeah first of all let me say I think the title of this entire series is the ethics of health reform so there are how many 28? 28 yeah there are 28 sessions on this and if I if mine falls short of the expectations I apologize but in terms of the cost I think that is obviously a huge issue and so part of what the Affordable Care Act is meant to do is to make health care affordable for people for whom it's unaffordable now but it's also meant to encourage the kinds of practices that will reduce health costs over time I've seen a reduction in the last several years in terms of the health care inflation that's marked and you know at first the question was is that a result of the recession or is it a result of effects of the Affordable Care Act I think some of the studies that I've seen suggest that a quarter to a third may be attributed to the Affordable Care Act but certainly encouraging a more efficient the theory of the Affordable Care Act is that you can be both more efficient and more effective in providing health care and by reducing infection rates by using health care IT by doing a range of things by going to bundling of care rather than fee for service a variety of things to reduce costs and that was one of the impetuses for the health care act because at the course and speed that we were on at the time that this debate took place if we continued that way as the president said to us the health care system would eventually implode and you know that's a reality that I think we've helped that's a prospect that we've helped reduce by passing this act but it needs to be implemented properly let's maybe we should take a question from the front Thank you for your time I just had a question it seemed like the 2012 election was in some ways framed as a referendum on health care reform and obviously the president won and I think shortly afterward Speaker Boehner even came on and interviewed and said that this is a law of land we're essentially going to move on so I was just wondering how much of the yet again we're having this talk and the shutdown and everything I was wondering how much of it is I guess an internal battle just within the Republican Party that I guess the president has less power in moving in whether it's just I guess the increasing right wing elements pushing the more moderate I guess in the Republican Party to bring it up again because I know in terms of the shutdown a lot of people say well you know why are you know what's the rationale but the political calculus seems pretty clear because a lot of these you know representatives were elected to oppose health care reform in many cases Well that's the point that I made before you're right that Speaker Boehner did say that others said that I guess you could attribute it to short term memory loss but I don't think that's it I think that the political pressures within the Republican Party were such that you know he's had to give ground on that for the reasons that I was discussing before that within the Republican caucus and within the activist Republican ranks this has become sort of the great white whale and they're pursuing it with the maniacal energy of Captain Ahab you know and the speakers responding to that I mean it is a at some point he's going to it appears as if there's a majority in his caucus even to move on now and at some point he's going to have to confront this but look there are there's a dynamic situation in the Republican Party it's a divided party you're right the president won an election and the Affordable Care Act was part of it it was a little confused because Governor Romney of course was the author of a health care act that very much resembled the one that we passed and so it limited his ability to critique the law and that's what the argument is among some of the Republicans but nonetheless everybody was aware of the Affordable Care Act it was out there there's advertising on it the president got re-elected but in those districts where the folks who are now moving the dynamic in the house are elected I'm sure that that support for the Affordable Care Act and the president were low let's take a few more questions Sam broad we are admired we are criticized but there's one area namely health care where the world doesn't understand this country how come that the majority of the world has care for in one form or another for the entire population and we a country that is very advanced do not have it and so when I talk with people when I travel they say they cannot understand how we can be so backward in this sense so in the president's travels has that been approached what kind of message he gets from abroad you know I think you're right that there are a lot I mean I get the question all the time when I travel about this but you know I think that he would say and I would say that you know we do have this sort of you know our country is a little bit different in that we believe in this rugged individualism you know and so there's traditional resistance to things that limit or that are perceived to limit choice perceived to limit one's options and a resistance to centralization and you know it is part of our political culture and you know you can see in the debate today that that's still true but it doesn't obviate the fact that we have an unsustainable we had an unsustainable system that absolutely demanded reform and you know now the question is can we move forward to implement it and make progress on this issue understanding that we're not going to make some big transition to a single-payer system which is what most of these countries have but perhaps we can embrace the concept that no one should go without health coverage and you know that I think is an achievable goal sure this one thank you very much John Alverde I'm a general surgeon here can you speak a little bit about your choice of coming to the University of Chicago perhaps and maybe in the context of your talk how you see embedding some of your politics into the Institute of Politics here I actually came here for superior medical care I've learned how to pander over the years no I look first of all it's not mine to insert my politics at the IOP in fact you know in the last year we had 159 speakers from January to June we opened our doors in January those speakers range from Newt Gingrich and Haley Barber to Jerry Brown and Gary Hart who was a fellow here and you know our goal is not to locate young people with a particular point of view but to expose them to many points of view and one of the things that's wrong with our politics right now is we've organized ourselves in such a way that people tend to have their own views affirmed rather than being exposed to other views and there's not a lot of respectful debate or recognition that perhaps there are other answers that make some sense or some amalgam of views make sense so you know we try this quarter you know we have Robin Carnahan as a fellow who was the Secretary of State in Missouri ran for the U.S. Senate there comes from a great democratic family there we have Vin Weber who is a conservative Republican congressman from Minnesota and Ramesh Paneru one of the great incisive younger thinkers in the conservative movement who writes for the national review I'm glad for our kids to be exposed to all of them and really at the end of the day what our goal is at the Institute of Politics is to try and encourage young people to get into the public arena if not as candidates then as policy makers strategists commentators because you know and I'm sure all of you who deal with young people here and there are a lot of young people in the room know this that I think this is the most public spirited group of young people that I've met since the 60s and I was thinking about why that was the other day I kind of think of my generation as a lost generation because you know our parents went through a depression in a world war there was a sense of sacrifice a sense of common purpose and even when we had big debates those debates did not spill into the kinds of ugliness that we see I think it was awfully easy for us our young people today have gone through 9-11 they've gone through now a very devastating financial crisis and what I see are young people who understand that there are problems in the world there are challenges and that they want to get in there and try and make things better the real question is politics the way to do it and that's a very good question given the spectacle that we're witnessing today and that we see every day in our newspapers and on cable television and what I say to them and what I say to all of you is that whatever the equity you care about and obviously everybody's here because they care about health care and that's a very prominent one but if it's climate change, budget deficits, human rights, education every single one of them is going to be impacted by the decisions that are made in Washington and state capitals and city halls and world capitals and you know I'm not sure that if you care about these equities that you have the luxury to walk away from this I think it's much more productive to get involved to become part of the discussion to try and guide the discussion to a more productive place and ultimately I'm actually more optimistic than most about the future because of young people and because I think that what I see is more tolerance what I see is more public spiritedness and I think as this generation filters into positions of leadership we're going to see changes that we all want to see and it's not always going to lead to solutions that I wholly approve of or you may wholly approve of but I think they'll be more thoughtful answers and we'll get past this episode we're in so the point of the IOP is to make a contribution to that and we're going to measure our progress based on the number of leaders that we produce and we want to look back in 5 and 10 and 20 years and say there are some young people in the institute of politics and now they're helping to guide the public debate so my job isn't to persuade young people that my point of view is the right point of view my job is to encourage them to get in the arena and fight for their point of view