 Okay, well welcome back to our afternoon session. We wanted to set something up because we know that after lunch people tend to experience an insulin dump that slows things down. So we have asked Norm Ornstein to provide us with his energized and occasionally optimistic view of the world. This is a man who has co-authored books that talk about the broken branch and it's worse than it seems. And I don't remember from 2017 that perplexed the befuddled, the soon to be deported or something. Norm is a resident scholar at the American Enterprise Institute here in Washington. He's a political scientist. He is a frequent commentator on basically all of the networks. And he's a frequent contributor both to the New York Times, the Washington Post, to Politico and others. And I'm not sure what I'm going to leave out here, but I think many people will know you and I should just get out of the way and let you talk. So, Norm Ornstein. Thanks so much, Murray, and I'm delighted to be with you. You did leave out that I'm a very stable genius. And actually when President Trump tweeted that, my first thought was, I know only one stable genius. His name is Mr. Ed. And I will tell you, the arc of my books does tell you something about my thinking. It went from the broken branch about Congress to it's even worse than it looks. And that was revised to it's even worse than it was. And I almost titled the last one, Run For Your Lives, but hope it's not the next one. That's One Nation After Trump, a guide for the perplexed, the disillusioned, the desperate, and the not yet deported. So I'm not feeling wonderful right now. Today is day 441 of the Trump presidency, or as he says, longer than any other president. But what I want to do in a brief period of time is to provide at least a little dose of optimism. And what I'm going to do is give you the bad news in a very brief dose and then go into the good news. I do want to start with a cautionary note, which is a story that has been a favorite of mine for many years. It's about a first year anatomy class in medical school where the professor uses the Socratic method. And he comes in and says the question of the day is, what human organ, when appropriately stimulated, grows to eight times its normal size? And he looks up, he says, Miss Jenkins, and Miss Jenkins reddens and says, I'm not going to answer that question. And then he looks across the room, Mr. Logan, and Mr. Logan says, why the pupil of the human eye when it enters a darkened room? And the professor says, that's right. Now, Miss Jenkins, I have three things to say to you. One, you have a dirty mind. Two, you didn't do your homework. And three, you're doomed to live a life of unfulfilled expectations. So I'm just hoping we have better than that. So starting with the bad news, I've now been in Washington for, it's frightening to say, almost 50 years. And I've been immersed in our politics at both ends of Pennsylvania Avenue, and I have never seen it this bad or this dysfunctional. Now, we all know about the polarization, but the polarization is not the biggest problem. And the fact is you can have polarization and still solve problems. You have a little something in your packet about Hatch-Waxman, which was an attempt to solve a problem about drug availability and pricing, an imperfect one, but still something that went from Orrin Hatch who was at the time anchoring the right end of his own party and Henry Waxman who will never shrink from the label liberal. Then you had Kennedy Hatch, also an odd couple ideologically and in lifestyles. But whenever I would see Orrin Hatch for decades and whenever he would give speeches, he would say his proudest moment in public life was when he worked together with Ted Kennedy to get the Children's Health Insurance Program. Even if he came pretty close to abandoning it this year, which tells you something about the arc of our politics, not to mention the fact that within his party now Orrin Hatch doesn't anchor the right end of the party. He's close to being a socialist in that context. It's tribalism that's the problem and that's been emerging for some time. You can be polarized and say I don't agree with his or her ideas, but he or she is a good person and we can find some common ground and if we want to solve a problem that we all acknowledge is a problem we can give a little here and get a little there. Tribalism is you're the enemy. You're trying to destroy our way of life. And if I work with you, I'm sleeping with the enemy and that's just not allowable. And that's been building for decades and it started in Washington and it's metastasized out to the states and to the public as a whole. And now our politics are driven more by what we call negative partisanship. People not embracing their own party so much as motivated to make sure that those evil bastards don't take over and destroy what we've been trying to do. Now that's been amplified by another long standing problem and issue and that is what we call the permanent campaign. It's all campaigning all the time and that means that even if you don't view the other side as evil, if you work with them, you might give them a little more traction, a little more ability to win seats and less ability for you to gain the holy grail and take over the majority. So all of that has driven us apart long before Donald Trump and of course there are many other reasons that led to the presidency of Donald Trump. But now that we have him, we have another set of related problems. One is that Trump may be the worst deal maker we have ever seen in the presidency. He clearly did not read the art of the deal, much less write it. And as he steps in and steps on himself and his party as he's done repeatedly on immigration with that famous, since he used the word I will, shithole country meeting, as he did repeatedly on the healthcare front when they were trying to do repeal and replace, as he does with tweets that step on the message of his own party, he's made it more difficult for them to figure out how they could work things out. And at the same time, while he ran as a populist and he has populist rhetoric, he has governed in an opposite fashion. And that's true whether it comes to tax cuts or now with a set of tariffs that are aimed far more at people in Trump country, soybean farmers, pork producers, people who need aluminum and steel and the work that they do than anywhere else. Now along with that, we have a Congress that is more dysfunctional than any that I have seen in a very, very long time. They came in without much of an agenda. They've stumbled over much of what they claimed they wanted to do. They were able to enact the big tax cuts, but as we saw with the failure of the repeal and replace effort, which included not just a failure to be able to act, but a process that was among the worst we have ever seen in the Senate where they kept out those who were experts in health policy from the finance and health education labor and pensions committee, including their staffs, and had 15 old white guys, actually 14 with one black guy, put their program together and it faltered completely. It showed that there wasn't much that they were able to do. And now we have the fewest days in session left for the year that we have seen in a very long time and very little capacity to do anything other than the must pass things that are out there. So at the same time where there's no time for action, what we have also seen is that failure to repeal and replace Obamacare has been matched by a set of actions both taken inside Congress and in the executive that are aimed at sabotaging the law and you know all about them from not dealing with the cost sharing reductions to pushing through these cheap plans and moving through the tax bill to end the individual mandate that are going to poison risk pools and raise premiums in a lot of places without any ability or willingness to step in to try and resolve those things. That's bad news, but mixed within it is some good news in the subject that we're talking about today. First, what we've seen over the last few years is that there is on occasion capacity for bipartisan action and that capacity is as evident or more evident in broad areas of health policy than it is almost anywhere else. The Sterling example, of course, the 21st Century's Cures Act. I had a minor role in that over my interest for a variety of reasons in mental health policy reform and I worked with members of the House and Senate including former Congressman Tim Murphy and Fred Upton and Debbie Stabenow and Roy Blunt and others on the Republican side and that bill went through with near unanimous support and it was a model of give and take and finding some common ground that was shared very broadly. We saw it with the DOCFIX and MACRA, not quite as robust the majorities but pretty close to it. After years of failure to deal with this issue except by punning it year after year, they finally got together and did something that was reasonable and significant in health policy reform. So the capacity is there and if it's gotten a little harder in the last couple of years in the Trump presidency or the last year plus, it's still there to do so. The second bit of good news is that as you've heard some today, my former colleague Scott Gottlieb and the new Secretary of HHS are actually determined to try and do something in this area and what we've seen with Secretary Azar is that he now has picked the Deputy Secretary to basically run a lot of elements of the department so he can focus on opioid addiction and drug pricing. He's brought in an executive from CVS to work with him on this. I think he has something to prove given where he came from and we've seen Scott actually take some steps that were pretty controversial even if they are more rhetorical than anything else at the moment. But there's some willingness, even if it's not coming from the White House itself, in areas where they'll probably have a significant additional amount of slack, especially since they are among the few officials who are not in the crosshairs through corruption or ineptitude or both among others in the cabinet. Next is public opinion. When Tim Murphy left under his own cloud of scandal, we had a district that opened up to a special election in Pennsylvania in a district that Murphy had won almost by a claim and that Trump carried by 20 points. And it of course was won by Democrat Connor Lamb and what we've seen from the deep dive into polling in that area along with other research is that the number one issue was health prices and drug pricing was right at the top of that list. So it's not just that we have overwhelming as you know from your packet public support for doing something about prescription drug prices. This is at the top of a public agenda right now. It's that we've already seen it operationalized in elections. We've had a lot of other issues in the past where you've had overwhelming public support and obviously one that's been in the news of late guns where the support for background checks has been over 90% for some time. It didn't make any difference to Congress and it didn't make any difference in elections. All that they need is one example where an issue made the difference and it gets the attention of members of Congress. And also more broadly now not just because of Connor Lamb with the elections last week in Wisconsin where we saw an astonishingly large margin of victory for a liberal justice for the Wisconsin Supreme Court in races that in the last couple of years had gone very much the other way and this candidate woman won by 12 points this time. A state Senate seat that had been firmly red turned blue as well. What we saw in Alabama and elsewhere has Republicans fearing a gigantic blue wave in November. Scott Walker the governor of Wisconsin tweeted just that. How big will it be? And we had the Senate majority whip John Cornyn say we don't know if it's going to be a category three, category four, category five hurricane, but we have stiff winds in our faces. Fear is a great motivator for action. And given that the tariffs and other policies are going to hit hard not just in the suburban areas where Democrats have traction and some ability to move ahead but in rural areas and rural states that are firmly Trump country the desire to do something that mitigates against that sentiment and given the economic perturbations out there the news today after of course we've seen the stock market decline a little bit but with a job growth that's quite disappointing this time. The desire to do something as health insurance premiums are likely to rise for large numbers of their constituents and they own the issue now is going to be much greater and this is one area where they can do something that would be palpable for people. In Tennessee a very Republican state. We had a poll out today that shows that the Democratic candidate for the Senate Phil Bredesen the former governor is up by 10 points over the likely Republican candidate congresswoman Marsha Blackburn. And if that poll might be a bit of an outlier every poll in the last couple of months since Bredesen indicated he was going to run has shown the Democrat ahead in a state that Republicans had taken for granted that will also add to the fears. So I'm expecting to see at least a lot of discussion and some movement towards action in the area of drug pricing. What I can't tell you is exactly what that action will be and whether it will take significant steps to solve the problem. The easiest and most tempting thing for them to do is just to push to have the rebates go directly to consumers but of course that's more likely to raise health insurance premiums. The question is whether they decide to do that now and take the short term and hope that it doesn't have an impact until after the election is over. But whether they're willing to take further steps along the way is something that I can't answer right now. And against all of this is another set of realities for Democrats right now facing the possibility of not just a big win that will give them control of the House of Representatives. But options in the Senate that they didn't see before doing something in conjunction with Republicans now that will give them a little more traction or the ability to go out there and brag that they're taking action in an area that their constituents care about doesn't leave them with a lot of incentives to go along. And given the nature of the ideological framework of Republicans in Congress doing this with Republicans alone especially if we're talking about things like enabling Medicare to intervene in drug pricing more directly or having government play more of a role job owning is not likely to reach support from the safer members of the Freedom Caucus for example. So the question is whether you can get broad bipartisan agreement along with whether they're going to have enough time and ability to bring up something and frame it in a fashion where they can actually get some bipartisan support. So it's still an uphill lift. There's still more obstacles in the way of action than anything else. But in this area more than almost any other in public policy. I think the conditions are there for some positive movement in a political system that is incapable of acting in a positive fashion in almost any other way. So I think with that Murray I will stop 18 minutes in which is the best I can recall minute 13 seconds and open it up for questions or comments in the form of a question. Use the balance of your time. I'll reserve the balance of my time. Okay well again we'll open it up for questions with a microphone in the center and one up by the light stand here. Norm you offered a couple examples of bipartisanship with 21st century cures with macro. We could maybe throw in the recent budget bill. Yeah. What were sort of the similarities and maybe working backwards from the budget bill which obviously had some deadlines attached to it that the others didn't. But what are the similarities? What are the factors that bring together that kind of activity whereas all the rest of the tribalism is pushing stuff apart. So I would separate out the budget agreement the spending agreement because that was a must pass piece of legislation. Neither party saw a great advantage or at least both saw enormous potential pitfalls in a government shutdown. More true for Republicans than Democrats but Republicans also knew that in this case unlike with the tax bill they needed Democrats. They were not going to get anything done without Democrats and if they brought up a spending bill and the Freedom Caucus blew it apart. Or a few if they passed something that won the Freedom Caucus in the house they lost the Lisa Murkowski Bob Corker Susan Collins element in the Senate. They'd be blamed squarely for it. So that gave Democrats enough traction that in the give and take they could gain a great deal in terms of additional appropriations for things that they cared about and a few other substantive changes. I want to give you a little caveat there though on this one. Stan Collender who is goes by the Twitter name the budget guy has just written a column in Forbes saying that he has a great fear that Trump who got enormous criticism from his base for signing that bill because it had a bunch of spending that they didn't want that there are a lot of signs that he may refuse to spend the money. Now he may do that under the provisions of the budget and impoundment control act that require Congress to agree that he can't spend the money or he may just do it illegally and Congress may not act and if that's the case it will poison even more the relations between the parties because Democrats will see it as a bait and switch. So put that to the side for the moment what I saw with the 21st Century's Cures Act which actually melded together two separate pieces of legislation. The mental health part of it was a separate bill until it was brought in more than anything else. That was Fred Upton trying to find something when he was chairman of the Energy and Commerce Committee that could be done in a broad bipartisan way. Democrats joining in part because both sides were very nervous that the budget out there was going to cut money from NIH which is an enormously popular thing and that they could cut a deal where they would have some changes in the speed with which we could move drugs forward in return for more spending and then they could throw a lot of other things in and it was able because of the efforts of some of those members but also because of the efforts of both Pelosi and Ryan to pull things together. It was easier to make it work in the Senate but it was in an area and that includes especially health research which is enormously popular that could find that common ground. With the DOC fix it was pressure from the rank and file as much as anything along with pressure from doctors and an understanding that what they'd been doing year by year was not helping anything and then they were able because they had some agreement on doing that and finally resolving it so they didn't have to deal with it year after year after year they could put in some other useful reforms. So you've got to have a situation where you can give each side a little something where you have a train that you agree is going to reach its destination and maybe you can throw an extra car along the way and that may be there for drug pricing and it's very clear that all across the country this is of concern to people and there's a belief that something has to be done and that cuts across a lot of the ideological and partisan lines and so the question becomes since it's not must pass whether you can find an avenue to make it work and frankly it also becomes a question of whether if you're moving along and it's delicate you get a tweet from the commander in chief that blows the whole thing up or a meeting where he decides he's not going to let it go forward. Well we're out of the model so to speak in that arena. Peter I saw you standing up. No it was a narrow point about point of sale rebates just to be you cut right to the heart of the matter. So the idea of point of sale rebates is that beneficiaries or patients when they're paying essentially are paying a price that's calculated off of this net of rebate price and it does it shifts it has a modest effect on premiums. It has a big effect on premiums indeed because of the donut hole effect which is you know it's just an artifact. But it is sort of it cuts to this fundamental question there's a very small segment of patients who pay enormous amounts out of pocket for drugs point of sale rebates would lessen their burden and of course it gets shared across the many. So I actually think like that trade I just want to reemphasize the importance of that trade off because it seems central to what we're trying to figure out which direction we want to go in health care policy. Sure and if you are in Congress and looking at it and you don't want to get into or can't get into an area where you have a direct government price setting or price leverage option which is going to meet with some significant conservative opposition and you look at the timing of all of this. If you can make this happen and in the short run it means that those people who get horrible burdens have those burdens relieved and prices will look like they're coming down for a lot of people but the cost shifting isn't going to take place for some time after when premiums are set for the next year. If you're a politician that has some significant appeal to it but obviously it doesn't solve a problem it just shifts the burdens stunned you all. Well I have another question here because you held out the DOC fix the fixing the sustainable growth rate mechanism again as bipartisanship. I don't want to be the skunk of the garden party but that did take 18 years and in retrospect it was it had a lot of proponents in the entire physician community not a lot of opponents except for budget geeks not much public support. Now we get into drug pricing where we have lots of public support but a much more complicated set of issues to deal with. Give us grounds for optimism and I guess for probably the vast majority of the people in the room who would like to say how can we leverage that public opinion to get something done. So the optimism is it's not going to take 18 years but we know what happened there basically and the reason the fundamental reason that it wasn't dealt with over 18 years is that if you deal with it you are creating a bigger budget burden for yourself and for all of the bills you're going to have to pass each year and just as with all of the supplemental appropriations that Congress has done in the past where you throw in money in the middle of the year for disaster relief or you throw in money for defense where you don't have to consider it when you're doing your budget and you can do it outside of whatever caps me exist for the rest of spending there's it becomes almost a no brainer for people in Congress because you don't want to take the short term hit and they're focused on short term hits. Now I think there is a real difference here because of that public support and because of the political fear that exists out there. If Republicans in Congress are smart about this they don't try to basically get Democrats who have lots of reasons not to do anything this year but they put something forward and frame it and bring it up on the floor where it's going to be very hard for Democrats then to vote against it because it is solving a problem for a lot of their constituents. The big challenge I think we face right now is they don't seem to know how to bring up legislation anymore or how to work it through some process of the regular order or how to frame it even within say the help committee given that now relations for example between Lamar Alexander and Patty Murray have been poisoned by the Democrats unwillingness to embrace a bill to help deal with the CSRs and other things because it included a new provision on abortion that's going to make it a little bit harder. I think what has to be done now is that all the groups involved in policy here in Washington and back in constituencies at home really focus on making this an issue this year and make it clear that the failure to act is going to make it an even magnified issue in its importance in November. That's what grabs their attention more than anything else right now and I do think because Republicans are framing and setting policy and because you know Trump campaigned basically by hitting the pharmaceutical companies during the campaign. That was a common theme of his and it met with enormous approval from people at his rallies and then dropped it once he became president and of course has met frequently with the pharmaceutical industry representatives and they've played this brilliantly and I have little doubt that some of the people in his cabinet have their own ties and have reinforced that but if it becomes clear that this may make a difference in terms of whether he has a Democratic Congress investigating collusion and corruption or maybe having it come out a different way he is less likely to step on the opportunity that his party has to do something about this. So this is a time for everybody to up their game and I would say that's the best bit of advice I can offer. We can all stand up our game. Norm. Yes. Thank you. The audience please join me in. Thank you. And when you fill out your surveys at the end of the day please indicate whether you were uplifted or not. Thank you. You're all stable geniuses.