details and, you know, is it going to be -- is it where you're sitting at your computer that's going to matter, where the company is located? you know, where's amazon.com located? where are these places located, and to who were they paying taxes? i think that's going to be the issue. i think clearly they're going to tax internet sales and, you know, it's hardly -- [inaudible] why they shouldn't since they tax you when you go to the store and buying? this is real not dissimilar. >> host: doug gansler is the attorney general of the state of maryland and president of the national association of attorneys general. he's been our guest here on "the communicators" along with juliana gruenwald of national journal. >> in seven days c-span's live gavel-to-gavel coverage of the republican national convention begins in tampa, florida, followed later by the democratic convention in charlotte, north

carolina. c-span, your front row seat to the presidential nominating conventions. up next, a look at the shortage of accessible oral health care in some communities. then, democratic congressman chris van hollen talks about his colleague, republican vice presidential candidate paul ryan, at a recent politics and eggs breakfast in new hampshire. after that, school and business representatives discuss policies to help fight childhood obesity, and later, live coverage of a forum on housing enforcement of immigration laws is affecting families. a representative with the pew center recently said that 40 million americans live in areas with a shortage of dentists. it was stated at a forum examining oral health care access and other issues including the high costs facing states for preventable dental treatments conducted in the emergency room. this event was co-hosted by the alliance for health reform and the robert woods foundation. [inaudible conversations]

>> why don't we get started? my name is ed howard, i'm with the alliance for health reform, and on behalf of senator rockefeller, our honorary chairman, and our board of directors, i want to welcome you to this program about a very much-neglected aspect of health and health policy in the united states, and that is oral health. now, you probably heard and will hear more today about the fact that the most common childhood disease in the united states is cavities, and poor oral health is linked to serious physical conditions like diabetes and heart disease. but that connection is not very widely recognized. in fact, i was listening to a presentation about dental needs a week or two ago, and the speaker felt compelled to remind the audience that -- and these are her words -- the mouth is part of the body, unquote.

now, we've had a lot of reminders about the sorry state of oral health in america from the institute of medicine, from gao, from former surgeon general david. satcher, from former hhs secretary lou sullivan, from rwj. in short, plenty of documentation of gaps in our current system, and today we're going to try to update that story, take a fresh look at both the problem and add some policy options being considered to deal with it. as we were talking just before the program started, nobody is more pleased than jay rockefeller, our honorary chairman, that we're discussing this topic today. there's a story that he tells about coming to the little town of emmons, w, as a vista worker -- west virginia back in

1964, and i actually had someone in our office transcribe what he said a couple of months ago in describing that experience. these are his words. when i arrived in emmons, i was shocked to learn that there was absolutely nothing school-age children living there could get in the way of dental care. they'd never been to a dentist, never heard of a dentist. there were no debittal services available. -- dental services available. you saw teenagers whose mouths were already beginning to go bad. we worked to get a bus to bring children to this grade school in charleston to receive dental care. i remember that after the dentist checked some of those young teenagers over, he said, jay, it's a nice thing for you to do for them, but it really is much too late. if you don't get the baby teeth right, anything else that follows is going to be bad and get worse.

so the senator has been working on dental access issues ever since, and the alliance is proud to focus on those program problems today at this briefing. we're very pleased to have as a partner in that briefing the robert wood johnson foundation which has been helping america enjoy healthier lives and get the care they need for 40 years. i have a button to prove that. you can't see it, but it says 40. [laughter] and thanks very much to dr. david krol and his colleagues at the foundation for their help in thinking through this topic and helping to pull the briefing together. david krol is a pediatrician, he's a team director and senior program officer for human capital at the robert wood johnson foundation, and we're very pleased to have him co-moderating today's briefing. david? >> thanks, ed. thanks to you all from the

robert wood johnson foundation for coming today. we really appreciate that the alliance is taking on this topic and that you're all interested in this topic. oral health is an integral part of overall health. now, if we believe that to be true, and i do, that seemingly ho-hum statement holds within it an abundance of challenges and opportunities. so the challenges, well, in many ways as the statement says are the same as overall health. there are racial, ethnic, geographic disparities of disease and access to care, there are financing challenges, there are issues of determining and maintaining quality of care, and there are work force controversies just like overall health. the opportunities, however, are great. one really great opportunity, and i'd really like to see it, is that all conversations on health and health care will naturally include oral health.

so while we've taken the time to have a specific alliance forum on oral health, it's really nice to see future alliance forums that talk about medicaid, talk about financing, fill in the blank. remember that oral health is a part of that. oftentimeses it's forgotten. and not just by the alliance, but even by our foundation at times. as we continue to recognize that factors influencing health are expressed at individual, family and community levels, we can develop legislative, regulatory, educational, clinical policies to improve oral health and health care. another opportunity is that funding schemes for prevention and treatment of disease will naturally include oral health. i think that's important for us to remember. right now we fail pretty miserably in medicare where we don't have coverage for dental disease and dental services. you can argue that there is some

coverage when -- in certain parts of medicare. but we don't do as good a job as we should. and then finally, and perhaps most importantly -- and i think something if you learn nothing from me today, um, it's this -- that there's a great opportunity in remembering that all makes and models of patients, providers and policymakers can play a role in improving oral health. and i just hope that you'll leave the forum with that in mind as you go out into your work whether it be as a policymaker, a policy influencer, a patient or a provider for those patients. so thanks very much for your time, and i enjoy listening to the rest of this forum. >> are great. thank you very much, dave. a couple of logistical items. there's a lot of good information in your packets, including biographical information about all of our speakers. there's a sheet that lists additional resources that you can use for further edification,

and all of that is also online at our web site, allhealth.org, as of monday. you'll be able to rook at a webcast -- look at a webcast of this briefing on the web site of the kaiser family foundation which we're grateful to for providing that support. there will be a transcript available in a week or so on our web site. and if you're watching on c-span at the moment, you can go to the alliance web site, tsa allhealth.org -- that's allhealth.org, and you'll see the presentations and the rest of the background material if you happen to have access to a computer at the same time. you can see on the slide behind me that there is tweeting going on about this briefing and at this briefing with the hashtag

oral health if you care to join in in one way or another. want to get to the program now. we have a great lineup of folks with a lot of different experiences to share with you. and as soon as i get to my proper space in the notes, i will introduce our initial speaker, lynn mouden. dr. lynn mouden -- i'm sorry, yes. is a dentist and chief, i got confused because we had shuffled the order, and i had, you don't care why i did that, actually. [laughter] so i'm going to stop and just say that lynn mouden is a dentist and the chief dental officer for the centers for medicare and medicaid services. he's a founder of the prevent abuse and neglect through dental

awareness programs, felicitous acronym panda, and before joining cms, dr. mouden spent 16 years in private practice, 20 years in state health departments. he's a past president of dental directors and serves as the american dental associate's national spokesperson on family violence prevention, and we're very pleased to have you here with us today, dr. mouden. >> thank you, ed. and i think you're the keeper of the clicker. >> i am. >> okay, thank you. certainly want to thank the alliance and robert wood johnson for putting together this briefing today, it gives us a chance not only to highlight oral health issues, but also to talk about some of our successes. i'm sure many of you have talked about the cms triple aim of better health, better health care and reduced costs. and this particular briefing gives us a chance not only to address the triple aim, but to

show how oral health is making great inroads into addressing those. cms has an oral health initiative. we have two goals that are specific to dentistry meaning we are increase by ten points chip children who have received preventive dental service in a year. that is ten percentage points, not 10%, so it doesn't mean going from 20% to 22%, it would mean, for example, going from 20% to 30%. so it's not only a national goal, but it's a goal that we have set for each of the states. and this information is based on what we know as the cms form 416 reporting epsdt data in the states. the baseline year for this particular goal is 2011, and we anticipate that we will be addressing this goal, hopefully,

nationally and in the states by 2015. the second goal is to increase by ten percentage points the proportion of these children who receive a dental sealant on a permanent molar tooth. and as you will hear other speakers talk today, i'm sure, you understand that the combination of dental sealants and community water floaration can prevent virtual all tooth decay in children. so we have set this as our ten percentage point goal for the nation and for the states, and we will be phasing in this particular goal as the data come in, comes in for this year. the cms oral health strategy will help address these two particular goals. first of all, we have the opportunity to work with states on developing an oral health action plan, and we'll talk more about that in a minute. it's my pleasure that i get to work with the various states and their medicaid and chip programs

in providing technical assistance and peer-to-peer learning as they develop these action plans and move forward in addressing the two goals. we, obviously, work a great deal in outreach to providers. without the providers, there is no oral health care. we're also working on outreach to beneficiaries and, in fact, we'll be having the second cms learning lab, an oral health web inar, dealing with outreach to -- my contact information is available at the end, and if you want more information, please, contact me. we also get the opportunity to work with our many other partners in health and human services not only through what's called the oral health coordinating committee, but also in various other issues and programs as we work with our partners in hrsa and cdc, fda,

indian health service, and the list goes on and on of all of us who are working toward oral health issues. the state action plans that we're asking the states to develop on a voluntary basis to help us address the oral health issues, we're asking them to do this action plan and, hopefully, to address both of the goals by 2015. obviously, stakeholder participation is extremely critical to this process. addressing these goals is not something that a medicaid state agency can do on it own. it requires bringing in all the state partners, all the advocates, all of those who are interested in improving oral health for our children. we're going to be aligning efforts not just through this state action plan, but also through state oral health plans which most of the states have developed, some of them at the behest of the centers for disease control and prevention division of oral health if they have that funding. ..

not only describing what's going on, addressing the issues, but also in how we can make these improvements. first of all we are asking the states to identify existing access issues and barriers. we of course understand that every state is different. there is no way to develop a national action plan and as each of the state's work through their individual issues, their

individual problems, their individual resources, and frankly their individual politics. we want them to describe in detail the state's existing oral health delivery system, providing data on providers, and that's not only dentists but also non-dentists house well. we appreciate the contribution of dental hygienists and other members of the dental team coming and we also recognize the fact there are some oral health services that can be provided in physicians' offices as well when we are talking specifically about fluoride varnish applications and risk assessment on young children. we want the states to talk about what they have done for oral health improvement, things that they have done, the results, their analysis, their evaluation of the effectiveness of the programs. we want to know what succeeded coming and we also want to know what may not have been quite so successful. we would ask that the state's compare, again, the form 416

mcdata against the measures which talk about whether the person has had an annual visit. reimbursement rates are always at the top of the discussion. i.t. was a medicaid dentist for many years in private practice. i know what it's like to get paid 23 cents on the dollar to provide care for these patients. i know that state budgets continue to be an issue as we are funded medicaid treatment and delivery. but by the same token i think there are things that can be done at the state and national level that will help address these issues, specifically when we start talking about eliminating it administrative barriers that makes it easier for dennis to participate in medicaid. we want the states in the action plan to talk about what they have done to address specifically the placement of dental sealants, again a proven method of preventing tooth decay.

to describe their collaborations with dental schools, dental hygiene programs, because again, without the providers, there is no dental care, and finally, to describe the status of the use of electronic health records coming and electronic dental records are slower in coming on but we know under the provisions of the affordable care act we will be moving closer and closer to electronic of records. as a, what might they do to address the specific goals? first of all we want them to discuss the activities underway or planned for implementation to describe the goals and how they are going to achieve them. providing specific details on these activities, which of course then will give us the opportunity to share that information with other state programs as well. and again, to describe barriers to success. not everything we try always works 100% and that is all part of the learning process and the lessons learned can be extremely

valuable as other state programs work to either model what has been done were take on that issue and modify it to their own uses. the template also provides examples of some successful programs things about reconfiguring reimbursement rates, which is not necessarily the same as increasing rates. reducing administrative barriers and showing some of the state examples where they've done except the that, and a chance to develop and improve collaboration and partnerships because state medicaid programs don't work in isolation, they work with all the other partners in a state that are also addressing oral health issues. as a, the technical support we are providing from cms to help address these goals and the state action plans, working with them specifically on their part to ships and collaborations' the

health coalition and the state where one does not to fix this. we have an opportunity for the partnership for alignment project, which i will go ahead and tell you has often been called the sand box project because we know people want to play well in the sandbox together. but not making light of it, this project is an effort the will put public health programs and state medicaid programs in partnership and collaboration to share the resources come to share the ideas come to share the ways they can improve access to oral help from children. we are working with the medicaid chipped state dental association on the best practices project, a formal process with criteria and degrading want to just recognize promising programs but going through a rigorous evaluation to decide what our best practices are for steve vindicate programs. and we are working with the

states to connect one state with another to share these successful models. i was asked to highlight one part of the affordable care act which talks about the demonstration project for alternative dental health care providers. part of section 5304 talks about community dental health ward leaders in the best practice hygienists. you can read the list. i don't need to go through it. we realize there are issues of access to dental health care in every state. there are parts of the population that have a difficult if not impossible time accessing dental care coming and we need to be looking at these various other models that many be useful in addressing these issues. with the affordable care act does this calls for demonstration projects where the different models will actually be proven in one way or the other. there are in the act lists of

eligible entities that include higher education, dental schools, health departments and such. and those specifically say the programs must be accredited by the commission accreditation which accredits all dental and dental hygiene programs in the country. so i appreciate the chance to talk a lot of these issues and what cms is doing to address them. please feel free to contact us anytime as you were a keeper of the national level or the state level as we work to improve oral health for children and yes, for adults and the elderly. thank you. >> now we are going to turn to dr. monica hebl from milwaukee and is the elective chair of the american dental association council on access prevention and professional relations. she's also past president of the wisconsin dental association and has been walter entire career in

extending access to dental service for under certain populations. thanks for being with us, dr. hebl. >> thank you very much for allowing me to address you this afternoon. towns you have already heard, oral health also takes a backseat to medical and a good or ill health as integral to overhaul health. i appreciate the time you are taking to learn about oral health issues. there will take a paradigm shift for oral health to gain the enough support from the massacres to achieve lasting improvement and optimal oral health for all. we are working hard to build momentum and increase the focus on oral health issues by partnering with groups and organizations involved in the oral health. you just heard a little bit of my background, that we would just like to put a little flavor, local flavor. i am a private practicing dentist, so this is an unusual experience for me.

a little nervous. i got involved in dentistry's a 14-year-old dental assistant and in my mentors office i still work in the same practice along with his son and my brother-in-law. in 2000 we moved from our location to the northwest side of the city and chose to remain on three bus lines so we could continue the mission to continue the legacy of taking care of those in need. we devote about a third of our time to medical assistance even though it is economically challenging. we also purchase of a and charity care programs. i've been involved in the industry since i graduated dental school, and i've worked tirelessly to improve access for pewter requires activity on multiple fronts. there is no silver bullet to

solving access. poverty, geography, lack of oral health education and transportation of language and cultural barriers, fear of dental care and the believe people with are not in pain to not seek care affect a person's ability to access care. you'll take a collaborative approach of all stakeholders to improve the nation's oral health. ada has programs and activities to address the issue. recently we made it a priority to collaborate with others and literature our activities for greater gainey and i'm going to highlight a few of these programs. the cdc named one of the ten most significant public health achievements of the past century. the cost savings in a decrease in disease deutsch a fluoride are significant. it's unfortunate we are spending so much time and energy fighting for such a public health measure. we worked with states and local

dental societies as well as pew as you will hear two if required information is available to those fighting for fluoride on local level. here's a map that shows you just how hot a topic is. 43 states have some type of activity in the life and is protecting it even a medicaid is chronically underfunded streamlining the administrative process of medicaid programs have achieved increased access for patients and participation by dentists. states that have successfully improved their medicaid programs usually have many stakeholders working together and by doing so the achieve greater gains in excess and cms is thankful for that. covered if efforts that included reimbursement, education, care that is ongoing instance of episodic and involves public-private partnerships yield the greatest results.

each state medicaid pergamus different and each state has different issues to solve. here are a few exceed those of reform that demonstrate gains and access, but i'm only going to highlight one deutsch a time constraint. michigan's healthy kids dental is a partnership between a state dental association and commercial dental plan. the streamline administration reimbursement is the same as the commercial plan. access for kids enrolled is approximately 70% for seven to 10-year-olds. in stark contrast to the counties where the kids dental program does not exist efforts to expand the program are under way. there are many volunteer programs that the member dentists are involved in throughout the year. we recognize volunteer programs are not an adequate health care system due to their episodic nature.

therefore, 2006, or give kids a smile effort changed from providing care on monday to establishing. ada is involved in professional activities because we realize the advantages of the expanding the number of health professionals capable of assessing oral health and the importance of linking the dental and medical homes in an effort to reach kids before they have the disease. there's increasing activity across the country and the utilization deutsch of the potential cost savings one successful program, again in michigan in calhoun county is modeled after habitat for humanity. dentists provide care free of charge to low-income individuals to perform community service. this has led to lower cost for hospitals in the area and it is a win-win for the community. at its essence oral health

education is prevention at the most effective level and has the greatest potential to yield the best results and improve oral health. it is proud to be a part of the partnership for healthy lives so one-of-a-kind national coalition has resulted in the launch this week of an ad council campaign with an oral health message. you will begin to see the messages encouraging flossing two minutes twice a day. the council has other messages you might remember smokey the bear and the crash test dummies. it is exciting that is an oral health message for the first time and we are excited to see the results. we are in the evaluation stage of the public to create a community dental of coordinator. this dental team member is a different approach modeled after community health workers. the goal of the team members to break down barriers for patient and provide a link between the

patient and the dentist. they will educate and help them navigate the system in addition to tasks like open them find a home, secure child care and arrange transportation. they will also be a will to provide limited preventive services rather than focus on treating disease. the cd8c is based on some of the ada's key principles of breaking down barriers to principle. education, disease prevention, and maximizing the existing system. in addition to the ada web site, we are launching a web site for the public. the url is mouthshealthy.org and i would like to think you for a loving me to be part of this panel, and we look forward to working together on initiatives moving forward. >> thanks very much, monaco. we are now going to go to julie

stitzel, who is a manager for the children's dental campaign of the pew center on the states where she focuses on work force issues. pumas you have heard in the references by the first two speakers directed a heavy amount of attention and issued several important reports including the state by state evaluation of how well their needs are being met and we are pleased to have truly representing the program today. >> as i mentioned and you've heard repeatedly, dental care is the single greatest health need among children in the u.s., five times more prevalent than asthma, and a lot of times when we are talking about health care reform, we are focused on medical and it's important focus on dental as well, so our research and advocacy efforts focus on the efficient cost-effective strategies.

one is insuring that medicaid and the children's health insurance program work better for kids and providers to make sure that insurance translates into care. second this community water. the third is increasing sealant programs for kids than the demo stand fourth is expanding the number of professionals who can provide high-quality dental care to low-income kids to read as i mentioned a lot of you might be familiar with our work we least two state reports that essentially used eight benchmarks to evaluate oral health access and if you haven't taken a look where you're state stands on a highly recommended. these are the grades from the most recent seeking coverage matter which you can find on the web site but a lot of folks in the roomy effectively use the reports as policy letters to increase oral health access in their states'. earlier this year they released a report on emergency room utilization for preventable dental conditions.

we examined a large sample of the emergency room data collected by a federal agency called the agency for health care research and quality. we then projected the national number of emergency room visits by identifying the specific hospital codes for dental problems that were considered to be presentable. unfortunately, the data is not available from all 50 states for two reasons. first, not all 50 states collect or mandates that the discharge their records but also, some states collect the data but they are not required to interpret it for a report it. succumb here is an example of our findings. you also i believe have a copy of this in the packet or it's on one of the tables, so i highly recommend taking it up. we found preventable dental condition is the primary diagnosis in more than 830,000 visits to the hospital emergency room nationwide in 2009 children

accounted for nearly 50,000 of those visits, and many of the visits remained by medicaid enrollees for the uninsured. so the states are paying a high price for is a member to the two sycophant number of children seeking care in hospital emergency rooms and they could have been prevented get treated more effectively. so, it's tragic about the scenario that the kind of care that folks are receiving can go in with a toothache generally won't provide lasting relief to beat you traditionally don't have a dentist in the er, and the response is either to subscribe pin medication or antibiotic and this isn't actually solving the problem, so it's the wrong care at the wrong place at the wrong time. the more than 830,000 visits to the emergency room represents

16% increase that's the bad news. the good news there is an opportunity to save money because these visits again are totally preventable. we know the getting treated in the emergency room is much more costly than the care delivered in the dental office and states are bearing a significant share of these through medicaid and other public programs. in florida dental related visits to the emergency room produced charges exceeding $88,000,000.2010 about one hour of three emergency trips paid by medicaid. in washington state dental problems are the leading reason for emergency room visits by people who were uninjured the coinsured. here are more examples from the report that showed the

essentially taxpayers and consumers are paying a high price for this care that is delivered in the emergency room. so why is this happening? it boils down to access. the current system isn't working for everyone and it's taken from the american dental association and while the census data shows roughly one-third of americans like access to care, dental care in the u.s. this is in line with what we are seeing in the day the so the logical next step is to get the safety net. the safety nets are not capacity and are only able to treat 10% of the third of the population that is left out of the system something else needs to happen. in addition many people lack dental insurance and even if that isn't a problem for you a lot of people have trouble

finding a dentist. currently more than 40 million americans live in an area that have the shortage of dentists. there is no silver bullet when you talk about increasing access to care it's a pretty complicated situation. a lot of states are taking a look at evaluating the existing make of the dental work force by talking of the allied providers. i don't know how many of you are new to the dental world, but when i first started i thought l.i. providers were one provider but it's a larger dr. hebl took of the coordinator and the therapy need in minnesota but there are multiple models that we are talking about when we say allied providers including the dental health therapist and the

hygiene practitioner across the u.s., so it begs the question why are we having this conversation now? in addition to the research showing this is increasing access to care we can't afford not to. while it's clear states are bearing the cost and the consequence of folks not having adequate access to care in certain circumstances it can be dire. people that are not new to the dental world are familiar with a tragedy with the driver in maryland but it's continuing to happen in my home state of ohio you recently had an unemployed dad passed away at 27 because he didn't have access to care. so this map is constantly

changing the states are talking about work force and states that have also used the providers alaska and minnesota and the green states represent states where pumas rich working from kellogg, the american dental association is working and states that have taken the initiative it's not an easy conversation to have come and i also appreciate the alliance. if you if like to keep up with information what we are living at the campaign please feel free to sign up for the dental news and my colleague that jacobs is right there and we are happy to share what we are doing. here's my contact information if you have additional questions after the briefing. thank you. >> thank you.

>> finally we hear from christy fogarty who is a licensed dental therapist on of the first to people in the nation to receive this recognition. she started as a dental assistant then became a licensed dental hygienist and last year she finished two years of training as an advanced dental therapist and received a master's degree as an oral health practitioner. she works for children's dental health services in minneapolis and some of you may have seen her featured in a recent documentary. we are pleased to have you here to tell about your experience. >> thank you so much for having me here to assure the project we have going on out there. i'm going to cover a few topics briefly and talk about yet advanced dental therapist and what we do in our testing and training, tell you where i work and the things we do in the demographics that i served.

and then a little bit about the financial model what you're seeing develop as i know they have been practicing for children providing a year. i'm also as was noted a licensed dental hygienist and a therapist those together the tool licensor served me well for the community. in talk about what is going on in the future and what we are looking at in minnesota. so i will talk to a little bit briefly about with a dental therapist is coming in at level practitioner and the best comparison has been made it much like anders practitioner in medicine but in dentistry. all i can do just about any kind of filling this i can do the extractions of primary teeth, beebee tecum i can do stainless steel crounse, root canal on a baby tooth and hemp nurse. in minnesota there are actually two types of their pasts, there's dental therapist said advanced dental therapist. according to the position they're required to have a bachelor's but many have a

master's and the university of minnesota is the only schoolteaching dental therapy. evidence to dental therapists are required by legislation to have a master's degree and metropolitan state university where i attended the school is the only school that teaches therapy and one of the pre-requisites is you are inexperienced hygienist. when i applied i had to have worked to thousand hours as the hygienist. yet 13 years of experience and i was in the middle of the level of experience we had the least amount of experience and one hygienist who had been a hygienist for 18 years. after i complete 2,000 hours which is a lot like a residency, i will become an advanced dental therapist. the board is currently trying to figure out exactly what they are going to do to test me when i hit that time in november of this year that i can do that lysander. the difference between the two is the supervision level. dental therapist have to be and

what we call direct supervision. it means the interest seems to be on the promise at all times while different procedures are being performed. once i become an advanced dental therapist i can call a general supervision meaning i can do everything within my scope of practice but i can do it without a dentist needing to be on site with me. that's a huge a vintage is officially when it comes to talking about working with mobile equipment in rural areas. you'll see later there are people that travel very far distances to see me and get access to dental care. if i can get to them and not have to have a dentist in the same building it will open up access to care significantly. one thing i do always like to make sure is people understand it is widely center that allows me to do a lot of things by of legislation, dental therapist and advanced therapists cannot do a simple cleaning. so i can do both which really helps. when you get population people are struggling to get access to dental care you certainly want to do as much as you possibly can. it is not uncommon for me to do

a stainless steel crown, clean their teeth, do sealants and applied fluoride. for the training and the testing that we go through, i went for 27 months and a master's program, metropolitan state and in my scope of practiced i actually brought a book here that talks about the 75 pages of the codes that a dentist is licensed to do and of the pages there are 6i can do as a dental therapist and advanced dental therapist and there are 3i can do as a hygienist so if you can imagine in 27 months for the exact scope of practice i am trained excellent, very highly of the same level as it and to stand by dentists side by side with dentists command of the testing that we are given is the same testing a dentist this and they do not know if it is a dentist that is taking the clinical exam. after i have received my messenger, i was able to get into a collaborative management

practice agreement. currently where i work and in collaboration with nine separate dentists. as i started out there's different levels of supervision they give me by statute the have to know what i'm doing. when they began the start by questioning some of my work. most of them and now just want to know what i'm doing. a little bit about us. we provide care to about 28,000 children and this year on track to about 30,000. we work with mobile equipment. you can see we are a head start based program at about to enter the sites statewide about 300 sites. sophos lardy of the care is actually not done at the headquarters located in northeast minneapolis the vast majority of the work is done on site in community centers, schools, and different types of permanent sites that we have established. you can see that we take anyone with any kind of insurance and we have a sliding fee schedule. basically we turn away no one.

we see children under the age -- children under the age of 21 from birth to 21 and pregnant women. we also work a lot of children with special needs. i see a lot of children with autism, wheelchair-bound, really the whole spectrum. and also that the headquarters we can provide quiet rooms where we can decrease the stimulus and help access those children who struggle not only to get care once they get care they struggle to be cooperative with the care. we also have surgeons that also do have dentists that do surgery hospital care. obviously i don't do that and we have a dentist that comes twice a month to root canal. a little bit about the academics that i served in since september 2011 i've seen about 900 patients. you can see the demographics. i always like to tell one little story because it kind of brings home x ackley why i do what i

do and why i believe so much we need to work on access to care. when i first started doing dental therapy, working in the clinic there was a 2-year-old little believe you can imagine he was in so much pain he had fallen to 94 and above his front teeth and she had spent the entire morning calling dental office being told again and again we don't take your insurance. we were the last call before she was going to take her son to the emergency room and all of you have heard it's expensive and it isn't conclusive. they would have given an antibiotic, pain medication and she had tried all morning session was tremendously grateful they were going to see her son. once they got them in the chair we worked with our determined the two needed to be extracted you can imagine a 2-year-old and on traffic experience it was awful for him not to mention he

hadn't slept and he was in pain. you can imagine how all of lot situation is. she was grateful we were able to get him out of pan and because i may hygienist and i think of preventive detention for a regular exams and make sure there is nothing else going on now that we've got him out of pain. a week later and in all way and i see this little boy, around the corner with a grand with a missing two in the front. he takes off by sprint as much as a 2-year-old can do and wraps himself around my legs. the mom comes up and saw all he can remember is that you're the lady that took the pain away. this is why do what i do and why i am so passionate about it. the mother was grateful for care, the child needed to care. it could have gone awful and instead he's on the right path to a good dental home. excuse me. i'm just a little bit to talk about the finances one of the

managers the was given a presentation to other clinics about the business aspect of the therapy she put this slide up and one person raised their hand and said okay that's great save about $1,200 a week in collaboration a reduced the number of dentists and office and it doesn't eliminate the need for a dentist zero. that's great but how do you get grant funding to pay her salary and how do you afford her? she was a little confused by the question because he hadn't put this out yet. and this light shows that i produce more than the majority of the dentists in the office and there's two reasons. i were to the headquarters which its b.c. all the time, and i have amazing collaborative dentists that let me work hard and complete a lot of work. i am fortunate because i'm not

disturbed by an advanced therapist acting to be doing exams because i'm not quite licensed to do that yet and i won't be able to until lamb and advanced therapist it can be very challenging and his group. that helps a lot. my boss likes to say this is an unfair slide because it shows you are the third highest producer but the reality is you shouldn't be compared to the dentist's because your scope of practices and 75 pages. granted they are probably the sixth most critical pages of the procedures that need to be done by the population. so, it's a very important set of pages the the of production because there are far more expensive than they can do. we did pull out the month of may this wasn't the only month in the this is the highest i've been. i generally set in a third come fourth or fifth every month and my numbers continue to rise

while i was the fifth highest producer in the month of july by productions went to $320 an hour so the question said you don't need a grant money you need to work in your practice in a proper way. so for the future i continue to work towards my 2,000 hours i expect to hit this year and what julie didn't mention in her slide she showed the greens are getting minnesota has been but it was actually an a- and i will be killed i become the first therapist she will reconsider that great. >> the other question i get asked it's important for people to know is what has acceptance been like. and i think god every day furriners practitioner because this becomes very easy to explain what a medical practitioner is and what it can be like and i had one parent say i prefer my child to see a dentist said the acceptance rate is high and you're talking about

population that is really needing dental care and it's great to have the care. it's a very in part a message to get out there that this is a great tool there is no one silver bullet. we need to solve access to dental care and what i am saying is dental therapy is a great range to use. >> thank you. >> thanks very much, christy to really get to this part of the pergamon you get to ask how our panelists, where you want to get out of this conversation. you have the opportunity to ask questions orally and you can take out a green card in your packet, write the question, hold it up and bring it forward and give a chance for that person to respond to.

i would invite dr. krol to join in the questioning. i wonder if while we are getting started i could ask dr. hebl about give kids a smile program the you were talking about, and the effort you described in 2006 to focus on continuity of care and establishment of a dental home. how do you do that in a voluntary situation? >> there are training opportunities and best practices so that programs that provide care on the one day and found ways to get dentists to accept the patient's ongoing it was the train the trainer kind of thing

and they're pretty generous, so if they build that relationship a lot of dentists are willing to take those kids on once they get to know the family. >> a question for julie. i was looking at the map that you were displacing about the impact of the emergency department. and i wonder if there is much of a variation from state to state among the states you were able to get the data. you have had 800,000 of these visits a year out of the total number of visits or something like 140 million, and some of these percentages are just stunning in that context.

>> we were only able to gather the data from 24 states. so it's not al 50 states, but i think the general takeaway is people are utilizing emergency rooms because they don't have access to care so it is an issue. >> david? >> a question for dr. mouden. with the medicaid expansion coming, what are the efforts to broaden the provision of the benefits especially for adults what do you see on the horizon? as we looked after the supreme court decision recently, we are still in the position where states can provide dental service for adults under medicaid or not. that hasn't changed. obviously we are still concerned with an underserved area a child

has dental service until they turn 21 and now we cut them loose. it doesn't matter the dental problems or need for dental care have gone away. but unfortunately we are still in a position where it is up to the states individually to decide whether or not they are going to provide adult dental service under medicaid, and with competing prairies and the state budget it's going to continue to be a concern. >> have there been any discussions about dental benefits and care? >> in my office there's been those discussions. [laughter] unfortunately as i get within a couple of years of that magic number is amazing when people turn 65 in this country we apparently no longer care about their oral health. i'm obviously being a little flat flippant about that. but seniors and their oral health is obviously a huge discussion for budget issues and i can only hope that maybe

medicare will catch up by the time i get there. islamic a question for christy and maybe even surely you can help out with this. can you talk up the process minnesota went through to get this legislation passed? >> the process actually facing it's like making sausage. you don't want to see it, you just want to see it passed. we had a lot of great advocates out there working hard making the best thing that minnesota did prior to going in the legislators and prior to presenting the case about why this is great to be such an important thing because if you look at julie's information, minnesota was the seat buy any means most in need of access to care. but we created a huge coalition of people. one of the biggest advocates we had was a pediatrician who said we are going to have to fix this because i'm seeing kids every

day with a toothache and we don't have any solution. the best thing we it is create a safety net ban of pediatricians and dentists and a broad spectrum of people from a broad background to come to the legislation to say we agree this is something we want to try and expand the work force this is how we want to do it and we want your support. but it's not an easy conversation to have because you have a lot of different perspectives coming to the table and it's important to take the time to understand where people were coming from and expect where they're coming from and try to build some sort of a consensus as you are moving forward so it's not just a policy win but you have an infrastructure to sustain that new policy coming and you have lasting change with respect to access. >> i can dovetail on that before the legislation was even prevented that it give it the metropolitan state university had an entire program approved

by minnesota comes to the education peace was already approved in the proper channel as soon as the legislation was passed i was in a classroom three weeks before the legislation was signed was ready to go. >> if i can just follow up on the general topic of how you get states to act, you folks did the state by state evaluations of children's dental health policy after the death of a driver the state made major improvements. they don't show up on the map here with respect to dental therapists, but what kind of things they do and how did that happen? >> with the state of maryland she might actually be able to talk about what they did, but i say they focused more -- let me touch on the bench marks.

dated benchmarks we use to agree that the states are a focus on prevention and wellness focused on work force in the theater is on medicaid reimbursement rates, so maryland tackled more of the prevention and reimbursement rates on maximus, not necessarily the work force lines, but i sure others in the crowd might be able to add to that discussion. >> a follow-up on the number of students. how many are enrolled in the metropolitan program and what is the pipeline? how do things look going forward? >> the first court that i was in our very small numbers. the second is about halfway through. my understanding from the university of minnesota and please do not quote me because i didn't go to school there, the first class was nine and the second i believe was seven, so

we are looking in the 20's number range in the next months working in minnesota. >> other than minnesota can they practice in any other state including alaska? >> we are not licensed. minnesota is the only one of his dental therapy as the state's get part of the dental practice act. in alaska it's a different situation. there's someone on the panel that can speak more authoritatively than me but i cannot practice in alaska or any other state. we have had several people move from other states to minnesota including one of the first who moved from florida because she was seeing problems with access to become part of the solution even though she couldn't go back to florida which is what she would have loved to have done to help in florida but we can't practice in any other state right now.

>> i have a question that sort of grows out of the presentation as we've heard and its ticket to dr. hebl what is the american dental association take on advanced and dental therapist like christy and are the and the ada's view providing appropriate care of the appropriate level? how do you feel that minnesota the coming in all for other states? >> i knew i was going to get this question. the ada believes that with the scarce resource available to improve access to oral health we believe a lot more can be done to fix the current delivery system. we have demonstration projects

all over the united states healthy kids in michigan is just one and there are other successful programs, so we really believe that the providers are there we just need to fix the system around them. we caution against the rush to create work force models that are allowed to perform irreversible procedures, especially in the scarce resources could be directed towards dentists providing the care. it seems a little upside-down to me to be having the sickest people to be treated by the highest trained. i don't think treating two-year-old with a dental abscess is a simple extraction, and in fact in preparation for this it just seems like i have been inundated with some difficult extraction's.

the hardest extraction i've had in the last two weeks a gentleman came in with swelling, and a woman that i took the tooth out that i thought was going to be simple extraction and had a bleeding emergency, and so i think we would like to see dentists be involved not cutting the hard and soft tissue and we think it can happen with the better system and all of us working together to make that happen instead of delude and the message and having it be on the issue. >> do we need more dentists as well? >> there are 20 new schools in the pipeline. when you look at christy's training, that's about six years of training, so i just think that it takes a long time coming

and i don't know that that necessarily is going to be an immediate health and we need help now so we should find ways to make it so that we can involve all the people that are already members of the team and use them to the fullest capacity we of dentists who are not busy right now. it is an economic issue and when you work in a subsidized system you can make things happen coming and we need to try to figure out how we can make the health care dollars for oral health work in the system that exists. islamic we have some folks that are standing in the microphones coming and we would ask them to keep their questions as brief as they possibly can, and to identify themselves. >> the institute of social medicine and community health.

i think dr. mouden mentioned that medicaid pays maybe 20% of the private pay rate. >> i was speaking from my personal experience practicing in misery almost 20 years ago that isn't a national data by any means. >> my question is how could medicaid as a federal agency allow the states to pay so much less than the private insurance market or the private pay market? the medicaid statute says that the medicaid programs are supposed to ensure equal access coming and that usually means paying a rate comparable to private pay, and so i am surprised states are allowed to pay less but i'm also curious what percentage of dentists

choose not to take medicaid patients. why is it is allowed also as a licensing issue, and other words, shouldn't states used their licensing authority to ensure that dentists are making their services available to the population in their area? >> i will give those a try because what you actually asked about or to state issues. there is something called sufficiency in the medicare program where access is to be basically equal to what is available in the private market. again, that is a state issue which is totally dependent on budget, and the second thing that you ask about is licensing. very much a state issue, and whether any health care provider be a dentist, physician, nurse or otherwise is required to take public assistance programs.

it is a discussion that i do not think i am allowed to have. >> don't feel constrained to the >> anyone else? yes. go ahead. >> i am the executive director of the association of commissions for the underserved. first, think you for a very informative panel. david krol and i have worked on this for a number of years and it's the first topic that we actually brought together people across the discipline to look at early childhood care prevention. my question is addressed to christy. what is the cost of the preparation for your advanced into a therapist, and what are the opportunities for state or federal loan prepayment in the future? >> that's actually a really good question and one that a little bit of a struggle in minnesota. but the answer to the first question as education becomes an advanced. the program i went to required that i already have a bachelor's

in dental hygiene. when we are talking about six years of education versus eight, we have an educated hygiene work force right now that can step in and 27 months so it's not another six years i just want to clarify that. but just a dental therapy program at the metropolitan state is about $70,000. i know that the dentist i worked with was about $350,000 in debt so we are among the most expensive trained. dentists and hygienists and therapists and expensive process to train. the second to answer to the question is all i was able to apply for some loan forgiveness. however, it is a national program and unqualified because i license hygienist. dingell therapists are not right now eligible for the program, so unless you are going through a program that starts in the foundation of hygiene coming joint be eligible for the

statewide or national right now. >> do we know anything about the total cost of the program as opposed to the cost the students are asked to bear in either case whether we are talking about dentists or any other professionals. >> i do not have those numbers, but i can get them. >> if we can get those we will make sure we post them on the web site. yes. >> my name is cody smith. my question is basic and i apologize most of you know the answer but i would like to know why is there a shortage and dentists in the country what are the factors in addressing that and why is the answer getting and wider than of recruiting people to become dentists? >> there is a distribution of

dentists in the area in the urban areas there are not enough dentists because you can't economically sustain a practice in those areas, so we need to find ways of loan forgiveness and incentives to get the dentists to be able to practice so they can sustain. we had a pediatric dentist that had to sell his practice to a hospital system because he couldn't compete wasn't a federally qualified health center and he doesn't get the subsidization from the government coming and he couldn't keep dentists employed. they would leave and go somewhere else. and so, i think that that's where i was talking about the system that we had with the dental schools opening. we have the capacity and be the boomers are not retiring like they were before the economy downturn. so, there are professionals and hygienists that are already on the ground that we could expand the scope of with the dewey and

utilize them to the full effect in defendant assistance. so we think the capacity is where they are located is the problem. >> i reiterate what i used my presentation that 40 million americans currently live in an area where they don't get access to a dentist. so, the research shows why all that is the fact and the reason why we believe dental therapy is a possible solution is because it does make economic sense and que released a source research in 2010 that produced an economic model that showed that adding this as the real data backs off at the tarnow is a theoretical model but christy is living proof that it actually does -- it doesn't affect the bottom line of the private practice. our model focused on private

practice. but our overall reason is because we believe it increases access to care and the third of the population is left out of the system. .. >> so there's rigorous research, um, that absolutely demonstrates that nondentists can deliver safely and effectively irreversible procedures.

um, and i've just, i've never seen a that shows anything contrary. i don't know if dr. hebl has some studies to share with us, but -- >> i guess my response would be that, um, whether we have christy jo out there or you have, you know, anybody, unless we get people navigated to those places and, um, teach them that they need to access ongoing prevention to stay healthy and that they need to brush and floss their own teeth, it doesn't -- it almost doesn't matter who's out there. so -- >> well, i completely agree that oral health literacy really, really needs to be improved and, you know, and i think, and, you know, that advanced therapists like christy jo and hygienists, they really do know when a patient needs to be referred to a dentist, because i don't think

anybody wanted to supplant the dentist. but because there aren't enough depptists, i -- dentists, i think we need to supplement the care that's provided by dentists. >> thank you. >> thank you. >> first of all, thank you very, very much, robert wood johnson, for organizing this session, dr. krol, and for all of the speakers. i'd like to change the direction of the discussion just a little bit. um, what my perception of what we're talking about is who gets to hold the drill to fill the holes that we could have prevented. and i think this is really so unfortunate. um, we know, and this has been stated by at least three of the speakers, we know how to prevent tooth decay, and that's basically the disease we're talking about. when floar rides are used appropriately, we can prevent carriage, for the most part, tooth decay, and yet we're focusing on who's going to hold the drill. and why aren't we sharing more

information about, to the general public, especially low income, people with low health literacy, they don't even know that this disease can be prevented. we have data in maryland that demonstrate clearly that low income, low educated don't know what fluoride is, how it works, that it prevents tooth decay, never heard of see hasn'ts. -- sealants. yet we haven't shared that information? so it seems to me where we should put focus is on trying to educate both health care providers, because they don't necessarily though the correct information either, as well as the general public. which brings to mind in a question for dr. hebl is on your slide, one slide what it said what the, um, new campaign is about -- and i think ada put in

several million into that as i recall -- it says tooth brushing two times a day for two minutes to prevent tooth decay. now, there is no evidence that brushing two times a day for two minutes will prevent tooth decay. you have to put fluoride on the toothbrush. and yet that word isn't even used in any of the documents that are online -- not online, that are available to the general public. this would be a major step ahead if you even used that word. thank you. >> sure. >> um, the ada was part of that huge coalition, and the group that does that ad council really does a lot of research and focus groups, and we kind of had to take a step back a little bit and take off our hats of wanting to try and control that message and trust them that they knew what they were doing in the

marketing world and that this was through their focus group research that this was an appropriate message to get at what you're talking about. so i agree, you know, that it seems like, oh, is this going to work? and, um, they do, um, a big part of this campaign is to measure the results. and so if it doesn't get results, it won't, it won't continue to happen. so it could be tweaked, and, um, the group, the marketing firm that does this is the same one that, um, did the messages of the little baby in a crib, up, for the e-trade. so they usually do put out some effective campaigns. o i'm hopeful that this is the first step and that we can get to the point that you're talking about. >> [inaudible] >> yeah. [laughter] >> a couple people now have talked about prevention, both

fluoridation and the see hasn'ts. sealants. where is that in a national policy sense? is it covered by any of the medicaid programs? do the private, um, insurance companies that we all rely on for the most part cover that service? um, where is there some opportunity for progress? >> well, i'll jump in for starters. obviously, medicaid is very supportive of dental sealant programs which is why application of at least one dental sealant is one of our oral health goals. we also, obviously, in states cover the provision of fluoride treatment including fluoride varnish and including fluoride varnish provided by nondentists, by physicians and nurses especially on toddlers. whether there's a national program on community water fluoridation, that we leaf up to

our -- leave up to our colleagues at the cdc, division of oral health, which have provided a considerable amount of funding to state programs to support water fluoridation, and i'm always very thankful to some of the private foundations that have also helped support community water fluoridation across the country. >> at pew we've, um, that's one of our areas of focus because we know that 74 million folks on the private water system do not have access to community water, or to community water fluoridation. so we are working to create a sort of national home base with the web site ilikemyteeth.org, i believe, i always get the org or the com mixed up. it provides a tool kit for folks who are interested in fighting either rollback attempts or increasing fluoridation in their water. but it's a tricky topic because the antis are somewhat effective in planting a fear factor which

you have to bend, combat with science, and you tend to lose people that way. so finding the right balance of communicating education, but also providing tactics so that people can effectively keep their water floar dated or get their water floar dated is a challenge. >> could i just add on that, you know, i'm over here. [laughter] i jump around. um, i recognize what you're saying, and i agree with that. um, here's a major problem. with all of the bottled water that's available including in here most people are not drinking tap water, and a large part of it is because they don't know that fluoride's in it, and it's good for them. so it seems to me we field major educational -- we need a major educational campaign about water fluoridation and get it from the tap. it doesn't do any good to have water in -- tap water and community water fluoridation if

it's not being consumed. you have got to drink it. you can't just wash the car with it. >> do you have anything there you'd like to get to? >> dr. mouden mentioned the focus on issues at a state level. is there a national oral health plan or a national strategy for oral health, and are there opportunities for groups like, coalitions like the u.s. national oral health alliance or other organizations to help push a national oral health agenda? >> be well, i'll jump -- well, i'll jump right in. there are the oral health coordinating committee, again, made up of the dental representatives from various federal agencies is in discussion now about what could be called a plan, but we tend to not use that word because there have been too many plans, and whether it's called a strategy or whatever, getting the different federal agencies to work together in a combined

effort to improve oral health and access to oral health care. beyond that, of course, we've had the healthy people goals now in our, what are we now, in our fourth iteration of healthy people plans? and we continue to see oral health as major focus in healthy people now, healthy people 2020, and we would, obviously, want everybody that is represented in this room and anybody else watching to take those seriously. they're not just pie in the sky, there are things that seriously can be done through various partnerships, federal, state and local. >> yes. we have a repeat offender here. >> i'm cokie smith from youth today again, just have a couple of follow-up questions. just based on, i guess, my previous question on why dental care is not readily available in certain low-income areas, um, i guess the question is then, does that mean that dental care is too expensive for most people, and then the question is, why?

because if we do have more dental therapists, for example, as part of the solution, from what i understand they can only address a few of the procedures, not the full spectrum of dental care. and so if there's a low-income person who needs more advanced care, that's still going to be very expensive. who then pays for that? how do they still get access to that more advanced care? and so, i guess, connected to that is a second question, what does the affordable care act doing to address dent l care? -- dent call care? can you speak to that? low-income people to have access to the full range of dental services, not just the small piece that dental therapists can provide. i understand that's an important part, but what is the bigger picture, how do we get care to everybody, the full spectrum of care? >> i'll take a small piece of that. under the affordable care act, we do have what are called essential health benefits that will be covered under the

various insurance entities whether it's the exchanges or private-pay insurance. it will be a basic package that does include dental benefits. >> i'll take another small stab at it. i think that's why prevention is so important, because this is a disease that doesn't have to happen. and so while there are people out there that need some expensive care, if we can change the perceptions and the home care and the attitudes and get people to go for preventive visits and ongoing care, we can get them healthy so their oral health care costs are much less. and then dentistry has always been an industry where there are out-of-pocket costs. it's been treated kind of as a discretionary income kind of thing, and that's why this downturn in the economy's been so tough on private practice, because people can put off going to the dentist, going to the eye

doctor. and the advantage of that is that there's transparency in the, um, cost of oral health care as opposed to medicine where there isn't a lot of transparency. and that's an advantage. and one thing that we don't think is being translated to the medical world as well. and so it's a complicated issue. you know, again, that's why so many people need to put their heads together to figure out how we're going to do this and how we're going to fund it fairly and effectively and make sure that the most appropriate person is treating the most appropriate patient. >> one more thing about the affordable care act, it appropriates 11, i think what is it, 11 billion for community health centers over a five-year period, so that's something specific that the affordable care act does. >> and mow the demonstrations that dr. mouden was talking about are included in the aca, but they're subject to appropriations as i understand

it. >> uh-huh. that's correct. authorized but not yet appropriated. >> okay. by the way, we're getting toward the end of our time with you, and i would ask that as you listen to this exchanges -- to the exchanges and questions and answers that you pull out the green evaluation form, make that the blue evaluation form, and fill it out so that we can try to respond to the kinds of topics and the kinds of speakers and the kinds of formats that you'd like to see in these briefings. >> can someone explain the difference between the dental therapists, the different types of dental therapists and -- which are limited to a state but expanded function dental assistants who seem to have some similar work scope but are widely used and accepted by

dentists and dental organizations? >> i can probably take a little bit of a stab at that. um, nationwide dental assistants, dental hygienists have different scopes of practice, and every state has their own dental practice act. and they can allow certain types of procedures to be done. for example, prior to being a dental therapist, i was what's called a restorative expanded functions dental hygienist, and assistants can do this as well in the state of minnesota where a dentist can go in, prep the tooth for a filling, and that i can come in and do the filling. what that does is allows the dental team to work more efficiently, see more patients and, hopefully, open up access to dental care. that's what it was designed for many minnesota. and -- in minnesota. and there are those types of allowances in lots of different states. not all states allow it, um, not all states require licensure. another thing that i also am is i'm a collaborative practice dental hygienist in addition to being a dental therapist which

means there are times i still actually work as a dental hygienist. i can place dental sealants, i can do a cleaning, i can do x-rays, things of that nature. those are all under that collaborative practice agreement that's allowed in the state of minnesota for dental hygienists to do. so that's what they're talking about, and it varies from state to state which is actually very appropriate way to do it because the state is best knowing what its needs are. >> yes, monica. >> so just, basically, the difference is the cutting of hard and soft tissue. a dental therapist can cut the tooth and do the surgical part of it, and a advanced, um, dental assistant just restoring it and doesn't cut the prep. >> i want to come back to the question of rates and compensation and a couple of questions that arose. one is for christy jo, looking

at the slide that you displayed showing you the third ranking producer in that practice. what's the mix of payers? are there any private insurance memberses in that list? >> we do have a small amount of, um, private-pay patients. there are some patients who just really enjoy our clinic because it's a great environment for kids, it's a close location to where they live. um, we also have a i wouldn't say a large number, but a thurm of people who kind of move out of the public and private system depending on employment, but the vast majority of patients i see are on some type of public assistance program, and we go all the way down to zero for patient responsibility depending on what their income is. >> and what percentage, that's probably too precise a question, how able are you to respond to the level of need for folks in vulnerable populations either without any coverage at all or coverage through medicaid?

>> you mean in my scope of practice? >> no, i mean in terms of the number of minnesotans who are in need of those kind of services. >> sure. i probably couldn't give you a percentage, but what i can tell you is like i said before, we have 300 off sites, and we go all over minnesota. i've been 60 miles south of my home working at a school for the deaf and the blind, we have people who go all the way up on the iron range, if you don't know how minnesota lays out, that's probably about 500 miles from our home where we can go into a community for three or four days, do exams, treatments, cleanings. we try to be consistent in getting there at least once a year so the people that don't have access in that community have something. it's more of a safety net. but we do have permanent dental homes in duluth and st. cloud. so one spot in southern minnesota, northern minnesota and, of course, the twin cities is in the southern part of the state. does that help answer your question a little bit?

>> yes. >> we try and go to the people because one of the biggest obstacles to accessing dental care is quite often getting to the dentist, so we try to go to them. >> we know somewhere there are 47 million people who aren't served by your kind of an agency or any other. >> correct. >> what about the national health service corps and the federal resources that flow from it? i suppose this is more a hrsa question than it is a cms question, but you must do some -- you mentioned your connection with your colleagues at hrsa. >> so i apparently said too much. [laughter] i, frankly, know very little about the national health service corps. i do know those scholarships are available, there is loan repayment available to those practitioners going to underserved areas, health professional shortage areas. i also know that there are literally hundreds of national health service corps sites still

looking for oral health providers. >> monica? >> actually, that vacancy number is, um, much lower than it was before the economic downturn. amazing what a recession will do for those kind of programs and getting people involved. um, one of the things that happens with that program is you don't find out if you get that, um, loan forgiveness until after the fact because they kind of put it in the hopper and shuffle it around and then spit out the loan forgiveness. and then also if you take the amount of the loan forgiveness and you would have a dentist providing the services, if you took the writeoff for the medicaid program, basically a wash. and so, you know, we always say in wisconsin we need meaningful loan forgiveness programs to make a difference. >> well, i think what we have

demonstrated today, if nothing else, is that this is a multifaceted area of inquiry. opportunities and challenges abound. and i think what you've heard today is a rich description of both the challenges and some potential options for dealing with those challenges. i want to thank our colleague at the robert wood johnson foundation, particularly dr. krol, for allowing us to get into a topic we don't get into often enough, you are absolutely right. want to thank you for showing up on a beautiful august day. um, and sticking with this discussion. and i want to ask you to join me in thanking our panel for an incredibly useful and basic discussion of a very complicated topic. [applause]

you can take the rest of august off. [laughter] >> in seven days the republican convention begins in tampa, florida, followed later by the democratic convention in charlotte, north carolina. watch live, gavel-to-gavel coverage on c-span, your front row seat to campaign 2012. up next, chris van hollen talks about vice presidential candidate paul ryan. then, a look at school efforts to help fight childhood obesity. and later, live coverage of a forum on how the enforcement of immigration laws is affecting families. now, the ranking member of the house budget committee, chris van hollen, talks about his colleague, committee chairman and vice presidential candidate paul ryan. congressman van hollen recently spoke at a politics and eggs breakfast in new hampshire. it's a regular stop for presidential candidates and their surrogates.

it took place in bedford and was organized by the new england council and the new hampshire institute of politics at saint anselm college. this is about an hour. [applause] >> well, thank you, jim, for that very warm introduction, and thank you for your leadership with the new england council, and thank all of you who are members of the new england council. it's great to participate in this tradition of politics and eggs, and i look forward to try and sign a couple more of those eggs as the morning goes on. i also want to thank, um, the new hampshire institute of politics for helping organize this effort. and i do want to recognize some of my former colleagues, one person who i had the privilege of working with, paul hodes, who is here this morning. thank you, paul, for all your service is and what you're continuing to do in various

different capacities. and, of course, mike harrington. mike, thank you for your leadership and past service to the country. larry zabar, thank you for helping pull this together, and to all of you, it really is a privilege to be up here in the granite state of new hampshire at what we all know is a pivotal moment in the presidential election and other elections that are taking place which presents a very clear choice for all of us. and i know from my own state of maryland and from my travels around the country including in new hampshire that the american people are fair and that they will examine the facts and that they will very clearly examine this choice. and i know new hampshire, given its unique role in the presidential selection process, takes those responsibilities very seriously. so i'm very privileged to be with you here this morning. now, i do believe that the

choice in the presidential election has come into much sharper focus since mitt romney, governor romney selected paul ryan as his running mate. and i should say at the outset, and larry sort of indicated this, jim indicated this, the, the personal relationship we have is a very good one. we get along well. we have, however, very, very deep and fundamental differences. on where we should go in this country. the good news is i believe that in the budget committee and on the floor of the house we've been able to express those differences in a civil manner, in a way that i think has sharpened the debate and elevated the debate and made the choices more clear. and i very much hope that as we head into the final days of this

election we will focus on those choices that are before us, focus on very deep policy differences. because i fundamentally believe that when you examine the ryan and now the ryan/romney plan, that you will discover that it is simply returning to a failed trickle-down economic strategy, a strategy that we tried during the bush administration which crashed against the hard wall of reality. because after those eight years we, in fact, had lost net private sector jobs and, of course, the deficit was skyrocketing. and if you look at the ryan/romney plan, it does provide these big tax breaks to folks at the very top on the theory that somehow the trickle-down effect will boost everybody and lift all boats. and that simply did not happen. so i don't know why we'd want to return to that approach. so let's just review the facts,

and i think it's important to sort of start at the beginning of the last four-year story. because we all know that the day the president was sworn in he inherited a huge financial and economic mess. there can be no disputing that fact. and let's just review some of the specifics. because we know at that time that the economy was in total freefall. over 800,000 americans were losing their jobs every month. the gdp was plummeting down toward great depression levels at a negative 8% gdp rate. that is spiraling downwards. if you compare americans' retirement savings from the fall of 2007 to the time president bush left office, their value had collapsed by one-third.

these are retirement savings, 401(k) plans. so that's what the president walked into, and i should say it's a very good thing that we did not take the advice of former president bush and paul ryan to privatize social security. because the reality is had we made that choice that they were strongly advocating, there would have been millions of americans who were put at total economic risk at the time of the collapse of the economy. and i'm glad we didn't roll the dice and take that chance with seniors at that time because millions of seniors rely entirely on social security, millions more have social security as their primary source of income. and yet when you had that collapse in the 401(k) side of the retirement system, that's all many people could have fallen back onto.

so if you were also rolling the dice with that, people would have been in great jeopardy. so that is the situation that the president inherited, and he acted very quickly, acted very quickly. in the face of that economic collapse, he worked with the congress, the democratic congress at the time, to pass the economic recovery bill. he worked with the congress to rescue the auto industry and american manufacturing. he took those steps immediately, and the results were good. now, we all know that we have a long way to go in the economy, but let's just review the results as determined by the nonpartisan congressional budget office. because on the budget committee, you know, we have lots of back and forth, but there is a referee. and the referee is the this agency called the congressional budget office. and they're called upon as

professionals to examine the information, examine the facts and make the best projections they can, in many cases, and best analyses they can. they have determined that as a result of the recovery act and the other actions that were taken we saved over three million jobs in this country. again, you're spiraling downwards, you enact the recovery bill, you begin to turn the corner, and you begin to move upwards, and we've now had 29, 29 consecutive months of positive private sector job growth. those retirement savings that took such a big hit have actually now come back and they're at a higher level than they were before the the big fall. so there's much more retirement security there for the american people. now, since elections are about choices it's important to ask the question, what was mitt romney proposing at that time? what was paul ryan doing?

what were the republicans suggesting? well, mitt romney said he thought there was an important government role in rescuing the financial sector. so when it came to the meltdown on wall street because of the financial collapse, he said, yeah, i think there's a role for government there. but when it came to rescuing main street and the auto industry and american manufacturing, he said, no. let 'em go bankrupt. so it's not that he doesn't see the government playing any role in times of emergency in the economy. he was all in to rescue wall street. but he was awol when it came time to help main street and american manufacturing. and you probably all remember when he was out in nevada where the housing prices plummeted through no fault of specific homeowners in nevada, and he rejected the idea of coming up with some kind of plan to help

creditworthy homeowners whose home prices had plummeted through no fault of their own, who were underwater on their mortgages through no fault of their own. he said just let it hit bottom. that was his answer. so, again, didn't want wall street to hit bottom, but auto industry, american manufacturing, homeowners who were underwater through no fault of their own, no government role there. what about the new vp candidate, paul ryan? well, it's been reported that three days before the president was inaugurated, before he was inaugurated, paul ryan with a group of what are called the young guns who now are the big leaders in the republican house leadership, they gathered in washington and decided to come up with plan on how they were going to work against the president. and as one of them said, their

land was essentially to oppose whatever the president proposed. this was before they even knew what the president was going to propose. that was their plan. and, of course, we all know the remark that was made by the republican leader in the united states senate, mitch mcconnell, who when asked what his top priority was said not jobs, not the economy, but defeating the president. so right from the start the president was facing a major effort to defeat him rather than focus with him on solving the problems that the country faced. so what happened? well, the first bill the president proposed was the lily ledbetter legislation. this is legislation to allow women who have been discriminated against based on pay in the work force have an opportunity to get justice. so every republican in the house

leadership voted against that. that was the first bill to the president, pretty straightforward, but voted against it. i think only three house republicans volted against it, but the whole house leadership voted against it, paul ryan voted against it, and next up was the recovery bill. not a single house republican voted for it. again, that playbook was what the president proposes we're going to oppose. now that, of course, didn't stop a lot of republican members of congress once the recovery bill was passed from asking for some of that help, recovery money, stimulus money to help boost jobs in their own states, in their own districts. and many of those have been widely reported on at the time. interestingly, just yesterday "the boston globe" had a story about how paul ryan had sent a letter to the department of energy in december 2009 asking for funds to help boost the

local economy in wisconsin. and, in fact, the letter said that it would help stimulate the local economy by creating new jobs. so, again, no votes for the recovery bill, hard ideological line against it, and yet republican members of congress recognized that it could help this their local economies. now, the president has been the first to recognize that we need to do a lot more to help put americans back the work. he understands that this recovery remains very fragile, and millions of americans are hurting. and he has proposed, he has proposed another major jobs initiative. he submitted that to the congress last september. includes a number of very important elements. one of the most important elements would be major, new investment in our nation's infrastructure.

in our roads, in our bridges, in our transit ways, in our ports. because if you look at the reports by the american society of civil engineers -- not a right-wing group, not a left-wing group -- they give the united states a grade of d, d when it comes to the state of our infrastructure. if we're going to compete with our international competitors, we need a 21st century infrastructure. on energy infrastructure, on other forms of the foundations that help move goods and services around the country and, of course, around the world. and the president proposed that, $50 billion. major initiative. he also proposed additional measures to help small businesses. that was this september. that was in september. we haven't had a vote in the house of representatives on the president's jobs initiative. we have now voted 37 times in the house of representatives to repeal obamacare, to repeal the affordable care act, but not a

single vote on the rest of the president's jobs initiative. now, last september the president also submitted a plan for long-term deficit reduction. because we have two big priorities. one is to nurture and boost the very fragile recovery that we remain in. and it's important to pass the jobs initiative to do that and to take other measures to accomplish that. one of the other measures the president, of course, has proposed is providing some confidence to the country by extending immediately tax relief for the vast majority of the american people, middle class taxpayers. 98% of the country, 97% of pass-through businesses. overwhelming number of the american people in small business. we need to do it now to provide that confidence. but we also need to be serious

about taking a credible plan and posture with respect to our long-term deficits. because our long-term growth is going to require that we get our deficits under control. and we should do it in a balanced way. because if we don't get our deficits under control, over time that additional spending, government spending will crowd out new private investment. so we've got to do that. and so the question is, how do you do that? and last september at the same time the president submitted his jobs initiative that hadn't had a vote, he also submitted his plan for long-term deficit reduction and, of course, he resubmitted that again in january as part of his budget. and it would reduce the deficit over the next ten years by $4 trillion. that was the target established by the bipartisan simpson-bowles commission. he does it in a balanced way. in fact, it includes $2.50 of spending cuts for every dollar

of additional revenue, a balanced approach. a shared responsibility approach. and can erskine bowles -- and erskine bowles, of course, one of the co-authors of the simpson-bowles report, recently penned a piece in "the washington post" that said the following, and i quote: in contrast to romney, the president -- like the gang of six and other like-minded members of both parties -- has embraced the central principle of simpson-bowles, that america will turn the corner on its debt only if republicans and democrats come together to support a balanced deficit reduction plan. that the president has embraced the central principle of simpson-bowles, that we need a balanced approach to deficit reduction. and anyone who's a true fiscal conservative, you know, old style fiscal conservative recognizes that we've got to get

our deficits under control over the long term, and if you're serious about it, you recognize that we've got to deal with both sides of the budget equation. spending and revenue. and that is, of course, the great failing of the romney/ryan approach. because the ryan budget, which has been embraced by governor romney -- he said it was a marvelous document, he said he would sign it if he's president -- takes a totally uncompromising, hard-edged, right-wing ideological approach to our economy and to our budgets. it doubles down on this notion that somehow tax breaks for folks at the very top will boost the economy, and it does so at the expense of everyone and everything else. so let's just unwind this a little bit. it would provide these big tax breaks, right?

again, the theory is that providing people like mitt romney another tax break, it will trickle down and boost up the economy. and as i said at the outset, we've tried this before. no longer a theory. we have the evidence, the results are in. at the end of the eight years of the bush administration, after tax cuts that disproportionately benefited folk at the very top, we actually had a net loss in private sector jobs. the only thing that went up was the deficit, and it went way up. so why in the world would we go back to a playbook that didn't help the economy and drove up the deficits? we know from the clinton years that a balanced approach to the economy and to the budget and to deficits can lead to huge job growth. 20 million jobs were created during the clinton administration after the 1993 clinton tax plan.

and the president's simply saying with respect to folks at the very top, we can no longer afford that. and, of course, republicans have taken a position they won't pass it now because they've got to hold the middle income taxpayers hostage until they can get tax breaks for the folks at the very top. when i thought they agreed that we had this long-term fiscal challenge that we had to deal with in a balanced way. so that's one problem. the economic theory has just been tested by reality and failed. but here's the thing i think will become really clear during this campaign to the american people. it's not just that the tax cuts for the wealthy don't work in terms of boosting the economy, it's that they come at a huge cost to the rest of the country. because if you're serious about deficit reduction over the long term, and all of us should be, if you ask nothing from the folks at the very top, if you subscribe to the grover norquist pledge as 98% of the house

republicans have, they signed that pledge, it says that not one penny of additional revenue can come from the wealthiest americans to help us as a country reduce our deficit. not one penny. well, the american people can do the math on this. if you say from the outset you're not going to ask for one penny from the wealthiest americans and you want to deal with the long-term budget deficits, everyone and everything else gets hit. so let's look at a couple of examples. let's start with middle class taxpayers. the tax policy center, which is an independent, nonpartisan body, recently did analysis of the romney tax plan. and they concluded that by providing these big tax cuts for the very wealthy, if you want to do that in a deficit-neutral manner, you're going to have to end up raising the tax burden on middle income taxpayers because

you're going to have to eliminate a lot of deductions that are in the tax code that do help middle income taxpayers; mortgage interest deduction, the current exemption for the costs of the health insurance that's provided by employers. all those deductions are at risk. and, therefore, the price to be paid for tax breaks for the folks at the very top, another round of them, if you want to do it in a deficit-neutral manner which is what they say they want to do because they say they're real fiscal conservatives, that means that other people are going to have to pay more through eliminating some of those important deductions that people rely on. so i can support tax reform, but i cannot support tax reform masquerading a as a trojan horse for just another round of tax breaks for the folks at the very top at the expense of everybody else. and i should say that earlier in

his campaign governor romney pointed to the tax policy center as an authoritative, independent source when they did analysis that worked in his favor. because they are an authoritative, independent source. it should be said that under the ryan road map tax plan mitt romney's tax rate would drop to below 1%. now, i can understand why governor romney likes that plan. but an independent analysis was just done the other day by roll call and others. it showed if you applied that version of the ryan plan to mitt romney's 2010 taxes, it would drop from 15% -- which, of course, is already a pretty low effective rate for someone at that income -- to under 1%. now, who picks up the tab for that if you're serious about reducing the deficit? everybody else. and so it will hit middle income taxpayers harder. we had an amendment the budget

committee democrats offered when this plan was put forward in the budget committee by paul ryan. it said, okay, let's test this. we had an amendment that said, okay, when you do tax reform, do not increase the burden on taxpayers under $250,000. they voted against it. because they know that's the fundamental implication of that plan. so who else does it hit? well, it hits our economy and our growth, and it hits the opportunities for more americans. because, again, if you're serious about deficit reduction and we all should be and you ask nothing from people at the very top, you're going to cut deeply into education funding, your going to cut deeply into research in science and innovative technologies, and you're going to cut deeply in our infrastructure. in fact, the ryan budget cuts deeply into infrastructure spending. it would dramatically under that budget plan reduce it next year. reduce it. not provide a bigger investment

as the president's called for, but actually cut it. and that's at a time that not only do we have unmet needs, but we have 14% unemployment in the construction industry. so if we're going to compete with our, you know, with china and india and everybody else in the world, we need a first class 21st century infrastructure. and it would cut deeply into that. training at community colleges, education for kids. that's a bad choice to make to get rid of those important investments, to allow everybody in this country to reach their full potential. and finally, and i just want to focus on this very important issue in the closing. it hits seniors very hard. it hits seniors very hard. seniors on medicare and people who rely on medicaid. now, there's no doubt that now and over the longer term we need to deal with the issues of rising health care costs.

rising health care costs are not unique to the medicare program. we have rising health care costs throughout our health care system. we spend 18% of our gross national product on health care, far more than any other industrialized country. so there's no doubt we need to deal with those rising costs. but there's a fundamental difference between the way the president has proposed to do it and the way democrats have proposed to do it and the way that governor romney and paul ryan have proposed to do it. so under the president's approach as we began in the affordable care act, what we say is we need to move the health care system -- especially in medicare -- away from a fee-for-service system that rewards the volume of care and the quantity of care over the value of care and the quality of care. we need to move the incentive structure away from that to

reduce costs in the health care system. let me give you an example. hospitals. when you have a patient that dose into the hospital -- goes into the hospital, the hospital gets paid by medicare, right? it should. they get paid. patient gets released from the hospital and develops complications from the same condition the patient originally went into the hospital for. readmitted into the hospital. the hospital gets paid again by medicare. the hospital has no financial incentive under the current system to coordinate the care for the patient once the patient's left the hospital. that doesn't make sense. so as part of the affordable care act, we changed that. we're moving to a payment for accountable care organizations to make sure that there are incentives to coordinate the care for the patient so that you avoid the extra costs from repeated hospital admissions. let me give you another example. you know, a lot of people don't

realize that medicare already has a private plan component. medicare part d. private health insurance. so it turns out that the medicare program was compensating the private insurance plans, medicare advantage plans, on average 114% of the fee-for-service plans. in other words, these private plans that were originally established to try and reduce costs in medicare actually increased costs in medicare. so one of the things we did was we began to eliminate those overpayments at excessive subsidies that was not only paid for by taxpayers, but by every medicare recipient who is in the fee-for-service plan because they pay higher premiums for those plans. so we said that doesn't make any sense at all, and we reduced those. and we used some of those savings to strengthen some benefits in medicare. the prescription drug doughnut

hole was closed so that seniors with very high prescription drug costs aren't left high and dry. we used that to encourage more preventive health care by eliminating the co-pays for preventive health care so more seniors would get early preventive care before they developed more chronic conditions that were higher cost. so those are the kind of things that we did to save money in medicare, and that's how we used some of the money to strengthen benefits in medicare. and i should point out i only have one, i may have two, but i'm near the end here, don't worry. i just want to point this out. here's what the medicare trustees -- this is really an important issue, and we should be talking about these issues. this is what the medicare trustees' report says. this is the nonpartisan, these are the guys of the trustees. quote: the financial outlook for the medicare program is substantially improved as a result of the changes in the ray ford bl -- affordable care

abouting. that's obamacare. substantially improved. again, because of some of the savings we talked about the dollars can go farther, and we use some of those dollars for the purpose of improving the benefits i talked about. so what's the romney/ryan approach? it's not to reduce overall health care costs. it's to simply transfer those rising health care costs from seniors on medicare, from the medicare program to seniors on medicare which is why the congressional budget office said under the earlier version of the ryan plan, ten years from now, seniors on medicare would pay $6,000 more for the same set of benefits. and the new plan which is amorphous, it is going to cost seniors more for the same reason. you're simply transferring costs off of the medicare program, not reducing costs and saving costs in an efficient way,

transferring them to seniors on medicare. at the same time your budget says we're going to provide these big tax breaks for the folks at the very top. now, the other point i want to make is that the health care plan for members of congress, members of congress are on the same health care plan as federal employees. provides protection for members of congress against rising health care costs because it's a fixed percentage. it's really premium support as opposed to a voucher plan. so as health care costs rise, members of congress can be assured that 72% of those costs will be covered by the health care plan. they are proposing a much worse deal for seniors on medicare than they have for themselves. a much worse deal. because under their plan, again, it's the way they save money is to delink, is to delink the

amount that seniors receive from the ped care program from the costs -- medicare program from the costs of medicare. and the result is, and i guarantee this will be my last chart, if you see this green line here, that represents the steady support, premium support members of congress get under their plan. about 72% covered by the federal employee health benefit plan. that red line is what happens to medicare recipients' support under their voucher plan. the amount that the senior citizen gets from medicare drops dramatically and, of course, that means either their costs go way up and it becomes unaffordable, or they get less coverage and less benefits. again, at the same time folks at the very top are getting the better deal. now, i'm going to -- i want to make one last point on this medicare issue before i close. you hear a lot about the fact that, oh, the republican plan doesn't touch seniors over 55 years old. that's not true.

and here's why. i mentioned that we used some of the savings by getting rid of the overpayments to the private insurance companies in medicare to close the prescription drug doughnut hole and to cover preventive health care services. the republican budget doesn't cover those things. it reopens the prescription drug doughnut hole. so if you're a senior on medicare with high prescription drug costs, you are going to be paying thousands of dollars more over the next ten years. thousands of dollars more than you would today. and if you used a lot of preventive health care services -- and we hope people will because that will save money in the long term -- it'll cost you more under the republican plan now, immediately. not ten years from now. so it costs you more immediately, and in ten years when the other plan goes in effect, that's when seniors get a much worse deal than members of congress. now, this is important because romney's out there running this ad saying that, you know, the

president and the democrats, you know, they cut medicare. i think i, hopefully, i've been clear that no benefits were touched. we did get rid of overpayments and subsidies to some of the private insurance companies that were being overpaid. it was a waste of taxpayers' dollars. the medicare trustees said that helps extend the life of the trust fund. and we used some of the savings to strengthen medicare benefits. and in the ryan budget, in the ryan budget they took all those savings. they wanted to pocket the savings we achieve from medicare reform in the affordable care act, but they didn't spend one penny on strengthen medicare benefits. they didn't close the prescription drug doughnut hole, which i said will reopen, they didn't improve the coverage for preventive care. they didn't do that. took the money and not that. and that's why you saw paul ryan on television last night getting all twisted up in knots.

because the total hypocrisy of their position is being exposed. because in the ryan budget they take all those savings that they're running ads against. only they didn't use any of that savings to strengthen medicare in their budget. we did. and they would take those away not ten years from now, but now. so this is a fundamental debate. again, the approach we've talked about is the trustees said reduces those health care costs by finding greater efficiencies in the system and changing the incentive structure. it's not just a question of rooting out waste. there is waste, and the obama administration's actually rooted out more than any of its predecessors. you've got to change those incentive systems that i was talking about, and we do that. and that way you can reduce costs without hurting the seniors. so let me -- i'm going to close now. i know i've gone on. there's been a lot of talk about how this is a brave and courageous budget, and i disagree. because i don't think it's brave or courageous at all. to provide another round of tax

breaks to very wealthy people at the expense of seniors on medicare, at the expense of investments in education and infrastructure and economic future. and at the expense of middle income taxpayers. and i don't think it's courageous at all to change the tax system to encourage offshoring more american jobs rather than creating more tax incentives to build jobs right here at home. and i don't think it's courageous to whack the medicaid program which millions of seniors rely on, two-thirds of which helps seniors in nursing homes and individuals with disabilities. and they really whacked that as well. i don't think that's brave or courageous. take on grover norquist. take the balanced approach that, as erskine bowles said, the president's approach takes. that's what we need to do. not the uncompromising, our way

or the highway approach that republicans are taking which will simply take us back to the beginning of the road of the eight years of the bush administration, and we know what happens at the end of that road. so this is going to be a huge election for the country. i appreciate your time and attention. i hope very much that this election will be about fundamental choices about the direction of the country, and i'm confident that if people get out and go door to door -- and new hampshire's known for that grassroots politicking -- that the american people will make the right choice and reelect president barack obama. thank you very much for your attention. [applause] i'm happy to take questions, yeah. >> i know we're running a little late, but we can take one or two questions. for the congressman. yes, sir.

do you just want to identify yourself when you ask your question? >> yeah, i'm bob dent, spokesperson, volunteer spokesperson for aarp. i'm glad you mentioned medicare toward the end here. everyone that i -- fortunately, i get around and meet many of our 230,000 members and other seniors, and seniors are concerned not about themselves, but what's going to be there for their children and grandchildren. now, what's -- what they tell me from my, the few audiences i have, they are concerned something on both sides. on your side would be they're concerned about what they read and hear about a $500 billion reduction in medicare, and now the other day that was bumped up to $700 billion. part of that would be, i gather from your talk, savings. is that right? >> that's absolutely correct. there are no changes in the benefits, and that's the great hopes that the romney campaign is trying to perpetrate on the american people. >> yeah. well, that's why i wanted an answer like that to make me look

smart before my audience. [laughter] so let me -- >> let me put an exclamation point under this. this is the great hoax, this is the great hoax that's being perpetrated by the campaign, the romney campaign. as i mentioned, we achieved medicare savings by doing things like eliminating the overpayments and excessive subsidies to some of the private insurance companies that operate under the medicare advantage plan. that's part d of medicare. and went then used some of those savings to strengthen medicare benefits including closing the prescription drug doughnut hole and providing improved access to preventive health services. so under the ryan budget they not only, first of all, take the savings -- because they recognize that those savings are important to medicare. after all, the trustees said that those savings substantially improve the strength of the program. they knew that. but they didn't want to recycle anything back. and now they're in, tying

themselves in a pretzel because they're running these totally misleading, hypocritical ads saying that the affordable care act cut medicare, suggesting that it cut benefits when it didn't cut any benefits and, in fact, as we have said again, increased benefits which the republicans now cut and not ten years from now, now. >> thank you very much. >> thank you. >> you're right on target on part c. why should we be subsidizing private insurance companies? that's part c. >> yeah. thank you for the clarification. i've been saying part d. part d is the prescription drug part, part c is medicare advantage, so if you could just substitute that where i said part d, and this is another thing about medicare. it is a complicated program. you have part a, part b, part c, part d. when people talk about the trust fund insolvency, that's part a. that's the hospital insurance fund. that's not the part b, physician coverage, that's not part c, medicare advantage -- although it's a component of that.

it's not part d. so these are complicated issues, and the romney campaign is taking advantage of the fact that it's complicated to confuse people. and that's shameful. >> victor dell vecchio from -- [inaudible] a few weeks ago a former commissioner of the irs testified before a congressional committee regarding the impact of the affordable care act on the irs. and, essentially -- and i don't claim to understand all of the details, i happened to look at his testimony -- he postulates that it places the irs in a somewhat unusual and unconventional role in terms of enforcement and policing, and he's not certain that they are really suited for this. whether you agree with that contention or not, um, i think we all agree that it's a 2,000-page bill, it's complex. are there ways that you can envisioning that the -- envision that the act might be made simpler, a little less complex, and what's the likelihood of

that occurring after the november election? >> well, the president has said that he's open to any constructive suggestions to improve the implementation of the affordable care act. he will, of course, strongly oppose any effort to take away affordable health care coverage for millions of americans which will fully kick in in 2014. the reason the irs is part of this program is because in order to make sure that people can afford health care, it provides tax credits based on your income so that when you go into these exchanges, these sort of shopping markets for health care insurance very much like what federal employees and members of congress have, when you go into those exchanges, you will qualify depending on your income for a tax credit which, of course, would be administered by the irs. the other part of the irs plays

a role is in the same way that the romney massachusetts plan does. and, again, this is going to be a very interesting debate between, you know, governor romney and the president of the united states because i think the president of the united states probably turn to governor romney and say you had a great idea up there in massachusetts, and if you go to the massachusetts web site for the program, you'll find that they also have their equivalent of the irs, um, managing this part of the program. because the fundamental idea, and this was an idea that i think everybody in this room knows was originally a republican idea. it was the republican counterpart to medicare for all or single-payer. and the idea was everybody will come into contact with the health care system at some point in time and, therefore, everyone should take some personal responsibility for the costs because otherwise everyone else's premiums go up, and everybody else's taxes go up for uncompensated care to hospitals. so let's try and have everybody take some responsibility.

for those who are needy, you would provide some tax credit to make it affordable, but you bring down the costs overall by creating this exchange. and those costs will, when they go o down, it'll also help bring down costs in medicare and other parts of the health care system. but, again, so the reason that the irs is in that position is, number one, to provide tax credits to make it more affordable and, secondly, in the same way that the romney plan in massachusetts, for those people who now can afford health care but decide that they're going to freeload on the system, on everybody else, there has to be some mechanism for some penalty. now, a very, as you've heard, a very mild penalty. in fact, a lot of people say it should have been stronger. but it's patterned after that design that mitt romney had in massachusetts, and just go to the web site and take a look at it. >> maybe just one last question. gentleman in the back.

>> tom maher, health care leadership council. i was just curious, do you think after the dust settles in this election, and there'll be a lot of dust i assume, do you think there will be an effort in congress to reform medicare for the long term that encompasses the sgr and some of the shortfalls that they do anticipate, you know, a decade or so down the road? >> so you raised a couple issues. one, of course, is the sgr which is the so-called doc fix. it's the rate at which doctors and medicare are reimbursed. and at the end of the year if congress doesn't act, doctors would face a significant cut, over 20% of their reimbursement. so we need to deal with in this. we've been dealing with this on an ad hoc basis in congress for a long time. we need to put that on a sustainable, long-term footing so, yes, i hope we will address that. second, we should build upon the ideas in the affordable care act in terms of reducing the costs

overall in the system. right now as we speak a lot of states as a result of the affordable care act are experimenting with improving the delivery of care to people who are in both the medicare and medicaid programs. there are about 10% of the overall population in both those programs, but it represents about 30% of the costs of the program, and there are misaligned incentives between medicaid and medicare for providers. so there are opportunities for some providers to game the system. so rather than take the, again, the romney/ryan approach which is to simply offload rising costs onto seniors or dramatically cut medicaid which, again, millions of seniors in nursing homes and with disabilities rely on and others, we should look for ways to eliminate those misaligned incentives. and there's much that can be

done there. and some is underway now, and we can, as i say, build upon those ideas. but, again, just a fundamental difference here is between a proposal that the president's put out which builds upon the affordable care act to reduce overall costs in the system without reducing benefits to seniors to the ryan/romney approach which simply shifts, it's simply a cost-shifting mechanism, offloading those costs onto the back of seniors who, by the way, have a median income of $23,000. a median income of a senior on medicare is $23,000. a good part of that $23,000 income comes from social security. for many seniors. so, again, i get back to the essential point of the totally unbalanced nature of the romney/ryan approach which is to give more tax breaks to people like mitt romney and leaving

everybody else to pick up the bill if we're serious about reducing the deficit. >> okay. well, thank you very much -- [applause] >> thank you. >> i think you can see why he was chosen by his colleagues to be the chair of the democratic campaign committee, because he articulates the positions of his party so well and so clear, and these are complex issues, needless to say. and these are not issues you can explain in 30 seconds. he's done a great deal of research, he's done a great deal of analysis, and, obviously, it shows in his presentation here today. we just hope that these issues continue to be discussed with the presidential candidates as well as the federal candidates and congressional candidates

throughout the country. these are very, very important issues. but i think you've got to feel pretty good that we have people like chris van hollen studying these issues, studying them very, very hard and trying to be objective as much as he can in trying to find some resolution also. so as "the washington post" says, he's a man to watch. we're going to watch him, and we want to thank him for being here in new hampshire and look forward to having him back here again. so we look forward to seeing all of you here. thank you very much. [applause] >> thank you for having me. >> really well done. >> hey, thank you. thanks for having me. [inaudible conversations] >> nice introduction. >> i work on 'em. >> i know, i can tell. >> i work on 'em. >> oh, yeah. when you got to middlesex, i knew you'd been doing your homework. [inaudible conversations]

[inaudible conversations] [inaudible conversations]

>> you did a really nice job this morning. we appreciate it. >> i just -- that's the problem, you know? in this sound bite world, it's really hard to -- [inaudible] >> thank you so much. >> thank you. [inaudible conversations] >> thank you for coming, terrific talk. >> thank you very much. >> thank you. >> so how are things going in -- [inaudible] >> not too bad. [inaudible conversations]

[inaudible conversations] [inaudible conversations] >> there are a lot of changes in the districts --

>> right. thank you very much. [inaudible conversations] >> help clearing things up, but i want to ask you, what do you think about -- [inaudible] is that your forte? is that where you -- >> well, no. under the -- [inaudible] you have a fee schedule. >> right. >> that is very thoroughly vetted. >> right. >> of course, in the private market these are -- [inaudible] >> they want to control -- [inaudible] wanted to control all the -- [inaudible] [inaudible conversations] >> so there's constant sort of back and forth. >> yes. >> insurance plan -- >> right. >> and physician. negotiations back and fort. what's interesting is in some

parts of the country you will have insurance policy plans that are very strong, virtual monopolies -- >> right, right. >> then you've got other areas -- [inaudible conversations] ..

[inaudible conversations] the likelihood of the automatic cuts there's a probability. >> i was thinking and might be a pressure on that report. >> we actually have a proposal in the house we put together a plan that makes a balanced approach to the deficit reduction. [inaudible conversations] they won't accept 1 penny from people even as willing as we

have been -- >> it's the probability. >> we have to see after the election. [inaudible conversations] thanks for coming. it's nice to see you. >> thank you triet i appreciate that. [inaudible conversations] >> so now he's going to have to answer it. [inaudible conversations]

>> thank you. >> did you get one? >> all right. he's got to go. >> all right. thank you very much. >> all right. >> i just want to mention real briefly my daughter is a friend of one of your staffers. the election of 2008 -- >> do you remember which staffer? >> [inaudible conversations] >> nice to see you. >> here we go. sure. it's nice to see you again. >> youtube. >> thanks for your time. it's very informative. >> yes, sir.

>> it's a serious group and the voters are serious, we just often deny them -- >> people have a tendency to simplify this to the point >> thank you. >> it's nice to meet you. >> that would be great. absolutely.

how schools can implement policies using the nutrition, exercise and other methods to help fight childhood obesity. you'll hear from a panel including a school chef, administrator and the president of the american beverage association. it was held this summer in washington, d.c. and hosted by the online magazine "the root." >> hello. we will be discussing today how schools can do a better job with helping our kids through nutrition, exercise, parental outrage and other strategies. we have assembled an excellent expert panel to walk us through some of the challenges we are dealing with and also please share best practices on that to serve as potential solutions. so, to my left, we have susan

neely, the president and chief executive officer of the american beverage association, the leading policy and public education advocate for the nonalcoholic beverage industry. and under her tenure at aba, they voluntarily reduced calorie beverages sold in schools baiji% through its national school beveridge guidelines. next we have chef in the childhood education center in philadelphia. in 2009, children's village eliminated all processed food from the menu and they serve fresh and seasonal food wherever possible. chef bell is honored as the national a jacket of the year by the american culinary federation. and next to her we've got daniel moody mills, director of education advocacy at the

national wildlife federation and she leads the federation's efforts to reverse the trend of the sedentary child through federal, environmental education campaigns which emphasize the importance of outdoor time as well as other aspects for healthy development in putting general physical fitness and unstructured play. and we have massy jones of d.c. which some murfs students with disabilities and has a comprehensive curriculum focused on health and wellness. so, from the school nutrition to the physical the education curriculum, the community support is the focus of this school. the experience in the education field is also included special-education coordinator and a dean of students and we are also joined by dr. fran meijer, an educator with broad experience as a teacher, administrator, researcher,

author and professional development specialist, a member of the board for governors for the american alliance for physical education, recreation and fans. she works with schools and organizations on policy and program development for coordinated schoolhouse programs and comprehensive arts education. so, welcome to the panel. [applause] >> i want to kick things off talking a little bit about schools nutrition. first we're talking about low-income children we know those who participate in school breakfast and lunch programs are getting the bulk of their meals every day in the school setting. and then we talk about all of the problems for the school lunches and we talk about pizza being counted as a vegetable or french fries and catch-up counted as nutritious items. i think it's important to also talk about the context under which a lot of school kitchens are working. after you are accounting for labor and transportation and

other costs, the average school has about 1 dollar some change for each meal. so i know chef bell at children's village you are mostly dealing with low-income students that are attending the pergamon skulls subsidies, so you are also dealing with a limited budget coming and yet you have managed to sort of overcome some of those challenges and have some amazing offerings. i just wanted to know what can school cooks and administrators due to stretch their dollars when they're faced with such a tight budget constraints and what are maybe some of the other challenges? it's not just budgets, it's also capacity sometimes, not having the equipment to serve fresh produce and things like that. so what are some of the strategies you have been able to utilize to overcome some of those things? >> i have a unique program.

i deal with fresh fruits, fresh vegetables and my coke. i don't buy processed foods like chicken nuggets and chicken fingers and frozen pizza. my kids still eat pizza but i use flatbread, i use fresh spinach and part of the low mushrooms and i make it interesting and i cleaver the food with natural herbs, not a lot of salt and sodium and all these other things and things i can't pronounce and know what it is. so very fortunate with that. and i have a local provider can call every day to bring me fresh fruits and vegetables. i call him every other day because he gets kind of tired of me. what ever is in season, i have him tell me if the food looks good, if it is right where ready. i don't have to keep mass amounts of fruits and vegetables

on hand and run the risk of them spoiling which would cost more money or not being able to utilize them. >> the cost for fresh fruits and vegetables -- >> they heard it when they heard from the shot from the white house under the impression it costs more to eat healthy, and it's really not. i make fresh suit. i would buy cases of soup with all those chemicals and sodium it is just as easy for me to make a pot of soup using fresh tomatoes and put fresh vegetables, and a lot of things, you know, the thing is they need the kids want to eat it. i hide a lot of things. i will pureed carrots and hyatt and the are getting all the vegetables and nutrition they need, but it also has to taste good. >> a want to ask another question of mr. jones. i know you're not directly in the kitchen preparing the food,

but as an administrator, you've got to be thinking about the challenges of how to get healthy meals to your students. >> actually i'm sort of envious of the kitchen that they have. we actually once upon a time had a kitchen in our school and it became a tedious process, something very difficult to keep up with the guidelines. we are part of the school lunch program coming and it has -- there are just so many limitations for a small school with limited funds, limited budgets, limited resources, the ability to move food to and from. so we have hired vendors in order to bring our food in, and it just takes away all the great things that i hear the chef talk about that we lose. the biggest thing, and i think this is the biggest problem i have with our kids eating and eating healthy is they have to enjoy the food. it has to be something that is

in our taste buds, and what i find is that the food is over processed sometimes undercooked, overcooked, and kids don't really enjoy it. i have a number of kids who choose not to eat because the food just doesn't have the taste. they all liked pizza, but only so often. that's the challenge we have is how to create a lunch program in which kids truly enjoy more than anything if it's good food to them they will take it and enjoy it and ask for science, so we are talking about just the taste of food, the limitations and providing extra portions if needed, because a lot of our kids that may be their meal for the day. >> following up on getting the kids to be excited about the food. i know that part of the program at your school is to sort of find ways to make people feel more connected to their health

beyond just walking into the school cafeteria every day. are there other ways that you are able to meet the students feel more interested in what they eat? >> as a part of our health and wellness challenge we do have a health and wellness program in the school. part of that challenge is to actually create an atmosphere in which kids want to eat vegetables, fruits and vegetables, and it's a part of the challenge that the kids have teams they work together on those teams, and they get points for eating fruits and vegetables. they also -- we also through our health and wellness challenge we have invited parents and families to purchase paid in, so families also can provide points through their eating of fruit and vegetables. it is an honor program, for the most part, the kids actually are taking to the challenge. one of the things we do have, we get pretty decent fruit and vegetables. and as a, it's now giving the kids the mindset that this is

good food. it's good for you. along with the exercise component that we have it's really showing, it's having a great impact on not just the students but the staff and the staff or part of the health and wellness program as well. >> okay. and for susan i know that the aba made a lot of changes to the drinks that were available in the schools such as taking away full calories sodas. i'm just kind of curious what kind of responses, if any, you've got from students. was it a meeting nor was it actually not that a dramatic of a transition to just give people different options and were they able to adjust? what was your experience? >> just to make sure everybody knows exactly what we did as part of the alliance for a healthy generation which was the sort of program that preceded mrs. obama's a very dynamic effort, we agreed that we change

the beverage mix in schools, and after talking to parents with kids in those schools, k-12, we found they wanted to things: one etcoff for little kids only limited choices. little kids meaning under 15. for those little kids, it is low-fat milk, 100% juice and water only. and then for the high school kids, parents said they can have more choices, but let's make sure we are pushing them to words moderating their calories. as we took out all calorie soft drinks and anything else that had calories and that it was less, we lowered the portion size. so you are either getting with calories in a smaller size, work you are picking a water for dalia beverage or low-calorie. so that's what we did. but the feedback, first of all, as a big consumer beverage company we are going to listen to the moms first because that's the gateway to the futures that's what the moms want, and we are glad to be aligned with

them in a policy that makes sense. in terms of the students, i think as the companies have been able to innovate and provide more choices -- so it's not just a diet soda or water or 100% juice, it's all the other things that are out there, powerade, sobe, life water, there's things that it tasted good and have low calories. that's what's worked with the students, so we think it is working pretty well. >> i want to go back to the related issues but another big chunk of the panel to talk about physical the education. and i want to get into that peace. we have seen around the country that kids are dropping physical education from their curriculum. it's usually tight for budget cuts when we are thinking about how your priorities for schools. sometimes it is going to be math or science programs, technology,

and it's seen as an easy cut. so, in that context everyone's asked dr. meyer if you work with schools on programming around physical the education and how you explain to schools and administrators at physical the education should be a priority for students. >> students can't learn if they don't have a good physical activity program. that is the basis for learning. the basis for brain development, for building synopsis or all of learning, physically education is critical. there are two books that belong in every professional development library right now, and that is one that is why charles -- i wrote this because i knew i would forget. "help your students are better lerner's."

the missing link in health and education reform and in the second is the one by the cdc, which is the association between physical activity, school based physical like to the education and academic performance. so, these books belong in every professional development library because these are all have taken hundreds of studies and analyze them according to what benefit they have to academic success. we have hundreds of studies that document the students learn better the more physical activity they have, the more time, the more intensity they have tortes physical activity, the higher the test scores and just better students in general, they of better discipline and the schools, there are -- they are demonstrating less stress levels as we talked of before. so, there are so many benefits

to physical education and physical activity that if people drop it, they are doing a total this service to advance the field of education. >> and mrs. moodie-mills, part of your were going into schools and promoting physical -- of physical the education in terms of a type of factor curriculum but it is a collectivity in some sort of ways, and i'm curious what kind of conversations or having it schools, what changes they are discussing with you about why they are not doing this and how you have been able to work around some of those. >> one of the major challenges that schools are facing is the fact that -- i mean, one, you cut down on physical education, kids don't have jam any more but they also don't have recess either. a lot of people don't realize that over 40% of the schools no longer have recess. i don't know about you, but i don't know if i could survive in school today because without recess -- recess was the thing i look forward to and needed my moment to be compressed.

kids don't have that. games like tag and a red rover. remember those? if you ask kids today exactly, i saw happy and -- if you ask the kids today with a look at recess they look at you like you have two heads. it's something that's really, really important. it's really important for kids to be able to have that time to be compressed. it helps that they are learning. it's not just about structured physical activity and having physical the education in the schools, which is another opportunity for them to be told what to do and how to do it, but it's also a recess in that time provides them the unstructured kind of been able to learn what it's like to put together a group and figure out and negotiate with one another and develop social skills that we are missing and now because we are all like this. all of the kids are like this down at the device speed and like sam said, screen time has gone up astronomically where kids are spending ten hours a

day -- and that doesn't include school time by the way, the ten hours a day on a device doesn't include time in school. as a, there's a lot that can be done. there are organizations like play work which teaches kids how to play, because now they have to learn how to play. >> how does this organization work? >> they have played coaches to go to schools and teach kids how to organize groups, how to organize a game and play, because they have lost the art of learning how to play, and i know that most of us now have learned that at school on the playground and there are those of us that don't even have the grounds any more or have areas, green areas to runaround coming and that is a tremendous problem. >> back to the more structured vigorous curriculum that

dr. meyer was espousing the benefits of just earlier. i think that another reason i would imagine that schools aren't really taking gym class seriously is because so often it's just kind of seen as a free period. it's kind of like -- especially in the high school age sitting on the bleachers talking to your girlfriend's coming in your not really doing a whole lot. so i just wanted to know what does an effective physical the education program look like and what sort of aspect should the require? >> being the educator. the cdc was the adolescent school health even though they've reorganized would be a school health programs they have developed a physical education curriculum analysis tool. this is excellent. every school needs this manual,

and its online also, and it explains exactly what a quality physical education program is, how do you access it and know what the children need at what level, and its preschool through 12th grade, and it explains -- it's everything in here and they have done a nice job, and i can't say enough. there's training available how people can use it, and i think administrators need this, not just the teachers in the classroom or the program supervisor. but administrators need this because many times administrators when they are observing the teachers they are not sure of what they should be observing. they don't know what is educational in the physical education curriculum, and so there are people -- and i hate to say it that led the program

fly because they know that there administrator doesn't know what is a quality education program. >> i will let you respond to that in the second. but we are talking about here is what you have to do. can you give a specific example of what an administration looks for, what is the education component. is it to be hyper competitive? let is it? >> it should be just like any curriculum should have learned not come, they should be accessible, they should have planned lessons consequential that are developmentally appropriate. it should have the lessons should be tied to the outcome and it should have all of those components. what type of delivery is the instructor using are the interactive or are they just

lectured? are they going over what are the rules of things? and this should be a lifelong learning the students are getting their curriculum. it shouldn't be a lot of competitive scores. it should be how are we developing that child mentally and emotionally, socially and intellectually address in all four of those components. >> mr. jones, can you describe i guess some of the applications you are doing at the school with regard to the physical and education. just to piggyback on some of the comments here the president that we had in public school was the fact that academically we are pushing to get we are constantly pushing our kids to go for standards are always increasing, and it seems it is a great idea

that we know where our country is ranking among other countries around the world. we are in a panic zone to compete on all levels. we've taken out the other aspects of learning that i once had. learning having a howe home ec plus weare as administrators we try to decide who will get jim this year -- gym this year and it's important because everyone can benefit from gym. the music program come stripped from schools because we are in such a panic mode to create a streamlined the individuals to create holistic individuals that grow into something and find something and be productive members of society. so that is one piece. where i am now, we decided to

create a health and wellness environment we wanted to focus on. we totally believe that a healthy person with activities i also remember the tv going off i felt pretty bad that i was one of the few that remembered that. but my students come to school with an npv player, their telephone, something connected to their years coming and if you don't force them to let go, they won't let go. so our focus was to force them to put those things down and interact because through those interactions a lot of the social skills, a lot of social skills start to bloom. kids start to mature in a faster rate where if you allow them to sit in the corner they will sit in the corner and just to now and tuneup the world. so what we have done is make sure that all of our students are physically active. we also included a free time for

our older kids you don't quit recess your tool to have a recess that free time coming and we also engage in different activities during that time as well. so, our focus is to keep kids active as much as we can. even within our lesson planning and in our curriculum from our curriculum and i encourage my teachers to make students moved. it's very difficult to just learn. get up and go, interact with the community, find things in the community to do. even if it is just a short walk around the block to engage in something just to keep the focus on. as a, my focus is on movement. >> to add to something in encouraging the kids to be active i'm also chaired by the local schools and we have local school health councils, building local councils within our school

system, too. and the teachers -- we are encouraging all the teachers especially at the elementary schools to have activity breaks and we call them brain breaks because it is to get the brain active and get this analysis going and to encourage more efficient learning they will be all to learn that much faster and be able to get the learning. so, we are using that activity break and encouraging and now at the middle and high school level. >> i want to touch on something mr. jones was talking about coming and that was talking about the community involvement and bringing sorts of ideas into the home. because for all of our efforts that we are making in schools, i mean, we don't just want to try them all in the reverse and then go home and go into their neighborhoods. is, i am curious what sort of efforts you are making so

schools can ensure those efforts don't go to waste once school is over. how are you involving parents? are you getting pushed back from the parents when you try to sort of employment these ideas about health, nutrition, physical fitness back at home and anyone can jump in the national wildlife federation has a program called eco schools usa in this international program promotes healthy schools from the inside out, it's about what kids are eating, it's about outdoor space and creating gardens where you can decide you learn about such doubles and then put them on their plate and it can be part of the curriculum it also encourages parents to get involved and to come and be

eco parents. when kids get excited about something they can't wait to share it with their parents. they can't wait to share it with their friends. that is a way to kind of bring parents and come is to have innovative, you know, wonderful food. what did you have for lunch today? they can say i had a piece of with part of velo mushrooms and we grow it in our garden in science class, just going outside and getting our hands dirty. and i think those are the type of things that we need more in schools because that will leap out into the community because parents will have these really excited kids that are -- that they want to keep that excitement. where did that come from? and you are actually talking to me. you are not testing this across the table, which i think is really important. >> when you are talking about the national wildlife federation eco schools program and all these efforts, i mean how the

schools get on board with this? do they come to you? >> they can sign up. it's a voluntary program. there are three -- there were like three flags you can either focus as a school on water quality, you can create a recycling program, you can create an outdoor garden and you just sign up, eco schools usa. you can find out more about it. >> nutrition obviously we talked about in the last panel talked about people maybe not knowing how to cook. if you have parents among about level when the kids leave your kitchen how are there ways you are finding to bridge that gap? >> first one to talk about incorporating the community. i worked out of the high schools with that and we do a lot of community based functions because it goes back to the

communities where they have different affairs my kids will go and cook. they will talk about nutrition. they do a lot of different things. at the other end of the spectrum, i teach parents at my child care center i have culinary class's for the parents because what happens is a lot of times the kids will go home and they won't eat the food the parents give. i want it like chef bell has it. quite apparent classism and it is always based on nutrition. how you can go home and make a meal for your child if you worked all day and you say i don't feel like cooking let's go to mcdonald's is an easier answer but it's not. they teach you how to make healthy desert, healthy food and a diverse group of people all, i have mothers and fathers go to

this cooking class and at the end i asked them to you have any suggestions you want to do for your next class and i had a pile of up to hear that it's always fun and i teach them also how to cook with their children to read a lot of times it's eaier because they put it on the plate they are part of that so that is the initiative that use and my program at children's village. >> i think we all would like to have you in our school somewhere. what i like that listening to the panel the way everyone is trying to do their part one of the things we have done naturally in response to mrs. obama to get the private sector involved which is designed to help moms, parents, consumers make the right choices

for them is to put a calorie label on the front of every kim, bottle and packed. so now, if you are picking out what your family is going to consume in terms of beverage it is very clear with 150 calories per serving, this has 10 calories per serving. so just another step to give parents and consumers information so they can make the choice that is right for them and to try to moderate your calories come take something with your calories. >> one of the things that has been difficult as getting parents involved in the schools and the schools in general in the programs they actually tell us they are working many jobs so they can put food on the table. we have been trying to do some things with you and educating them about those that do have computers at home that they can go on line and will get things right from the national pta.

they have a web site that has loads of activities of ideas about activities that parents can do with their kids and how to get them involved. and so, we have a wonderful -- in one of our schools it's an early childhood school, the parent -- when the kids are upset we of the nutritionist that goes into the home of the students that need that type of assistance to help them teach the parents of the kids need. so, there are some programs out there that are doing wonderful jobs. >> i have a question that is really not super specific in terms of programming which what about children and whether it is in schools or outside and especially in the wake of what has moved, we often talk about it in the framework of childhood obesity, and there has been pushed back around the discussion particularly with

kids because we are focusing so much on size and issues of shame to wonder what are your thoughts on how we should be discussing health and child to obesity with kids and do you think focusing on obesity is probably not the way to go for me -- may be given the reality of the situation is it something to confront head-on? should we be talking about these that are not making it about something that i guess they're self-conscious about his political the physical the education program they should be working on this for every child is looking at how are you personally -- helping to educate them about what their body should be able to do at what age level, and helping them set their own personal goals and how to reach those personal goals,

and if they have a good program and should be included. >> they should make it fun. fitness should be fun. a week, again, we used to play and that was a marrec devotee. i remember the first lady said recently it used to be called play. you just played. you wrote your bike and ran around with your friends. i think that focusing on obesity does bring up a lot. they are putting bmi on your report cards, body mass index on the report card and they are doing that because they say that they are trying to do it in a way that will help schools and help kids regulate their health, of the that the same time it's like do we really need that number on their? does the kid really need to know that? may be as an adult, yes of course, pay attention to you, go to your doctor.

but i think that we need to make some movement fun. we need to tell our kids to put down the device. the tv doesn't go up any more so it is our responsibility as parents and caregivers to turn it off and to say, to have a green hour. we have a green hour we're using we are going to do this old school. we are going to turn off the device is and the computer, and you're going to go outside or we are just going to sit and have a conversation face-to-face. you know, not a device to device. focussing on the fun instead of the detriment would be the way to deliver the message of health to kids. >> can you hear me? it's kind of hard in today's society with so much information and the media being available to sort of separate the conversation know on obesity and

size, fitness, things of that nature. one of the things i think we are overwhelmed with how much it misinformation there is on television or even online there's always a vision of a perfect person trying to get even more perfect. and the images that our kids in the panel prior to us there was this discussion of expectations and stereotypes and how we find those things and not just of the conversational health and wellness. one of the things that on a deal with all the time and every time i get on an airplane i realize i need to get to the gym. and those -- i have those moments throughout the day coming and i think if we force people to come to the realization that things in our society are not necessarily working on our best behalf it's

because there is a mcdonald's on every corner doesn't mean that it's the right thing to do all the time. there are a number of things that seem the images we get to our kids are not always positive images. we should work to really control what are some of the things we are feeding our kids, like curves are not meant to be over curved. so, and the health aspect of that. so, it's something that we all deal with. i have my own challenges and so, you know, as a part of what i do i make sure every day before my kids change into my workout clothes so when i leave the going to work out and hopefully encourage someone to take up that same type of activity throughout the day. so it's a holistic view i think

we have to take culturally. how do we raise our kids in a generation where so much is available. as a child wasn't an option to leave the house because if we stayed around there was work to do. so we left the house because you didn't want to do all that work. whereas there is so much now to keep you glued to the television and keep you glued to computer screening or some type of device and sitting in a chair. so, it's just i think the way we have to look at a society has to look at the change. >> i think that healthy eating is very important. you know, you could do the work out as important, but if they buy chips afterwards it kind of tells the workout situation. i think that we need to address healthy eating. like i said, in a unique position because i work with children as young as 18 months all the way to 12-years-old. so they are eating hummus and

zucchini at an early age. teach them how to eat healthy so by the time they get to high school and things of that nature the have already had a pattern. they've already been introduced to a lot of things they may normally not be introduced. and because i work with such a diverse population, and a lot of it is asian, introducing them to different foods as well, introducing the rest of the population but by choice and some other foods they wouldn't possibly be exposed to. so, for me i just think that it starts with healthy eating and then we can address the obesity. kids carry around a lot of luggage and baggage and when you add them on to it, i mean, come on. when we talk about the stress earlier, even on the me sometimes overweight expert that's stressful. we focus a lot on healthy eating

it helps on the road for the obesity. we can cut it off. >> thank you. i wanted to open up to audience questions. if we have any questions in the audience this microphones going around. one up here. >> a question for the chef. i know we do a lot of work in the organization that works for d.c. ponder solutions with schools and school meals and the quality of the meals that are served and one of the things we have run into with the other food service workers is they say okay i understand the meals are changing. we have to put this out but then i have kids asking me questions why are my character sticks with miti's or white you switch this? why it we have to have this deal and said? sometimes they don't know how to answer those questions. so i guess i was wondering what suggestions you have to educate other food service workers about how they can be proud of the product they're putting out, the food they might not have had the

ability to prepare fresh but still, understanding some of the nutrition guidelines and being proud of the vegetables and the changes that are being made. >> well, i also have to cook for bolten three children. i have a lot of what they call a lot of different types either a larger to tomatoes or this peery is the question comes why does this look like this or like that? you have to explain to the children sometimes it's, you know, it's fresh. it's different. it's not frozen, it's more healthy for you coming and the flavor. the important thing is i use a lot of herbs to flavor the food. you have to make them want it. it's okay to ask the questions. the question is how come you're eating black beans instead of red beans and what is the difference between the flavor? then i give the question back to them and i say you tell me.

you tell me what you taste. what do you think is the difference? that's how i usually deal with those problems. i let them start, you know, i ask them questions and make them think and taste. i like to taste tests. tell me the difference. so, tell me what i added. try to develop their talent. a lot of times they don't know what it is. that's honey and there's different kind of honey. i give them a lot of inspiration, and a lot of times i think they are not and because i do a four week cycle of food i do for each season because i like to deal with seasonal vegetables and then i might come back the following three months and say how, they don't have this? i like that honey and its lavender. the parents say where do you get lavender honey? i always try to include the children as well as the parents and make it a full circle. everybody loves to be involved. he would be surprised how much

information or how much they want to give back to you to let you know what they are eating. >> another question. >> i think that will work. >> [inaudible] from the dialogue on the school days is the educator awareness, teachers, principals, staffed wellness and we talk about the correlation between stress and health. you know, there's standardized testing, a teacher evaluation system so all of these are adding to the challenge of students, and teacher stress trickles down to student wellness also and student achievement. so i'm wondering how we can elevate this to the district leaders and state education, the

federal you the start of education. how can we elevate this issue of teacher and educator awareness and how important it is. >> i'm a former teacher as well and i would say it means to be part of the professional development over the summer all the time and it usually is based on the curriculum around with the kids are going to learn. but it doesn't include wellness and how to have a healthy classroom and one different types of activities and bricks and all these different things that you can do to encourage productivity without doing if the drill and kill all day long. so, i think that it really needs to be a part of professional development for all teachers wellness and health and movement need to be a part of learning. ischemic there is also the center for disease control that has developed what they call the school health index, a self

assessment and planning guide. and this has a component about employee wellness. and that really -- when the school system implement that assessment system, they really get the data that they can show to the central office staff that our teachers are not doing so well. they really want help and these are the issues they need help with, and in our system it was already doing a pretty good job, but it helps to make it more evident that more needed to be done. and there was one of the issues that came from every school that the employee wellness needed addressing more than the other issues did. so that is a huge issue. i'm curious how you are addressing that. >> we always talk about we

recognize around thanksgiving and christmas that we have a few teachers that are beginning to check out because of the high levels of stress, and it's not unusual for a few seats in the professional development because some have simply decided it is too much. i think it has to be a national approach. one of the things we haven't looked at as no child left behind really just is too narrow and the holistic peace looking at it from every angle and every aspect and given every opportunity to succeed, a lot of that has been taken away, and it seems like we are focusing on giving every child a chance. but we have taken a lot of opportunities away. it's important to have a healthy child. a child that get enough sleep, who has inappropriate amount of food to eat and the right food to eat it comes to school with

the right frame of mind to recognize that this is something that is a place of refuge and they will get something out of it. you know, home economics was a big class when i was in school. was huge because everything i learned about running a household that i use today i learned in school. kids don't have that opportunity anymore. so, what i believe is the focus has to be a national focus on everything on holistic child. not just about longer school hours, but about how to serve and how to help the entire childhood, how to get into the communities and provide some resources and some hope to distress in the communities so it is a holistic approach. as much the academic data. i firmly believe if we serve the academic peace will take care of itself. we are looking at it from another perspective where we are

creating a bigger divide in those that can and those that cannot. >> i'm just curious as apparent where you think we are in the broad economic community originator community assessing that as the objective, you know, looking at the whole child. because we have been through a decade or more of academic standards, and i just wonder where we are embracing the point that you just need. >> i think sometimes my purse all believe is probably counter intuitive to i don't believe we are headed in the right direction. i think our focus was trying to compete in a global community that has surpassed us in other areas, and the focus is not -- we are going to race to the top

how do we make sure that our communities are safe and our kids are healthy? what is important? and this to me is a political conversation because, you know, what about the work force. how do we have people who can be gainfully employed? right now i believe we are in a position we are saying it is all or nothing. and in net, we create stress and you look a lot of major cities there is a 50% dropout rate. kids are not engaging and they are turning to behavior's that are on productive. even in the conversation about health and wellness if he can at least it's not about exercise. it's about a holistic person either we eat the right food and getting enough sleep or we are

putting more appropriate things in our body, and we as a society facilitate that for our kids and i would say now we wouldn't facilitate. there's not enough being done to serve, and in those areas in d.c. we have a few schools that have this holistic approach, but a lot of that stops at 4 p.m.. our kids have to survive that. there are a number of issues. >> there are organizations that are focusing on this now come and ascd which i mentioned earlier has a whole initiative on the child, and this is now the tenth year of the initiative that started out slowly and it's gaining momentum, and i think it is gaining momentum and understanding, and so i think

the more partners they bring on to it because several organizations that i'm involved amaral also partners to hold child and that has been my career is focusing on the whole child. my life is built around that, and so when ascd accepted that as one of the position statements then a major initiative i was very happy to increase. so there are initiatives out there to help people to understand this, and we just need more people going into the website understanding what's their and then joining into the partnership. >> okay. i have a few more questions but i want to see if we have more audience questions. we've got one right there. >> my name is angela and ayman

internet the u.s. department. as a college student, college students are always busy with homework, schools, then they've got to go to work and after that may have an internship or something they are always on the go, and obviously they are spending a lot of time not sleeping and stuff so they rely on the energy drinks and all these things and shots. do you think those energy drinks should be banned from the campuses? >> that's a good question. i would say energy drinks are not sold in schools so when you are talking about, you know, k-12 with sold in the vending machines on the press they are not available. you know, as you move into over 21, there is a lot of personal decision. in my day we were taking no doze

to stay at and study so it is a different question when you are getting into the adult population. i will tell you that a mainstream energy drink 16 ounces has two-thirds the amount of caffeine as a cup of coffee from one of the popular coffee houses we might mention of the same size. so it's -- i think for the adult market i would argue that there could be more choices and people make their decisions with full knowledge and they should know how much caffeine is in there and what affect it is going to have on them and college students as adults choosing whichever they choose. i believe they have that right. >> no matter what age the brain needs rest and sleep to function, so we think we are doing a good job and we're doing things just like last night i

was working and i wanted to get something done before i went to bed, and i realized my brain isn't functioning well. i have to sleep so then i got up and i did what i needed to do before coming here this morning. the brain needs rest and sleep. >> all energy drinks do is bring your sugar level up and then bring you the worst crash ever. i remember being in college and drinking red bull like it was water and this crash that it gives you is disastrous worse than the tired that you felt before. take a break, go for a walk, allow yourself to recharge naturally. i don't believe in banning anything for adults because it is your choice. ..