washington, where the differences between what they might have been visions during their first campaigns and a reality of day-to-day life. before we begin, i would like to turn it over to you, congressman mercy. finally have words about the news from this morning -- congressman murphy. >> thank you for your support. unfortunately i think we

sometimes lose focus that we are a democratic family, and families fight and we have dif -- different caucuses, but one of the family members, democratic nominee for congress, 2008, sergeant bill kerr, was not successful but one on his third deployment. he was deployed twice and on his third deployment this time to afghanistan, was killed yesterday morning. our thoughts and prayers go out to him and his family, and his wife, renee, who is pregnant with twin daughters due in september. sometimes we get wrapped up in the politics of things going on in washington, but when you lose someone who is a democrat and who was proud to be a democrat, and marine who served his country, you have to sometimes sit back and reflect on these heroes who are trying to do what is right for the country and why it is important for policy- makers that we get our foreign

policy right. >> thanks very much. i am not sure if all of you heard that news this morning, but i think it is fairly important we all give some thought as to what that really means. thank you for starting us off. it is hard to turn the end -- of course, the discussion, but that being the part of real the and mike, we will talk about some of the reality of life -- being part of the reality of life, we would like to talk about some of the reality of life on the hill. maybe i will start with you and work back. some general thoughts -- tell us a little bit about what first motivated you to go out and run for congress. i do not think any of you were legislators before? correct? i would like to hear what motivated you to run, a little bit about what you really hoped to get done when you were

elected, and then may be an honest assessment of how difficult it may have been to see some of that come to fruition. if you've got some success stories, i would love to hear them. we are also a little bit interested in -- because we want to get to reality -- what are the frustrations and roadblocks? >> i remember in july of 2005, drinking liberally at the brewery in philadelphia and i set out was running for congress. a lot of folks didn't know who i was, rightfully so. i talked about how i just came back from iraq, was a captain and 82nd airborne, running convoys in ambush alley. the fact that 19 of my fellow paratroopers did not make it home. and i wanted to run for congress to change the direction of iraq, bring the troops home, and also

changed the direction of the country here when you talk about domestic policy. i am proud that we fought in the congress -- and i know carol and i served, we are both in the second term, and allen is a freshman, and doing a great job. but if you look at carroll and i -- and i don't speak for karrow -- we make tough votes. -- i don't speak for carol. we passed the time line in the house. i stood with then senator barack obama, offering the direct de- escalation act. then it passed the senate. then it was vetoed by the president. but then i promised my constituents when i ran for congress that i would not give this president a blank check. after it was vetoed and they brought it up with really no

time line, i did vote for that. for may, patrick murphy, the end of your congressional career -- for me. you want a close election, two 0.6%, and they said, there goes that 30-second commercial -- 0.6%. if my congressional career -- career was only two years, four years, i would look at myself in the mirror, be with my wife and my daughter, and she is going to be proud of her daddy and what he stood for. i hope it is more than swans of years. i hope i can win reelection. -- i hope that is more than a two years. i hope i can win reelection. both democrats and republicans in my district, want me to do what is good for the country. >> congresswoman? >> first, i will say, i will never forget your speak budget

speech on the floor of the house of representatives about iraq's -- i will never forget your speech on the floor of the house of representatives about iraq. what got me involved is watching what happened. i taught paulist six for more than 15 years and i was a social work and in a state -- i talked politics for more than 15 years and i was a social work administrator. i have great concerns about what was happening. but still, i thought my job was to get more involved, and i did. i became head of our city democrats and i were -- i worked in wesley clark campaign. i wanted to find someone to take away one of the enablers for the george bush administration, at

least defeat our congressmen and put someone who would stand up to the bush administration. for a long time i was working for that. and then i realized that we are the people we were waiting for. i went down to katrina. i came back and i said, this has got to stop now. this has got to change. people ask me to run -- i said, no, but i will help you run. after katrina, i never looked back. i knew we fail that so many levels that we had to do something. when i saw what happens to the people. i had to turn around a woman who had 78 cents to her pocket. she was elderly and she said, if you don't give me money or something, i can't come back. i am living in a campground and i have absolutely nothing. and i could give her nothing, in this country. i said, this can't happen anymore. i came back and i decided to run and i will tell you that i

raised $17,000 for the primary and i ran against the house minority leader. it was not much money, obviously. i started off with $100. my $100. my message is, if you think you have a voice, get out there and do it. i did it with regular people. i didn't have any paid staff members. no polls, absolutely nothing. the fellow members of the state of new hampshire that wanted to see change. they worked alongside of me. in my campaign literature in 2006 i said that i wanted to make this country safer by having an independent program -- energy program so we did not rely on countries not friendly to us and can prevent -- can protect the environment. we had an us to make the change, we just had administration that did not believe in the american people. i ran on energy. i also ran on health care.

for many years i have known people, i had people in my own family who have not@@@@rr$'"rr i have children that deserves the education and the same opportunity we had in our generation. that really pushed me into running. the reason that i one was because it was a shared

message, a message of everyone -- the reason that i won. my logo was, running for the rest of us. >> congressman? >> i was shocked to see how incompetent and sometimes malicious the bush administration was. in my case it was my direct experience, prosecuting war profiteers in iraq. i was the lead attorney for every case being litigated against war profiteers and iraq when i was elected and i saw time after time that the bush administration, old people who were cheating the troops, the taxpayers, at getting away virtually with murder and certainly plenty of mayhem. when you have troops being elected you did in the showers, being fed poison water by -- it electrocuted in the showers, being fed poison water by contractors, something was very wrong. i saw a different stages.

at the beginning i saw that the fraud was furtive, hidden, people tried to keep it out of sight. but when they went through a year or signs of this and the administration knew about it and did nothing to stop them, they became almost proud. everyone else serving honorably felt like a fool because the people who were cheating the government, cheating us and the troops, they would talk about their swiss bank accounts and all of the money that they were raping out of the war and raping the soldiers in the process. something had to be done. i found the only thing -- way i can do something about personally was to run for congress. >> thank you vermont. i would like to talk a little bit also about the mechanics of what it was like to arrive on the hill. you didn't have prior legislative experience, but not everybody does.

i am sure you found that most of the members are tied in some way to the legal profession. many of them are legislators when they arrive. what was it like in trying to secure committee assignments you were interested in? did you have committees in mind before hand while you were running? did you study that after you realized it was going to be a reality? did you get what you wanted? how did you select second choices? how did you find yourself on subcommittees'? >> in my case, i ended up on the financial-services committee and a science and technology. i wanted to be on both. i think the leadership does a great job matching ones interests to assignments, and one is district to assignments -- one's district to assign it.

it put me in ground zero for what we experienced in the economy and what we are doing to make things better. we passed some real landmark legislation already on financial services, and more is on the way. i have also seen lots of opportunity to affect legislation in many ways. i think the oversight function is sometimes underrated, but you can do a lot with it. i also think there are a lot of opportunities to change bills on the floor. as we get more experience than learn the ropes it becomes easier. i think in remarks -- earmarks have had a bad effect. we have brought money that are almost amazing. they are 500% more that what my predecessor was able to bring in. there are ways to do a job well that are not limited to how you draft legislation in committee. but in the case of both committees -- financial services and science and technology -- the path is open

for even junior members to contribute significantly to the process, and i am very happy to see that. >> as we address this, i interested in, when you have made your choice is, do you need what the chairman or representatives of the staff -- do you meet with the chairman or representatives of his staff? >> in my case, i was out of office and did not give in until a little after 10:00. just after i got in the receptionist told me that i had just missed barney frank. i thought, this is really bad. i actually never met him. he came into my office and announced to talk about my committee assignments and i just missed him. -- into my office unannounced to talk about my committee assignments.

the support is there. in this case, barney frank is a very active chairman. he spends a lot of time talking to us individually. we also have meetings open to people as a caucus. we learn a lot about the legislative come -- legislation coming up from the staff directly. lines of communications are wide open. >> congresswoman? >> when i arrived in 2007, january, the democrats were just taking over leadership, and so we had to jump right in and be fully engaged. there really was not much of a learning process because so much was happening, as you recall. we were really fully included right from the beginning, which i thought was wonderful. as for committee assignments, i was a military spouse and my husband was a veteran so i had a deep and abiding interest in the military and also that spirit i

receive an assignment for the armed services committee -- also the vets. therefore i received and assigned for the armed services committee. i have had an opportunity to quiz witnesses that have come before us. i have taken on issues about contractors. i just got a provision passed out of the house that would say if contractors -- i am not saying which -- but if they are found responsible for gross negligence, they won't get their awards and bonuses and the secretary of defense could then decide to bar them. this comes from my position and armed services committee, my knowledge of the. and the reason why i am one that committee is because of my interest before and my background. i am also in that education and labor committee.

i have been a social worker and administrator and i ran for the middle class. we have a terrific chairman, as in the armed services committee. he is a great proponent for americans, middle-class americans. so we have been able to work for -- on a lot of legislation that reflects my interest. i was never a supporter of no child left behind, it was a sticky point, and i am happy to be a part of issue. i received a waiver to be on the resources committee, natural resources. that is because i am an environmentalist, i ran on that platform. so we have a great opportunity to actually engage in the great issues and then to vote on them when you are in congress. i always said it is great to be, and we need people in the front yard yelling, and i encourage people to be out there and express viewpoints, but the

conversation and the votes are in the living room. as far as i'm concerned, it is a great honor to be in congress, in the living room, getting to vote on policies that serve the american people best. >> a technical point, and a follow-up. can you explain the waiver you had to get? normally it they are limited in committees. >> two committees and four subcommittees. if you ask and they look and you have been able to do your work and do everything they need you to do in the other committees, you can ask for a waiver for a third committee. >> it comes from -- >> right from the leadership. i have to tell you i have my legislative director, who has now taken on a greater burden, and i said, let me just ask for the committee and i will not be on the subcommittees. i couldn't resist when they talked about the subcommittees, so i could see the legislative director going -- and i put myself on two subcommittees. you know what that means.

both of you know. but, you know, you can't resist the opportunity to be involved in the issues of today. this is our time for change, and we have to seize it. i think that is what the three of us have been doing. >> i think why now americans love her because she is such an overachiever. she has three committees and the others have two. i serve on the armed services committee and the intelligence committee. i know carol and i have partnered, we sit next to one another. we often pass notes, because i also offered the iraqi accountability act. and on the intelligence committee, i want to make sure when it comes to the farm policy, that we are getting it right. obviously overseeing what is going on with the cia. part of being in the

intelligence committee, the unfortunate thing is you cannot always talk about what you're doing. it is a small committee, you are dealing with the nation's secrets, but it is really a chance to serve and make sure we are getting it right for those trying to keep us safe. but while we serve in these committees, does not think we -- it does not mean we cannot go to the judiciary committee. i have a passion for grain energy. i think one of the reasons why we are in the middle east is we are too dependent on foreign oil. there is no magic bullet. i call it the magic buckshot. wind, solar, geothermal, conserving. .

>> these are issues that we're passionate about. you have a responsibility, as a congressperson, to do right by your constituents and to right by your country. that is what we bring to the table every single day. >> thanks very much. i'm glad we had a chance to point out how the process works and i work for "the daily coast" and we also right in congress on matters. it gives people a greater

understanding of what you are doing and what you are facing and why things happen the way they do. >> could i add one point? it is part of the process and how we work together. allen came and sat next to me on the floor a few weeks ago. he asked me to think about signing onto auditing the federal reserve. we had a conversation and i listened to him and i look it up again and i did sign onto that. not only do we sit on our own committees but we talk to each other constantly. if you watch c-span, you will see us milling around there. we are actually sharing what we heard in our committees and asking people to either sign onto a bill or talk about a certain witness. sometimes i think it is difficult for people on other committees to know what a witness said of the armed services committee. you know i have a particular interest in that so you will

take it to them and let them know the general so and so testified on a certain committee and this is what he said. we share the information back and forth to help each one of us make better decisions as we go forward. it is an important process, talking to another and communicating what we have heard. >> i know people are watching on c-span, when voting is going on, they are probably wondering what is going on when you were watching on c-span, the sound is turned down and you cannot hear anything. if you are in the chamber, it can get very loud and it becomes difficult to hear. at home you are watching and you constantly hear from the chair pounding the gavel, asking people to take their conversations off the floor and no one at home years and a conversation. if you were ever in wondering, that is a sort of thing that goes on on the floor. >> can i mention something about that? >> yes. >> it is amazing what you can't accomplish on the floor with regard to,rra

>> it's time well spent and a lot of business gets done that way. >> is that most frequently where you'll run into other mothers, i guess, who aren't on your leadership committee folks? >> i would say that's your best chance to build relationships. this is the relationship business in that you have to work with your colleagues. you have to be accountable to the constituents you represent and they have to have a certain trust and confidence in you and the colleagues in congress they have to know you're a person in

your word when allen or carol come -- they'll talk to me a certain vote they're interested in, i'm take a look. and if i believe it, i'll give my word and, you know, i'll cosponsor it. and some things we can't work on for whatever reason. and as long as you're straight with people, i found in the congress is that people that you're straight with them. you don't try to talk both sides of your mouth which happens in politics. if you're straight with people that provides a level of trust and confidence that really breeds success. >> and what about whipping on votes? is that where you're most often found? are there times you really want to get off that floor quickly before they get to you or is that expected? where do they find you most often when they're counting votes? would you like to start? >> nobody wants to answer that one. i'll answer that.

you know, it is part of the process and so they will come around and first sort of take your temperature. they have caucus and they want to know which way you're leaning, and so that's your first opportunity to stand up and by the way you're not told to do and you can be strongly encouraged if you're down to two to three votes you might be really encouraged but the reality is you have make your own decisions. i remember the speaker of the house saying to us you answer to your constituents. never get confused who you are and where you come from, you know, that you answer to your constituent. i want to make that clear. obviously, there's some legislation that you really want people to get behind, for example, the energy bill. that was a tough one. you can stand up -- you know, we've all stood up there and really argued something and then

you can continue it as long as you want. you can ask for a private meeting if there are some issues that are still driving you crazy and they can work it and they do. they try to compromise and work it but ultimately you have the bill, and your protest may not be fixed, you know, it might still stand the way it does and then you have make a tough decision, is it good enough and serve more what you want and are you able to vote for it and you sometimes might to have swallow hard but you don't want to throw a bill that's 90% good and 10% terrible. you've all seen it on the floor and it's close and people are looking and say can you do this? what's your concern here? and when they say what do we need to get you there. is there some way that we can legislate again and something that we can do when the bill

comes in conference, you know, before it becomes a bill when it goes to the senate and comes back. if the answer's no, the answer's no. i mean, i voted no on the afghanistan money, and i was -- i explained that i simply could not, and i certainly honored and respected everybody who did because people had their reasons and they were very good reasons and my reasons was because my husband was in the military during the vietnam era, and i saw many, many, many men and women who had been impacted. and i just felt that until we really knew exactly, in my, you know -- it's clear to me what our mission was and what the metrics were going to be and some kind of a sense of when we'd know we had reached our goals i couldn't do it. i know many terrific men and women who voted for this and they voted for it for the right reasons for them, too. it's one of those tough votes,

you know, you could get whipped and you could vote your conscience either way and so regardless of what the whipping was, i put my feet on the ground and said i cannot do that. and others could because, you know, these are difficult votes. nobody knows this roadmap, right? >> i always love the saying, democrats want to fall in love, republicans want to fall in line. as democrats, you know, we're a family but sometimes, you know, we battle like family members and we have disagreements and, you know, we all appreciate and at the end of the day sometimes we are in disagreements in times and sometimes we have policy disagreements i have a trust in confidence as a legislator she's going to follow her confidence and do what she thinks is right for her district and country and not what's good for the leader or patrick murphy. she's going to do what's right for the country and i appreciate that and the same goes with

allen as well. >> well, i think whipping is a real misnomer. >> it's a tough term. >> i don't recall being whipped. i think i would recall if i did. the first meeting we had with a whip, congressman clyburn, he told us -- he promised us that we would never see the rubber hose. [laughter] >> and he stuck it and i have done this for eight months and i have seen no pressure to directly or indirectly for a bill and it's always been come, let us reason together. if you vote you'll know you have 165 people voting with you because the republicans always vote as a bloc. as a democrat, i think it's easy to understand why we take the approach that we do because the first time i went to a caucus

meeting when we were choosing a leadership of four and we got sworn in and it was nice to be invited to be allowed to vote. i looked around and i saw america. i saw white people and i saw black people. and i saw men and i saw women and i saw english-speakers and spanish-speakers in our caucus. our diversity is our strength. and when you have a diverse group the way you create solidarity is through shared values. the kind of discussion we have when a vote comes up that seems like a tough vote for me because the way my district is or because i just have problems with them on the basis of conscience, the discussion is always on the level of what's right, what's good, what's right, never, what's in it for me, what's in it for the leadership? it never takes that kind of turn. and the democrats don't vote as a single bloc and some close and some unpredictable.

we had a couple that took a long time to vote. but the net result of that is that through our diversity, we have our strength. now, you compare that to the other side which seems to operate on completely different principles. doesn't have anything even remotely resembling diversity in our caucus and it seems to fight the very idea of diversity. i remember one situation on the stimulus package where a republican member from louisiana, from a heavily democratic district whom most people was elected because his opponent was found with $80,000 cash in his freezer. that member learned there would be over a billion dollars coming into his district because of the stimulus package, republican members. so he announced publicly that he was going to vote for the stimulus package for his district that was hurt for katrina and other things as well. and then the next day with every other republican member of

congress he voted against that bill and i can imagine that whipping that took place with that 24-hour period with him. i think it was pretty harsh because he announced he was going to vote for it. the district really needed it and he voted against it. we don't operate that way. >> yeah, i've been told many times by leadership, vote your conscience. >> well, i know we do have a very big difference in the way the two sides operate. you mentioned diversity. we have, as all of us, i think we are all aware watch what you do in congress sort of subcaucuses and we have up here members, both the progressive caucus and of the blue dog caucus. on the other side, of course, i rarely see him sort of thing. i think there may be more than one, two groups but they

typically compete for being the most conservative. but in recent years we've seen the moderate group of republicans be defeated or disappear or go into hiding if they managed to survive. >> or turn democrat. >> yes. and that happens, too. [laughter] >> how did you come to choose to affiliate with the subcaucuses, progressive caucus? were you approached by members? did you know where you wanted to go? what was the process like in joining up? >> i'll take this one. >> yes. >> well, i'm a blue dog democrat. and i know frankly that's not very popular but i'm very frank with people. when i stood yard boros with the netroots drinking and the banner

talked about progressive values which is fiscal responsibility. and i believe, you know, as a father and as a policymaker i have a moral obligation to make sure we have balanced budgets. sometimes you can't a little have balance budgets or the stimulus bill to put our economy back but on social issues i'm a progressive. and, you know, i'm proud when it was a blank check for president bush i voted against it 'cause i thought it was irresponsible spending. when it comes up don't ask, don't tell policy, i think it's a national security issue. i think it's been a waste of $1.3 billion. [applause] >> i think it's a disgrace that we've kicked out of our military 13,000 troops since the don't ask, don't tell policy hash implemented. it's 3 1/2 combat brigades. so i know that's -- these are values i believe in. the values of equality because

we all take an oath to support and defend the constitution of the united states. i taught the constitution when i was a professor at west point and so i take that obligation very seriously. so i have caucused with the blue dogs and trying to cut fraud, waste and abuse from some spending programs and do what's right for our country. but i happen to, you know, vote with a lot of the progressives when it comes to don't ask, don't tell when it comes to the stimulus bill. we cautioned every week as a group and i learn things of what's gone on in different committees and, you know, that's what that group happens to bring to the table but i think sometimes the disparity within a democratic family is a good thing. we should have these disagreements and arguments. we work it out and what's right at the end of the day for our country. >> do you then spend a certain amount of time meeting with the

group -- with blue dogs. is it a similar situation where there's whipping in the group or you hang together. the power of the blue dogs in particular is the leverage you've got. you've limited your membership and you keep, i think, purposely the number of members about at the level that it takes to be able to leverage a bill off the floor if you want to stand in the way? or if there's someone who's got a problem with something. i mean, so it's clearly a leverage group. how much time do you -- >> well, i'm one of the whips for the blue dogs. but seriously, i think let's take healthcare for example. i can't say i'm a blue dogs -- you have to believe in those values and have a record for standing for fiscal discipline. and in our group, when it comes to healthcare, i happen to think that it's a good thing. i am for public option. that's my personal opinion.

i think it shows competition. [applause] >> i think that's what we need. and the blue dogs -- what they stood for, they didn't recognize the options, i'm one of the ones who wanted it. what they did say is that we wanted to make sure it's deficit-neutral. that our country is going to incur a debt that we'll pass on to our children or our children's children. i think that fiscal discipline, that deficit neutral when we look at the healthcare, that's what the president agrees with. and it's an element of healthcare reform. health insurance reform that we need right now and i think most democrats would agree with that. >> there is room for disagreement even among the blue dogs who are already breaking down in smaller groups. >> absolutely. >> members of the progressive caucus i think probably find -- did they meet as often? did they organize in the same way as blue dogs?

>> well, we're progressives so we're disorganized. i belong to no organized caucus. i'm a progressive. >> it's mark twain. [laughter] >> i think it's generally the impression people have. although i do see it's beginning to change and they're beginning to organize a bit. and try and exercise some of the leverage. congresswoman -- >> i'm not neither one of them. i mean, i love both of these men and i will tell you that they are both driven by a moral compass that is wonderful to behold and we share almost all the same, you know, kinds of goals and values and alan and i do as well but i don't belong to either group. i come from a family where both my parents who are my heroes -- if you asked me to name is male hero and a female hero they would be my parents and they were republicans. they were the old time republicans, remember them? and they were just absolutely wonderful. and they were fiscally conservative and i carry that. i share that with both of these

men here. and i'm very concerned about the size of the deficit. very concerned that the cost of the iraq war in afghanistan was not on the budget and all the ways that the bush administration -- and everyone needs to understand us drove us in the greatest deficits in history and created these tremendous problems where we had to reinvest in america and so, yes, we are spending money but we have not invested in america in many, many years. and we have not invested in our people and so we are now trying to invest in our people. so when i hear patrick talk and i hear the blue dogs talk, i agree with them about a lot of the issues that they're confronting and i'm concerned about. and when i hear of the progressive caucus talk, i agree with them as well. so what did i do? i joined the populace caucus and i'm a cofounder of the populist caucus. we can stand to each group there because the populist caucus, we're just out for the issues that are affecting, you know,

the people of this country. >> and that's a relatively -- >> as i understand a new or revive populist caucus. >> it's revived. we have the same interest where we support a public option in healthcare where we call for fiscal responsibility. we want to see things on-budget. the bush administration hid their true value from everything from the american people. look around you, do you see a lot of that money that was spent around our state or what do you really see? and what we see those deficits were run up but they were not put on the american people and that's what we're trying to do now. in the populist caucus we share the same values that the other do and, you know, maybe veer slightly different at times. but again, i would tell people that the men that i'm sitting next to and the men and women that i sit next to in congress, first of all, work very hard

every single day. work to represent the district but also to try to do its best for their country. they don't report to their state legislature every day. they report to the u.s. and so we have a huge task and we find common ground most of the time. it's really remarkable. >> i think these tives are sometimes challenge rated. if you look at the voting records and we've had 700 votes already since the beginning of the year. you'll find that there is not a single democrat who votes mostly with the republicans. and there's not a single republican who votes mostly with the democrats. so the deep and serious chasm is between the party of the yes and the party of no. that's the reality that we all live with every day as democrats. and it is true sometimes the republicans come close to peeling off the 40 democrats they need in order to put no into effect but it's not as a result of the caucus you belong to, it's more of the result of the result that seems to be

coming to the floor. there are three main caucuses at this point. no disrespect for the populist but the three main caucuses are the progressives, the new democrats, and the blue dogs. and what you find when you talk to people who are members of each is that they don't actually disagree core democratic values at all. they don't disagree at all. what they disagree with is a question of priorities. in general, if i can speak for the others, the blue dogs emphasize fiscal responsibility. that's not to say that the rest of us are against it. that's not true at all. it's certainly not true in my chase -- case -- and the new democrats emphasize free markets. and again, this is not the socialist party of america. this is the democratic party, and you'll find people are very comfortable in this party with free markets in general. in the case of the progressive, the emphasis is on human needs. but they are not at war with each other or competing with each other. they are just matters of emphasis. >> thanks very much.

i think that's something we tried to take a close look at who's voting with the larger democratic caucus and who deviates from that most often. i think the data certainly is that it tends to be blue dogs and more conservatives, but again, you make a point that in almost no case over the long term is anybody voting more with republicans than with democrats. it's sometimes difficult to gauge that because a great number of the votes are overwhelmingly in favor of things and if you're counting voting on suspensions bills, that'll tend to boost the numbers. i think it's okay people observing more casually or closely will find that blue dogs find themselves certainly on the opposite side of where progressive observers are, but i do think it's interesting to note the disparities is also

between the mechanics of the way the groups work. the progressives i don't think -- do they meet weekly? >> no. i think we find we don't need to spend a lot of time coordinating because we do have strong shared values. it's less important to talk things over. we pretty much know where we are. >> i did find in taking a look at the voting patterns that the progressive caucus was a much more cohesive unit voting together more often and there was a great deal of diversity inside the blue dog caucus, you know, while we found them on the other side on some key votes, plotting them on a graph, we found a much greater spread among the blue dogs than among the progressives. i know that among the progressive blogosphere that's become a source of irritation and it's a larger caucus with more cohesive voting and yet they seem to be able to leverage things less often than blue dogs with their smaller numbers.

but i think there's a difference in the focus perhaps of what the groups are about. but moving on from that, i don't want to make anybody too uncomfortable with that, but -- >> but i think it's important to remember that when people are sent to washington, they are elected and they do have to reflect, you know, to a large extent the values that the people back home have. >> yes. >> it's critical. and so i pointed out that you are in the united states government and that you have to look at the whole picture of the united states, the map, the relationship of the world and you have to make sure you are speaking up and representing the people from your district. it's a very delicate balance and i think sometimes we beat up on people too much and say what's that about? you know, and i'm not going to defend every vote everybody takes, except mine. but that's the whole point of it. that they do have to listen to

their constituents at home and so we have to pay attention on many different levels. >> and i think that, you know, some of the themes that you hear about between the three of us -- i mean, accountability. that's what democrats stand for. al made a point earlier about auditing the federal reserve. that you guys talk together. i happen to be a cosponsor with that and that's cosponsoring with republican ron paul. i want to make sure we know where we are spending our money and putting our money and i think the accountability democrats bring to the table. we don't write blank checks and get a bang for our a buck. and i think most americans appreciate and that's why we have this responsibility right now to govern. >> i don't think you can expect democrats or republicans to vote against their district and because of the success of our party there are now 50 democratic members of congress who are in districts that mccain carry.

we are a large, diverse caucus that reflects even a larger and more diverse america. and the result of that is that we do have members of our caucus who vote their districts and properly so because that's what we're there for. >> i think though it is a big source of frustration, it becomes a source of frustration only because the group observing and to whom we're speaking is themselves cohesive and they have a position that they'd like to see voted but as you pointed out, i think that's the flip side of what you started out with in saying that the leadership is very clear in speaking to members that they have the freedom to vote as they need to in order to represent their districts. so it's very important, i think, to bring both sides -- while that's a frustration -- >> it frustrates us when we're trying to get to a certain number of votes. it's very frustrating and we have to respect that. and there's a lot of passionate debate in caucus what we're going to do as we try to come to

some consensus but the wonderful thing is that there is a debate in our caucus that everybody can stand up there and say whatever he or she wants to and then we can work to persuade one another and i can be persuaded by a very good argument and so we have that dialog and that's what people should hope for a democracy that each one will engage with each other and keep our minds hope >> i think ultimately it would be the hope of progressives that it never come to the point where the leadership really had things -- was twisting arms so hard that people weren't able to vote their conscience. i don't think that's in particular -- not a particularly progressive value in itself. but the consequences of having that kind of freedom and engaging in that kind of debate is that occasionally things don't go your way. i thank you for addressing that.

and if i can jump back quickly -- if we've got some questions, i think we'll save the last 15 minutes or so of our session for that. one last question before we go to that. congressman, you mentioned the earmarks that you were working on for your district, and i know that that is like whipping, another term that if not unfair, certainly, you know, pricks people's ears and whether you came to congress about any idea about earmarks being a problem? clearly not the issue for you but i'd like to you describe a little bit about what your position is on that in general. that's something i think it takes a little bit of experience in the house before you really make a decision on what you want to do but i noticed a lot of people campaigned on that as an issue. so if we can start with you and move over. >> well, in the case in my district we've been dramatically shortchanged over the years on

federal spending. we export taxes and we import debt. we send our tax money to washington. we get back very little in return. it's easy to see result of this. if you look at the phone book for chicago and you look at the blue pages and you look at the federal government listings you see page after page of federal government listings, telephone listings in chicago. you look at orlando, which in the whole metropolitan area you're talking over 2 million people and there's less than one page. we have no military bases in my district. we have virtually nothing in the way of federal facilities. we have basically some military recruitment centers and not much else. and the result of that is that our money keeps going out of the district year after year after year and that saps the strength of local economy. so i think it's our turn. last year my predecessor in his eighth year in congress brought $1.9 million to the district in designated spending.

we're already over 13. sfl and we're working to improve that all the way time. and i understand the arguments both for and against earmarks but honestly in my case, i don't understand why some federal bureaucrat who works for the federal highway administration would be a better judge how to spend highway money in my district than we are. i don't understand. so i don't have any hesitation about doing everything that i can to bring every spare dollar into the district especially when we're talking about a district with over at the point % unemployment, that's been hit extremely hard in the economic basis of the market. the housing market is down 30%. we have the highest rate of home vacancies in the entire country. so every spare dollar i can grab i take. >> when i was being criticized at a town hall about earmarks when i do support, i said to the

crowd there, if you think that the 53 members of congress in california are wondering how new hampshire is doing, you're wrong. you know, we have exactly two members from new hampshire. we were receiving about 68 cents for every dollar that we were sending and that dollar -- the rest of that dollar was being sent to states like alaska. you know, i believe in congressionally directed spending because we know our district. what i don't believe is the waste and the fraud and the lack of accountability and transparency but when patrick and i came in, that was part of what we talked about in government, and we fixed that so we request an earmark. it's posted and we have to sign a financial affidavit that there's no way that we're going to receive or anybody in our family will receive a financial benefit and we should have that transparency and accountability. i completely support that. but i just got money for men and women who need it because they are in iraq and afghanistan who would say no for that.

the ports and naval ship yard and a number of them for healthcare centers? so i guess what we have to make sure first of all is that it's justifiable. then we also need for people across the country to go to these websites and look at them. because the only way we can reassure the american public who have been burnt many times, many, many times, like the republican bridge to nowhere, they should look and make sure and by the way, every time i send a letter to anybody in my district, i also tell them how to go look up my record. i think we should have to do that too, you know, you want to know go to such and such a site and are my sites are the earmarks and other information so we have to have the accountability. and we now do. we have to have the transparency. and we now do. and then if people aren't happy with it, there's an election. if they don't think there should be money for healthcare centers or money for the military or they don't think there should be money to take care of our vets,

you know, say so in the next election. but democracy is not a spectator sport. everybody needs to be in and watching all of us. >> and lastly, i think part of it is frustrating as a policymaker it's frustrating when you see the politics get behind it. when carol and i came in we made it completely transparent. they used to be secret in the past. number two we cut the earmarks in half of what they used to be. and the third thing is, you know, people can now go and look at these things on the website because it's more transparent. are there abuses in the system? absolutely. that's why we have to make it transparent in that practice. that doesn't mean the whole system is bad. you know, there are really -- it goes back to, you know, when i used to teach cadets at west point, there's three branches of government, rocks, paper and scissors and one is not more important than the others. case in point be our troops in

iraq utilized the predator drone plane. an unmanned vehicle in the air that helped them out. that was an earmark that the department of defense says that's a waste of money. that has saved american lives and saved iraqi and afghan lives and that's an important thing. i'm proud about it. it wasn't happening to me in my district. that was something that's right. there was actually was abuses from democrats and republicans and that's who we have to go after and say, no more and change the policy and we need to make sure that we're on top of it. and that's why now your name is next to every single one. it's transparent and we got to make sure we have the full faith and confidence of the american people moving forward when it comes to it. >> and patrick brought up a good point, you know, sadly there were democrats doing the same. there really were. and that accountability and transparency should have been there all along. so that's something our class did. >> i agree the point is very important. you can't say all earmarks are bad just like you can't say all earmarks are good and if you look at our earmarks, our

earmarks do two things. they -- first of all, they meet human needs and secondly they bring jobs to the district. and from top to bottom, that's what you see. one of our earmarks is for providing surgery to troops in the field. that work is being done -- that research is being done by a hospital in district. i'm prepared to defend of earmark. another one is a shelter for battered women. i'll defend that earmark. another one is rebuilding a bridge in my district. it's the only escape route for hurricanes. that's an 80-year-old one-lane bridge. i'll defend that earmark, too. and most people in congress -- the overwhelming majority of the people tell the same thing and those who are specifically against earmarks all the time. out of 435 members there's only 70 who consistently vote against earmarks. 85% of congress well understands that we know a little bit more

than the federal bureaucracy how money should be spent. >> i have watched members from the other side who specifically i've seen rail about earmarks come to the floor every time congressman flake comes with one of his amendments to eliminate them and as it turns out, the majority of the republican caucus is happy to see that money earmarked because they know they've -- a, they've got their own and, b, it does make a certain amount of sense. >> i know we're going to go to questions. you want to be straight with the american public. when people criticize the stimulus -- i mean, our economy was in a recession. under president bush. it was going to go every single economist said it was going to turn into a depression. i voted for the stimulus act it was a big price tag, $780

billion but what's frustrating from my perspective is i voted for it and i thought it was the right thing to put our country in the back right track. the ones who voted against it and saying, look, these stimulus dollars are doing my bridges and roads, they voted against it and they continue to criticize it and yet they're home look what i brought into my district? that is not being straight with the american public and that's what ticks me off because, you know, what? stop being the hypocrite. at least stand for a principle and don't try to play both sides. and that's what the american people want in their elected leaders, whether democrat or republican. [applause] >> exactly. show some courage. you know, we have to sit there and watch that road show. there's a certain number who come to the floor, as you know, and rail against these earmarks and insist they would have nothing for them and then they vote for them and they go home. if you're going to support this, be bold. tell the truth. you knows be the american people are very smart. just the truth and explain that's our job to take the tough

vote and then go explain it to our people and telling the story is not going to catch the rest of them it infuriates the rest of us. it does. >> we have some questions so let's try to come to the floor. >> thank you very much. in my fifth year as a state legislator, i've only had to deal with one issue that has over 1,000 pages in the bill and that is our budget. everything else is only about 36 pages. now, i know you folks get bills that are 1,000 pages and more. how do you deal with it? how do you know what may be hidden in between and how do you find out the information that gives you the ability to vote on something that may be very, very critical but is so huge that you know you can't read through it in time? >> well, ma'am, thanks for your service to your community.

i think for me, you know, if i could talk about the healthcare bill, you know, it was 1,018 pages and i believe in my office as my colleagues will probably agree is the buck stops with me. i am the yes or the no vote on a specific bill so i make sure i read every single one but i have an incredible team of 22 folks who works their tails off for our country. and i split the bills -- the bigger ones that are 1,018 pages and how it's going to affect our district. we call out other experts. we make amendments that way. we ask people's advice. you know, my wife reminds me -- she says, patrick, god gave you two ears but only one mouth. for a reason. and i try to make sure i do my homework, to do what's right for our constituents and that's how my office is able to succeed and do well. >> well, on the healthcare bill i was one of the three

committees in jurisdiction in the house and i certainly knew and followed all of it but it is a huge bill but what patrick said is what happens. you have these people on your staff. you choose them because of their ability and their talent and you work with them every single day and then they're working, you're working. you're talking to people -- if it's not your committee and we had so many meetings. i figured how many 75 or something for people to stay up to speed on the changes in the healthcare bill. we had outside experts come. i know when we had the t.a.r.p. bill, i voted against it but first i read it. my staff read it. and then we called congressional research service and brought a couple of professionals in there and so we reach out all the time. we have tremendous resources available to us. and we read newspapers like everybody else. we probably read many more newspapers and get a lot more feedback and then our constituents, you know, i have people who will help me from the banking committee who want to

express their opinion. i have people from healthcare. i have been meeting with different groups and meeting with two different physicians. i have met with physicians and hospitals and consumer groups and all of us have stayed very engaged on these issues. it's a tremendous workload. i have to say -- i'm going to talk about congress right now in a very positive light 'cause i think that we do work extremely hard. but i think the average american would be shocked to see how many hours we put in. i had somebody follow me for two days ago he wrote me a note that he had no idea how much work we did, how long the days were and how much, you know, we stayed engaged. i'm honored i had to it and i know my colleagues are too. we're grateful to have the opportunity to be the voice of the people. i think we're pretty responsible in making sure that the legislation is what we think it is. occasionally, something happens. somebody adds something.

i'm not happy about it and i know other people aren't but we do a very, very good job of following this legislation >> well, i've had people follow me around for a few days also but since they were sent by the nrcc that i didn't get the pat on the back that you got. but i will tell you this, we have america-size problems and they result in america-size bills. no one could possibly think that we're going to be able to reform the health insurance system with a five-page bill. it's just not going to happen. so the result of that is that we understand that it's incumbent to create the best bill that we can and the result is we spend an enormous amount of time doing it. we had a session that we literally went page by page and i'm pretty sure the republicans didn't and the result is we do make, i think, in the end very good choices based upon real facts and not misinformation against setting a sharp contrast with our opponents.

>> take another question. >> thank you. after receiving billions of dollars of taxpayer dollars and bailout funds goldman had record profits and paying enormous bonuses. what steps have the democrats take heads we win tails you lose situation on wall street and to regulate banks? and how can we ensure that banks that are, quote, too big to fail are regulated? so a more meltdown doesn't happen? >> i think i heard you. and we'll see if my answer is right. i know what's being proposed is that these banks will have to put up more money. they'll also have to prepare what's called their funeral so they'll say what they have to do if they do fail. what's the plan out. so the call is for them to have more resources to deal with the problems and also plan in case they don't because when you have too big to fail, you've got a

huge problem. >> i think too big to fail is too big to reflect. i'm hoping to see that reflected in the legislation before too much longer [applause] >> i voted against every bailout. i think that's a gross abuse of taxpayer funds. and all of us who are fiscally responsible feel very uneasy can the idea of taking hard earned taxpayer money and putting it on private speaks. in the case case of goldman we sent a letter to the chairman of the federal reserve explaining that goldman was taking advantage of its status as a so-called bank and borrowing money from the federal reserve discount window while having enormous appetites of risk according their chairman of the board they have a high appetite for risk so we're doing what we can to make sure they don't take advantage of the taxpayer any further. >> and i think that's our job as policymakers to make sure one it's transparent so again where the government dollars are being

spent. number two that there's accountability and you don't let them get away with it and you need to make sure there's accountability and legislation and the execution of the legislation moving forward. >> we are actually out of time. if you have a few minutes afterwards, we'll be able to answer some questions. i don't know if our next panel is ready. i'm sorry we didn't get enough questions on the floor. i think we had a freewheeling discussion. >> thanks. [applause] [inaudible conversations]

>> as the healthcare conversation continues, c-span's healthcare hub is a key resource. go online and follow the latest tweets, video ads and links. also keep up-to-date with healthcare events like town hall meetings, house and senate debates, even upload your opinion about healthcare with a citizen video.

the c-span healthcare hub at c-span.org/healthcare. >> president obama spoke to the vfw's national convention in phoenix yesterday. the first time he's delivered the traditional annual remarks as president this is a little more than a half hour. >> our next guest is no stranger to the veterans of foreign wars or to veterans. service members and military families we serve. he was born in hawaii, raised with good old midwestern values and ivy education at columbia university and harvard law school. he served in his state senate for eight years before becoming a u.s. senator from the state of illinois in 2004. he would go on to cosponsor landmark vfw-supported legislation like the g.i. bill for the 21st century and an advanced appropriations for the department of veterans affairs.

and now he's given us is historic increase in the va healthcare budget. this is his third conservative appearance before the vfw national convention. but the first wearing the mantle of our commander in chief. comrade, sisters and distinguished guests i'm honored to present the 44th president of the united states, barack obama. [applause] [applause] >> thank you. thank you so much. thank you very much. thank you. thank you. please be seated. thank you so much. commander guardner, thank you for your introduction and your service i was proud to welcome glenn and bob to the oval office before july and i look forward to working with your next

commander, tommy tradewell. i want to acknowledge gene gardener and dixie and jan title and all the spouses and family of the ladies auxiliary. also, governor jan brewer is here of arizona. and mayor phil gordon, our host, here in phoenix. i want to acknowledge president, dr. joe shirley, jr. president of the navajo nation and this wasn't on my original card but this is just an extraordinary story and you may have heard from her but i want to publicly acknowledge and thank helen denton, the secretary to dwight eisenhower. [applause] >> who typed up the orders for the normandy invasion and is here today and what an extraordinary story that is. [applause]

[applause] >> members of the veterans of foreign wars, i am honored and humbled to stand before you as commander in chief of the finest military the world has ever known. [applause] >> we're joined by some of those who make it the finest force in the world. from luke air force base, members of the 56th fighter wing. [applause] >> whether you wear the uniform today or wore it decades ago, you remind us of a fundamental

truth, it's not the powerful weapons that make our military the strongest in the world. it's not the sophisticated systems that make us the most advanced. the true strength of our military lies in the spirit and skill of our men and women in uniform. and you know this. [applause] you know this because it's the story of your lives. when fascism seemed unstoppable and our harbor was bombed, you battled across rocky pacific islands and stormed the beaches of europe marching across a continent. my own grandfather and uncle are among your ranks liberating millions and turning enemies into allies. when communism cast its shadow across so much of the globe, you stood vigilant in a long cold war from an airlift to berlin to

the mountains of korea to the jungles of vietnam. when that cold war ended, and old hatreds emerged anew you turned back aggression from kuwait to kosovo. and long after you took off the uniform, you continued to serve, supporting our families, our troops when they go to war and welcoming them when they come home. working to give our veterans the care they deserve. and when america's heroes are laid to rest, giving every one of them that final fitting tribute of a grateful nation. we can never say it enough. for your service in war and peace, thank you vfw. [applause] >> thank you. >> today the story of your service is carried on by a new generation. dedicated, courageous men and

women whom i have the pleasure to meet every day. they're the young sailors, the midshipmen of the naval academy who raised their right hand in graduation and committed themselves to a life of service. they're the soldiers i met in baghdad who have done their duty year after year on a second, third or fourth tour. they're the marines of camp lejeune preparing to deploy and now serving in afghanistan to protect americans here at home. they're the airmen like those here today who provide the close air support that saves the lives of our troops on the ground. they're the wounded warriors at lanceville walter reed and bethesda whom the path is not to fight, to speak, to stand, to walk once more. they're the families that my wife, michelle, has met at bases across the country. the spousess back home doing the parenting of two, the children

wonder when mom and dad may be coming home. the parents who watch their sons and daughters go off to war. the families who lay a loved one to rest and the pain that lasts a lifetime. to all those who have served america, our forces, your families, our veterans -- you have done your duty. you have fulfilled your responsibilities. and now a grateful nation must fulfill ours. and that is what i want to talk about today. first, we have a solemn responsibility to always lead our men and women in uniform wisely. that starts with a vision of american leadership that recognizes that military power alone cannot be the first or only answer to the threats facing our nation. in recent years, our troops have succeeded in every mission america has given them.

from toppling the taliban to imposing a dictator from iraq. like mayors, they've run local governments and delivered water and electricity. like aid workers they mentored farmers and built new schools. like diplomats they negotiated agreements with tribal sheiks and local leaders but let us never forget we are a country of more than 300 million americans. less than 1% wears the uniform. and that 1% are soldiers, sailors, airmen, marines and coast guard men have bourne the overwhelming burden of our security. in fact, perhaps never in american history have so few protected so many. so the responsibility for our security must not be theirs alone. that is why i've made it a priority to enlist all elements of our national power in defense

of our national security. our diplomacy and development, our economic might and our moral example because one of the best ways to lead our troops wisely is to prevent the conflicts that cost american blood and treasure tomorrow. as president, my greatest responsibility is the security and safety of the american people. as i've said before, that is the first thing i think about when i wake up in the morning. it's the last thing that i think about when i go to sleep at night. and i will not hesitate to use force to protect the american people or our vital interest. [applause] >> but as we protect america, our men and women in uniform must always be treated as what they are. america's most precious resource. as commander in chief, i have a solemn responsibility for their safety. and there's nothing more sobering than signing a letter of condolence of the family of

servicemen or women who have given their lives for our country. and that's why i made this pledge to our armed forces. i will only send you into harm's way when it is absolutely necessary. when i do, it will be based on good intelligence and guided by a sound strategy. i will give you a clear mission, define goals and the equipment you need to get the job done. [applause] >> that's my commitment to you. [applause] >> which brings me to our second responsibility to our armed forces. giving them the resources and equipment and strategies to meet their missions. we need to keep our military the best trained, the best led, the best equipped fighting force in the world and that's why even with our current economic challenges, my budget increases defense spending. we will ensure that we have the force structure to meet today's

missions and that's why we've increased the size of the army and the marine corps two years ahead of schedule. and have approved another temporary increase in the army. and we've halted personnel reductions in the navy and the air force and it will give our troops more time home on deployments which is less stress on families and more training for the next mission. [applause] >> and it will help us put an end once and for all to stop loss for those who have done their duty. [applause] >> we will equip our forces with the assets and technologies they need to fight and win. so my budget funds more helicopters and the surveillance, re -- -- for all

those serving in afghanistan and iraq including our national guard and reserve, more the protective gear and armored vehicles that save lives. [applause] >> now, as we fight in two wars, we will plan responsibly, budget honestly and speak candidly about the costs and consequences of our actions. that's why i've made sure my budget includes the costs of the wars in iraq and afghanistan. in iraq, after more than six years, we took an important step forward in june. we transferred control of all cities and towns to iraq's security forces. the transition to full iraqi responsibility for their own security is now underway. this progress is a testament to all those who have served in iraq, both uniformed and civilian. and our nation owes these

americans and all who have given their lives a profound debt of gratitude. [applause] >> now, as iraqis take control of their destiny, they will be tested and targeted. those who seek to sow sectarian division will have more senseless bombings and killing of innocent civilians, this we know. but the iraqis know the united states will keep its commitments and the american people must know that we will move forward with our strategy. we will begin removing our combat brigades from iraq later this year. we will remove all our comrade brigades by next august and we will remove all of our troops from iraq by 2011 and for america, the iraq war will end. by moving forward in iraq, we're able to refocus on the war against al-qaeda and its extremist allies in afghanistan and pakistan.

that's why i announced a new comprehensive strategy in march. a strategy that recognizes that al-qaeda and its allies had moved their base from the remote tribal areas -- to the remote tribal areas of pakistan. this strategy acknowledges that military power alone will not win this war. that we also need diplomacy and development and good governance. and our new strategy has a clear mission and defined goals. to disrupt, dismantle and defeat al-qaeda and its extremist allies. in the months since, we have begun to put this comprehensive strategy into action. in recent weeks we've seen our troops do their part. they've gone into new areas, taking the fight to the taliban in villages and towns where residents have been terrorized for years. they're adapting new tactics, knowing that it's not enough to kill extremists and terrorists. we need to protect the afghan

people and protect their daily lives. and we are hoping to secure polling places for this week's election to afghans can choose the future they want. these efforts have not been without a price. the fighting has been fierce. more americans have given their lives. and as always, the thoughts and prayers of every american are with those who make the ultimate sacrifice in our defense. ultimate sacrifice in our defense. as i said when i announced the strategy,@@'4mrr@ @ d

this is fundamental to the defense of our people. going forward, we will constantly adopt new tactics to stay ahead of the enemy and give our troops the tools and equipment they need to succeed and every step of the way we will assess our efforts to defeat al qaeda and its extremist allies and to help the afghan and pakistani people build the future they seek. even as we he could our troops for the missions of today, we have a third responsibility to fulfil. we must prepare our forces for the missions of tomorrow. our soldiers, sailors, airmen, marines and coast guard to adapt to these challenges every day but much of our defense establishment has yet to fully adapt to the post cold war world, with doctrine and weapons suited to fight the soviets on

the plains of europe than insurgents in the plane of afghanistan. 20 years after the cold war ended this is not acceptable. it is irresponsible. our troops and our taxpayers deserve better. that is why -- [applause] -- that is why our defense review is taking a top to bottom look at our priorities, questioned conventional wisdom, rethinking old dogmas and challenging the status quo. we are asking questions about the forces we need and the weapons we buy. when we are finished, we will have a new blueprint for the twenty-first century military that we need. in effect, we are already on our way. we are adopting new concepts, the full spectrum of challenges demands a full range of military capabilities. both conventional and unconventional. the ability to defeat an armored division and the suicide bombing.

the intercontinental ballistic missile and the improvised explosive device. 18th-century stop piracy, twenty-first century cyberthreats. no matter is a mission we must maintain america's military dominance. we are real intent of our force to the future, on an army that is more mobile and expeditionary, missile defense to protect our troops in the field, a navy that projects power across the oceans but operates nimbly in shallow coastal waters, and air force that dominates the air space with next generation aircraft, both manned and unmanned, a marine corps that can move ashore more rapidly in more places. across the force, investing in new skills and specialties because in the twenty-first century, military strength will be measured not only by the weapons our troops carry but by the language they speak and the culture they understand.

here is the simple truth. we cannot build the twenty-first century military we need and maintain a fiscal responsibility that america demands unless we fundamentally reform the way our defense establishment does business. it is a simple fact. every dollar wasted in our defense budget is a dollar we can spend to care for our troops or protect america or prepare for the future. you have heard the stories. the indefensible no bid contractor cost taxpayers billions it to make contractors rich. the special interests and their exotic projects that are years behind schedule and billions over budget. the entrance lobbyists pushing weapons and even our military says it doesn't want. the impulse in washington to protect jobs back home building things we don't need, has a cost that we can't afford. this waste would be unacceptable at any time, but at a time when we are fighting two wars and

facing a serious deficit, is in excusable. it is an affront to the american people and our troops and it is time for them to stop. this is not a democratic issue or a republican issue. [applause] this is not a democratic issue or a republican issue, it is about giving our troops the support that they need. that is something that all americans should be able to agree to. i am glad i have a partner in this effort a great veteran, agreed arizona and a great american who has shown the courage to stand and fight this waste, senator john mccain. [applause] i am also proud to have secretary of defense robert gates, who has served the eight presidents on both parties, leading this fight to the pentagon. already i could end to a necessary no bid contracts, signed bipartisan legislation to reform, defense procurements of

weapons systems don't spin out of control. even as we increase spending on equipment and weapons our troops do need, we propose cutting tens of billions of dollars in waste we don't need. think about it. hundreds of millions of dollars for an alternate second engine for the joint strike fighter, when one reliable engine will do just fine. nearly $2 billion to buy more f-22 fighter jets when we can move ahead with a fleet of newer, more affordable aircraft. tens of billions of dollars to put an anti-missile laser on a fleet of vulnerable 747s. billions of dollars for a new presidential helicopter. maybe you heard about this. among its other capabilities, it would let me cook a meal while under nuclear attack. let me tell you something, if the united states of america is under nuclear attack, the last thing on my mind will be whipping up a snack. [laughter] [applause]

that is pretty straightforward. cut the waste, save taxpayer dollars, support the troops. that is what we should be doing. [applause] special-interest, contractors and entrenched lobbies are invested in the status quo and they're putting up a fight but so are we. if a project doesn't support our troops, if it does not make america safer, we will not fund it. the system doesn't perform, we will terminate it. if congress sends me a defense bill loaded with a bunch of pork, i will veto it. we will do right by our troops and taxpayers and we will build the twenty-first century military that we need. [applause] finally, we will fulfill our responsibilities to those who served by keeping our promises

to our people. we will fulfill our responsibility to our forces and our families. we are increasing military pay, we are building better family houses and funding more in child care and counseling to help families cope with the stresses of war. and we change the rules so military spouses can better compete for federal jobs and pursue their careers. we will fulfil our responsibility to our wounded warriors. for those still in uniform we are investing billions of dollars for more treatment centers, more case managers and better medical care so our troops can recover and return where they want to be, with their units. [applause] but as the vfw well knows, for 70 veterans the war rages on. the flashbacks that won't go away, the law ones who now seem like strangers, the heavy darkness of depression that has led to too many of our troops

taking their own lives. post-traumatic stress and traumatic brain injury are the defining injuries of today's wars. caring for those affected by them is a defining purpose, billions of dollars more for treatment of mental health, screenings to reach our troops on the frontier, on the front lines and more mobile and rural clinics to reach veterans back home. we are not going to abandon these american heroes. we are going to do right by them. [applause] we will fulfil our responsibility to our veterans as they return to civilian life. i was proud to co-sponsor the post 9/11 gee i bill in december. thanks to vfw members across the country and leaders like gary mitchell in congress, it is now the law land. [applause]

as president i am committed to seeing that is successfully implemented. for so many of you, like my grandfather, the original g.i. bill changed your life helping you to realize your dreams. it also transformed america, helping to build the largest middle class in history. we are saying the same thing to today's post 9/11 veterans, you pick the school, we will help pick of the bill. [applause] as the veterans start showing up on campus, i am proud we are making this opportunity available to all those who have sacrificed including reservists and national guard members and spouses and children including kids who lost their mom and dad. a [applause] in an era when so many people and institutions have acted irresponsibility, we choose to report responsibility

and service of our forces and families. with the you have left the service in 2009 or 1949, we will fulfill the benefits and care you aren't. i picked a lifelong soldier and wounded warrior from vietnam to lead this fight, general rexene said. [applause] we are increasing funding for veterans' health care. this includes hundreds of millions to serve veterans in unique needs. we are restoring access to health care for half a million veterans who lost eligibility in recent years. there's so much misinformation about health insurance reform, one thing that will not change is veterans' health care.

[applause] we are expanding access to your health care. we are keeping our promise on concurrent receipt. budget insures that veterans will receive their military retirement pay and their disability benefits. [applause] i look forward to signing legislation on defense appropriations so the medical care you need is never held up by budget delays. i have also directed the secretary to focus on a top priority. reducing homelessness among

veterans. [applause] after serving their country, no veteran should be sleeping on the streets. no veteran should have 0 tolerance for that. we're keeping our promise to fill another top priority, cutting the red tape in inefficiencies that cause backlogs and delays in the claims process. [applause] this spring i directed the department of defense and veterans affairs to create one unified lifetime electronic health record for members of the armed forces. electronic record with privacy guarantees that will stay with them forever. after fighting for america you should not fight over paperwork to receive the benefits that you earned. [applause] today i can announce we are taking another step.

i directed my chief performance officer, chief technology officer and chief information officer to join with secretary shinseki in a new effort, we are launching a new competition to capture the very best ideas of our va employees that work with you every day. we will challenge each of our 57 regional va offices to come up with the best way of doing business, harnessing the best information technologists, cutting red tape and breaking through the bureaucracy. then we are going to fund the best ideas and put them in action, all with a simple mission, cut the backlog, deliver your benefits sooner. i know you have heard this for years but the leadership and resources we are providing this time means that we are going to be able to do it. that is our mission and we are going to make it happen. [applause] taken together, these investments represent a historic

increase in our commitment to america's veterans. a 50% increase over last year's funding levels and the largest increase in the va budget in 30 years. over the next five years we will invest another $25 billion to make sure that our veterans are getting what they need. these are major investments and these are difficult times. discipline demand to make hard decisions, sacrifice and certain things we can't afford. let me be clear, america's commitment to its veterans are not just lines on a budget. they are bonds that are sacred. sacred trust we are honor bound to uphold. these are commitments we make to patriots to surf from the day they enlisted the day they are laid to rest. patriots like you. patriots like a man named jim o nor noree. his story is his own but it is a

larger story of all concerned. he was a child of the depression who grew up to join the greatest generation. a paratrooper in the 500 second parachute infantry regiment of the 100 first airborne. jumping in a daring daylight raid into holland to liberate -- at the battle of the bulge where his commanding general surrounded by the germans and asked to surrender, declared famously, nuts. for his bravery, jim was awarded the bronze star but like so many others he rarely spoke of what he did or what he saw reminded us true love of country is not boisterous or loud, but rather the tranquil and steady dedication of a lifetime. jim returned home and build a life, he went to school on the gi bill, he got married, raised a family in a small oregon

farming town and every veterans day, year after year, he visited school children to speak about the meaning of service. and he did it all as a proud member of the veterans of foreign wars. and then -- [applause] -- then this spring he made a decision. he would return to europe once more. 85-year-old, frail, gravely ill, he knew he might not make it back home. but like the paratrooper he always was, he was determined. he returned to the places in new so well. the dutch town liberated by our g is, schuylkill lined sidewalks and saying the star spangled banner. he walked among those perfect lines of white crosses of fellow soldiers who had fallen long ago, their names forever etched in stone.

then, back where he had served 65 years before, jim norene passed away at night, in his sleep, quietly, peacefully, tranquil and steady dedication of a lifetime. the next day, i was privileged to join the commemoration and normandie to mark the day when the beaches were stormed and the continent was freed. there were presidents and prime ministers and veterans from the far corners of the earth. but long after the band stopped playing and the crowd stopped hearing it was the story of the departed vfw member that echoed in our hearts. you have the new duties your comrades, your communities, your country. you have always fulfill the responsibilities to america, and so long as i am president of the

united states, america will always fulfill its responsibilities to you. god bless you, god bless all of our veterans and god bless the united states of america, thank you very much. [applause] ♪ [the stars and stripes forever playing] ♪ ♪ ♪

♪ ♪ ♪ ♪

♪ >> in a few moments, rand corporation study of health care in massachusetts. in 40 minutes, the first news conference with dr. francis collins, the new director of the national institutes of health. after that, a forum on relations between the united states and egypt. later, a hearing on how the federal government response to catastrophic disasters. a couple of live events to tell you about on our companion

network, c-span. health and human services secretary kathleen sibelius focuses on medicare fraud. and 10:00 a.m. eastern. at 11:00, a pentagon briefing on the presidential election in afghanistan. our special prime-time book tv programming continues tonight with bailout nation, how greed and easy money corrupted all street and shook the world economy. he focuses on how financial firms have been allowed to self regulate. you will hear about a special forces secret mission from doug stanton in his book horse soldiers, the extraordinary story of a band of u.s. soldiers who rode to victory in afghanistan. also rent scowcrft focusing on foreign policy. book tv at dccc p.m. eastern on c-span2.

now a rand corporation report on massachusetts health care system. under a program established in 2006, the state requires all residents to have health insurance. this looks at the results of the program and how to control health-care costs. this is about 40 minutes. >> welcome to the rand corporation congressional briefing on options for controlling health care expenditures in massachusetts. the briefing is being recorded as part of rand corporation's multimedia cds. you can access it on www. rand.org or listen to the discussion by tuning in to congressional briefing series on itunes. rand corporation is a nonprofit research organization that does research across a variety of areas with our single largest area being held. in 2006, massachusetts passed an initiativealth.

in 2006, massachusetts passed an initiative for universal health care. today dr. christine eibner, co-author of this study, will discuss the projections of massachusetts health care costs and options for policymakers about how it could be paid for. her current research is extensive, focusing on trends in the availability and affordability of private health insurance, socio-economic disparities in health and modeling the effect of health care policy changes on cost, insurance coverage and other outcomes. dr. eibner played a key role in the development of rant's compare, a new transparent evidence based approach to helping policymakers and the public understand and evaluate health care policies and you can't compare on our web site. today's briefing is the first of several rant briefings on health care costs. the next one is next monday at the same time in the same room and it will address health care,

growth and relationship to the economic performance of u.s. industries. i hope to see you all there again next week. in addition, rand corporation is participating to compare in what we are calling a critical conversation in nashville, tenn. on august 29th, focusing on the third rail of health reform costs. i would like to turn this over to dr. eibner. >> thank you, surely. i am going to be talking about options for health care cost containment in the state of massachusetts. i should say all the options i will be discussing today have been model specifically to address the needs of the state of massachusetts however we think this exercise is important from a national perspective as well because most of the policy options we have considered in this analysis are being currently discussed in the national health care reform debate. in addition to the fact that the

policy options for cost containment are being discussed in the national health care reform debate, there's also, as i am sure you know, massachusetts has been one of the first states to enact health care reform. in 2006 massachusetts enacted landmark legislation to ensure nearly universal coverage to the population, the three major components of the health care reform legislation in massachusetts included a mandate requiring all individuals to obtain health insurance or pay fines, a separate mandate for employers also requiring employers to either offer health insurance coverage to residents for their workers or pay a fine and also state regulated options became available that would make it easier for people to purchase health insurance coverage even if they didn't have access to an employer sponsored policy. with this set of reforms the insurance rate in massachusetts fell to 2.6%. this is a big achievement. however it is worth noting that

going to health care reform massachusetts had relatively favorable demography for reform. the on insurance rate in massachusetts price reform was 8% compared to 50% nationally. the median income in massachusetts is higher than the national median income, the poverty rate in massachusetts is lower than the poverty rate nationwide and even relatively recently, the unemployment rate in massachusetts has been lower than the national average. so far the reform has been successful in achieving close to universal coverage in massachusetts that there is a question about whether or not the reform is going to be sustainable. the key issue relates to sustainability, the cost of health care in the state of massachusetts. we projected trends in health care spending over time in massachusetts starting in 2010 and moving to 2020. in 2010 we reported health spending would be $43 billion. this will grow to almost doubled to reach $82 billion by 2020.

one question about this growth is we know that all sectors of the economy are growing overtime, at least that is the general pattern, so there's a question of how this growth compares to typical inflation or to the growth in other sectors of the economy. it turns out we were able to constrain the growth of health care costs in massachusetts to match the anticipated growth of gdp, we see health care expenditures rising at a lower rate, growing to only $71 billion between 2010, and 2020. this is a stud -- substantial difference, 7.7% difference to me know if lee over the years. we read this as if health care costs would continue to grow at the rate of growth of gdp we would not see health care concern and a larger and larger share of gdp over time. health care consumes 16% of total gdp. i am sure you have heard that number a lot. do we want to see it even larger?

probably not. this is one of the rationales for thinking about constraining growth to match gdp growth. in order to address this question, we at rand corporation were asked to evaluate the effects of various potential cost containment options. our project involved the 3 steps. we had to select the options we going to consider for analysis and for each of the options we selected we had to conduct -- to understand background, the series according to the effects of those policy options and for options that show promise and for which there was sufficient evidence and data we did a modeling analysis to estimate numerically what the likely effect of those policies and health care spending in this state. the first step was selecting the option for analysis. in order to do this, we interviewed stakeholders and came up with a list of 76 cost-containment options. it was too much for a single

study. we narrowed this. will group the reforms in to five different categories. redesigning the health care delivery system, reducing waste, encouraging healthy behavior, medical malpractice reform. the options across those five categories, with the clients, we selected options, total of 21 options that reflected all five of those categories to do more in depth analysis. the options were selected to the ones that have the most momentum at the time. in conducting this analysis, to have an option you think is going to be a promising option, you have two criteria. we have strong theory and logic suggesting the auction is likely to work but in addition to the theory and logic we like to have implementation and experience,

evidence from implementation and experience to show that it has worked in practice. broadly speaking, the kind of reforms we can fit are grouped into two categories. we have a relatively strong history of implementation reforms. we can draw on that to see what works currently. we have a lot of theory and logic to suggest why they might work. when the regulatory reforms were implemented in the past, they didn't necessarily show natural implementation effect on health care spending. in considering these reforms we

have to think about why they might work better this time. for the market-based reforms there is a lot of logic to support the idea that they might work but we don't have as much implementation experience. this has been a challenge and i should point out is not necessarily a fair fight between the two types of reforms because we have some experience to draw on and we can draw conclusions based on that experience and for the other set of reforms we are relying more on logic. with that i want to go through different reforms that we did to consider for the modeling analysis. out of the 21 options for which we did the in-depth review we ended up with 12 for which we created model estimates. the first four we considered grouped into the general category of reforming payment systems, i listed them here, the first two reforms on the list are more market-based oriented reforms and a second reforms on this list are more regulatory. the very first bullet point on

this list is bundled payments. i will go through what bundle payment is and give an example later on in the talk. the second fleet to policies on the list relate to pricing for academic medical centers in the state of massachusetts. these two policies are in the state of massachusetts. massachusetts has a lot of academic medical centers. they tend to charge higher prices and community hospitals. these policies would be trying to reduce spending at academic medical centers and are not necessarily as relevant for the u.s. overall. the fourth one on this list is hospital rate settings, regulatory reform, one of the reforms i am referring to with his adopted in the 70s and 80s and has been abandoned more or less by all states except maryland at this point in time. the second group of reforms that we considered selling to the category of redesigning the health care delivery system, the first three bullets on this list are all about expanding primary-care and increasing the

efficiency of primary care. the last bullet point on this list, better managing chronic illness. the third group of options we considered had to do with reducing waste in the health care system. we hear a lot of reducing waste as a potential policy for achieving health care savings, so the challenge was articulating exactly which policies we used to reduce waste. we came up with three that might be promising, eliminating payment for potentially preventable events, encouraging less intensive resource use at the end of life and finally accelerating the adoption of information technology. finally, we evaluated one reform in the area of encouraging consumers to maintain health, that reform is called value based insurance design. that bears more explanation. value based insurance design is setting co-payments for medical services so that they reflect the value that a patient

receives for that kind of care. they're frequently discussed in the context of pharmaceuticals and for the idea would be for someone with a serious illness who has a great need for a particular drug would get a lower copayment than someone who is using that drug for an off label use or has a less serious condition or something. the model in methodology, i should say there were originally five categories of reform we considered. when we narrowed it down to select options for modeling, the options we selected for modeling felling to four categories, the category that was left off the table for the modeling analysis was medical malpractice reform. i will talk briefly about our methodology. we developed baseline health care spending projections in the state of massachusetts from 2010 to 2020. these projections adjusted for population change and may also allow for health care cost inflation and we projected that over this time period, massachusetts would spend

$670 billion on health care. then we modeled the likely effect of implementing any of the 12 policies on health care spending trajectory in massachusetts and for--when we model these options we created those and upper bound or lower bound estimate. the upper bound reflects the most pessimistic -- the most optimistic evidence and data that are available and the lower bound takes a more pessimistic view. i want to talk briefly about medicare before i move on to the results. medicare spending was included in the $670 billion estimate of total health spending projected cumulatively between 2010, and 2020 for massachusetts. however, it was challenging to determine how we inc. medicare into our estimates. the reason is that our charge was to think of policies that could be implemented by stakeholders within massachusetts, and medicare is outside of the purview of

massachusetts in general. so for many options we assume there would be no medicare policy change, medicare spending would remain constant and if that was the case, medicare spending would be unaffected by the policies. there are a few exhibitions been made to this rule. the first exception was if we thought a waiver could be obtained for medicare participation in a particular type of policy. this applied to hospital reregulation. for the case of hospital rate regulation the evidence from past experience suggested medicare has been willing to participate in those options if states want to institute this type of regulation. we had medicare within the savings estimate for rate regulation, we also allow medicare to be included in the estimate, if we thought that medicare enrollees or providers would be likely to make use of a health care delivery system change. an example of this is health information technology. we think if provide is adopted health information technology, they would use it for all of

their enrollees regardless of who was paying for that care. in that case medicare was included in our estimates. i am going to move to the results. for story and you to how i am presenting this, the red star on the graph represents the 7.7% decline in health spending we would like to see cumulatively between 2010 and 2020 in order to achieve a reduction that would match the rate of growth of gdp. going to the original slide that i showed, the difference between those two lines was 7.7% difference. this is the target we are trying to achieve. the option that turned out to be the most promising for reducing spending, at least in the upper bound estimate, was a policy called bundle payment. bundle payments, we project, would lead to a 5.7% reduction in cumulative spending over the time period that we are talking about which is 2010 to 2020.

before i move forward with the rest of the policy options i am going to go through what we did for bundle payment in more detail to give you a flavor of what bundle payment is but also how we conducted these analyses more generally. so currently, 80% of care in massachusetts is paid for on a fee for service basis. providers are reimbursed for each single service they provide. that could potentially lead to the overuse of care. with bundle payments, the total cost of caring for a particular condition or providing a particular procedure would be calculated, and that bundle payment would be given as opposed to fee for service payments and the idea would be that all care for that patient's condition or that procedure would come out of the bundle. the bundled amount is usually a reduction on current average spending for the condition or the procedure. it would be applied across

multiple providers and care settings. this is one of the market-based reforms i talked about before for which there is not tons of lebanon's, the limited evidence unbundle payment suggests it would save money. we considered bundle payments for 10 different conditions and four different procedures and they are listed here. the conditions are chronic conditions like diabetes, high blood pressure, the procedures include heart attack, barry after surgery and it and need replacement. the streets and conditions, there is a payment reform condition, the prometheus payment system that has developed prices for these different bundles of care, so we were able to draw from the data to figure out how much this would save the state of massachusetts. to walk through an example of how this works at least in the prometheus mechanism, for a typical patient with diabetes, the average spending for that patient is about $6,000.03-year.

they have this untangle the spending and look at evidence based guidelines on how much care a diatic patient should be receiving and they have determined 39% of payments for care for diabetes is for evidence based guidelines recommended care and the other 61% of spending is for care that was potentially avoidable. by potentially avoidable i mean it could have been a test that was ordered twice so you got the same test results back for the same situation, or it could be something that became necessary that could have been avoided. an example of that would be an emergency department visit for hypoglycemia. the idea in pricing the bundle would be to provide the amount of money necessary to pay for the needed care, but then to reduce the spending on terror that is potentially avoidable. in this situation we said that the reduction on potentially avoidable payment would be 50%. this causes the payment for

diabetes to fall from an average of $6,000 to a fixed amount of $4,200 for patients 3-year. the reason this is attractive is gives providers a little bit of a cushion in case some of the care that was deemed potentially avoidable was actually inevitable, but it also gives an incentive to participate because if you are a provider and you think you can get your care level to the deck of what you are providing recommended kerri you can stand to make a little money off of this policy. in order to model it, we multiplier that out by the $6,000 of average current spending and $4,200 we expect under bundle payments and came up with an estimate of savings but there's a question of how this would work in practice. i mentioned before that there is some evidence that bundle payment has worked but the evidence comes mainly from hospital based conditions and is mostly for coronary artery guy -- bypass surgery. the lower down we estimated, when i said the first slide, the

lower down estimate included hospital based conditions and you can see from the slide, there was zero effect, there was a marginal impact in spending when you include only hospital based conditions. chronic illness is the biggest cost saver but we really don't have as much evidence at this point. another issue about bundle payments that would have to be addressed is who owns the bundle and allocates the payment. in an integrated delivery system this might work well, if primary care opposite of this physician valid to hospitals or specialists but a more traditional physician doesn't necessarily interact or communicate with saw hospital or with the specialist it might be hard to figure out how that bundle will be allocated across different providers. there are difficult to develop and price, we used the bundles that developed by prometheus for this analysis. it turns out it took prometheus

three years to develop prices for those ten bundles that i showed earlier. then there are no effect on quality of care. one concern is by capping the amount you pay for a particular service that providers would pull back not only on providing the necessary care but also potentially care that could have been necessary. this goes back to the original estimate for bundle payments. turns out the four options that were the most promising in the upper bound were options related to reforming payment systems in massachusetts, so one of the conclusions is the options that show the most promise are aimed at changing how health care is paid for. we had three options in the middle in terms of likely savings potential, information technology was one of the three options but the two others that are listed are options that are aimed at improving the efficiency and extending the

capacity of primary-care. there were three options group at the bottom of our analysis. these options are creating medical homes, using value based insurance design and in urging disease management. if you can see the slides, for these options, they crossed the line at we 0 -- zero, decreased spending. for each of these three options, they are about better managing analyst for patients. to do this you have to invest in better management for a wide group of patients and savings come down the road hopefully from people who end up using less hospital care and less emergency care because they have managed their conditions better in the first case when something started to develop. the reason these might provide and certain savings is the spending that you have to give in order to better manage care is a certainty and the savings that come down the road are very uncertain. to summarize, we have limited

experience with most policy options. the policies that are most promising at least in the upper bound of our estimates are focused on reforming payment systems. the policies that were aimed at better managing chronic illness show less promise for reducing spending and that is because they require enough investments that may or may not generate savings down the road. i should deck out that for these options we are looking specifically at health care spending, we are not thinking of the value that is added by in terms of quality of life that would come out by implementing these policies. we don't mean to suggest they are not good ideas but we need to see this from a spending perspective that they are not necessarily going to save money. the final conclusion is no single policy is a magic bullet. bundle payment which was the most promising option in the upper bound, would lead to a 5.7% reduction in spending over this 11 year period.

the target is 7.7% reduction in spending. we are not getting all the way to the target with any one of these policies implemented alone. and obvious next step would be to think about combining options. it turns out that is more challenging than you might imagine. we don't think, in terms of protecting the likely effect on spending, the reason is we don't think these affect our likely to the additive. for most of the policy options they are addressing the same sources of unnecessary spending. many of the policy options we considered our about reducing spending that occurs in hospitals for conditions that might have been avoided. you can only save the money once regardless of the specific policy that you used to get that out of the system. we can necessarily add these together. we think it would be possible to come up with an estimate how combined packages of the reforms affect health care spending, but we haven't done that at this point and it would be another project. in terms of the next step, we

delivered this report to the client earlier this month. the findings were released publicly on august 7th. three weeks before we deliver our report, the massachusetts payment reform commission recommended global payment as a strategy to reduce health care spending in massachusetts. global payment is really an extreme form of bundle payment where all care for a particular patient would be bundled at a specific price and a provider would receive one payment per patient per year. with the mentioned in the report provided by the pan and reform commission is bundle payments could be a first step on the road to implementing global payment. i should mention again one of the drawbacks of bundle payment is there's not a lot of implementation evidence. rand corporation is evaluating a bundle payment demonstration at four different sites and hopefully with that evidence we will have something more concrete to say about the effects of bundle payment. that concludes the recorded

portion of this briefing and at this point i would like to take questions from the audience. >> going towards the effect, that bundling is a valid concept but how reliable would it be, if you were to have a disease and you get a price on how much to pay for that disease, what would happen if other diseases came about because of the form of disease you have, how would bundling be able to compensate for that and how would you compensate with, i guess, the cost of different health? >> there are a couple different issues that you raise. the quality of care that would be perceived under bundle payments, the way that this is being implemented is usually implement alongside performance or other types of quality policies intended to promote quality to make sure quality of care doesn't suffer when the

bundle payment is implemented. the second question you raised is what if someone had additional illnesses, how would that affect the prices of the bundle payment? they would likely be risk adjusted which means the bundled amount could differ from different patients depending on their other conditions. yes, tony? >> a lot of people confused but the payment and capitation. >> a bundle payment is for a particular episode of care. capitation, we usually think about a broader concept that would apply to all care, across a given time period. beyond that, we also think of bundled payments as usually being coupled with a different performance incentive to make sure quality of care doesn't suffer, that is not necessarily the case with capitation. yes? >> a lot of emphasis on the

bundle payments. for chronic care patients, reducing the use of the r. most of the bundling i have seen being talked about is demonstrations, is anyone evaluating 3 acute-care to key to not of a hospital in the first place? >> i'm not aware of whether or not that his underwear. this is my co-author, peter, who might be able to answer that. >> that tear as far as regulatory care, there is an incentive. >> in the back?

>> are dead bundle payments or is that the basis? >> airbase on the conditions earlier, they were intended to the payments for six conditions, annualize payment per patient per year for each -- there were four bundles related to acute episode of care like barry after surgery. in that case it would cover all of the care that went along with barry after surgery whether it occurred before or after but was related to that particular care of the set. we see savings accruing overtime from 2010 to 2020. yes?

>> i have a question -- somewhere in the report, going to prices that are negotiated in the process? >> we only look at the original case, the state regulatory board. was there another question over here? >> does increase in price -- companies or manufacturers of that policy, increasing price in a projected cost, spending in massachusetts, and price control offices? >> we didn't evaluate either of those options. i can't speak to that question. >> why don't you? >> we started with 75 different

options and narrative down to 20 one options based on stakeholders and what our clients far with the most promising options to consider. that is how we narrowed it to 21. we left off the list were not necessarily options that were not promising, we didn't have the scope and resources to evaluate. yes? >> bundle payments that they come up with, taking into account geographic variation. >> that is a good question. my colleague, peter, was more involved in the prometheus analysis. >> the normalization process, to analyze the prices. but also the evidence so that they are tailored.

to be monitored. particularly -- you can normalize any -- and so the health plan addressing all of that. >> does that mean hospitals or providers? >> that is a good question. if it were -- i think the model would be typically integrated so the primary care provider for the patient with holding the bundle. how that would work in practice is difficult to say. we see it working well in the integrated delivery system but it would be more challenging to implement if there wasn't a link across the different providers.

yes? >> these cost savers, i think that would encourage that. >> this was actually not one of the things that we considered. the three options that group in the middle, two of those three are delivery system reforms focused on improving the efficiency of primary care provisions. substituting lower cost primary care providers like nurse practitioners. >> what else might occur in the department? >> as the model for that option really considered narrowly to focus on substituting for primary care providers using more nurse practitioners as opposed to people with in thes but we discussed the possibility that there could be implemented

more broadly for primary care physicians and over specialists and there would be other examples of how that might work as well. additional questions? >> the cost saver in terms of the republican ability, keeping that from being available, or able to adopt hire systems? >> i am not sure the announcement we did spoke to either of the specific questions you raised. we thought about having savings across a number of different dimensions including reduced paperwork, battered drug prescribing so there was redundancy, i am trying to think of other areas, nursing times, saving to nursing time for having information technology available. we had several categories we

considered that went into the health information technology pricing. yes? >> not withstanding the estimates that you got from changes to the health care delivery system, given that bundle payments, seen upper bound estimates, seemed to work in the case of an integrated delivery system, at that point, wouldn't that argue for medical home concept or some other concept that does integrate the delivery system, vertical, horizontal the? >> i agree. we discussed that a little bit. to implement some of the reforms you might need to have that structure like the medical home structure. in the cayman reform commission's report for the state of massachusetts where they talk about implementing global payment a discuss it in the context care organizations linking providers and holding them accountable for the quality of care delivered.

>> implementing global payment without having these other delivery systems? >> emt would be to implement them in tandem. yes? >> for consumers, what i the possible down sides of bundled payments? >> the downside would be if quality of care could be negatively affected by capping the bundle in a particular amount. the way that would be dealt with is by implementing pharmacists incentives alongside bundle payments to ensure quality of care being delivered appropriately but it is unknown at this point, something we need to study further. >> these concepts current, they started 20, 30 years ago when managed care was first introduced in california. can you give a concrete example of some o t