talking about a shootout they had in kenya or something at the end of the week when i went to pick her up she was a lull discourage and said everybody is better than i am and i got to watch her play a little bit. yes but you are now better than everybody in your school. and she became allstate. some of those things payoff. i appreciate the three east that you presented your to the media exposure expectation and experience. it's very important and i can hardly wait to read your book find where the windows. on friday because of the time change with wyoming i can get on a plane and usually in wyoming in time to talk to some classrooms, and one of the things i talk to them about is the importance of the coating to the kids are usually into coding and don't know whether it is star track or what but i tell them that is actually what

reading is. it's wanting to decode books and there are so many out there on so many topics on anything they want to know about the confined in the bucket they learn to code eight. with somebody else is going to be reading that book and they are going to be doing much better than them and i would like to ask how many of our athletes and if they are reading books about their sport that helps, but it sounds like this could be -- we exchange books based on the books i ought to read and i mentioned some books they ought to read and i suspect this is one that i will be suggesting that will help girls quite a bit. and i used up my time. but i will submit some questions for the record if you do me the honor of answering them. most of the questions came up here when we were doing this and

i appreciate the testimony and the answers that you have given today. tremendous help and there are things we need to do in this and that is what the questions will be about, what the next steps are. so i appreciate your comments about we don't need the litigation, but we'd probably sunday that transparency and some compliance reviews and i have some questions more on that. go ahead. >> there is only two things to argue about in the lawsuit. the facts and the law and that is another case that is clear and now after 40 years of litigation bill walz is clear. usually people's behavior, but we do need to have it there in case. one of my favorite lines and i'm talking to an athletic director is you can either believe me or a federal judge. so i'm glad to have the back up behind me. it's not my personal good idea

that these girls should have the same educational experience that the the boys had. >> i appreciate that from a law school professor. >> senator. >> mr. chairman i believe senator franken is next. >> you were here before even though you had to duck out but if he would like to yield to senator frank and. >> thank you. i apologize for leaving but i know about the testimony that you've given and it's certainly inspiring. we must counter the notion that the field is a male only club. women like you have played an important role in the global quest for innovation but women still account for only 40% of the nation's science and engineering degrees and just 25%

of math and computer science drops, and i think the challenges of the next century are great for half of the population to set them out. we have to start thinking outside the box. what are your thoughts on ways for us of the federal level to better support girls and young women in the field. and i have heard so many times we lose so many of the work rules and middle school that that is the age when all of a sudden they are no longer -- it's interested in math and science as they should be and i have to admit as a mother on of one daughter that has her ph.d. in geology and it is -- i know as a matter how hard it is to find all of those science programs, find all of those after-school activities. there are lots of sports activities but now think goodness for title ix. we also need a lot more science and engineering. what i but like to start with saying is what we do to correct

and help stem the field and achieve will also improve stem achievement for males and the first thing we need to do is look at the teacher training because teachers who were in elementary school which is where kids get a lot of that zest for life and enthusiasm for what's going on in the world around them in elementary school that is being alterman by people who teach just by looking at the right answers we need hands on education. succumb teachers' training is important because most elementary schoolteachers don't take any science classes in college. so that means what they are bringing to bear is whatever their bodies and everything was when they were in high school that's where they have the last science class. hands on education makes a difference. can you imagine trying to learn how to read without having a book to practice on? that's what reading is about. with sieminski to do experiments to the needs to be hands-on.

kids love it. you have to allow them to experiment because it's about the critical thinking and problem solving skills, confidence that you gain when you try something out and that doesn't mean putting a computer in front of you and watching things on computers. it means putting the potato in, measuring how fast they go in to stem. that's the kind of things that welch children to explore and the kind of things need to do early on the. i think one of the other things we have to really pay attention to come in and i don't know how we do this at a federal law when terms of the government but particularly nationally is to change the expectation of what kids do. we say all the time we excuse the poor of accomplishment in mathematics to but i'm not so good at mathematics but it's okay. that's not appropriate because everyone can do these things it

is just a matter of us paying attention to it and making a difference. i would also like to say that when we start talking about bill loss of talent when we don't include women and they don't graduate or they don't get involved in the jobs whether it is not to require a four year degree or the are a machinist for things like that, yes we are losing a lot of talent that we have available but i think that there's something just as important. we are losing the perspective that the women bring to different issues and i don't mean in terms of, you know, whether they pay attention to what's going on at home or not, it is literally a perspective. people bring different perspectives. i read and write as the money i remember in medical school when i went to medical school the correct therapy was a mastectomy for breast cancer. very disfiguring and harmful kind of surgery yet it wasn't until women were involved that

we started doing the lumpectomy. when i was in medical school, people tried to with testicular cancer they would do everything they could to keep from removing it testicle. [laughter] i just bring this up because it is a different perspective. we have different perspectives that bring to bear and it would be a shame if we lost that perspective. and then finally, senator harkin had mentioned earlier about people's perceptions folks lose out and man lose out because of title ix how many nurses do you see that are a male before title ix? i know fundamentally it's changed things for the better as well. thank you. >> mr. chairman and ranking member, i do appreciate you holding the hearing today. i think it is lots of good information. >> thank you. senator franken. >> i second that.

dr. jamison come in your answer you primarily went to teachers, and i think stem teachers are really important. you know, if you are east and teacher and a really good one, your value on the marketplace if you have those skills might be higher than the great english teacher that teaches moby dick but if you have engineering and mathematics skills and talent, you're in value on the open market is higher. so i put a piece of legislation called the stem master teacher corps, which is basically to

support the master arts to support excellent stem teachers and to give them a little bit of elevated salary but also to give them the responsibility to mentor the less accomplished teachers. we are spending money to recruit them let's retain the stem teachers in our junior high and high school. what do you think of that approach? >> i think the approach of having the teachers is a very important. yes it's important in high school, but i'm going to hearken back to the elementary school because it's elementary school where kids are still fascinated by science and they haven't learned they aren't supposed to be. it's middle school the store to fallout so unless they have the effect of science education

early on it won't make a difference and i should add that most of the education and science mathematics education in elementary school is done by general teachers in first come second, fourth, fifth grade, rarely do you have a teacher that specializes in stem so i would add on to that that the teachers should be available to help mentor, augment, provide professional development for elementary school teachers because that's where we really have to take advantage and explore the incredible capacity that students have for learning. it's right there where you can capture and then get through eighth grade and puberty in hormones and everything and they are able to go on through high school and maintain that same enthusiasm and then your master teachers can also help to change the way the teachers teach in high school. >> i want to thank you for that answer.

i think that is a great function for these master teachers to go down or to be there for elementary school teachers. i will through this open to everyone. i once read that the number one determinant of whether a kid graduates from high school is whether he or she identifies with her school. and so this can be through an athletic program or a dance program, it can be through the chess team or anything, but it seems like we've put this emphasis on testing and testing in a very narrow way, and not enough on those kinds of extracurricular some that are associated with the school to

keep for those students that may be their identity with their own school comes to something else. does anyone have any comment on that? again, this is about high school and not about college. >> i went to long beach and i absolutely love it because every morning i looked up to my left and saw the home of scholars and champions, scholars first, champions. then as i entered the school, enter to learn, go forth to serve every single day i went to school which is almost every day -- [laughter] absolutely embraced those things. absolutely embraced them. we had great scholars and our school and a great athletes with

other sports the girls that was a different situation when i attended. now it's obviously much better. can i just ask something about the order the math is taught? because i talked to the doctor that you mentioned and she said that most countries do the math in different proportions that physics comes first and i know i had algebra first and i would love to understand it does that make a difference? >> the was a big discussion the life and involved. i loved science and math, but we know we have to be strong in that area in this country. stat some people teach physics before biology because physics is actually much simpler to learn, but you do need the algebra and other things, said you needed algebra and the geometry. some people think that you can teach algebra much earlier in schools in seventh and eighth

grade students are capable of taking algebra and geometry, so i think that some of the -- we do have to go back and really review our curriculum and whether or not some of the ideas that we held before are really -- >> i keep hearing other countries teach physics almost first. islamic i see the point. >> are you competitive in some way? [laughter] >> senator, you started this teacher thing in this damn thing. picks back as a recipient of high school graduates into the

academy, i can't attest that they are thirsting for identity and they're filled with more and more choices and innumerable number of trees and not always the direction that we would like to see them get with those kind of targeted instructors, teachers on the air in an elementary school to develop the matter leon without the sense of core values and character that we need to see when they come to us they are thirsting for identity and to be a part of something bigger than themselves >> i would echo that the engagement makes a difference that as you have students engaged in and part of a bitter doing that makes a difference it together a program called the earth we share be of 12 to 16-year-olds i would like to play with that hard age group and they solve problems in the team's, and fundamentally the appreciate the fact that we are asking them to solve problems and asking them to give their answers in front of everyone because that means they are engaged and it makes a

difference that that individual was a part of the process. they couldn't have been anyone else that comes with that same answer and that is a part of the identity that we see both of the recognizing what high school student to as well as whether or not it should belong to some group that's doing good. islamic i saw that you had a comment. >> let me point to two different research studies, one again i was quoting before that looked out athletics and she compared with other after-school the activities, so your book debate team etc uniquely provided this bump in education that other activities did not. so i don't know if it is gender identity if it is identity with the school and then one more interesting study that was done by the professor out of duke university that looked at men who attend schools with a

successful programs and when the school is in a season that they actually do worse in school and they do not make it up early on in their academic career, so it has this only affects males and a successful team doesn't affect females in the grade point averages but there are fewer downloads of scholarly articles that never get made up later on there's more articles come so in the high school level i have not heard that before and i am interested to sort of dig more intimate and see how these other researchers nixon's with that. it seems like a very successful football and basketball program may provide identity with the school but has a very negative impact on their education.

>> i've gone well over my time. i blame ms. king. [laughter] >> i apologize. you got me thinking. it's all your fault. >> you are a hero of mine. >> thank you, senator. >> thank you mr. chairman. i just want to make it clear if you want to ask questions of each other, fine with me. you can even ask questions of me. i'm not at all threatened. i am impressed. let me thank if you mr. chairman for having this hearing. it's been extraordinarily useful and think you for being here. you are genuinely heroes, not only will models for other women

and girls but i want to thank particularly when you and i have seen each other in a variety of locations for the difference that you made in just the year. were the most difficult challenges that you face and leading that educational institution in attracting and keeping and supporting women and what are the lessons you think that we can apply to other military academies in that way? >> it's interesting to ask what it alleges that we have in attracting women because actually we offer young women a chance to serve their nation as part of the five federal service

academies of a different mission some law enforcement to search and rescue to marine environmental protection and the biggest major for the women in the coast guard academy of our eight major is the marine environmental science major. there are women more than men this year and we have 37% of our income and class of this year. we reach out to the young women and attract them to the coast guard academy come and i guess the biggest challenges with retention comes after graduation from the coast guard academy when young women graduate and start to have to make tough trade-off decisions of marriage and having children and serving

the country, moving around a lot there comes the retention challenges when all of these choices have to very trade-off decisions for young women. >> thank you. those are really the same kind of choices that face women in many different professions. >> yes, senator. >> let me ask you, professor hogshead-makar you can believe me or you can believe a federal judge, so i know that sometimes you have to tell someone that, but i wonder if you have found that enforcement by the federal government has been sufficient because as you know as a professor of law, any mall is only good as the enforcement. so would be your judgment on how

well federal or other authorities are doing? >> i think if you get a good investigator you can get a good result but many times either don't get a good investigator, or after a complaint is filed, then the two parties come together, the school and with the lcr get together and the school will have some excuse about, and that is a legal term, about why it is that they are doing something or why it is that something should be considered legal, and the plaintiffs or the person that filed the complaint is left out of the process. so, it can be effective and sometimes it is not. but what is missing is in terms of enforcement is having the the board of education and the office of civilized go in and

get an entire region, forget this one by one school. we had too many we don't have the resources for. let them go and final complaints and give compliance reviews and have the school say here is our defense work here is why we are not giving the boys and girls the same amount. as the mexican broad enforcement approach. >> a broad enforcement approach, yes. there is a guy that has been previewed in various magazines named herb dempsey and he is a guy that's daughter has played sports and he's gonna run and has done this was a mole kind of thing and he is tired of it and he is tied to file these broad complaints and the department of education said frankly right now they just don't have the resources. we need to give them the resources to be able to offer all the reasons i talked about before. there is no reason 40 years

later i used to be sympathetic to schools. that's too bad it doesn't build the same softball facilities. now it is a budget crisis and what are you going to do. 40 years. i'm not sympathetic anymore. you couldn't plan or figure this out in 40 years this isn't news for anybody. >> thank you. my time is expired but i would like to follow-up on this issue and if you have thoughts perhaps we can talk about it more. thank you mr. chairman. >> thank you for being here and senator harkin and senator enzi it is just exciting to me that 40 years ago a mere 37 threw open the doors to athletics for education it is pretty simple. title ix is powerful and has some amazing results of the

statistics back in the 1972. it's 42% and has made a lot of progress. it isn't just about statistics, it's about real people and i've seen it in my own family when i went to college, the university there really was maybe one or two opportunities for women coming in really the scholarships were just unheard of, and 15 years later watching my own daughter go to watch her classmates compete in high school basketball championships in the entire state in the state convention and my daughter playing soccer and all of her friends that succeeded, it is just really great to watch so i am proud of the progress that we have made. but i also know that the work is not yet done and you've talked a little bit about that today, and we can't let up because we need to keep expanding opportunities. so my granddaughter one day will be able to say now here's where

we are. and that's really why i have co-sponsored the bipartisan legislation with senator olympia snowe to strengthen title ix and make sure that it continues to deliver the results for every young woman and a girl. the high school data transparency at what it does is shine a really bright light on how high schools are treating their female athletes to make sure we have good data on the number of female and male students as well as the budgets and expenditures. to give the information at that level and so professor hogshead-makar, i wanted to ask you today how have female college students benefited from the transparency that surrounds the funding and resources for the men and women's college, and what would have been the implication of not having that at the high school level? >> sure. you are referring to what is called the equity disclosure act that was passed i believe 1990

or 1991 right around there you can go onto the web site and look at whether the opportunities and budgets and all those kind of things. they do a number of things. number one is the tell girls before they go to the school with or not they should go to the school, are they really going to be value in the boys and girls experiences if they want to go to a particular school but have the kind of elite or not the elite level of sports they want to let them know what that is also let them know whether or not it is fair for them to go into the athletic department and say i want to start a new sport or whether or not for a club team to go in and say we want to be elevated to the first status -- for city status. jacksonville florida, university of north florida i went on to the equity disclosure act and talked the president of university unless you can show me something different you cannot cut your women's program and within a week, the program was reinstated.

high school is not so easy. parents are very typically unsophisticated. to be able to get that kind of data and make those thought changes adding new programs it's difficult to get that information. it's also the way that they are usually given information most schools to provide boys and girls in the high school level with the same number of sports. but the boys sports have a lot more participation. so football is 125, baseball is 35, basketball is 15 and on the girl's side you have 48, gulf will be eight come cross-country would be ten. looking at the number of teams doesn't tell you very much. that's why we need to have this transparency act that would avoid the litigation as i was saying earlier and enable families to go in. this is what we do. we sit there with the phone, and i try to educate them and so they can talk to their own athletics department and explain and get the resources that they

need. >> many years ago. believe me, parents in front of you acknowledges it is a pretty powerful thing. so information is important. did you want to add anything to that? >> i would love to have this pass. we've been trying for gears because we know it is so necessary as diluted to. >> the schools already have the data and they already have to report it to the department of education. this is just making it available on the public website so every family can see this information. >> it's not just a number come its actual individual members. >> right. they already know how many kids are playing tennis or swimming or golf. >> mr. chairman, we are working very hard on that. i think it's extremely important. i think it's an in protest at making sure that 80 years from now we can really celebrate. things, mr. chairman. i appreciate this hearing. >> thank you.

senator murray. i wanted to ask about that act. i'm glad you came as a sponsor of it and i hope that we can get through. i know the data is important to make sure the public knows the data. did anyone -- yes, doctor? >> i want to ask in terms of data and transparency of data that sometimes comes not just from looking at what we are doing in the united states and looking in other places. right now we are very comfortable with, say, how many women are in engineering in the thinking that as we are here in the united states that we are probably best that that's not true. ..

who you are and i know what that data how do we respond to it. >> romanos, like you, but also i think that in our elementary and secondary education, we have to do more to focus on young women in our grade schools. middle schools, to get them involved in more science and engineering. and when i was a kid, engineers were men. they were just men. young women did not aspire to do that. i think that we have to do a better job in early grade

school. making sure that they have the right course of instruction, but also, just making sure that they have the support to become engineers or scientists or medical researchers. we have not done as good a job as we should have in the past. we have to do better in that area. anything else that anyone wants to add that i didn't ask her bring up or has not been said? >> one thing, the national women's law center said something on pregnant parenting students, pregnant and parenting for both men and boys, girls and women. to keep them from achieving their goals. it is is prohibited under a timeline from a lot of people don't know what that means. if the girl has to go to have a positions appointment -- i'm treating her just like everyone else.

in fact, the regulations are pretty clear the need to treat that. the same me you way you would treat any other short-term disability, and that pregnancy is a special category, even if you don't take care of mononucleosis or knee injury coming you still need to take care of pregnancy in a way that is different. certainly, we need to make sure that women, not just in athletics, but that women, probably, are able to participate regardless of their pregnant or parenting status. >> inky. senator blumenthal, did you have anything else? >> thank you, mr. chairman. i might just read one sentence from that report. far too many students, lawmakers, parents are aware of it protecting parenting

students. i think that lack of awareness is apparent in everything. i wonder what your foundation may be contemplating in terms of raising awareness order other steps that you are thinking about taking. >> i had the privilege of working with ncaa in regards to parent and pregnant policies with our schools. julie went into the story outside the lines, showing the girls or pregnant or being forced to have abortions or give up their scholarships. runway come in and see if they got on it, they hired me and another phd nurse practitioner, and so we wrote up a legal memo and an overall peace a policy that schools can take out of the material and put into their student handbook to let them know that they don't really need to slink away and go off into

the future. their scholarship is protected and their ability to come back is productive and their rehabilitation is protected. you know, we need to make sure that our biases on what pregnancy does to a woman's body and whether or not women can still perform. a lot of coaches think that after pregnancy it is all over. it is just not dead there are model policies out there. >> thank you, mr. chairman. >> you are an inspiration to all

of us, trailblazers. for me, this has been a very valuable hearing. it reminds us of title ix and what it makes for boys and girls, men and women, and their entire country. we have come along way since 1972. and we reflect on the positive strides on this issue. also, for the reminders that achieving full equality will require continued effort. i want to thank my colleagues for all their hard work, not just on quality, but also the other important issues that we work with on this committee. we stand adjourned. >> thank you, thank you very much. [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] >> this week on the senate continues work on the farm bill and the dozens of amendments connected to it. the details on the senate's action, we talked with a capital hill reporter. this is a founder and executive editor after a two-week stalemate on the farm bill, and its amendments, there is an end in sight.

i think a hundred dollars a very strong desire to pass it from though. we have a lot of debate over phone bills, but in the end, popular legislation, we just did a poll at the national journal that showed that 75% of americans think that since youtube% believe that food stamps should be the same level that they are now good stance should be the same level that they are now. farm bill so popular, and i think congress wants to pass the bill. >> what are some of the key amendments of your watching for an foreign debate over the next couple of days. >> well, we are watching a debate over amendments that would cut farm subsidies. also, amendments that would either cut the food stamp programs or leave the benefits exactly the same. there is a provision in the bill that cuts food stamps slightly, but some want to put it more and some don't want any cuts at all.

>> the underlying bill has often been referred to as a food and farm bill. what is a cover? >> the bill, of course, originated as farm legislation in the 1930s when the program was established. more than 70% of the funding in the farm bill goes to the food stamp program and other nutrition programs that provide food to people who are low income. it covers the food stamp program and commodities and distribution programs, but it also covers the farm programs that generally pay farmers when prices are low, although in recent years, farmers have been getting something called direct payments. the bill would get rid of those, what they call direct payments from the ones where the prices are high or low. >> specifically on issues relating to peanuts and to rice farmers, how would the disagreements resolved?

>> welcome in the disagreement has not been resolved. i guess you would say they agree to disagree. the rice and peanut farmers claim that the program that has been put in the bill is better for corn and soybeans and doesn't work for their crops because they are grown under different conditions and in particular ways in which the payments that are triggered just don't work for them. senator kent conrad of north dakota and senator chambliss of georgia have come up with a proposal that would be more generous to the rice and peanut growers and establish what they call target prices that would generate payments on all crops. in the end, they withdrew the amendment and said that they will bring it up again when they are in congress. >> were some of the major policy changes with this reauthorization? >> the first thing is that the bill repeals the direct payment and several other farm subsidy

programs. and it replaces them with a program that will make up for some of the losses that farmers have when they have a bad year, that are not covered by the crop insurance insurance programs. i would say that that is the major change in the bill. also, there are continued programs that benefit the fruit and vegetable industry, which is the reflection of the concern of obesity in the country. these fruit and virtual programs, which include a snack program for children in schools, and other kinds of research programs on fruits and vegetables, were not in the bill until 2008. this reflects the popularity of fruits and vegetables and the need to encourage americans to eat healthier foods. >> lastly, what is sport look like in the senate and what is happening with the farm bill

in-house? >> well, of course, we won't know until the last vote. as to whether it will go through on final passage. i think the way they have constructed this, they have avoided controversial amendments. i think it is ready for passage of it all possible. the house is going to write its own bill, they have a different idea on how to write the commodity title. they definitely want a title program, but the house committee is supposed to mark of the bill. write the bill in committee, before the fourth of july recess. >> jerry writes for national journal daily and the founder and editor of the haxton report. thank you for the update. >> thank you. >> coming up next on c-span 2, the state department releases its annual report on human trafficking. then come a house hearing on medicare payment policies.

followed by a hearing on the title ix law that mandates gender equality in education institutions. >> the state department today released its annual human trafficking report and added syria to the west of offending countries. tomorrow on "washington journal", we will talk with a guest to combat human trafficking. and we are joined by north dakota senator, john hogan, a member of the culture committee. the senate this week is working on the farm bill. also taking your phone calls, peter elkind of "fortune" magazine about his article on mf global. the financial firm that collects with more than $1.6 billion in customer money missing "washington journal" is live on c-span everyday at 7:00 a.m. eastern.

>> have you approached book interviews differently than news reporting interviews. >> i think of the book interviews as gathering history. i think you're interviewing of interviewing when i am working for the new site. as gathering contemporary information. >> how difficult is it to remain impartial in your reporting and not get caught up in the campaigning of one campaign or another? >> i try to give people is full and understanding is what is happening in this campaign. it is not that difficult to put the biases to the site. >> how has social media change your line of work in terms of reporting and getting news and information. >> twitter is a primary news source for anyone who covers politics and anyone who pays attention to politics. twitter did not exist 12 years ago for all practical purposes. >> sunday night, purdue university students are interviewed on the newspaper business, covering presidential

elections. and the rise of social media. sunday at 8:00 p.m. on c-span. >> the state department annual report on human trafficking outlines what the u.s. government is doing to bring traffickers to justice. secretary clinton honored people for their work in trafficking. this is 40 minutes. [applause] [applause] [applause] [applause] [applause] [applause] good afternoon, everyone. and welcome to the department of

state. it is wonderful to have you all here. i want to especially welcome will smith and jay pinkett smith for being here with us. thank you for being here with us. [applause] [applause] [applause] [applause] every year, this event brings together committed leaders and activists from across the anti-trafficking movement. the enthusiasm that is surrounded this shows us the momentum that we have built. i am maria otero, the secretary for celine security democracy and human rights. my office oversees the bureau's to help countries and other content governments create just as i do some of the societies in democratic principles, to

guarantee respect for human rights and apply the rule of law. whether we are helping strengthen judicial systems, or we are denouncing human rights abuses or helping build strong capacities or combating trafficking in persons, we are aiming to help countries protect the individual citizens in their countries. >> trafficking challenges are one of the problems that we have. and it is also the one area that deals with one of our most fundamental values. that is the basic freedom and dignity of every individual. trafficking also chairs at the very fabric of society. it rips families apart, it devastates communities. it holds people back from becoming full participants in their own political processes in economies. and it challenges the ability of countries to build strong,

justice systems and transparent government. that is why fighting modern slavery is a priority for the united states. in that fight, we partner with governments around the world to improve and increase the prosecution of this crime, to prevent the crime from spreading, and to protect those individuals who are victimized by it. while governments bear this responsibility of protecting their individual citizens, this despite depends on a broader partnership as well. without the efforts of civil society, the faith community, the private sector, we would not be able to advance, and we would not be able to see the advances that the report highlights. the report that we are issuing today guides our work. it represents the very best knowledge and information on the state of modern slavery in the world today. it shows the fruit of

partnerships around the world. it shows the strides we have made in protecting individuals, and it shows how far we yet still have to go to a sure that basic human rights. i want to thank everyone who has worked this last year to compile these reports. from the ngo that cements this information is, to the government that provide us with data, to the diplomats in our overseas missions, to the staff of monitor and combating, trafficking in persons, who are here today and today really is the culmination of tireless work over many months that they have taken on. for that reason, it is really my pleasure and privilege to be able to introduce my colleague who runs that office, and who has shepherded it and given given leadership.

luis cdebaca in. [applause] [applause] >> thank you, madam undersecretary for the introduction and for your leadership. the state department. bringing so many different issues together under this label of civilian security over the last year, it has allowed room here in the state department and across the u.s. government for constructive collaborations, whether we are dealing with human rights, migration, criminal justice, war crimes, counterterrorism, or as today, human trafficking. because building democracy, growing economies, unleashing the full potential of the individual, these things just don't happen. they start with people. around the world in the last year, we have heard those people. their voices calling, calling

out for democracy. for greater opportunity. we recognize that sound. it is the sound of hope. and traffickers ensnare their victims by exploiting that hope, especially the hope of the vulnerable. come with me, i'll help you start a modeling career. pay me $10,000, i will get you that job. i love you. i will take care of you. just do this for us. as long as the trafficking in persons report is needed, we will find in its pages account after account of traffickers peddling false hopes. but that is not all that we find in the pages of this report, because every year that passes, those also the are overtaken more and more by real hope. the real hope that the modern abolitionist movement provides. and justice trafficking takes many forms, the way we fight slavery today, the way we

provide hope for those who have been exploited, is growing. it is growing more diverse and more innovative. and so are the people who are stepping up. >> we see it in the private sector where corporate leaders are using their business skills. they are hearing from consumers who don't want to buy things tainted by modern slavery. leaders like ceo tom mazzotta. when he read about reports about forced labor in the fishing industry comment he wasn't just shocked, he acted. he wrote two letters, the first was to the company he used, until that day to source calamari. the second was an open letter to all of his customers, telling him that his band was his family -- his family name, and he would not take it or his customers with slavery in the supply chain. we are inspired by his principled stand. we see it among activists like jada pinkett smith and her

family, who have a unique platform from which to act. when her daughter began asking about these types of subjects, she didn't just explain it away as something that happens over there. she got to work. she is launching a new website to serve as a resource for victims and survivors, and is an information hub for those who seek to learn more about this crime. jada pinkett smith, we thank you for your advocacy. we see it in people's day-to-day lives. like one day remco latch with was watching a young boy castrated because he refused to take part in a betting ring. he was and is horrified by modern reality of slavery, he did something. he got in touch with the boy's family in the paper and come to the united states for surgery. we are moved by your compassion. if i can take a moment of personal privilege, we see it in the men and women who contribute in this personal rapport.

our colleagues and our regional euros in washington, especially the reports and political affairs team. we thank you all for your rigor, your commitment, and the zeal with which to attack this problem. and we see it ultimately in the victims, in the survivors, whether they choose to become activists or whether they choose to lead a life of quiet anonymity. when you log onto slavery footprint.org, and i hope you do, and it asks you how many slaves work for you, remember that those victims are not statistics. it will give you a number, but these people are not numbers, they are people with holds, with dreams, with courage. and with names. remember, remember their names. names like amina, maria elena,

joel, ashley. it is my pleasure to introduce someone who has never turned away from that challenge, from from the start of this effort when most people didn't want to talk about modern slavery, to this day, when we recommit ourselves to the vision of a world without slavery, ladies and gentlemen, secretary of state. [applause] [applause] [applause] [applause] [applause] [applause] [applause] >> thank you. thank you all very much. i am delighted to see a standing room only crowd here at the benjamin franklin room is very important annual event. i welcome all of you here to the state department.

and i want to begin by thanking ambassador luis cdebaca and his team for all the hard work that goes into this report and the passion that they bring to the fight against modern slavery. i would like for you and your team to stand, because we have everyone -- thank you. i so appreciate what you do everyday. not just when we roll out the report, and i'm very proud to be your colleague. i also want to welcome our 10 tips here i was his work is making a real difference. you will hear more about each one individually when we recognize them. but i want personally to thank

them because they do remind us that one person's commitment and passion, one person's experience, and the courage to share that experience with the world, they can have a huge impact. i am delighted to welcome all of our heroes today. thank you. i will join lou in thinking jada, luis cdebaca and jada pinkett smith and will come and your daughter. as lou said, it was their daughter who brought this issue to jada's attention, and i am so pleased that she has taken on this cause. we look forward to working with

you. in the united states today, we are celebrating what is called juneteenth. that is freedom day. the date in 1865 when a union officer stood on a balcony in galveston, texas, and read general order number three, which declared, all slaves are free. it was one of many moments in history when a courageous leader tipped the balance and made the world more free and more just. but the end of legal slavery in the united states and in other countries around the world has not, unfortunately, meant the end of slavery. today, it is estimated, as many as 27 million people around the

world are victims of modern slavery. what we sometimes call trafficking in persons. as blue said, i have worked on this issue now for more than a dozen years. when we started, we call that trafficking, and we were particularly concerned about what we saw as an explosion of the exploitation of people. most especially women. who were being trafficked into the sex trade and other forms of servitude. but i think labeling this for what it is, slavery, has brought it to another dimension. i mean, trafficking, when i first used to talk about at all it all those years ago, i think for a while people wondered whether i was talking about road

safety. what we need to do to improve transportation systems. but slavery, there is no mistaking what it is. what it means, and what it does. all these victims of modern safeway are women and men, girls and boys, and their stories remind us of what kind of inhumane treatment we are still capable of as human beings. some are lured to another country with false promises of a good job award opportunities for their families. others can be exploited right where they grew up. were they now live. whatever their background, they are living, breathing reminders that the work to eradicate slavery remains unfinished. the fact of slavery may have changed, but our commitment to ending it has not.

and the deeply unjust treatment that it provides has not either. now, the united states is not alone in this fight. many governments have rallied around what we call the three p's of modern slavery, prevention, prosecution, and protection. it gives a clear and honest assessment of where all of us are making progress on our commitments, and where we are either standing still or even sliding backwards. it takes a hard look at every government in the world, including our own. because when i became secretary of state, i said when we are going to be issuing reports on human trafficking, on human rights, that talk about other

countries will also be examining what we are doing. because i think it is important that we hold ourselves to the same standards as everyone else. now, this year's report tells us that we are making a lot of progress. twenty-nine countries were upgraded from a lower tier to a higher one, which means that their governments are taking the right steps. this could mean enacting strong laws, stepping up their investigations, and prosecutions, or simply laying out a roadmap of steps they will take to respond. but this issue and the progress we have made are about much more than statistics on prosecutions and vulnerable populations. it is about what is happening in the lives of the girls and women i recently met calcutta. i was able to meet with some

extraordinary women and girls who were getting their lives back after suffering unspeakable abuses. one young girl, full of life, came up and asked me if i wanted to see her perform some karate moves. and i said, of course, and the way she stood up so straight and confident, the pride and accomplishment in her eyes. it was so inspiring. this was a child who had been born into brothels to a young mother who had been forced and sold into prostitution. but when her mother finally escaped and took her daughter with her, they were out of harms way, it finally able to make choices for themselves. now, i don't know what's going to happen to that young girl, whose image i see in my mind's i

come in the years and decades ahead, but i do know that with a little help, her life can be so much better than her mother's. that is what we need to be focused on what we need to try to do for all victims and survivors. that is why in this year's report, we are especially focused on that third p, victim protection. in these pages, you'll find a lot of practices and innovative approaches to protecting victims. this is a useful and specific guide for governments looking to scale up their efforts. what kind of psychological support my the victim need inouye how should immigration laws work to protect migrant victims? how can labor inspectors learned to recognize the warning signs of traffickers? and what can you and all of us do to try to help?

when i met with the people who are working with victims, i met several young women from the united states who had been inspired by reading about and watching and going online and learning about what was happening in the efforts to rescue and protect victims. and they were there, working with organizations, ngos and the faith community to do their part. this is a moment for people to ask themselves, not just what government can do, what government can do to end modern slavery, but what can i do and what can we do together. oddly, this report reminds us of the human costs of the crimes. traffickers prey on the hopes and dreams of those seeking a better life. our goal should be to put those

hopes and dreams back within reach. whether it is getting a good job, to send money home, to support a family, trying to get an education for one's self or one's children. for simply pursuing new opportunities that might lead to a better life. we need to ensure that all survivors have that opportunity to move past what they endured to make the most of their potential. i am very pleased that every year we have had the chance to honor people who have made such a contribution in this modern struggle against modern slavery. and i am also pleased that this is a high priority for president obama and the obama administration. it is something that is not just political and not just a policy, but very personal and deep.

you might have seen over the weekend, a long story about this is obama's roots, going back to the time of our own period of slavery and the family that nurtured her, which has roots in the fields and the houses of a time when americans owned slaves. as we recommit ourselves to end modern slavery, we should take a moment to reflect on how far we have come here in our country and around the world, but how much further we still have to go to find a way to free those 27 million victims. and to ensure that their are no other victims in the future.

thank you all very much. [applause] [applause] [applause] [applause] [applause] [applause] >> we are joined today by 10 amazing individuals representative of thousands of more amazing individuals who work so hard to do their part in this fight. and i'd ask that the tip heroes from this side of the stage, come over and join us starting with marcelo colombo. marcelo colombo from argentina,

his efforts to investigate and prosecute human trafficking cases and taking a bold stance against corruption and official complicity. marcelo colombo. >> in recognition of her extraordinary commitment, her innovative strategy to which the race awareness and a proactive approach to providing services to victims, jeannette richardson-baars. in recognition of her ambitious efforts to strengthen legislative and criminal justice responses to trafficking in southeast asia and her substantial contribution to identifying the core elements of a comprehensive anti-trafficking model, from australia, anne gallagher.

[applause] [applause] in recognition of his amazing courage to escape slavery in his remarkable activism to end human trafficking, raising awareness of labor exploitation in the fishing industry of southeast asia, vannak anan prum. [applause] [applause] in recognition of his unwavering effort in the face of threats and acts of violence against him and his family, to provide aid to trafficking victims in the republic of the congo, raimi vincent paraiso. [applause]

[applause] >> in recognition of dedication and support and tireless work in the new partners and anti-trafficking efforts in greece, phil hyldgaard. for her compassion, courage, and in bringing attention to the suffering of human trafficking victims in the sinai, and groundbreaking projects in identifying these abuses, sister azezet habtezghi kidane. [applause] [applause] for her ongoing and exemplary leadership and strengthen commitments to fight trafficking in the transport region, maria

grazia giammarinaro. in recognition of her courageous advocacy on behalf of vulnerable people and her pioneering work to outlaw slavery once and for all in mauritania, the country where she was the first woman lawyer, fatimata m'baye. [applause] [applause] the founder of international justice mission, an internationally recognized human rights organization for his work to preserve the rule of law around the globe, gary haugen.

[applause] [applause] [applause] >> if i could ask vincent to please come to the podium and speak on behalf of the tip heroes, please. [applause] [applause] >> bonjour. madame secretary, honorable undersecretaries, honorable ambassadors, heads of diplomatic missions.

distinguished guests. on behalf of my organization, alto-afrique enfants, and all of the heroes that here i have the honor to represent, i would like to think the united states government for honoring us with this award and at this unforgettable moment. the phenomenon of human trafficking has reached alarming

proportions around the world. my country, the republic of congo, and many others represented at this meeting are unfortunately not spared from this crime. therefore the international community cannot remain silent against this evil and must continue to respond relentlessly. i would also like to thank the u.s. embassies in our respective countries for their advocacy and dialogue with host country governments in the fight against this phenomenon.

[speaking in native tongue] [speaking in native tongue] in my career as a medical doctor, the numerous dramatic injuries i have seen inflicted and cured on child victims of trafficking, have led me to stand as a pillar of support for hundreds of children. these child victims of trafficking have been identified, rescued, protected, and sometimes supported by organizations of ours in the

republic of congo. this work has led to several kidnapping and assassination attempts against me by potential traffickers. but it has also filled me with joy and happiness when, for instance, i heard a senegalese teenager who i rescued tummy, you are my father. [speaking in native tongue] [speaking in native tongue] [speaking in native tongue] [speaking in native tongue] i have the honor to represent alto-afrique enfants, and we will continue to fight against traffickers with passion.

as for its commitments to the fight against trafficking and forced labor, alto will continue to work jointly with the government, unicef, and other international and national organizations. [speaking in native tongue] [speaking in native tongue] [speaking in native tongue] this is a problem that must be resolved through a joint effort. human trafficking is a human rights violation. [speaking in native tongue] [speaking in native tongue] [speaking in native tongue] [speaking in native tongue]

and approach grounded in human rights in the prevention of and the fight against trafficking has several requirements in both law and practice. most of all, victims ' right must be fully respected and they must be respected. these victims are entitled to justice, reparations, and should be treated with close attention, as they are vulnerable. [speaking in native tongue] [speaking in native tongue] and approach will lead us to success in regards to this phenomenon. [speaking in native tongue] [speaking in native tongue]

madame secretary, distinguished guests, ladies and gentlemen, i would like to conclude by stating that i hope we can work together to build a better future for all children of the world. thank you. [applause] [applause] [applause] [applause] [applause] [applause] [applause] [applause] merci beaucoup, vincent. c'est magnifique. c'est tres magnifique your words are inspiring and her leadership is a struggle is also is inspiring. you and the tip heroes are once

again reminding us that the individual actions of each human being has her menace impact, it and that we are all responsible for playing a role in eradicating this horrible crime that continues to persist in our societies. i want to thank you all for joining this event today. the commitment, the passion, the responsibility that all of you take on end that is represented in this room, once again reminds us that we are not only moving in the right direction, but that we are going to make this goal be within our reach. so thank you very much for being here with us today. thank you, madame secretary. [applause] [applause] [applause] [applause] [applause] [applause] [applause] [applause] [applause]

[applause] ambassador luis cdebaca will be a guest on tomorrow's "washington journal", where he will discuss the human trafficking report. he will also talk to senator john hogan about the farm bill in the senate this week. "fortune" magazine editor on the story about the collapse of financial firm mf global. "washington journal" begins at 7:00 a.m. eastern. john c-span 2, live coverage from london of prime minister's questions. that starts at 7:00 a.m. eastern. >> nothing has attracted more attention than the academy, the

ticket line outside the supreme court. a line that is formed three days before oral arguments commence. some have described the controversy as unprecedented and they may be right if they mean the number of press conferences, protests, counter protests, going on outside the court, oral arguments being a inside. >> she also spoke about press reports on the decision. expected this week or next. >> although deliberations are private, that has not dissuaded the media from publishing a stream of rumors and 50 and accounts. my favorite, wisely observed as the supreme court. those who know don't talk, and those who talk don't know. [laughter] >> watch the rest of the comments from the american

constitution society online at the c-span video library. >> you're watching c-span 2 with politics and public affairs, weekdays featuring live coverage of the u.s. senate. on weeknights, watch key public policy vends and every weekend, the latest nonfiction authors and books on booktv. he can see past programs and get our schedules at her website and you can join in the conversation on social media sites. the medicare advisory commission recommended restructuring the fee-for-service payment model at a congressional hearing today. the head of the commission testified before the house ways and means subcommittee on the medicare payment report this month. the medicare payment advisory commission is an independent congressional agency established by the balanced budget act of 1997 to advise on medicare payment policies.

today we will be hearing from med-pac on the analysis and recommendations contained on the june 2012 report. this subcommittee has heard from numerous witnesses over the last year, about the financial challenges facing the medicare program. in fact, the medicare trustees report in april that the program would go bankrupt in 2024, in a mere 12 years from today, clearly, time is of the essence. subcommittee has also heard from several experts on ways to reform and improve the program in order to bring the program into the 21st century, slow the rate of growth, and protect medicare for future generations. it is in this vein that we

welcome chance you, glen hackbarth to discuss the report. the commission has scrutinized the design of the traditional medicare benefit and found it lacking. the traditional medicare benefit consists of a patchwork of premiums, deductibles, copayments, and coinsurance. it neither encourages appropriate utilization of care, nor protects beneficiaries from the high, out-of-pocket costs. because of this structure, nearly 90% of medicare vision and 10 beneficiaries have some type of supplemental insurance. the evidence shows that supplemental coverage that eliminates some of the beneficiaries cost sharing responsibility results in higher

program costs and higher premiums for all beneficiaries. i look forward to hearing more about medpac's recommendations come on how to design a new benefit structure that needs and reflects the health care needs of today's seniors, rather than remaining trapped in the 1960s. the june report also contains a chapter that examines several topics related to medicare beneficiaries in rule areas, while maintaining an appropriate level and quality of care in rural areas, it is what our constituents deserve. this issue is a critical important -- of critical importance, it is also important to many of the members of this panel as well, as to maintaining a high functioning health

system. we must ensure that payments made on behalf of beneficiaries and taxpayers are appropriate. medpac took on the challenge and provided some suggestions on how congress may devise policies to maintain rural beneficiaries access to quality care while ensuring taxpayer dollars are spent wisely. this information is especially helpful. ..

may be at risk. further integration is clearly necessary, but i'm concerned that the administration's unilateral action to address the population's needs may undermine

the protections guaranteed to all medicare beneficiaries. this is a critical issue to get right the first time and i know that made pac is concerned about it as well. for the purpose of an opening statement i ask unanimous consent that all members written statements be included in the record without objection so ordered. i recognize ranking member stark for five minutes for his opening statement. >> thank you, chairman and for being with us today. i look forward to your suggestions on how we can improve medicare, and i want to congratulate and thank you for accepting the appointment for another term as chairman. medicare is one of the nation's

best programs but it's been a work in progress that needs ongoing fine-tuning and changing to keep it relevant so that it will operate in the best interest for the millions of seniors and americans living with disabilities who rely on this program. for that reason i'm concerned about the proposals or any proposals that would shift costs to beneficiaries. doing so i think would devastate them to be the majority of the little tyke fixed incomes, and what's more research has shown that increased cost sharing leads to the reduction modeling in unnecessary health care that these increased costs also discourage people from receiving necessary health care. the co-payment for instance i think is largely ascribed to be

used by old, sick, poor what those and raising the price that they have to pay is just one more republican effort to deny equal rights to women. i'd like to remind all of us that medpac report has given a bunch of recommendations for payment updates that would yield savings without squeezing the beneficiaries. as we look to the year-end business, we need to take the lead to fix the physician payment system, and there are other offsets available as well. the overseas contingency operations is available to us by commercial me to increase costs for beneficiaries in order to fix the physician payment system. i look forward to your thoughts, chairman, and for the people

eligible for medicare and medicaid. i hope he will address this idea that medicare is going to go broke one of these days. the adjustments necessary to keep medicare alive the next 75 years i think are less than a 3% increase in premiums coming in a while i hope we don't have to do that, there are many other options and age, differences and changes that we've already done that raise allowing the your income, on the earned income to be used in the tax as a host of changes all of which are modest and would keep medicare alive and i hope that we will address some of those options that are available to us. thank you for holding this hearing and inviting you back to inform us about the state of medicare. thank you mr. chairman. >> thank you.

today we are joined by glenn had porth of the chairman of medpac. he served as the chairman for ten years and is appearing before the subcommittee for the second time this congress. we are pleased to have you with us once again you have five minutes to present your testimony. you're entire written statement will be made a part of the record. you are now recognized for five minutes. >> if you could hit the microphone. >> okay. thank you, chairman and ranking member stark, other members of the subcommittee, i appreciate this opportunity to talk about the our june, 2012 report. the report contains six chapters and covers quite a bit of ground including reforming medicare benefit to sign and care coordination come care coordination in particular for

the dewey eligible beneficiaries, risk adjustment adjustment, serving the rural beneficiaries in medicare coverage for home infusion. i'm going to focus my opening comments on two of those chapters, the one on benefit design and the one on serving the ruble beneficiaries. our chapter on the benefit design includes a unanimous recommendation that the congress should redesign medicare's benefit package with the following elements. first, no change in aggregate beneficiary cost sharing of the point of service and to the program and out-of-pocket maximum catastrophic limit that is sometimes called. third where ever possible use the specific dollar amount co-payment instead of a percentage of coinsurance.

fourth, i give the secretary of hhs broad authority to modify the benefit package within the parameters established by the congress consistent with the principles of the value based insurance design and finally imposed an additional charge on supplemental insurance purchased by medicare beneficiaries. this recommendation is based on the following conclusions. first of all cost sharing of the point of service is a blunt instrument that nonetheless is and the essential tool in the fee-for-service free choice of provider insurance program like medicare. that said, we do not believe that aggregate patient cost sharing should be increased above the current level. we did believe however the current structure is outdated in

its design creates uncertainty there why foster's demand for supplemental insurance coverage. we believe in effectively designed medicare benefit would reduce the uncertainty by adding catastrophic coverage in converting coinsurance to the fixed dollar amount co-payments. we do not favor providing supplemental coverage, but we do believe the beneficiaries should bear at least a portion of the added cost that the supplemental coverage imposes on the medicare program and the tax payers. now let me turn to the chapter on rural care. the patient protection and affordable care act asked medpac to follow on what aspect of several health care for medicare beneficiaries. first, access to care, quality-of-care, the adequacy of medicare payments to the rural providers and the

appropriateness of the special payment adjustments in the medicare payment system for the rural providers. to respond to your request, we collected information from beneficiary surveys and focus groups, site visits to the rural providers, medicare claims and cost reports from medicare reports on the quality-of-care for the providers as well as meetings with many associations that have an interest and expertise in the rural issues. our major findings are follows on access we find that there are large differences in the service use across regions in the united states. in fact it is well known to the subcommittee. but only small differences between urban and rural providers in the same region. this provides access to care is similar for their role and urban beneficiaries. we also find that beneficiaries satisfaction with access is

similar for the rural and urban medicare beneficiaries. on the issue of quality, quality-of-care, we find that the quality provided by the providers is similar for most types of services although the rural hospitals have somewhat higher mortality and score was well on some processors of care. in part these differences may be due to lower volume and rural hospitals in different incentives for coating accurately as well as the need to provide emergency services in remote areas. third on the issue of payment of a pussy, we find that medicare payments are comparable for the role in urban hospitals and that does for the special payments of which there are a dozen, we evaluated each using three petraeus.

lummis the payment provision targeted to the isolated providers and the magnitude of the adjustment empirically justified and the special payment incentives for cost consciousness. for many of the 12 special payment provisions targeting could be tighter and the magnitude of the adjustment better justified all the same might be said that some of the urban special payments as well. with that mr. chinn and i'm happy to answer your questions. >> thank you. as you noted in your report and as the search committee addressed on previous hearings the medicare benefits has not changed and structure since its inception in 1965. can you please explain why the commission felt it was necessary to offer recommendations on how the fee-for-service benefit should be redesigned? >> yes. the most important element of any insurance program should be

to protect people against the very high cost of illness and as you well know, medicare does not include any catastrophic limit on how of patient cost. in addition to that, the existing structure of patient cost sharing is quite complicated and very difficult for many beneficiaries to understand the complex web of co-payments and coinsurance that can be frankly a little bewildering to all of us not to mention medicare beneficiaries. that lack of catastrophic coverage and the complexity of the benefit cost sharing creates uncertainty and anxiety among medicare beneficiaries and we believe contribute to the demand for supplemental insurance as a way of buying protection against the some certainty. we think that by redesigning the

benefit package along the lines we've described, we could update it and make it more consistent with modern benefit design, reduce uncertainty and more fairly distribute the burden of cost for medicare beneficiaries. >> as someone that represents a district i'm well aware of how challenging it can be for some providers to remain viable and i completely agree that we need to make sure that role beneficiaries have access to quality care while also being responsible to the taxpayers footing the bill for the program. as congress has to make tough decisions pertaining to a specific payment adjustment policies can you elaborate on your principles for evaluating special paris with an example of how to apply them? >> sure. >> so, hour three principles are that a special payment

adjustment should be targeted to isolated providers. by that we may provider if the provider or to go out of existence that would compromise needed access to care for medicare beneficiaries. second, we think that the amount of the adjustment ought to be based on data as opposed to grout at the ears and exemplify would be if we adjust for low-volume providers have higher costs we may have lower volume and the package represented in the past the field low-volume adjustment but we think in the amount of the adjustment either be consistent with how much cost increase when you have low volume and we don't think the current low volume adjustment is justified in that way. in the third principle is

wherever possible we would like the payment adjustment to be an add-on to a prospective payment which retains the incentive for cost consciousness as opposed to just move into the cost reimbursement which woody eliminate those incentives. i appreciate commitments work to find out which approaches can improve the coordination of care in our too often fragmented health care system. i'm interested in the notion of establishing payment policy rewards good patient outcomes. in fact we heard testimony from a private health care plan and a previous subcommittee hearing that uses such an approach that the providers decide who they want to collaborate with and collectively determine what they need to do to provide high-quality deficient care. does the commission believe that giving providers the flexibility to determine how best to care

for their patient population is a promising approach? one of the lessons the we draw from the demonstration projects that have been flown in the cms on becerra coordination is that to be successful the program of care coordination has to be carefully woven into the practice impairment where it occurs. it's not possible to achieve good care coordination by an imposing it externally. it's not the sort of thing that you can design from a distance but to just sort of put in to a local health care delivery system. instead it needs to be more organic and part of the care delivery so our general approach is to say that the medicare should move away from fee-for-service payment to the payment systems that a stylish but financial and clinical responsibilities for the defined

population or for an episode of carow and then allow the providers the flexibility to adapt care coordination to the particular circumstances but hold them accountable for the results of on quality and cost. >> thank you. mr. stark is recognized for five minutes. >> thank you mr. sherman. >> fran, thank you very much. in reforming the benefit design, you've got both cap to protect high of pocket cost and changes to a supplemental insurance and i have reservations about the medigap policy that would increase cost but i agree the catastrophic cup would be an

improvement. i'm afraid some people might separate this into the medigap policy without the cap. why do you recommend that both of these policies have been together? >> they should be done together and in my opening comment we think that they are linked in fact that one of the reasons the beneficiaries want to have supplemental coverage as the inadequacies in the signing of the existing medicare benefit. if we correct the false and ed catastrophic coverage and meet the cost sharing more predictable and understandable the demand for the coverage and then in that context that if the beneficiary continues to want to buy supplemental coverage, they

should faced at least a portion of the additional cost that imposes on medicare. >> okay. in your recommendations, the current cost sharing stays the same in the aggregate so even though some of the serious go up and some will see them go down, the average beneficiary will stay the same. why was this important as the principal? >> when we look to the medicare benefit package and compare it to the benefit packages offered in the private market we don't think the existing medicare benefit package is too rich compared to the privately insured. in fact given the population covered, the elderly with higher health care costs if anything it

might be to mclean, not too rich. we recognize of course the fiscal constraints that access to so we adopted the guiding principle but we ought to not make it richer or leaner, keep it as it is in terms of the actuarial value but reallocate the cost. >> but you've got with a catastrophic capito the average liabilities you see remain the same but will there be some that will see the cost could run by about 250 pervez understanding you are going to have a lot more of the costs go up and down. is there any reason for that? that's the way the numbers work. generally speaking the members would see the costs from are those that have high expenses

and benefit from the catastrophic limit. this is what insurance should be doing. it's the first responsibility of a good insurance program. the beneficiaries to receive the cost go up under the redesign would be the fisheries who tend to use fewer services especially the beneficiaries of use on the part b services and do not have a hospital admission. it's important to note though that if you look at one-year snapshot you've got a and a ray of winners and losers but for any given beneficiary the risk of incurring high cost goes up over time so if you could the measure of the risk of having a hospital admission in a given year in any one year the average beneficiary has a one in five risk of being hospitalized. but if you look over authority year period it is one in two half of all beneficiaries will

have least one hospitalization and a four year period. so having that extra coverage for catastrophic illness we think makes a lot of sense and over time will benefit the most beneficiaries. >> thanks again for your testimony and then to mr. chen. >> mr. johnson is recognized. >> thank you mr. schramm. mr. huck part in your recommendations to the additional charge for supplemental insurance to have to agree the commission feels supplemental the insurance coverage leads to increased utilization of services. can you talk about why you think it's important to address medicare supplemental coverage and what affects your proposal would have on medicare spending and a beneficiary behavior because i am of the believe that if a guy thinks he needs extra coverage over and above medicate he ought to be able to buy not at a premium go ahead. >> we share your belief that if a beneficiary thinks that they

need supplemental coverage that they should be free to buy that coverage and that's why we didn't propose any regulatory restriction on the devotee to buy supplemental coverage. having said that, the evidence to us is clear that private decision to buy supplemental coverage increases cost for the medicare program and the taxpayers, and we think that it's appropriate for the beneficiaries to make that private decision to buy supplemental coverage to face at least a portion of the additional cost that then imposes -- panicky said that you think. you have any empirical data that proves it? >> the costs go up with supplemental, yes, we do. >> and is there any one part of the country where it's more prevalent than another? >> the supplemental coverage is more prevalent than others i would be happy to get data for you on that. i don't have the data in my head, mr. johnson.

there are variations. >> to the commission upheld status of the beneficiaries that were involved in that decision? >> yes. >> could it be the beneficiaries are just doing treatment and procedures determined by the dr. based on their health needs instead of just going to the hospital? >> we believe that the evidence shows that the increased use in service from a supplemental coverage is especially large in the discretionary services. so if you look at the effect of supplemental coverage on hospital additions the effect is relatively low because most hospital admissions are not discretionary. there is a much larger increase in services in the areas the more discretionary. are there any concerns that some beneficiaries don't have supplemental coverage that they might pull treatment procedure

until this too late when the cost is much higher than it could have been? >> we think that when you take into effect, take into account all of the different effects that in opposing what the supplemental charged on supplemental insurance is warranted and result in lower cost for the medicare program. >> how do you account for that, what makes you believe that? >> the empirical research that we and others have done. >> i am weary of that. what happens to the fisheries of families of the recommendations are implemented the additional charges implemented without making the benefit package better for beneficiaries could devotees olden beneficiaries dropping their coverage and then having to pay more for their health care and the long term? >> we think all of these recommendations that we've made

on the benefit redesign are a package and should be done together not one without the other is we would not support the charge on a supplemental insurance without the benefit we design. >> you know you are charging people for by an expert insurance the sec putting an extra charge on the gasoline tank because you're buying gasoline. i don't understand that. i think that is wrong by the way. >> the time is not expired. islamic may i respond to that? >> the difference is that the charge on gasoline will come the purses of wrestling does not increase the cost of taxpayers, the individual decision to purchase counseling. the individual's decision to purchase supplemental coverage costs of that or not borne by the beneficiary. most of the costs are borne by

the taxpayers that's why we think the charges warranted in this case. >> to the of any of insurance at all? you know, under your condition any time we buy health coverage it's going to raise the cost of health care according to you. islamic that is a different issue. >> beneficiaries who are injured by the taxpayers making a private decision that further increases the burden by the taxpayers. >> thank you mr. chairman. >> thank you mr. treen for having this hearing. german heck with it always a pleasure to have before us and the key for the work that you and medpac those on your report every year. obviously as a representative from the large district in which thomas constant i attended to dial in quickly on what ms. deepak is looking at in regards to access to care in the rural and rural areas and they've established their i

think it's important we continue to review that also in light of the fact dealing with some pretty tough budgets around here and show the incentive payments for the providers is something there will be considered in the context but you're a portnow is not recommending any type of cross the board cut as far as the incentive payments. is that correct? >> our approach would be to better target adjustments using the criteria that i described earlier isolate the are the adjustments empirically justified and to preserve incentives for cost consciousness. >> do you any type of analysis, the potential impact for some cuts for the providers might be? >> again our goal is to target as opposed to just to cut across the board and i emphasize that because they're seems to be some confusion in the commentary on the report and we want to do is

targeted not just in order to make sure the medicare dollars are used wisely but also has very important and provisions for the quality-of-care. once the issues that we discuss and the chapter is the relationship between volume of services and quality, and i think you know that there is a well-established relationship between a volume and quality. to the extent that we support many low-volume hospitals and discourage consolidation but only does it cost medicare more money, it results in lower quality for the beneficiaries. some also the utilization shows that medicare use in rural providers settings are substantially higher than urban settings and approximately 46% of all patients in rural hospitals are mckiernan officious versus 31% in urban

facilities. medicare payment custody of a much greater impact obviously in the area and the urban area. one study showed that 39% of all rural hospitals currently operate in a financial loss. do you ever look at the margins when you're doing your analysis? demint yes, we do. included in the chapter is a summary of that analysis. we closely look at the margins for the report each year as you know on the payment updates and we repeat some of that analysis. as well. many of the service is especially in the post to the area the margins for the providers as well as urban providers are really quite . in the case of hospitals, the medicare margins for the rural hospitals are actually higher

than the medicare margins for the urban hospitals granted however that they are - and bookcases. we base our payment the recommendations for hospitals, urban and rural a light on what we refer to as an efficient provider analyst with in fact that as we are required to do by statute and suffice to say that we've concluded that both urban and rural providers could provide high-quality care at the existing medicare rate. >> in the hearing room today they're waiting to see with this record is printed with the for the care act i think there are three major revolutions occurring in health care system that's when to continue regardless of what the court may decide in the next week or two. one is the buildup which is long overdue and that is moving forward now we need to continue to have that move forward. beavers delivery system reform we talked about this before and the other is the payment reform

we need to keep striving for getting payments based on value and not come of care. on the last point what more can be done in order to exit on the health care system? >> we think there's a lot of good work on three looking at the new payment methods whether it be bundled and run a hospital but passions or medical homes or accountable care organizations and we've long supported those efforts. my biggest concern is the pace of change and problem we have collectively is that to some extent payment reform cannot proceed without delivery system reform. the two are inextricably linked to one another so i think the critical question for the medicare program as well as for private payers is what are the

steps that we can take to accelerate the rate of the organization of the care delivery system that's the big topic. part of that is frankly -- and i know this is welcome advice is that life under fee-for-service medicare has to get more difficult. despite the complaints we often hear from providers how to became the reality is that it is laid under fee-for-service is still very comfortable for a lot of people. if we want them to migrate to the paymt >> you are recognized for five minutes. >> thank you mr. treen for holding today's hearing and i think we all recognize that the medicare payment at friars rick commission is an important to us and a useful resource as we move

forward to work together to reform the medicare program to make sure that it's there for generations to come and protect those current beneficiaries and i want to thank you mr. hack porth and your fellow commissioners for your work and i know it's not easy work. i've noticed some things in the documents provided i know you hold the community hearings and try to reach out to the public as you locate your information but you talked about the analysis of some of the data and the evidence that you've collected and i am just wondering in the process you are presenting today to do have the opportunity to assemble both as groups were do some polling wartell the town halls to talk to the beneficiaries? i think that's important and you

said yes so what did you learn from the beneficiaries as you talked about? >> i think mr. johnson's points to concerns to live or not people might delay or ford or treatment because some of the costs increase he's talking about the co-payments for supplemental insurance to could, on what are you hearing from the beneficiaries as you are looking at these changes? what we heard in our focus groups on the medicare package was that there is a lot of anxiety among the beneficiaries about the devotee to afford care they also find the six system medicare payment structure the existing benefit structure to be

quite confusing and the combination of those of fear of high-cost and the complexity are very important factors to buy supplemental entrance coverage and i think we can all relate to that. another finding from the focus groups is there is a bit of difference that leads it and held current medicare beneficiaries and people that are before medicare eligibility of look at these issues. some people are not quite yet eligible for medicare and are often insured through the sponsored coverage they are a little bit more willing to say look, i'm prepared to have some payments to the point of service so long as they are understandable and predictable and exchange for a lower premium to make the trade-offs more

readily restaurant beneficiaries -- >> there's a little fear connected in the current beneficiaries around this change and as their work being done to help these concerns >> we think the most important work that can be done is to restructure the benefit package to make it simpler and to provide catastrophic coverage. that's what the focus groups want. i was also choose which frequently year, what to the section of the report that refers to the care coordination fee-for-service i was a little surprised to hear in your comments there is no overwhelming evidence that the care coordination saves money and is more efficient. >> in recent years, cms has run

a substantial both the purchase. cbo several months ago did a much discussed element that there were not a whole lot of dramatic successes in reducing costs and improving quality. we did our own examination of those demonstration projects and the results and came away with you get a slightly different conclusion. what we found is some indication of some things but when we look at the overall picture seems what works and care coordination is highly dependent on the context. and as i said in my written comment, it is reducing the cost and improving quality needs to

be a part of the care delivery system. they can't be readily in post as a module if he will want to be if we want good care coordination, and i know that we do, the best approach is to create both political and financial accountability for the groups of providers. have clear measurements of success, and then give them some room to doubt the care coordination capricious that particular circumstance. >> mr. hackbarth we didn't have a hearing on march medpac report. so i want to take the opportunity to ask a question about if i may.

as we look for the end of the year and the need for a physician or other health care health extender, i'm worried that my colleagues across the aisle hope to offset. i'm not saying that's what their objective is, i'm saying i am concerned about that, and that is totally unacceptable and the whole purpose of the health care act was? >> we have of many of voluble offsets. spec you've been on that. can you have recommendations on the march report with regard to the market updates policy

justification for the recommendations and when these recommendations yield a savings? the madcap estimates which would save $60 million over the next ten years, so i would like you to answer those questions. whether we thought was, major. in the march report we had a series of recommendation most of them were related to the update. in the group you had as you say rough estimate is that if they're in a report where we are adopted they would save roughly $60 billion from about ten years to revive the desk the caveat.

that is our roof estimate of the savings. >> can you remind us. we make up eight recommendations for each of the different provider groups. nursing facilities, home of the engines, long-term care hospitals and patient rehab. each case what we do is refer to as the pan and adequacy analysis where we look at a variety of different types of data, access to.

there are margins on the medicare business. and that's the foundation, the loving foundation for the recommendation. none of the recommendations were higher than one per cent. we recommend 1% for hospital inpatient and outpatient services in the fall dhaka. all of the others were less than 1% or zero and in a few cases we've recommended the freebasing which would actually be a reduction then the rates of time >> i would recommend, mr. chairman, that the members make sure they go back to this march report which is pretty succinct. i felt more so than usual, and this close savings isn't just a myth whether we are talking about cbo numbers or anybody

else. we are talking about real savings coming and that's what we need in health care reform. one of the things we need in health care reform. and i have a question if i may do you believe healthcare reform does indeed move us towards a medicare program that pays providers based on the quality of the services and not the quantity? do you think that is what actually does or will do >> as i said in response to mr. klein, we do believe that there's a lot of important work in terms of changing medicare payment systems bitter reward quality and cost. i'm happy to say that much of that work is based on a related to the recommendations in the past. as we are encouraged to see that

moving forward. >> i would ask you the final question if i may be for we stop here. if i may ask a question. >> the gentleman's time is expired at you are welcome to come and visit with me. dr. price is recognized for five minutes. >> thank you mr. chairman and good to see you again, dr. hackbarth. we appreciate the information you provided and i want to go over mr. pascrell commending the march 12 report as i think it outlines a lot of things that may or may not result in a higher health care. the decisions we make and decisions you make have consequences. how the real world can receive their health care are affected by the things you recommend and the things the we do. in response to mr. reichert's question coming to talk about the beneficiaries, you say the

town halls you talk beneficiaries with. any of those beneficiaries say that they want to get a life under fee-for-service to get more difficult? >> no, i don't think that the beneficiaries typically think in those terms. >> i think they are generally speaking beneficiaries like the medicare program will. i don't think they think of fee-for-service as much as so much. >> but life under fee-for-service has to get more difficult, end of quote. >> what does that mean? >> better care. >> getting difficult means better care? >> life getting more difficult for fee-for-service care encouraging them to move for new payment methods more focused on producing high-quality care.

estimate you said life getting mark difficult you want life to get more difficult for. and opening the doors to new payment methods. spec when life gets difficult for the doctors of the land how does it get patient? >> the point dr. prices that article was not just to make life more difficult. i guess i just heard you say. >> the means to be pressure on fee-for-service to encourage people to move chinua payment small walz three >> it's eliminating and i appreciate you being candid. i think this is extremely helpful because there are.

we ought not have individual patient is being able to find an individual doctor they trust to say i want, please, for you to provide the service for me and under a fee-for-service model >> we didn't say that and i'm glad you raised this. we believe medicare beneficiaries should have options for their insurance coverage. there could be plans under medicare advantage that say what we want to do is offer old-style fee-for-service. >> and that makes month difficult arena. >> of the patients and physicians and other providers choose that, we think that option should be available. >> in the report, you say that access medicare patient screening getting access to physicians is becoming more

difficult in fact your survey found that one for medicare patients looking for a new physician were having trouble finding one. >> tell me do you believe that an increase or out of pocket spending limit decrease in the benet fishery cost projections, does that increase or decrease access to care? >> if i take the information from your report which says the medicare patient are having trouble finding to take the impression from the june report that says there ought to be a cap and you ought to have a co-payment how maraniss you have any data that demonstrates that your recommendation in this report would increase medicare patients access to primary care physicians? >> we think that >> do you have any data? >> the response to the problems

of access to primary care is to increase payment rates specifically for the primary care services. there were multiple reports that made it clear that we think that the payment rates for primary care service is too low and that is a major factor in access problems not just for medicare beneficiaries but all americans. >> my time is expired but i would like to follow in writing and encourage others to do the same. thank you. >> mr. blumenauer is recognized. >> i want to follow the line of inquiry and give you the chance to elaborate because first of all i didn't hear you say that he wanted to make life more difficult for patients one and i am informing from what you've said that having a situation

where the default is fee-for-service and rewards volume over volume may be more convenient for some providers but is not necessarily the best optimal care and is not necessarily in the best interest of patients. i don't want you to be trucked into saying because you -- i understood you to say that he wanted to have some friction with so the default is and what is easiest, but necessarily not optimal care. d.o.t. lubber it on that? did i misunderstand what you were saying? >> you are correct in your description i ran a very large physician group in boston were 600 physicians and feel like a understand them pretty well and work well with them our group

was able to practice high-quality medicine as good as anybody in boston and do so at a lower cost and that is because we were not dependent on the fee-for-service. we were paid through other means that actually allowed us to better focus resources on the needs of the patients to do things in the care coordination without worrying about whether the fed the medicare billing code and deploy resources with the one goal in mind how to read the systems and get the best quality-of-care. what we think is that over time the whole system would benefit from moving away from fee-for-service, all of its rigidity towards the system much more focused on the value for patients and for the taxpayers who pay the bill. >> and nothing that you

suggested would eliminate the option for people who want to use what most of the united states is being clear is being outmoded and ineffective but people could still have the fee-for-service options if they wanted to the old-style reward volume overvalue, the consistent theme over the years in the recommendations and shows up again in the benefit redesign recommendations that we don't want to do my choices. we think that people love to have traces of putting medicare beneficiaries. but they need to start seeing the cost implications of the choices of they made. that is the only way we are going to deal with our cost challenges in medicare in the broad medicare system. >> you are seeking to do this and i holistic fashion, right, rather than an instrument.

i know of no small amount of irony that some of my republican friends are all in favor of shifting much higher costs onto the backs of senior recipients looking for systems with higher co-payments and out of pocket expenses, more confusion if you will and complexity of this is in the aggregate that somehow when you are offering things that are more nuanced and fine-tuned that somehow we are biting and and suggesting that this is something that is nefarious and with all due respect i reject that notion. i deeply appreciate what medpac has done in terms of trying in an unfurnished fashion. it's congress that is continually added complexity that hasn't stepped up for

decades now we've reached a point it can't continue as it is the transitional care process in terms of care coordination. we have legislation we're reintroducing to have a transitional care payment in light of the larger context. despite mr. cannon is recognized for five nights. >> thank you mr. chairman for holding this hearing today. i represent two entered thousand seniors to rely on medicare in my district. i want to assure the seniors have access to care has lost two. millions of americans are struggling with seniors on

incomes and a stand the income of a policy holder is less than $30,000 a year. we have over 650,000 seniors on medicare would pay medigap paul cielo and the seniors on fixed income to the budget year in unexpected medical expenses. should we be concerned that the supplemental coverage can result in the script doctor visits and could lead to more cost of care in the long term? i want to emphasize our approach is not to restrict access to supplemental coverage or deny people the option of buying supplemental coverage. we do think that they should face of leased a portion of the cost implication of that choice when you pay supplemental the insurance premium, you are only paying a small fraction of the added cost to the medicare

program. so we think people need to see a bit of that added cost the taxpayers in her as a result of the decision but for sure they want to retain the choice to lead in our chapter on the benefit redesign, we present an analysis that shows that if the benefit package is redesigned along the lines that we distribute catastrophic coverage and restructuring of the co-payment some people react to that by reducing the supplemental coverage in fact they may be better off financially. and that's because right now a lot of people are buying supplemental coverage out of fear and uncertainty because of the lack of catastrophic coverage and the confusing benefit design but the amount they pay interest upon coverage they don't get out. so they could actually be better

off if we had a redesigned benefit package in less comprehensive coverage. >> second i want to ask the commission highlights the program cms is implementing for the dual eligible. i am concerned with these concerns expressed to me cms is implementing the program if nothing defended in terms of measurements there are some ways to compare the outcomes. shouldn't we be using some measurement stick to gauge by helping the people what risk in terms of population? >> we think that having a strong system is an important part of moving towards a new approach for the dewey eligible beneficiaries. many as you well know are quite vulnerable patients that have

either caulking metaphor physical limitations and have really unique clinical social service needs so we think in the important part of the movement needs to be a robust measurement system. we have limited measures currently for the so-called snips special needs plans that serves the do wedgie eligible under medicare advantage. the measurement system is not robust enough. the good news is that cms is engaged in the national quality forum, which is sort of the national arbiter of the quality measurement to enhance the measurements of the duly eligible population that's encouraging but there's more work. >> why haven't taken a more aggressive approach in measuring at and how you manage it if you can't measure from the

standpoint? .. >> we need half doctors to

be in primary-care. we only have 1/3 because of compensation. you ask the relative value committee to do the comprehensive review. they talk you out of that to. they came back with coats for chronic care management. clearly the ruc is the recommendations that is dominated by specialist. primary-care people don't have a chance.

i would like the to hear you talk about how what would be balanced so they could make a decent living or we just have the same mess until we have a breakdown in the system? >> i don't remember been talked out of anything for the record. >> that may be my interpretation. >> i will make a few points. we have pushed aggressively so across the board with the relative payment system. what we said cms is overly dependent on the ruc we have

urged them to develop alternative sources of information not necessarily replace the ruc but complement it. we are concerned estimates of time involved are off maybe not all little but substantially. the time estimate is the single most important factor to determine the relative value. if time estimates are off, that is a big deal. ruc values is the raw material but that is the response rate. but cms needs to have the

alternative database. on a specific issue of time. >> i said you should have your own people doing this. what prevents you from that? >> what prevents cms? we tell them to do the same thing. be less dependent on bet ruc bit more sources of been permission. i think we are together on the issue. but the problems that we face are so urgent we need to do some day in addition to relative values. that is with the affordable care act that is a

constructive step. maybe we do additional stopgap measures. >> can i make another suggestion? also make primary-care repayment as we do with rotc officers? >> otherwise we would have people coming out trained and not deeply in debt. >> thank you, mr. chairman. >> just raising a quick question instead of replying now but it deals with the march report, not the june

report. with the hope you could provide us with inside. i have a constituent who got three days of home health care services the agency build $1,500 they were reimbursed $3,000 because of this of or care regulations. so we wrote about the issue and then got a response back from mr. wilson who said basically in your march report it shows payments to freestanding agencies on average we're 19.4% higher than the provider cost. that is reimbursement of of the cost.

the med pack testaments 2012 is estimated 13.7%. as a result cms our word came diligent need to implement the affordable care act for a health care services to make sure they are more accurately aligned with services. but as to where it is with their examination of the issue with a higher reimbursement rate to make those more accurately reflect the cost by those agencies. >> but with those circumstances with the issue

of medicare margins but it's on average they are very high. their breed recommend of series of changes in the home health payment system. but also changes to improve the system is a function and adjustments for the patient's condition. we think those are real problems that need to be fixed as well. >> please get back to less as the progress and with the higher rates of returns we

appreciate that response. >> part of this is in the cms core part of it is congress setting the base rate. >> thank you. >> ms. black is recognized iraq. >> i want to go back to go back to the financial alignment program. as you indicated many are dealing with complex physical and cognitive disabilities. if the state passes to put them into the plan is it possible they will seek treatment plants disrupted?

>> is a possibility. they need to be designed in a way to be minimized. for example, there could be transitional steps taken. before the state enrolls any beneficiary in a plant there needs to be clear communication. also with the providers so there is opportunity to say i don't want to to be a part of this. >> they are fragile individuals a change of doctor or hospital or provider could negatively affect them. >> that is why the communications needs to be not just to the beneficiary but to others who may advise the beneficiary like positions are family members.

also those with cognitive limitations have difficulty understanding. care needs to be taken before anyone is passively and roll. without making the affirmative choice. even if they approve to have a transitional mechanism to have the provider in the network for a period of time >> is there an opportunity for them to make this choice or just before stock? also the private plane and could that compete to with the transition? >> the opportunity for the existing medicare and print page plans, that is a function how the rules are

set up that the state level. those that vary state by state. it needs to be evaluated on that basis. >> i hope allows people to have a choice as viggo forward. to allow people to have a choice propose some say the beneficiary cut off doubt but as as you have noted that by challenge chain to navigate the opt out process >> it is a concern that we have. rethink communication has to be beyond the beneficiary providers, fam members, state agencies that

buys beneficiaries. of very a carefully designed communications plan to make sure they are not ended for and they coerced into arrangements that will not work for them. >> is there a possibility the opt out mechanism could lead to resemble a waiver program? >> yes. that is the principal concern and launched after talks about that the state proposals as i understand it now in excess of 3 million beneficiaries the move into the new arrangement by our reckoning is a program change we would pervert to see a much more smaller

number so we have the means to carefully evaluate how well the effort has worked. >> if it is a wave, it is a waiver program and we will not get good information by moving their group all at once. >> thank you mr. sheen 94 your testimony to discuss medpac analysis and recommendation is a great value to the subcommittee her appreciate medpac is taking on issues that is important to the medicare program considering the extent of the fiscal challenges facing the program it is essential

congress consider all available options. a comprehensive review is needed to make sure they have access to high quality care that is on sound financial footing. it must change the current course look forward to continuing to work with med pack -- medpac they have 14 days to submit a question for the record if any are submitted by last witness to responded day time the manner. the subcommittee is the churn to. [inaudible conversations]

>> how do approach book interviews differently? >> i look at it as gathering history. interviewing for the news side as gathering contemporary information and. >> how difficult is it to remain impartial and not get caught up in the campaign? >> i tried to give people a full understanding of what is happening in the

campaign. it is not difficult to put your bias to the side. >> how has social media helped? >> twitter is a new source for politics. that did not a system for years ago for all practical purposes.

>> over the past century with men have made remarkable strides since

society. we take it for granted and a girl can become a doctor, lawyer, famous tennis player or aster not for the head of the coast guard. today america's leadership is unmatched. there was a time when they could not envision this kind of progress. the passage of title 91972 opened the door for academics come a sports sports, workforce. we are hachette -- year to chan bn the success of title nine. it states that no person in the estates shaw be excluded from participation in or been denied them benefits of subject to discrimination in a program receiving federal

financial assistance. that is it it ensures quality and of the law for men and women and applies to any education program receiving federal assistance. everybody can have a chance to participate in athletics barbaro '02 and an armored free of harassment. is believed it only goes to a athletics. it applies to all i activity is. the highest growth highest careers that are critical to economic success and national security used to be off limits to women before the passage of title ix. according to the u.s.

department of education women -- girls take math and science glasses at higher rates than boys and doing better. the women received a doctorate degrees has risen steadily since 1970 to. today one 1/4 of technical students are women. by doubling the potential talent pool, we become stronger as a nation. today we hear from a distinguished panel, a legal scholar and others who will discuss how things have changed. the first woman supreme court justice the first woman in space or the speaker of the house

athletes come of business executives and military officers and their role models for all of us title line has some much in common with other was of the century like the civil-rights act or the americans with disabilities act about expanding the scope of free them to ensure fair and equal treatment. with fat i introduce senator enzi. >> this is my favorite day generations to come well have more famous by have to say i was intimidated buy you as i was part of the

group that now is of pleasure i have gotten to see mrs. king and our famous swimmer as they perform. i do come from wyoming first state allowing women to go to while we were still eight territory hoping to increase boaters to become a stay. [laughter] there is more to the story. they did say you can become a state if you take away that approach. to that credit they said we would rather not be a state. but then when it happened, we had the first

woman judge, first woman governor, woman councilman, most everything including the first woman to own a bank. i am please title ix fits in with tradition and is then they example what congress can do when we work together. just look at the statistics will it has opened opportunities over 40 years. 1975 the degrees exceeded men over women but now winn-dixie stores then undergraduate and at over graduate attainment. win it early -- earned nearly 60% of the batch the decrees nearly half of the doctorate degrees. title ix needs to acknowledge that the demint it for athletics.

only 295,000 girls participated compared at 3 million boys that is just of percentage of athletes than the numbers have grown. today millions of girls practice the plate and high-school. despite progress we cannot afford to be complacent. we're add a crossroads we have to graduate more mathematicians and engineers to be the technological leader. this is where is the greatest possibility is. we need to do more to achieve progress. eyewitnesses' today are for extraordinary individuals buy it for them to pass

title ix to make sure women and girls of the same opportunities men have enjoyed. but to make sure they took a vantage to become all models and then look forward to hearing from each of you how we cutting krutch greater achievements in the future. think here. >> because she has been such a leader in this area or in the house and senate alike to recognize this senator mikulski for her statement. >> thank you for your extra courtesy. celebrating the 40th anniversary we recognize patties who led the fight in the house here in the senate. 1970 to nine never thought i

would have thought but here we are today. but to move with four redoubt his support i don't think we would have been successful. but to have opportunity for women and girls. sports achievement that all nine was meant to open doors to establish parity with the field of education and also then that of participation of college athletes prepare 1972 johns hopkins, my home town who is all male and white.

women were not included at the national is toots of health. when all one been achieved something she was a celebrity rather than a scholar or athlete. so much has changed. today we will hear from the founding mother and the first to move to many advances for word. each and every one has an incredible personal narrative and we support them. billie jean king. i remember that famous tennis match. beside you give the word in new meaning in terms of that challenge. but i remember with