hearing, and i'll now recognize thehairman of t constitutional law subcommittee of arizona, mr. franks, and then to the constitutional law subcommittee. .. mr. chairman, the medical liability litatn stn the unitedstes, i tnk by al cotss ok a i deere edf refo. the current system is as ineffective a mechanism for adjudicating medical liability claims as it can be, which leads to increased hlth care costs, unfair and unequal awards for ctims medical mlpractice an recduced access to health care for all americans.

unfortunately the massive health care overhaul that president obama signed into law last year did not meaningfully address medical liability reform. thus we are here today to exinehisoinngrlem anvaataon sutns toh,wh bie to be a crisis. one of the largest drivers of this crisis is the practice of defensive medicine. defensive medicine leads doctors to order unnecessary tests and procedures, not, mr. chairman, to ensure the health of the patient, but out of fear of malpractice liability. the cost of defensivemeci is iee stgeng cointo 2003 department of health and human services report, the cost of defensive medicine is estimated to be more than $70 billion annually. additionally, medical liability litigation increases the cost of health care by escalating medical liability insurance premiums. this, in turn, leads to higher costs throughout the entire health care system and reduces

access to medical services. however, mr. chairman, despite the increased costs medical liability litigation imposes, this litigation fails to accomplish its ostensible purpose, tort law first place, that is fairly compensating the victims and deterring future negligence. the system fails to compensate victims fairly for several reon fit,ccdio e tues thva mjotyf iidts mic nglen do not result in a claim and most medical practice claims exhibit no evidence of malpractice. so, victims of malpractice or most of them go uncompensated and most of those who are compensated are not truly victims. . aman, medal mal practice awar vary greatly from case to se, even where the claims and injuries are virtually identical.

finally, attorneys regularly reduce damages awarded to victims by more than 40% through fees and costs. moreover, there appears to be little evidence to suggest the current medical liability system deterz negligence, but the available evidence seem oz to suesththat titi us dto n t ve me eoranopr fensive medicine. and this, of course, subjects patients to unnecessary tests and treatments once again. so we must reform the medical liability system in the united states, mr. chairman. among other benefits reform could do some of the following, could lead to a significant savings on health care. it could reduce the practice of defensive medicine. pr to health care, and save the american taxpayers billions of dollars annually while increasing the affordability of health insurance. mr. chairman, meaningful medical liability reforms have woed in states such as california and

texas and it is timeor action at the feder level to extend th benefitsf reform to all americans. and i thank you for the time and yield back. >> thank you, mr. franks. the gentleman from new york, mr. nadler, the ranking member of constitutional law subcommittee is recognized for his oping statement. >> thank you, mr. chairman. mr. chairman, i've not prepared an opening statement because i didn't know we were going to have opening statements for rankings and the chairman of the subcmittee b i'l me an opening statemen noneeless. i have always believed that this problem is the wrong problem and it is a solution in search of a problem. if you look at the evidence over many years and i've looked at the evidence since 86 consideration of reforms to this problem in the new york state assembly when i was a member there, i've been involved with this off and on for 25 years, you find that the real problem is not the excessive costs of malpractice or that -- the excessive costs of malpractice

insurance is not caused by lack of the so-called tort reforms that are being advanced here and that have been advanced over the years, namely making it harder to get attorneys capping fees or cappingrov fale who are very seriously injured. first of all, we know that most people who suffer real damages as a result of medical negligence never sue. so the amount of recovery is very small compared to the amount of costs. secondly, study after study has found that the real problem is that the states, some people might say the federal government should do it, but that's a separate discussion, but the states in any event whose job it is under current law are not disciplining doctors that something like 90 or 95% of the claims dollars that are awarded come from 2% or 3% of the doctors. those 2% or 3% of the doctors are hurting patients, killing

patients and should not be practicing medicine. they should be stripped out of practice and if they did, everybody else's malpractice premiums would go down because the amount of costs would go way down and the other 97% or 98% of doctors would find the malpractice premiums much reduced. now what do we find from the kinds of proposals that we consider? number one, in may 2009, wellpoint, a major malpractice insurance, said liability was not driving up health insurance premiums. the -- an economist at harvard university, in an article malpractice lawsuits are a red herring published by bloomberg in june of last year concluded that medical malpractice dollars are red herrings. there is so many other sources of inefficiency. we know that preventable medical errors kill as many as 98,000

americans each year at a cost of $29 billion. and this -- these proposals would do nothing about tha we're told that e defensive medicine is costing us huge amounts of money and incleesing the cost of the medical system as a whole. the gao, the government accountability office, issued a statement saying the overall prevalence in cost of defensive medicine have not been reliably measured so we don't really know. studies designed to measure physicians defensive medicine practices examined physician behavior and specific clinical situations such as treating elderly medicare patients with certain heart conditions. given their limited scope, the study's results cannot be generalized across the health care system. multiple gao studies concluded eliminating defensive medicine would ha a minimal effect on reducing overall health care costs. but the proposals that i assume will have before us, the proposals introduced by the colleague on the other side of the aisle every single year, all

have in common putting a $250,000 or so-called -- limit on nonicmas,ha aynageotr an directedal ctsnd lost wages, which may be the main damages for someone whose wages you can't measure, like a $250,0 is n vy much. they fthat $2,0 w reonle amou he in d's dollars, or rather in 1975 dollars, that's worth $62,000. would they have enacted a $26,000 cap in 1975? and if we wanted to take the 250 and inflate it to keep it at the same value, it would be over a million dollars today. so if we're going to be -- if we're going to pass this kind of legislation, which i hope we won't, at the least we should put in an inflation factor and start at a million dollars if we want to dplat atmicra d

lora. they did not prerhee dureduce ts at all. only after insurance reform was enacted in 1988 by california g perfect experiment for the 13 years, which california had the tort reform, but not the insurance reform, the premiums went up 450%. when the insurance reform was ented, pemiums went down8%. so may w should be talking about insurance refm instead of tort reform, but unfortunately that's not in front of this committee. so i think we're offonhe wr track ife' nctrinon is ani he relit on. i apologize for exceedg my time i yield back whatever me i don't have left. >>ha you, mr. nadler. with that objection, other members opening statements will be made part of the record and now i'll introduce our witnesses. our first witness is dr. ardis hoven, chair of the american medical association board of

trustees. prior to her election to the ar d hen sved a mb aref eam counl micse e s ember of the utilization review and accreditation commission for six years and served on its executive committee. most recently she was appointed to the national advisory council for health care, research and quality. we welcome you. our second witness is joan doroshow, executiv director of the center for justice and democracy.ericans for insurance. she is an attorney who worked on issues regarding health care lawsuits, since 1986 when she directed an insurance industry and liability project for ralph nader. welcome to you. our third witness is dr. stuart weinstein, a physician spokesman for the health coalition on liability and access. dr. weinstein is a professor of orthopedic surgery and professor of pediatrics at the university of iowa. he is a former chair of doctors

for medical liability refm and we wcome you as well. just a remder, eh of the witnesses' testimonies have been -- or will be made part of the record. we do want you to limit your testimony to five minutes. and there is a light on the table that will indicate byts llow lighthen you ha o minute lefand ten the red ght willome when e five minutes is up. so we look forward to your testimony and we'll begin with dr. hoven. >> thank you, and good morning. chairman smith, ranking member conyers and members of the committee on the udiciary, as stated, i am dr. ardis hoven, chair of the american medical association board of trustees and a practicing internal medicine physician and infectious disease specialist in lexington, kentucky.nkto talk a important issue. this morning i will share with you results from ama studies that prove how costly and how often unfair our medical liability system is to patients and physicians.

most importantly i will talk about a solution. that solution is a package of medical liability reforms based on reforms that have already been proven effective in states like california, texas, and michigan. our current medical liability system hasece ineangrriolysm dreny mecoumg titi a onend nocomidage as at brg instability to the liability insurance market. it is also an extremely inefficient mechanism for compensating patientsarmedby gligen wre cost cots and attorn fees ten csume a substantial amount of any compensation awarded to patients. let me share with you some of the alarming statistics from an august 2010 ama report that shows how lawsuit dvenur stem h come. near %ofphysicns aged 55 and older have been sued.

before they reach the age of 40, more than 50% of obstetricians, gynecologists have areadyeen suednd 64%f medical abity claimshat cled 20 wroeddiisd. these claims are clearly not cost free and let's also not forget the emotional toll on physicians and their patients involved in drawn out lawsuits which is hard t quantify. out of fear of beisued, physicia and other health care providers may take extra precautionary measures known as the practice of defensive medicine. a 2003 department of health and human services report estimated e costof theprtice of feivmecito etwee 70 and $126 billion per year. every dollar that gsoward medical ability costs is dollarhat does not go to patients who need care, nor

toward investment in physician practices, a majority of which are small businesses that create jobs that benefit local and state economies. the good news is there are proven examples of long-term reforms that have kept ysians liability priums stable, but more importantly have ensure and proteed patients' access to health care. back in 1974, california was experiencing many of the problems we are facing today. in response, california's legislature enacted a competenve package of reforms called the medic injury compensation reform act of 1975, over 35 years ago, which is now commonly referred to as micra. while total medical liability premiums and the rest of the u.s. rose 945% between 1976 and 2009, the increase in california premiums was less than one third of that, at just about 261%. recent public pollfod a majority of amerans suppo

reasonab limin noneconomic damages, and believe that medical liability lawsuits are a imy as r rin hal ca s weoo fwa tth inodti of the al a at mro lirn's fos and so otts current and future medical liability reforms at the state level. by supporting patient safety initiatives along side enacting meaningful liability reform, congress hashe opportunity to providaccess to mical services, reduce the practice of defensive medicine, improve the tient physician relationship, support physician practices and the jobs tey create, and curb a wasteful use of precious health care dollars, the costs both financial and emotional of health care liability litigation. on behalf of the ama, i would like to extend our appreciation for the leadership of the committee and the a looks foard to wking withyo all

toass federal legislatio that wod bring about meaningful reforms. and thank you. >> and dr. hoven, thank you. and miss doroshow. >> thank you, mr. chairman. mr. conyers, members of the committee, the center for justice and democracy of which i am executive director is a national public interest organization that is dedicated to educating the public about the importance of the civil justice system. this isth urth te ive beasdoteif bor ngssnacoite t la nne years on this very important subject of medical malpractice and i'm honored to do so. i also spoke at two different informal hearings chaired by mr. conyers which featured families including children from all over the country whose lives were devastated as a rtheir stories pleaded with congress not to cap damages and enact tort reform. they're all paying rapt attention today from afar and i

will do my best to represent them, but i do hope this committee decides to hear from them directly because these families are always the forgotten faces of the debate about how to reduce health care and insurance costs. while i understandhisan ovsit hearg d we n knowhabills may coideredy e committee, typically the push has been for caps on economic damages and other measures that force patients who are injured by medical negligence or the families of those killed to accept inadequate compensation. meanwhile, the insurance industry gets a pocket money that should be available for the sick and injured and they force many to turn elsewhere, including medicaid, for further dinocalifoia fodoctoruntil 88,h insuraeegulary rerm was paed. it was not due to the cap. these measures will reduce the financial incentive for hospitals to operate safely which will lead to more costly errors. in fact, when congressional

budget office looked into it, they looked at several studies that looked at the negative health outcomes of tort reform and one of them found -- would lead to a .2% incase in mortality in the overall death rate in this country. at's another 4,000 killed. now while i cover many issues in my written statement, i want to highlight a few other points. first of all, there is an epidemic of medical malpractice in this country. it has been over a decade since the institute of medicine study finding 98,000 dieing in hoitals every year, costing 17 to $29 billion and experts agree there has been no meaningful reduction in medical airers in the united states. in fact, in november, just last november, hhs rorted tat one in seven hospital patients experienced a medical error, 44% are preventable. second, medical malpractice claims a lawsuits are in sep declinaccording to t national center for state cou and the insurance industry's own data. to quote from the harvard school

of public health study that the chairman mentioned, portraits of a medical malpractice system that is stricken with frivolous litigation is overblown and only a tiny percentage of victims ever sue. this is the press release issuing that study that said study casts doubt on claims that the medical malpractice system is plagued by frivolous lawsuits. premiumsave been stable and dropping since 2006 and if you read the industry trade publications, you'll find out that insurers so overprice policies in the early part of the last decade that they still have too much money in reserves and that rates will continue to fall. and this has happened whether or not a state has enacted tort reform. as far as texas, health care costs did not come down when caps passed at all. applications for new licenses are only part of the picture. when it comes to physicians engaged in patient care, in other words, considering

physicians who retire, leave state or stop seeing patients, the data shows that the per capita number has not grown. in ct,th nber gr ealyhrgh03nd leveleof this is not a pattern you would expect of 2003 tort reform law is responsible. when competing for physicians, texas is more hampered by the extraordinary size of its uninsured population, which exceeds just about every other state. in terms of defensive medicine, cbo found that it was not pervasive. .3% from slightly less utilization of health care services, but even this is too high. we what we don't -- what cbo did not consider, for example, are what happens -- the burdens on medicaid, when there are no lawsuits, or the fact that medicare and medicaid liens and subrogation interests. if a lawsuit isn't brought, they can't be reimbursed. all the costs need to be added in. finally, these bills all ignore

the insurance industry's major role in the pricing of medical malpractice insurance premiums, an industry that is exempt from antitrust laws. this needs to be repealed. we need to do more to weed out the small number of doctors responsible for most malpractice attsan mr. chairman. >> thank you, miss doroshow. dr. weinstein. dr. weinstein, if you'll push the button on the mike, we can't quite hear you. there, thank you. >> thank you, chairman smith and ranking member conyers for holding this important hearing to consider fixing our country's broken medical liability system. i'm stuart weinstein, the ponseti chair and professor of orthopedic surgery and professor of pediatrics at the university of iowa. i've been practicing for more than 35 year and the past president of the american

academy of surgeons. i would like to begin today by asking each of you to put yourself in someone else's shoes. imagine your young pregnant mother living in rur america with no practitioner or your local hospital is closed its door to obstetrics or imagine your young doctor saddled with debt trying to pick a specialty. despite the great need for obgyns and general surgeons, you choose a safer specialty because of risk of lawsuits. and imagine being an orthopedic surgeon but you're facing high costs for liability insurance and the threat of potential litigation. to reduce your liability, you decide to avoid high risk cases like trauma cases or maybe you decide to retire altogether. dilemmas like these play out across america every day as medical lawsuit abuse undermines both our health care system and the doctor/patient relationship. moreover, medical lawsuit abuse is driving up health care costs at a time when we're still centered care by reforming the

medical liability system that continues to put everyone's health care at risk. the current system is clearly broken and there is widespread agreement amonlawmakers, health care policy experts, opinion leaders and the public that reform is needed. today more than 90% of obgyns have been sued at least once.gi relationship. it is driving doctors to get out of medicine or to practice defensive medicine. dense miceisthe antithisf health care reform because it increases health care costs and has the potential to lessen access to care and quality of care in two ways. first, doctors practice avoid assurance behavior including ordering tests, particularly

imaging studies or referring patients in order to provide an extra layer of protection against abusive lawsuits. aectalp suey fun te arf lsus she iv bend21ofalltes treatments ordered by doctors which equates to 26% of all health care dollars, a staggering $650 billion. defensive medicine inclsurgery, deliveries or procedures prone to complications and they avoid patients with complex problems or patients who seem la tithous. in 2008, half of america's counties had no practicing obstetrician. this shouldn't be happening in america. there are remedies to fix this broken system but it is imperative act now before defensive medicine practices and costs associated with it becomes the standard of care.

before health care costs go high are an unemployment along with it, before doctors shortages change the very nature of our health care system. successful reform efforts in states, especially california and texas have given us aoutlin legislative proposals that preserves state laws working effectively to make medical malpractice systems fair for both patient and health care providers and broaden coverage across the nation. i'd like to close by telling you about maryland gynecologist dr. carol ritter who stopped delivering babies in 2004 when her liability premiums hit $120,000 a year. she couldn't deliver enough babies to pay the trial bar's tab. today, dr. ritter maintains a gynecology practice and still delivers babies, but does it in haiti, and honduras and dozbosn. she says she does it for the sheer joy of what she does best,

but she can't do it in maryland. i would say to you today, that something is very wrong when a caring, committed physician like dr. ritter can't bring an american baby into this world for fear of frilo laui. laesndenem, ha thali a tin t responsibility to help right that wrong. thank you very much. >> thank you, dr. weinstein. and i'll recognize myself for questions and dr. hoven would like to address my first question to you. you heard mention a while ago and you know, of course, that the congressional budget office estimates that we would save $54 billion overte years if we redu the cos ofensive dicine there are he studies, for instance the pacific research institute says that defensive medicine costs $191 billion. pricewaterhousecooper studyut it at 39on a w reports that all told doctors

order $650 billion in unnecessary care every year. i don't know which of those figures is correct, but they all point to the same direction, which is defensive medicine is expensive and costs, let's say at a very minimum tens of billions of dollars, probably every year. my question is this. who pays for the cost of all that defensive medicine? >> thank you. we all pay for the cost of that defensive medicine. at the end of the day, patients pay for it, we pay taxes that pay for it, we all pay for the cost of that defensive care. now, it is very important to realize, in the culture of fear in which we are all practicing medicine now, i use that term because i think it is very real, this most physicians want to practice medicine the best possible way they can. they want to do the best job they can, but what they recognize is that their clinical judgment is not allowed to carry

any weight in the court of law. so that in fact we do these things for assurance, to protect ourselves. and at the end of the day, that's where those costs do come around. >> okay. >> thank you, dr. hoven. dr. weinstein, the congressional budget office estimates that if we were to enact medical liability reform, premiums would drop 25 to 30%. who benefits from a drop in premiums of 25% to 30% or maybe i should say is the benefit limited to the physician and medical personnel or not? >> i think ultimately, mr. chairman, is that when medical liability premiums begin to drop, the culture of fear amongst physicians eventually will change. it is a cultural change that will have to occur over time. and once that cultural change occurs, then the practices of defensive medicine which you've heard about over and over again will eventually change as well and our health care costs will go down. so ultimately patients and the american public will benefit. >> patients and the consumers

benefit. my last question is to both dr. weinstein and dr. hoven. i want to ask you all to respond to a point that miss doroshow made that where he had said is wasn't medical liability reform that reduced premiums it was insurance reform. and she gave the example of california. who would like to respond, either california or texas, dr. hoven? >> i'll go first. it takes eight to ten years to see the effects of these reforms when they are enacted. there really is not firm, hard evident that in fact the insurance change was theresult. it was theact that across the country it takes eight to ten years to begin to see the evolution of change when these reforms are put in place. >> okay. and dr. weinstein? >> i think all would agree that the system in california compensates the patients in a much more pid fashion, and also more appropriate so patients who are injured get the

majority of the reward. >> okay. and dr. weinstein, or . v, respd ts,f yul rardo lirn inrae fo, lki at a newspaper article that said that proposition 103 that required a rollback of insurance premiums and not california's health care litigation reforms have controlled medical professional liability premiums. that's the assertion. accord to the orange county register, "a rollback under proposition 103 never took place because california supreme court amended proposition 103 to say that insurers could not be forced to implement the 20% rollback if it would deprive them of a fair profit." it is hard to see the correlation therefore between the insurance reform and the drop in premiums and clear the drop in premiums were a result of the medical liability reforms. i thank you, all, for your responses and i'll recognize the ranking member for his questions. >> thanks, chairman. and i thank the witnesses. where are we now in terms of the

health care reform act, which metimes is derogatorily referred to as obama care. i use the term because i think it i gng to dwn hioral aon o t gea adnc in health care. but didn't the health care reform act, which still, by the way, is the law of the land and will be until the president signs the repeal, which i wouldn't recommend anybody to hold their breath we provided money for

subject, section 10607. does anybody know anything about that here? >> yes, sir. >> i do. >> mr. conyers, are you referring to the demonstration projects? >> yes. the $50 million f five-year period that demonstration grants for the development to states for alternatives to current tort litigation. that's right. >> if i could address that question, i would say that the way the demonstration projects, which haven't been funded, i don't believe yet, the way the demonstration projects are outlined, i believe that the patients can then withdraw at anytime and choose another alternive. and i'm a full-time educator clinician scientist and when you design a research study, which allows patients to css over or change, you don't get good information at the end of the day.

it is not the good scientific method, if you will, if you want to fd out what works best. so i would argue that the way that is designed has a flaw to it. and also there have been demonstration projects across the states for a number of years. >> if i could comment? >> could i? >> sure, you can. >> actually, in conjunction with the provision in the healt care bill, hhsasctually awared now numbe gran toany states, up to $3 million to develop alternative procedures and other kinds of patient safety oriented litigation reforms. so those grant proposals w aladve theas mey anthese demonstration projects are in the process of being explored now at the state level. i live in one state where that is true, new york.

>> well, are we here -- can i get a response from all of our witnesses about the whole concept of or more people that can't afford it? and are any of you here silently or vocally in support of a universal health care plan? >> i may speak to that, sir. >> sure. >> the american medical association recognizes this is not a perfect bill, but it is a first step in getting us to where we need to be in this country. medical liability reform, alternative mechanisms for dispute resolution that are to be funded through that legislation are under way as we speak. we in no way support a mechanism

that does not recognize that every person in this country needs affordable care and access to quality health wel t bl tat was just repealed yesterday provided for millions of more people getting health care because we raised the ceiling on medicaid and we allowed the inclusion of children in the parents' health care plan until age 26, a seven-year increase. did that help any? >> we'll wait and see. >> we'll wait and see, you mean you wait to see if there are any parents that want to keep their kids included for seven more years? i haven't found one yet that doesn't want that provision in

the bill. >> let me go back to my earlier comments. access to care for everyone is what we want and need in this country. >> well, i know it. yeah, that's a great statement. that's what i want, too. and that's why i was asking you about some of the provisions of the billress. but i thank you, mr. chairman. >> okay. thank you, mr. conyers. the gentleman from new york is recognized for his questions. >> thank you, mr. chairman. i thank the witnesses for appearing day. i'll ask dr weinstein, when i looked at the national commission on fiscal responsibility and reform, the president's commission to explore ways to reduce the deficit, it was recommended in there that health care litigation reform as a policy could save money and go to limit the deficit.

deficit is a huge issue and a priority for many new members of congress, of which i am one. do you agree that lawsuit reform could and would reduce the deficit? >> yes, sir, i do. i think that's been shown. i think the cbo report that senator hatch had requested information on showed it reduced it by $54 billion over ten years and depending what study you look at, i think there's been widespread discussion in the media by members of congress and also by various groups who have looked at this issue, senator kerry and senator hatch this week, and i think both felt it would be a significant step forward addressing the medical liability issue. i think to us there's no question that this would indeed reduce health care spending. >> dr. hoven, would you agree? thlas tumre wrealngabut we clearly need to move ahead

and that's a con >> and would you agree or disagree, miss doroshow? >> i disagree with that. i think what cbo did, unfortunately, avoided a number of very important issues thatn . three things in particular. one is when you enact these kind of severe tort reforms, there are many people with legitimate cases that cannot find attorneys anymore, cannot bring cases. this is well documented as having happened in california. in kt fact, you had a witness before this committee in 1994 testifying to that effect and it is certainly haeningn texas. so you have many people that are going to end up going on medicaid that otherwise would have been compensated through an insurance company. second, as i mentioned, there

are liens and subrogation rights that medicare and medicaid have when there is a judgment or verdict in a lawsuit. in other words, they can get imrs. tre no wst,hat imrsenisgo soth lomoyin t gard. third, these kinds of measures are going to make hospitals more unsafe. there are going to be many, many more errors. even the cbo in its letter to senator hatch talked about one c by.2nd ttdon'ev inudthinri soouogtoav more pele hurt, more expense taking care of those peoplend frankly, when you enact any kind of cap on non-economic damages in particular, those have a disproportionate impact on senior citizens, children, low income earners and certainly senior citizens, what has

happened in texas with the cap, those cases really are not being brght anymore. so senior citizens who a on medicare who should have a right to seek accountability from a hospital that caused negligence, no longer are bringing those lauits, so medicare is paying. there are lots of costs that are going to end up increasing the byerth. noki ou legitimate lawsuits. we're allowing economic damages to be fully compensated in the bration gh ttou fetore dived from th econom dage calculation, because those are medical bills, past and future, the suogation rights are derivedfro what we'realkingbout focusing in on the frivolous lawsuits that are there. i guess i don't follow your logic saying that's a reason why -- >> no, i think that's actually not what history shows. history shows when you cap

non-economic damages, there are certain classes of cases that are no longer brought. that is what hasapnedin califoiand tha iwhat this individual -- insurance defense lawyer testified, before this very committee in 1994. entire categories of cases can no longer be brought. those that involve primarily non-economic damages. for example, one of the people we brought to washington a couple of times, a woman named linda mcdougle, she was the victim of nglence - >> i think my time hasexpire the. thank yo m airman. >> thank you for your questions. ms. doroshow, if you want to finish the sentence, you may do so. >> well, she had an unnecessary dole msttoecseh lamiiaos nc wen she dn heit, and she came

down to testify a few times but her damages were entirely noecom itu c wul hefct cases, her case. >> okay. thank you very much. the gentleman from virginia, mr. scott, is recognized for his questions. >> thank you, mr. chairman. one of the problems we have in this discussion is a lot of the problems are articulated and then solutions are offered and very little effort is made to see how the solutions actually solve the problems. mrs. hoven, did i understand your testimony that physicians are routinely charging for services that are not medically necessary to the tune of $70

billion to $126 billion? >> i'm talking about defensive medicine. >> i asked you, are those services that are not medically necessary? >> they are services that are medically indicated and medically necessary if you look at guidelines and criteria. however, what does not happen employ that test is disregarded. >> are you suggesting that the services are not medically necessary if liability were not a factor, would the services be provided or not? >> it depends on the cae. itependsn the tuation. dends thenvonmentf ca. you're suggesting that in $70 billion to $126 billion worth of cases, services were rendered that were not medically -- were not needed? >> that's not what i said, ngm saying health care delivered in the examining room, in the operating room, is driven

by what is based on clinical judgment and based on assurance testing which is documentation and proving that in fact, that is what is wrong with the patient. when we about the fact that -- andhis go to the whol su of ct coainmen wch isiin my medical judgment and allow me to decide when it is important to do a test or not, then our patients would be better served. >> by not providing the services? >> if in my judgment, they don't need it. >> and you're not able to -- and you charge for services that in your judgment, are not needed to the tune of $70 billion to $126 billion? >> i do not do that. however, let me -- >> i mean, your testimony was that physicians are charging $70 billion to $126 billion more than necessary and then blaming it on liability. that is my tes.

>> that it is not necessary, you're providing services that are not necessary. either they're necessary or they're not. >> we're practicing at a culture of fear and that culture of fr lends itself to protecting i have been sued, congressman. let me tell you -- >> wait a minute. i just asked you a simple question. $70 billion to $126 billion. i just want to know what that represents. >> that is costs for tests and procedures which, if ylookat idines, uld b medally nessy,uty medal mentsdiscounted. >> that based on your medical judgment are not -- should not have been provided? >> not necessarily. >> okay. well, i'm not getting -- miss doroshow, if physicians are not necessary, how is that different from medical fraud?

>> that's a good question, because in order to get reimbursed, to file a claim with medicare and to be reimbursed, physicians have to file a form and certify that the test and procedure, the services that they provided, are medically necessary for the health of the patient so it does raise a question whether or not some claims may be false, if the physicians are not -- >> if someone were to do a survey to say why did you provide the service when it was not necessary, what would be the convenient answer? if they asked you why did you provide the services that were not necessary, what would be -- >> you say they -- >> because they're afraid of lawsuits so they can charge for services that weren't even needed. mrs. hoven, did you indicate that you supported a fair determination for medical malpractice issues so that those who had bona fide cases could actually recover?

>> most definitely, congressman. >> you're aware that it's estimated 5,000 to 10,000 wrongful death cases are paid every year? >> if you look at the statistics which are obviously very familiar, we are talking about apples and oranges here in many situations. we're talking about errors and adverse events as opposed to true malpractice and negligence. i think you have to be careful about the terminology. >> so what would be the barrier to 90% to 95% of the cases that were caused by medical errors from recovering? >> they should be able to recover. what the health act would do would allow them to recover. so that they would be appropriately rewarded for what happened to them in their loss. the health act talks about that in terms of all of the economic elements that are involved, including their health care. >> mr. chairman, my time has expired. >> thank you, mr. scott.

the gentleman from pennsylvania, mr. marino, is recognized for his questions. >> mr. chairman, i yield my time. thank you. >> all right. we'll go to the gentlewoman from florida for her questions. miss adams. >> thank you, mr. chair. miss doroshow, i was looking thinite of mdinetu d u ceditin yur en statements and in your packet and it says that as many as 98,000 patients die annually due to medical errors, and what we found was it has shown to be exaggerated and unreliable. isn't that true? because based on shortly after its release in 2000, the study came under heavy criticism for imprecise methodology that greatly overstated the rate of deaths from medical errors. for example, the study data treated deaths from drug abuse

as medication errors, and dr. troy brennan, the lead harvard researcher, who compiled much of the data upon the report, which was based, later revisited his methodology and determined that the actual figure could be as little as 10% of the oim's estimate. is that true? >> well, what's true is that many other studies since then have found far more than 98,000 deaths. many other institutions that have looked into it, and just in november, hhs took a look at this issue again and they found that one in seven patients in hospitals are victims of an adverse event and 44% of them are preventible. also, there was a study just also released in november of north carolina hospitals, north carolina is supposed to be a leader in patient safety, basically finding that since the institute of medicine report, patient safety has not improved

at all and it really kind of shocked the authors of this research study and they found that the errors that are causing deaths and injuries are continuing at an epidemic rate. so i would say that the 98,000 fire ath point is lowand has been probably upped by every patient and government study that has looked into it since. >> so your testimony is that every adverse event is a medical malpractice issue? >> i'm looking at the studies and how they define it, and in for example the hhs study, they found one in seven medicare patients are the victim of an adverse event and 44% are preventible. >> again, are you saying that -- >> preventible errors -- >> isn't adverse, in your eyes, is an adverse event medical malpractice? >> a preventible adverse event is. >> the other thing i wanted to know is, i know who dr. hoven is

representing and i know who dr. weinstein's representing, but i couldn't find in your documentation where the justic center for democracy and justice gets its fuing. could you provide the committee with a list of your fellow and associate members so we have an accurate understanding of the point of view which you are representing, and also, you mentioned the demo projects and they are going to get grant funding. are you or anybody associated with the center for justice and democracy able to apply for those grants? >> apply for which grants? >> the ones for the research thatou were spking about earlier. >> well, we are tiny. we have about five people on our staff. we are not a high budget operation. so we don't really have the staff to do research projects like that. we hope other people would do that. >> again, i would like to know, like your fellow and associate members, are they going to be applying for those grants?

>> our associate members, i would have no information about any of that. i don't know. those grants were already -- that process has already taken place. hhs has already granted the money in new york, for example, it granted $3 million to the office of court administration in conjunction with the department of health that is looking at a specific proposal that was presented to them. so actually, i know a lot about that proposal. i know about a few of the others, but that has already happened. >> are you aware, and this goes to all three of you and i think dr. weinstein and dr. hoven have said this and i want to make reourea, al,he arceairossnsnth dil el tt have stopped practicing because they can't see enough patients in order to cover their insurance cost. just the cost alone, not because they have done anything wrong,

but they cannot see enough patients to cover their malpractice insurance cost. >> well, i hopeat yore e at 6, av n ftnsan rt. at wyo d'tear a loerbo dtopietg on state legislatures and capitals and trauma centers, et cetera, that we did in the early part of the 2000s when we were in a hard insurance market, when rates were going up 100%, 200% for doctors. this is a cyclical industry. this has happened in the past 30 years when rasah u ts. ie t gaste h anhi tdoititou ul tobes engineered large awards in 1975, then stopped for ten years, then did it again from 1986 to 1988, then stopped for 17 years, and then started up again in 2001. ofoue,tht' ner en ue thclmsavelwsee steady and stable, so what's driving insurance, rate hikes is

the insurance and accounting practices of the insurance industry. the solutions to that problem lie with the insurance industry. they should not be solved on the backs of injured patients. >> i see my time has expired. >> thank you, miss adams. the gentlewoman from texas, miss jackson-lee, is recognized for her questions. >> thank you. let me thank all the witnesses for their presence here today. i want you to know that each of your presentations are particularly respected and admired. i want to start with the representative from dr. hoven, from the american medical association, and coming from houston, i think many of you are aware, proudly so, for me, that we have one of the greatest medical centers in the world, the texas medical center. i'm very proud of recent $150

million private donation just recently received by the texas -- by m.d. anderson so i have a great familiarity with a lot of physicians and applaud their work and thank them for some of the life-saving research they have been engaged in. but building on the present national law which is, of course, the patient protection and the affordable care act, dr. hoven, one of your peers, one of yo cleuewhhaen t see ts odenor it iicedha that law was a fundamental platform upon which we could now base our desire to go forward, to have additional provisions, so i just want to get a clear understanding. it's my understanding the american medical association supported the bill. is that correct? >> the american medical association supported parts of the bill. we believe that access to care

covering the uninsured, decreasing costs and improving quality are very, very important first steps. >> so you would not -- you're telling me doctors would not support eliminating the pre-existing conditions and allowing children to stay on their insurance until age 26? >> we do support that. >> so i think a great part of the bill, you did and you probably would -- i'm not sure, maybe because you're before a large group that you don't want to say that the ama supported it, but it was my understanding that they did. i see someone shaking their head behind you. do you support the bill? did the ama support the bill? >> the ama did support the bill. we recognized it is an imperfect bill. >> you are absolutely right. i will assure you, those of us who are lawyers as well agree with you, because it is very difficult to write a perfect bill, but as dr. fritz said, this is a bill that is the law of the land. he even said he would have voted for it. i want to clear the record that this is a bill that really does answer a lot of questions but we can always do better.

let me indicate to miss doroshow, if i have it correctly, in the process of hearings, we have witnesses that represent the majority view, majority is represented by republicans, chaired by mr. smith and we have a right to have a witness that maybe has a different perspective. so to inquire of your fundinger on whether you're getting grants, every hearing, we will find that we will have witnesses that will agree with the predominant view by the majority but we'll also have in this democracy, the right to have a different view. i suppose you have a different view from the health act that is before us. is that correct? there is a bill that you have a slightly different view, is that my understanding, between this question dealing with tort reform or medic malpracti? >> i rtnly he a dfferen ew fromth other witnesses, yes. >>es. that's t point i'm making. >> yes. >> let me inquire and as i do

that, i think the point that i wanted to engage with dr. hoven was to say that i want to find every way that we can work with physicians. i want their doors to be open, i want them to be in community health clinics, i want them to have their own private practice, i want them to be og-gyn. in fact, dr. natalie carroll daly, former president of the national medical association, i count her as a very dear friend but also someone who counsels me. let me be very clear. answer these two questions. what is the reality of how many frivolous lawsuits we have? you have a notation of the ho harvard school of public health. number two, insurance companies, isn't that the crux of the problem? are patients the ones charging doctors $120,000 for insurance or is it the insurance companies who have documented that they will not lower costs even if

there is a low count of medical malpractice lawsuits in that doctor's area, in that doctor's office and in that state? isn't that true? >> absolutely. >> would you just comment very quickly? let me as i say that, say to you my mother had a pacemaker for 20 years. she had a procedure to give her a new one. the next day she was dead. i would like you to be able to answer my questions if the chairman would indulge your answer, please. >> in terms of the harvard study, this is important because this is the study that gets i think misrepresented often and figures about 40% of cases are frivolous. actually, the harvard study found the exact opposite. in fact, i will read the quote from the author of that study, the leadoff. some critics have suggested that the malpractice system is inundated with groundless lawsuits and that whether a plaintiff recovers money is like a random lottery, virtually unrelated to whether the claim has merit. these findings, the harvard school of public health

findings, casts doubt on that view by showing that most malpractice claims involve inrythlaitror and sou riarfa relio idhait. there is a lot of extensive research done on that study and the headline of harvard press release was study casts doubt on claims that medical malpractice system is plagued by frivolous lawsuits. >> you didn't -- the gentlewoman's time has expired. thank you, miss doroshow. we will recognize the gentleman from virginia, mr. forbes, for his questions. >> thank you, mr. chairman. i want to thank all of our witnesses. i truly believe all three of you are here to do what you think is in the best interest of our patients and of the united states. i feel the same way about the members that w h e, bueavspif ci cotituencies. as much as i love the chairman, i know there are times that he's from texas and he has a texas constituency. the gentleman from arkansas has an arkansas constituency.

gentlewoman from florida has a florida constituency. that's what we tell everybody, the gentleman from florida, the gentleman from arkansas. i think it's important that we know when you're stifying who your constituencies are and two of our witnesses have set that forward and the congresswoman adams asked what i think is a fair question to miss doroshow, and that is, if she would just be willing to give us your sources of public funding and your membership, would you make those public so we know who those constituencies >> we do not release the names and information about our donors, i will say we get different kinds of funding. we get foundation grants for example. in fact, i started the organization in 1998 and it was just myself sitting there writing letters to the editor with a little money from a friend of mine, and i got a large grant from the stern

family fund. >> i have five minutes. the answer is you won't let us know the membershian irs ofuing? >> asote nt. ka we'll take that into account, and let me just say that sometimes this is not as complex as we try to make it. eli haerod a hoat ris doo e issues, they know when you're talking about changing tort reform, who the true beneficiaries of that are. they are the trial lawyers. they put the dollars behind it. the trial lawyers sit here and tell us if we don't do this, we will be impacted, and we could be losing o jobs on the other hand,enow who so othe major beneficiaries are if we do tort reform and that's the doctors and they say, hey, if we don't do this, we could lose our jobs. e, h ti a singleesting things

constituent walk up to me and say i'm worried because i n't findrial lawy o tre, bui ha them ming or a over to me now truly worried they cannot find doctors to represent them, and doctors, tht sometimes falls on hollow ground because the same people that point and say, oh, yeah, we cant do malpractice reform because it's 3% of doctors fight us every time we try to get rid of the 3% of bad doctors just like getting rid of 3% of bad teachers. my question to all three oou is ts. i'm firm believe in modeli and simulation. we use it in the arm services committee to model for us our most difficult weapon systems, military strategies. we are so confident in it

although we know there's flaws that we put the entire defense of the united states sometimes on modeling and simulation that we can do. do we have any efforts at modeling and simulation that would help show us what the health care world would be like if we did tort reform, and if we got rid of the litigation and whether it benefits us or not, and if we don't, what can we do oelrlp you move forward inths th'she tes rorm and cafornia wita long hior the taseformbvus shows lowering premiums, but increasing numbers of critical specialists also in underserved counties. if i might, can i come back to the issue of the lawsuits? >> absolutely. >> congresswoman adams asked about this, and i think the

issues is the data would be 64% of suits are withdrawn, dropped, or dismissed because they lack merit. less than 1% are decided for the plaintiff, and when you come to the new york study which is call the the harvard study looking at new york data, you're talking about extrapolation of 280 cases of error, and in that study, errors could be someone falling in the hallway walking, and that's lumpled together with a surgical error. the study has been flawed. >>my tis up. i don't man to cut youff, but i wnted tosaythe point you made of california and texas is so accurate. we're going to do demonstration projects, but you have two big projects, and if we ignore those, we'll ignore the others. i don't have time for your answer, but can you submit it in

writing, we'd love to have it. i yield back. >> thank you. the gentleman from north carolina, mr. watt is recognized. >> thank you, mr. chairman, and let me apologize to the witnesses. i had to believe to go to a meeting and didn't hear anything other than a small part of the first witness' testimony, but i assure you i will read it. i didn't come back to ask questions about what you said because i didn't hear what you said. i came back really to make sure that a perspective that i have on this issue gets into the record because this is where i differ with a lot of my colleagues who thought this was

an inappropriate issue to deal with in the u.s. house judiciary committee. i'm kind of a states rights old school guy on this, and i have always believed that tort law was a matter of state law. i can see that we have the authority to right tort standards for medicare recipient s and for others we do, but general tort law from my perspective has always been a matter of state law. i happen to live in charlotte, north carolina, and that is right on the skas -- south carolina line, but i have

never seen a hospital that straddles the line. they don't operate -- i've never seen a medical pocur tke ple teta cmee. i can see the used stuff that comes through state commerce. everything we do comes through interstate commerce, but i just think that this is an issue that my conservative colleagues, the state rights have lost their way on, and were i a member of the north carolina state legislature, perhaps i would listen very intent to whether we need to in north carola do tort reform, and they have at the state legislature level in

north carolina -- i happen to think they are as intelligent and bright in the state legislature of north carolina as we happen to be here in the congress of the united states. we don't have any monopoly on that, on knowledge of this issue. it is a state issue. it is historically been a state issue, and i think my conservative colleagues have lost their way trying to make this a federal issue, so i want that in the record. used to be the chair of the states rights caucus on this committee. maybe this is one of those times that i got that reputation as being the chair of the states rights caucus, but we can debate

state by state and whether we should be.cc this. we can apply other standards on medicaid recipients, but i just think as a general proposition, having a debate about doing general tort law reform in the congress of the united states offends that constitution that we read the first day of this session on the floor, so that's my perspective. i appreciate you all being here as witnesses, but i didn't wnt toisshe opptutyo put th per srgve inhe -- perspective in the records in public, not that i even done it before -- [laughter] if you go bcko the11 core, 10th congress 1th congress, and all the way back to when the started, whatever congress that was, i think i've

because we have been talking about this for the 18 years that i've been here, and my position on it hasn't changed. we don't do malpractice interstate, and doctors operating on somebody who lives in another state, they can get in the federal courted and apply whatever state law it is, apply it in that jurisdiction, so that's my story, sticking to it. i appreciate the -- >> willheenemid? >>on'taveimef >>the timexred. we appreciate his consistency over the years in interstate rights and appreciate him being an original founder on the judiciary committee. now to mr. griffin for his questions. >> thank you, mr. chairman,

excuse me. dr. weinstein, i'm interested in the gallop poll that came out in february of 2010. i've talked to doctors in my district who are advocates for medical reliability form, and during the last year, this poll came out, and i was struck by the numbers, and i saw that you referenced this gallop poll in your statement. the first question i have for you is the data in this gallop poll, the one that came out in february, is it consistent with other data that you've seen particularly the point that physicians attributed 26% of overall health care cost to the practice of defensive medicine, and then secondly that the 73%

of the physicians agreed they have praiced some form of defensive medicine in the past 12 months. my first question is whether that data in the gallop poll is consistent with data you have seen elsewhere? >> i think the data on the cost of the defensive medicine is crrbly low estimates of $56 billion in ten years to $650 billion. you can go back to other studies looking at it, and the costs are astronomic. physicians practice defensive medicine. it has not gone away. a very well done study by lawyers, this harvard group, show 90% of doctors practice defensive practices. doctors in training in the residencies in pennsylvania found that 81% felt they could

not be honest with patients. they view parents as lawsuits. 28% of residence across the spectrum in pennsylvania regretted their choice of becoming a doctor because of the liability crisis. >> with regard to the pennsylvania data that you're discussing, have you turned that data over to the committee? >> yes, sir, that's in the written testimony in reference to that. >> okay. what procedures could you give us specifics on the procedures that are ual subject to th actice of fee medicine? >> sure. there's two areas. one is assurance behavior. assure yourself you haven't missed something. it's pointed out, but in medical school you have a history, a physical examination, and put this puzzle together. occasionally you need a lab test or an imaging study, and then you take it in orderly progression, but the climate of

spheef that exists from the medical standpoint is such that you need to keep taking that progression, an orderly progression from to the end from the beginning. should you miss something, your life and ability to practice medicine and your craft is over. that's the assurance behavior. avoidance behavior is most medical students come out of medical school with over $100,000 in debt. when they choose a career, they come out of our residency able too take care of anybodybrought in from the highway, had an injury, put them together again, but the majority of them don't want to do that and cover the emergency room because that's high risk. you avoid ob, emergency rooms, head injuries, oragli h gettingc

procedures subject to that, you mentioned head injuries, you mentioned ob jsh gyn, -- ob/gyn, but can you be more specific? >> head injuries, there's few surgeons wanting to take care of head injuries on a child. 40% of ob/gyn were doing delivers. ob gyn now they get out at age 48. that's a mid career point. there's another 20 years of practice, but now they stopped practices add age 48 because of the liability risk. iou he a numr oes beg couc using equipment and resources and in some instances, they are not necessary. they are more to assure or to

avoid, can you comment on that crowding out test that need to be conducted that are necessary? >> yeah, i think when you crowd a system with, i don't say they are unnecessary tests, t gelen earli kd o plied es tests are illegal and defrauding medicarement i think that's not the truth, but sillas i mtiedwh yourogreso sveule in taking care of a patient, you follow an orderly progression. if that didn't work, we'll do this test, but we can't afford to do that anymore. what happens is you use valuable resources, imaging resources in particular to do defensive message to take that step number ten bringing it down to step number two and deprive someone who actually needs that resource from the use of it. >> so if a young child with a

head injury comes into the emergency room, an ideal situation is a doctor looks at that child and says i'm starting at step one, and if i need to go to step 2 on the way to 10, i'll do that progressively, but in the current environment, they see the child and automatically say, we have to do 1-10. >> well, i think if there's a peedeaturonilng dohaurger a t hospital because three quarters are at risk because of a lack of on-call specialists, that doctor will receive the entire battery from step one, not necessarily in an orderly progressive fashion that you learned in medical school. >> thank you, mr. griffin. appreciate the questions. the gentleman from georgia, mr. johnson who went to law school in texas.

he's recognized for questions. >> thank you, mr. chairman. dr. weinstein, it's a fact that doctors are human beings? [laughter] >> yes, sir, they are. >> and it's also a fact that human beings aoterct isn't that true? >> absolutely. >> so doctors just like human beings make mistakes. would you disagree with that? >> errors occur. >> errors occur. mistakes can be made. isn't that true? >> th and so, now when a doctor makes a mistake, it can cause a deh or itanae

mish qli of life in the victim, anybody disagree with that? hearing no objection or nothing, i assume that you agree with me on that. now, that diminished life of a victim of what i'll refer to as medical negligence, it has a value that a jury puts on it and we call that noneconomic flaws, what do we call that? noneconomic laws, recovery for -- >> permanent disability, blindness, disfigurement,

mutilation. >> pain and suffering for whatever may arise as a result of the doctor's negligence. pain and suffering, noneconomic loss. that is worth something, don't you think? now, the question is how much is pain and suffering worth? that might be a little different for scott who back in little rock arkansas in 2007, 2007,29-year-old went for a partial thyroid deckmy and later she developed a shortness of breath and felt the neck tighten. her condition was not apopriatyonorr poedo a ysia

wen respiraty arrest and suffered severe brain dage itasisvedhe h aome meatthe site of the surgery. she now bedridden and dependent on her mother for care. now, that's pufferring. do you think that pain and suffering is worth more than an arbitrary cap of $250,000? if you do, i disagree with you. if you think that the dy out in denver should be limited 250,000 for pufferring, she went to a denver hospital for kidney stone surgery in february of 2009. six weeks later, her health deteriorated with feelings of exhaustion and a loss of appetite. after a week of her illness, she

was jaundiced with an inflamed liver. the doctors at anker gent care clinic diagnosed her with hepatitis c. 35 other patients became infected from that hospital at the same time. hoitff person who used hospital ries and inkillsurgru ue. enced to a lifetime of pai and suffering. w much of is that worth? is that worth $250,000? no. it's worth a whole lot more than that, and what this legislation

does is put an arbitrary cap of $250,000 on noneconomic losses on pain and suffering. it is actually in the frontf e ited stesonitutio e 7 amdmt, whh guarantees people a right to a jurylx $20, so on one hand, we're talking about eliminating health care for everybody, and now we're talking about one day later, we're talking about denying access to the courts for people who have, who have been hurt, and that's about all i got to say. thank you, mr. chairman. >> thank you. the time expired. next chair recognizes mr. rach from florida. >> thank you.

being from florida, we did research and saw for an internal medicine, they pay $57,000 for malpractice, but in minnesota, it's more than $3,000 which makes you wonder if the injuries are more severe in florida than minnesota or as a result of the litigation environment. i want to step away from the parts we've been talking about, but talk about the procedure. for example, in my practice, i will probably say that the vast majority of my cases have resolve at the mediation level whether it's court ordered or voluntary mediation seems to work. i guess i would ask would you not agree that dispute resolution as opposed to actual trial is more efficient, more effective in getting the needed benefits to the injured party? >> 90% of cases do settle, but it's because of the threat of a jury trail, the possibility of a jury trial that that happens, and you take away the jury trial option, and that won't happen. >> i'm not saying that, but i'm

also saying when you're in the dispute resolution, a lot of factors come into play where you want to stt the hets o lw. sas,t' a burden of proof is it not? >> the studies i looked at is the cases settled is there's negligence, injury, the cases that end up, a small number of cases that go to trial, the ones where it's a little more than unclear, and they need a child to re-- a trial to resolve it. i think the system as it rightow i vy eicnt cause st case settlnd that's really, that's a system that really shouldn't be played around with. >> in terms of burden of proof, many have evidence rather than clear and convincing. burden of proof will be a factor whether a party -- >> well, the example in texas for emergency room injury, they made the burden of proof so

difficult that it's knocked out every single emergency room negligence case, so what has happed there is the state of care and emergency rooms have become much more unsafe. the state law does determine that.h ti that physician groups subscribe to? >> thank you for that question, yes. thmaaseeupfront going rwardin th mid-90s in terms of quality guidelines, outcome objectives. we have had a major role in this and it is now standard of care. these guidelines are extremely useful 234 allowing us tore -- in allowing us for evidence based care. >> not only essential, but they lead to defensive practice of

medicine. if this diagnosis is made and this former treatment is required, sometimes physicians may do that even though they may not need to just to say within the realms of the practice protocols. >> that's correct. in fact, legislation needs to be out there that gives need using clinical judgment and clinical knowledge the ability to provide the best care for ttatnt tharcur in i me wodn ygr i w taisd practiced protocols and require by way of the funding of medicaid or medicaree protocols are followed and the burden of proof would then have to shift from the physician to the plaintiff to show that by way of either of clear and convincing evidence they deviated from the practice protocols or committed errors, would that in and of itself provide a substantial reduction in the amount of litigation and

thamountofawds o tre >>el ihinkir a, l medical groups have been working on guidelines appropriate for this criteria to help physicians establish a safer method of practice, but all patients don't fit in every single guideline. patients are individuals. they provide a general framework in which to start, but it's not a one-size fit all. medicine is not a cook book that you follow this step and go this step. it's a physician interacting using their clinical skills to determine whether that guideline fits that particular patient or that appropriateness criteria to deviate for that issue. >> no those cases where practice protocols are deployed, should not the practicing physician have at least the defense that the burden of proof would now shift to the doctor established

he did the following protocols required of that particular specialty and now must be a showing by a greater weight of the evidence that the physician deviated from or committed error? >> again, i'm not a lawyer. the guidelines are very good foundations for me as a practitioner to look at when i see an individual patient, but i have to use my skill and judgment acquired in 35 years of practicing medicine to decide if my patient fits exactly that paradigm, otherwise i need to have the ability to not have my hands tied or i hurt the patients. >> the time expired. gentleman fro of narrowly tailored questions in hopes of a narrow answer, ok ang

of lawsuits that are dismissed orwhosraed >> i think rule 11 is positioned enough -- >> i would prefer that of taking away the rights of victims -- >> i may not have phrased the question well. do you support a toughening of rule 11 sanctions for frivolous lawsuit? >> i think that -- obviously what has to see the provision. i don't have a problem with that. >> the answer is you don't have a problem with that? >> i don't he aroemi at >> u spp tt? iprid, looked at what you were asking me to support. >> how about this. how about joining several liability forms. do you support that? >> absolutely not. >> do you support a hh quantum

of proof for emergency care? >> absolutely not. >> do you support any tort reform? >> i support provisions that would repeal tort reforms currently in existence in states, absolutely. >> do you support any tort reform? >> for example? >> i just gave you four of them. >> i support a law that would prohibit confidential settlements where there are public health and safet issues involved m oos the currentt tort health care law because in our judgment individual man day-to-day is beginning to make the commerce clause to be e mori miss. for those of us who want to support to the reform, draw the connection for us where it's an appropriate use of congressional

d u'weto grant st nd ste d scope of issues if you federalize tort reform? >> there's a role for both. the law we're talking about, the health act, in fact, supports states in what they have already done and profited and putting into pce. intates that don't have it such as mine, kentucky, we desperately need federal legislation to get us to a different place for all the reasons i've talked about before which have to do with access and cost. there's a role for both, but they recognize i believe would achieve what we're looking for in the global topic of medical liability reform. >> would you say the health act recognizes that, you're referring specifically to the state flexibility provision that doesn't plant current state law? >> that is correct. is there any concern that if you allow congressional encrchment

inthe area, they want a scope of issues between ophthalmologists and other traditional state issues? >> no, these are two separate issues. we fully recognize scope of practice issues. we have beenoihor ar a yar es a o su. on lwehe bar on the commerce klaus by tort reform in >> i trust you. >> i' a lawyer,don't. [laughter] >> final question, more implicit in the questions asked this morning has been very thinly vailed accusations for health care for all, medicare for all of what we consider to be defensive medicine. would you take a crack at explaning the predicament that they find themselves in with densive medine

>>s phyciou ve skills, history, physical examination, tests, there's an orderly progression, if this turns this way, go in this direction or another direction, but what happens is if you have this progression of multiple steps to get to the end, you don't stop at square one and say let's see how it works? if the treatment doesn't work, let's do something else. from the doge nos tick stand point r you do everything for fear there's an adverse outcome or something happens, then you are at risk. what happens is that the patient gettings everything that's out there under the sun as oppose the to just a step wise progression to an oralely diagnosis or management plan. >> i'd like to thank all three panelists and thank mr. chairman. >> thank youenemro

aron tnkyo m hama a thkso all of you for showing up and this is a very important topic if we're going to address and take corol of our health care costs and going forward, this is an important thing to have access to quality of care. first question is to dr. weinstein. specialties faced the brunt of lawsuits, but over the last decade as insurance premiums rise exponentially, while some leveledr--unt of abusive lawsui. while some insurance premiums have leveled off recently or decreased slightly in some areas, they remain a serious burden for many doctors across the country. moreover with the implementation of the new health care bill, we may discover this has been a brief lull before the storm. can you expand on what you mean by the brief lull before the storm and why the insurance premiums may have gone off in a lull for a short amount of time? >> i think we're in a lull, if

you will, until we see how the health care reform act plays out and what happens here in this body and across the way. i think that right now we need to look at the provisions of that and what actually becomes law, what actually is high blood pressure medicine for the patient. that patient had an automobile accident where someone is killed and now the physician is being sued for not treating the patient's hypertension. there's avenues to be pursued. the front page story of the "new york times" in november showed how investment banks are investing in medical liability lawsuits. this is big money. this is big business, and it's unfortunate, but i think with the new health care law, we'll have to see how things unfold and what happens as to what avenues are opened by that. staying on that with the high-risk specialties and look at the doctor, the aging doctor population that's happening, you

don't have many people going into the profession and the high risk specialties. if we cannot actually control the little insurance costs and people don't, how will that affect the quality of care for these different areas of expertise? >> well, when you lose high-risk specialty, i think every american is in danger when they have a problem, let's say, you know, your state of arizona,lave trmaenrs aaiblin reasonable distance, minutes matter, and i think the american public can now no longer to expect traveling on the highway, expect that they are going to an emergency room to be saved. that is unrealistic expectation because the shortage of high risk specialists, and where they are, they are unwilling to put themselves at risk by taking on high-risk cases. >> do you know -- even i know from talking to some people i know in the ob/gyn

profession, it's over $100,000 in areas to turn the lights on. what's the average? >> i ink the rangesre siifan canndepends on thste. in some areas in spine surgery, there's physicians paying several hundreds, 300,000 in ll y tra.is. ig iswoerhe was a big toll or doctors when they defend lawsuits, but what ishe otnato aowo t affectth dct-prk rope going forward? >> it's traumatic. doctors want to heal, provide care, and when all the sudden you are confronted with a lawsuit over which you have no control, or you are part of something else in the sued process, it devra devastates you. i was sued. i was sued. for five years after that, and

this goes to the issue of practicing defensive medicine, i refuse to add any new pairkts to my practe. i found myself constantly thinking what i have missed, thff t physician'st cre health. this affects their family's health, and most importantly, it begins to affect the relationship between the patients and the doctor because all of the sudden that threat, that fear of threat and trauma is out there. i consider myself a very good physician, and yet in that process, i felt that i was damaged by the process >> all right. thank you very much. mr. chairman, i yield back. thank you. >> we recognize the bcommiee at has posion overhis issu mr. fran fromrizonaor fi minus. >> thank you, mr. chairman.

dr. inein is you a rhs d. hovenyouan llow-uas well. components on health care liability knows that reforming the medical liability system through limiting noneconomic punitive damages leads to the practice of medicine itself being less safe. i think that's a pretty critical important question to answer. based on your experiencesdo you believe placinglimits on noneconomicmpugntive damages affects whether doctors practice high call medicine or not, sir? >> i don't. it's clear the current system we have neither protects patients who are resources, and when you talk about economic damages, those can be quantified whes you talkbout noconomic damages, there's no way that's quantifiable, and without

resources, it does not effect the quality care of a system such as that. >> do you have anything to add? >> i agree with the doctor's comments and also over ten years doctors and commissioners have taken huge leadership roles in moving medicine to a different place, improving qualities, diminishing errors, and so the discussion of liability in this setting is difficult because we, in fact, have made major, major strides in improving health care throughout this country. >> dr. weinstein, your written testimony talked about how how broken hurricane program disinsent vises people from performing high risk procedures or treating high risk patients.

how could legal reform similar to california's nicra or the health act which passed the house in 2003 here positively affect doctor's decisions to practice in high-risk specialties or tree high-risk patients? >> well, i think with reasonable reform, i think physician culture will change. physicians will then feel it's worth the riive. there's always a risk when talking about hi risk med sigh, but it's worth the risk to use the skills you learned in your training to help restore, function, e leaveuate pain and restor ones you outlined is implemented, that just won't happen. >> d hoven, you know, have to tell y just rsally, iemple extremely grateful to the

medical community because of having them have a tremendous impact on my own life. i had major surgeries from birth, so i think that, you know, the importance of allowing doctors to pursue that calling that they have to try to help heal fellow human beings is a profound significance in our society, and if i could ask a hypothetical or ask you to reach out ring if you could do one thing, and dr. weinst erk in, you can be on deck, if you can do one things in terms of public policy that we might pass that would strengthen the doctor-patient relationship that allows you as a doctor to work better if your patients and would also deliver the best care possible where you protect both the patient and the doctor and the entire medical process in terms of liability reform, what's one thing you would do?

what is the one priority you would tell us if you could only have one? >> thank you, thank you for your comments. the answer to that is stablization. the medical liability situation must be stabilized, and that stablization includes dressing economic and noneconomic payments. it also has to remove from us in that stablization the culture of fear, and when somebody's looking over our shoulder all of the time, and that will improve and continue to enhance the patient-physician relationship. it will stabilize care in this country. it will improve access to care, and it will improve quality. >> thank you. >> i would say we need a rational solution to this situation because right now it's irrational. nobody benefited from it, and unless we do have some type of stability, injured patients will not get compensated

appropriately, and the system will never get better because system errors require a system of transparency, and you can on have that system when you have a stabl situation where everyone works together towards a safe end in making a safer health care system. >> thank you. >> gentleman from virginia is recognized for five minutes. >> i'd like to follow up on a question by the gentleman asked from south carolina. the question asked whether you support a higher proof of negligence or substandard care for emergency care, and yousaid not just no, but absolutely not. if we have, and all of us have some time or another been in a theater, a sporting event, when somebody becomes injured or ill, and the first question is is there a doctor inhe hse w, you expehat dctorto

idenfy themlv and come forward and help that individuals if they know very little about thecircstan, meca recds ar previouss history treatment, what they are allergic to, to try to save their life? you wouldn't provide a higher standard of protection for those doctors in those circumstances? >> the standard is already high. you're not finding lots of emergency room cases moving forward in this country, but when you do that, first of all, the emergency room according to -- >> so you would support a higher standard -- >> no. >> that's the questi asked higher standard of negligence or sobodynn engy situio >> temgeyrosarhe most unsafe and dangerous parts of the hospital. that's according to the institute of medicine. >> how about -- >> manyeople who go -- >> how about a theater or a sporting event or somebody injured in an accident on the

highway or a doctor happens to come by to provide assistance? >> i believe that the civil justice system that exists in this country is able to handle cases that go forward based on the state common law that exists, that has been developed by the state. if the state common law and frankly if the state decide -- >> reclaiming my time. most states have scic stuty liilyrosions >> ll lk-- >>n ddiotothomn w. >> look at texas. what happened in texas is they have made the standard of linnet for emergency room malpractice so high that it is knocked out virtually all cases. you have a situation where a woman was in an emergency room, was misdiagnosed.

as a result of that, her legs have been cut off. >> well, i'm beginning to reclaim my time because i'm limited to tell you you are avoiding my question. >> i'm not. >> what about in the highway, theater, sporting event, public, away from a facility, a doctor provides care, volunteers that care under circumstances, different than the emergency room. i agree emergency rooms are different than other standards of care as well, but in an emergency itself, should a doctor have greater protection? >> i believe that the law should be what the state common law is. >> i'm going on to another question. thank you. dr. hoven, some argue lowering the malpractice bill doesn't benefit patients. i don't agree with that. what are your views? >> i disagree as well. it is clear that a liability

costs have to be something to budget for and build into the cost of running a practice or a clinic. money that i don't spend on liability insurance, i can and do turn back into practice to retain a nurse to provide care to 100 diabetic parties so the costs are lawyer. i think we have to be careful in this phrasing, but in actuality, if i can bument, i know what my moneys are going to be, they are not out of site, i can improve quality and care and clear and access to my patients. >> "newsweek" magazine reported that younger physicians are especially frustrated with practicing defensive medicine between rising insurance rates, increasing defensive medicine, and the regulations in bureaucracy in the new health care law, are you concerned that in the future fewer of our best young students will choose to pursue medical careers? >> yes, the evidence there is clear. it is born out in the two

chartable trust study by the harvard group and columbia university legal team that shows that physicians in all residencies are discouraged number one to be doctors, 28% regretted choosing medicine as a career, and that 81% viewed every patient they encounter as a potential lawsuit. i think this is a teacial state of affairs. the younger generation is profoundly affected in career choices, practice locations, and the context in which they practice. in other words, what they cut down their skill set to and what they are willing to offer the community in which they live. >> they can spend a lot of years and hundreds of thousands of dollars to receive a line to practice medicine, and the cost then of liability insurance and the risk if they have to make a claim against that insurance or more than one claim against that

insurance to mare future as a physician, what is that risk? >> i think the issue here is there are plenty of people who need good medical care that are not necessarily high risk, and if you feel you can have a satisfactory practice without putting your life and family at risk by up necessary liability -- unnecessary liability, many younger physicians are taking that ruth. >> that is, indeed, the crux of the problem. the quality of medical care and the availability of medical care is very much affected by the perception of the medical profession and the reality to the medical provings of the current standards with regard to medical liability. >> yeah, there's no question that access in quality of care is profoundly affected by the current situation. >> thank you, thank you, mr. chairman. >> thank you. i yield myself five minutes. i come to this as everybody else as a product of my experience, i

confessed my dad was a doctor. he was board certified cardiologist, chief of staff in the hospital in southern california. i was his wayward son going to law school, but i spent five years doing medical medical malpractice defense and some other cases in california. my practice bracted the time before and after mcr fo anyon tugstha di't make a difference, you weren't there. i happen to be a young attorney at the time, and i had some classmates from high school and college who went to medical school, and they were about ready to enter the practice of medicine, and a number of them left california because the insurance rates for so high. a good friend of mine left the state. some ob/gyn's i knew left the state.

some doctors involved in brain surgery ft the sate becau ofhe high cost i don't ow whe uet these figures th it was not until 88 we saw progress because the absolute increase on a yearly basis of the premiums paid for by the doctors leveled off after we passed micra. it was interesting to hear the gentleman from georgia talk about noneconomic damages. that's true. it puts a limit on noneconomic damages, pain and suffering, why? because that's the most abused part of the system. i can prove losses for future earnings. i can prove what the costs are, the direct costs. pain and suffering, i mean, if you think about it, before an instant you were to ask somebody how much is it worth to you to lose your arm or your leg?

they'd say you couldn't pay me enough money to do that. after the fact when you talk about pain and suffering, it's a ryifcu figur to tein a s yak a rational judgment by the legislature or the people as to what that limit would be because otherwise it has an adverse effect on the potential for people having clear and access to medical care. it's not a perfect system. it never has been a perfect system. i'll just say from my stand point as someone there when we passed it in california, we saw a tremendous difference. there's people talking about frivolous lawsuits. let's talk about the real world. when a plaintiff's attorney files a lawsuit, agains the lawsuit, he or she sues everybody in sight because he or she can't be sure who was responsible. by the time you get to trial,

you ought to know as the plaintiff, plaintiff's attorney, who you think really is responsible, and you ought to let out the other people, and if you don't, we ought to have a very simple modifiedos y prisnhaathe t o trl, you can present to the judge and say if they have no case, or they get less than what i am offering now, all attorney fees and costs should be born by the plaintiff. i was in settlement conferences where the judge would say to me, i know your hospital or i know doctors c doesn't have liability, but the cost of the defense is $10,000, so throw in $10,000, and that was considered a quote-on-quote settlement. in every case i'm aware of, you have that dilem,nd w yore gv cas o malpractice, a lot of

other people are involved in the case, and they may settle out, buthe w reia, anunssouort hae that dynamic, you're going to have this situation, soa orcom rucnctoo thn a federal level because i thought california was heading the rest of the country when we did what we did, but i am -- i'm sorry the friend from north carolina is not here because he said clearly to me that health care is not covered by the congress clause, so i would hope that he'll make that presentation before the courts that are considering lawsuits right now. i don't have questions for you, i'm sorry, but just listening to everything. i have to put it into my sense of -- no, no, he said someone is not taken care of a state border. he's in a hospital there or

there. that's not interstate commerce. that's what he said. it's not covered by the commerce clause. anyway, having heard all of this, it brings me back to the arguments that we made in california in 1974 and 1975, and we made a reasonable judgment in california, frankly, i think it's work very, very well, it's a model for the rest of the country, and i don't think there's any doubt that the specialties available to california are available to larger numbers today than they would have been had we not passed micra. there's no perfect system. i think we all recognize it. what we're trying to do is define that which will give us the best overall response to a continuing problem. or challenge, how do we provide health care for the people of the united states? last note is, i take my hat off to the medical community because i had major surgery at 4, five

new surgeries, i have a new hip, new knee, replaced my heel, i'm a walking example of what medical care does for people in the united states. my wife says i'm getting older, and i say, yeah, but i'm getting new parts. ..

♪ >> washington, d.c. the capitol of the most powerful nation on earth where decisions are made that affect the entire world, including canada through, it's friend and next-door neighbor. let's face it, the relationship is one indeed the world over but that's not to say that when decisions are taken in the hallways of government in this town the way that canadian interests are always heard or considered, or that canadians don't sometimes feel ignored or even exploited by the relationship. but canada is important here. washington is a city of breathtaking monuments and world renowned museums. and yet, just look at the prominent location of the canadian embassy here. it sits right on pennsylvania avenue, between the capitol building and the white house. in fact, it's the only embassy

located so close to the capitol building. and right next door to the embassy is one of the great washington attractions, the museum that traces the history of journalism from the 16th century to the modern-day. it's interactive and features canadiancontent, too. at the newseum is our host tonight for this town hall event. in conversation with mclean as we ask canada and the u.s., best friends or perfect strangers? >> hello, everyone. welcome to our viewers watching us on cpac in canada and to their american friends watching on c-span this evening. this is a chance for us to bring together an impressive group of people, talk about the current state of canada, u.s. relations and that is what we are going to be doing tonight. we are going to be covering all of those topics you think we should cover, trade and security, the border, energy and

the environment. we will be talking about a social policy, our attitudes toward each other. all of those things we need to talk about. and there's something else that we really need to get setled herisening how an e ashinon capal have aay better hockey team? [applause] there are canadians playing well there are americans playing for the senators and american planning for the capitals so i've come to the conclusion it has to be a russian thing. [laughter] but that's for another show. for this show we were together a group of pepl whc sd tmeoulight t iue we we lkg autth seong. e ve dp owdgf canada u.s. relief actions because they spent a lot of times on both sides of the border, some of them have even been part of the decision making process so let me tell you we have here this evening david frum is a citizen of both canada and the united states born in toronto living in washington. he's a best-selling author, journalist and conservative commentator. cana, mewresengrgand

was once briefly arrested by a guard who did not believe the canadian national was permitted to have a job in the white house. he's also the editor of the website frumforum.com. christopher sands a senior fellow at the hudson institute where he specializes in u.s.-canada relations. he lectures at the johns hopkins university school of international at fenster study and adjunct professor and government of the american university school of public affairs. he's also been a fulbright scholar and a visiting fellow at the norman patterson school of international affairs at carleton university in iowa. mary scott greenwood, scotty as we know her, is a managing director of the law firm at the washington office and specializes in trade policy issues on both sides of rd, d e'theci reorf e naan eranusescoci shwalsapinedy president clinton to serve as chief of staff at the united states embassy in canada.

pamela's a conservative senator from canada, the chair of the senate committ on national security and defense and also serves on the senate committee on foreign affairs and international trade. she was canada's consul general in new york for 20 o2 2006. the former broadcast journalist is also a senior adviser on canada and u.s. relations at the american society and the council of the americas, new york and washington. and gary doer was appointed canada's ambassador to the united states in october, 2009. ten years before tt wa woin xtense wth.s steron cro bder ises chs trade, climate change, water protection and agriculture. now in his new role, he inalofhothi tat thcadi iesrsa t don itonnd that includes fighting protectionist sentiment in some circles and still from time to time dispelling the myth that line 11 terrorists entered the u.s. from canada. and as always, andrew quinn, the editor of maclean's is with us and paul well, the columnist to

back to all of you in a minute but let me bring in luby's to get the discussion started and get a sense where the state of relations are between the two countries. louise has been a reporter for seven years, five of those years bureau chief with maclean. where is canada on the radar these days? >> it is a very small blib. that's not necessarily a bad thing. the countries that to get the oxygen in the air when you have a discussion as china, north korea, iraq, iran, and these are the countries that worry policymakers and the white house that they spend most of their attention on. but canada has a huge 600 billion-dollar trade relationship with the united states and is generally assumed everything is fine and we get along fine, nothing to worry about here. >> okay. so, so much is always made of the personal relationship between a prime minister and a president. if they are getting along well, chances are the state of

relations is pretty good and when they don't get along it can be a bit of a rocky road. do we make too much of the personal relationship? >> i think sometimes in the media we tend to fetishize are they to close, are the closing of, are the happy today, are they upset? how many times to the pass each other in the hallway at the g20 meeting? but really, in washington power is so divided and the contras is incredibly important, not just to passing legislation that affects americans, but also that affects canadians. and a lot of the issues that canada has been dealing with in recent years, whether it was the position of a passport requirement of the border, or whether it was the american legislation. those things come out of congress and that is a big part of canada has to deal with not just whether it is steven harper and barack obama getting along or not. >> one of the big issues that is being discussed between the two countries is this idea of a continental security perimeter. where does that stand? >> there are discussions ongoing between the two governments and the whole idea has been around for the past decade of securing

the outer borders of north america such that we can have easier flow of goods and people inside north america, but so many issues have told us down, whether it be issues around information sharing and privacy and how much information about power is coming into canada, this canada want to give to the u.s. or about harmonizing policy on the outside of north america when we have different views of requirements for different countries, different policies, different criteria for who is a refugee and who isn't for example. those are the kind of very delicate issues that need to be discussed. and so the two countries, the two governments have been working on them and we hope to see something in the near weeks or months, but i think it is still very much an ongoing negotiation. >> let's finish on the issue of energy to get the discussion sort of started here this evening. we have heard a lot about doherty oil from the oil coming in from the united states. where does that issue stand?

is the sentiment still the same? >> there's a big debate going on in washington and the united states that should get more attention and get better known. to have a pipeline that is supposed to be built from alberta into the united states as far as texas that can potentially double the oil exports from canada into the united states most of which would be from the oil sands, and from the critics on the democratic side predominantly say this is dirty oil we don't want any more of it we want to lessen our dependence on hydrocarbon in general and then the supporters say no. when we would like to get more oil from canada and less from the middle east, and number two, there would be a lot of american jobs involved in this project. so the state department is reviewing it and it's under a lot of pressure from congress to either cut slim down that review and take more time to look at the entire middle aspect or to speed it up, so we just recently had an election and the new congress came in and then the house for a sample we had a chairm of an energy committee,

very powerful committee who is committed to opposing the oil sands port in the united states. henry waxman, the - california. now he's been replaced by fred upton from michigan who calls himself a fan of the oil sands and has written to secretary of state hillary clinton saying let's move this faster. we can't wait to read this is a big economic issue as well as an energy issue. and what's interesting, peter, is after 9/11 all of the attention was on security but now we've had a recession, unemployment at 9.5%, and all the issues are starting to be framed in terms of jobs and in terms of ey. warsengeneedocus now onelhodoege t border moving more smoothly in addition to keeping it secure? and how do we use this energy relationship to help the economy in both countries? and i think that is where canada, despite the little bit of attention that it gets on an average day, is able to yb t e antn w both e whe use d t cgrs setheseisuett

canadians have been talking about for quite some time. >> luiza savage come thanks for getting started tonight. appreciate it. now we will broaden the discussion and bring andrew quinn and paul wells. if you watch the conversations theory is you know they will not be seeing eye to eye on this topic as they don't see eye to eye on every other topic as well. that's why we have them here to lead the debate. paul, canada u.s., both friends or perfect strangers? >> more strangers i would argue. you know, andrew, listening to luiza and peter i felt nostalgic for the good old days when at least on our side of the border nta with controversy and self doubt. [laughter] that was great. [laughter] remember, we got the attacks against the world trade center and the pentagon when president bush addressed congress with tony blair sitting next to mrs. bush and he mentioned all the friends that have been such great allies to the united states and he didn't mention

canada. we hear from one of the speech writers it got in an earlier draft. our american friends would not believe the extent to which this caused the intersection and panic on the canadian side and how we have been a friend of the americans and what's going on. a decade before that we saw an entire national election whether to have free trade with the united states. as one of the nastiest campaigns we ever had. there were tv commercials are doing if we took the step as a preacher agreement at the border between the two countries would be based and we would be asmite. the on reason i felstalgic r osdays ibeusin the last decade there's been a surprising amount of drift that slide into the relationship. i ran into a former u.s. ambassador on the way down here this week and i said we are going to do candidas relation and he said no one talks about that anymore. and yet, we have the world's

most active commercial trading relationship. we have reduced be the world's longest undecideborr, it's noth world's longest tinly defend border. and yet canadian trade with non-u.s. partners has grown st an cana's tre with the u.s.nd ery arsince 2000. i n't -- can't name a large project that is undertaken tother in thwod excpt fo the ahanian war om in ich at last the anadn involvement is winding down, not ramping up. and it seems that there's kind of a draft setting into the relationship. >> this is the difference between you and me. you see darkness, i see light. where you see discourse i see are many, where you see draft i see peace. if you go back through the decades, you know, on the issue of the military, flexible, think of the discourse between khrushchev and kennedy, between pearson and johnson, the kind of

argument that took place over the vietnam war and now as you mentioned we have troops side-by-side in the largest military option since korea involving a two countries. on the trade front, the 80's and the 90's we were constantly talking about to treat and now it's down to a couple of minor things. a small, tiny fraction of the overl trade when obama came in we were all ing to be very ecited because he was going to renegotiate nafta and the relationship was in jeopardy. that didn't prove to the case. i think what you have is a relationship that's working well. the neuroses of canadians have much diminished over the years, and i think it's become to be infected. we are not as defensive of the americans as we used to be. that's a good thing. it's progress, that's ntbungor t pntl fothegsin thutu. tnkou for that. let's go to our panelists now and get their opening comments. baador d, let start withou >> i agr with iz who gv ouintroctn ineek

president hu is visiting washington, and the crawl along the bottom of the screen in many of the newscast's go along the lines of are we best friends with china or are we rivals? and it seems to me that that is really a kind of simplistic question if you will. i do agree that the relationship is very, very strong between canada and the united states. i do believe over the last number of years before i was ambassador and while i was it from here and now during that time i've been in washington and around the united states there's a lot of confidence in canada. i also think you're dealing in an extraordinary time in the united states. if you go back to the 80's and some of the trade disputes, canada's unemployment rate was 11%, the unemployment rate was 7.5%. we had protectionists act after protectionist act after protection next act to be a year having an unemployment rate

still lower in the united states. we didn't go through the anger of the questions of accountability that these gone through in the united states with the banking sector and i would say we've got lots of issues that pop up, but they are very manageable and we have a very constructive, positive working relationship with the united states. that doesn't mean to say it's perfect. but we buy more goods from the united states than any other country including the european union. we sell more energy including clean energy including hydro and traditional fossil fuels from other places in canada. we have more people visiting i think it is 25 million visits a year to the united states from canadians for a country of 35 million people that is a lot. and even in the olympics where we have had a lot of trash talking going on in washington and thank god we won that final hockey game. [lauter] want to mention the comedian's

stempel canceled the hockey cup in washington i won't mention that. even the perimeter cooperative security for air and shipping and the original border cooperation was done in colorado springs with canadian and american military personnel working together. so, lots of work every day another bill can be proposed means there could be negative for canada, but i would say on the whole it's a very constructive, mature relationship. we don't have our hnd on the horn every hour with each other. we troubled our sleeves and get things done. >> i was going to say the best thing that happened to the relationship of until the hockey, and i was going to say the best thing is gary doer, fantastic ambassador and canada should be very proud and very lucky. you know, we talked about the differences between canadians and americans and some people

see that coming canada is an unarmed american with health care. [laughter] i'm not sure about that but i do think there are lots of differences that you don't realize right at first and it's sort of like carbon monoxide you can't see it or smell it but if you don't detected it's deadly. my example is sensibility is really different. fred smbo in cada e qution is aoutpublic oly has what hasthe govnment done for us? in the united states the question about public policy and what has the governmen de us d ere s adirusana ffence ith pop view policies. so for disabled americans might be suppressed lower in canada one of the big debates of the last year had to do with when the federal government decided it wanted to take away the long fo cens,o as eran tug i maes ns. th pbay n't nall that information, and the reaction was striking. it was a controversial issue in canada, and it was like we need all this information because we have all these people we have to help and what ever, and the was

surprising. in canada, canadians might be surprised to know that when the united states finally got along to getting health care for most of our people covered the first thing so there's a distrust of government here and it just illustrates to me a real difference. the other thing i would say is we speak the same language that we often don't understand each other and i think we need a new vocabulary. the example here is sometimes the ministers come to town, no offense to ministers of the audience, and they complain about what they call border sickening. and so canadians, you know, you know immediately that a figure border is a bad thing because it's the relationship, but to americans and in fact secretary napolitano said to me they say thickening like it's a bad thing. the border is the last line of defense, so we mean the same thing. we want a smart, workable border but needs to be secure salinas each other sometimes.

>> i will start with the old adage that canada is america's best friend whether they know it or not coming and we are -- they are our best friend whether they like it or not. [laughter] and it's really still a little true. although i agree with andrew that the chip is lifting surely off our shoulder and i am so grateful for that because my time spent in the united states when i was in new york after 9/11 what we've got so many things to be proud of why are we running around always complaining this big brother is, you know, kind of beating up on us? i remember having dinner one night with ray kelly, the commissioner of the new york police force, and he excused himself from the table to go and answ h lacberrcon and came back to the bland apoged or leaving the table. i said look, not a problem. just glad we could help.

he looked at me and i said we invented those things. [laughter] he said no kidding? i assumed was the japanese. [laughter] and so we sometimes don't make our own case the way that we are an answer to people's problems, but i think that's starting to change. and even in these last few years of geor bh andhe fir few ars of rac obaa, ware gettg to the point, i thi, where that relationship is maturing, which, you know, we can disagree that we can do so agreeably, and you knw, just have a grown-up conversation. that said, we can't lose sight of this importance of the trade relationship. it's huge. despite the focus onin, e u. eno, intes o titys ilthr tes larger than that of china. it's 40% of our gdp. it's 60% of our investment in canada. we care passionately what goes on here. and a bad day for america is a bad day for canada, so we need to be concerned about that.

and looks like we are starting to fix i think a bad call that we need ten years ago, and we did start first having the conversation about parameters, securities and protecting north america. canada, again, was kind of concerned about its sovereignty. now i think we are grown up enough to say let's put that border around our country and try to de-thicken because of the tree and because of the people and because of the security issue. >> i would agree though one of the things underlining a lot of these comments is that in a lot of ways washington is the same old story it always is, contrasting issues out in the public, nasty, etc.. this is the way we are. but canada has changed. canadian self-confidence about themselves, where they fit in the world is much stronger than it was. there's a better sense of who canadians are. it's not the little brothers and drum all the time worrying about

the shadow we cast. canada in the u.s. stage or on the u.s. relationship stands up for itself and that shows. it's funny because the disconnected of canadians feel this and their relationship with americans they fe ke qual t cau.rensp aayseo is a much cold relationship in which canada allows the smaller dog. now i think we are starting to have these conversations as equal at the diplomatic level which is reflecting the reality of the canada-u.s. relations and canada in their everyday lives and that more than anything else is changing the way we see problems, handle issues, and i thk s inng us lile biclosetohe e herngn wei w i init beebeneical f ircent years is the transition to the obama administration. many of the things that can after 9/11 were shocking to canadians because it was such a change, and americans have reacted -- which had always been a more security minded people than canadians are. i might remind some of you, you probably remember when george bush was running against al gore

in 2000, both men were for more police, less gun control, more prisons and a bigger military. but in 2000, it wasn't clear against whom we needed all these things. but it's part of the psyche that the united states had and i think was disturbing for canadians to see this light that was so up front and so direct. what's happened with the obama transition is i think canadians have had a chance to see what the change the continuity. whether it's on homeland security, the war in afghanistan, a number of the free trade policies that andrew mentioned that have stayed, the obama administration found some of the same lines and that reflects a very american desire for how the relationship is managed and hopefully for canadians that takes a step back from the george bush has a mean, before hitler. he is just another american politician as obama is, and the consensus of the united states is a little to the right of where canada is, but as the

canadians start to see that as normal they've been able to adjust policy and it's unfortunate as well. >> when barack obama was elected, i was worried about a series of very specific challenges to the canadian relationship that he arrived eiermiedtorpeoe in e ire mmte t. head campaigned against nafta and was for reopening it so that was worrisome. he had endorsed an idea floated by john kerry in 2004 of rewriting the corporate tax system of the united states and the way the would be discouraging to investment in other countries and there was a huge question about the future of the oil sands and what attitu he would take. the good news from a canadian point of view and bad newsfrom the democratic point of view is barack obama so often of the case is the campaign commitments and has brought the clinton administration 3.0. >> why is that that? >> it's bad for democrats

because they are upset about it. the democrats were hoping for a transformation. this was going to be an administration the was going to -- you are a democrat, you know, you remember how unhappy democrats were in the last years of clinton and they felt that clinton hadn't fulfilled the potential on how so much going on in the 2008 primary is a referendum on the clinton years, so many of the act democrats saying we don't want to go back we want something different. they got something that was very continuous, which from a canadian point of view is reassuring. the question you have to wonder about is how did this go forward because a lot of those anxieties are -- there are reasons for them to recur. it really has been amazing to me there has been so little protectionist reaction to this extremely severe employment crisis. i wonder if that will continue. if the unemployment remains at very, very high levels. i think there is a second order problem which is of the

u.s.-china relationship becomes more tense, and it is bound to be more tense because of the trade and the relations of currency, energy clash, canada has a strong interest and a very stable and koln and trinkle and commercially oriented u.s.-china relationship. i don't think that kind of relationship is in the cards for the future, and oneof e are at be areaf ficon ats qit new digreement between the two countries that had to manage. >> okay. let's so that we are not certain time in to grab too much in one bite we will break it down into categories and i can bethe traffiofficer we all ree. auter] let's dig deeper on the issue of trade and security and let me start this week. if the united states once continental security, are the not going to get it whether canada wants it or not? >> well, you're asking the question -- the bottom line is we have a cooperative relationship for 53 years and norad now. it's a cooperative system that

has evolved and modernized as the fritz change, including, you know, it's gone from the alleged threat of the soviet union or the actual threat. it's gone hr s. a jma ra springs, canadian and military just as recently as the olympics. they work together to provide the outer circle of protection, the shipwrightherrogm, th ai s, d tnk ve to modernize that approach obviously every year to make it more relevant. on the issue of post 9/11 -- and we were discussing issues of sharing information at the border to deal with crystal meth and other issues that were a threat before 9/11. this wasn't a new thing although 9/11 made a much more serious and much more both emotionally and in real terms. i think where we have a difference with the former

administration, and particularly not tom ridge but with secretary chertoff to be dealt with it cuty siterity seri othber a i believyocanhave security and economy in a more balanced approach. but it was difficult i think with secretary chertoff on those issues. so we are trying to get recognition of the economy as much as we acknowledge that the safety of our own citizens and the safety of americans is important. one of the biggest challenges as ambassador that i have on the issues o security is to speak at canadian audiences and let them know in my view it's not a human right to cross a border commesso that is part of our message, the job of ambassador is to communicate canada's concerns about the economy and trade to the united states but also to communicate to the ceos that they'vgot to be rtf the solutio onh he sid. >> dyouhi caadns have

come becau ofhe years of how the fluid movement was across the border? canadians have come to believe that, attisan rgh too henid ste >wellentcross e bde tolay baseball or soccer or -- it was a lot different, 20, 30 years ago for those of us a little bit older. so - -- >> it is one of those things that is lost in translation, because right after 9/11 this was, you know, when paul said a security chumps trade, what he was doing was sending the message which is understanding this is the biggest trading relationship in the world and it's going to continue to be. we have to put a security emphasis on that because we did think we could just go back and forth without -- and people were doing it. our borders were getting really lacks at that point and i think we kind of misunderstood, and the language wasn't always clear. we would have cabinet members come to new york and say trade is the ultimate question here. you know, if we can't let security stand in a way of trade. and the americans were going are you people not?

of course we want trade. we are the biggest trading partners. but if that trade and borders are unsecured we can't do this, and it was a little bit of going like this. i think we are closer now to speaking the same language in part because canada has been educated, too. canadians have been educated. we have on growth terrorists, we have some of those issues we didn't feel we were dealing with in 2001, and we are in 2011. >> andrew and then scotty. >> do they think we get it on the security because it is going to be crucial to be put in addition to any kind trimeter if anybody is going to trust us to come up with our part of the deal. if there's an eater reality or perception we don't get it, that we are not as price of security as americans, not prepared to do the steps necessary to secure those borders, then we are not going to be able to -- >> i think we are getting into the sea that we are getting it, and the thing that is why we are actually even having the discussion again to get it off the table. >> to that point, andrew, i think the debate on the border

perimeter security has to be argued in canada first. because i really believe in canada puts it mind at something, it can get almost never it once with the united states particularly with the leadership in washington. drexel, the canada-u.s. relationship for years was viewed through a prism of softer, and the narrative in canada was poor canada, the big bet american coalition is so well connected in the southern senators are always going to trump so we are never going to have the politics. the truth of the matter was canada didn't hae a coherent position with all due respect among external b.c., internal b.c., the mayor times aligned with new england, quebec, and so all of the lumber producers couldn't get it to get there in canada and on the u.s. side of the state your position to read this is the number-one issue. and honestly come to the credit of the current government, you had a lion. there's a little bit of problem in d.c. right now. and harper asked and bush said you've got it.

so, the truth is on the border delete and on the continental security, have the debate in canada, and if this is the thing you want from the united states -- if you can stand a sa iss our nbeonprri, th iwht wto coabatone s. and the apparatus of the government wants to help you got to have one priority and you have to speak with a single voice on it. >> this is exactly rh this by exact rht abo thway in whichheo s manad. the ailtoreve these kind of things, but you're also right, peter, that the united states on security is going to ask regardless, and i think one of the great disconnects has come from political leadership in canada that has been unwilling to be direct with the canadian people about the national interest. when the pimer was pod by gor. ushit m ns for americs why? we underestimated for decades. the canada u.s. border looks like it did in the 1950's. it was beaten up was undetaed. we moved onehird othe personal tthe sotherborder

to nticate ftan we didn'treplace th unil 20. we hadeedelict an neglect and ourselves, we had a very big test to upgrade that security and a parameter would allow us to skit that step and just reinforce the military side of the border, deal with the external and shift the resources. it was a good solution. the canadiens seemed that might be a little too hot. step back, and we did concentric. we are going to reinforce the border and we are going to have a perimeter and their relationships with allies are not of the world. this is the challenge today because i hear canadians talk about sending the border as a result of parameter the new can't get rid of those bodies. you can't get rid of the peonelthcl m, faliesow thbdeso 'soi treinre foifd t a t canadiens were used to back in the old days. that is the cost of not having made them, not having made the commitment when it was first stopped. >> if i could follow -- >> [inaudible] debate over the security versus

trade in canada before we can make progress bilaterally. you've been out of iowa for a while. the odds are great. we've only heard of the existence of these strteg aks. the is no aptitefora nationwide conversion abt these thngs becuse this government is in a minority situation every to fall and therefore afraid to have these ebates andt'too bause secrary nalinoays a thk border sousike a god thing on like me she doesn't come from sarnia which is one of the greek border cities, one of the - border cities on the can of the u.s. border. >> [inaudible] >> it used to be there would be a sign of the quarter mile away from the border say and look out here is the border. now says ten models that because many days that is how far the traffic backs up and the traffic is carrying rolling stock for american factories, goods for american stores, its carrying prosperity for both of us and the its back to the border to be a >> what i am saying this for a

good big idea in the bilateral relationship to succeed it's got to come from canada. it just has to. now maybe the reason there isn't a debate you're talking a that is what the ambassador said which is canadians think the if a constitutional right to go to the united states any time they please and they don't realize the hour guests or visitors but i think that it's actually something else that's important. that is we need to look not just of security but traditional security, defense and security. we need to look at economic security, and if we look at our -- if youlook at cyber warfare it's shutting down business networks, shutting down wall street. so if we start to think about economic security there is no better partner than canada. also by the way on the sense of security, norad, the border, etc., but if we can get homeland security to get their heads around the mission isn't just to stop bad guys and correct duties but to figure out how to be smarter about this commerce so that we are more competitive with our -- we are more competitive with the people abroad that we are competing

against that would enhance our were security in an economic way which i think it's material to our general security. >> it is a tree the security. they are connected. >> it's interesting what comes up in the discussion is that canadians need to have control over their sovereignty of the border and a lot of canadians are saying we don't want americans to have the same sovereignty over control of their own border. >> one of the reasons the border thickening is such a concern and goes back to scott d., it is very characteristic of americans to think of the border as the ultimate line of defense. but in fact the order is a terrible place to do security. one of the reasons the americans focus on the order is because the american position is very uncomfortable with dealing with the internals base of the united states as a security issue and this is one of the reasons for

the simple white american immigration enforcement is so ineffective. the rule is if you or any illegal immigrant there's a massive militarize the presence on the southern border to stop it. but if you can get past it it is all yolly oxen free. there is no reliable method of testing whether people are legally in the country. social security cards don't have pictures on them never mind some prints and ret maaskant and other things would have on an e card to suggest the id t cotrwod hav aica i scngt n'be coidedutt'in dispensed with. so that's how you get things very outrageous measures like this one in arizona which is a real concern where the police are authorized to stop people who look like they might be illegal immigrants to check their papers but nobody else. now it would be rational to say every time an employee, a prospective employee goes to an employer must prove they have an

entitlement to work but that is anathema in the united states seek the militarist border enforcemen attitude towards sharing security with the united states and canada needs to make the i would argue for its own reasons canada needs to make getting a wide open a refugee policy a priority. that said, the americans also need to understand the border cannot be the primary focus of the security. you have to have the interior space of the country with a method learned from countries in europe and australia and canada. >> i would agree first of all from my perspective we do not want to have an incident in canada where anything we didn't do lead to the debt as a citizen in our country or a citizen in the united states, so it's important to have an honest debate about the risk in letting people see that everyday. taught at sarnia, i don't know

how many were on the plane landed in detroit last year or windsor, it's not just american landing on plants and plants from the united states only flying over the united states. so we have got to point out all of the potential risks to be able to take action to correct it. our discussion with homeland security have been more than just the security that security is the safety of people is going to be a priority for canadians and americans and we are working on ways of working much further away from the borderto keep citizens safe and i think that is an extremely important in terms of what we are doing. on refugees that was one of our perceived weakness is in canada, the fact that it took up to five years to add to the cade a refuge case in canada and they are not necessarily be known whether they were after a couple of years and in a minority parliament there was a law passed in canada the americans are very impressed over which has a much shorter time frame

than for agitation, which on the left i guess if you oversimplify is faster and on the right is more secure because you are tracking more effectively and that is why three of the four parties in parliament voted for the ll that the miister fahioned together in a vy effective way and it is a step forward again on canada saying we care about fairness for the refugees. we've always cared about that, but we also care about the length of time the was completely undefined and raising questions of, legitimate questions. >> i wonder what the attitude david was trying in america or changing before a big part of for the original intent the parameter didn't succeed to read it wasn't just canada, it was also this over insistence of the americans for sealing the border as the first security which is like a fool's errand and i wonder whetr wihetas thecomanainghe ony lavee ecriy

inheexpacu the need to be competitive with the chinese and the need to have an open border with north america for that purpose with a deficit and cost, the need to get the control cost and the emergence of the homegrown terrorist threats in the united states all of that simply adds up to much less emphasis on the border, the border is our salvation and much more opening their for a more cost-effective approach that treats canada as a part of the solution rather than the problem. >> you both had that experience which is why the nature of the conversation is different. >> we focus a lot of securities and have a few minutes left in this area. we talk about some of the irritants the personal care and one of them is the legal length in the country of origin labeling and, and some of the comments, sometimes you get -- that's important to understand the difference with the system works you will have bills coming forward all the time that could

have an impact on canada that never go much further than being tabled. let's talk about that issue and then the country of origin labeling and whether that is a threat on the road. >> i think food safety is an opportunity and a potential threat in agriculture. it is a very important issue and the canada has to have cable competent sciences and we do in our departments to ensure that there is no trojan horse under the kind of cover food safety to stop goods from moving back-and-forth in the agricultural sector so we have got to make sure our capacity on science is first and top shelf and i think we have that i have to work out of the new farm bill. the new food safety belt. secondly, the country of origin legislation was negotiated with the congressional committee that interpreted by a cabinet secretary in a way that in the

short run as hurt farmers in canada in terms of live animals and the integration back and forth. ironically in the long run will probably end up more with that agriculture being processed in the value-added jobs in canada, some in the shor trm it is a real hit on producers in canada, that in the medium term this was going to happen if to get going, too, the would end up driving more production to canada in terms of the vow to add than an unintended consequence of these issues in agriculture have got to be watched, but having said that, it is $32 million across the borders and it's really interesting to 16 million or billion, 32 billion both ways, jury integrated agriculture system and we may find kashmoula kuran other product there, but i would suggest that it hurt a lot. we are going to the worst trade organization in the medium term

will hurt them more and that's the point we are trying to make in washington. you are going to lose jobs in the packing industry in five years because of this action. >> i think there is a congressman who has a bill to label country of origin on all fuels and the united states so americans can know what they're putting in. >> good local labeling of the electrons. the good things there is a misunderstanding about the way that the economy works, and particularly about the way how integrated in our economy was if canada and the united states and there is a dispute that had to do a glamorous topic that you remember that had to do with hawk and how the and on the country of origin labeling if you are beaten or sausage is american, product of america, and having a common sense approach that says this is a product of the united states and

canada. they were trying to figure out how to use the decide as it is american or canadian. is it where the pay was born, is it where the pig was weaned? is where the piglet is aware it was slaughtered, it gets gross, is it where it was processed? the trick is to go back and forth across the border several times as do most things in north america before they reach the marketplace, as we have to make sure things like the country of origin labeling don't meet our border a disadvantage for the north american businesses and do just need common sense and you have to have a well and from time to time stand up to a particular narrow interest that doesn't understand the broad economy. >> it's just understanding the difference in the politics scott and i were at a meeting together. this is probably nine years ago and there was legislation post-9/11. there were canadian businessmen on the stage and american businessmen asking questions, and the americans said has the legislation been tabled and he

said that canadian smiling of course it's all going to happen. and the americans were looking crestfallen and it was kind of a who's done first and finally be set to a former ambassador will you please stand up and explain this because tabling legislation in the united states means it's bad tabling legislation in canada means it's going forward. sometimes we are just missing the obvious when we are having the conversationncy to react. sometimes we change our minds very quickly. one minute we love the matter and i and the next minute we hate. this sometimes doesn't lead us -- >> koln down, sit down. >> i don't do it but at least it is overreacted and then have a second but later.

we never succeeded with canada surprising canadians. it doesn't go well. we propose to the ovement we would have free trade decades before we got it because we cannot defend their and we had a perimeter of the time it made sense to us it was a shock to the system. we might have done better in that regard. the second thing i would say is now in washington because we are concerned about jobs it's not so much the economic cost of the border. i can we are starting to realize there is a compliance cost of about fossilization. we know that to follow the rules that takes a lot of people work and the jobs in the trade if you look at what it was that we lost in the volume of the trade a lot of that is small and medium businesses. the same who don't want to fill out tax forms or be harassed by more government regulation and just walk away from trade with canada because it has become too much of hustle and there are canadian small businesses that have done the same command tourists who don't want to get a passport for the kids in the back of the minivans of the

desire to go to disney and the u.s. and of canada wonderland and so on. we need to think about the compliance cost. weo believe in regulati that we need to make sure we are being reasonab and thikin about the cost of doing what we are doing. >> let's move to the next topic of energy and environment. we touched a little bit on doherty wheel and climate change and both are hot topics and both countries, so i guess just as a general question where are we headed on the issue of, a unit of canadian energy experts to the united states and on climate change because we know we in canada the government in canada said that they want to move in lockstep on the issue with the obama administration. david, do you want to start off? >> canadians are bumping of the gates of incoherence of the american approach and the total lack of an energy i wouldn't say policy, but set of priorities. nancy pelosi famously said she

wanted energy to do three things, energy the was clean, secure and cheap. anybody that has lok atthe ise owy c ybe g t ofhehr b y cno get three and it's one of these cycles where abc, bbc, where you have radical determinants and policy and a complete round of . the united states really needs to first leaders need to be forthright with the pulic abou two ofre buonepart tes e side, almost like shirts and skins. sign randomly. one party takes one side and another party takes the other and then you see which one wins and you give it that way because in the ordering of the three would produce a better result. there is no rancor ordering of the street. if you decide that when you want is time limits that's your top

priority and the security for example is your last priority than the oil sands don't look so good. they are very secure but comparatively expensive and not cln. buamerics e not tt level of tradeoff yeand s cadians ar gngo wain for a fundamental american understanding nofit atheustchse anwahoes wl b ithtm py pollyanna i am going to say that there has been a great degree of convergence the last few years on the broad question of climate change, call it what you will. if you go back eight, ten years, canada within the process, americans were out. we were lecturing the americans out why weren't they playing ball and the were adopting the traditional superiority position on this even though we were not coming anywhere close to hitting our own targets. now you have it processed the americans are engaged in, it's a different process, it is post

kyoto, one more to the liking of canada as well, and the current government of canada is saying we are going to target our policy with the americans decide what they are going to do. so where you have a lot of discord and finerged is a differ that is less of at it seems to me if friction between the two countries. islamic to listen carefully it starts to become a recurring theme. we agreed after years of arguing and having difficulties had to not do much and then so everyone is fine with it. but whether it was fine with not doing much it is true that after about two years of arguing canada should have a made in canada climate change policy which meant rejecting kyoto steven harper realized the main chance lay in claiming to want to billy climate change policy with the americans which essentially meant bidding on obama's inability to get much done. in so many things harper turned out to be why is better.

so now that he's serious, cap-and-trade scheme is dead in congress and we are happy to have a climate change partnership with the americans. it's been a companion of the climate change partnership with the americans? there isn't a giant wall, where we have a different climate on either side. >> we plan to have partnership with the americans and the rest of the hemisphere in the world. last time i checked we don't have a climate parameter from canada and the united states either. you know, so either everyone does something to get your or each country does its part -- >> i think that's where we are headed. [inaudible] >> we did have an acid rain agreement between the two countries and all the predictions about how much it would cost proven to be wrong, the health benefits have proven to exceed that. canada and the united states is involved in the montreal protocol and started with 16

countries on the ozone depleting the materials and it's on to 185 countries and its decrease more and kyoto in the world. i know that fact isn't used because it's not understood a lot and it doesn't lead the news and we are obviously think that is a good vehicle. it does make sense thave the same reduction target as the united states and will not be easy to reach anybody that says 17% by 2020 is going to be easy to reach and is just a well it's nothing. i was involved in trying to reduce the amount. that is not going to be an easy target to reach. now it does make sense to have the same vehicle emissions standard with trucks and vehicles because we have the same auto industry and people say why should you go -- people say you should lead instead of followr ve e samepolcy on cas. oundofpeople wornn thcainusy it's good for the air and it's good for the economy to have a harmonize

regulation approach which actually exceeded california because it spoke in air-conditioning. we are going ahead in some areas on our own. the regulations tabled by the minister of the coal plants are way beyond the draft standards that it interpreted in different ways by the media way beyond what is being proposed here in the united states. now the united states may go further with the epa and by not sure they will but i think in some areas we are going to be down 50 present of the coal emissions in canada and not only good or the ghg but other things. >> i just heard can't do that. >> why can't we? >> well, that's my question to the estimate we can do it by regulation council, and here the -- >> it is the actual example -- >> we signed an order in council. we tabled, worked together with

the epa and announced the new regulation change on the same day and it was good for the auto industry and it was good for the eanir. >>hanna ubles as e coal-fired emissions quicker than the united states because you've got this natural abundance of queen hydro and less of an entrenched shall we say coal lobby. what i want to say about energy though is that it tends to invert the traditional a summitry. when you think about energy, canada really is the superpower. canada has got it and we needed and whether it is traditional fossil fuels or queen hydro orht it is worried about things like low carbon fuel standards which 20 or 40 of the united states are proposing which would disadvantage the canadian crude if they don't get enacted properly and the question i have about that is why are we always talking abut carvin as the only measure of whether or not fuel

is good or bad? carbon is an important element to be we all want to get to a lower carbon economy but what about the low conflict standards? why don't you look at the debate, canadian diamonds are considered the most strategic to get in the world because they are the blood is the same democratic so when you look at something that you can just carbon which is important that ad where do you want to get your next beryl's oil as long as you are addicted to leal would you rather ge fr a baguw teshe nid tas g fm caa hiis grt paneand bythe way the dollars it recycled into the economy? like it needs to be retrained. >> some of the issues on the oil sands go right to that. david's point, a lot of the pictures people have on their mind of the open mining that you neacn e oil sands is

now in a statute which isn't massive mining operations and big scars on the land and take a true and go straight down and you can hardly see it from the air it is such a small footprint. and a lot of the clean technology for the extraction is coming out of it as a whole new industry that is developing around that. so we need to educate canadians about that but also make that point so there is the two points on the so-called dirty oil that it's not so dirty on the carvin side and also not so much in terms of taking t. aa b as ormer litici pntg of the differences of political debate and policy which it obscured because we now have 24 or news cycle and the internet and everybody is an amateur convent and some people are amateur think tank and we are trying to shed light but what happens in the the date is the ends obscure the means to be the

focus that nafta is going to create hundreds of jobs, some people losing their jobs and to find jobs in other sectors. the promise is there but people don't see the details and that are disappointed at the results. we talk about canadian oil and what scotty astelin this is there are this and you were mentioning, all of that is a model obscure. they want a corrine climate or cheap gas because i've got to get to work tomorrow, so i think that we sometimes suffer from having a shallow debate at the level of those ends and not really talking more about how we get the means going together and respecting the fact that it is complicated and it is just the only way it i col the estimate may be the investor wants to jump on this. what is there for the state of play on the wheels and? how big of a threat is it? what do they have to do to stop them from stopping the oil and the high and rising oil crisis help in that regard with a little more focus on secure and

cheap oil rather than the environmental concerns where people are weighing the balance. some actors the macrofuels' brought into the debate some people that basically say we should go to copenhagen in a kayak and therefore not go on an airplane and fossil fuels so thats part of the debe n evy couny incdingher. and i wouldayo don't what the cost is the ssuene oisas e to bes the emissions so we totally reliant on the energy reliability and security and not told the story of the emissions 80% higher than the conventional wheel 15 years ago and down to 18% said they are actually below california servile oe alana venezuela so it's got to continue to improve. it aork inrogsso tha ptof ocha