with this group that was having parties have now come out showing behavior that wou be offensive to most muslims what do you think should be done about that tuation at the bassy? >> well, i don't think we have the information to be able to say what ought to be done but if those allegations are true, those activities are not just offensive to afghans and muslims they are offensive to us and they are inexcusable. ..

there ample opportunities for dialogue from one another. >> their invasion and obviously this hour know they left wih the war in afghanist, might it come back to haunt russian participation >> i thank whatever russia's rolen the ground in afghistan might be really is up to the afghan government. >> to follow-up on the polling conaerns about perhaps the

following public support in mounting concerns on the hill r the one of the reasons that is cited for that is as you well know casualty's but there's still not a strong sense among the american people of what the mission there is. the president has defined it but i wonder if you often speak to that and also whether general mcchrystal's report shed any new light on exactly wha the-- >> let me address thatnd invite the admiral. i thank it is important to keep our perspective. the fact is that 9/11 represented the first foreign based attack on the continental united states with significant casualties since the war of 1812. that attack emanated from afghistan under taliban rule. pit taliban did not just provide a se haven for al qaeda.

they actively cooperated in collaborated with al qaeda. they pvided a worldwide base of operations for al qaeda. so it seems to me that we are in afghanistan less for nation building then we are for-- in giving the afghan state the capacity to oppose, to oppose the al qaeda, to oppose the use of their territory by other violent extremists and for them to have that capacity that can be susined over a period of time. the reality is terrorists lehrer can a number of countries, but the problem is manageable because the governments of most countries are opposed to their activities and have

intelligence, law enforcement and internal security capabiliti to sustain that opposition and to be effective. it seems to me that in the context of the president's goal, of destructing, dismalingnd destroying al qaeda kooi seek and afghanistan that is our partner in that endeavor and that can sustain that endeavor after we are gone. >> my only comment is that the intelligence continues to support that aqaeda and its extremist affiliate's, one of him are the taliban, very specifically still target this country, our people as well as other western countries. that is not abated and it is not going to go away based on anything that i have seen and what the secretary has desibed is they thrive in on governed

stasis. >> during derek debate general petraeus had been very public in testifying on the hill with ambassador crock come a being a public face forhe war. two questions, when mr. secretary you think the administration needs to do more publicly to clarify what the messages sent to keep kind of reminding skeptical ordered by polling the wore and mr. chairman to you have any plans currently for general mcchrystal or others from that command to come back to the u.s., testify and try to serve as public surrogates in the way that general petraeus did during the debates? >> first of all i think that the president's messagin his speech at the vfw was crystal clear abouthat we are doing and what we are about. i think that clearly, press opportunitie like th and other opportunities for us to talk about this and why we are

in afghanistan and why it is important are important. i think all you have to do is look to the front page of any newspaper or turn on the television to see that afghanistan right now, at least as far as the media and the government are concerned are at the forefront. there are a lot of pele out there talking about this, and debating the issue already in the in terms of the way forward and i tnk there is clarity in terms of our strategy. i think the president has described it. i think i just described it, and we wilcontinue this effort as we go forward. last question. >> asked what progress would be in afghanistan sai we will know when we see it. n both the eurojust marks explicitly how to address of and

is a part of that, is denying a safe haven from pakistan part of this mission as well for removing the safe haven that some would say is sliding there now? >> i think first of all one of the most significant new elements of theresident's strategy that he announced at the end of march was in fact recognitio that this is a regional concern. a regional problem and the chairman has spoken often about the pakistani part of this and he mentioned earlier in this pressvailability that this is a piece that is independent really, this is not part of general mcchrystal's rich if you will but it is certainly an integral part of the president's overall strategy inur integrated civilian military approach, so i think that come i think we do take that into account.

>> are we making progress? >> first of all the administration-- let me ask skin that into ways. the administration has developed measures of effectiveness. those have been shared with staff on the hill. they will be shared witmembers and the members come back next week. the deadline to have those completed is i think september 24th, and my view has been and i assume it the case, that those that are classified will beade public, so one of the things, and they have, we started this ourselves. this is not something composed by the congress. this is something so we can evaluate how we think we are doing and not keep rolling our goals in front of us but in fact try and genuinely measure whether they our approach is making headway or not. and, i think that is a very important thing.

but, i think in this one respect, there is a comparison between iraq and afghanistan, and that is success is the afghan national security forces assuming a greater and greater role in controlling and protecting their own territory. as ge recede into an advisory capacity and ultimately withdr. >>.s. specifically, or specifically with respect to the safe haven, a current safe-haven in pakisn i think the way do we get through that is the right growing and sustained a trusted partnership with pakistan and one of the ways i measure progress is by looking at pakistan over the last 12 months and the success of their frontier corps, the success of their militarx in terms of it operations in swat and the movement in that direction to

address the extremists in their own country and thatind of continuing pressure that eventually will provide security for their own people so that in fact their own people, who now protect al qaeda, turn them out and that applied to some sort of almost an approach with pressure from the afghanistan side. that is going to take some time to create thatut it thing strategically we know how to get that don >> thank you. >> what did the mcchrystal reports they?

>> mr. g justice n mitt plse the court, the government concedes that the construction of documents in anticipation of a proceeding was not a crime in 2001. based upon-- >> something is different is going on here tn what goes on in the capitol building or in the white house and we need to appreciate how important is to our system of government. >> this is the highest court in the land, and the framers

created its afder studying the great lawgivers in history and king a look at at they thought worldwide was important for the judicial branch to do. >> i put in as much blood, swea and tears on the little cases as i do on the big ones. we don't decide what to win, we decide what the people have opted. >> you will be surprised by the high level of collegiality here. >> if there ape ur of us that want to hear in any of these cases, we will hear it. >> we are here to decide tngs. the job is to decide, we decide. >> why is it that we have an elegant, astonishingly beautiful, imposing impressive struure? it is to remind us that we have an important function. and to remind the publi when it seized the buildinof the importance and the centrality of

the law. >> i think the danger is that sometimes you can come into a building like this and think it is all about you or that you important, and that i something that i don't think works well with this job. >> supreme court week, starting october 4th on c-span. >> now a dcussion on the health care debate as congress prepares to return from its august break the president has scheduled a

primetime address on health care to a joint session of congress. nita the house nor the senate have passed health care legislation. the alliance for health reform and the robert wood johnson foundatiol are the hosts of this event. itasts about an hour and 20 minutes. >> on behalf of senator rockefeller and senator collins and our board of directors i want to wcome you to this program, a look at what might be in store over the next 100 days of debate over health reform or insurance reform, i am not sure. we are pleased to say is the robert wood johnson foundation and the largest philanthropy working to improve health and health care. you will hear in a few minutes om the ceo, dr. risa lavizzo-mourey. we are right at the cusp of a period of a few mons and we are either going toet to y on a substantial initiative to reshape the american alth care

system, or we won't. what ist stake is not just the two and a half trillion dollars we are going to spend this year on health care in the u.s. and more in the yea ahead of cose, but the qualityf lives, maybe even the fact of life for millions of people who lack access to affordable and quality health care and everybody knows that the idt obama will probably launch this next phase of the debate with his speech to the joint sessionf congress next week. the reason these weeks are so crucl is, and you may have heard this before, the is still a level of digreement about what to do on some of the major issues. in fact, there is some controversabout almost every majoelement and the packages that are being debated in congress and the president are going to have to succumb to some agreement on these major issues

oree not to decide se of them if there's going to be a significant rorm plan enacted, and that is what locations today's meeting. we brought togethe some of the best health policy analyst in the country to address as many of these issues inesponse to your questions as we can cram into the next 75 minutes or so, so without further filibustering let me present michael moderator ha the psident of the robert wood johnson foundation, dr. risa lavizzo-mourey. let me just say she a geriatrician b training. she still sees patients. she also onhe side runs the largest philanthropy in the country devoted to improving the health and health care of all americans d she is the only going to service the cold moderator but i hope the taking an active part in the discussion as well. thank you for being with us. >> thank you for hosting this and inviting me to bee

moderator. this i obviously a critical time to have this conversation. the robert wood johnson foundation has been working on this for @ long time am back in january, if we can all remember back tt far when we began talking about this debate in earnest, we laid out six big areas th we thought needed to be addreed in order to achieve what we all want, which is a healthier population and health care for everyone. first we need to have coverage. we all i think agree having the equivalent of 24 states githout having health coverage is unacceptable. and, it is unacceptable because if we don't cover everyone it is hard to see how we are going to get to the second thing that most people agree we need which is higher quality, higher value health care in more equity in health care. you can get to that without having everyone included, and we

have to address issues of health care spending. we are spending, as you have already mentioned, more than any other country and yet we don't have the highest health care. the next area that we have identified as being critical is prevention. we have had a lot of debate over these last 100 days about clinical prevention but i think most people agr with the date of that primary prevention and community-based prevention does lead to a healthier people and that ultimately is going to be needed if we are going to reduce theurden of illness in this country. then there are a coue ofther things that are absutely critical, improng theublic health system and addressing what makes us healthy in the first place, thats those things that happened outside of the medical care system, the socialeterminants of health. now these last two, it is hard

in today's environment with all the heat we have had over the last month, to see how we are goifg to get to all of those things in the next 100 days but i hope as we have this discussion today, we stay focused on the fact that what st americans want is affordable, high-quality care that is accessible to them when they need i that is something that i think most everyone ca agree on and hopefully we can bring out during this debate that doing nothing is not an option. the ititute, the urba institute's study that showed that if we don't take action we are going to have more uninsured, higr cost and probably higher costs of the government as we need more people to be enrolled in medicaid and the like. so, doing nothing the thing doesn't lead to universal coverage. it will just lead to universal pain and with that i turn it back to you. >> thanks very much and i think the urban institute paper about

the cost of inaction is iyour packets. pickwick majestical note, you have and those that it's not just the paper but extensi biographical information about our speakers a a lot of background information and if you happen to be watching this on c-span, and have access to a computer, you can see all of those materials on our web site, which is all health.org and follow along, and in about a week there will be aranscript of this seson that you can read on that same web site, in speaking of web sites would commend to you health reform but ward, which is organized by the robert wood joson foundation. used boldly your ally wanted but it is bad lots of useful background information. we are going to just kick things off by asking each of our panelists a single question,

letting th respond and then we both give you a cnce to weigh in with your questions. any problems or questions that you have to, bill irwin, our communications director who did all the hvy lifting putting this session together will be delighted to help you and adam going from e foundation is also here, who can answer some of your questions. let me give the briest and least deserved introduions that i can four, that i can get away with four panelist. we are going to start with gail wilensky. she is a senior fellowt project he. she is from the medicar and medicaid programs. she has served as george h.w. bush's health advisory intercurrent areas of concentration include military health issues which is described as o of the greatest fascination she has run across and comparative effectiveness.

dallas salisbury at the far end of my left is the ceo of the employee benefit research institute, head its debt since its inception in 1978. if you hen't discovered the resources yet you have been missing out. what tell us doesn't know about employment-based coverage probably you don't need to know. at the othernd of theable is ken thorpe. he heads the policy department at emory and is the driving force behind the partnership to fight chronic disease, which is a group of more than 100 national organizations of restripe that is trying to shape the health care system that events and treats-- chronic conditions better. now, let's get to the questions to start this offn dale, why don't we start with you. i mentioned your connection to medicare, and medicar plays a big role in the plans that are

beingeveloped from generating savings that are going to be used to offset expansion of coverage, cost to testing new models for payment to improving the drug benefit and a whole range of other things. our most of these provisions likely to survive and how should medicare beneficiaries like me or for that matter the rest of us feel about those provisions? >> i regard the proposals affecting medicare that we have heard thus far in many ways as a metaphor for some of the challenges that are facing health care reform i genal. medicare program has a clear sustainability issue. it has made promises. is not in a position to fund as of yet. there are clinical appropriateness and quality issues as is true for the rest of health care. in soee ways, it is lagging further behind the rest of

health care in terms of moving toward integrated delivy systems and morph management of chronic disease. we see the challenge that medicare and health caeform in general face very clearly in theropols that have been laid out to raise money. what the administration is looking for an order to finance health care expansion is quick money, because it is clear we can spend money very quickly in order to expand coverage. massachusetts has made that vy clear. the problem is many of the changes while ultimately likely to benefit the system, medicare and in fact produce savings over the lon term, might not do so in the short term and i want to use to examples to try to clarify the attention than challenges that the administration and the congress based in trying to come up with sure money quickly versus doing

thin that in the long term are likely to provide sustainable important spending but probably not much money that would be squared by cbo in the short term. one is reducing in appropriated missions. this is a major piece of funding that t ainistration has listed as a pential thunder for health care expansion. oneth by the admissions to medicare is for readmissions. some of them appropriate, many of them on the appropriate, reflecting quality problems in the mission itself so you might say what is the problem here? well, the problem is the way you reduce inappropriate admissions test is by getting nurses to follow patients when they are discharged to make sure that their medications have been fulfilled and are being taken and that the doctors appointments or nurse practitioner appointments that are necessarare in fact scheduled and met. all of these take money in the

short term and it is particularly problematic when you look at where there are large numbers of hospitals with high readmission rates and they happen to be rural and disproportionate hospitals, for those of you would don't know what that means, have a lot of medicare and medicaid patients. now, since medicare reimburs hospitals, adding-6% rate, that means not covering the cost and medica frequently does worse, it means that the hospitals that are most likely to have these inappropriate to admissions are the least able to be able to finance the kind of strategies in the short term to fix the problm. rural and those that have aot of medicare and medicaid. can it be de? absolutely. will it produce savings? it will. the problem is you want money now for expansions and most of what we need to do will take

time and aecond one is nursing home rights. it is been knownor a long time that medicare is a relatively generous taer for nursing homes, but it makes up for some of what medicaid does not pay for nursing homes. if you pull out money for medicare, which is a for of medicare which i hav some sympathy to, without making sure that the other big payer, medicaid, changes its reimbursement strategies you are going to put at has been a pretty fragile area of health care into financial distress. so, these are the tsions. any to slow spending. yocan do it but the ways to get money quickly are not the ways that produce the kind of anges you need to improve quality and it is a dilemma. >> okay. thanks gail. let me turn to dallas i can. al the bills that we have seen

emerging at least on the democratic side, seem to affect employers substantiallyn directly, either imposing some requirementsr some alternative taxes that would have to be paid to provide or pay for coverage for their workers. how do you you characterize the positi of big employers or for that matter small employers on the reform proposals that we have been seeing so far? >> some things are a sense of deja vu as we started doing our surveys and data on this in 81. and, consistently if you think about employer opinion the number one issue they have always cited i similar to what gail 'tis noted, which is cost. and a genuine view across all entities that is similar to where the president is and the republicans verbalize things which is then sustainability of the existing system, be it

public or private on a cost basis, and they include employment-based coverage and that. the second reality that employers deal with across the spectrum and have for decades is the key role that they recognized, health insurance pays an attraction and retention and even in the exit decision and our value of befits surveys the go back to the early '80s repeatedly underlying 80% of workers say that health insurance is the number one most important supplement to pay. if you then say, the could have a second benefit, what would you want? 36% say more health-insurance. when asked, are you willing to take a reduction in current wages in order to have better health insurance, over 50% consistently say yes. and then you take another factor, about one-third say they arin their current job bause of the health insurance so if

you want to keep people, that is the good thing. if you want labor force mobility, some emplors to, that is the bad thi but the other is that 35% say health insurance was the key factor, the most important factor in taking the last job that they took. and, so it is ver important to job selecti. so, employers are in a catch-22 of knowing cost is an issue, knowing that there employer-- employees want health insurance but e third factor, the employer winning choice and exibility,nd that comes down to what big business has supported since the early 1970's, when it was enacted in the employee retirement income security act of 1974, cled the rest of preemption, which allows employers and self insured to avoid 100% of state laws, state

mandates, the state differentiation and maintenance of erisa has been a number one priority of all businesses since that point in time. in fact, in the current debate, if one tries to find the differentiion point on that one can't because one of the strongest points made on the web site and in speeches and testimony by the small business and, the chamber and the national federation of independent business is what they wt out of health reform is the ability for ery small business to have the equivalent of erisa preemption without even having to self-insure. they want the federal government to say here is a high deductible catastrophic protection program that is the barest of their buns coverage and avoids persol financia disaster, which any small business should be able to provide on a nationally

consistent basis through state cross-border or purchased etc., etc. with the structure be it a called a association health plan so that they can avoid 100% of the current state mandates, steak regulation etc so there is consistency there. and the other piece of that flexibility that comes through om all of the group's is most readily identified as a total repudiation of tax change, of employment-bed health benefits which the largest business is saying maybe a lite but as the months have gone by, that seems to have dropped off in y willingness to discuss that. in the clinton years and during the 1980's, this was very heavily debated on capitol hill, the tax reform act of 1986. included many debates and

discussions and so-called treasury won in 1983 and four. it would have fundamentally change the tax treatment of employment-based health benefits of this is not a new issue but the positions have not change. then perhaps the most import issue in the context of house and senate bills beyond the erisa changes that are in the house bill that are uniformly opposed by busesses are issues related to mandates, be they individuals or employer mandates across the business expect from when one looks and listens to, any form of employment mandated this point is generally uniformly opposed, en though they have been willing to live with some of that in massachusetts. that was the price of the navigability if you ad some of the surveys. and, on the issue of an individual mandate, some flexibility b not much, the general statement that

businesses make across the board in their trade associations is there any cost savings need to come out of the system in order to pay for the universal coverage and it shouldn't be done in a way that leads to cost shifting, the best also you will find in the positions in the surveys fairly uniform opposition to the public plan or any government takeor. but, then i will close with a final irony. about the only business group at this poi that has been willing to be aressively, at one might describe as negative is the national retail federation. almost all othe business entities and business groups have taken instead the position of plan a is the necessity of comprehensive reform because the current system is unsustainable. there is no plan b. the must be reformed and then if you look at the letters and

statements tt they send to capitol hill, for example one ted june 8, will we have got problems with any change in taxation of health benefits. we don't want creation of a public pla we favor no employer mantes. we favor no employee opt out then we want national uniformity and preemption and oppose all the provisions in the house bill relate to erisa t we still strongly support comprehensive health reform. if you go to the nfib web site you get similar. with the gto the business roundtable, there is on there web sita full verbatim texts of a conversation in early august and it is the same type of thing, support for most of the provisions that reason-- risa mentioned except when one gets to the specifics and i was

born and raised in the state of wainon at the feet of a great senators warren magnuson and henry baston and warren magnuson's that produced the book the dance of legislation, which is good reading for this topic and every other and henry jackson always at home said, pay no attention during the process because legislaon is like making sausage and at the end of the day you just he for a compmise that has a taste that is good. that seems to be where we are at here, tremendous disagreement ov t details but a recognition that employees want health care, that employers must make sure they have it, but employers don't like being told to do anything, so they want a ee rein tied to the current erisa preemption and that seems to be universal. >> see how easy this is going to

be? let me just fish off this initial round by turning to ken thorpe. everybody who has spoken so far as talked about health care costs and certainly the bill is moving forward have attempted to put some cost controls into their provisions. they have also been criticized pretty severely for n doing enough to hold do health care costs and i wonder if you think that is a fair criticism and if that is what changes would he would vies congress to make and the president to make in this final plan? >> keep in one-- keep in mind what the nfib was doing. >> a tough starting point. if you take a step back and think about it we started this discussion about health care reform trying to address two major issues, one is to move towards universal coverage. and i think as those mentioned, i think theres broad agreement about that as an objective. obviously there is a

digreement tactically about how to do it but i think we have broad aeements abutt moving to unersal coverage and i tnk 95% of the attention and discussion and reporting on the issue has really focused on that particular topic of the approach for moving to universal coverage. on the other hand if youhink about it the other thing we ar ying to do and if you go back in look during the campaign and of the candidates talked about this, was to controlhe growth of health care spending. that that was a major objective of health care reform. and i think while the reform packages as they stand are a good start, none of these things are going to be perfect. i think the queion is directionally is the one moving in the right direction and and i think so but i think i we do this since that's which i think we will have to come th isn't going t be when bill and then we go home and forget about it. this is going to be pass something and then we wl have to come back and continue to improve on the legislation but i think what we have to do is

focus some more over theoming months and i think years on finding ways to control the growth in health care spending in addition to moving to universa coverage. i think if we are going to be serious about it we have got to go back to the basics about what is driving growth in spending and gail touch on one of the issues. we know the share of adults that are clinically obese in this country s doubled since 1990. that by itself accous for a third of the growth in health care spending. is led to a explosion o diabetes, hypertension, back problems, pulmonary disease. you can go down the lt but the way to crete chronic illness in this country is rising at a rapid rate across the board. kids, adolescence, young adults and seniors as well. so w have to reay pay attention in terms of cost containment to a broer toolkit then we traditionally used to really attack this issue o lifestyle but do it in a way

that is not punitive, to it in a way thats thoughtful,o it in a way that gives people options about programs that work and if they want to make the change they can. targing smoking and weight is one objective of health reform. to is that if you like it where we spend the money, 75% of the spending is on chronic illness. and indeed in medicare 95% of what we spend up in the medicare program is linked to chronically ill patients, people that have four, five in six different conditions. th irony is medicare is the only program where we do absolutely no care coordination. of any program needing to have care coordination builds into a, working with patients at home, making sure they are not admitted to the hospital in first place. and gail talked about reducing the rights of freed mission. this to me are improvements in the program would improve the qualit of health care provided medicare beneficiaries and it the end of the day would save

money. one of the things that we could do in health care reform is ovide care coordination overtime nationally in the program by building on this medical home model but really building primary prevention using nurses, nse practitioners, other primary-care providers to work with physician practices and patience, to keep them healthy, to keep them out of the hospital and keep them from being readmitted. we are going to have to invest in this. this is an important change in the delivery system infrastructure and oneell worth making. it will provide dividends over time, no question. i will give just a quick financial example. if we are going to build care gordon to the medica program nationally, based on some models that are already up and running in north carolina and vermont and some other states to do this for their populatns, it would

cost 25 or $30 billion over the next ten years. that sounds like a lot of money and it is but in the context of the numbers we are talking about in terms of the overall package of reform that is almost in the second and third decimal points of what we are looking at in this is almost an estimation error in terms of the cost of moving towards universal coverage but yes it is going to cost money to do this. if we took preadmission rates in the medicare program for a 20% andut them in half which we know we can do. we have programs in place in pennsylvania, colorado and other states that have been shown to randomized trials can cut readmission ratesn half and medicare has very high rates of read mission. if we build that transitional care program into the care coronation model, we cou save $100 billion over the next ten years on just that on aspect of care coordination. we know how to do this. we just have to make the

investment so if you think about it on the cost-containmentide if we really are going to deal th the long-term deficit we have got to address per capita growth in medicare spending. there is no question about it. if we are going to improve the qualit of care in the program i think we need to make these instments in primary prevention but we really need to change the delivery model to imove the quality of care provided, imove the health of seniors, and we can do a lot to reduce readmissions and admission rates in this program but we can't do it within the current payment structure and delivery model that we have, so i think as part of the promise of reform that we should not only does the doing health insurance reform as a major piece of what we should be doing but we should also be doing health reform, which is trying to find ways to improvehe health of the population, redesigning, reengineering t delivery model to improve the quality of care and at the end of the day in the public and

private sector we have the chance of producing a better health care system that generates better outcomes. >> thank you. let me just s that there are green cards in your packets to right questions on but given the overbay of either people in front of me, i would urge you to accurately ask a question orally because you probly won't get a chance to have your question read it that is the way you choose it. we have microphones a few want to ask a question. raise your hand and please wait for the microphone to reach you so that those of us in the room and those of us around the country can hear you identify yourself and try to keep your question as brief as you can and i would, and right in front of me as their first questioner. >> i was curious, i am curious

how each of you think the threat of death penalty has been addressed in recent weeks and have any of you had the opportunity to read this booklet that the veterans are supposed to have the opportunity to reive injured veterans that may actually give them it seems like the optio of choosing death over life? it was addressed on fox news and the former bush administration i think, it was addressed on the fox news on sunday morning a week ago. >> i have not read the va booklet so i will not comment on that but i would like to comment on the death penalty charge, which i have the know a number of times. i think it is really unfortunate that this has been raised and

received so much attention because there are serious iues to debate in the health care reform, how we fijanced the money, the wholeotion of the public plan and whether it is or is not compatible with private insurance as we know it, whether we are talking enough about reforming health and health care costs and talking only about health insurance reform. many issues. i regard the death penalty as a red herring issue to the extent we are talking about proposing payment for physicians that are asked by their beneficiaries, by their patients, to have counseling on either haass this benefit war end of life advanced directives once every fe years and the reason i think it is unfortunate is twofold. in the first place, this is already the hospice is ady in medicare covered benefit now,

and in addition, nursingome administrators and hospital admissions individuals are supposed to ask people who are on medicare when they are admitted to hospitals and nursing homes if ty have their danced directives and it's so to market in their chart so that those advanced directives can be folled. given that that is already the se, i regard this as a way to take positions to provide that counselingf they are asked to buy their patients and fundamentally to empowdr patients to have their wishes known about to advance directives if they choose to do at. i don't know how many of you in the room hava dance directives. i do. i did when i was at medicare i had been made. this is one it first arose in medicare. allowing people particularly not when they are going into a

nursing home or a hospitato have this discussio with their physician or their nurse practitier or their family members to try and help them think through what isn issue that individuals may face being put in a position where they are not able to register their own will in terms of how they would like to be treated is an important part of life. it doesn't in any way require people to have these discussions. just as medicare doesn't require people to hav hospi as a benefit. it allows, i think a major empowerment for seniors but in the senior that doesn't wan to have this discussionither about a hospice benefit or an advance directive need not do so d that is why i find it so upsetting that there's this notion of death panels. >> recep. >> i think you said it

beautifully,ail but it geriatrician i have to comment because what people don't often appreciate is that the vast majority of people don't really undersnd what kind of care i availae to tm at thend of life, what kind of palliative re they can aess that would actually make their quality of life better and our foundation has funded a lot of this research. it icritical that people get this information so you said it so well but i think that for those of us who have actually had to counsel people at the end of life, this is an important part of being able to do what we want to do which is deliver high-quality care. >> if i might just quickly personalize it. i recently lost my father just short of his 94th birthday and my parents both for many years had advand directives. i have had one for 25 years and i can just notes tt that's 93 and a half and 92, my mother and

father were both awfully glad that medicare provided for the hospice care that he got at the end of lif so i think that it is extremely unfortunate that this has been turned into political rhetoric and that is a personal feud, but it is something that i fully agree with. >> joe wexle managed health care magazine. i am wondering if the panel inks that the public plan option at this point is dead or if it is not dead whether it would be advisable to in orde to have health reform legislation for to fade away quietly and disappear? >> it clearly is not dead. it is one of the most contentious issues and unfortunately, it seems to have

dug itself into a prized possession tt is going to make it hardo negotiate a round because you have people like the speaker of the house and howard dean in a prram that i did wi him iicating that without a public plan health care reform isn't worth doing, and other people who headset having a health care public plan is going to im@act the rest of health care and have a lot of negative consequences as i indicated, i think that the public plan is not desirable as an addition because i do not believe the public pn will avd using the power of government to set below mket reimbursement. that is, to not in fact pay for

the cost of health care being provided. we see this in medicare. medicare pays physicians about 20% less than private plans. medicare is t mentioned pays hospitals about 6% weshen there cross. if you have a public plan als doing this you are going to do with medicare does which is push cost into the private sector, which will over time unravel private insurance. there are a lot of ways to accomplish in my view what a public plan has been postulated as doing in terms of driving ange, making sure that there are choices available andaking sure that insurance companies don't discriminate according to health status and preexisting conditions, which is a product i think of any insurance reform that is likely to b a package. but its very unfortunate a it is particularly in some ways

frustrating because as several of us has mentioned medicare in many ways is the least desirable model to think about driving to an integrated delivery system that focuser on chronic disease management and moves away from a disease focus and acute care and to one of wellness a managing chronic disease. medicare is even a step behind the private health care system, which does pitifully too little of that as it is, so i just thin we need to be clear what th objectives people look to for a public plan and find other strategies to achieve them which i think are quite achievable but when you have people making statements, people in leadership potions making statements that would out this very contentious strategy, health care reform is not worth doing, u have just put yourself in a box. i would think as a politician

you never want to be in. >> i just was going to consider comment from my experience working on this i guess 1 years ago or so, with president clinton. and at that time we really had a strategy that was the universal coverage or bust. and, we had bust. my conrn with this discussion is that want to take a step back, we are trying to accomplish slowing the growth of health care spending both in the public sector and in the private sector to make it more affordable for families and more affordable to businesso keep their health insurance. and also improve the quality of care that we get it and two we want to move the universal coverage. those are the to object is. we are having a technical discussion about how to do it. i think is gail mencia and pandith i talked about one of the things we should be doing is

adding two and building on some of the good pieces that are already in the legislation on cost control and overtime trying to expand them so t@at we can do these programs nationally so i think this discussion about the public option i really speaking volumes to the fact that we need touild nd more things that are going to control the growth in health care spending. for me, i think the best way to do this is to attk the core problems and the core problems are this explosion of chronic disease, it is also the fact that we have poorly managed chronic illness in this country particularly in the medicare program. we can do better on both of thosfronts and as il and i were talki about, these are no partisan issues. this is good common-sense clinical preventive medicine and clinical management of patient's. we should be able to get this done. this is something that i think we could build a bipartisan approach to do because if you think about it, andur group,

the partnership to fight chronic disease i've got 120 groups and yes it has the national retail federatiol to aarp and pharma and the labor unions and we have come together to agree on this issue around coscontainment built on these two principles of primary prevention and really modernizing in improving how we deliver health ce. that is the direction we should be gng on this so if were really serious about doing cost-containment those of the areas that think we need to focus on a not wedded to reelects from the broader objectives of slowing the growth in spending in moving to universal coverage. >> i just want to quickly add one point, which came to mind when cannon did his opening comments is universal coverage to many means everybody has health insurance. if one uses the harris of pensn example in you apply it to health benefit programs, coverageoesn't mean you have

health benefits. it means you have access. participation means you have it. and this goes back to the debate in 91 towards the end of the bush administration and multiple times since then, is the public plan when u read everything surrounding it, the public plan is using that term univrsal coverage as the objtive of every bute actually having health insurance. everyone as a participant in a program. if one looks, the groups that n just mentioned, the nfib explicitly says in all of its documentationtestimony and speech is their definition of coverage is the old bush administration definion. it is access to the opportunity to purchase coverage. it is not participation and if one looks at it numbe of the business group positions is

coverage equals access, not coverage equals participation. pandith yuan the other hand turn to governor dean's statements and all, agree with them or disagree with them, they are equating it to participation. they are arguing the public plan is the way to get actual participation and all the other means, including massachusetts, where you do not have universal participation, or even frankly the netherlan where you do not have uversal participation. you have 3% choosing not to purchase and another 3% among stand in between jobs so setting aside, i think the public plan issue is really ends up almost being this absence of a clear debate over participation versus access, which really underlay a bunch of it. >> but that is really a completely different issue.

you can have a mandate for inviduals t have coverage and not have a plic plan. it is a question of how do you want to enforce it in with the default position is for people who may not choose it. again it is why i think people rather than talking about the public plan as a holy grail, are to indicate what it is they are trying to accomplish them because it has become so contentious see whether or not there other strategies. individual mandates are an issue that has been discussed from time to time. massachusetts has a soft mandate where they allow people who don't have access to might be regarded as affordable verage to not be fined and define itself is quite gentle. but, thd question of whether or not yo want to push required coverage is a good issu to have out in the open for people to be debating and not hiding behind this debate about the public

plan, so again we need to be sure we understand if you want them what is to think it is going to do for you. achieve consensus on? what are the issues that will be too controversial that they will get tossed by the roadside? >> i am optimistic on the issue of cost that we can do something meaningful in modernizing the medicare proam and do something effective in helping to slow the growth on medicare by improving the quality of care we provide in the program. those are the purchase that are well-undersod in the private sector. they are approaches we have seen otr states do this

there are approaches we have seen other states and do this statewide, vermont, west virginia passed statewide legislation that would basically modernize the delivery system infrastructure statewide in those states, and it had wide bipartisan support so i think those are areas we coqld build bipartisan support as i mentioned before i think ty e common sense who things to do, things we've been talking about the last year or so is central to doing health reform. i think the road to universal coverage always has been a bumpy one and i think we can expect to get there. i guess the question will be how big of a package, how much too weak to of this time. whenevere pass it is not going to be perfect. i think it is the notion if we can pass something that is fairly major with the notion that directionally we have moved in the right direction and we can come back and take another

wac added perhaps next year and the year after is t way to go. it is hard to get everythg you want, your entire wishist the past in one swoop. we learned that 15 years ago when we had a comprehenve package. perhaps if we had broken it and had its trajectory of two or three years but agreement on ere we are going to end up which i think is universal coverage and better cost control maybe we could get it done. >> i don't know the answer to your question. it's a very good one. it will depend first how much can be financed. what hasee clear is as a result of the package passed last november in the stimulus bill passed in february ther is no additional appeti in the congress tohave any additional unfunded expenditures which has ma all of this more difficult

so the question is going to be where will there be agreement on funding not just among the congress, but anowledged by the budget office as being real money in the eviden time range. and i don't know how much the agreement will be possible in terms of what the funding package looks like. i think it may well be smaller than what we are talking about right now, the 900 billion to a trillion dollars over ten yrs. and my assumption is that the subsidies at the higher end of the income scale are what will be cut bk and or eliminated so more of the concentration will be on expanding medicaid coverage to the 133% and the subsidies foreople beyond that to purchase health care in a health insurance exchange about

how big and how much subsy i don't know. and i don't know whether or not this will be a go it alone strategy as people have been increasingly talking about where it is only the democrats and on through the reconciliation process, which would be unfortunate but has clearly been raised as a possibility. if that occurs is not only lowers the bar on the senate in terms of leang 50 votes it may restrict the kd of legislation that can be passed in terms of doing the kind of things kenneth and i and dallas talked about reforming the delivery system because as most of you know the rules about what can be included in a bill if it goes through the budget or reconciliation process are narrow and therefore some of the health care delivery might be out of tha i don't know where that is going

to end up. clearly is a big challenge not just whether or not they are going to be able to find a bill that attracts several republicans but where the more conservative democrats areoing to be on these issues. the blue dogs and the house and the six or eight more conservative senators, democratic senators in the senate but directionally tt is what i expect. i am hopeful as others here we might see health care reform package of se sort come out these issues of expanding coverage and slowing spending and improving quality-of-care are not going to be helped by just kicking the can down the road for five oren years. we have seen over the last 15 years these are issues that will only be addresseby direct

policy changes. weeed to start making these changes in the course of several bills over the next few years. >> yes, right here. >> thank you. my name is reva adkins, i wrote for asian pacific audiences and also correspond for publications in asia. thereas been the assertion which has become sort of a belief that legal documented people in the united states right now contribute in large measure to the health costs. now other than being perpetrated in talk radio but also among the asian pacific community including doctors it is also

been asserted by advocacy groups with data. would you be able to address the seous side of the question or this anxty how precisel the health cost is being gobbled up were caused by people who in the first place areot supposed to be here? >> that's a very hard question. about 30 years ago my activity in washington was focused on helping put together the first of the large expenditure surveys called the national medical expenditures survey. it is now an ongoing survey that the department of health and human services collects. i actually have been curious about some of the numbers i had been seeing reported as to how many of the people either currently who are repted as

being uninsured are peopleho are illegal immigrants and how many people who wld remain uninsured are likely to be illegal immigrants and so i have had e-mails with some of the people i have worked with who continue giving surveresearch because my question had been how would we ever actually know that and the answer is it is almost impossible to know that. though when we need guesstimates -- when we make estimates it is to use the svey done by the ceus and every t years you have the full census which we are getting ready to do. and the populations are blown up to the no numbers of the country an then estimate down to 50,000 household population surveys are used to get estimates of who does not have insurance or who

has and, of various amounts. it is extremely high difficult to get estimates about the number of people who are here in an illegal status, reliabl estimates. when you think about it, it is so much more difficult to imagine getting information about the iurance status of people who do not want to have discussions with people who are from the census or anywhere else that is part of the offical, so i think the answer is there really are parts of the cotry along the borders who face stress because when people are in acute illness, hospitals may not turn them away. it's one of the serious charges fell law requires hospitals that

provide medicare services to not turn anyone away if they are in an emergency situation and they will come get you as a hospital if you are charged with pushing people away for whatever reason including th didn't have coverage or anything else so it isn't that there isn't care particularlyrovided in communities along the borders or where there may be unusual congregations. but there is very ltle that is known accurately about the impact of illegal immigrants. the house then some work i think actually robert johnson may have found it there has been some work looking at the impact of immigrants who are in a legal status and as i vaguely recall, i fought the use of services was more or less offset by the tax contributions and in employment

th these individuals were providing, but i don't recall the studs very well. i just want to cauti people take any ofhese estimat about the impact that illegal immigrants are having on cost or insurance estimates or on in short estimates with a large grain of salt, because we do not have good information about this. >> i would stress gail's point on this and the censusureau will go out with new numbers actually next week's are you are likely to see se attention to because of the new numbers. the census doesn't ask people in the process whether or not you are a u.s. citizen. studies we have done over the ars, there are numerou of them which have looked at the border states specifically on this issue. but the census and the c clearly show in the border

states the percentage of uninsured of hispanic origin is exceinglyhigh but it doesn't tell you legal or illegal status but that is one of the primary drivers for the state of texas having the highest percentage uninsured of any nation etc. but to gail's point, there is no way to make cegorically the division because my understanding from the hospitals is when they do provide the service you're describing the do not ask either and so it is an awful lot of assumptions and hypothetical. >> let me just raise the broader point on this because -- and it goes back to the discussion we are having on health care reform. i agree with both dallas and gail. no one knows the answer tohat question. if they say they do i don't know if they're making it up or where theyre getting it from because we don't have the data but w

have stayed on the folwing. we know there is roughly 45, 46 million people that don't have health insurance coverage and that is a mix of local residents. if you look up the total spending in the population the incur spending about 50 to $60 billion a year. a lot of that spending is not explicitly paid for. which means two things. one is we are spending a lot of money todayn the uninsured. we are not spending it well or wisely or doing preventive care and so on. we could do a better jobhich is what this discussion of covering the uniured is about. but if you look how we pay for this we are spending about 20 billion a year in federal spending today to provide financial assistance to hospitals and other institutions to provide health care for the uninsured so we already have $20 billion we are spendin and what isn't fully paid for gets

bumped into the cost of private health insurance and there is a whole bunch of different estimates how big of a bomb that is what we are paying for it one way or another he is our heal insurance premiums or payin for it in terms of federal funding in atlanta, agreed the hospital, our big publicospital, the local taxpayers pay for a piece of it so fulto county about 110 million a year to offset these costs. so i like the point because it brings us back full circle to what we are trying to do in this discussion. there is a lot of money being spent on the uninsured were we in high-cost places, too late in termof when they get their health care and i think it highlights the fact we can do a better job providing health care services to people who don't have it and redirecting some of the resources we currently use to fund a piece of it. >> but to be sure people understand the uninsured use about half the health care of

the population even when you adjust for status so while it is true the uninsured receive se health care now usually fragmented in an expensive place when they recve coverage they will use a lot more care and hopefully care that will allow them to lead healthier re productive lives and may be over theong term to receive their care and better environments. >> let's go here, and i have been ignoring this side of the room and i promise not to do that again. >> i and a finance writer and i friend for the news. on the question i think you said there was $100 billion in savings for better care coordination. you sd there s money to be had by reduced emissions and i presume that is the score a goal but in t current political environment these are perceived as medicare cuts and of course

we don't want the government putting their hands all over our medicare so my question is politically what do you think wille in the final bill in terms of medicare administrative changes wi improve efficiency and quality of the system and how can that be pitched so that people don't describe them in ways people perceive as medicare cuts and then a question i think for doctor we had one study that said prevention doesn't pay or 's very long te and you have to take 25 years time horizons. out of curiosity why do we have the entire economic profession raid against the idea prevention will p? >> let me start with the take on the second one first. [laughter] this prevention one a curious decision bause if you think about it there is a bunch of things we can do on the prevention side. 99% of the discussion has been on detecting the disease, during screenings and iunizatio.

the imary goal of doing the disease detection is not to save money primary goal is to inrvene earlier, clinically to make sure people haveealthier lives, better quality and hopefully live longer. there are other forms of prevention averting disee in first place preventingt is a way i taed about in terms of getting caughmaking sure people pre-diabetic don't become diabetic. people who are overweight become normal weight. we have intervention that not only work and we have randomized trials, diabetes pvention is a good exit polls that show that they work. we do them in community-sed settings that sh they save money so those interventions save money and work. then there's another type which is for people that have multiple chronic health care conditions to make suree can manage the conditions so that we don't have complications relting from them. the lead then going to the hospital or the clinic and yes we have programs that are well

designed not all of them work but the ones well-designed save money and improve outcomes so there is sort of three dimensions. those 2i talked about which are designed to save money if you design than light. detecting disease which is it desied to save money can work if you target people appropriatelto intervene earlier to improve outcomes. on t medicare site quickly, we have good reforms built in. they are moving in the right direction changing how we pay moving away from a unit fee-for-service payments. doing something on the divery system side the challenge iwe need to build those out so they are available nationally so that an make a dent in the growth anspendi. those are not cuts. in fact if you think about the care coordination that adds to the benefits of the medicare beneficiaries. that improves the benefit package. you have people working with you

at home helping to manage your disease. you have a nurse working with you in the hospital to do discharge planning and medication reconciliation when you leave so those are benefit enhancements just not only good quality care but if you do it ght save money so the combination of pment changes, care coordination are not only good things to do i think they enhance the value of medicare benefit package and those ar the types of things we should be buildi in is discussion. >> to the comments were the studies that you see by economists with regard to prevention, typically our focus has kenneth said is on the screening and very narrowly focused activities and it's important to understand that whatever the ppose of usg additional screening is it may

even if it is a good thing because it ppovides a strategy for interveningarlier it doesn't mean it will necessarily save money and you ought to again make your argument correctly. if you are doing it because you think it is a way to be able to avoid human cost and medical cost on the road it m or may not actually save the system money depending how well you can target who is at risk and h expensive the tes is. you may choe to do it any way and gard that as money well spent but you shouldn make the argument it saves money if in fact it doesn't save the system money or particular pay your money and many of the specific prevention activities that are cited in the studies fall in that category whereas if you could change behavior with regard to obesity or smoking or otrs that would ha in the long term potentially bng able

to intervene more effectively with regard to medicare, you have to be careful about how we phrase this and at it is we are likely to be willing to score because a lot of what we have been talking about is directionally the right change. we don't know exactly how to make some of these payment changes. kenneth mentioned there are a loof demonstrations and pilots that are either on the wing or included in te legislation. we need to make sure there is the ability to scale up and pose them as they showed themselves to effective. cbo isn't going to give a lot of credit and they shouldn't becaus we don't know which of these will work in practice in terms of changing away from the system that rewards more and more complex and more treatment of acute care to when the attempt to provide incentives for more integrated care and chronic care. we know what we would like to have it look like but we are not

sure how to actually getheir. what we do know is the kind of spending we are talking about for expanding covepage is quick and certain and if you don't plan to spend on funded money you need on the other side of the ledger quick and certain funding and that is the dilemma that is being faced. most of the quicknd certain mone is either lacking at reimbursements likely to be unethical to all of the changes that we have talked about doing that will be good on the road, where it's increasing revenue through additional taxes or changing the tax treatment of employer provided insurance which have their own issues. but that is the dilemma. now can you tell a beneficiary medicare don't worry they're going t slow down speing by five or $600 billion you won't have any affect? i don't think you can do that.

aq i have indicated there are a lot of things you can do to slow medicare spending that's going to cause money up front, the kind of chajges we talked about with regard to lowering the readmissions which would give you some spding down the road but if you are concerned how much you spend the first five years and if you'rusing reconciliation that's the relevant window and how much money you were going to spend or save the second five years and spend or save the of third five years you need to be careful with a good change like lowering the readmissi by having peopl be able to have interventions further medication fulfillment and their schedulinwith their physician a nurse practitioner you need to watch out how much is that going to cost you up front and how much might you alistically save in the second and third five-year period so

this is going to require very careful crafting because if you want sure scoring by cbo just whack at the reimbursement. that gives the best score that is why i am worried about the public plan is when the government is pressed for money it usually either goes after the benet, the population served or it x reiursement because that they can count on in the short term with ctainty. unfortunately it is an ethical to delivery anges we are talking about that would allow savings in t long term. that is the tension that has to get sold by the congress. >> let me make three quick points because i think that deal gail and ken spoke about this. when someone speaks about prevention my question is what kind of prevention are we talking about because whether you are talking out screening tests or community-based prevention it gives you a very

different answer with the return on investment is. we know that investments in making the entire community healthier to yield a very positive return on investment in a short period of time. studies have shown $5.60 for every dollar invested within five yea so that is the first point. second is what is the outcome to are looking for if you are looking for saving money which is a different standard than we hold the rest of the medical care system to i would say that you are asking the wrong question because what we are trying to do with prevention i prevent disability and allow peopleo have more productive lives which then will produce more benefit for the country. and the third point we have to make when we think about prevention is whether or not, whether we are using their right timeframe for understanding what

the impact is going if you look at how long it takes to get the negative impact of let's say obesity it is ten or 15 years and yet cbo is scoring things only withia ten year horizon so often in order to see the benefit of thenvestments we make in preventive strategies you have to look out beyond what we typically do. sohose are the three things we have t ask ourselves why we are trying to assess whether or not prevention saves money which as i id is often the wrong questi to ask. >> we have only a couple of more moments and i know there are people over here trying to get a question and. since the gentleman just left we will go further. >> i'm with community devepment publications and several health newsletters. i cover this thing for a million

years and i hate insurance companies. the thing i am really interested in is what the panel say is the absolute bottom line on the bill being passed that could be called health care reform? >> for me it has to deal with these two issues, health reform so the bill has to have things that improve the health of the population focusing on preventing disease, focusing on for people who have chronic illness improving their health status, tkeep the out of the hospital and keep them om progressing in ways that are preventable and those are things we can do. gayle mentioned and i mentioned we need to invest in them just like in health information technology we invested $19 billion over a five-year period to put in place information technology which we know is a good critical infrastructure investmt to

make. we need to make the same investment in doing prevention and care coordination national lisa that is a piece of it. i think the bill also has to have a very clear path to move to univers coverage. we nee to have a track that we are doing both of these which are the major objectives of the reform initiative in theirst place. i am sort of dog into a specific trajectory on the second issue how we do it. i think it's more important to get their and not hold hostage the goal of universal coverage to exactly the approach to how we get there. >> all i am hopeful we will revert back to what started as a discussionn health care reform and hasorphed into a discussion on health insurance reform. i am hoping that was because of colin decisions and not in focusing on health reform.

it's important. we need to expand covrage and to reform the health insurance market but sustainability and spending and improving quality and clinical appropriateness are even more importa because they affect 85% of us with coverage as well as the 15% of us who do not have coverage. a bill that is worthy of health care reform needs to have a lot of attention focused on how we are going to begin changing the delivery systeand payme system so we will reward the kind of anges we want to see and we don't move in the oppote direction. it better have a lot of authority given to the hhs secretary said that succeful pilots or to another government official. successful pilots that show they can help move fee-forervice acute-care focused health care

into more integrated coordinated chronic disease focused delivery systemsan be encouraged and scaled up and down so quickly and we need to acknowledge that we don't actually know how to get from here to there so we are going to stumble along the way. a lot of credit from the office in terms of theavings that coul be provided if we do a right and it is because there's so much uncertainty how to do it right and how long it will take to see the savings. >> allyson? >> if i take the question more narrowly whichs an assessment will there be a bill that my response would be s i think there will be largely because what i mentioned in the front end which is most all of the interest groupinvolved with

this business labor, insurance, format etc. are still sticking to we have a plan which is we need health reform and driven by the factor that has been the most readily stressed at this ble whh is dealing with cost, dealing wh quality, dealing with prevention chronic disease in the ways you're describing driven by recognitionf necessity to a highly performing well workfor that they have health coverage, they have health insurance and health treatment so employers are absolutely committed to the knowdge that in the absce of reform of any type they have to continue to provide added the cost curve is on sustainable said they are in this conundrum

and whether it bipartisan or ends up being a single party bill i think all of that is going to come together and you're not going to see what you saw that killed it last time ich is a whole lot of those interests relatively early in the process moving to plan b which is to lift from plan a which is we need something. back then it was nowhere near the consensus across the surveys be they public employers, insurers, you name it. back theit was not the absolute belief that it was on a sustainable. today there is the belief that is just repeated. what i wentver from tse positions there's lots of disagreement on the details but when push comes to shove even if it ends having to be the interest groups just with a democratic party, i think you will in fact see something that

is relatively comprehensive because of this absolute recognized necessity that you cannot accept a provision and sponsorship of health insurance even if you want to and have any hope of attracting and retaining the people you need to run your enterprises, and that is a fundamtal diffence of if you will believe behind the necessity reform compared to the ppior points in history >> let me underscore that by saying that belie is backed up by very credible studies like this one from the urba institute that underscores the comments dallas just made. whether you look out five years or ten years there is likely to be more people uninsured by 30 to 40%. the cost to and lawyers for

their premiums is goi to go up. the cost of individual premiums will go up and that does not address any of the issues we've been talking about in terms of refoing the delivery system so that it is more efficient and higher value etc so at this point ihink there is consensus we need to have changed. it is obably going to require some evolution of the policies in ord to get it where we want to be but there is no question in anybody's mind ing nothing is an optn. >> and that is the bottom line of bottom lines. i don't want to hold you on the type we said we were going to. we've already done that a little bit. i know therere people tha have questions to the extent the panel can answer questions. i know you will appreciate that. but let me just take this chance

to thank you for some lively interchanges. thank the folks of the foundation both for theupport and the participation of the staffnd its president, the staff of the alliance for making this run smoothl and we will convene i guess on december 12th the hundred the day and see how far we've gotten. thank you very edge. [applause] [inaudible conversations]

house democratic caucus vic chai becerra posted a briefing on legislation with a focus on seniors. , chr returnsrom th august recess next week. president obama scheduled to address a joint session of ngress on health care. >> will you be able to -- [inaudible] >> are we ready?

did morning. thank you for attending this press conference this morning. today we have some good news for americans throughout this country and certainly seniors in america. my name is off the air becerra, a member of congress from los angeles california and the vice-chairman of the democratic caucus in the house of represtatives and today we are going to release something we ink will help americans make good choices about health care reform a to know the truth as opposed to the myth. today we are releasing a study that talks about quality affordable health care for seniors. and what this reform means for america's senior population under medicare. 48 million americans. and we think it is important we get this right.

wi me today we have several individuals who will speak. richard is with the alliance for retired americans. we have carl cohen member of raising women's voices for the heal care. we also have patricia with the center for medicare advocacy and also as a resource cindy pearso executive director of the national women's health network. we have heard stories, death panels, euthanasia. we have heard any number of things, seniors will pay for the health care younger americans the myths abound. what we are here to tell erica and america's seniors is health care reform will be good for their health. first, for seniors receiving prescription drug coverage under medicare, prescription drug coverage under medicare part b,

guess what. the ugly doughnut hole you encounter about halfway through the year where all of a sudden your support and help pay for prescription drugs goes away, this legislation finally begins to close the loophole. secondly for those saying i am going to need micare for quite some time and i keep hearing stories it's going uer. well if we pass the lislation today, h.r. 3200 we will extend the life of medicare by five years simply by goi after some of the abuse and overuse of the medical care system under medicare. this legislation will also extend preventive care benefits at no cost, cero cost to seniors. something criticay important to make surour costs go down because get senior services not later on in life. we also do something important for doctors and hospitals. doctors have been saying i don't

know if i wl be able to treat the senior who receives medicare servicesrom me because we are going to receive a cut in reimbursement. this legislation would prevent those cuts in some cases up to 21% physicians from taking place whicheans america's seniors will be able to continue to go to the doctor or the hospital they choose and finally, i think it's important to remember we need to reduce the overall spending in medicare when he have a system of health care that spends $2.5 trillion, and hundreds of billions of dollars comes out of the medicare system. we need to do something to reve mor of the waste, fraud and abuse. this legislation enact reforms that will require more accountability on the part of all providers and we believe that is good for the seniors because that means more of what they pay for will go into services they need. this document we hope will help dispel many of those myths. this is not socialized medicine.

there is nothing that will stand between you and your doctor. this document spells that out to be we believe it's important for people to know that. i would like to have reaed come forward now and be gur first presenter and get some information about this reform we are undertaking but more importantly help seniors understand what they stand to gain if we reform the health care system for them and all americans. rich? >> thank you, congressman becerra. i am with alliance for retired americans. we are an organization ofearly 4 million retirees nationwide. i am here today to say that seniors do indeed have a lot at stake in health care reform and h.r. 3200 will help them. will make it easier for seniors to see the doctor of their choice and make it cheaper to have a prescription drug filled when they need it and it also will begin to provide a system

r long-term care and long-term care insurance in the country as well. as we all know recently there have been many media accounts have any seniors have been skeptical abouthe death penalties, euthanasia and the like there. a lot of this stirred up by the folks who are already winning in the health care system. the insurance industry and oftentimes allies in congress because they are the winners right now in the system that is broken with in some stes near monopoly stranglehold on the health care systemo it is time to put the public interest in charge and not the special interests. it's also important seniors and all americans know what is at stake in this bill. retirees need to know how we have an opportunity to close the doughnut hole in party to lower drug cts and help early retireeset affordablhealth care coverage. seniors need to know how we can control out of cost premiums and

drug prices and even high-quality public option will help bring prices down natn wide. in addition, seniors support health care reform because they see their childn an grandchildren struggling every day as well in excess coverage and cost. they would worry what would happen if the job loss also creates health insurance loss at times. so on behalf of our organization alliance for retired americans h.r. 3200 help seniors, helps them get preventive care and helps bring premis down and also bring this most importantly prescription drug costs down as they are the group that used prescription drugs more than any other group thank you. >> carless cohen, a businesswoman who can talk from a real world experience. >> i am a senior in case you can't tell. own politics and prose bookstore

in washington,.c.. we have about 60 employees most of them full-time. we insure them but we also assure them if there are costs they cannot, that they cannot pay that the co-payments we will help them if there is a need to. we have a woman mauney responsility extds to not only my employees but my family. i still am very lucky and have a mother living. i have answered and uncles living. i have friends most of them who are collecting medicare some of whom are single and need support, and some of us also worry as the previous speaker said about our own children

whether they wil have -- whether their health care will follow them in their jobs, and we worry about some catastrophic illness happening to them and maxine out and their payments and being tossed out of the system. we need to be assured in this country that we will be able -- everybody will have the chance to pay for his or her health care. it's something that preys upon a lot of people and it's just a very important -- it's an important asset going forth as a country to be sure our country is providing what people tually need. to hear people say i might have

my benefits cut in order to give other people benefits that's not america. america is a country where it is sent you win -- i win, you lose. it is a country where we want everyone to have some basic equaty in their ability to meet their family needs and health care is one of the most important family needs. thank you. seabeck patricia with the center for policy. >> i became a new medicare beneficiary of this summer so my employer's own client in one sense. i also the mother of a 27-year-old who has no health insurance. i have a great deal with personal interest in this legislation but i've been asked to speak about the medicare

aspect and i will do that. the centers for medicare advocacy is a national nonprofit non-partis organization that works to advance their access to comprehensive medicare coverage and excellent health care for older people and people with disabilities. we represent thousands o beneficiaries each year. we also do policy analysis of proposed changes to medicare. we believe the house bill is a very important and strongly beneficial piece of legislation for medicare beneficiaries. the bill does not cut benefits for individual beneficiaries. it ds not reduce health care or services covered by medicare for anyone. what is covered now under medicare will continue to be cored under the reform legislation. the cuts to medicare that have been subject of a lot of

confusion mostly have to do with subsidies to private insurance which on average a 14% above the same costs in the traditional medicare program. these payments have resulted in higher part b premiums for all medicare beneficiaries. secretary sebelius released a report that says about $90 per beneficiary per year in extra cost just for those subsidies. they also cost tax payers money since part b is partially funded from general revenues. andhey have hurt the financial soundness of the medicare program. besides that, they are fundamentally unfair. the bird in the entire program and all beneficiaries but providbenefit to nly some beneficiaries. the change in payments that are part of the bill will slow the increase in the premiums and help extend the life of the medicare trust fund and help

eliminate waste in the medicare program. reducing overpayments to the private plans frees up money for program improvements to all medicare beneficiaries. one such improvement as has been diluted to eliminate the scheduled cots and payments to doctors. that will protect medicare beneficiaries ability to continue to see their own doctor and not have doctors leaving the program. the bill actually provides bonuses for certain kinds of services one of which is care coordinationhi will promote and assist people with complex medical needs which of course, many medicare beneficiaries have come and my organization has been a long proponent of having a care coordination benefit in the medicare program and we are pleased with this particular provision in the bill. other improvements in the bill some have been he alluded to. there will be no requirement to

pay for preventive services, any out-of-pocket cost for preventive services. congressman becerra has been a champion of low-income beneficiaries and their improvements in the bill that will substantially improve the coverage for low-income beneficiaries help them pay their bill as well as helping identify who the people are who are entitled to the extra help. as i mentioned there is a new care coordination benefit and we have heard several references to closing the doughnut he. there's also a provision in this bill that is near and dear to my heart that creates an office i the medicare agency that will help coordinate care for the poor, sick andost vulnerable beneficiaries, those who als have coverage from medicaid and coordinating the care between the programs has proved it very difficult thing. as i stated the goal forhe

center of medicare advocacy is to protect and promte accesto comprehensive benefits for older people and people with disabilities. we are pleased with the house legislation a support this enthusiastical. >> thank you. cindy is available as a resource as well. we will take questions in a moment. i want to make sure i emphasize this for seniors with this reform will mean for micare and all of our seniors is available by contacting any member ofongress. you can go on the web site for the house and get information that we are more than willing to make this available and if i uld say quickly in spanish because know we have journalists and media from anish-language stations, [speaking in spanish]

[speakg in spanish] thanks very much and we will take any queions you might have. >> why is it seniors seem to be more susceptible to the distortions you've been talking about the and other portions of population and is it too late? do they already believe these things? >> everybody has heard the keep vernment o of medicare, out of health care, don't touch my medicare. that has been so commonly stated

for years now and we have heard more of it. we know that people like medicare. older people who like medare and theiramilies le medicare because it helps the whole family by providing coverage for the older people in the family. and i think it is a matter of helping people understand providing coverage for other people will not reduce the coverage you have and i do not think this august we have been doing with our membership and number of meanings making presentations to other seniors groups and what we are finding is when you explain what iin the bill simple things like you no longer will ve to cope pay for preventive service for example. the doughnut hole will actually become closed and in the big picture the medicare trust fund gets better we find people are

much more willing to not believe what may be television or see that there are good and positive changes, so i think a lot of it is an educationrodu and to actually help seniops understand the health care rorm for them as individuals makes it better, not wor. >> [inaudible] >> i.t. this is a very good step on winning that battle. >> what do you make of the so-called compromise @y senators know? the idea of the scaled-down on public option but leave it as a possility down the road? the scaled-back bill doesn't do as well -- >> i think when the president next week addresses the joint session of the congress we will have a good idea of the direction this country can go on health care reform when the

president gives a good outline and clear path of where to i think all members of congress, senators and house members alike will try to work within their framework and so i think everyone of us has our goal, our bottom line buat the end of the day what the president would like us to do becomes the most influential comment because we have to try to get something donend the president ishe most powerful voice. i think that he's going to ask us to move in an ambitious way to deal with this broken health care system, putting our broken health care stem on steroids isn't a good reform and so i believe we are going to have an opportunity to be ambitious, bold and provide change for america to make sure everyone whether you are in short or not will have access and choices to quadity health care. the president i think will give good directiono go with. >> there is no proposal?

>> the president said nothing is off the table. everything is on the table for the conversation. whever you try to do large meaningful refm everything has to stay on the table and that is why some of us are concerned some would take things off the table before americans have the chance to make those choices. why for that americans to select? if a senior or american decis not to do th an insurance plan that is his or her choice but for congress some bureaucrat or some insurance industry bureaucrat to limit america's chce on health re is the wrong way to go >> the significance of having the speech the obama administration tried to avoid pages in the book president clinton had done 16 years ago delivered a similar speech and what that means where the health care bill is after this august.

>> i was here 16 years ago when we tried to do health care reform under president clinton. there is a big difference. the speech president obama delivers comes under a different circumstance than the speech that president clinton delivered. president obama said from the beginning i am way to give you general outlines what i would like to see but i am going to let you put the mt on the bone. this next week when the president comes and speaks to the american people quite honestly, not just to the congress what i believe he is going to say is this is my selection and i think it's very important now that we lte because we had a chance over these last eight months to try to shape a good bill for america. now i believe the president is going to weigh in and tell us this is now how we get this across the finish line and that is very important and different from 16 years ago and why i think this year, 2009 will not

be like 1993. yes? >> you think you cou support the idea of a trigger for the publicption after being home and hearing people's concerns about it? and you think it could be some great compromise where you coult more moderate democrats on board that you are not eliminating the idea of a publ auction? >> i still have a difficult time as a vote, one of the crucial vos, 306 million americans and only 535 degette to vote. i have a difficult time from the beginninlimiting america's choicest on wha they can do with health care, how they can get it and who they can get from. i think it is better to give americans as many choices as possible when the president said at the beginning of this debate if you like what you have you should get to keep it. he made it very clear we are going to start from the choice what you think is best.

but if there is somethinthat could be better, good f you, you get to select it. but for policymakers, for politicians to tell americans we are going t limit your choic before you get to see at i can't accept that. i have a difficult time believing that is reform so when people talk about trigger a loosy applied across the board when we look at some options but not others? to mehat sounds more like a playbook of those w are happy with this current bloated broken system versus those that want to see real reform so i am opennd i will listen to anything on phe table but before decide to cast a vote on a choice on health care i'd bett be given a really good reason. >> what is your analysis of the democrats and president obama lost control of the debate over the last five weeks? i wouldn't say there was a loss of control.

i would say what happens is americans started speaking. some spoke not to be heard, some spoken to drown out. some spoke to distort and some spoke to delay but americans spoke and that's crucial. i heard from a lot of voices most ofhem were the reconstructive. most of them were very interested what we were planning to do to the system so now the members of congress come back and we are better armed with information we can do d at the end of today with the president's help we move forward with broken health careystem so that it isore efficient and offers people more and choic and guess what, we will finally k the cycle being the industrialized country that can't figure out how to provide millions of aricans health re while we spend twice as much as any otherndustrialized country so we are going to go in aood direction and it's important to hear americas

moises. .. and to the new technologto stay in touch so i think when members come bacwe will be sharing stories and i think we

will be ready to go forward and with the president's remarks next week i think it is the great roadmap to move us forwd and i believe most democrats are prepared to take that leap. as they keep saying to my colleagues your packing my parachute, i am packing yours, america needs to know when we are packing the parbhute we are doing it the right way. now it is timeo start to get ready and take the jump. thanks all very much. [inaudible conversations] [inaudible conversations]

>> mr. chief justice you may i plea the court. e government concedes that the destruction of documents in anticipation of a proceeding was not a crime in the fall of 2001.

>> something different is going on here than what goes on in the capitol building or in the white house and we need to appreciate how important is tour system of government. >> this is the highest court in the land, and the framers create it after studying the great lawgivers in history and taking a look at what they thoughtorldwide was important for the judicial branch to do. >> i put in as much bloodsweat and tears a lite cases as they do the big ones. we don't sit here deciding who we want to win, we decide to wins under the law of the people adopted. >> you would be surpred of the high level of collegiality. >> if you are for nine as the want to hear these cases we will hear tm. >> we are here to decide things. the job is to decide, we decide.

>> why is ithat we have an elegant, astonishinglyeautiful imposing impressive structure? it is to remind us that we have an important function, and to remind the public when it sees the building of the importance in the centrality of the law. >> i think the danger is tha sometimes you come into a building like is and think it is all about you or you a important afd that is something that i don't think works well with this job. >> supreme court week stting october 4th on c-span. >> the head of the centers for disee control and @revention today said the h1n1 swine flu has not yet mutative. manning th virus is not become more dangerous since it first appeared earlier this year.

this cdc briefing from atlanta is 30 minutes. >> what i would like to do this afternoon is to give you an update on some of the recent developments with it h1n1 influenza and just one second. the first point to make is that h1n1 influenza is here. it is spreading in parts of the u.s. pticularly in the southeast and in fact it never went away. behead h1n1 influenza throughout the summer and summer camps and now with colleges and schools comi back into session we are seeing more cases. the good news is that so far, everything that we have seen both in this country and abroad, shows that the virus has not changed become more deadly. that means that although it may

affect lots of people, most people will not be severely ill. however, the h1n1 influenza and influence the generally is unpredictable and that means two things. first, we have to vigorously monitored to see whether is changi, who it is affecting in what is happening with the then second, we have to be ready and prepared to change our approach depending on what the virus does. today cdc is releasing additional data on some tragic pediatric fatalities that occurred in the spring and that will provide you with more information on that. in addition on flu.gov the can see report that outlines the experience with h1n1 influenza in five countriesn the southern hemisphere and the experience inhose five countries is very similar to

what happened in this country in the spring. large numbers of people, particularly school kids, became ill. in some locations, hospitals had challenges to keep up with the number of people coming in but over all, no increase in the level o severity, no increase in the death rate. in these countries, some possibility that indigenous populations were more severely affected by h1n1 influenza evetteou have a greater likelihood of having severe illness from h1n1 if you were a member of they try or ingeus population. that is not proven buit is a possibility. this information as well as the child information i will be presenting shortly emphasizes what we should do to prepare and what are the groups that are at highest risk and therefore we need to reach out to the most.

the study bng released today out lines 36 deaths that were among the first deaths among children inhis country. in two-thirds of those, the child had least one severe underlying illness or underlying disability rather than ellis in most of the cases, cerebral palsy, muscular dystrophy, longstanding respiratory or cardiac problems, so most of the children who had fatal h1n1 infection this past spring had been underlying condition. there wereome childrewho didn't have an underlyin condition and who did come severely ill and they were generally affected also by bacteria. when you get the flu, your admin system can be weekend. you can be more susceptible to other infections. that is an important message for

doctors to know that someone has the flu they get better and then they get worse again with high fever, that is a clue that maybe they should be treated with antibiotics, things that will help them. most people with the flu don't need treatment and i will discuss that more in a bit. the review of several dozen childrenho died this past spring emphasizes that flu can be very severe and it as important that we do everything we can to pct people from the flu and i'm going to outline some of the things that we are doing. it also identifies groups that are particularly important to address. we have bee working closely with pediatric society, parent groups and others to ensure that for example children with special needs, children with cerebral palsy, muscular

dystrophy and other developmental disabilities are promptly treated if they develop fever, and are at the frontline for flu vaccination when it becomes available. also, earlier today, about an hour ago, the institute of medicine released a report on the protection of health care workers from influence the. protecting health care workers is critically important. we want to ensure that health care workers are and feel safe when they come to work. they are the first line of defense and we need to ensure that we do everything we can to reduce to the greatest extent possible their risk of becoming ill on the job. protecting health care workers in false many different factors, includingow the health care setting is organized, whether people who are not severely ill come in for care and over from the system and how many different health care workers

have contact with people who may be infectious. what is particularly important are circumstances where we think the risk is the highest but in all cases we want to ensure that healthare wos are safe. the institute of medicine was charged by the centers for disease control on preveion and the occupational safety and health administration was looking at what kind of mask or respirator health care workers should use. they are charge consistent with the osha mandate required them not to look the economic or logistic considerations but to just look at theiriew of the most recent science on protecting health care workers. we have just received it their report. we are studying it in a bebo review it in the coming days and weeks. the next issue that i would like to discuss has to do with vaccination. there is a lot going on with

vaccinations. we continue to anticipate that the vaccine will be available by the middle of october. the vaccine itself will be free. the administration may be charged by individual providers althoughn a public health system, all vaccinations will be free we anticipate. it will not be easy to get vaccine uptake. we have the possibility or even the likelihood that it will be a to dose series for children at least then perhaps for others who are going to be trying to reach out to children in large number and parents to get kids vaccinated because we know so many kids can get the flu and the vaccine is likely to be quite effective. my kids will get the flu vaccine when it becomes available and i would recommend that all school chen get vaccinated. welso are recommending that all people with underlying conditions get vaccinate people who have asthma,

diabetes, lung disease, heart disease, ner muscular conditions, neurological conditns that increase their risk factors and women who are pregnant. vaccination programs will be run by t states and localities throughout the united states. we areorking closely with all the jurisdictions to help them identify the challenges that they will face in vaccinating the people in their area and in addressing those challenges. we are in the process of releasingbout $1.5 billio in vaccine planning, preparedness and administration funding. that will allow each jurisdiction to identify what are the strength, some jurisdictions will work largely with the public sector. other jurisdictions will work largelyith the private sector. each place will know what the strengths are in their area of bostomill be able to reach out to the scialty clini.

for example children as special needs, for people with asthma or diabet, to have the detailed planning available. we also are looking very closely at the possibility of reports of adverse events. we know that every year there e cases of palysis and guillion bre syndrome. there are women who have miscarriages. there people who have sudden death. in all of those situations, we need to knowery clearly how many we would expect of the vaccine does not cause any problems whatsoever. in an average of flu season, just as an example, a round a half-million pregnant women get vaccinated. that is important because pregnant women are more likely to get severely ill from the flu so it is the way of protecting them and ensubing that they have a healthy pregnancy. among those half a million women, if they hadn't gotten vaccinated we would have

expected more than 1,000 miscarriages within week after vaccine. if there vaccinate we expect 1,000 or 1500 amman half a million women whare vaccinated. that is the kind of number we need to track and understand to see whether, when we do see adverse events reports, because we know there will be at bense-- evers reports they are occurring at a higher rate than expected or not. in the coming weeks and months, with school resuming we do expect to see more cases. we are seeing it now and w expect it will continue. how long no one can prect with certainty. influea is unpredictable. that means we need to monitor closely and be willing and ready to adapt to the different approaches. one of the challenges is preparing our health care system for the likely increase in the

number of people who will seek care. we know that there are lots of things tt can be done to reduce the spread of the flu and that needs to occur, but for most people with the flu there is no reason to see a doctor or go to the emergency department, unless they are severely ill. for example you have trouble briefings or you have an underlying conditions such as diabetes, pregnancy, heart disease, lung disease. for people who do have an underlying condition it is quite important to be seen promptly if you get a fever. that can make the difference between being severely ill and recovering well. treatment in the first 48 hours to make a big difference in hastening your recovery. we also know that as of now, not only has the virus not become more virulce or more deadly but we hav't seen lots of drug-resistant strains so the drugs that we have available are

still very effective against the virus at this time. the big picture is that there are two things we can do to reduce the impact of the flu. one is reduce the number of people who get infected and the second is reduce the proportion of those who get infected who get seriously ill. to do that that the nation is our strongest tool. with vaccine not yet hear what we can do now is to reduce the number of people who get severely ill, stay home if you are sick. cover your cough and sneeze and wash your hands frequently. that mea that workplaces for example should increase the availabilif-- to the extent possible and we should encouge peop to stay home if they are sick and employers should not penalizeorkers for staying, they are sick during flu season, nor should employers require a note from the doctor to return to work becausehe doctors will

be very busy taking care of people who were sick with the flu. and ordered to duce the number of people who become severely ill from the flu, prompt treatment of people who have underlying conditions or severe illness is very important. lewison predictable. flu season is just beginning. it is very unusual to see the flu continue to the summer as it did in the u.s this year and it is unusual to see this many cases this early in the year but only time will tell what this flu season brings. what we are doing is everything in our power to be as prepared as we can for the things that may occur inhe coming weeks and months. i will now be happy to take questions. >> we will start with questions from the audience. >> i was interested in these bacterial infections becse

most of their reports up until now have been about viral pneumonia and so i just wondered if you cld comment on is this bacterial pneumonia or what kind of cohen factions are they a is the upshot of this that more healthy childrenay be at risk of severe disease? i also wanted to ask you separately if i could about how significant you think these findings are in china that on dose of vaccine may be sufficient? >> so( taking a last question first, we look forward to seeing the data frochina and elsewhere about the vaccine efficacy. it is very important in this and as we seit will help us reform the policies here. but, fundantally we need to look at the u.s. vaccine and how that vaccine does in the trials that are underway. baerial pneumonia is a known complication of the flu. this is one of the tngs that is often problematic.

if findings that we are releasing are not unexpected. this is what we see with the seasonal flu. it is quite similar with h1n1 influenza. it is primarily of importance to doctors to know if someone has the flu and they come backwith a high fever is little later it is important to think it may be bacterial pneumonia and to treat for that. it also emphasizes the use of pneumonia vaccination for all people for whom it is indicated, including children and the eldey. >> the operator we will ta a question from theun. >> cnn medical news, please go ahead. >> thank you for taking my call. looking at the pediatric deaths, and people are very shocked by it, i know you tked about the bacterial infection but what ir the message you want to get out to the parents who were saying i need to go to the doctor even though that is not what you are

recommending. what is the most concerning data you found within the report? >> it i important to put in the repmrt in context. in new york city for example where we have the big picture on how many people got infected, hundreds of thousands of @eople got infected and the overwhelming mahority of them had moderate illness. they didn't require testing. they didn't require treatment and they did find. if children ha underlying conditions and two-thirds of the children in this report had conditions such as muscular dystrophy and cerebral palsy, it is very important that they be treated promptly and if a child of severely ill, if they are having trouble briefings, if they are fever comes back after it went away, if they are having difficulty keeping fluids down, then it is very important to get tread promptly but your question is an important one. this is a real challenge and we

need assistance from the media as well as the public to understand this balan between on the one hand the overwhelming majority of people with h1n1 influence are going to do fine. they don't need testing, they don't need treatment. on the other hand if you either have an underlying condition or you have severe illness itis really important that you get treated promptly. that is a complicated message but getting it right is notnly going to be important for helping people stay healthy, it is going to be important for making sure that our hospitals and our emergency departments are available to the community and the people who really need the treatment. >> operator will take another question from the phone. >> could you please explain again what what you said about the numbers of miscarriages that would be expected if people were vaccinated or not vaccinated?

i could not quite follow that. >> the basic point is that certain conditions occur, whetr or not vaccination happens and we need to anticipate that those conditions will occur after vaccination evenf they are not caused by a ccination. in 1976 for example there was the increased rate of guillion barre syndrome. that occurs depending on the age of the population you are looking at, somewhere around one per 100,000 people as a routine for a norm even if there is no vaccination, so we need to recognize that there are baseline rates of things like neurolical syndromes and miscarriage in an average flueason and around half a million pregnant women get vaccinated. in that group there will be miscarriages. those mcarriages, even if you have they placo vaccination,

you would expect more than 1,000 miscarriages, re than 1,000 miscarriages in the one week followg the vaccination for the half a million women so if we see that after h1n1 vaccination, that does not imply that there is a problem. what we need to see is whether the rates that occur are high are ben wadih kurd no vaccine had been given and with that only time will tell. i think the bottom line here is we will look very, very carefully to see whether there is a problem with this sexting in terms of safety. we don't anticipate that there will be. it is produced in the same way that flu vaccine is produced each year. it is a new strain just as we put new strains into the flu vaccine each year and flu vaccination has a long term, very good safety record with literally hundreds of millions of doses haven't bee given.

>> operator, next question. >> our next question comes from the canadian press. >> hi dr. frieden. i was hoping i could get you to talk about something you touched on earlier, the balance of identiing when people need to seek care. some people will, and you know think they are fine and then start to get worse and need to go see a doctor and they may be outside of the 48 hour optimal treatment windou for antiviral drugs. if you can recommend what doctors think about treating with antivirals, start treating with antivirals later than 48 hours it looks like somebody's developing severe disease? >> if someone is severely ill then they should be treated even if it is more than 48 hours but the most good is done at the treatments when-- within the firs48 hours.

>> dr. frieden i am a producer with fox news. i just want to ask littleit re about the vaccination that's novartis and sinovac and in chinese in switzerland because theynnounce they he a ondoes vaccination. this is that something we are going tsee here in the united states? are we going to have the one dose vaccination as opposed to to? >> the novartis steady i believe was de with an adjuvanted vaccine, a vaccine that has another matial added to it to boost the immune resnse. we don't anticipate that we both using adjuvanted vaccine in most of these scenarios that we anticipate now or-- but that could change and we would expect th likelihood of needing to dosewith the vaccine that is not adjuvt is higher than within adjuvanted beck singing for the data, add of china we will have to review it. for seasonal flu for kids under the age of 90 current use two

different maxene does this otis very likely that it leaves for kids to doses are going to be required but only time will tell. this is one of dhe things our basic message here is we are going to look the data. are going to understand the situation as well as possible and provide the best possible it buys for people to have the best options to take to protect themselv and their families. >> cbs of lyndon is. a lot of parents are very concerned about this. yet they feel that h1n1 starts, they learned that h1n1 starts poppg up in their school or their daycare center, if they don't feel that the school or daycare center is taking the necessary precautions should they pull their kids out? >> we hope that schools will continue. kids need to learn, parents need toork. there is a lot that happens at schools that i very important.

we have had a handful of schools clos, most of them just for a day or two. if your kid is sick, please keep them home. they will get better quicker and they will not in that peop around them. schools shouldn't sure that kids who were sic are separated and sent home with a parent or a caretaker and that kids cover their cough, cover their sneeze and wash their hands. at the simple steps are taken the number of people who become infcted will come way down and when vaccine becomes available schools will be an important location to give the vaccine in many parts of the country. >> questions in the room? operator we will take another question from the phone. >> thanking. i want to rescue the 36 children who died, how does that compare to a typical influenzaeason? i know there is no such thing but can we get kind of a range

what is given in the reports more given in percentages. could we talk about compressed time period during which these deaths took place? >> child dths from influenza are really tragic and one of the things that has prompted us to recommend broad based influenza vaccination for children even before h1n1 came around. each year there are on the neighborhood of 50o 100 deaths from influenza among children in this country. in this year only time will tell what that number is. the flu season this past year was very unusual. very unusual because you had first a normal flu season which was a relatively mild since then. then you had h1n1 influenza says these deaths are outside the normal time period and again only time will tell what will happen in the fall and winter. the take-home message from this

study i think is that particularly kids with underlying cditions need be treated prptly if they develop fever and fir on line, or at the front of the line for vaccination when it becomes available. >> operator another question from the phone? >> "usa today," please go ahead. >> hi dr. frieden. thank you for taking these calls. there was a note in a report on influenza and the southern hemisphere that struck me. it said in argentina and chile among hospitalized cases of acute respiratory syndrome kids up to ur years of age were the most effective. however both countries report of the low percentage of cases in this age group represents the h1n1 a more than 70 to 80% represents respiratory virus.

could you explain and expand on t@at? >> in parts of the country and the world where flu is spreading it has been very important within the hospital, from hospitize patients particularly patients in intensive care units to determine what type of infection they have and the testing for influenza not only is it not necessary for most people who have only moderate or mild illness but for those with severe illness that is not sufficient because there are many false negative test from the available test. so, in the areas where there are large numbers of people in innsive care units doingery vigorous inestigations to figure out what is making tm sick is quite important and we have seen it in different parts of the country, different parts of the world that it isn't always h1n1. it could be other things that only testing at that intensive care unit level of care can determine that.

>> i just had a quick question. in the southeast were you saying? to do you attribute that to the return of schools earlier en the rest of the nation or what do you attribute that to? >> we are seeing a lot of h1n1 influenza scattered a run the countryarticularly in the southeast and the most likely explanation for that is that schools started earlier here. in georgia we have relatively widespread h1n1 and that again is most likely because we had this schools starting earlier. it may also be that some of the parts of the country that have less of these h1n1 in the spring may see more of it now but only time will tell. this is one of the many things that we have to monitor very carefully so we can figure out what is going on in the just our approa based on what is actually happening. >> orator we have time for two more questions from the phone.

>> thank you for taking my call for gorge is wanto follow up on the institute of medicine report o the n91 respirators. as you well kw, there's not a lot of them in facilities and mayb even a week or to supply in many hospitals and there are some of them in the strategic reserve but given there is a potential shortage of these if there were to be a very larg outbreak of the disease, how would you like health care workers to resnd to this information and how you think they shouldespond? >> we have just received the institute of medicine report. we are studying it carefully. they are charg with specifically not to consider either economic or logistical concerns such as supply and as we look at guidance for health care facilities we will be looking at this carefully in the coming days to weeks. i think we have time for one more question. >> "associated press," please go ahead.

>> hi, thank you for taking my question. to questns. first of all in the pediatric thateport, do you know where the ki pick up those infections? were they hospitaacquired infections in the second question is given the proportions of the kids who were under five or so, is a clear yet, is swi flu deadlier to school-age children than the seasonal flu is? >> so, for the first question, most of those infections were picked up in the community rather than in the hospitals. the kids came in with the infection. in terms of the relative severity of seasonal versus h1 in one i think the jury is still out. so far does no more severe. we don't know that it is less severe. clearly the number of deaths are now at re than 500 deaths from h1n1 in the country in all age groups emphasizing influenza can

be a very serious disease. that is why it is so important that we take every step that at our disposal. that means staying home with you are sick, covering your coffin sneeze, washing your hands and if y are severely ill, trouble briefings or have an underlying condition get treated promptly when you have a fever and when the vaccine becomes available make sure that we get as many people vaccinated as want to be vaccinat. thank you l very much. .

and here's just a little bit of the book festival as you can see here right there on the campus. well, our next call-in guest is going be larry willmore. he'she senior black correspondent on the daily svr last call is is goin to be larry wilmore for goles dissing a blood correspondent fo the shown we want to show you a ittle clip from "the day show" and then we will be back to take your calls with larry wilmore. >> how much of the game-changer is this barack obama? for more i am joined by larry wilmore heresey near lech

correspondent. [applause] this hirth. >> it is unbelievable. obama is not only popular here, but around the world and it is not his rhetoric. is not even his smile. it is something a little more basic. >> in that regard my ynger so is h, d now says that he would like to be black. [laughter] i am not kidding. it has a lot of advantages. black is in. [laughter] >> two things jon, of larry king has an 8-year-old son. that is messed up. [appuse] also, but secondly black is in. that has not happened in a long time. >> i didn't know you kept track of that. >> oh yeah. weave had their moments for good during the 60's we had civil writes for godave us a lot of buzz.

the 30's, joe louis david sale lull keat but those canno compete. the last time we were in was way back when the build the pyramids. [laughter] >> i don't want to rant on that period but i believe you made us build the pyramids. >> like i said, we were in. [laughter] >> host: the book is "i'd rather we got casinos" and the author is larry wilmore. mr. wilmore how long will this black is in period last? >> guest: probably about 42 years is my guess. it is a net seven year cycle, so six or seven year cycle black will be in and then we will move onto mexican, chinese, and knows. >> host: where did you get the title of your book? >> guest: e title of the book came from a piece i did on "the daily show." john could not understand why wasn't crazy about it for good

28 days of trippi, i would rather we got casinos and i always like that line. thought it would make an interesting title for a book. >> host: in your buckey spent quite a bit of time writing to the naacp. why is that? >> guest: the book is like a fay collection o op-es and fake radio interviews andhat sort of thing in the first op-ed i suggest changing the name of african-american to chocolate, and throughout the bakari series of letters, a series of letters to the naacp where i'm trying to convince them to get on the talking train. and i were chocolate today in honor of that. >> host: what is the impetus behind that campaign? >> guest: well, my feeling is that african-americans, it was finished, it was done in black people we change our name lightbourne stars. it is ben, black, afro-american.

it was afro-american. we were named after a hairstyle. that is how far roudik god. americans of african descent and african-american. the thing is that when i think of africa ali think of is hot. it doesn't really do that much. there's no romanticism but i might get beleria a something like ep and brothers to speak french. i feel li if i want to be around brothers i can understand and in the unbearably hot in very much where my ancestors once rum, i will go to the check cashing place. let's move on to the 21st century. who doesn't love chocolate? >> host: how did you come up with your title on the daily show, a senior black correspondent? >> guest: actually d.j. who was the head writer at the time is now executive producer, we were trying to think of what would be the right lane go and any time we are on he daily show" the first thing we have is steve colbert who is the best

ever nd you don't want to imate that. you were trying to find what your own thing is and i didn't want to be the opposite of something. we thought it was funny that, well i thought i was funny that i was going to do a bit where i was chiding jon that finally we have a black corresponded in d.j. thought it would be funny to be the senior black correspondent in really on that title and it just kind of took off from there. >> host: what re you doing prior to "the daily show"? >> gst: the daily show mark to return to performing. before that i was a writer producer in hollywood for a number of years ago that thing that will probably w the most well-known was the bereac show which i created and i had just come from doing for years on the office. itarted as a stand-up comic early in my career and i thought maybe now is the time to start performing again and kind of stumbled inpo "the daily show" i guess you could say. >> host: how often do you appear? >> guest: really is only once or twice a month but because o

refunds and cable and the internet it feels like i am on a lot more than i actually m. i givehe illusion that i'm on the show more than i am. let's go by the way we are going to put the numbers up on the screen. (202)585-3885 if you live in the eastern central timezones in 202-58386 for the mountain and pacific timezones. you are watching booktv ve from the "lns angeles times" festival of books. from african-americans what kind of reaction do you get to your book? >> gst: well, i have gotten a great reactions from people thad have read it and know about it because most of the people who know me and my work from "the daily show." ibar is insisted only three black people in total watch "the daily show." but i think they are really, also in seriousness there hasn't been what you call black satire out there so this is kind of a lot of blacks call nd say

this is a refreshingake on a lot of issues that we don't always see. >> host: a rreshing take. text messages from a birmingham jail. are you walking on sacred gund here? >> guest: i don't think so. that was one of the first titles the came to my head when i was thinking of doing a piece. it was one of the hardest ones to write but i belt it was really a kind of hit in the middle of the target zone in terms of the satirical title. >> host: larry wilmore is our guest. we are and the c-span bus at the "l.a times" festival books. the first call comes from buffalo, nework. going at buffalo. >> caller: hi larry, ho are you this afternoon? listen, cents, when i saw that barack obama was probably going to become president i got pretty serious about calling into c-span exclusively, requesting th he addressed the issue of

reparations for the slave descendants. basically, and i have got to follow up on that so how do you feel about that personally? >> guest: in the book, i have a chapter called give us the superdome were eye and says that you know a lot o people want reparations and the argument is that slavery had been soong ago and i understand that argument. many people today have nothing to do with slavery and we were supposed to get 40 acres and we didn't get a statute of limitations. in the book i argued there have been more recent transgressions that maybe you could giv reparationsor like hurricane katrina. give us the superdome comissary connect things that you think you can get reparations for and then go for it. >> host: jackson, wyoming. >> caller: larry, i always like to see you on the show. you are a real kick. >> guest: thank you. >> caller: do you knowt has

been estimated that when michael jordan throughout his career, every time the ball went into the basket, he made $360,000. and a teacher makes about $40,000 a year. i think our priorities are kind of screwed u if you think of the mexicans, they are very family-oriented. they get together and buy a business or they share in the rent. with the mexican people thrive because they are so family-oriented. it seems like black people, because of thelack male, having the black woman be the mother and i justhink that's stars like you or other famous black people should be helping out the black community by a luning people money for

businesses that e. i think that would be an excellent way for returning to the community. >> host: larry wilmore. >> guest: apparently you want me to be fannimae or freddie mac. i am not sure that is the right business to get into but it sounded like you are making a point about what they sell it-- a lot of sociologists refer to as the destruction of the black male ego through slavery and jim crow and some of those things and some ofhe reasons why the black female had to kind of be donant in the household and me of those are still run today. some of those are, some of the things that pop up especially in impoverished areas and those are real concerns and that's sort of thing but i think the best thing i can do personally i have always felt this to be a role model to my own kids. i think everybody was that then we would be a lot better off. puka what you think when white-collar from jackson, wyoming says the black people.

>> guest: the black peopl that is okay. i am not mad at wyoming. >> host: that caller talked about the blackommunity. ir there suc a thing? guest: there is the bck community. it is a planned community actually, the kind of like irvine california and there's a waitg list to get into the black community, now that obama is president. but it is very nice. it is very nice. >> host: stanley town va, go ahd. >> caller: i would like two of you about your previous career and the concept and the ideas you all came up with because it was so revolutionary and i mean if i see horseshoe now-- if i could see your show i would still watch it because it is just great. >> guest: thank you for that call. all the credit goes to keenan ivory wayans on that. he did a movie called-- or you

did a l of parodying ends satire kind of the humor that i really love and keinan, i felt the brunt the hip-hop culture into america's living rooms. before we had black humor, but we didn't have the satirical edge that it had with the hip-hop culture, the dancing, the fly girls and all that stuff and there's an excitement about the show that i felt that the time, and i love watching the reruns and that kind of thing but i do miss that i have to tell you. >> host: are you married? >> guest: yes i am and have two children, donnan lauren. >> host: how old are they? >> guest: 12 and ten. i live in pasadena. wifio new york when i do "the daily show." >> host: the nasco, moab utah, go ahead moab. >> caller: hi, i am enjoying so much during the conversation then all the people's perceptions. there is 34-- people in the

whole town and i think a lot of the white people-- >> guest: bonilla. caller: fennell look, thank you. you will have it togeer and we are so disconnected from each other and i wanted to thank u for your body of work, for the tumor, the way you have approach things. your a beautiful human being. thank you very much. >> guest: i want to be on c-span every day of the week from now on and i would like to say that fennell is a very underrated flavor. it goes with chocolate ferry will and that. was do you have been behind the scenes a lot in your work and all of a sudden you are not behind the scenes anyre. you have go to book out there. you come across a rather shy. are you? >> guest: i was very shy growing up, extremely shy so i still have some of that in me. when i did stand-up medy i started as a performer. after the show i would usually

be in e back of the room so i still, i am sure there is still some of that in their but i really love performing live. >> host: what is a shetland? >> guest: this is a very important issue. this is a person who like gary coleman or webster, they don't grow past is certain point much like a shetland pony and in the book i argue that that is the way to say this to come because america loved gary coleman and western could not get enough, bring back the shellenberger of at is probably what of the most politically incorrect titles but i think if we bring them back we will save the sitcom. >> host: philadelphia you are on with larry mill mark, please go it. >> caller: larry, i am a big fan. i have a couple of questions. first of all, in europe, to which are often referred to as

french jewish org german jewish for goo do you feel like african-americans in the united states should be referred to as american african instead of is subcategory of americans, african-americans? >> guest: or you could have georgia blacks or for that afrin-americans and we will regionalize it. i wouldn't be mad at that. >> caller: y could do that too. >> guest: california chocolate. >> caller: my second question is clearly your involvement with the daily sw, you are a politically interted person. are you worried about barack obama'residency? it is brought us so much closer to a coherent american identity of multiculturalism but if his presidency fails, if he is forced into capitulation to special interests and the financial mess, you know what happens then, and whether your

feelings about that? >> guest: well, on the comedy side i would say that i would not worry toouch about change for barack. just keep giving me e hope and don't reduce the to glimmer of hope. i don't want glimmer of hope, i want hope. on the serious side at think the impact of barack obama will be felt more in the younger generation. there won't be a question that a black man can lead something and to be in charge of the country. when i was a kid a black kid could not even be a quarterback in the nfl. but it will be just a given for the younger generation for gude won't even be a question that a black can lead at that high level. lescallet thee press the obama? >> guest: no i never have although i was on "the daily show" up so that he was appearing on and i heard he was on satellite watching the show and was laughing at the bit that i did and i think i did joke

maybe chemo little to close. i can remember what it is the but i read a blog about it or somebody said he was really laughing at the bit and then gutkind of the little quiet. i think i talked about his reverend oromething, but i heard he enjoyed it for the most part. >> host: it is coming up on 100 days, a lot of media coverage of the first 100 days. what is your impression of the first 100 days? >> guest: so far so good. he had that kind of scary amazon book moment with hugo chavez. didn't want to be in his book club that look like you know, but it is a bit overwhelming. there is so much going on. i can remember in the first 100 days where there is such a big agenda of things to do. so i don't know how he is handling it. i think michelle is in little bit upset that she has to take care of that dog though. i don'think she is too happy abou tha i want to see what is going to

happ with the mother-in-law. that to me is in the untold story. you get to be president did you have your mother-in-law with you. good move for rock. >> host: boca raton florida, hi. >> caller: i just want to s you are a very funny man. as a fennell man talking to a chocolate man i want to say i enjoy you. on a serious note, what you think the position of the status of the jesse jackson right now compared to the election of mr. obama as president? do you think jesse jackson is envious of him, angry abo him or happy about him? his election, because no jesse, and i'm being respeful, is considered a chockley leader. >> guest: i understand. it could be a comnation of all three, y never know. i an he would certainly that

shot of him crying on election night was pretty powerful, but just do you kn he is not so much a leadoff batter nemore. he is more like it third base coach, probably giving signals and that kind of thing wanted to still be in the game but chassi's legacy will always be solid. he was the first viable black candidate to really exced the populace. but he really open the door and paved the way i think for obama's i think his legacy is pretty solid in that regard. but i think it is that to be hard for anyone who has been at the front of a movement or the spotlight because keep in mind jesse had martin luther king's blood onim on that balcony. he has seen a lot in his lifetime let alone feeling like he is very close to e white house so i think there is a myriad of the motions that go through his body but to give themredit i think he is mostly proud of the fact that there is an african-american in the white house. >> host: where did you grow

up? >> guest: i grew up in los angeles. my family is from chicago. my fatr was a probation officer growing up. my mom with an educated. she was a part-time teacher and part-time mom and my father at about, in his late 30's or '40's went back to school to become a doctor. the scope and what do you remeer mostbout your childhood? >> guest: where doe start? the thing i remember most is my brother and i kind of making each other laugh all the time. by parents divorced when i was pretty young and they kind of fadl lot. i think my brother and i soften the blow by making each other laugh an making fun of everybody. it seemed we had so many characters and our lives growing up that everybody was the character and we had so much fun making fun of all that stuff. that is what i remember the most is spending time with my brother and laughing about a lot of things. >> host: on the mo serious note, do you remember racism?

>> guest: absolutely, very much so. it was so different back then. i grew up, i was born in 1961 so the watts riot happened when i was very young in their remember martin luther king being shot. that w the very first thing that happened. i rememr being treated a certain way and not understanding why. and i remember my mother writing on the jacket of a department store with an n on it. things like that. but at the same time i feel fery fortunate that i had a lot of good friends of weitz, black. lagger up in a big mexican-- big mexican, i guess i should say heavy latino area. i always have a lot of friends and i thought that always helps me. i didn't grow up with just one culture i guess you could say so i treated racism as acts by

individuals rather than byig institutional finan a personal level. was go to be in your queue here in the state's subgroup ourselves too much? >> guest: i think so. personally i think so. some of it makes me laugh. i love the fact that we spent all these years tried to desegregate and then you go to your coleges and you have your black forms in your mexican forms but a lot of that is out of comfort. it is funny how you fight for all those things and tn, we like it like tha >> host: from "i'd rather we got casinos", random black thought number three, don't taze me. ib ty let me have a taser sorry roe, i am teasing you. >> guest: absolutely. and love the w said brother. >> host: the danette beach california, 50 miles down the coast from where we are right now. >> caller: it is a beautiful