. .

how did it happen this time? what went on behind the scenes? and the deals that were done with the important players in it? the health care industry, the insurance industry, the drug companies, what went on? what made it happen? what were the special ingredients? and did america get a good deal? finally,are we going to see cost controlled health care? we'll talk about that today. will health care be safer? will will there beless overextreme? what will health care look like for future physicians. a really important question. did we build in health care reform a sustainable system? we built a house, but will it be one that generations will be

able to live in? let get started. why health care reform? just a reminder of why it's so important. you hear see it every day. last night at zipper we were talking about the clink for the unensured here. and you see patients come with unmanaged diabetes, people with cancer that has spread. why? because they lack health insurance because it's so expensive and they have enormous suffering that takes place because people don't have access to health care. this is a photograph of what volunteer physicians, nurses, others come together. this has been america's safety net. and yet another picture. if you're insured and can't afford medical care this is with

they drive to receive it. a pair of glasses, a sore tooth, or cancer treatment and can't afford followup care. this has been health care for millions of people. the decisions about what to do about it wept here. this is picture of blare house in washington, d.c. the white house summit in early 2010. democrats and republicans together debating with quarreling with over what it should look like if it should happen at all. and "the battle over health care" will continue today health care reform is the law of the land. it's been signed by the president passed both houses of congress, the supreme court confirmed the constitutionality of the individual mandate last month but still the battle will continue. republicans about to repeal it, if not that they have vowed to prevent it from being funded and

there are many issues that remain to be addressed. we still have a shortage of primary care physician. the balance between primary and specialty care. are there enough physicians and nurses to take care of the 32 million people who might have health insurance because of health care reform? and then we have the surge in the elderly population as the boomers turn on medicare. 30 million people will be on medicare additional people. do we have enough doctors and nurses to take care of them? health care reform couldn't fix everything, but there's still a lot to be cone and the battle will continue. so the presentation is a nonpartisan look at health care reform. we can't cover it all because it's a huge bill. if you want to build a house be a god foundation.

will it be strong? the residence here now 40 years from now you look back on it did we do health care reform right? that's the yes. there will be four parts to the presentation. did health care diagnose the right problem? you as physicians now important getting an accurate diagnoses is. did we do that as a matter of public policy. the second question is what will be covered and what will it cost? third we'll focus on what does health care reform mean for you as future physicians and for those currently practices. finally, where are we headed from an economic point of view and fiscally can we sustain financially the systems we're creating? and if we can't, what can we do about it and what should we start doing now to fix it? the part one, did health care reform diagnose the problem correctly? the reform law diagnoses the problem as lack of health

insurance. and it's true, there are up to 50 million estimate suggest people don't have insurance. and so the solution that has been prescribed the treatment order is let's have more national hurricane insurance. and now up to 16 million people will have access health insurance. many with subsidizes. we'll talk about that in a minute and people could have medicaid coverage. one of the reasons that so many people cannot afford to buy get insurance because they can't afford it. it's too expensive. health care costs are too high. we're going drill down on that for the next few minutes. the study published in archives of internal medicine earlier this year that looked at the cost data for uncomplicated append sietsd. they have access to data for all the hospitals in the state. immediate cost of a hospital tboil treat uncome plaited was

-- which was $44,481 in 2010. what is specially interesting is the range of how much the hospital bills were. the local county hospital, it was only $1500. at other hospital it is went up to nearly $18 3,000. some of the higher cost hospitals according to the study before profit institution. how do we sustain this? is it sustainable? i'm writing a book on medicare presently i have a pleasure of interviewed a gentleman from kentucky who was 45. he went into a hospital he said he needed an operating room and chances are he might had a pacemaker or defibrillated implanted.

he got a hospital bill for $2 4,000 for the one night in the hospital. that's about the cost to buy a house in his community. in fact, for some of the houses, you can buy houses cheaper than that in his community. he was on medicare and medicare paid only $18 ,000. he was floored by the bill and said what happened if i didn't have insurance? he said, well, we'll still make you pay it. i recently did a radio interview in washington, d.c., and a woman called in and he said that her husband had gone in for treatment of kidney stones he had two and they -- the bill they got was $52,000 for each one. this is the reality of how much health care is costing. and this is why we have health insurance premiums that keep spiking. in 2011 a drug company gains

exclusive rights to a shot to prevent premature birth. it used to be $10. when they gained the right they increased the price to $1500 in injection for a total of cost for $30,000 in pregnancy. is that sustainable? and this happens in the united states because there's nothing to stop it . there's nothing to stop the price increases. in the case the american college pushed back. they issues a state saying the u.s. health care system can't be expected to ab absorb the cost without the negative reper cautions in the company the backed down. it's the exception rather than the rule individual partials don't have the power to put pressure to reduce the hospital bills. so we have a problem of uncontrolled prices in american health care. and a toot imwhen 32 million

people will be getting coverage. we also have an interesting situation this country with volume. i recent study in "the archives of internal medicine" was survey of sphtionings primary care physicians 42% of them believe their patients receive too much medical care. 25 percent of them believe they themselves provide too much medical care. the good news about 85% of those surveys said they're interesting in learning how their practice cares so they can curb unnecessary medical treatment. as young residences you have the opportunity to do that. i'm sure with the leadership, you'll learn how to do that. and you should. you'll be aware of the american board of internal medication choosing wisely campaign do encourage doctors to provide the care they need not what they don't. they are issuing five groups

coming out with 27 different specialties of medicine to doless of and have good care for patients. top five in internal medicine. you might already know them. i'll run through them. imaging for low back pain often overused. let's go watchful waiting. don't do the blood chemistry panels. an annual lek to card games. don't dot bone screens in women under 65. these are recommendations coming from the evidence. from primary care physicians. we'll take more ability it later about what we can do to curb the rise in health care spending so we can have health care reform that lasts for generations to come. this is a medical index of

annual cost for a family of four for medical care. at note, in 2012, 0 $20 727. it's been rising $1,000 a year. you can see that. that's where we are in health care today there's nothing to do stop that that trajectory. the median family income was $50,000. so how on a family of four the average annual spending is $0 ,000? how do you do that? and either even enough federal subsidizes enough money in the federal government to keep subsidizing that? well, i was writing "the battle over health care," i listened to an interview on abc nightly news. the secretary of health and human services was being interviewed this is the in context of stories being reported about tremendous

increaseses in health insurance premiums individuals were having to pay. 20, 30, 40%. i found the question and the answer quite remarkable. the question that was asked by the interviewer, what should people do if they get an increase in their insurance premiums of 40% and they can't afford it? and this was after health care reform. and the most remarkable, which i frankly was not aware of, until she said, her reply was they should contact the governor of their state demanding that laws be changed. she's referring to laws pertaining to health insurance rate review. they told me there's nothing in the health care reform law to stop the increase in the cost of private health insurance or candidate. there's nothing. so we defined health care reform the problem as a lack of

insurance. is that the real problem? is the real problem affordability? are the subsidizes a ban decade on exploding cost? while i was writing the book you'll remember the oil spill in the gulf of mexico. and the pictures like this were sewn -- seen around the world of the oil coming out of the earth. day by day by day people watched around the world. the engineers were able to cap it. i couldn't help resist making a comparison with health care. there's nothing to stop it. there's nothing to stop it. just a word about medicare, one part of health care reform law that has brakes on it pertain to medicare. there a number of other provisions adding preventive benefits for annual mammograms and colon colon os i without payments. closing the doughnut hole for prescription drugs.

all good things. here's where we're heading in medicare inspect is a medicare trustees report. the report on the state financial state of medicare. it starts in 1967. this is data for how much the average person was over 65 and collecting social security, let's take someone who earned $50,000 the average wage over the course of their working life. they retire. when you retire you have to pay for medicare. it's not free. you have to pay premiums and copayments. you pay it for part b. which is doctor charges and part d. is prescription drugs. in 1967, two years after medicare was started, the average person on social security paid 6% of that are their social security check just for physician visit. there wasn't part d. 6% of the social security check. in 2010, it's 27%.

in 2035, it's going up to 40%. 2085 when the young people in the room when your in your 80s within you'll be spending 46% of your social security check just for physician visits and prescription drugs. it doesn't include the cost of hospital care the deductible nor the copayments you have to pay. again, these are projections but this is very sobering. so in the health care reform law, there's a recognition that medicare, we need to find way to address that cost. there's a provision for independent payment advisory board set up with fifteen members appointed by the president and confirmed by the senate. they recommend ways medicare can keep spending in check. there's one thing that believe it or not, president obama and rush limbaugh agree on. they agree that medicare is unsustainable as it is now.

they agree on something it must be true. here's what president obama said, the u.s. gast is not going to be able to afford medicare on the current trajectory. the notion how we can can keep doing what we're doing is okay it's not true. rush said i don't like the idea of letting medicare collapse. there won't be any if we don't fix it. it's not sustainable. so independent payment advisory board was nblged in the health reform. it can't change things. if congress doesn't like the recommendation it doesn't have to implement them. but congress does have to find an e qvc -- equivalent amount of savings to pair back. they have been targeted for by very powerful forces. and in part because this is a scintd pattern in health care

reform and how the deals were done any curve on any revenue any effort to curve the revenue, they want to stop. so just as 32 million poem have health insurance industry will be getting 43 million new customers. that's a lot of revenue. they don't want any impediment on getting the revenue. the year the health care reform law was signed, the "the wall street journal" reported the annual ceo compensation survey. they reported the highest median compensation of any sector in the u.s. economy that year was health care. it wasn't the banking industry, it wasn't the oil industry. it's health care. i'm also mindful of during the financial crisis charles prince who was head of city group said when the music stops things will complicated. we have to get up and dance if the music is still playing.

i sometimes feel that about health care. we have the looming trajectories and where are we headed? the question remains, is health care reform built to last? what do you think? let's talk about the cost and coverage provision under health care reform. who will be covered under the patient protection and affordable care act? what will it cost? the good news up to 16 million low-income people may be covered under medicare the joint federal state program. i said maybe because there a number of state governors who are not inclined to expand medicare. i think it's more for political reason, they have very serious budget situations. i suspect there will be a lot of pressure from hospitals and other in thes state that will wear down that the opposition. so it's not clear all 16 million projected people will be on candidate. medicaid. new jersey estimated 450, 000 people coming to the clinic

uninsured now will have insurance. that will be a good thing. so what is the individual mandate? it requires almost everyone under age 58 to have insurance either from the employer or medicaid. you have to be under 65. or private insurance. and if they adopt have it, they'll have to buy. the individual mandate applies to those without medicare it effects up to 16 million people. they have to start getting insurance starting in 18 months in january of 2014. what hasn't received a lot of attention how much will it cost? there's been a lot of talk about about subsidizes. how much will it cost. the family foundation has a wonderful subsidize calculator. they're estimating and projections based on data from the congressional budget office. and they report that a 45-year-old head of household with an income of $45 $46 ,000

will pay $26 00 year for insurance nor 2014 and that's subsidizes. in addition they'd have maximum out of pocket cost for more than $4 ,000. the way sub cities the structured the benefits are different. the 68-year-old pay $10,000 for sentencer in 2014. plus out of pocket cost up to $6 ,000. i was surprised how much that is. that's enormous. so what is an exchange and how will it work? people will be able to get their private insurance on online exchange, they'll also be able to access it by telephone. it'll provide information to help consumers shop for state approved health insurance plans and ably for subsidies and tax credits. like a travel website like expedia. it will all be there. you can select your choices from

that. make it a lot easier thans what what it is now. you might have heard about the penalty. do i have to pay a penalty if i don't buy insurance? in 262016 the penalty will be $6 5 a year or 2.5% of income which every is greater. you'll have financial hardship, religious reasons and whores went have to pay the penalty. so as health care reform moves from the supreme court to the court of public opinion will people buy insurance? will they be able to affordable? even with subsidizes. are the penalty strong enough to encourage people to buy insurance? you can imagine that people with a serious illness who haven't been able to buy insurance because they have been excluded, they'll be delighted the prospects so relieved. they'll be happy to buy it. other may differently.

only the sick people enroll what's going to. to the proposal yums? -- premiums if you have only sick people they're going to go up higher. there's no enforcement of the penalty no liens on your property. even though we have come this tbar, still many unanswered questions and uncertainties. what about employer provided insurance? that will probably effect most of you in the room that are fortunate to have it. how many of you have insurance? so what will a employer-provided insurance cost in what benefits will it offer? will employers continue to provide insurance? most employers will continue to provide insurance as they are now. it's changing. i'm sure you have seen the changes yourself. you're paying more of your income for insurance. people are getting fewer benefits, the deductibles are higher.

i called the swiss chief. health care insurance has become like swiss cheese. it has more holes less cheese. here's data there the kaiser family foundation and hr et on bottom line you see the growth in employees income from 1999 to 2011. so people's incomes have been growing over the time period by about 50 percent. accumulative increases. but then look at the top line, that's how much people are paying more for health insurance. the increase in their health insurance out of pocket for employees is 169%. they have a huge gap. what it means means is incomes are not rising anywhere as near as fast as the cost of health care. and you see that trajectory. it's going up and up and up. if you look at the top right

corner right here, the cost for insurance is going up employees are being asked to pay the higher share of it. and that's reflected here in the slide. if you work in a company with three to 29 workers that's the top line here. you'll see that 29% of employees are paying $2,000 deductible before their insurance kicks in. look at the growth trajectory from 2006 it's 6%. and much higher in 2011. so we'll have there will be insurance. but it'll have a lot of holes. there's a penalty for employers, if this f they don't provide insurance depending upon how large the employers are. employers with more than 50 employees that don't provide insurance and have at least one full time employees that will

pay a penalty of $2,000 per full time employee excluding the first thirty. the businesses have calculated it's cheaper for them to pay the penalty than it is for insurance. what's going to happen? this is trajectory of all firms offering health benefits from 1999 to 2001. the researchers can't -- i'm not sure about what causes the blip you see here, but you see the overultra ject i are is moving downward. and i predicted it will continue particularly amongst small employers. what they may do is offer just like we have done retirees benefit west have moved benefit to defined contribution. you get a set amount of minute and you get your insurance. i predict that's what will happen. what about states and medicaid? does medicaid expansion in the federal government will pay 100%

of the cost in medication expansion to from 2014 to 2019. beginning in 2020 that will change and states have to pay 10% of the cost. if you have been reading the news, if you have time, you'll see that, you know, california and new york both headed by democrat governors had to slash medicare budgets because overall state budgets are under tremendous pressure. a former state medicaid director in california under governor swars negativer said this medicaid provides care -- is falling apart as they cut benefits and enrollment increases because of the recession. we are seeing the after effects of the recession. it's a challenging environment out there still. what is health care reform mean

for you as physicians? what will be different? what will life be like? the good news is more of your patients will have health insurance. when we were having dinner last night the doctor was mentioning how when he was around in 1965 when medicare got started, basically to close the clinic because older people no longer needed a free clinic because they had medicare. here there will be uninsured americans there will be far fewer of them. that's a good thing. what about primary care? access to primary care will be more challenging than ever. the way i talk about it as health care reform is like building a house without a first floor. there is some provision in the health care reform law terms you may have heard called patient center medical homes.

they are wonderful but there are not enough and there are not enough primary care physicianers or nurse practitioners to be able to handle the number. if you call to get an appointment with the primary care physician, you can't. we're going to have 32 million more people come into the system. for people on medicare, while we close the doughnut hole for prescription drugs, the number is shrinking. so who is going to take care of the 35 million more people who will be on medicare in the coming decades as the boomers retire? who is going to take care of them? who will coordinate their care? as future physicians you will be practiced at professional-team based care. it's an expected competency for you. they need high functioning

teams. .. >> the question we have for

today have a danger health care reform is built to last? in-house will be around for generations to come? if current trends continue, the data are clear we cannot continue. whether or not with health care reform. it makes telerate it but it will have been even without health care reform. everyone bears responsibility. what happens if we don't act? hearing about the national debt to is how much the

federal government knows to people who have lent money. 1985 we were a net creditor. we used to loan money. 2012 we're now to the net debtor. we don't loan people many anymore. we borrow from them. with the bill's going into medicare. and the federal government has us to borrow money from china to pay the doctor bills. presently the total debt is $16 trillion. it is hard to get your hands around that. this is $1 trillion.

if i pay the doctor $1 million per day since the year jesus christ was born, that would not trillion won trepidation count at 1 trillion. we have 16 of those. if you hear the debate about raising the debt ceiling. that is what this is about. the scenario with the battle over health care, if we don't do something now places like greece and spain that cannot repay their debts they're asking for bailout money from the imf.

hopefully we never get to in that position. it is already monitoring and because we are a member. look at the debt situation for our country. that is where we change course and you come in as future physicians. the institute of medicine estimates 30% of all health care is wasted. it does not add value or improve their health. it includes overuse overuse, inefficiency, fraud. we will talk about each of these.

$760 billion is wasted every year. if we could take out a portion we would be in good shape and build a house of health care for generations to come. it will dupont -- depend on you. what about over treatment? would you order tests and prescription drugs is a very powerful tool. with the choosing wisely count -- campaign now there is a top five list of things we can do less of or stop doing at all. there aren't other surgeries in procedures as documented

as being overuse. angioplasty, webex surgery surgery, prostrated to me, antibiotics, all overused. there will be of first meeting on over treatment looking at these topics on what it can do as the creditor of hospitals to reduce unnecessary treatments we have a moment now with unnecessary procedures. use the talent and resources of those who do need them. if we could make switch now everybody will be intact. main and so were board

certification in 2015 appropriate use is part of certification when is inappropriate to do imaging for low back pain, screening for osteoporosis what about the third round of chemotherapy when is angioplasty of four. you will be required to learn to keep the system hole for everybody. one is a potential for harm exceeds the benefit. it is not about rationing or cost control. but good care of the patient.

i am continuing to work on over treatment. i was here two years ago to talk about the treatment trap been out there is more momentum to address the issue. this is what some patients are saying. a colleague said i have got in the cagey of my physical exam since i was 27. i have no heart disease. my husband gets one. >> recently she said she talked to her doctor and does not get them any more. they're not medically necessary perk up. >> i get a chest x-ray every three once. i have no underlying medical condition. next time i will ask why. >> came from a state

legislator. >> i give a talk recently. to address the issue of overuse and he brought this up. >> he would say why? think of the cumulative radiation. who is counting that? do you know, how much that is? we're not tracking it. we should. >> my knees were hurting. the orthopedic surgeon said he could do surgery. i found a personal trainer who helped me to strengthen my muscles. i am much better now. >> educated people make good decisions. it is not everybody but we

begin to see it. good doctors have good choices. this is the choosing wisely campaign. i am glad you use that as part of your curriculum. might 83 year-old mother had problems with her shoulder and he said he could operate. physical therapy and time for healing, she was fine. there are abundant opportunities to do this. the way i think about health care is the way we think about food. people eating too much food and pockets of communities people are malnourished.

also health care. some people get too much and others cannot get to what they need. if we can put that to produce we have enough. we can do that now. we have to get started. we don't have time or money to waste. finally, the fact i found interesting. the fbi did an estimate of fraud and health care. about 10% of health care spending is lost to fraud. the sophistication is

enormous. if we take 10 percent it is 2.6 trillion dollars per year. that amount of money will cover every single and insured person in america. the law includes provisions but there are important steps and it is a far cry from removing from the system. giving it to those people at your clinic who could get better care. we have to preserve and sustain and take out what does not add value.

what can you do? positions and nurses? asked if the test or procedure will really do good? what is the evidence objectively? do your peers agree? we do see more consensus of lo there is different points of view. a quote from muhammed ghandi recalled the face of the forest of the weakest man and ask yourself will it be of any use to him? will he be better off? then you will melt away. that is how we can make

health care sustainable and live for generations to come the care that will system they keep for all you do i wait until questions and. [applause] >> >> good morning and is nice to hear you again. the starting point* but on

its way to collapsing there is pain and other avenues to materialize in the global world even health care maybe exported. knowing all but and seeing the globalization of the trade and industry is growing abroad who is this along the way.

but they crop up along the way. one of the things that comes to mind is the way we are taught to. at medical school we're taught the indication or treatment. but then to take care of a patient by the way i am a surgeon. i have an operation to offer you. nothing else in the patient's left. rightly so.

what is the treatment? not only the most rewarding treatment for yourself. i leave you with that thought to the medical establishment that i thought myself 40 years ago. >> mentioned the word disruption in. because of a federal law officials are required to report when the medicare program reaches the situation. but with george bush and

obama officials have issued funding warnings. using the term disruptive consequences to society you are right about that. to speak at the british medical journal with overuse i ask the audience of people i asked has anybody ever had medical care that were unnecessary? how many reside outside the united states? i was surprised

finland, germany, australia, new zealand, the evidence of overuse. a global phenomenon. if you do that to your not spending on infrastructure. is the intermission -- enormous question and globally. >> i am aghast joe -- gastroenterologists. i was in primary care. i could counterpoint in his infinite. the first the issue of primary-care.

the primary-care physician and is asked to be the foundation. they have the most responsibility to know everything. heather wright and left-hand and responsible and the least amount of time and to go to the orthopedic surgeon going so warehouse. but they have to go faster it is crushing. there is no incentive to become primary care. the least amount of money. and this brings me to the

issue is the imbalance that we have. with the whole obamacare was implemented but i have to believe there were not enough of us to formulate a plan. i have to believe because of the lawyers we cannot control cost part of the overuse is that we're shaking in our boots about being sued because using clinical judgment and standard of care is not good

enough. the players sprees downer throat we have to worry about the court room that takes us away from a patient's. even if not guilty we lose money. and then i wil close. i am going on and on. [laughter] as long as you have political action committees that are powerful so what do we do? everyboby pass to have health insurance now they'll laugh all the way to the bank but there is no

competition nothing gives good care that will provide with the care they need but instead we have deductibles and premiums going up no competition to pick any insurance product in the country maybe we would have the insurance and this deal would take less of the bonus. it is a fraud we have a lot of work to do. >> thank you very much for your comment.

[applause] washington is making well laws. of the ama supported the health care reform law due to the opposition of physicians. that now continues. looking at the patient's perspective with the battle over health care look at price bubbles. drugs that go on the market and then go off. too big to fail makes it very difficult to change. may not so sure it was built around that. it is not good for doctors

or patients. >> can you address the issue the dartmouth atlas said 50% of health care costs comes in the last two years of life. new jersey leads the way. can you comment on care at the end of life? >> there was an attempt to put it in a provision to allow medicare to have a conversation of a life limiting illness. now we have the term death panels that took the

provision out. the intention was to recognize impatiens are seriously ill, seven minutes is not enough time the intent to was to create a space and time of what people's choices are. but for political reasons was taken out. at the foundation into the mainstream health care system, a major study showed how poorly we care for people at the end of life.

in helping doctors and nurses establish which is good. the early form of shared decision making. the question remains why does end of life cost go up? the other side is families who are deeply troubled what they see the lo bonds going through. a manifestation we do not know when to stop. that will rely on physicians and future generations for those that will benefit them. we think there is a cure for everything.

you think we can work miracles. we believe there is a cure for everything. look at house. every test should be done. how do we reverse that? when there is the third round with no evidence why do you do it? it is tough politically but the first time i heard patients and families describe they see their loved ones going through because of the intensity.

and dead desire to do good. thank you. >> is impossible to get to your brain around the cost of medicine. it cost 33,000 but you get to. what does it cost based on what they get? >> i hope the imposition small start asking what does it cost? and talking about how physicians need to look

resources and asking financial people to go through the inventory. he had no radio. and $700,000 worth of equipment been the inventory. 10% spired. they whittled it down. enormous savings. mini he said imagine if we do this system why? millions of dollars by asking a simple question. you don't want it done on the basis of price but to be aware how much it cost.

we all need to be good stewards of resources. now we see more price transparency. patients think they pay 1500 of a colonoscopy but that is with no polyps. no guarantee we will see prices come down a much does that cost? >> i am a fourth year medical student. whine is about medical education. that goes with dr. gould seen earlier with the debt

to the changes the opinion of the student. how do i sustain myself? the way we get our loans and subsidies what is being done about that? i know more medical schools are opening up but more and more i feel a lot from society college, medical school and training. >> we should ask the same issue what does it cost to train and why? on what basis?

with medical education health care cost goes up with a perfect storm health care and education coming together. and then people going into primary-care health care reform did not fix that. >> one final comment. >> i am a urologist. eyes of the five is with the students plate with the educational system and the burden that they have. this is what we need.

there should be incentive enough but then to be specifically geared for primary care. >> psat has happened to geriatrics. it is symptomatic of that. their harmony many other things that need to be put to on the agenda. thank you for all you do.

[applause]

[applause]

hello everyone. can you hear me? this is so exciting. this is my very first book and probably my only book signing. i am so proud of this product. american grown is everything i would have imagined. the pitchers are beautiful. the gross picked it up. nice. but they were pulled in by the pictures and could not put it down.

then i got the thumbs up. news not just the white house garden misses triose and tribulations but the story of community of gardens across the country from hawaii to excellent school gardens happening in the middle of new york. the story use are an important part of the book says well. might key initiative is let's move. interesting statistics and then it is practical i am not the best gardiner but i

had the national park service and my a bancroft kid are my partners in crime. these two schools have been with us from the beginning to plant a garden on the south lawn would have to be a teaching garden. because when i'm a involved my own children and got them involved they are involved more. these kids are working in the gardens bringing back

questions changing the way they eat. it is a pleasure. they come to the white house. they are not starstruck. they get to work. planted and harvested within 50 minutes. we could not do it without them. i am so proud proud proud of you all. [applause] day q4 standing in the rain. and it reads to a healthier generation of kids.

some recipes are very good. i look forward to seeing you appear. [applause] [inaudible conversations] and [inaudible conversations] [inaudible conversations] >> and who gets the first signed copy?

and do you want to come around to get your but? here you go. [inaudible conversations] and there you go. thank you for all of your

helper growth there you go. maybe you can see pictures of you end there. >> it is so good to see you guys. are you a gardener? very cool. we could not do it without you. >> so good to see you. >> you are amazing. oh my goodness. this is a good way to end the year.

all my goodness. how are you? i remember. [laughter] why graybar un? are you ready to party? you know, may.

oh my goodness. thank you for taking the time. however you? are you a partner? how are you doing?

the recipes. yes. a. [inaudible conversations] and i think so. [inaudible conversations]

how are you? how are you? how is everything going? i am glad everything worked out. do you see all of those old people? argue a gardiner?

if i we're doing this myself [laughter] had thank you for taking the time. >> why is going on ladies? give me your name is. are you going into high school? congratulations you are eight years old?

and you are "the battle over health care." high-interest did it in the gardens and good healthy eating? it is nice to meet you. the girls went to their concert. but they are a little older. [inaudible conversations]

>> there are wonderful political books i am always interested at history. the third of the serious of lbj in but this documents the vice president when rate against kennedy says he was taught -- tapped for vice president for both london

johnson and president kennedy they were in different of every aspect. it was a time of trial and then this is one of the more interesting times to see this from the background. he did an incredible job looking at other books to hear him talk about others, he is nonjudgmental. and let's people decide for themselves. he has done so much research.

in the early growing up years. every time he goes further he has detailed research. he is an excellent writer. and would invite him to speak because the senators are interested in the experiences as majority leader. which is different from any tactics of today.

i went surgeon may recommend roberts books and his research is so good. another buck is of book of cronkite we love him in texas. then he was a foreign correspondent and got to a lot of reporter experience. but when the cbs evening news feathery major networks

have them, walter cronkite started in the '60s through the early '80s. he said he covered eight presidents. he was fascinating because he was so thoughtful. douglas brinkley is a wonderful historian. also teaching at the naval academy he is a historian the bagger fee of cronkite is the definitive one. and the fact that douglas

brinkley wrote it to and the fact walter cronkite is so well known and loved to have this by our coffee this or documentation in the future. fu. last book is final voices in organization formed to list senator hillary clinton as the honoraria co-chair. i have ben so impressed by a their role women have taken particularly in countries that are in trouble.

to create honesty and integrity to fight for human rights where it is so lacking. follow the us word taken with the treatment of women in afghanistan. how some of them demerged in the face of torture and death to say we can create a society. since we have been in afghanistan to help them be

free we have insisted all the aid america puts forward for women as well as the ways and the men. with these experiences each year they made a difference. secretary of state clinton and i have come to the award events and the zero women get to a validation. in some cases a woman builds

the economy. to build opportunities for the micro business. sometimes it is just standing up. one who pursued justice and turn back to create schools for boys and girls. i will never forget her. she was so magnificent although she was illiterate. she had a wisdom beyond her experience. women are honored by a 50

voices to talk about the great story is to honor these great to leaders with the economy and the quality for the treatment for those in countries who don't have luxuries of freedom that we have. i would recommend to those two fellows they are not funny or light but very substantive. look get lyndon johnson end all are the stories of the women who have done