driven by the developed countries is examined by the whole world, no way we're going to solve this stainability problem. .. mr. friedman, how to go about lifestyle change which will be absolutely necessary. >> that's a good question. president cad -- calderon, if everybody adopts an american size lifestyle, do we have any chance? >> well, no. [laughter] the person is right. we need to change this, the way of life, and actually, we have tremendous effort in order to reeducate, if i can say that, to

all society. i was thinking about former questions about this and the united states doing enough for that and the answer is no again because we need the leadership of the united states on this issue. i know that there lot of troubles now, not only american, but a lot of people are thinking how to recover economy, recover income, improve the conditions for their own economy.

even today may be converse of the united states are trying to move now and say there isn't climate change at all and we need to change that. we need to mobilize public opinion and strain again that first there is increased carbon emissions in the world, there is an increased global average temperature, there is a correlation between carbon emissions and global warming is provoking serious changes with climate and finally, that there are solutions related with

reductions of omissions. but in order to do so, we mobilize a lot of resources and mainly we need to change our style of life, and in order to do so we are doing with the secretary general was saying. it is important the effort and leadership of the developed country and i mustn't say the effort and leadership of the most developed country in the world which is the united states. i'm sure that president obama has realized the problem and understand some that he's facing a new congress and political reality. however, it is not enough to a understand the problem. we need to mobilize that society and congress and of course try to find out what could be the solution. >> i want you to take this up.

even with all the best innovation, dewey and can we read what your people in a way that they would want less? that's not all the necessary. reduction by saying to the yolly in india use one camel every two weeks or taking an attrition level but a typical in northern india and say yeah we have to cut back on mess. there is no doubt more food and more energy is only just as appropriate. sure, you can say that the u.s. could cut back by even three but it's a meaningless number compared to the justice of letting people live and type that -- have the type of communications and freedom that

developed countries have. so fortunately that is in the there a solution or be, going to happen. we want people to live better lifestyles, and all of you have to do is make sure the energy that you are using isn't emitting co2 or causing other problems. let me get some more questions but go ahead quickly. >> we can improve with people but the point is we need to do that in a way to use energy. >> you cannot -- you have to make sure the energy you are using doesn't cause a problem. you do not have a just world by telling those people use less energy than the average european. >> it's not a question we are going to ask these people to use only one campbell. people need electricity but it

is possible to use traditional lamps those houses in order to use energy lamps and that is a practical kind of measure we need to take. >> if we can get a few more questions before we have to close i can't see that far. anybody back there this is an awfully shy audience. peter are you out there? where is my friend, peter? [laughter] -. >> my question is for you as a technology still in a clean energy space is been a disappointing period where we've not had national comprehensive energy legislation was in the press on carbon or even most sort of basic steps are found

providing the kind of technological framework jimmy looted to earlier we have a comical lack of consensus in congress. what is your view, and i heard you say 2013 of your earliest, what is your view on what it's congress to get serious in terms of implementing its technological framework that sends a signal to the market about what this clean energy future should look like in energy efficiency and generation. >> it is a good point. both mike and jim to take it up. i think it is going to be a signal from the market or mother nature. it's going to be a spike in oil prices that goes up to $200 a barrel or we get some from mother nature will call the perfect storm to find the end of the debate about climate change that's so big but not so big that it ends the world so that we can actually still do something about it, but i want to hear from mike and jim what would a more coherent

longer-term framework around as you've been so missing mean? >> first of all, i would say that business shouldn't be sitting back waiting for government. business can be leading in this area, and this past year we set our own aggressive a greenhouse gas reduction of objectives, we may get a part of our dna as i said. we start investing in renewable energy and we can sit back and wait in the debate and wait for government leaders, but i think is responsible business leaders that's not productive. i think the government -- >> what response have you gotten from consumers? >> frankly it in up over time to the inappropriate response from consumers. i think in the short term in particular in the markets consumers are still wondering great deal of personal pressure to get jobs, economies and so i

think right now they've got things under mind about their own family and their own livelihood so it's probably not one that isn't getting a great deal of feedback, but in the long term consumers are going to provide the benefits to take responsible action. i think in the future companies will buy from responsible companies and associates will work to companies that have a purpose, and i think that's how business moves in the future and if we sit back and wait for the government, we will not be taking our responsibility seriously. >> what is your take on this? >> you know, the nexus of these issues is unambiguous. it is a linear relationship between gdp per capita and the number of people in the energy consumption, and that's just -- any way you look at the map is going up four or five next 23

years and so you need a dramatic adjustment here and i just think this is the kind of stuff we are going to have to rethink economic and talk about food and the numbers quoted we make about eight times the food we need to feed the world so this is the market breakdown so somehow we are going to have to -- the time i spent on mass everything comes back to political pressure. you know, and devotee here says give me political pressure, give me political capital, that's what i need. and so, business is going to make money. businesses can make money either through an adopted frame three modified from work or through a crisis of a politician in a perfect set of scenarios. business is business. you know, the question is what role does this want to play? i just don't want false

positivism because any way you the map it is we worse and the problem with innovation is innovation is about creating energy, and it's not about avoiding cartons because you're competing against 200 to $300 billion a year of subsidies to the use of carbon has its negative values and so until you rethink economics and factor the public goods, social capital which you brought up and the natural capital, there is no chance. i just think we have to be radically ambitiou and there is an enormous opportunity. business is always going to make money. that's what it's here for. i think this comes down to our intellectual capacities and what is the role of business in this forum in getting the political

capital to the leaders to face and make the changes that everybody who's been a short period of time being briefed knows that the math is tough. >> is their anything you want -- >> just to underline your point that we are talking about dealing with climate change, the global warming, with the world is doing now is not enough. we have to double our efforts, accelerate the process, and i would agree that if a lot congress must take the lead but developing countries must do more as well. based on the principal of the common principal, a responsibility, and if we are talking about the planned change about avoiding the crisis this is important responding to the

question of the lifestyle and innovation and technology and of course correct and sound policies practiced by the, that's my point. >> would you like to follow? >> i think the answer is public policy. you were saying we need to reduce and eliminate the substance and study the policies internationally which is very costly in political terms that we must do that. second is pricing carbon because i'm sure business is business, but if the governments are able to establish the right economic incentive you can make business according to those economic consensus you need to pay more

because your technology, suppose you can switch your own technology to produce more efficient or you are going to use energy be you can use the energy coming from and that we can promote so there are measures in which we can win the necessary growth and the necessary consensus of energy in order to make it more competitive most environmental friendly if i can see that. so it is possible in terms of the public policies and international cooperation to do that. of course it is necessary the energy to grow and it is necessary to the conditions of the people you're going to use the more energy than now but also another way. >> as we draw to a close here i hope we can come back next year or the year after and secretary-general you will be presiding over a different kind

of competition. during the cold war we have a space race who could be a first to put a man on the moon and only two countries could compete and only one could win and it's clear to me right now who can convince the most queen technology so that both men and women can stay here on earth, and i would love to see mexico competing against indonesia and indonesia against brazil and russia, china, everybody trying to win that race we would all be better off and hopefully we will come here and be able to say that actually molecule co2 was affected by what we say and do here. thank you very much.

>> good afternoon. and welcome to the signature

panel session, insuring the future, the financing of health care. ms. hill as an ally of the university of miami where i received my bachelor's degree in 1975 and my m.d. in 1979, i am particularly delighted to be here today. i am also proud to be here as the chief medical officer of diagnostically worldwide and honored, truly honored that quest is a sponsor of the global business forum. for those of you not familiar, we are and 8 billion-dollar company. we have 43,000 employees, we are connected to 150,000 physicians in the country's doing lab orders. we do 550,000 of laboratory tests every night. we touch 150 million people a year. so chances are, if we haven't stuck you, we have stuck one of your friends. [laughter] but me talk briefly about diagnostics. you see, for the positions in the room you know you do four

things when you see a patient. you do history, a physical, you may order an x-ray and you do a diagnostic test. you see, the diagnostic test contributes to 70 to 80% of every single decision that a physician makes. so although we are responsible for only 3% of the cost to the cost of health care, we probably contribute to 80 if not 70% of all the cost of health care in the country. the question i used to get asked a lot is why is quest health care -- cost felker expense of which the panel will address. as i travel a presidential campaign in 04 and actually as a candidate for lieutenant governor traveling all through the 59 of the 62 counties the question was the same in 04 and 06. why does it cost so much and the same issue is why does it cost so much today. so just briefly before it to the other intro hundred 25% of the cost of health care is paperwork. one-quarter of 1% of all health care is responsible for 20% of the cost to 80% of the cost of

health care is used in the last six months of life. prescription drugs have tripled in the last ten years, it costs $15 for every transaction in health care compared to less than 1 penny in banking. the reimbursement system is based on volume of quality. we have a third-party reimbursement system where the consumer is not responsible for the cost of a technology drives at least 50% of the cost. we have a malpractice system that just doesn't work. we have poor quality by many, many measures. and the obesity at the then it is contributing to a huge number of the cost across the country. so with that, it is my pleasure today to introduce pact, first vice president and chief operating officer of the federal reserve bank of ballan tuck read in this capacity, pat not only oversees the day-to-day operations and administrative matters of the atlanta fed, but he has a direct hand in the development of banking policies. he's also the retial payment product director for the federal

reserve system nationwide. he's a fellow kaine who holds a bachelor's degree in management from the university of miami school of business administration. he's also a trustee of the university of miami and serves on the president's council and the university alumni association board. it's with great pleasure i welcome patrick baron hill the global business forum. [applause] >> thank you so much, john. youre such a key part of the hurricane family. we thank you for your involvement and contributions. certainly today, i would be remiss if i did not recognize you and quest diagnostics for your support of this signature panel and for all that you have been engaged in through this global business forum. i also want to take this opportunity because it is my only opportunity with the microphone to express my gratitude to deanne for everything she's done and

express my best wishes to her and bob as the move on to the next sector of their life. i would say that the luncheon speaker made a reference to my generation and he drew the analogy of a pig and a python, and why why didn't particularly like the view from being that pagen i discovered one of my colleagues said there's three things about being in that generation. that is that during a crisis situation if you are taken as hostage you are generally the first to be released. [laughter] secondly, you can take up bad habits without worrying about them telling you. and finally, and finally and relative to this panel, you would begin to get more out of the health care system than he have to pay into. last year after many months of shall we say spirited debate, we come of this nation got a jury

historic health care reform bill passed. as they say, the devil was in the details, and even this document was some 2,000 pages -- 2,700 pages to be exact has left several unanswered questions. but perhaps the primary unanswered question, one that john e. lewd it to is how can we contain health care costs while providing every american with access to high-quality health care? today's panel brings together the perspectives of physicians, hospitals, finance years and insurers to discuss the overarching issue but is so critical to the future of the nation. and so let me introduce our distinguished panel. let me start with richard clark. richard has served more than 14 years as president and ceo of healthcare financial management

association a professional membership association with more than 35,000 members. he is the past chair of the commission on the accreditation of healthcare management education. among his numerous professional activities, dr. clark serves as a faculty member of the university of miami school of business administration. recently launched the m.b.a. program in the health sector management and policy. a very important program for us. his academic degrees include an m.b.a. and management and finance from the university of miami school of business administration. our second panelist is michael tuffin. he is an accomplished strategist with extensive experience in public policy, healthcare and national politics. as executive vice president of american health insurance plans whose members provide health care, long-term care and dental and disability benefits to more than 200 million americans, he

leads a hip's public affairs strategy which includes communications, advertising, media relations, new media, and grassroots mobilization. he has worked on a wide range of political campaigns on the legislative staff and both the u.s. senate and the house of representatives. i would say that his focus has been on economic and fiscal issues, but more germane to my area in 1996 he was the deputy campaign manager for a successful referendum campaign that enable the miami heat to build the air lines arena and certainly we thank you for that. [applause] which umbenstock serves as president and chief exceed officer of the hospital association and is the past chair of the board of trustees. prior to assuming his current position, he was executive vice

president of providence health and services, which provides an array of health and housing and educational services including 27 hospitals and more than 35 non-acute facilities in communities in the five western states. among the numerous activities that have drawn on his extensive expertise in health care administration, rich has consulted with voluntary hospital governing boards throughout the united states. and cecil wilson, an internist is practiced in central florida for more than 30 years and former navy flight surgeon. he became the 165th president of the american medical association in june of 2010. as the florida medical association and chair of the board of governors as well as its executive committee. dr. wilson is a member of the board, physician run organization that accredits more

than a thousand physicians, office laboratories nationwide. our panel today is moderated by the university's distinguished president, donna shalala, and i think we would all agree she knows a few things about health care, so it's a nice warm welcome to the panelists and donna shalala. [applause] >> thank you very much. thank you. thank you very much, pat. we really appreciate your coming out to do this with us. let me thank john cohen and his loyalty to the university's legendary, and we are just delighted to have him and thank quest for their sponsorship. i would also like to introduce my senior vice president who is responsible for advancement which is fund raising communications and politics, the advancement is particularly important because it means i don't have to contain costs if he does it the right way.

sergio gonzalez. [applause] and you have all met barbara. i'd like you to meet her successor at least temporarily. we still when someone from the private sector is a distinguished career in private banking and whittle's all -- was also one of or sophos lacasa who has joined us today. [applause] >> now every time i get on fox they say to me so, why did the president do anything about cost containment? the real criticism of the clinton and the obama health care plan is they really didn't do any thing about the cost containment. we are going to answer that question today but the simple answer is it's very hard to do. making up this panel are stakeholders. people who represent significant parts of the health care

business. and it is hard to do. i believe that probably twice a week i get an e-mail from someone somewhere in the world who wants an hour with me because they have an idea that saves health care costs, that they want me to talk to the president about, not that i talk to the president every day or even whether he would be interested in a specific suggestion, but everybody has an idea about how to contain cost. but those who say we can't afford health care reform i say that we can't afford not to reform the health care system. and whether they like the specific parts of the bill or not, the gentleman that make up this panel also believe number one we need health care for everyone in the country, and number two, we need to make it affordable for everyone in this country. but we need to do it in a way in

which we cannot weaken the quality of the health care system and make sure everybody that needs access to health care in this country gets high quality health care. today we get an extraordinary chance to be the proverbial fly on the wall to read these panelists from the key health care sectors may disagree somewhat, but we are all going to struggle with the same issue, and all of them have a pivotal role in how we are going to resolve the financing of health care as a nation because over the next decade we are going to need to try some things that contain to cost. and each one of these people, and i know them all, care deeply about the quality of health care in this country and about our patience. so, i'd like to begin by asking our distinguished panelists to answer a pretty straightforward

question. so everybody talks about in the curve. what is the single best idea for the end of the curve in health care? richard? >> welcome that's a very easy question. we will do world peace after that. [laughter] we will be able to solve anything else within one answer. obviously it does have -- it is a very complex question, and if you look at the reform bill and you look at a cost containment element within the reform bill, the single largest cost containment or cost reduction element in the reform bill was the payment cut. that was the single largest element. and so from one perspective you could say simply cut payments and the system would have to figure it out. obviously there is a lot of danger in that the unintended consequences of making substantial cuts in any component of the system is that

first of what kind of shift over to other parts of the system for example of the federal government makes a sycophant cut in medicare, then the pricing mechanisms are such that it starts to shift over to the private side and the private side starts to pick up the slack that the government has cut back on, and so that is what we often refer to as a hidden tax if government pays less than for example should be or expect to be paid for something it is shifted over to the private side and the private side is paying for that which the government should have paid for and might have paid for. the argument is whether the government and the medicaid program does pay a fair amount of money because the belief is that if you look at the level of reimbursement to the cost of providing services for a simple medicaid patients and especially medicaid patients, you would find that the payment is below the cost of providing the service. so at least in the current

structure of organizations, it's very difficult for us not to have a situation where there is in fact a shifting. you simply deal with it by making payment cuts. what makes more sense to change the incentives of the payment system towards the care delivery model that we all understand more appropriate and hard to get to because we are very fragmented. the payment system creates situations where certain components of the system are rewarded for doing more volume and other components of the system are rewarded for doing other kinds of things. there is a real question about quality, so my answer to the question is we need to be able to focus on the payment system as a primary vehicle, maybe primary lever to start to move us from a fragmented system to a

system that is much more integrated, a system that has the incentives for aligned, etc.. so there's a simple answer. i would say the payment system is probably the lever that is the most likely to have an impact. there's a series of things that has to happen as you make changes to the opinions system simply because the delivery system such as the delivery system is organized in a way that would facilitate accountability for the care of populations that would over time we think at least slow down the rate of growth and in fact been the cost curve. >> michael? >> thank you madame secretary and for having me. i guess before i touch on perhaps the substantive side one thing that is overlooked is a real education effort to make sure the american people understand mistakes. people are acutely aware of the problems of the high cost of

health care in their own lives. if the work for a small employer, if there's someone falling through the cracks perhaps working class take to much to be eligible for medicaid but don't have the kind of job offers coverage and certainly not in the position to afford it on their own, so lots of people are acutely aware of the affordability issue when it comes to their own personal circumstances, but what i think the american public doesn't really have a grasp on at all is people don't think systemically, they think of their own circumstances, their own family, their own employment situation and the trajectory in terms of health care cost and what it's going to mean for the future of the country. we are on a trajectory and pretty soon the vote one-fifth of our economy to health care, and not laughter that one out of $4 we spend of economic activity in the country will be devoted

to health care, and that would be -- and that's not all bad because if we are consuming health care, people are choosing to pursue life enhancing and lifesaving medical care. but we are not getting enough for what we spend, and we are on a path that is not sustainable, and if that continues unabated on the public side of the ledger, other important national priorities, defense, homeland security, the environment, education are just going to be swamped. there is just not enough dollars to go around and we are operating in an environment in which we already have a trillion dollar structural budget deficit. so we think we really have to -- stakeholders, elected officials have to get to work to educate people about what is at stake so that a substantive conversation can proceed and compare itself

to make changes, to make tough choices. we had a one year debate on health care reform, which on the one hand was terrific and engaged the american people across the political spectrum. more people contacted their member of congress about this piece of legislation and on any matter that has ever been before congress in american history. that is just astounding. we think about the war and recession and all the country has been through. so that is obviously a positive but there is nonsense around the def panels and demonization of the private industry and health care and a lot of substance along the way so and education efforts that reaches people and on the substantive side health care spending is the cost of

health care times the utilization of health care and we have to look at the whole equation. we have much of what richard said, we've got to find ways to eat with people to make the safest decisions, the highest quality decisions and yes, the most cost-effective decisions. right now in health care so much of our decision making is made on the word of mouth basis. we take a particular medication because we saw someone -- we saw a nice ad or we visit a facility because of its reputation, and that reputation may be exactly in line with that performance, and that drug maybe the best drug for that particular patient but we are not making those decisions based on data and based on objectives information and in the economy to make people better decisions and

cost-effective decisions. >> thank you madam 63. pleasure to be here. i'm going to build on the parts of what my colleagues have already touched on. my direct answer would be the same as which is change the incentive. but i would supplement that by saying to change the incentive for all, for every one. there's a very simple answer who pays for health care. we do. how do you want to pay for it, how do we want to pay for it? privately, publicly or philanthropic week. there is not a fourth option, so we have to figure out how we all contribute to this change. the position during reform, part of our reform from work was the call for coverage for all and to be explicit to say paid for by all because we can't continue to think that somehow or another somebody else is going to pay for some portion of the care that we consume.

when i say all, i mean providers and suppliers, employers and purchasers, consumers directly, all of us. there is a saying that cannot at least i heard it for the first time during the reform debate that one person's waste is another person's revenue stream. we have to figure it out and agree upon what is essential, and the incentives don't naturally drive us to that so if you look at the same side of the coin, utilization on the one hand, and consumption on the other, i think there are some answers that we just can't not address or certainly some questions, and i think some fairly obvious answers that we are willing to. on the utilization side, the aha is very much in agreement that we have to have incentives that drive utilization in a different direction. a volume oriented set of

incentives isn't here for the long run. that's going to change someday. if we knew during the reform debate to what model we should change i think it would have been put forth and we would have debated it. but what you see in the bill has as was mentioned before a variety of approaches to try to see which works. so whether it is bundled payments or whether it is to tell you based purchasing or whether it is the medical home or an accountable care organization or whether it is a negative incentive of penalties around the admissions for example all of those are attempts to say we've got to try some new and different things here or we are not going to drive down the utilization of services. so i think for the providers, both providers and practitioners, that's a major challenge for us to deliver. each of those done in the right

way and implemented in a way that keeps the system strong getting from here to there. the second site is consumption. i often -- when people like the secretary say, when people see how you drive down cost, or my goodness, my premiums are going crazy, i often use a little attempted humor and say to them, you know, i assume you have three forms of insurance. one is homeowners and won his wife and one is health. last year to pay premiums and at the end of the year when you hadn't made a claim because your house burned down did you feel ripped off? most people say no i felt protected along the way and greatly i didn't have to use it. i say now you know where i'm going with the second. dupage life insurance premiums all year. [laughter] and i don't think he made a claim. [laughter] and they say don't give it to me. i say yeah right.

it's now december 20 if, we are at a holiday party. how many dollars you have left in your flexible savings account and how will you spend them before the end of the year because you don't want to leave any on the table. have you ever thought about the difference in health insurance incentives from a consumer point of view, veazey, any other form of insurance? i would argue that its prepaid health care in the minds of most of us. if we are fortunate enough to have that. we have to change the mentality to one that says i'm glad i got to the end of the year and i didn't have to make a major claim a and i was happy to pay the premium when i didn't need it. that's really insurance. last time on the consumption side, and the last comment is we her some great things today at lunch about investment opportunities, business opportunities in health care. couldn't agree more. think it's a wonderful sector on into the future, but we have to make some changes and some trade-offs or changes in measures of success.

for a simple, this weekend's "washington post" had an article in the business section about health care property olden reach, real-estate investment trust. and i was struck by the average annual return over the last decade of 19.9%. and one company that was cited as having 31.2 annualized returns over ten years. think about health care from an investment point of view and retirement point of view back to the same cocktail party. how many of us have an account on health care stocks in our 401k? and weld will be the impact on that if this isn't done right? the conclusion over breakfast sunday morning for me was we not only want healthcare that protect us and protect cells from cost in our retirement, but to some extent we also want health care investments to fund our return.

you can't have it both ways. the changes to come in the sectors. we tend to focus on the pay sector and we tend to focus on the government, this will change just as soon as we as voters and consumers are also ready to change. >> thank you so much and for the opportunity to be here on behalf of the american medical association and the nation we represent. let me just emphasize and echo the point the president made. we care about the nation and the position that wasn't without controversy a of and we felt was responsible. we feel this legislation does so much to help this country that we could not walk away from it as what we would do is to be engaged and to improve on it has

things need to be getting rid of and that is the mode in which we were and which we are to be the answer to the question about the cost and the curve that i agree with everything said so far the other answer is like the answer we gave people during the health system reform debate. people would say why don't you just tackle insurance or just tackle medicare? do one thing at a time and the point we made not unique to us is this system is so complicated and so interconnected that you can't do one single thing at a time, and let me just suggest that that is true for the cost of health care. the costs do not have the luxury of just taking one thing that will make a difference. i will end this suggesting one thing of the top of the list. if we ignore things at the peril

of not being effective, for example, if we just decide the way to save costs to cut people and programs, we would do those of us on the panel would engage in the battle of the carcass and in the and some will lose and some will win and the net result wouldn't be enough savings to make a difference in the country, and you will continue those. so we do need to do things not in the same way but we need to do things in a different way, and the ama has looked at the categories that we think make sense. one estimate the delivery of care more efficient and among those we would include all of the alternative delivery systems and the accountable care organizations. the other is to get rid of cost that doesn't contribute to patient care. some claims in the insurance companies, the defense and the cost of the defensive medicine would be an example related to that and then another is to

promote value based decision making at all levels and i will mention one related to that as mentioned today and that is the need for the comparative effectiveness research so we can no not just evidence based matters and what works but we can also the comparative effectiveness what works best and we think that's critical, but the one that i would put the first of the list of what we call the burden of disease. 75% of the disease, the cost of health care in this country is related to chronic disease. heart disease, lung disease, lung cancer, a diabetes, pretty much preventable, so unless we tackle those problems i would suggest we are to a lack of effectiveness, just to take one obesity onset type ii diabetes.

$140 billion a year. that is about an expenditure of about 2.4 trillion, just that one disease to a disease i would suggest in my practice of 15 or 20 years ago wasn't a big part of a landscaped, so we have to tackle those kind of measures. one by educating physicians about the best way to motivate the patient to be involved. another is how we motivate the patient to understand the importance of that and we have had some sessions today that are related to that and then there's of the national campaign for this country which focuses on the importance of the health behaviors and things we can do. as it was planted on the earlier panel today we have made remarkable strides in the area of cigarette smoking in this country for such a long time and i think the lesson is if you are looking in health system reform for a solution as effective as it is it's going to do it tomorrow, then that is not clear to happen. this is going to be a path we

will be engaged in over the coming years for the decades to make a difference. >> thank you very much. very thoughtful all of these remarks. jim forbes said today health care costs of actually slowed down. we are down to 4% to he suggested that is because we have shifted the cost on to the employees for the most part. i pointed out to him that there is less evidence of that damn of job ownership. during the times in our history and which we have debated health care reform, the costs have actually slowed down. so if you look at the chart from mix in -- nixon to carter to clinton to obama for the couple of years that we have been engaged in the health care debate, health care costs have actually slowed down in the period that maybe we should just be debating health care reform

for the purpose of pain and stop trying to figure out the cuts. all of you have given a list of things that we can do, and i would like to go to the kind of system change richard suggested. you suggested payment reform, but what you're talking about is how we organize the panic of health care, and that means moving away from the fee-for-service system that we are all very familiar with. i always thought people were pretty thoughtful about that, that it's harder to do than it seems because we don't have consensus reached about whether there should be the bumbled payment for hospitals. we will hear from the specialists if we start to squeeze down on the drug costs for instance that the cancer doctors can diagnose because their cost shifting to cover their other costs so it becomes

more complicated to do that. have you seen any models that you can suggest? could you talk a little about what you what specifically do to move the fee-for-service and i assume we are talking about medicare because the fact is the rest of the health system follows the medicare division. i sit on the board of a united healthcare for a long time one of the things that shocked me is how much they watched the decisions of medicare and how much they dictated and drove with the private sector did in their own insurance systems. >> to a start with you, rich, and then maybe go to steve and move down. >> i'm often reminded of a metaphor that says we are all good actors in a bad place and if the script had been rewritten our rules change some and how we play that role in this new script to read the areas where

promising things are done in and around health care is the example of brandt james person who is meeting the quality and innovation center. it is a non-profit system that is in the rocky mountain western comes love of the rocky mountains utah, idaho and a variety of other states and group practices and health plans has all the components, many components of the delivery system. and what they are doing is they are understanding the payment system has to change, so they are starting and in fact they are actually pretty far along in changing the way in which the delivery system is going to respond to the better incentive and the better incentive being that the payment is much more aimed towards paying for all comes or protect the care of the population as opposed to simply the episodic coverage where you get paid for each volume of work that's been done. in the example that brandt often

uses the example in obstetrics in the way in which the exchange to the approach to obstetrics with a sycophant plea reduced cesarean sections for the delivery simply by going through the care protocols and training programs with their physicians. the first time they start doing that, the chief financial officer by the name of burt who i know very well told me it cost $100 million the first time they started working this through simply because the payment system penalized them for doing it, but they felt was the right thing to do so they are continuing to move down that road. and i think that there's good examples because they are using comparative effectiveness research. brandt is a scientist and is very focused on outcomes, measures and monitoring performance, using the tracks and kind of shifting the way the pattern works and so that is a great example. another that is used is by singer with they're proving

care. they have a system of again where it will incorporate a series of services within the party back for example and a bundle those services and a single payment and warranty that they will do the services within the cost and they will take care of any issue that might come up within the scope that the defined. so they're moving toward a bundle payment with a warranty that encompasses hospital and physicians, etc.. those are models that i think our organizations reaching out before the payment system really changes to get at this idea of moderating and eliminating the practice which often times as identified in the cost escalation we have. >> that suggests we have to be part of larger organizations, and is the era of the individual

physician or small group practice over dow's we move into this discussion? >> when i first got of the navy and went into medicine they were already talking about dinosaurs and the was several decades ago. but let me just talk up the fragmenting care. the payment system does provide for fragmented care and increase in the as medicine has become more complex, we know and can now talk about things that coordinate care. you can't do that under the present payment system. just to take the federal government payment system for medicare, for example, the part d which is paid separate from part a which is hospitals, and some savings the physicians meek by keeping the patience of the hospital actually increase the volume of care they give and they are penalized for that and the savings from that, so we need to get rid of those.

let me just on an aside on one of my semi pet peeves, and that has to do with the issue of the fee-for-service. i think if we use that as a metaphor for the fragmented system, adding it is hard to say that. but i would suggest to you paying people for how hard they work and how much they do, it is an american accountable way that you three ward four working hard and i suggest honest honorable people can do that in a way that is honest and honorable. clearly the option for abuse if you are going to use that system you do more, you order more. on the other hand, if you -- people can work very well in a salary position, honorable and decent and providing a dollar value but if you're going to use that you get paid regardless of how much or how little you work, and so that sort of takes me to the next point.

we had a white house briefing for the team and brought in people from around the country some of whom represent these integrated groups and who are doing what we think and accountable care organization ought to do, and to the question should physicians be paid fee-for-service of salary it was a mixture so that wasn't the critical thing. the critical thing is that you have a group of physicians who are working together and that is maybe we will talk more about the accountable care organizations, but they take responsibility for the outcome of care throughout the disease problem and that is the sort of change now and we have got to go down that road and see if it works. now we know in the 90's the tax payers and hmos will be the same thing to consult it but we are going to try to make it work and i think that we are going to have to go in that direction.

just a final point to the demographics of physicians in this country. 70% of those in private practice or in groups of nine or less, and over half of them in groups of three or less so you've got to figure out a way for those physicians to be able to work together, and i've been meeting with the chair of the federal trade commission and inspector general and the department of justice to say that we need to have some changes in the rule related to antitrust and fraud which will protect physicians to coordinate care among themselves what we call clinical integration so they can share information about quality, they can share some of the expenses related to the electronic of record and can actually even negotiate so we are going to need a new structure that allows that to happen and we all think not only that should have been but it probably will happen. >> michael, you represent an industry, the insurance industry at stake in flat of managed care

every time someone is turned down when they go to get a certain kind of operation or something else. what my employees say to me, you're the insurance company, we are self insured, they don't realize -- laughter, we have an insurance company that manages care. they say you should fire them because they will not cover this. mike response to them is quite honest that we made that decision, not the insurance company. yet the insurance companies have taken the flak for decisions employe years of essentially made because when we are looking for an insurance for someone to manage our work here we decide how much coverage we are going to have and how much cost shared there is going to be in the system. so how do you navigate that? and as you are talking to your constituency, how are they thinking about the cost containment? because they have some real complaints about their ability to negotiate in certain markets and their own challenges.

>> you're absolutely right about -- >> i may be the only one in america that admits we make those decisions on the insurance company. [laughter] >> tens of millions of americans get insurance that way through an employer who sells funds and they work with an insurance company, a health plan to administer the benefits and yet, when there is a case of denial it's the insurance company that takes the flak and that is in some high-profile cases that get national attention. frankly, when those situations arise, the health plan is not going to throw its employ your customer under the bus, and it's a kind of fact for life people don't realize and 60 come 70 million people in america get their health coverage that we. through an employer who does sell funds and makes the determination about what is covered. and i think -- rich was kind of the looting to this in his opening comments i believe, and

i personally have probably said to be cassatt and more health care focused groups than any person in america the past couple of years as health care reform was proceeding, and you watch these focus groups and it's hard to the escape the conclusion that what people want is unlimited access to care and they want someone else to pay for it. and that's natural. we are human. we all want that. and thus, when there is a situation where there is a coverage determination that the patient doesn't like, it's a very difficult circumstance, and there are no easy answers. i think we need a lot better education on the front end, and it's also incumbent on consumers and workers to perhaps do a little more to understand what is covered in the plan. a lot of people assume when they get insurance cards this means anything i might possibly consume in the health care

system is covered, and obviously that's not always the case. .. >> to work with these patients to, for example, encourage them to adhere to their medication regime. you know, so much -- free admissions get a lot of attention. a the problem with three admissions is the patient leaves the hospital, really isn't an

opposition or perhaps not have the education to follow their discharge instructions or to adhere to their medication. for a lot of the population, again, the disadvantaged, stressed population, they may have five or six chronic conditions. maybe on eight or ten medications and seeing three or four specialists. so health plans are stepping in and working with hospitals and doctors to try to coordinate that care and assist those patients. we are seeing returns on the cost side and in terms of patient health. and also, medicare advantage which is a private medicare part c. cecil mentioned a and b. medicare part c is a controversial program. payments are being cut due to health care reform, but there is increasing evidence coming on line that medicare advantage plans are doing a better job of working with hospitals to prevent the admissions,

preventable remissions, the fee-for-service medicare program is equipped for that. and, so, those are examples where you are both helping people stay healthy, stay out of the hospital, stay on the medications which ultimately yields benefits. >> i want to put you on the spot a little bit about saving money. we have all of these -- lots of people from the industry that make money out of the health care system as it is currently organized, and i always wondered, other than some public health things like washing hands and clean-air, actually, reducing some medical errors and vaccines, can you think of a technological breakthrough that we are using now and our hospital or any kind of scientific breakthrough, new drugs or anything else that actually saves money? this seems to be that health

care is the one area where we come up with something that costs us more money in the long run. >> at think you're right. >> a different industry than other industries. >> well, bigger than a couple of things. one is certainly with each advancement comes almost a new demand. that is for the latest in a racist. we have not amortized the last investment and a moving onto a new investment. the compound the problem. so, that is one issue. i think that there are some incredible breakthrough is going on. what we are finding out is that they are really on the low-tech. not on the highest. very low-tech, very hard to get compliance. >> we actually have a new monitoring system to real or his carrying it. if they walk in and don't wash their hands, it tells them to wash their hands so that we don't have to -- the port nurses don't have to tell the doctors.

>> they tell you if you have come close. >> right. so they come out. but it is promising. another evidence of low-tech, frankly, is the checklist. the safety and quality checklist approach was mentioned this morning. i believe it was by the secretary around the michigan experience. associated infection. we have partnered to take that michigan experience national. forty-six state associations now and hope to have every hospital in the country eventually using this. you can ask the question why didn't they all use it yesterday just as secretary kathleen sebelius did. at think it is a matter of so many dawn things in a priority in box, so to speak, that we have just got to find a way to get focused on those things that are for sure going to work and work with less cost investment.

the next thing besides infections that we hope to take to the same scale is the surgical safety checklist that dr. bill on the is so well-known for and has shown such incredible results. now, i'm not going touch tell tell that school, but within our family we have of budding anesthesiologist. i say, well, why doesn't this just happen every time? she says well, the next time and first time you will understand. it is not the culture, not the way we have done it before. we are pretty darn sure that we do it right every time. why would we have to stop and work our way through a checklist? that is all practitioners in the equation, not pointing fingers at anybody. now, again, i imagine all of us on this panel fly a lot. and the take off announcement was, you know, we have this check list and have used it for years. we are running a little late and

we think we won't do it today. most of us would ask to get off the plane. why? it has got to be culture. some of the great advances that we are coming to is because we are getting that knowledge, we have gotten the data. now we are getting people's attention and moving forward. >> does it help if medicare tells you you have to do it? is that an incentive for doing it? >> it is not a happy day. you know, let's look at a real-life example. reporting on quality indicators. we are in favor of that kind of transparency. we don't have a lot of agreement on indicators. five, six, seven, eight years ago. now we have measures. what happened was medicare did say you won't get a full annual update if you don't. so now you get paid for

reporting in order to stay home. everybody with enough cases reports. it's nice to think you don't have to get there, but if you know something is working, that eventually you have to look at all the positive bandings. >> i would like to get to the audience for questions. have a couple of microphones. i don't think anyone. i don't want to move this up to the back. okay. you are telling us. okay. identify yourself and i'll ask one or two of you to volunteer to answer the question. okay. >> hi. dave hopkins with pediatrics, international medical group. a degree of the largest medicaid provider in florida and the largest for physician services medicaid provider in the united states. so, part of the reform is to increase medicaid. we will see more and more medicate folks. as you know, medicaid pays very low rates. at the florida is one of the

lowest paying states in the nation for physicians for medicaid. more and more medicate vote for all providers, and those are low rates, maybe six years 70 percent of medicare. medicare is getting gatt. it's getting more cautious. the health of the private health insurance folks. more and more disparity in payment with panels on payment. more and more of a mass with really high rates, really low rates. isn't it just going to be a road toward some kind of national insurance, national payment plan? >> point out that florida intends to give sovereign immunity to doctors to treat medicaid patients in the state and to the extent that that will save them money. >> that is a good point, certainly. and managed medicaid at basically the same rate. >> very interesting to see if they can get away with it. >> first, bless you for what you're doing. second, your observation. fortunate enough to practice in an affluent neighborhood.

sometimes my patients would become eligible for medicaid. i can tell you as an entire estimate that seeing them, but it was not worth the effort be to file. as i think you know and probably many in the audience know, the affordable care act does provide for increasing medicaid payments. medicaid payments up to medicare levels over two years, 2015, 2014. so that is a temporary reprieve. what it means is it is a start, and it means we have to work this year and those payments to stay at that level and we have to increase medicare payments are at an appropriate level as well, and i have a long speech related to medicare payments. so that is a start. the important thing for state budgets, of course, the federal government will take -- will pay the 100% of that increased cost as they will also pay at least for the first couple of years, 100% of the increase that will be required at the state.

eligibility up to 1303%. then it goes down to 90. there is a british there which i think does recognize the challenge for state budgets and also the increased payments but gives us a start. encouraging people to be able to take care of medicaid patients. >> interesting. the secretary said that she also thought that we were going to have to continue the disproportionate share of payments that this new coverage should not take away the safety net money. you want to give a quick -- >> the projections are that at the end of the decade, at the end of the 10-year run there will still be some 23, 24 million people without coverage. it is not as though the uninsured issued those away. to the gentleman's questions about medicaid and the incentives, it's true. if you have a paint, commercially paid and covered patient who is moving to medicaid, that is a heck of a hit. on the other hand, if you give somebody into medicating has

been totally non pay, well, $0.60 on the dollar may look pretty good. so we don't know exactly how that is going to model how. >> particularly if you have volume and the systems. it may just give you another margin. >> it really, we have to see how that works. this theory, at least, is that the presently uninsured will now bring some level of -- they will have for coverage and bring some level. >> craig anderson, a partner with cleveland ohio. outstanding conference. talking of what about macro issues. we all agree that there is a definite case for change. we all agree, and you have really highlighted it, the need for culture as we bring organizations and high performance teams together. my question is this, and it is really to honor all of the individuals and green shirts that interviewed for and were selected to help keep us in line

all week. at thank you all very much. the question is this. we have the green team of in front of us right now, richard representing cfo, rich representing the ceo and cecil, our cmo. do we have the leaders that we are going to need in our hospitals to lead this change that is on the doorstep? and what would your message be to the students and those that are here to learn about the skills that they need to capture to be great leaders in the future that will enable our country to be great? >> i would be happy to start. first of all, i think we do have the leaders. one of the answers that i would get to the earlier question about why costs are moderating his because at least at the hospital level within our and across the team you just identified, people have said, you know, it is pretty clear. we are never going to be better paid than we are right now. think about that.

it has been true for a long time. we have more, but we will have to be more efficient and at least from the hospital point of view more people have committed to living on current medicare rates trying to get the cost structure down to close that $0.10 on the dollar gap that was talked about, and they are doing it now. at think you're seeing had dropped, at least on that side. at think there are other factors, but that is one. it takes real to say we have to change before we absolutely have to. so a couple of things i say to the students. one is that somebody once said that the you discover the future that has already happened. and i think that it has already happened. the cost, the cost pressures have pushed us from a revenue oriented industry to a cost oriented industry even though some of the incentives it will cost us to do that, but you can see that tide is running in that direction real fast.

the second thing is a quote that i saw just before the election, immediately before the election, somebody was talking about from the political point of view. all of our organizations are highly political. all organizations are, but he said, you know, leaders are disappointing your own people at a rate that we can absorb. yes. yes. and i think that is going to be the role of leaders, tell it like it is and then move people there. >> one of the things that i am hearing more and more, first of all, we go through when we are talking to financial officers especially, a litany of things that a changing within the health law, the medicare payment and the center. and it can be very depressing when you listen to these things. people feel like they are being beaten up and blamed for things that are outside of their control in many cases. but the last question i easily

will ask, and we use the audience response system so that they can do it anonymously to be optimistic or pessimistic about the future. i always get optimistic. people say yes, i'm optimistic about it because i think that we are finally getting to the point where we are thought starting to change. one of the examples is that and talking to finance folks i am hearing more and more, having them talk about the amount of time that spending with clinicians. more and more time with doctors to. the minister of folks are spending more and more time walking the floors, getting back to the idea of in an institutional or clinic setting, there is, in fact my patient interaction that has been kind of divorced from the business side. what we are finding now is that the business side, what is referred to as the business of caring, the business side of care is touching to become better ms and connected. >> and we are integrating nurses. >> exactly. they transform the delivery.

>> and i find that positive. >> one, two, three. >> thanks to the panel for a very wonderful and informative dialogue. i am one of your faculty members at the miller school of medicine. my question is regarding direct consumer advertising that we are currently one of the two countries globally that allow direct to consumer advertising. i was just curious about what your thoughts are. my understanding is the cost of that marketing would probably be priced into some of our medications and maybe contributing to the price increases. >> i can answer that one because i thought bill frets with advertising. actually was a deal. this is allowing drug companies to advertise. actually, it was a huge debate. the administration took the position that if we allowed direct advertising even though you can barely understand what's going on there, in the end it would push up the cost of health

care. senator fritz who was chair of the committee at the time argue that it would not and that it was necessary as part of the day for the reauthorization of the fda. so it was an actual political exchange. in the middle of the night senator kennedy called me and told me he cut the deal and that i was going to have to live with the advertising. senator fritz told me last month that it was the biggest mistake he made. he said it indeed pushed up, and i don't think it is very much that issue. at the most of you would probably say it is not necessary and we should not have allowed it at the time. whether we can roll it back and not, i do not know. does anyone have a political view? >> i guess a related comment, and this -- >> it was a political deal over our very strong objections.

we knew better. >> this speaks, i think, to the important. a fancy way of saying, let's get the information on line. the fda does a terrific job of assessing the safety and efficacy of medicines on the front-end. once they are actually in practice we are not equipping doctors and patients with the information that they need to make the best decision, which will really be a powerful force. perhaps a more persuasive force and marketing. if a patient can log onto the internet and see that there are three medications for my condition and for people like me generally speaking this one does best. lo and behold, it may cost a fraction of the one that i'd just saw on tv. maybe the expensive one is the best for them, but the problem is right now we just don't know. if we do know we have the information locked up in a box.

and equipping providers and patients with that information, i think, well in tests that issue. >> advertising press the provider and a difficult situation. it puts the dog and a difficult situation. the patient comes in and says i want the strike. so you must have read into that. >> absolutely. i think they are not in that position, and some of that is political as well. we do have guidelines, guidelines about what the advertising is, and there are advertising. but that was absolutely correct. regardless of the level primary care that you have had with this patient, ten, 15, 25 years, i can say no one's. the next time it is a little harder. the next time there will probably go somewhere else to get that. having said that, what i did find in the last number of years

for my practice, it did change the conversation that i had with my patients. instead of them asking me about targeted medications for which there was no sign we were having discussions about medication that they saw. so to me that was a little bit of a positive. we were at least talking about things that have been proven to work. >> let's take the next question. >> my name is chris comfort from the past university miami graduate. now i am a local small-business here in south florida. my question is a little bit about change and the pain that goes with changed. anytime that change takes place in any organization, any family, and they think the big barrier to the change is the fear of the pain and the pain that goes with it, whether the pain is lost profit, i get paid more from my own health care or wherever that

sacrifice comes to get something changed. from what i have been hearing, you know, our health care system is like cancer. it has got to be treated partially in order to correct it. you have all of these entities that i think are fighting to minimize their own pain in the process. i would be curious from the different panelists where they see to get the ball really moving quickly, which part of the process has to suffer the initial pain to get the thing moving in the right direction in a positive and fast or faster manner. >> you know, i think one of the points that was made was that it shares pain. you cannot deal with cost containment unless every part of the system takes their share of the pain. the hospitals do not want you to do it. they want to be the first ones in line. the doctors and the nurses don't

want to. for health care financing everybody has to pull in their belts or agree on a new organization of health care that seems fair to all of the stakeholders. does that make sense in terms of what you all have said as an answer to this? >> my name is bruce. adult and geriatric in boca raton. we do research from and imh and clinical work. my question is about the relative absence of discussion of mental health services in this dialogue. whether the problem is obesity, the prevalence of anxiety and mood disorders in the american people, exceeding 20 or 30 percent of the population, whether it is a shooting in tucson or a readmission to a hospital because of an unrecognized delirium or in early dementia that has not been funneled into the health system properly. how are we going to integrate

better mental health services into this dialogue? >> that is a very good question and a struggle. who wants to take that on? >> a couple of observations. among all of the humorous last year, congress did pass legislation providing, as you know, mental health services as well. in addition affordable care act provides a 5 percent bonus for psychiatric care. i don't suggest that those are enough, but i do suggest that there are a recognition. they have been on this for a long time and are very supportive of it, but there are recognitions of this country at high levels of the importance of what your asking. >> one, two, three, and then maria tried to wrap up. >> harvey wagner, an alumnus of the university of miami. i am the president's council here at the university. i spent my first 35 years after

graduating from here as a financial person, chief financial officer for many high-technology companies out in silicon valley and boston. as we all know, in technology it is all about cost. health care, i think the two main issues are quality and cost if we are going to get things under control and also getting consumers to be somewhat responsible for their own health care. we have had quality metrics in health care for many years. being able to do it and reporting to the government. and i am just wondering, is every single hospital required to do quality metrics? there have been several hospitals that have won the malcolm award because of the ability to get the real data to understand what the root cause

is the of the higher cost and the variability in and out comes between position a and position the. i know that is a problem of measuring doctors against one another, but that is what it takes. you know, the automobile industry at one time in the u.s., at least the first time they get in terrible trouble was because of the quality of jobs in japan. when they installed their quality systems they were able to compete effectively. and i am just wondering how far we're going to be a i also spent seven years and health care as well. so, i understand the quality side of the picture and would like to hear how far we're going in that

what of the ways that we should be describing value. at some point that is with the purchaser is looking for to be looking for a level of quality at a reasonable cost. so trying to pull to of those concepts together is something that has been needed in this industry. very prevalent in other industries and is chilly -- slowly but surely, one of the issues that we found is that this project has the chief medical officer and chief financial officer together. what we are finding is that the chief medical i.d. officers argue about quality metrics before we can even get into the cost conversation because there is still lots of discussion about what is appropriate, but we are making good progress. >> add to that. >> no. i would love to. two more questions. you can talk to people afterwards. >> i left practice medicine there. a graduate of the school of

medicine, i have a question about patient accountability. all of this about the provider accountability and an earlier session and we have been talking about here. in my practice or experience, we have a really tough time getting patients to do things such as watch their weight, what's their fluid intake, do their daily heart failure clinic. as far as costs go, i remember distinctly when medicare decided to pay for the 20% of laboratory tests that they had previously. this was 1988 or 1989. all at once the same patients that said we really have to get this lab test. i want another cholesterol level. i don't here in all of this discussion and our previous discussion this afternoon and anything about patient accountability. okay.

>> health care. the payment. >> having said 75 percent of the cost relates to patient behavior , boy, that is a slam dunk and will be easy. how do you change behaviors? and so i think the thing that we do have to be careful about related to that is not to be in a mode which says you have to do this so we will penalize you. we have to be in a mode which says this is actually going to make you feel better, so it is going to improve the outcome for you. that is a big job. clearly i think that is where the major changes will be made. >> my name, i just graduated from the university of miami. as the previous question, thank you. kind of stole my question. >> looking for a job.

>> the quality aspect of this, but i guess i'm going to ask it again just because i'm standing right here. [applause] >> that's our students. >> and he has already graduated. >> one of the has mentioned that 20%, 80 percent in the country. the population is increasing, aging, but funding is still there. my question is basically how do you think the public providers will be able to maintain the quality of health care when reform comes and be able to approve that. >> a tough question. he wants to take it? >> well, i'll start. you're talking about work force issues and the workforce shortage. can you maintain quality under the circumstances. i would suggest to you that physicians when they see patients, it's exactly the same quality, and they will continue to get up in the morning and say how can i do this better.

the challenge will be access to the quality, but i don't see any reason that the quality should suffer. as a matter of fact, we talked about a number of physicians and the affordable care at the do relate to quality changing how we do the responsibility for private care, looking at out comes. i think those of the kind of things that will actually help with quality, a decrease variability, and increased. >> i think also there will be a natural migration away from things that you don't do well. >> especially with more interference. so if you can't hit the numbers players may not contract with you. purchases may not put you in their preferred network. once things are much more routine and routinely in the public domain around performance i think you will start to see providers and practitioners move a little bit more toward what they do really well and what they can make work in the

business model. >> okay. final question. the president has just been reelected. secretary kathleen sebelius decides to go back to kansas. she calls you in and says, -- he called you in and said, i would like you to take the hhs job, but your first assignment is to tell me what to say in the state of the union speech about cost containment. what -- and you only get a couple of lines because everybody else wants a couple of lines. so, let's start down the road. tell me -- you don't have to tell me whether you would take the job, but what you would tell the president, what you would tell the president to say about cost containment in his second term speech. he wants that to be the lead on health care in his second term. >> i don't have to think about

it. change party identification. [inaudible conversations] >> you know,. >> president obama. >> i think that i would suggest to him at one level do not open promise. try to get a sense of what we all know, and that is that it will not be easy. try at some level to engage us all because we all have to be involved. >> i would say the same thing. a call to action. somebody has to lead this nation in a different direction. the promise that we will make changes that are responsible, but that we have no choice but to make changes. >> and i would endorse the call to action. are reelected democratic president would earn great credibility with the american people on this issue by extending an olive branch to the other party on medical liability

reform. >> okay. [applause] >> i would not take the job. no way i would get through. but i think what i would do is link the economic growth of the country to containing health care costs and getting the health care system under control because they are absolutely late. >> thank you. let's think this absolutely marvelous panel. [applause] [applause] >> let me remind you that you are invited to receptions. we are buying the drinks. and we won't charge you. thank you. we have good sessions tomorrow as well. [inaudible conversations]

[inaudible

>> "washington journal" continues. host: whether it's on this program or other coverage charlie cook is a regular on the network. glad to have you back. guest: gosh. aye been doing it for 20 years or so. host: and you haven't aged a bifment i want to start with

the gallup poll that looked at solid democratic states. a comparison from 2008 to 2010. these solid blue states cut in half. what does that tell you? >> well, 2008 was a peak year for democrats. 2 republican party had been going through a really long slot. if you look at the broader party identification numbers, what you see is democrats have gone down. independents have gone up a lot, which doesn't reflect on the map, because that's just democrats and republicans. but the democrats have peaked out. it's not that republicans in this version where they push the independents one way or the other. if you look at the raw numbers it's for independents that go up. >> again, this is a snap shot? 2011. in terms of democrats and republicans, the states include

indiana, wisconsin, v virginia. florida, texas, nevada, minnesota and -- new mexico and arizona. not arizona but new mexico, and nevada. >> start off with the 2008 map which states that mccain and obama kwon. then you sort of assume mccain was a low water mark for republicans and obama was a high water mark. then look at the states where senator obama won just barely. and those would be the ones that republicans are going to try to reach if he could hang on to them. if president obama could hold on to the virginias and north carolinas and indianas. then he wins. and if he wins. if he can't, then he doesn't. >> you've been recapping some of the races. some of the candidates of 2010

and now 2012. joe lieberman, independent who sides with the democrats of connecticut and two republican retirements. guest: well, the top ones for democrats is that the two republican retirements, kay bailey hutchison and john kyle. it's pretty unlikely those democrats can pick those up that republicans have a better chance of picking up those open democratic seats than vice versea. but i think we're seeing that democrats have 23 seats at risk in 2012. republicans only have 10. two years after that democrats have 20, republicans have 3. so a lot of democrats are saying wow, the odds are pretty high we're going to lose control of the senate. do i want to stick around if i'm in the minority? if i'm in the -- if i stick

around, i'm in the minority and if i don't i'm defeated. host: the top states in the senate races include massachusetts, montana. nebraska, nevada. new mexico. and north dakota, virginia and west virginia. >> if you look at where democrats have problems now more than say 15-20 years ago, it's states with higher sort of small-town, rural vote. that sort of thing. democrats have lost a lot of ground in sort of rural america. in fact our house senator david wotsalman figured out while democrats last only 25% of the seats in their house, they lost 60% of the land area. and now the democrats strength

is more confined to cities and the suburbs, unless host: let me ask you about the presidential race. this morning david brooks writes run, mitch, run. and i ask you this with what you just said a minute ago about thousand political climate benefits the republican races. he says -- he is seriously thinking about not running. and govern daniels has been a comp tent manager. and it says governor calls for someone run things efficiently. governor daniels has spent his entire career preparing for this kind of moment. guest: yes. i've known him since he was a staffer in the early 190's.

as you probably did. incredibly talented guy and serious adult and i think he's really torn about whether to run or not. it's an enormous time out of someone's life. i think he genuinely hasn't decided. but if you took a poll of pundits, the feeling is he's less likely to run than run. but he's such a talented guy. he'd make the race a lot more interesting and i think would elevate the conversation. host: florida wants to move its primary up to january 31 pitting us back in 2008 where we were speppeding christmas of 2008 in iowa preparing for the caucuses. guest: i don't want to speak for you. but i suspect. i love iowa but i just as soon spend new year's eve at home. back in 2007, there we were

having dinner on new year's eve in des moines. yes. i think there's a feeling in both parties. let's not crowd christmas. let's just let the thing kind of not front led to quite as much. and we're sort of all hoping that florida will play by the rules. you know, the party's -- the parties can and will sanction states by cutting their number of delegates in half if they jump the calendar. i certainly hope florida won't do that. host: i'm going to ask you how do you think the republican field will take shape and when? guest: well, one theory, bill mack enturf you've had on the show many times, a republican pollster. he used to have a theory that think of it in terms of an ncaa basketball tournament where you

have brackets. so different candidates are competing in different brackets early on until you get to the semifinals and then finals. so the way you might look at it is there's a tea party bracket of people competing to be the tea party candidate and maybe there's a religious bracket. then there's probably a larger main stream kind of secular bracket. bracket of candidates competing there. so if you have people, like, let's just say hypothetical sarah palin and mike huckabee don't run, then whose the cultural conservative in that group? i know senator san torah running there but rick perry who i noticed was on c-span, is he competing in that early on that can pull somebody else in.

if certain big players don't end up running. host: in terms of announcements, governor clinton didn't announce until october of 191 and governor george w. bush didn't announce until june the year before the election in 2000. guest: but we might as well be talking about the dinosaur era. now the republican nominee will need to raise maybe $200 million between now and winning the nomination, the last primaries would be june of 2012. nobody's in yet. my guess is we'll start hearing candidates, people announcing march, april, may. so they'll be needing to raise, you know, just short of a million bucks a day from the day they announce their candidacy. so the luxury of holding back until the fall of this year, i

don't think it's there. host: and with with regard to president obama, you wrote hang on tight. it may not recommend the deepest cuts by any democratic in the history, but it comes close. guest: yes. i think what we've seen since the midterm election is the president's sort of shifted course and acknowledged that things have changed. and it's not a matter of republicans will be proposing cuts of this level and we'll end up somewhere in between, probably a lot more than democrats want and less than republicans want and hopefully it gets the country headed back on more of a st. court. but hopefully not too much.

host: you can send us an email or tweet us on twitter. in 2006 when the democrats gained back control of the house, they picked up additional seats in 2008 and lost in 2010. as you look early ahead for 2012 for the house and where the republicans and democrats stand, what are your thoughts guest: the factor going inspection democrats' favor is when a party picks up 63 seats, like republicans have picked up, there's some people that -- republicans that won because there was a 70 miles an hour tail wind at their backs that may not rezist at in 2012. so sometimes you get these land shide wins that are hard to

hold on to. democrats are going to be in a stronger position in redistricting than at any time in modern times, so you've got some offsetting factors here. then one data point that may or may not be the first time a -- my hunch is that you're not likely to see a over the of more than 10 seats one way or the other, which obviously, if democrats picked up 10 seats, they are still short of a majority. at this early stage i don't see a waive and so it would obviously be a departmentture from what happened in 2008 and

2010. host: do americans like a divided government? and if yes, what chances does that have on the president's chances? guest: well, i think republicans in congress are starting to kind of figure out that their success is not necessarily contingent upon president obama's failure. and that people do like this divided government thing. so i -- it's way too early. presidential job approval rate ings. but looking at where the economy is going. it's pointing towards a close race, but probably not quite as bad for the president as it looked five months ago. host: let me bring it back to this map from the gallup organization. the democrats losing 16 states

the viewed as solid democratic states. now introduced there are states that are put in the gallup category. in terms of identification. it's probably a bigger number than i would put. but this is a country that independence has played a huge role in the outcomes. for example, in 2006, independent voters voted by an 18-point margin for democrats in congress. in 2008 independent voters voted in favor of democrats for congress. and senator obama over senator mccain thirned around voted in favor of republicans in 2010. so if this were an austin powers movie is -- they are

going to play the key role in everything next year. host: let me take those numbers one step further. for 2010 listed 14 states, nine lean democratic. 18 competitive states. tossup states. five leaning republican and five are solid republican. diane is joining us from washington, d.c. with charlie cook of the cook political report. good morning. >> we're food. how are you? >> fine. >> first of all i'm very sorry that you had to listen to the gentleman's negative comments about you. i think that you are probably -- i will not say you're the fairest person on c-span, but that's not why we watch. we don't care if you're fair or not. what we do care about is you let people express their opinion. people get to call in and say what they want to say. you don't try to dissuade

anybody or convince them to think the way you think. so it doesn't matter if he our anybody thinks u -- so it's sfwreat to touk to a policy person or lawmaker or maybe somebody who wouldn't get an ordinary chance to speak to. so i just want to say i love when you're on. i always know i'm going to learn something and hear something interesting. that's the first thing. host: we'll give you his phone number so you can give him a call. just kidding. caller: [laughter] and this is so wonderful for me, because i met you. i'm sure you won't remember it, but i won't forget it. i was very rude, actually, because you had just picked up your dinner from a thai restaurant, and you were in an underground tunnel in the bethesda metro and this big,

black woman just got you. [laughter] but i introduce -- people were walking by and i was, like, do you know who this is? this is charlie cook! but what was so wonderful about it, you actually stopped for almost 10 minutes, and you just let me talk to you about my feelings about politics. and i won't remind you who the person was that i had voted for, but what i thought was just so wonderful was you actually listened to what i had to say and asked me questions, so i just want to say i think that's why you are and have been as successful as you are. because truly more than posters, i care about what you do and the opinions. as best you can, you really do try to base it on what people are actually thinking as opposed to, this is my opinion. guest: well, thank you.

i will have a spring in my step the rest of the day and no, this isn't my wife calling in. thank you very much. host: james tweeting in, sticking to charlie cook is a pretty big deal. he's a big star. guest: well these people are the most scrupe lousely down the middle eptty in american politics and i've never noted any tilt here whatsoever. so that's why i love going on, because you know it's always going to be abc louisly. thoip nation's governor is meeting here in washington this weekend and you write about the intense emotion and anger by the american people to the left and the right, and it's crystallized here right now in

madison, wisconsin. guest: i think part of thi thin comes from a frustration. but on a second with the problems facing the country and the fact that we haven't addressed them. but on a deeper level, though. i think one of the causes of frustration is that, and particularly just sort of aveiving from last year, the te party movement is there's a why won't these people in the building down the street address this? we are not talking about waste, fraud and abuse or foreign aid. these are rounding errors. 2 big stuff is medicare. social security. transfer payments. these decisions are really, real, really hard ones.

and very, very painful ones and you know, i wish that our budget problems were easy enough that we could deal with it in terdg of waste, fraud and abuse. but i think people have justifyably cy je to a point where they agree there's an enormous problem, but i think the suspiicaon is the solutions are easier than they really are. host: for charlie cook, jerry from ohio. our line for democrats. good morning. caller: good morning. one of the points i want to point out is the decline in the democratic party since 2008 i believe was caused by republican filibusters in the senate. the democrats came in with a very strong a fonda, and that was to have over 200 bills passed in the house, and they

were absolutely killed in the senate. the strategy when the supermajority was in the senate was to get a couple democrats to switch their way and then unveil the filibuster. but after kennedy died, they got a republican and they knew that was going to be the reper klican strated in. and once they took oorsice in 2009, they could have changed the fili he but they didn't do it. anyway, 200 bills that died in the house were the democratic agenda that never got passed. host: and this congress, no changes in the filibuster rule. guest: right. and the rules demhiorats and republicans must feel about tclibusters, you may have the

republicans frustrated but the thing is the upon crest of unlimited debate is it's part of the senate. part of the fabric of the senate part of the historal s and while the rules may be adjusted here and there and should be changed to a certain extent, the filibuster is never going to go awaal s s the part of what that institution is all about. but to say the demhioratic pas may, its downfall is becaus of the filibusters, the 2006-2008 elections were horrific for republicans and in 2006 the tpwhar iraq was at its to -- it did mark a rock-bottom low point for the republican

party, which a dio means a higd point for the democratic party. and once it gets past that, you're g cyng to have the two parties coming back towards the equi li and. yeah. in if -- now we're kind of moving the librium. host: we talked about two democratic states where two republicans seeking re-election. what's the challenge for these two in a year that might be good for republicans but these two states soven go democratic. guest: two months ago there were no signs. it was kind of like revpiiution

in tunisia or egypt. there was no sign it could happen but then you could really tell wow, something is going on here testibut irepubli have a reper klican senator in massachusetts is just extraordinary. and i think a lot of fpiiks on the tea party side are very frustrated with brobui, because he is moving to the middle. but if scott brown has any chance of bbusng re-electebut a he's got to find that center point in massachusetts which is a center point that's a lot far thur to the -- the folks on the reper klican and demhiorati side have to understand. i heard one tell a group in his

long, deep, southern drawl, i know you may mind to hard to understanbut a but i couldn't g itrepublica- get elected in ver so scott brown's got -- he's fot a lot of positioning to do to get himself in a place where he can run for ro thelection. nevada is ateaery,teaery swing state. harry reid had a really tough race and was able to win. but he had extremely weak republican opposition. j, jn ennisen with his scandal problems. i'm not going to say the guy's unelecti but it sure as heck looks that general direction. my hunch is there will be a different republican nominee and it's g cyng to be ateaery, he but i kind of doubt if you'll

see j, jn e oneisen on the ball nf st year. host: good morning. caller: i'd lan gentleman what he thinks of sara steelman. i've actually met her. she's ateaery good candidate. she's actually running for the hoenate seat against claire mccassical. i'd just like to see what the gentleman thinks about him. guest: inine never met sarah steelman. she's not necessarily a cookie cutter republican. i know, for example, she's had houppos ma from trial lawyers which is not usually normal for a republican. but i don't know whether she's foing to be the republican nominee or not. whie's certainly the best knobu republican running and jim

talented indicated he's not going to run for that seat. so we've got to wait and see and let the reper klican eny jination sort itself ou but she stepped aside previously, and that might give her sy je moral high ground, if you will, towards getting the republican ny jination this time. but we've got to let it sort itself out. but that's likely to be one of the premiere senate races in the countral s because missouri is a classic swing state and a state that sooked lan trend back towards democrats but leaning back toward republicans recentlal s it was one of the closest states in the election. the 2008 presidential election. but i think you'll see a first-classyer.s. senate race that mccassical is going to have. it's g cyng to be a tough race. host: we're talking to charlie cook and discussing the gal hup polls. you can log on to gallup.com.

looking at some of the states that are looking spiiid for the president, hawaii. a drop, the website is fal hup.coar frank? good morning. caller: good morning. i was calling to check with mr. cook to see if he was in the navy before. fuest: no. inine got a son that was in the army and a dad that was in the aessy air corps. but no. no navy connections. host: randy, reper klican line. caller: hi, mr. cook. how are you doing? inine got is to say that while don't always agree with you, i always respect your insights and opinions. ler cy jment is that i feel tha i see a skizzm in the

republican party between the old guard country republicans and the grassroots tea paray reper klicans. and in regards to 2012, the presidential ny jinations that possi it by someone like mitt romney and ateaice presidential candidate like alan west or herman kane or if sarah palin were to get the ny jination, maybe they could balance the ticket with halfer barber or ti there's at least two if not thee or four factions in the -- there's a certain amount of ticket balancing that has to take place. when you look the

senator mccain was behind in terms of polls and organization and behind in terdg of money. and you know, when he had to m ne his pick g cyng into the reper klican convention, it was sort of fourth and long yardage. and what were they looking far? they wanted somebody who had no co oneection to the bush-chenfe administration and never worked in washington and not be considered as part of the insider beltway crowd. they had to be pro lt goe. that some of the fpiiks, that senator mccain would have loved to have picked. joe liebeessan, for example. tom ridge were pro choice or eny jinally pro choice, tha was told the republican delegates will burn the building down t go you he was almost 17-18 points bipt.

among female voters, they could reallyyerse sy jt gody that somebody that's been to washington beforeteaersus hoy jt gody whose onlyteaisited couple times. so it is a time to shos maenyer whiort comings in the whole running mate contest. host: 193 democrats in the house of representatives. 242 republicans. 2essa needed for a majority in the senate. as we talked about it. 53 demblirats, 47 reper klicans 51 seats needed for majority in the senate. and looking at the governor. all0 dembliratic g repu independent in maine and 29 republican g repubernors. guesuall0 actually you're showi

a news article and we've got hoy je great scat graphs coming up where you have got the house of representatives ploing to ce every seat by which side young and by how much in the presidentuntl race. hosuall0 and this is what the s looks like. sease go aheaeb fuest: thank you. thanks for the plug. yes. the chas ma is s sinieedcantly dt gor. crent than it was six months ago and will be ict gor. crent again sy jewhat this election. buts the all a dynamic thing and we all have to watch events unfold and watch how if pendulum swings back and forth. the pent gor hum is the magic o should be thinking about. t go it ghe hs too far that waas i think we're sort of headed towards a middle spot for a while. hosuall0 j cyningyers from lake

charles, louisiana, your home hotate. food motheying. democrats line. caller: good morning. ler qphsstion is. what kind of plan did the republican bring? we alreasee i know what the demowashat brought. but the plan that the republican so say they are bringing, you don't see anything. host: on what issphs in hopeicaeedc? >> well, method -- guest: i'm actually g cyng to b in st. charles d cyng a luncheo for an awards dinner for a joutheyalistidedevent there. the way i would look at it is look, for the last two years, demowashats had the presidency and the house and senate. so what republicans wanted to t l a reper klican ait inda wou have been largely eirrelevant. now we've got a slightly ict gor. crent situation.

we have got a nominally testify t l you are stas maing to see m proposalsened with a budget that you may or may not agree with. wenine seen again impartial power for less than two months enow, but youtoml stas ma s what the agenda is. as i said on the outset of the hohowin what you're g cyng to b seeing is democrats advocating budit it cuts of this level and republicans over here, and we're going to adopt -- end up with sy jething in between. that's how this is built. on the premise of cy jpry jise. and i think one things that somewhat refreshing is that i

think spe ner bhe hhner is cy jmiing to ced to as much as possible doing open rules in the house. which means other members in a previous which -- it's messy, and i think we have seen and tsill see speaker boehn black eye and a fat lexa losing a flike.teaotes on the floor th way. but it really is a more demowashatic process. and -- but we'll see both sides putting up plans on it. and youtoml see better now that you've got gra great --

host: you write that the cy jin eedght repuber the dt gt ceili will require the legislative and preqitical delicacy of brai surgery. guest: yes. this fight over the resreqution it's gw ng to happen. in all likelihood -- hosuall0 no g repubernment shut guesuall0 well maybe but just a few hours or a day. yo e not gw ng to see air trafeedc controllers coming dow from the towers or those in beeghanistan t l if there's one i think most people will never noticemay- if the dt gt cs. isn't rrdssed, the u.s.

government will default on its ict gt. and you waust can, y have that happen. the question is what cy jpry jises? tshat really painful co are people going to have to cy je up with? you need 218 votes. my guess is there will be those in favor of rrdssing the dt gt ceiling and what does it take for these 109teaotes. conversely, y at demblirats h to say we couldn't let the f repuberh ent desetult. i know these are deeper cuts than i would want to do and you es.uld want to do but we had to do it, but it's going to require an enormous amount of delicaard. host: joining us, from arizona,

welcome to the convers caller: good motheying. i have a couple comments and a couple you'estions. number one for c-spass. i would love to see you do a show asking prin se in they were president for a day, how they would handle it. and reper klicans were allowed through the supreme court to pump in all kinds of money and the prank call in wisconsin proved it. so completely, and the kind of montivs that buyingteaotes. the rich against the poor. and also one morech a% pck thing. ico yolour. cel that what is bs. said in the newspapers and on the nlike.s is fuleedlling prophesies?

one day they say oil will go to $100. the nf st day it does. i've seen this several times. we lost our own tru seing cy jpany that way. knox they talk to gaddafi and say we are worried he might buthey his oil fs thelds. the next day he's doing something to sabote oe the oil eedelconv. host: thank you for your question and question. fphsst: let me als on another suggestion. if you could advise the president to talk to one or tes or three people and listen to them, who would it be waust sit icown and have lunch with and have a conversation with and pick ths. in terms of the supreme court decision and the big issue is lliout all these third parties, independent groups, independent of the candiwin tes and

independent of paray oing apparatus coming in and gending. and the caller is right. in 2010 there was an enormous amount of montiv cy jing in on behalf of the reper klicans and in fairness there was a lot more demblirats and ltest of center money. so again, this is the pendulum howasheaming back and forth. t go the money is evil in 2010. then doesn't that mean the icembliratic montiv on the othe side in 2006 and 2008 was too? and there's a tenden as i that pea le have that any money spent on behalf of the side i like is waust prin se earnestly seeking democracy and on the other side it's e200l. i think it's just sort of like fuel and used up. i forgot the last part of the

qphsstio nf or did i get it? host: i think you got it. i want to go back to the mle i that we've been showing from 2008 to 2010. do onea has this you'estion. hoo you think more states will be turning red in this nf st voting cycle? guest: i think it depends on what we're talking about. i think we're gw ng to have a very competitive presidential race. i would not begin to predih e i right now. but if the economic indicatorre and i noticed that the revision of third-quarter g.d.p. came in at 2 .8 instead of 3.2, whic how3 .00 is the point at which we sort of start to really look at job creatio nf

guest: i think the house, i think it wouldnt at change a tshole lot and i thi3 r if you were going to put odds on the presil iential racalki i would probably . i ve the president a little higher odds of getting reeldidted than not. keep in mind only one newly elected president has lost re-eleh eion which was waimknox carter losing to ronald reagan. eldidted presil ients see wto have or tend to have a lot more re stillian as i than we give them washedit for. host: grinn't e herbert walker bush succeeded ronald reagan. guesedi yes. cas maer was the only newly elected president that took repuber fro wthe other sil ie to sose. but the problem is when you come over, you get your lease

renewed once and carter-reagan is the when george herbes ma tsalker es. nf but that's the only time at least going back to roosevelt-iephsman that the party was able to win a third straight time. hoo that but we've got a long way to go. host: our viewers liked your you'estion. tweeting in talk to michael more, mr. president. fphsst: that would be one person. just make sure you're talking to who you know you're talking to and not a david coke a feaux david coke. host: good motheying. caller: my question is the incidents that are going on in the mil idle east as far as obviously you've gottliebya, greece. do you see aeau of the type of protesting that's going on over there, do you see that ah euall

ieicklating in the -- do you see maybe certain states that are turning more reper klican? ico you see a lot more protests in each individual state and do you see that swaying the next presidential election if enough states get together and see the i guess you could say order that's going on in these other countries, do you see that having an affect on the next presidenthal case? >> well, i thi3 r you rrdssed a steent storm we were not seeing that. themaychayou weren't seeing the protests you're seeing in greetia with sy je of the gending and budblyt cutbacks over there. and the reason was we wereng i doing anything. we weren't doing anything

dramatic. so naiody had aeau reason to particularly protest. because we weren't tr,ing a lot of the tough ah eio nf it would be very interesting to watch. i was talking to sy je britigo. government officials yesterday, and the blicblyt cut, f ses that prime minister cthe lron has pu into place, they don't really start and cicking in until apri that's when the pain from the cutbacks and theirteaery aggresscoke m repubes to balant their budget start kicking in. but as blicblyt cut, f ses. severe blicblyts stas ma gw ng place, yes, you're going to have pea le stas ma swasheamin ble atdy murderer. that's what happens. but the truth we the protests are a ls the ical outcome when start administering tough medi6 c13 bne.

repupresie the cut, f ses go back too far, maybe not far enough. but aeau cut, f ses drysical pain, and when there's pain, people scream. and that so i think you're going to see a lot more of it. and whether it impacts on the presidential race, who knows? hosedi we're talking to charls ce atk who writes for the "congress daily" and the editor and per kligo.er of "the ce atk political report." we have a tweet saying obama may be beatenmay- o, f repu may carter, if unemployment remains high and gas. guesedi i dong i thi3 r this situation in libya is going to remain wheres the today more than a week or % pro weeks or a

month. that's just my h" see w l spikes that economists will tell you that oil has to remrdsn ethinkraordiobrily h ih for lliout a year before fofe -- it will have a political ithe but before that. and in terms of inemployment. my general rule of thumb is in the last report, it was 9%. and it was kind of squirly. t one before that waslig.4 and before that 9.8. but i think unemployment.8 -- i think iftestsnethe down to 8%, closer to 8%, i think it would be harder for reper klicans to debate him. unemployment had been up to 10.8% at thes

eldidtion and dropped down to 7.4%. and he won a lanrmlide. this is not gw ng to drop to 7.4%. but if it's 8.1-8.3%, i thi3 r his chaemres are ge atd in gett re-elected. if it's up to 8.9%, that will be tostine a ople i had to predict today whether president obama was going to get re-eldidted or not and had a choice of knowing who the reper klican ny jinee was gw ng to be or what the unthe bhm rate -- but it's incumbent on the current president and voters vote their pocket books. host: a

>> ladies and gentlemen, let me welcome you to the united states institute of peace. this might be the last event that the united states institute of peace does in this building. we will be moving sometime next month if everything goes -- if everything goes well, which i expect it will. we are very pleased this morning to welcome the latest in a series of afghan officials who have agreed to come speak to you here at the institute of peace. you may remember that president

karzai was year less than a year ago. we are very pleased we have got this arrangement with the ministries and officials in afghanistan. before i introduce the panel, let me welcome afghanistan's new ambassador to the united states. we are very pleased to have you here. ambassador, we hope he will be here regularly or at our new facility. thank you peery much for being here. and ambassador tony wayne is also here. welcome. very good to have you. we also have added minister at the national defense university. we are very pleased this morning to have two very distinguished ministers, very senior ministers, very experienced ministers from afghanistan. mr. wardak of defense has had

experience which he can describe and i'm sure you have questions for him back to the time when he was fighting the soviets. he remembers many of the battles, many of the locations that took place then and those that terrain and that battle. we were talking last night. he's also spend some time in the united states doing some infantry training. he has been an airborne ranger having been trained at fort benning. so we are very pleased that mr. wardak is here. he's joined by the minister of interior, the minister which as people know has the police under his command, and this is a challenge he has taken on with

enthusiasm and to great reviews but his colleagues as well as the mentors that are in afghanistan from the coalition forces. finally, we have retired general varno who spent time with the u.s. forces, and i see that he was succeeded by several people now in putting general petraeus and so they were all filling his shoes and joe barno is now of course with the center for new american security, and we are very pleased to have general barno here. what we hope to do is to invite the minister wardak to make some comments this morning followed by a minister mohammadi followed by general barno. we hope he will be able to get

your questions in. we have people in another room right down the hall who may also have questions so if you see people handing me a little cards i will be relating those questions in the overflow room. this is a time for afghanistan and the coalition forces supporting the afghan forces. we are looking at a transition. we are looking at a transition now over four years rather than a shorter transition people have been concerned about earlier. so a four year transition during which time the forces of the army and the police led by the two ministers here will take increasing responsibility for security in afghanistan. this is both for the ministers and the forces that the command and for myself as it prepares to turn over the profits district by district responsibility for the security and these areas. so, this is a great time for us

and we are pleased to able to host the two ministers and i'd like to invite minister wardak to make informal remarks. we talked last night and he said he doesn't want to make a formal speech. i said please don't make a formal speech, but your comments and thoughts as you are looking for work in 2014. minister wardak. would you like to speak from here? debate >> good afternoon ladies and gentlemen. it has been a privilege to participate in this panel that some of our dearest friends and to others such prominent audience in this prestigious institution. i would like to begin first once again i need to express profound gratitude and the deepest appreciation of the afghan

government, the afghan people for all of the help, assistance and cooperation and the most genuine support which has been provided by u.s. particularly, with nato and the nato partners to my wartorn country. they are definitely playing a vital role in shaping the destiny of my devastated nation. i'm sure you are aware that danger which we are encountering recognize no geographic boundaries accept the human civilization and it cannot be overcome a single nation regardless of however far. so therefore it is needed strategic global response and a coordinated concerted effort by

the community of nations if we are going to defend of your collective freedom otherwise no place will be safe whether it is located on the surface of this plan -- plan planet. we are at a juncture and the media is portraying a picture that has been the longest war and in nine years we have not made any progress. much progress is made. i think the answers are really simple. i think we have underestimated the enormity of the rebuilding a

nation institution and its infrastructure which have gone through three decades of war and destruction. also, we underestimated the threat that the afghan national security forces 70,000 army and 60,000 police were far below based on the task on any other historic example. the insufficiency of the forces have much negative impact on conducting the proper counterinsurgency operation. relaunching too much on counterterrorism operation and also air strikes have alienated

some of the population. and also afghanistan was an economy of goods for many in 2007 and 2008 seeing some effort to build a credible afghan security force. and tonight we also have to admit there has been under performance and also the implementation of the aids programs with the overhead charges that have trained a lot of those forces and also weakened the afghan institutions so we have come a long way on the difficult journey but the

announcement of the strategy we had was clear, and it wasn't a strategy that was focused on the antiterror but on a comprehensive the bitter campaign which has the element to defeat the ideology and give us a lasting peace, and it had all elements of success which we have long since 2002. based on that strategy now our mission is unequivocal and clear for the elfgin population. we've all agreed explicitly that it is unacceptable, and all

efforts have to be directed to assure the afghan government authority and to reinforce the government's legitimacy. based on that to ensure we have all agreed to the growth of the nash gandy beagle afghan national security forces and improved government rule of law in the economic diplomat and strengthen our partnership with forces come afghan with operations including the transfer operation transfer of detention and also produce full support dhaka can lead peace and

reconciliation and strive to achieve regional cooperation, and finally, to optimize all elements of the afghan national. all these years i think you've been saying to secure afghanistan is to enable the young afghans themselves. poor it means to be able to defend the nation independently having isaf, nato and the united states is a strategic partner in support. and we do believe the afghan solution is cost effective and

less complex and it will save lives for our friends. now briefly i will touch the security situation. as you are all aware the enemy attacks have increased so the interest exclusive devices and respond to the number of casualties that have risen also. but some of it is because isaf and the afghan national security forces were operating for the first time in some areas which the of never won before coming in the meantime there was a high temperature operation for to isaf and afghan national security forces.

so with that, i think the violence had peaked during the the election, but after that with higher operation in isaf we were able to gain the initiative , and we were able to do that by conducting a proper counterinsurgency operation for the first time in afghanistan. the results were quite obvious in helmand and also in kandahar. we were able to establish control and some of the most difficult parts of the enemy

territory, and the result is now the people are not oppressed any more. the the right to choose what they are exercising and the perception of security in the government has improved immensely. and just to mention i think there are really good indications that there is a change in the tie on our table. if the key to success in operation is going to be support of the people, then in that case i think we are getting that support. and that can be illustrated that the number of ied which we help the people have been between 70

to 80% in the last two or five months it has been that high and has been identified with the help if you compare to those of nine it was 163 and now for the last three months of 2010 it was over a thousand. and the reason this has gone much higher. what we've done during these operations we have focused conventional forces on protecting the population and directed our special operations forces to keep the enemy off balance and that is the result

to have statistics the enemy has suffered and the fighters and taliban have been the case is that in three times the government appointed eliminated captured or killed so there is improvement which is concerned and we are hopeful that we have the capability enough that though i think some of those are predicting that the coming year will be bloody and difficult but i hope that will not be the case in the enemy is using the fighter now and the suicide attacks will taken place recently. i think most of it is the firefighters and also that shows some sort of desperation that in

actual combat operation they have lost their confidence to have the news making sensational attacks the multiple suicide as combined with commanders. if i go to the afghan national army, the afghan army continues to be a success story. i'm not saying it's perfect. there is a lot of improvement. it's difficult to raise an army and fight at the same time, but it is actually and a symbol of reform and it is the new afghanistan illustrating a hour transformation to a nation which we would like to take once again in its own hand.

we have with exhilarated growth, which was approved weaver worried that the quality of the force might be in danger, but fortunately that has not happened. the quality has improved more than 50% in the quality of the first based on all the statistics which are available and the result is more focused on the lesson learned partnering in isaf has enabled to sleep and learn and fight together so it has been a 24 our constant training process and in the meantime the trainees from one have improved from one to 29.

so that question of quality we do hope in the future we will be able to make further improvements the other issue accelerated growth have enabled us to about number our forces in a major operation like in kandahar i think it was 60 to 40% of the isaf forces. and now i would like to say that how i see the future and what is ahead how we will go and proceed. so i think that our journey to the line and professionalism will continue but even bigger. so we will also improve performance through

accountability and reinforcing our codes of conduct. with improved attention i think we will reach the 378,000 figure ahead of schedule, ahead of october, 2012. we will also have positive improvement to self-sufficiency in combat, supporting combat service support units in our broad institution building. we will strive to lead more operations and also we will increase the proportion of the off the afghan national security forces in some of the future operations. we will try to change the

winning of the war meant of perception which is - all along. and as we become more comfortable to defend our territory we do hope the neighboring how worse will come to the conclusion and accept reality and then we will be able to establish a mutually beneficial relations which we have sought since 2002. with the help of friends and allies we will vigorously address the question of centuries. and we will apply all the lessons learned and the protection of the population and ensuring their participation,

participation and government and rule of law security and economic development. and based on our mutually agreed plan, i think we will commence transition which is of significance to the afghans and also to the international community. transition is the result of the already jointly agreed plan of the afghan ownership and afghan leadership. so all our fourth generation attempt operations will be

conducted to work transition. and we have already agreed that it will be a process. it will not be just an event. it will also not be touched from the realities on the ground. it will be also not and dictum -- victim and held hostage to the agenda for withdraw the commitment of the international community in the longer term.

so we have all agreed that it will be meaningful, it will be conditions based, and eight should become irreversible. so based on that, we are totally dedicated to the ways in which articulated by the president in his inaugural speech to take the lead of operations and the whole physical security responsibility in five years so we will not spare in the efforts of sacrifices to achieve that goal. it is in a prayer ready. it will be a priority for us. what security will be playing a major role in the process of the transition. and for that, i think we have to remind ourselves something that

so far what we have built up in the national army it has been totally centric it is a slight centric good for the counterinsurgency operation. and so for the transition to be irreversible, there is the requirement that had to gradually get all that we are now relying on isaf which they are now providing i hope these enablers will be providing as time passes and once this transition store to the full role of the isaf forces will come to supporting growth and

that will also allow the gradual pulling out of the isaf forces. so for that, the forces which are required for tiffin to italy analyzed by the institutions u.s. analysis center i think that should have been agreed. people have the question of sustainability, but i think what we're doing today in afghanistan the international community is spending 100 billion for sure for the u.s., and 20 or 30 million for the rest of the community that the money the afghan national security forces could be sustained for the year. so that is cost-effective.

and the enablers are already needed. we will need improvement in our firepower, our productive mobility but integrated firepower, and then some power ied capability, and most of it will depend on air transportation capability, the support of troops, ground troop by air and also in the aspects of the isaf forces fighting we should have the capability also to secure our airspace. in the meantime, i think that the cooperation would play a very decisive role, as far as

all our joint efforts are concerned and even on afghanistan are closely linked to the development particularly in the region. so in most cases the country where the terrorists or traffickers have located i think they can act better, can be law enforcement, intelligence operation or it can be a military operation or developing an educational system to counter the audiology of extremists. we do see a better prospect for coordination as a result of the two, three recent try apartheid's and other meetings with our neighbor and we hope since we now should be

absolutely sure that we have a common enemy, a common threat so the cooperation, which between the two countries should be reality and also inevitable. ..

rather in a greater context of regional and global security. we do hope that afghanistan approximatety and role in the region and there's a role between southeast asia and its projected mineral resources should be taken into account. it should be dealt with as relevant and rely on partner in the future for peace keeping operations and also relations of mutual interest.

just one last comment, i think, and then i will stop. i think after many years of struggle, our goals or insight, what matter is we are well -- the cards have been high and the stakes even higher. the good news is that the hope has been replaced by progress though it has been deadly doug. -- bought. the debt of gratitude we can never be able to pay.

we pay tribute to all those who have given the ultimate price for the struggle of stability and prosperity of afghanistan. no one knows more than our afghans the pain of losing a loved one. we pray for the families of the fallen and owl -- all the wounded. now, i would like to say that no one shall doubt our firm determination, the afghan determination, to succeed and also you should be assured that we really don't want to be a burden on the international community or on the u.s. more than it requires. we are quite confident that you

will stay with us in this last part of our journey which the final destination is now weatherable, and i'm sure that we will prevail because of our causes that are just and our endeavor is a noble one. thank you. [applause] >> thank you. [inaudible conversations]

>> william -- >> can't hear you. >> translator: in the name of god, most gracious and merciful. we gather today, ladies and gentlemen, good afternoon, and thank you all for being here. i would like to express my gratitude to all of you for your presence here in the united states institute for peace. i would like to also express my gratitude to the excellency, minister of defense general

wardif talking about the affairs, and i'd like to concentrate my talks with you on the afghan national police that i've been heading for the last seven months for minister of interior. i am very grateful to have had the occasion to be here in washington and be here with you today. it has also been an occasion to have fundamental talks and conversations with our friends and ally here in washington, d.c. about the strategy for afghanistan and its future stability. most of all, i would like to express my gratitude to the

government of the united states, to the people of the united states, and to the department of defense. i am well aware that the cost of the united states has been quite high, and it has cost the lives of many of your young men and women who have selfless sacrificed their lives. you remain committed to this assistance. the debt of gratitude we owe to your country can cannot be repaid, but it can earn the infinite gratitude and appreciation of the afghan nation. i serve as chief of general

minister in afghanistan. i came to the interior at a time bh the afghan national police was facing severe challenges, but during the eight months, also were results of growth, collaboration with my colleagues in the minister of interior as well as the support of the international community, we have made tangible progress. training and education has been the core at our list of priorities and during the last eight months, the capacity of our training centers has in connection withed from 950 -- increased from 9500 to over 12,000. one the main challenges also in the afghan national police has been the undereducation or illiteracy rate among peacemakers, as i'm here

speaking with you, more than 20,000 officers are enrolled and receiving training and education in literacy courses and education and other courses. leadership development has been our second highest priority. having committed professional leadership -- without having committed professional leadership, all of our efforts would be fruitless. on this path and towards this objective, over 66 general officers in over 2,000 police officers have been removed from their position due to erroneous conduct, and this will continue this process started from the top, and it will continue to the lower ranks. corruption is another high priority that we're focused upon during the last eight to nine

months. we have taken many tangible and fundamental steps and actions, and we have made significant changes in the leadership structure, the hiring and retention based on proliferation, accountability, transparency in contracting, and also filtering out those who have potential ethically questionable backgrounds. we have improved the criminal investigative division as well as the prosecution of those who were involved in corruption at any level. in order to increase the transparency and accountability, new commanding officers have been sent to all of the zones and provinces of the nation in

order to vividly and tangibly verify the possibilities and the equipment and the supplies that each unit has available and with which they operate. in order to increase the capability of a system that would hold people accountable for their actions within the police structure, during the last eight months, i personally visited 28 of our 34 provinces and permly verify -- personally verified the capability gaps and attempting seriously to decrease those capability gaps. the level of attrition has increased on a daily basis. even though we have taken many fundamental steps, we still have a long path ahead of us and much hard work remains to be done.

the security situation. in results of joint nato and afghan security forces operations, particularly in the north and south, the security situation has improved vastly. the losses suffered by the enemy in result of having lost high ranking and mid-ranking commanders as well as notorious drug dealers have put a severe blow to the enemy. areas and provinces that were traditional safe havens for the enemy have been cleared of their presence. joint and nighttime operation between special operation and afghan security forces have hunted taliban leaders successfully as well as terrorist organization leaders and notorious drug dealers.

this goes to show that our mutual strategy, that our mutual strategy is our fight against this enemy has been correct and we have been on a road towards mutual success. the secret to our recent successes has been earning the trust of our nation, of our people. we now keep our presence in the areas that from which we drive out of enemy, maintain security, and we bring fundamental help to improve the daily lives of the people of the local pop populous. the development of the police force. given the level of security threats, the area the nation ties, and the level of the

current threat, we have established the level of 170,000 for the personnel of the afghan national police forces in order to be able to bring widespread security throughout the nation. on this path, i would like to express my gratitude to the international community, in particular to the united states for having brought us vital assistance in the development and expansion of the afghan national police. the development of the afghan national police has been done with a great deal of concentration with the fact it is primarily a law enforcement agency. one of the priorityies -- one of the priorities of the afghan

national police during expansion and development has been to separate the authority and responsibility between what is the afghan national police's and what falls on the shoulders of the afghan national army. the transfer of responsibility, the transition. transition entered a sensitive phase, and it requires a logical and serious way of dealing with this phase as the afghan national police will shoulder the bulk of this burden because maintaining internal and domestic security is the primary role of the police. during the transfer, we must pay particular attention to the following points. increasing the capacity of the

afghan security forces vis-a-vis their weaknesses as well as their equipment. increasing the -- i apologize, decreasing their capability gaps by providing better equipment. the transfer must be done according to the realities of afghanistan as they are today. it must not be a political decision. we must ensure that the transition is indeed irreversible. it must ensure -- it must bring particular focus on the destruction of the safe havens in training camps of the enemy and the terrorist on the other side of our border. the sincere collaboration of our

nation -- of our neighboring nations will be a key component for this success. having said all of this and bringing particular attention and focus on the points that i just shared with you all will pay the road to success in this transition. distinguished friends, we do believe that in our mutual fight against terrorism and the taliban ensuring the stability and security with the objective of final victory, the role of the police has been a vital one, and development of the security forces without particular focus on the development of the afghan national police will not be realistic.

therefore, particular attention to the development of the police within the framework of their daily primary responsibilities must be a primary focus from now until 2014. recently, in representing the government, the nations, the people, and the police of afghanistan, i would like to again reiterate my gratitude for all of your country's assistance and sacrifices, and i do hope this state of assistance in training and developing our capabilities will continue during this upcoming phase. god bless you all. [applause] >> thank you minister

mohammadi. >> i know the audience is really here to ask questions of our two distinguished guests -- >> three. >> not including this one of course, and i'll be brief in my remarks here this morning. i'd be remiss if i didn't point out a late aifl, deputy secretary of defense who works the defense department's policy for afghanistan and pakistan and central asia and to my knowledge may be the most senior u.s. government official who's been working nonstop on this region devotedly since at least 2002 when i met him without any breaks, and he probably has a deeper knowledge of that in this room of people who are not afghans. it's great, senior david, and i hope we get some questions from you, and if not, i'm sure you will when we adjourn. i just came back from a trip in

pakistan in late january. that was intriguing in light of conversation we've had so far this afternoon. i expect to get out to afghanistan a little later this year and tromp around on the ground there a little bit. as bill noted, i'm a senior fellow at the center for new american security, and we just published a report that a coauthored called reasonable transition that tells what the five-plus years should look like in afghanistan. i'll draw on the research and the writing on that in light of the remarks of the two ministers here this afternoon. i clearly, if you're not aware, i'm not part of the u.s. government, and what i'm giving you is not the usip position. it's informed by having a deep family commitment in the

afghanistan enterprise, not only spending time there myself, but two sons who are army captains, one already sent a year out there as a scout helicopter pilot, and another is leaving in april in a military brigade. i get feedback whether i like it or not as to what's working in the captain level and i find that to be informative. i had the opportunity to listen to a former senior official of the afghan government who was coming through town talking to various groups, and at the end of his heckture, he -- lecture, he concluded by saying 30,000 taliban are not going to dictate the future for 30 million afghans. i raised my hand and say yes they are. 30,000 taliban have every prospect to takeover, unless the 3 million take prospect to war

against the 30,000. clearly, this has been the tremendous extent to which the afghan national army which is growing from a very tiny force when i was there of under 15,000, and the afghan national police have grown and developed and gotten into this fight in the last several years. that's a huge change that has gone somewhat unremarked here in the united states, and it's going to be more important than simply the status of where we are there today. it's going to be the future of the conflict in afghanistan. two years from now, three years from now, four years from now, this afghan national security force will be taking the fight to the enemy enabled by u.s. advisers and u.s. capability, but the large contingents of americans and nato forces that today are fighting that population center

counterinsurgency campaign will be replaced by this growing number of afghan solders and -- soldiers and police, and they won't be standing out there alone like in the past, but advised and mentored by nato forces and american forces, and that in many ways is their key to success. in the paper we wrote in december, we postulated a long term, post-2014 footprint with the united states and afghanistan along with selected alies with 25,000-35,000 troops focused on two primary missions. one, continue to put relentless pressure on al-qaeda and terrorists that can threaten the united states and the region, and secondly to advise, assist, and mentor the afghan forces to counter the battle against the

taliban and their movement. that's an extremely long term dimension. my trip to pakistan was very notable in connection with this dynamic in that for the first time i found the pakistanis beginning to believe that the u.s. is staying and not going, that the u.s. has now committed to having a long term engagement and most likely some type of long term presence in this region. these forces that can continue to enable and to advise and mentor the afghan security forces are a part of that commitment. clearly some ct, counterterrorist is part of that too. this has the potential to be a specific game changer in the calculus in this part of the world which for many years, many recent years, has been dominated by the question what will our policy look like? what will this approach for us as pakistanis, afghans, as the

taliban even, what will this look like the day after the americans are gone. if now the calculus begins to shift to how does this position, our interest for the day that the americans are staying for the upcoming years we're we have to interact with the americans, that's a different calculus. our long term commitment to afghanistan going back to something minister wardak said is saying something about the region and not just afghanistan, and our presence there perhaps beyond 2014 with a modest sized force, and yet that has to be decided by the u.s. or the afghans, but i think that the confidence in the u.s. staying power is a strategic multiplier for us. where that confidence exists and where we can grow and nurture there, where we can convince the friend in the region that that's part of the plan to stay engaged, then we have a strategic leg up on the adversaries. where we continue to erode or

contribute beliefs that we are looking to move for the exits and looking to the view in many of that world, abandon that role. i look forward to that and entertaining a few of your questions. thank you very much. [applause] >> thank you to all three. excellent presentations to get us started. the time is it's time for you to ask questions of any of the three. if i can get you to raise your hand when ryan comes from the mic, we can start here with the person here and please stand, state your name and quick question for them. >> yeah, sure. i'm jessica stone, a correspondent with cc english television. my question is for the minister of interior about the dangers of

infiltration. we saw recent reporting that there's a new plan to be unvailed next month to prevent that. i'd like to hear more about that and specific experience in afghanistan reporting on this issue, and it's only gotten worse over time. >> thank you. minister? >> translator: as you mentioned, one the enduring tactics remains to infill rate the ana and the security forces as a whole. unfortunately, as i'm sure painfully aware as we are, they have succeeded on these

objectives many times. >> translator: i also want to share with you that given the bitter experiences of the past, we have done our utmost to put those lessons learned to good use and proper use, so we are no longer accepting within our ranks those people whose identity is somewhat foggy or not completely mental anguished or whose background may even be slightly yesble. indeed, that is decreasing the

dangers of infiltration. >> bob in the back. >> i'm bob, security director of usip. i have a question for the minister of interior. there are two new entities that are responsible of your ministry, one is the afghan local police and the other is the afghan protection force. can you give us a status report on the forces and answer the question raised as to whether or not these new forces are a distraction from the main work which is to focus on the afghan police. >> sorry, can you repeat that last part? i wasn't able to keep up. >> whether or not creating two new forces at the time you're working so hard on with the

national afghan police is a distractions? >> translator: i do believe that the creation of the afghan local police over the short term is much needed ingredient towards achieving the objective of security across the region in afghanistan. . .

[speaking native tongue] [speaking in native tongue] [speaking in native tongue] >> translator: over 52 companies have been -- 52 security companies or institutions so to speak, have

been let go of. and all of their responsibility we are committed to executing the will of our president, which is to bring and encompass all of the responsibility under the umbrella of the administration of the interior. we are working hard on executing the wishes of our president, and we are studying the best mechanism in which to do that. we have worked days and hours on end with his excellence excelled ambassador wayne. [speaking in native tongue] [speaking in native tongue] >> translator: we are also certain that the temporary temp- the creation and the temporary use of the afghan local police, as well as the appf, which

brings all of the responsibilities of those parallel entities under the ministry of interior will be a key ingredient towards achieving success of maintaining security in afghanistan. >> yes, ma'am. all the way in the back. coming. >> i'm from voice of america. i work for a service that broadcasts in afghanistan. my question is for mr. wardak, withdrawal of -- excuse me withdrawal of u.s. forces after 2014 is the biggest concern of afghan people because in most areas there's no security or security is so bad. is there any guarantee that after the foreign forces withdrawal, afghanistan will not be the safe haven of militants

again? >> actually, i think -- i have already explained that there's drawdown of information forces will be very gradual. and it will happen as the way they have -- i will quote you the exact sentence that isaf will pin out as the afghan capacity increases and the threat level diminishes. so with that i think in the future, three or four years, i think there will be considerable progress and the capability and capacity of the afghan national security forces. but moreover what is really important that because of our location and dangerous and volatile neighborhood, we are

all seeking that afghanistan should be never allowed to become a safe haven to the terrorists again. and i think international communities are committed for that. that's why we are already discussing the nature of our security relations with the international community and particularly the u.s. and i think general barlow has already explained, so i think we should not be worried that something like after 1989 and '90s will happen again in afghanistan. >> mr. wardak, let me follow that up. >> please. >> on a question from the other room as i mentioned. and they have sent -- it's a related question. it says -- this is from omar

allebundy, the "u.s. times," and "washington post" says they will begin withdrawing from the bush she valley. do you think it will encourage tribes to seek a safe haven? >> i think i was the one that was interviewed by the "washington post," and actually, as we mentioned earlier, that are realignment of the u.s. forces based on this strategy of taxing the population is taking place all over. but as far as the kunar and providence is concerned, it is one the most difficult area in afghanistan. it is difficult. the area is not highly

populated, but it's on root to three or four other valleys which are directly having access on the road to jalalabad from kunar. i tried it myself. to cut it off in the old days. so it -- kunar providence has most important strategic significance than most of the providences in afghanistan. that is why the afghan jihads have initiated from kunar. before also, there were some -- against the government from the same providence because of the nature of the terrain. and then it's immediate proximity and accessibility to the other side of the boulder make it even more significant. so we have to make all of the

proper arrangement for the afghan national security forces to be able to hold on to the pech valley in absence. i think the capability to resupply a unit by ground is not there, by air is not there. so we will still rely on special arrangement to be made with isaf for resupply, for air support, and fire support. if it was required. it will have a political implication also. if the pech valley results in the fall of the district, then i think it will have a lot of psychological impact and all is such the districts are falling.

and moreover, whatever the importance that has been talk about insurgents coming from pakistan. and going back and forth. we have this discussed with other pakistani neighbors which they are claimed that. so giving them this opportunity to come and have a safe haven essentially is what matters on the question of -- i mean this realignment of forces. so i will say in addition to it's military significance, and the nature of the terrain, there are other political and psychological imperatives which should make us to make the proper arrangement to hold on to

the area. either by afghan forces with the help of isaf, or still have the isaf forces as they were there for the last six, seven years. >> thank you. joe barno, not speaking from isaf, but you have faced the same question about the cases of forces. any thoughts on the pech valley decision? >> we talked about this a bit before we came in the afternoon. i think the coalition, isaf is going to have to make difficult tradeoffs between where it can get the most affect out of the sources available. even with the surge that's brought 30,000 additional troops in this year, how they have been distributed, where the threat is right now i think is causing isaf headquarters to have to reassess a bit in terms of getting the best bang for the route there. today in the pech you have small outpost that are remote and

difficult to resupply. they are under a lot of pressure from the enemy, and they are not able to aggressively, and in many cases get outside of the fence line to take the war forward. i think my assessment from the distance is that isaf has looked at positioning those forces elsewhere and controlling the terrain in a different way. that would could be in concert h afghan security forces. this is a change. and it's going to be, i think more common as begin to go through this transition starting later in the year. >> thank you. this is for radio of liberty. the concerns about pakistan in iran still remain in its place.

because it is proved and confirmed by u.s. officials as well that taliban sanctuaries are in pakistan. and it's active inside pakistan, and even the recent u.s. reports say that he was treated in the hospital by isi. according to these concerns, what do you think -- what should be -- what's the way how to deal with pakistan? and i want to hear on the same answer, and i want to have the same question from general barno as well. so what should be? how is the way to deal with pakistan in such condition? thank you. >> this question on sanctuaries. probably all three of you will have observations on this. general wardak, would you like to begin? >> sure. i think -- there are some facts about pakistan that have been a lot of attempted by the international community, the afghan government, and also the

recent establishing the peace. i mean to improve the situation and to get more cooperation from the pakistani side. and as i mentioned and i think general barno also mentioned, that after all of these years, i think there are signs of improvement that we will have some cooperation that have been also recently some arrangement in the boulders that while there is an operation taking place on any side of the border, the other side will have to cooperate or making a blocking position or something like that. also, based on our experiences in the tribe par tide, and other engagements that we have, we think the situation have

developed in pakistan in such a way that it might compel them to increase and enhance their cooperation with international community and also with afghan governments so the prospects of looking brighter. but still we have to work harder on the issue. and i think the entire international community is working on the subject as well as the afghan people and the afghan government. >> mr. mohammadi, you heard you in a conversation, when you are fighting the soviets, you used pakistani sanctuaries.

so you know about the use of sanctuaries, as the taliban are now using them. [speaking in native tongue] [speaking in native tongue] [speaking in native tongue] >> translator: i am sure that you do remember during the conversation that we previously had, i also pointed in no uncertain terms in order for this transition to go from this initial phase towards a successful conclusion in continuity what comes after, we do not only need and necessitate an increase in the capabilities of our security and armed

forces, but one of the keys is also the sincere and and -- sine and honest collaboration of our neighbors. [speaking in native tongue] [speaking in native tongue] [speaking in native tongue]

>> translator: yes, and also, indeeding i did point out that during our use, his excellency and myself fought. during the years, i also said we used to take refugee in pakistan, launch attacks, and take refugee in pakistan again. at that time, the focus of the world was in backing our movement and our fight for freedom. this is why because we had refuge in pakistan and because there was a concerted worldwide effort, we were able to defeat one the two super powers of the world. and the same thing that i say to you is valid today. until the pakistan -- the taliban and al qaeda terrorists are not purged from their safe havens, it will be extremely difficult if not impossible for

the world community to ultimately and decisively bring them to their knees. >> general barno? >> i think i'll give a different perspective. based on my recent vision. i've been to pakistan 12 or 14 times. this was the longest visit. i was there for a week. and i had access to senior people in the military and civil service and other elements of the government, intelligence agencies, academic students, governors, so i had a fairly wide cast of people that i talked to. i'm also very sensitive to hearing talking points. and this is the first visit outf 12 or more i didn't hear the same script. i was having unique conversations. one of my major takeaways from the trip, if i can aggregate perceptions is the pakistanis want to see the conflict in afghanistan settled, concluded, brought to an end.

it was described to me by several people that the worse-case outcome -- take this for what it is -- the worse-case outcome for pakistan today is a taliban victory. the second worse case would be pakistan having to deal with the civil war in the aftermath of a very rapid u.s. withdrawal. so they are very concerned about the impact of the war next door. so you might ask why is it that pakistan has by many descriptions, perhaps most, had a hedging strategy in afghanistan over the last several years that many commentators have argued provide sanctuary for the taliban, provide resource, and perhaps even direction in the eyes of some. i think that has everything to do about their confidence in what the future is going to look like. and i believe their hedging strategy was based upon ensures that they were not in a position of grave disadvantage after the united states left the region

again. the u.s. as we all know, pulled up block, stock, and barrel after the defeat of the soviets. the pakistanis are incredibly aware of that, and expect to see that again. they are now beginning to believe that may not be true. that's beginning to, i think, change their game plan as far as hedging through the taliban. you know, we are not very far down that road. but if we can convince the pakistanis that we, in fact, are staying in the region, as opposed to leaving, i think there's an opening there for their strategy, their hedging strategy to change and for them to put their chips on a different part of the table. we are only beginning to do that though. >> sir? >> okay. here's a mike. there you go. >> for the ministers, i'd like to follow that up. both of you have stated it's essential that the sanctuaries close.

what is the plan if the pakistanis are unwilling or perhaps unable to close the sanctuaries? what do we do then? >> actually, we -- i think we have not discussed here that we have launched the kind of effort in peace and reconciliation. i think that is a great potential in reintegration, because everybody is not a radical extremist. the one who are fighting us today. they have different grievouses. and the way the situation is evolving in this regard, i think we can deprive them from their foot soldiers and their mid level and low level commanders, and that will have the impact. but if we can solve the question of the sanctuary, then i think our our -- we will have a shorter -- shorter journey with less effort. and less loss of life and blood.

that won't be the easier way to come and solve the problem. but even if that did not take place, then the requirement will be to make arrangement that all afghan and pakistan turn, and that arrangement has to be deprive from them also. them, i mean through the reconciliation and reintegration to deprive them from having all of the foot soldiers. i think that is very much possible. and i do believe that in the coming year, we will see some significant reintegration events. >> thank you, minister. minister mohammadi, would you like to address that question about if? no. okay. good answer. good. very good. yes, sir? this -- mr. mohammadi has another meeting downtown. let's see how the question goes.

it might be the last one. >> hi. my same is samhadi, i'm from afghanistan tv, i'd like to ask my question in personal and if possible, please translate. >> i am. [speaking in native tongue] [speaking in native tongue] >> i wanted to ask his excellency, the minister, whether in the recent talks in washington, d.c., where you have come across the topic of permanent bases in afghanistan or not. if you have come across this topic, what result has it yielded -- has it given so far? >>[speaking in native tongue]

[speaking in native tongue] [speaking in native tongue] >> translator: the second question is directed to his excellency the minister of interior howe howe -- mohammadi. there seems to be a mixed message, particularly when you earlier mentioned as successful,

joint nighttime operations that have eliminated a lot of high command level and mid commander level capabilities from the taliban and terrorists organization and yielded the apprehension, or elimination of high value targets in general. when we go back to his excellency karzai, he seemed to be against the operations that do not often yield the desired strategic result. so is -- should we take this as a difference in political views, in policy views, how should we translate this in afghanistan? >> so minister wardak, you will take the first question? >> yeah, i'm not sure shall i talk in his language or mine -- english. >> english would be fine. >> yeah, actually on the invitation of secretary gates, not to -- on the subject of

discussing the strategic partnership -- but actually i will tell you that this issue of basis have been blown out of proportion in the media. this is already some mention of access of u.s. to afghan bases if it is required, and the already signed enduring strategic partnership document which was signed in 2005. that's about -- our purpose for this trip was not discussing the basis, but we did discuss the nature of our relations after 2014. which will be related to some sort of strategic partnership, and both sides have a lot of emphasize on the need of that,

but the actual official talking and discussion on the issue is going to take place later on some time in the future by u.s. government and also the designated members of the afghan government. so that is actually has been dealt as a separate issue. which will be worked out in the future. >> thank you, minister. [speaking in native tongue] [speaking in native tongue]

[speaking in native tongue] [speaking in native tongue] >> translator: i would like to reiterate what i shared with all of you earlier, indeed, joint nighttime swift operations have dealt back breaking blows to the enemy, eliminating high value targets but high level and mid level commanders as far as high profile and active drug dealers. i will say this again and again because i am convinced of it. i don't think anything should be

made of this rather than purely