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A Real Look At Health Care

Feb 17, 2010|

TNT talk with Harvard Professor David Cutler, who helped shape Obamacare...

Transcript - will not be 100% accurate

I'm 680 W -- here. Good morning it is time inside the sun is coming up in the north side. Hostile Robin Hood of a sudden rise well above the horizon now it's good get getting a -- points you do notice that the -- -- -- -- little riled some of the north. It is starting to move that her it is not Clyde to east yet it's still these little -- released -- -- -- I dissect that if they got that I have a compass and my oh like the -- -- so we're gonna talk on healthcare again -- -- -- we had a Cato Institute dial libertarian. Correct and today we have whatever the opposite libertarian is a guy from Harvard yeah professor wrote David did David Kudlow is the -- -- -- -- to me but also -- -- the auto extent professor of economics with a specialty. In health yeah. Was the health care adviser to the Barack Obama campaign. In is the administration still solicits apparently. So much input from him as to a number of observers incumbent I'm sorry there's still talk -- -- -- -- you -- I don't devise a healthcare plan this cuff ha ha -- you closure of the Obama presidency. And unfortunately I had something to do with the stay -- go off -- father fingerprints -- all the party -- forensic evidence I wanna stop with with local stuff -- and I talk about this a lot it end I'm not sure that we have is completed grasp of it as we would like to an all subjects. It would been critical honestly of the Massachusetts. Health reform law. And is causing some of the budgetary problems. You not only take issue with that. Mitt Romney's -- a secretary of HHS very knowledgeable conservative guy Tim Murphy Sistani to says the main hero -- you don't know what you're talking about wanted to walk us through and through us to our listeners. Canada quick sketch of the Massachusetts health reform law and why you don't think. It has been. All will be a budget -- Okay did have a happy to do so and good morning to you good morning. I'm they're too big goals and healthcare. The first witness to cover everybody. The second one is to find out how to save money by making the system work better why is covering everybody needs an introductory go as opposed to making it affordable isn't the problem with health -- a lack of affordability. And that makes everybody run for government cover. So win the thing to do to be not try to cover reporting but to try to attack costs. In fact that you are intimately related. And that's really what the federal legislation is about is trying to do those two together trying to cover everybody in to make it affordable. Which of course is the only way that attraction green cover everybody. In Massachusetts. The way we. Covered everybody was we provided subsidies to low and middle income people. And we provided a place where they could buy it. The constant connect Arctic national call to help. An -- bureau you're on the board of the connector right have been no I'm not advise are okay don't know I just an okay I don't know official round -- Then basically if you make insurance be affordable. And you make it be accessible. Then people will go out and buy it and that's what's happened in Massachusetts about three quarters of the formerly uninsured have -- insurance coverage. Massachusetts has the lowest rate of uninsured in the entire country by 321 people approve of what's going on. Health care is expensive in the commonwealth it's expensive everywhere across the country. What's happening now is that. Revenues to state government fell by about 15%. When -- needs on state government have grown with the huge recession. Every single state in the country. Every single one is dealing with a huge budget mask around us because by the recession a health care. If we did not pass the legislation we would be in virtually the same budget mess as we are in now. But what is the legislation accomplished in terms of dealing with the underlying problem which is health -- -- expensive. And that's really what we need to attack I don't hear anybody turn and attack it. The Massachusetts legislation explicitly put off they dealing with the costs which I think was. We we need to come back to end it at the time it wasn't deemed. Who wasn't what it wasn't something we decided to attack then but let me compact they're actually two issues member you had a lot of people who were earning. 5060000. Dollars schoolteachers. Firefighters. Policemen. Who were one pink slip away one illness away from losing everything. Good medical bankruptcies are people in debt because of health care. You are people not going to doctors because you're afraid that they wouldn't be able to afford it -- an excuse -- Massachusetts law. Got rid of an enormous amount to that it provided a huge amount of security. To people who were veering very insecure as well. Let me challenge underlying problem said. What -- but I think he's indicated that the have to return to that otherwise this thing is gonna become. Just kind of a one sided solution which is really not a solution and ask your question though on you'd. -- -- dismissal of the claim that this is a has been a budget -- you indicated that because people poorer even you know somewhere in the middle class. They could not afford and so we provided subsidies but the -- he is is that not. The Wii is the commonwealth provides that subsidy so to a certain extent whatever they -- budget gap is largely caused by global recession. This some -- of this health kill law that is imposed a new level of costs that weren't -- before the passage of law. Yes but and that that's very limited for two reasons one is that the commonwealth already had money that was put away for people. So for example we had money going back to go Dukakis error that we had been raising that we do. Paying out to local providers particularly Boston Medical Center Cambridge health alliance. The end we redirected some of that money to care for. To provide insurance. And second as we had some monies that we had from the federal government that quite honestly we had gotten in a bit of a surreptitious way yes and a federal government was threatening to take it back show. And the commonwealth said suppose we use it in a way to actually cover people will you let us keep it. And since the federal waiver when you -- -- when I hear Mitt Romney talked about federal -- -- dollar exactly relish the move away from a little distortion a little political games and will be more up front about it and said just to be an insurance that's straight subsidy and didn't so the net new money to the commonwealth was actually very small. And one way you concede that is we took the money from Boston Medical Center Cambridge health alliance other charity care providers put it into coverage. Those providers are now hurting and that's the basis of the loss of lawsuits that are finally beginning to pile up cut it's that the lawsuits that the primary basis for the lawsuit is. We didn't do enough to raise new money. Because we took the money away and we didn't supplement -- we didn't come back a supplement it another way I did it. -- Willis from Harvard one of the architects of our President Obama say is that fair to say one of the architects of the health care plan or the desired plant is this so president Obama's plan that -- that played out in congress or is it to they did a move away from what you guys envision. Everything changes but in fundamental principles is there's a lot of resemblance to what the president has proposed on the campaign David we have a guest on yesterday from Cato Institute who used to figure I can't -- can't remember precise but let's say 25%. -- of money he thought is not. Spent and I'm on my health care talks healthcare it's administrative would have it. I thought it's a start and maybe article posted that I participated in a panel with you recently down in Florida which you used a similar number right kind of challenged by raise my hand down there it's and I find it had the belief. That we have the precious come whether it's from government on Medicare and Medicaid rates private insurers anyway we're not gonna pay for anything frivolous. That is maybe thirty plus percent of what would you would characterize and -- indicate a scholar is also characterized. As as waste could you walk at least -- through that president so I can get a better grasp of why you come to that number up. Yep let me give you a couple of examples. First think about what is typical nurse does every day. So you've -- -- nurse in eat eat eat eat EM in hot one of the Austin hospital -- -- hospitals. The most common thing that she does would you care to guess the most common thing that she does probably reviewing notes from a -- doctor. Dot -- him paperwork hurt computer work to tell you -- things just a third of her time is spent documenting things. Not providing patient care not checking on the vital signs not dealing with the family but documenting things. And we give you another example. 20%. Of people who are on the Medicare program good insurance 3% of people on the Medicare program were in a hospital. Come back again for the same condition within thirty days. And many of those folks never saw a doctor or nurse once they left the hospital. In other words is no coordination matters Arabs who you -- need prevention. You're describing to us why it's so expensive now I see this my father's and an assisted living. They send them in order to get him into rehab when he gets SA has a cold he gets weak they send him to the hospital. Costs 500 bucks in the ambulance he stays there a couple of days just so they get a referral out to an edit it down to rehab the Sox crazy let's take some call also for you because people wanna get a but little action going here on this conversation Debbie you're NW RQ -- David color from Harvard high. Good morning everybody -- want it might just wanted to say one thing I've never I had a surcharge in my whole life of my company had worked -- for twenty ideas. And the reason why they get their money now I have a surcharge on a thousand -- so blood trust. Any kind of -- I do they blame each until you reach a thousand -- I'm sorry guys I only got two minute. But that's not coming up with the money each and it's not for the people that -- -- -- every week the twenty ideas that I have to pay a surcharge now. And I'm really -- -- out -- sorry guys thanks a lot. It devil here he is just send her for her costs have gone up because of trying to insure people who -- a plan. At and. Across the country. People and employees are facing higher co payments. That being in the case of -- 2000 dollar deductible in the case of other people it's drugs costing more physician visits costing more. And the reason for that is because medical costs keep going up and employers don't really know what to do. And what they're doing is they're passing those costs back to back to workers who have seen it at. Entercom so help us get to the roof then of why those medical costs going up. So dramatically weeks we always read medical rate of inflate a million also moral -- everything else says the inflation and everything else. Get into separate deal yet and to some extent it's good to take your doctor can do more things and so it costs more. And to set that back to a large extent it's because we haven't dealt with that third of the money. Exactly is gonna come back to national average. Premium. For a family. Is about thirteen thousand dollars now so think about what that 13 means that means just from your premium. There's about 34000. Dollars of money that's not doing you any good. Get rid of that the employer says you know what I can be more generous and went out for you I can give you wage increase I can do all sorts of things for. Which makes it so confusing wide policy makers have been chasing these huge comprehensive health care plans -- on instead of trying to find out in regulation is one of the big reasons costs are so high we've been regulated and high costs so why hasn't that been the approach instead of trying to do these big plant. If you look at what legislation that's currently stalled in congress does it does two things one is it says let's cover everybody. We're century everybody second is it says let's train reform the way medical care works so we get rid of that third of the money. You know it it's interesting you know what happened when President Obama started talking about that. People started talking of the people on the rights are talking about death panels in rationing and all we're talking about. Is making sure that the nurse doesn't spend a third of her time documenting things. Making sure that people get good transition care says they don't come back in the hospital. Making sure that you don't have to get a repeat CT scam because the first one couldn't be found because the records aren't there is is just -- Then that claimed four for financing this of this big planned Omnia. The clan -- I have had a field day with that and edit it at Ogilvy Australia -- love Indian off on a the claim of 500 billion dollars in Medicare savings. First of all of boggles my mind it's just a staggering number he can tool it's a very logical question that all our calls have. If it's then half what the hell haven't we. File did saved it. Put it aside and demonstrated to the taxpayer is look we're serious about ring and -- the waste and that crap that's gone on and we're also serious and about. Control in this go on for what went when the things about the political system is that it's been locked. And you have let me give you the biggest single part that the biggest single item of that 500 billion dollars. He is private insurance plans that insure people who are Medicare people on Medicare choice. Those plans are paid more the end cost. The people they enroll. And the president proposed reducing it just to the cost the people they -- getting rid of the excess profits. That turns out to be close to 200 billion dollars over the next decade. And the -- and why I think it's absolutely unconscionable. That for the past decade. Political system the bush administration and congress. Wasn't willing to deal with -- they they they kept saying well we'll can deal with that is part of some comprehensive thing we'll come deal with that later welcome deal with that. Whatever and so we let all that money -- yeah we've known for twenty years that a third of what we're doing our wasteful. This wasteful and every year we haven't done anything it. Sorry we've got to take a quick break we're going to see your conversation I no -- with David Cutler from her one of the architects of the Obama plan. We'll take your calls coming up on 680 WR KOK. -- first to talk about the issues that are important to you. This feels Boston's talks vision AMs succeeding WTO. You also backlog that we are again it is indeed. They sunny day enjoy dad -- glistening winter wonderland -- road to pretty well Leo I -- This professor David Cutler the -- -- professor of economics at -- Specializing in healthcare. Adviser to -- Barack Obama -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- your tenure actually -- Stein was when the first people who modeled the macro economy the economy as a whole could we have a lot of models on the show we love to do that should tell you know we do the IR Jennifer good morning -- -- WRKO David -- we're talking health -- -- -- I think he didn't call I'm additional in the area French. My frustration at what I don't necessarily buy that -- -- you can talk about and that's about it does America and -- edit -- and documenting. Even though they -- -- stomach stacked litigation and and then a professional because they're less of a lot bigger and I'm I am go faster gaelic act but there's not try to pharmacists significant piece of the healthcare reform discussion and and that's the best and I find that I'm the. You're ex -- because there -- a lot of tires out there Jennifer try to pretend. That tort reform isn't that big an issue they say it's only 2% of the cost but that's not looking at the the way you change or Alter your behaviors that makes things more expensive because of fear of lawsuits can you give us an example. I can tell I mean -- -- -- -- on a daily beef -- I I would try to -- it's like gonna patent that's I think often have to think about. -- -- -- -- million -- that this is not even get as a bigger than just the climatic but got the brain can actually don't think alpaca nothing can get back. But you compared -- cat do you think that you know instead of waiting it out the risk of a lot you don't worry about the station -- he didn't get that -- I can't. And yet the edited diagnosed basis of a lawsuit did this one -- just to your Jennifer knows what she's talking about she does it every day so how do you respond to the absence in this comprehensive bill. Of of tort reform. I am I agree with Jennifer I think the bill should it should deal with tort reform I'm. President Obama had proposed it in in this presidential campaign he went before the AMA and I believe was April of last year and said he was in favor of tort reform. In congress it got held up I think partly because. The Democrats were hoping they could use that to talk to the Republicans and get something done in them when Republicans walked away. It wasn't there in the democratic base to do but I eight I eight I completely agree with Jennifer I think we we we really need to deal with that. It if not I mean they're two reasons one is for the cost which most of the studies including by. Right of center economists don't share that hybrid just because it's so frustrates doctors. And you can't go to doctors and say look we're gonna have a better system but we're not gonna deal with this thing which is absolutely not in the heck out of you. Beyond that to a 4% that these studies suggest -- come out of the health care costs associated with a malpractice premiums. Jennifer made the point of she's got to worry about that the nine headache is really not a headache at the tomb of the failure to diagnose. Is zero way to assess the price this defensive this abundance of defensive medicine yep people have tried to look there. A number of states that have passed Vieri. Strict to rip the restrictions on how much you can sued doctors for how much you can collect for. When it in this Texas for example very very strict regulations he -- to doctors in Texas and you say. You are you ever sued know nowhere near as much as we used to we just don't really worry about it you know where the most expensive medical care in the country is. In those areas. And areas where they're very very strict and is there any relationship between mr. -- relations in the highest cost. There's a little bit you get a couple of percent of spending so even the most. Optimistic studies in terms of how much you could say if say that the defensive medicine part would be about three or 4% of medical spending twelve that's pretty huge Shapiro -- are immigrants 10% of what we're looking to cut right there yes at at and I would do it but again I would not do it as the entirety of what I think is not the solution is not the little -- -- the start of a solution tell it it's particularly important. It I think it's more important because it's a sign of what we're telling doctors about them as professional professionals. As much as it is everything in about -- they feel that they're victims of the system they're working it and that's and you can't have to try to tell people we need this system to work better. Oh did I tell you what you sound reasonable hot professors know he has been reasonable yeah got them on the table with his own views when I get a different color to a -- part pandering here on WRKO. Good morning I have to go through a few things that the -- really really carefully but damn I wanna get first came on mr. -- He's said that that teachers firefighters and policemen -- only one check away from having all kind of problem than not having any health care. I would -- -- to different say that they probably one of the most protected in terms of their benefits but let me move on -- -- -- have a lot of good morning and -- the the health -- connector. While it does provide health insurance. Is for people making 50000 dollars a year they will spend at least a thousand to 1200 -- -- get a good family plan. Food is not cheap and it brings their income actually down about 38 grand before all the taxes -- it actually puts them in import category. Let's see -- about about. -- percent of doctor third fund both provide ninety or 95% of all medical malpractice. So what mr. Kelly don't we go after the 5% of the bad -- opinion that licenses and finally -- aren't. If it one of the reasons why we have to document is very important but the other reason is because your my patients. And I have to passing information along to the next -- going to be taking care field and part of the problem is. Patient -- really sick today and in community gospel especially and I'm not taking black and but -- -- especially north of up and take care 67 many patients today and it's simply too much Samantha and whenever gonna test safe -- world. Because hospitals don't wanna pay -- People who want to play -- 11 group of people that they really don't think it's -- even though we run everything. And you're given the you have. Have to do a lot of documenting do you see any ways that you could streamline the burden of documenting. If there were if it was standardized if you didn't have to worry about dealing with different health insurance plans and things like that. I put the put the problem is too many people with the group with the acuity that's so great meaning that there are too many people who are really really -- and that's not all of the patients. If not the fault of the system is the way it is but may be a nurse can only take care of three to -- both patient not 67 of those patients. And let's throw the a lot of issuing I had relays -- another -- raising the costs and got another front line health you know healthcare worker dividend how do you respond to that. Well let me let -- -- let me deal exactly with what Andrea said let me give you an example. Kaiser hospitals in California. Where they've had for about twenty years electronic records. They used to spend. I don't Tuesday they used to spend 45 minutes every at the end of every -- shift with nurses overlapping so they could explain each patient. They then. Who had the electronic medical records they went to the nurses they said help us figure out how to use this record. To make the process of transferring ships the easier half they cut the 45 minutes to ten minutes and they got. Higher quality. Dander or maybe has never experienced so they got an extra thirty minutes of nurse per share was up by streamlining of the questions or what technology changes were to that's savings of time come from. It was those using the technology. In it. In the end to end empowering the workers to deal with it and let me just come back if you think about any company you admire is being theory innovative company. It has three feature stealth three features when he is they use information technology a law. Course in health care nothing is virtually nothing is electronic. Second is the internal compensation systems reward doing a good job. In health care you get paid for doing more if you think about this patient volume not the volume not value -- And third is they empower workers to fix things and to make them work right and in health care. You you've we've heard from both Jennifer -- the doctor doctor an entry to the nurse how frustrated they are working in the system. So you have people with enormous every crushed by bureaucracy were being crushed not it and it's not. Government bureaucracy it's -- system. Bureaucracy -- big hospitals they have rules a lot of those rules are based on it. Government is it's a system that doesn't encourage that it's a system that -- not open to the question. How can you save money and do a better job -- and fundamentally what's going to save health care. Is by putting in place the information. There are paying for value and -- How -- solar eclipse those things through entrepreneurship as opposed to top down management from Washington are we -- talking about going in exactly the wrong direction and the federal government take more control. Do you want to Steve Jobs is of the world solving the problems not some a panel bureaucrats who nobody knows in Washington. Let the reform that's on the table is most. Importantly about. He is the so let me go back a year ago in the stimulus bill we put in place money to do IT thirty billion dollars to -- the medical system. What this bill is largely about when that stalled that's -- -- intensive care. -- is about taking the Medicare program which pays for about a quarter of all medical care. And saying. Don't just blindly payout for volume that payout for the value of care and create opportunities. Where people can figure out how to save money and improve quality. That's what it's all. 000 who oversees the distribution and money based on this creative new world. Essentially what it says is you private sector figure out how to do it so let me give you an example -- I had to go ahead I know listening to our example of having an idea Todd and I might be the next healthcare millionaires but go ahead actually this reform will create in new immense opportunity just give you an example of that. With this bill says one of the things nobody really focused -- knew about it when does things it said was. If you can figure -- you as any company. That any company. Google or Microsoft or doctor's office or an insurance company if you can figure out how to keep those re admits out of the hospital. And make -- be healthier and save us money. Will give you some share that. So here's my Iran to buy it if Todd and I uniform accompany high in the injury is of the world the knowledgeable passionate nurses it was so -- frustrated. And we'll have -- arrangements with all hospitals in Boston and as you just -- this you know this this whole group of senior citizens. We're gonna do idea best to make sure they're not readmitted for at least ninety days and hopefully a year erect two years because we'll have a skilled terrorists are occasional physician. At the home. To make sure that they're taken embeds in the the wound is healing and all those other thank -- In every other industry in the current -- -- to something fortunes have been made billions have been made. Figuring out how to deliver services to deliver goods in a way that's cheaper and higher quality. The only exception to that is health care. And the reason for that is because we've had these systems that have been so constraining. In -- no don't figure out how to cure for that patient better but we'll pay you when they come back in the hospital. Or don't figure out how to streamlined. So that you can save that half an hour per per nurse per shift. With this legislation is about is taking what is the single biggest insurance program in the world. The Medicare program. And saying let's turn that into a smart buyer and lead to health care system that way. Yup so let's fix this thing the government screwed up make it work in a more efficient way in an entrepreneur away. And and absorb the rest of the health care system at the same time and caller worked or not. Absorb the rest of the health care system lets. Let's work with the rest of the health care system. Let's take what the government is doing and make it work better. As as an example of synergistic -- working with the private health insurance system you know private health insurance coverage is declining every year. I had no three million we've got to take a break professor -- societies and stay -- We'll continue this time to say -- -- -- we have so many -- we wanna get through the college we had Steve Ciba would deadliest assault on healthcare -- yes we don't have much time David -- America with plenty of time to solve all of us and maybe move on to some other topics as well David Cutler. Was one of the architects of the Obama plan advise the campaign on health care so you'll have your shot them comin' up on 680 WRKO. Talk that makes the world go round here on Boston's talk station AM six ABW. Order. -- -- 680 WR give atomic side. Professor Cutler is here for -- that's right he's an expert on not healthcare healthcare has an economist and work -- Larry Summers that's right he didn't learn the interpersonal skills to Larry Summers have has -- very disappointed I was expecting would have had physical and -- -- -- sure does resolve every -- so why. It actually has been quite so -- questioned why left over from entry of the nurse who called. She mentioned nurse staffing ratios you mentioned California California passed -- -- few years ago spent proposed appear dozen times. Fought ferociously by the hospital's. David come close view on the new USC you know union rules requiring minimal levels a step -- -- But I don't know that this is stepping -- ratio is the issue so much is using the resources that we have been a better way. So if you. -- come back again to the third of time that spends. Document document retention -- by the way another 10% of time is spent running down the hallway to get supplies are running upstairs or downstairs to get supplies that aren't there. That effectively what we're doing is we're throwing away. Close to 50% of all the -- time. That's -- you could do an enormous amount for patient care by just taking the resource is that we have been using them better. This is the real tragedy of creating those kinds of rules is that you've created. The sort of wall to policy change they even talk about needs to be taken down you don't wanna put up new walls. They say this is what the ratio will be much better to incentivize -- creativity your talking about. That's right in the same thing with doctors you know we have a primary care crisis. At the same time doctors will tell you they -- 40% of their time and they spend time -- phone with insure all companies and with pharmacies them with. That all the approvals and so on and eat yes we have a crisis and when you're having a crisis -- stop wasting which senator resource. Our great -- WRKO. With doctor Cutler. I darker color. Well they're probably having you can't. Abuse -- if you try to keep blaming Republicans for thinking okay that stepped just a lot OK they were shut out of the process. If the Democrats had coerced they have the house and they have decided and they couldn't get it done. So you know when this -- it doesn't ability. You know don't go around saying that the Republicans killed it because that is virtual but you know certainly. I've read recently that the governor of a Canadian problem came down here for medical treatment. And video that is what you guys were pointing to his what you wanted. Us to become so why would -- politically connected up very could get the best treatment please go to our system. Two good questions for you professor and X excellent questions thank you Greg and actually that it would be interesting things is in this single Payer proposals like Canada and never went anywhere. And it's. About. A third of the population is a very ardent single Payer fan. But it's never more than a third and it's never less than tell you -- a single -- there is where we need to end up. No I don't necessarily think so in fact what what that bills that are before congress are about is not single pair that is. The government is not taking over anything with the government is trying to do in these bills is to take what it's doing and make it work more efficiently. And then to provide them money so that people who are moderate incomes low incomes can afford to get insurance. Most of that insurance will be private insurance. The way we're going now we're losing two to three million people with private insurance every year and they're going on the government. While they're going uninsured or they're going and -- my own view is if you like single parents in if you -- the parent church just do nothing will be there soon enough. What about the Canadian premier road coming down here because of but -- I think I am. Be that there's some Canadians who come here but -- enlarged. I tend not to lakes single Payer systems in knots so much because of that but because. If you think about that kind of care coordination we're talking about -- the -- you know better and though it -- in a place like Canada as best we can tell. Either with a similar way all -- if there's. We're gonna continue this conversation after news spread professor David color here from Harvard. One of the advisers to President Obama on health care we're gonna talk more about health care for today. Continuing so get on the phones and we'll talk to you coming off NWR -- Thousand want to. It's all gravy -- window of her. Rush Limbaugh every weekday from noon to three. Only here on Boston's -- -- -- -- In the forecast mostly sunny today heading for a high of 40 degrees sunset this evening at 590 right now we have thirty degrees and mostly cloudy in Boston good morning Jefferson Adams W mark geo news. House speaker Robert de Leo has some advice for gubernatorial candidates to Leo warns that if they make the legislature frequent target of criticism during campaign season he'll tell.