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>> despite her health problems she traveled as first lady even attending the pan-american exposition in 1901 where her husband was assassinated. we will look at her life as we conclude the first season of first ladies live tonight at 9:00 eastern. also c-span radio and c-span.org. >> general odierno said preventing sexual assaults in the military is his top priority coming at the sixth annual sexual harassment and assault prevention summit

known as sharp held in maryland. this is 10 minutes. >> good morning everybody. how are we doing? first-come it is good to see everybody here. i want to welcome every betty that is here today. it is a very important conference that we have once a year in i think it is important to have a discussion to talk through this with our leaders not commanders but leaders of other responsibilities as a leader. he might not have commander after your name but because of who you are, what you do we have to set the tone. for our civilian leaders as well. to make sure we're doing what is right.

because of many factors, i believe as you have heard me say in the public we have a huge issue. the main thing i want people to understand is this is not just a passing issue. for whatever reason this is one we have had for a very long time and we have not been able to defeat it. that is a term we are familiar with. we have not been successful in solving this problem. the issue becomes as women take on a greater role in the army, it becomes even more important that we ensure they have the environment they can excel. this is about creating a climate where everyone can excel. i realize men are sexually assaulted. i realize it is about

creating an environment where we do not tolerate sexual assault. but i will tell you i'm from the things i see, we saw the people out there who tolerate sexual assault or harassment. and until we solve that problem, it will get worse. so if i go around to everyone now here you will tell me i got it. no problem. i am understand. but lately we have been out to some units with the major and although we get it at this level further down mayor not there yet. the key and answer is i don't have a problem here. there is no problem in my platoon, at company, a battalion. that is baloney. that is the problem. we're not seeing ourselves.

thiamine and all male unit. i don't have a problem. that is not right. no. you probably have perpetrators. you probably have some creditors. and you probably have some males who have probably been sexually assaulted or harassed. so this is not about item have a problem because saddam has females in my unit. this is about getting down to start jicamas sgt first-class, lieutenant, a captain, and major, lieutenant-colonel where they take this on seriously. because we're not doing that today. the way i want us to do. we were talking earlier we have the i ed every soldier knows what to do. they have a battle drill.

they know how to react and once we started to figure out we have one in the war then may would go to the left to do all of this analysis how we can stop it from exploding so it doesn't kill or maim the soldiers. guess what? sexual harassment and assault is meaning our soldiers. we have to have the same thoughts. result needs to understand what is their role or battle drill to present this? -- prevent this? what do they do to the left of the incident or when it occurs? what you do after the incident ochers? so we put in military terms we have no problem. we can do with the. we understand but we have to understand better what it is here. and we have to do the same type of things.

so i want to go over the five imperatives that i have put out to make sure everybody understands. first, protect victims and prevent all offenders provide care, rights and privacy of the survivors. number one. number two, professionally investigate and seek appropriate action. number three, creates a inappropriate command where trust and respect to the cornerstones of what that command climate is about. that all of the soldiers the trust, actions will be taken appropriately by the chain of command. we have an attitude of respect for each other to wear this uniform. that is who we are.

then is who we are supposed to be. respect each other. we need trust. i talk about this all the time. it is critical to everything we do. the things we're asked to do require trust. the ultimate trust. the trust you believe and anybody that wears the uniform. you have to be there to save each other's lives under chaotic conditions, but if we cannot solve this problem would you trust this uniform? a few think he would be retaliated on if you make a complete? you don't think the chain of command will react properly it is he said/she said so forget it? it does not trust. that is not trust. that is what we have to work

on. number four, hold individuals, units, and commanders and leaders accountable. >> [inaudible] >> this is imperative of the chain of command accountable for what goes on. there is one thing that we all have to think about is how do we see ourselves? what is the system we have in place that allows us come i mean see our unit, directors unit, directors, formations, organizations, whatever it might be. how do we see ourselves? there are a lot of ways to do. demand climate surveys for i have dictated those.

every six months than 12 months after. that is one way. walking around for kiev to figure out the best way for you but you better have a system in place to see yourself. it is not just about sexual assault or harassment but that is what i am focused on right now. but how did you see yourself? as a look back when i was a commander or battalion i bet i did not see myself. you have to make sure you see yourself. not just based on statistics are what you get from the chain of command all the time. go outside from the command change. when i was in iraq i believe in the chain of command but

i also saw with my own eyes. every day. every day i went out to go see what was going on. get feedback from the chain of command but make my own assessments talking to everybody i could to make the right decision. it is no different. this is no different. i ask everyone to make sure you have a system to do that. this is ultimately about leadership. no different than any other problem. a requires leadership. it requires setting the tone. we set the tone. you know, that. when the commander or director or the leader of an organization comes then that organization reflects that. and if you we're doing the right thing they will do the right thing. if you hold people accountable, to make sure

they understand how important this is, they will get it. if you don't, they want to. they both realize it is not important to you. i will be here for the whole two days of this conference because this is important to me. this is important to me. i want to make sure everybody understands that. as igor around we will have discussions about this as i travel around the army because it is important to me. my number one priority i am not kidding. i am not kidding. this is about the health and welfare of our sons and daughters, american citizens. how many people have sons and daughters? you should understand that.

you should understand that. do want an organization to take care of your son and daughter when we turn them over to that organization or command? that is up to us. make sure we do that. that is up to us to make sure we do that. i want them to be proud of sending their sons and daughters into the army. that is what it should be. it is a great opportunity. we know it gives to people people of all races, colors races, colors, religion, a financial background, the opportunity to succeed. we all know that. it is up to us to make sure we know that and sustain that. that we don't get it after this one may start to have problems. i want to make sure that you

understand that. >> on tuesday defense secretary hegel m&m's seed testified in front of the subcommittee on defense and will face questions on the 2014 defense budget and sexual assaults in the military and other issues. live coverage at 10:00 a.m. eastern on c-span three. >> defense secretary and joint chiefs chairman also testify on the 2014 defense budget on wednesday at 10:30 a.m. eastern for the senate budget committee for live coverage on c-span 3 and at 1:00 p.m. eastern before the house budget committee live coverage on our companion network c-span three. >> and for health first lady ida mckinley suffered from epilepsy there for her husband with the minister of

state dinners so when she had a seizure he would shield her face from a guest with the large handkerchief until the episode pass. despite her problems she traveled as first lady to the pan american exhibition were her husband was assassinated. we will look at the life of ida mckinley as we conclude the first series -- first season of our series live tonight. >> on monday british foreign >>host: told the commons that they circumvented laws to gather data on british citizens were baseless. the statement comes after a former nsa employee reported the u.s. government is using phone and e-mail records to spy on its citizens. this is 10 minutes. >> i think that matters have

been fully explored for foreign and commonwealth affairs secretary william hague. >> i will make a statement on the work of the government communication to the legal framework about it. as far as secretary i am responsible for the of work of the secret intelligence service of mi and the authority of the prime minister. and am responsible for the work of mi-5 there has been media disclosures classified u.s. documents relating to the collection of intelligence by u.s. agencies and questions of rule. the u.s. administration has begun a review into the circumstances of the leaks in contention with the justice department and u.s. intelligence community and obama has been clear the work in this area is

overseen an authorized by congress and relevant to judicial bodies and the administration is committed to respecting the civil liberties and privacy of citizens. any law of classified information makes it more difficult to provide a powerful and potentially misleading picture of concern. it is the policy of the british government not to comment on the detail of intelligence operations. and the house will therefore understand that i will not be drawn into confirming or denying any aspect of the information but i will be as informative as possible to give reassurance of the public. we want the british people to have confidence of the work of our intelligence agencies and the adherence to the lot and democratic values. but i also wish to be clear i will take great care to

answer questions to say nothing that gives any clue or convert to terrorist criminals or foreign intelligence as they seek to do harm to this country and its people. three issues have arisen in recent days which i wish to address. first the action the government is taken in response to recent events events, second devil set out how the intelligence agencies' work and in accordance with u.k. lot and with democratic oversight oversight, third, i will describe how the law is upheld with respect to intelligence operations of united states and deal with specific questions that have been raised about it. with the action may have taken the intelligence ability received information and they will receive a full report tomorrow. kensington and hooch years the committee is travelling the united states on a long-planned visit as he has said the committee will be free to decide what, if any any, further actions it

should take in the light of the report. the government and the agencies will cooperate fully with the committee and i pay tribute to its members and predecessors on all sides of the house. second, the i sc is one part of a strong free-market of accountability and oversight that governs the use of secret intelligence and the united kingdom with successive governments have worked to strengthen and the two acts of parliament the intelligence service act of 1994 and the regulation of investigators one negative investigatory powers of 2,000. they require agencies to seek authorization for their operations from the secretary of state normally the foreign secretary. as foreign secretary are received hundreds of operational proposals every year. the proposals are details. they set up a plan of operation of potential risk

and the intended benefit of intelligence. they include comprehensive legal operations and comments from foreign officials and lawyers. so to assess the content of any individuals requires a warrant signed personally by me the home secretary or another of state. this is not a casual process. every decision is based on extensive legal and policy advice. also legally required to be necessary to be carefully targeted and on that basis considerations of privacy are also at the forefront of our mind. i believe also in the mind of our predecessors. take great care to balance individual privacy without duty to safeguard the public and the u.k. national security. these are not approve with every proposal by the agcy.

all of the authorizations that we do give are subject to independent review by the intelligence services commissioner and the interception of communications commissioner. both of town must hold high judicial office and report directly to the prime minister. they review the way the decisions are made to make sure they are fully compliant with the law, full access to all information they need to carry out there responsibilities and the reports are publicly available. it is vital we have the framework of democratic accountability and scrutiny but i have nothing but praise for the professionalism, dedication and integrity of the men and women. i know from my workouts seriously they take their obligation here in the u.k. and international law. indeed in the most recent report the intelligence services commissioner said it is my belief that the staff conduct themselves with the highest level of

integrity and legal compliance. this combination of needy a warrant from of most senior members of the government whip with legal and vice reviewed by independent commissioners and implemented by agencies with a strong legal and ethical framework and scrutiny by the isc whose power is increase provides one of the strongest systems of checks and balances and democratic availability of secret intelligence anymore in the world. third, i want to set out how the uk lot is held up with the formation received from united states and address specific questions the american equivalents the nsa that is unique in the world. this relationship has been and remain essentials to the security of both nations it has stopped many terrorist

and espionage plot against his country and it has saved many lives. the basic principles by which that corporation operates has not changed over time. we wish you empathize with a house but while we have experienced a extremely vivid period of diplomacy over three years the arrangement for oversight and the framework for exchanging information with united states are the same as under previous governments. they're growing nature of threats from terrorist, criminals are espionage only increases the importance of our relationship with united states. this is a particular day the case in the run-up to the olympics. the house would not be surprised our activity intensified and rose to a peak at the summer of last year. it it uses a partnership with the united states to get around the u.k. law obtaining information they

cannot legally obtained in the united kingdom and i wish to be absolutely clear this accusation is baseless. any data obtained by us from the united states involving u.k. nationals is subject to proper u.k. statutory controls and safeguards safeguards, including the relevant sections of the intelligence services act, human rights act and the regulation of investigators -- investigatory powers act. the work with united states the administerial oversight and the scrutiny by the intelligence and security committee. i agency's practice and uphold u.k. law at all times even when dealing with information from within the united kingdom. the combination of robust legal framework, and ministerial responsibility responsibility, is pretty by the intelligence service commissioner and parliamentary accounts through the committee should give a higher level of

confidence as the system works as intended. this does not mean that we don't have to work to strengthen public confidence whenever we can while maintaining the secrets necessary to intelligence work. we strengthen the role of the isc to the justice and security act to include oversight of the agency's operations as well as policy , administration and finance. we have introduced the national security council so intelligence if wait and assess of all other information available including diplomatic reporting and the insights of other governments and with all information is judge carefully to decide the overall objective. but there is no doubt secret intelligence including the work is vital to our country and enables us to detect threats ranging from nuclear proliferation to cyber attacks and our agents have work to prevent serious and

organized crime to protect our economy against those trying to steal our intellectual property. they disrupt complex thoughts against the country as when individuals travel abroad to get training and prepare a tax. they support the work of the armed forces overseas to help protect the lives of men and women in uniform. their work to help other countries lawfully fulfill the capacity and willingness to investigate and disrupt terrorist in their countries before the threat reaches the united kingdom. we should never forget the threat of secretly of new weapons systems and tactics are developed secretly in countries of terrorist groups that plan attacks were operations against us do so in secret. the methods we use to combat these threats must remain secret just as they must always be lawful. mr. speaker for citizens of this country to see the time and care taken to make these decisions with all the

intervention to strict democratic values are appalled if they could witness the integrity of professionalism of the men and women of our intelligence agency who are some of the finest public servants that we have and i believe they would be reassured how we go about the essential work for the british people can be confident in the agency's work to keep them safe with the would-be terrorists seeking to expire against the country against organized crime should be aware that this country has the capability in partnership to protect its citizens against though full range of friends to the 21st century and will do so in accordance with our laws and values with constant result in determination.

>> coming up next a senate debate on immigration legislation and then the impact of the health care law on medicare advantage. and later a discussion about the possible effect of the health care law on insurance for young adults. on the next "washington journal" real focus on issues in congress including immigration and tax policy. our guest is former head of the cbo. and the federation of american scientists will take your questions about data collection programs used electronic surveillance from internet and phone calls. also is the associated press to discuss the recent article how washington investigates in self to look at the relative power of the

executive, legislative and judicial branches of government. live on c-span every day 7:00 a.m. eastern. >> the name of this place still resonates in the heart of the american people. more than any of their name connected to the civil war except lincoln gettysburg reverberates americans retain the knowledge of what happens here was the crux of the terrible national trial and even americans are not sure precisely what transpired know that all the glory and all the tragedy we associate besides -- resides year. >> 150th anniversary of the battle of gettysburg live all day sunday june 30th on american history tv on c-span3.

>> the senate to be dan debating immigration legislation and >> when the senate judiciary committee had the markup session to contend with the opportunities and immigration modernization act in the bill, we worked late into the evening and we actually considered hundreds of amendments but what is interesting what we heard most about is the fact the

public witness to the consideration firsthand bandsaw all proceedings stream live on the committee web site and was broadcast on c-span and in fact,, even before the markup began we had a proposed amendment and there were hundreds of them. and then as we made changes or developments we reported it in realtime. i know this made a difference because after receiving e-mail's and calls over the country whether people agreed or disagreed or how much it meant to them to know what the senate was doing. members of both sides of the i/o praised the process and a significant improvement made by the judiciary committee and the bill as we

amended it was passed by bipartisan two-thirds majority. again, i think because everybody worked together and set politics aside come in many ways that is the way we didn't win a first came to the senate that we did not strange things five or have c-span so it is even more so now i appreciate what obama said this weekend about immigration reform. i agree we have to go in a timely way of course, the time is now to act so under the same steps in the senate that we took of the judiciary committee during the legislation to have an efficient and transparent process of the makeup of the senate judiciary committee

to go across the political spectrum. as well as geographically on the west coast in the east coast from the southern borders to the north, doing our committee consideration last month and editorial that turned proceedings as a lesson in democracy to demonstrate the american people that should fulfill its responsibility despite differences. the ranking republican from iowa and i are on different sides of the legislation that we can work well together. i hope we can continue to work here in a bipartisan way. although we voted against the bill the senior senator from iowa was necessary to report it to the senate would have done so. i appreciate that senator.

and look forward to his cooperation. i propose to senator grassley as the ranking republican on the judiciary committee to entirely replicate here in the senate fair and transparent process that we could achieve in the committee. to that end let's proceed to the bill i suggest we have a deadline for amendment as we did on the onset for consideration. so for us to take those amendments to group them by issue of titles that makes a lot easier for the public and the senate to know what we're doing on the bill that

will help us with the consideration of legislation of course, in order for the amendments to make it to the bill the senate has to proceed republicans and democrats work together for this legislation senators from both sides of the aisle including the senator from alabama about this legislation had a part of the committee almost none of the 135 amendments adopted by the judiciary committee were adopted of party-line votes but they're all adopted in a bipartisan way. so we should be able to work together to ensure consideration of the amendments and then to vote without a filibuster.

people want to vote yes or no or up and down they don't want to delay tactics to say maybe we would have been for it or against it but expect more. vote yes or no. i hope the senate will return immediately the consideration of amendments that with cloture is a procedural motion used to pay the bill villagization before us is not a piece of legislation but a bipartisan bill or a proposal from the so-called gang of eight and a process of a group of 18 supported by a bipartisan majority. they have come together to develop this to keep the commitments and i have no doubt they can and the unnecessary filibuster to

pass the fair legislation and immigration reform. there is broad agreement of the nation's immigration system is broken and in need of a comprehensive solution. also a broad agreement that people are tired of unnecessary delays in the united states senate and they like to see is to the work that they are paid to do, elected to do to vote yes or no, not continue voting may be to delay. and it is bipartisan legislation given the impact of the broken system has on our economy we cannot afford delay. that to come together to do what is right, fair, just. comprehensive immigration reform came to the senate floor six years ago.

what is backed by a minority party, republican party the former chairman of the immigration subcommittee ted kennedy said the minority in the senate rejected a strong free economy fare to taxpayers and workers the minority in the senate rejected their own immigrant history and ignore the nation's most urgent needs. the weariness for the long haul to continue the battle of the immigrants all around us. he is right. forever betty serving in the united states senate, senator kennedy from the time i arrived through the time that he died, i know how passionate he felt about this.

i also know a small minority in the senate that continues to reject this measure should not at this time close the door on so many in our country both those who were citizens and those who aspire to become citizens. i have taken inspiration from many sources. i have shared histories immigrants and the experience of my own grandparents when they came to vermont from another country and another language and another culture. from their parents to came to vermont from another country and another language.

as surging kennedy noted as millions of american families would be more secure to enact comprehensive immigration reform. as part of the judiciary committee and what do you want to do with us? what do you want to do with me? but this legislation answers to send a message as a nation of immigrants and i.m. anchorage from those on the other side of the aisle to give their support for this legislation i welcome those who supported immigration reform in the past for those in supporting web president george w. bush wants to do is comprehensive

immigration reform now president obama also as so many of us here in this senate want to do. i trust those republican senators who helped to draft this legislation it helped us greatly and they will be with us for the long haul. to defend the legislation the past 14 members of the judiciary committee to consider. and i hope and expect they do not look for excuses to abandon what needs to be a bipartisan effort. because everybody had to give some in this bill. now before the senate not that i would it address but

i voted for the amendment of the judiciary committee that we rejected and voted against amendments that were accepted or withheld an amendment of what is at issue of fundamental fairness and ending discrimination. that is when they pledged to abandon their support for this bill as that has been offered. and i cannot begin to tell the senate how much it hurt to withdraw that amendment. despite the shortcomings as a result of compromise the bill before the senate is working with his chambers immediate support there is time for us to stop voting maybe and get it to the business of legislating. after all that is what the

american people republicans and democrats expect us to do. over the last decade now the second decade of the 21st century we have the opportunity to make reforms that we so desperately need with the strength of the nation. as they sat on the floor late last week the majority of us stand together thatthe may of us stand together that if we stay true to our values and our agreements we can pass legislation to right the next great chapter of american's history of immigration succeeding generations they will thank us for. >> as to afford to difficult over made about immigration and want to share my thoughts on the

legislation, i was to speak about the committee process as well as the substance before us and also start -- sure my personal experience from the '80s and how we can learn from history and finally i want to express my hope for what i think a bill should look like before it leaves the united states senate. i don't know of any senator that says the status quo is the way it ought to be. in other words, , this issue be in on the floor of the united states senate is very appropriate. but while we are here we need to concentrate getting immigration right for the long term. in 1986 women had major legislation i was there and

i lived it and i voted for it might knowledge what we did in 1986, we got it wrong. we cannot afford to make the same mistakes of yesterday. from national security to economic security too much is at stake. do not repeat 1986. to make sure the borders are secure and no excuses from that point*. no exceptions on a point*. we are nation of immigrants you're also a nation of a lot and it is my responsibility to respect the law to insure it is upheld. so to do it the right way and not the easy way.

to take what time is necessary to get it right. we know what happens in congress and how what works and how it doesn't. and i think if we look back at health care reform as an example we know that we did it in to her reid of the way -- hurry of away and then to tear up the legislation now are legitimate points of discussion. earlier in the year with a bipartisan group of eight senators released their framework for reform, i was optimistic the authors would produce legislation that lived up to the promises and in their framework they stated'' matt we will ensure this is a successful permanent reform to the immigration system that will

not need to be revisited'' and without a vote -- without a doubt this is a goal we should all strive for. we must find the long term solution to fix the broken system so i was encouraged encouraged, the authors in the framework released to the framework before the language was available said the bill would "giveth tough their practical road map to address the status of an authorized immigrants in the united states contingent upon our success and secure the borders and address the be set overstay. '' who can argue that point*? that is exactly what we all believe a piece of legislation should do. bill was put forward in the framework was put forward, i

reserve judgment until all i saw the details of the proposal. i thought the framework had hope. but i realize the assurances that the group of eight made did not really translate when the bill language emerged. it seems the rhetoric was bought on the details were dubious. this is what the professor was professed by the authors that the border would be secured and the people would earn the legal status that is not what the bill did it was drafted it was legalization first and to track bees of overstay later if at all.

in 1981 when i was a freshman senator i joined the judiciary committee and was active in the subcommittee process. and wrote legislation we have 100 hours of hearings and 300 witnesses before we marked up a bill of 1982 and dozens hearings would take place before the 86 passage this year we have six stage of hearings 18 hours listening hearing on the needs of women and children and another focused on'' building the immigration system worthy of american values'' the judiciary committee received a bipartisan bill that to 24:00 a.m. april 17. we held hearings on april april 19, 22nd, 23rd.

we heard from 26 witnesses in three days, we heard from the head of the engage liked -- immigration you again and employers and lawyers and professors and advocacy groups even from those who are undocumented proving only in america would we allow someone not right with a lot to be heard by the american people. one was homeland security napolitano. we attempted to learn about how the bill would affect the function of the executive branch and whether she saw the same flaws that many of us are finding. unfortunately we have not received responses from secretary napolitano to the

questions that we've raised her hearing april 23rd. we should have the benefit of hearing from the secretary, searching questions raised about this legislation and particularly when it comes to someone in the executive branch that has to enforce what is laid before her. after those hearings, a committee was posed to consider the bill through the markup process and our side of the i/o made it clear to have an open and transparent process so we started work on may 9th to voice concerns and offer amendments hundreds of amendments were filed. 77 amendments i filed by offering 37 of those 3712 were accepted, 25 rejected.

those on either side of the aisle will boast that many republican amendments were adopted in committee. they are somewhat right however only 31 out of 78 republican amendments offered were agreed to and seven were from the group of eight but get this. of the 62 democrats amendments proposed only one of those was rejected. and even that way was just narrowly rejected. common-sense amendments offering common sense solutions were rejected. in sun made necessary improvements but the core provision of the bill remain the same coming out of committee as they were

introduced into the committee. now i respect the process that we had chairman leahy deserves thanks from all of us on the committee because he promised an open and fair and transparent process and quite frankly, it was. it is a good format for whitney's to take place on the floor of the united states senate if the legislation that is finally voted upon will have credibility. in that committee we had a good discussion and debate on how to improve the bill. it was a productive conversation focused to get immigration reform right in the long term. but yet i was disappointed alliances were made to ensure that nothing past to make substantial changes or improvements in the bill.

many of those same people gave high praise to the amendments being offered but continued to go against it. that have often spoken of the 1986 legislation how that law failed the american people and 99 other senators will get sick of my reminding them of my presence there in 1986 to say that we screwed up. because at that time promises were made and those promises were not kept we said it was a onetime fixes just like the group of eight says they have a one time fix but that did nothing to solve the problem. in fact, it only made matters worse and encouraged illegality. people came forward for

legal status that many more illegally entered or overstayed their welcome to get the same benefits and a chance at citizenship. the 1986 bill was supposed to be as related stool of control undocumented immigration legalization program and a reform of the bill immigration we authorize $422 million to create a special fund for states to reimburse the cost the 1986 bill included a legalization program for two categories of people one for individuals who are present in the united states since 1982 and the second for farmworkers who worked in agriculture for at least 90-- prior to enactment of a

total of negative people were legalized and for the first time ever we made it illegal to knowingly hire or employs someone that was here undocumented. we set penalties to determine the hiring of people here undocumented. we wrote the bill that won the essential element of immigration control is an increase of the border patrol and other inspection and enforcement activities of the naturalization service in order to prevent and to the turd the entry of aliens into united states and to violate the terms of their entry''. the same principles from

1986 is clear that that philosophy does not work and that it didn't work in 1986. so propose of the legalization today we did not get a rate and how true they are. i agree those enforcement's could have been strong for. that they protected every mile of our border. and knowing what i now know an immigration bill must ensure that we have secure the border first legalization should only happen with the american people have faith in the

system. and there needs to be legal avenues to allow people to enter and stay illegally in the country. to know how important the security of the border is come to the town meetings and i was 73 at of 99 counties in an immigration comes up to talk about legislation there is an outburst that we don't need more laws what you just enforce the law that is on the books like bring the troops home. put them on the border than we don't have a problem. unfortunately the bill before us repeats the past mistakes and does very

little more than the same promises we made in 1986 which the promises turned out to be empty and instead of looking to the past for guidance for what to do in the future the bill before us incorporates the mistakes of the past and even weakens the laws that we currently have. . .

>> we should learn a lot of lessons from past legislation. we should be doing more legislating and less delegating. you know, just think of the reason, things that have come out. the irs has too much power. health care reform, 1,963

delegations of authorities. now, you might think you understand 2700 pages of legislation that the president signed four years ago, but you aren't going to know what that legislation actually does until those 1,963 regulations are written. that think we're waking up to the fact that we delegated too much and legislated to little. we should not be making that same mistake with this piece of legislation. as it is written, we are making that mistake. i would not have such strong resentment about this issue if i knew that abcaeight have faith in this administration or any future administration. by the time this thing gets down the road, that's going to be a future administration to actually enforce the law. but show me the evidence. the present administration has

curtailed immigration enforcement programs. claims record deportations. but then what does the president say? he turns around and says that the statistics are to be the secretary says that the border is more secure than ever before, but she denounced any notion of securing the border before people here undocumented or given legal status. the administration implemented the dream act by executive fiat saying congress refused to pass a bill. decided to do something on its own. when you're the president told a group of people he did not have the authority to do it. a justification for the actions and very few. so the refusal of any executive branch of government, republican

or democrat, to refuse to recount ability, raises a lot of questions. they refuse to be forthcoming with congress on almost every matter. so when this bill was introduced i had to really question whether the promise for border security to in years down the road would never be fulfilled. no one disputes that this bill is what i have said already, a bill that legalizes and enforces labor. now, that's the core problem. that is the core problem from the standpoint of everybody that is going to tell us on this floor and during the weeks of debate that immigration reform is overwhelmingly popular. i'm not going to dispute that. but understand, there are many

things that are cats. number one is that we ought to have border security. so the core problem is, enforcement comes after legalization. so i core problem. the main reason i cannot support it at a judiciary committee. as the main reason. it's unacceptable to me and unacceptable to the american people. the sponsors of this bill disagree. if they would read their own legislation, they would realize this fact. later in the bill will discuss an amendment that i plan later in the week. all this does an amendment i plan to offer to change this central flaw that allows me to get tell my colleagues who are

not on the committee about this major objection i have. we have millions of undocumented people in this country. under this bill congress would give the secretary of homeland security six months to produce to reports. one on border security strategy in the other on border offensive strategy. as soon as those two documents are sent to the hilt, justice and as they come up here the secretary then has full authority to issue of legal status, including work permits, travel documents for millions of people that apply. the result is that beyond -- the undocumented population receives what the bill calls registered provisional status after two plans are submitted. regional, provisional emigrate. rpi.

rpi status is more than probation. rpi status is an outright legalization. after the secretary notifies congress that she believes her plan has been accomplished, newly legalized immigrants are given a path to obtaining green cards and a special pass to citizenship. without ensuring adequate border security or holding employers accountable, the cycle is destined to repeat itself. i use the committee process to attempt to strengthen border security. my amendment to fix the trigger so that the secretary would need to report to congress on a fast-track system and show that the border was secured to get congressional approval. it would proceed. we use the committee process to try and track who is coming and

going from our country. amendments to require a biometric exit system at all ports of entry which is current law was defeated. we tried to all the employers accountable and stop the magnet for illegal immigration. my amendment to speed up implementation of an employer verification system was defeated at the end the day the majority argued again securing the border from a decade. the triggers in the bill that kicked off legalization are ineffective and inefficient. if we pass the bill as is, there will be no pressure on this administration or future administrations or those in congress to secure the border. there will be no push by the legalization advocates to get the job done.

costa legalization takes place before the border is secure or after? because once the plants are presented there will never be any pressure from advocates for legalization or anybody else that is interested in solving this problem to push to get the job done. moreover, the bill gives congress the sole discretion over border security and fencing strategy and implementation of these strategies without any input from congress. so we have a lot of questions. will the secretary who believes that the border is driven never before been willing to make it even stronger? will a secretary here does not believe in biometric exit

systems, it's feasible insure that the mandated system is put in place? will a secretary here does not believe anything should stand in the wake of legalization insure that the triggers are achieved? proponents of the legislation claim that it includes the single largest increase in immigration enforcement in american history. proponents say that mandatory electronic employment verification is a solution to future illegal immigration. yet it is concerning that the bill delays for years the implementation of a mandatory electronic the employment verification system through which 99 and seven tenths percent of all work eligible employees are confirmed

immediately to that. i will speak later in the days ahead about how this bill weakens current law, particularly loss on the books that deter criminal behavior. it concerns me greatly that the bill of we are about to consider rose back many criminal statutes that are also -- there is nothing in the bill that enhances the cooperation between the federal government and state and local jurisdictions. in fact commit pre-empts state laws that are trying to enforce federal laws currently in place. we have a lot of work and aphorist. i know that there are some that don't want to see a single change in this legislation. for me this bill falls short of what i want to see because the fact is we need real reform, not gimmicks that fail to fix a real

problem in securing our borders. we need to be fair to millions of people who came here illegally. not bias the system in favor of those sues not get through the backdoor. we need a bill that truly balances our national security with our economic security. here is what we can do to improve the bill. i remain optimistic that on the floor we can vote on common-sense amendments that better the bill. serious consideration will be given to amendments to strengthen our ability to remove criminal gang members. a full perpetrators of fraud and abuse and prevent the weakening of criminal law. we must seriously consider how the bill works to the detriment of the american workers and find consensus around measures that require employers to cut recoup and fire from home before looking abroad but also

improving the mechanism by which people can come here when they're needed. we must be willing to close loopholes in our asylum system, prevent criminals and evildoers from gaining immigration benefits and ensure that we are improving our ability to protect homeland. i assure my colleagues that i have an open mind on this legislation. i want immigration reform. i want to get it right this time, not make the same mistakes that i did in 1986. i want a bill that i can support. to do that i need to see a stronger commitment to border security. i need to know that future lawmakers will be rewarded and that there will be deterrence for people who wish to enter or remain illegally in the country. basically in simply, i want the words of this bill to match the

rhetoric of those proposing the plan. the bill's sponsors want a product that can garner around 70 votes in the senate. doing so they seem to think would send a message to the house that they should just rubber-stamp bill that passed the senate and send the bill to the president. i don't think that's going to happen. the house is prepared to move on its own legislation. there will be a conference which is a rare occurrence around here, by the way. a conference of two houses will insure that the bill benefits from various checks and balances that we worship through our constitution. i am not trying to jump ahead to the next up of the process. i am simply telling my colleagues that this bill has a long ways to go through the legislature process. needs to change before it is expected by the american people were sent to the president.

if they are serious about getting this done or compromises will be made. allow me to end by echoing the words of president reagan. our objective -- these are his words. our objective is only to establish a reasonable, fair, orderly, and secure system where immigration into this country and not to discriminate in any way against particular nations and peoples. future generations of americans will be thankful for our efforts to humanely regain control of our borders and thereby preserve the value of one of the most sacred processions of our people , american citizenship. president reagan. the path that we take in the days ahead will shape our country for years to come. it is my hope that we can find a

solution while learning from our mistakes and ensuring that future generations don't have to revisit this problem down the road. thank you. i yield the floor. >> mr. president. >> the senator from utah. >> it's a travesty. it is inefficient, and compassionate, and dangerous. a does not suit america's economic or social interest and the rule of law and the democratic institutions. it is both badly needed and long overdue. that is why i support immigration reform, and it is also why initially joined a bipartisan group of senators to try and find common ground on this issue. but it is also why i left that group and is why today i must oppose the so-called gang of eight immigration bill. at the outset of this debate

they gang promised of grand immigration bargain, strict border security in exchange for a bath with his citizenship for approximately 11 million illegal immigrants already here. even before the bill was introduced gang members distributed talking points that a lot of the bills beefed up security provisions. new these reforms and measures that would make the pathway to citizenship both long and tough. about once again, they gain produce actual legislation and once senators, the media, and public members began to read the bill, it was clear that the talking points did not reflect the reality of the legislation itself. after putting out -- pointing out discrepancies between claims about the bill in the actual text, senators are told that they would have an opportunity to make changes. well, the four gang members on

the committee banded together as a bloc with democrats to defeat virtually all substantive amendments proposed to improve the bill. congressional approval of the border security plan, no. improve interior enforcement of strengthening workplace verification rejected. manage the flow of new legal immigrants, failed. limit access to some of america's most generous welfare programs, blocked. as a result the bill that will come to the senate floor this week is essentially the same huge complex and unpredictable, expensive and special interests driven boondoggle it was in a first into the committee. the secure the border. does not build a fence, create a workable biometric entry exit system for an address to this country. what standards and that marks it does set the bill simultaneously grants the secretary of homeland

discretion to waive. it will, however, immediately legalize millions of currently illegal immigrants, make them eligible for government services, and put them on a path with the citizenship. many critics compare the bill to the failed 1986 immigration law which like this one also promised border security in exchange for amnesty. but it did not deliver its promises. what the bill actually reminds me of a more recent piece of legislation. like the president's health care law, the bill was negotiated in secret by insiders and special-interest and then essentially it was offered to congress, a single take-it-or-leave-it proposition. grants broad new powers to the same executive branch that today is mired in scandal. total cost estimates are in the trillions according to some.

rather than fix our current immigration problems, the bill makes many of them worse. however well-intentioned, the gang of a bill is just an immigration version of obamacare that is why true immigration reform must be pursued on a step-by-step basis with individual reform measures implemented and verified in the proper sequence. but happily for immigration reformers like myself, this appears to be the approach being pursued in the house of representatives. it is the only one that makes sense. first, let's secure the border, set up a workable entry exit system and create a reliable and plumb a verification system, one that protects immigrants, citizens, and businesses alike from bureaucratic mistakes. then let's fix our legal immigration system to make sure we're letting in the emigrants our economy needs in the numbers that make sense for kutcher. once these and other tasks which

are plenty big in and of themselves are completed to the satisfaction of the american people, then we can address the needs of current undocumented workers with justice, compassion, and sensitivity. since the beginning of this year more than 40 immigration related bills have been introduced in congress between the house and the senate. on rough count i could support more than half of them. eight of which have republican and democratic co-sponsors. we should not risk for progress on these other bipartisan reforms just because we are unable to hire not each of the more contentious issues. the gang of a bill is not immigration reform. it is big government disfunction. it is an immigration version of obamacare. all advocates of true immigration reform, advocates on both the left and the right side of the aisle should therefore --

>> a cloture vote on the bill is set for tuesday at 2:15 p.m. after party meetings. the amendment process is expected to take weeks at the senate bill -- the scent of the bill forward. >> coming up tonight on c-span2, the alliance for health reform examines the impact of health care law medicare advantage. in the discussion about the possible effects of health care law on insurance written adults. that is followed by attorney general eric holder and his department's investigation into national security leaks. on that next washington journal, we will focus on several issues in congress, including immigration and tax policy. our guess is the former head of the congressional budget office. the federation of american scientists will take your questions about data collection programs to use electronic surveillance of phone calls and internet. we will also be joined by a reporter with the associated

press to discuss the ap recent article about how washington investigates itself. looking at the relative power of the executive, legislative, and judicial branches of government. washington journal is live every day at 7:00 a.m. eastern. >> on tuesday defense secretary and joint chiefs of staff chairman testify before the senate appropriations subcommittee on defense. they're expected to face questions on the 2014 defense budget, sexual assaults in the military and other issues. live coverage of 10:00 a.m. eastern. >> the interesting aspects of this building's history, the fact that it exists at all. and really much of the reason that this building is still here is due to our governor at the

time. when the civil war started to come to a close and union troops were camped outside, he was very concerned about the fate of the people of raleigh in this building. he knew what had happened and many of the other southern cities when troops came through. and so he crafted a peaceful surrender of the city. he agreed to leave the city and have the confederate troops leave the city peacefully. if the union troops would also take charge of the city peacefully and specifically they would spare the state capital with its museum and library. we do have a three representations' of george washington here at the state capital. one outside to inside. this is actually a copy of the original statue within the state house that burned, and that was destroyed. that statue was made by an italian sculptor.

he represented george washington in a way that he felt really nasty reputation as a military leader, as a political leader. and so he made in in a very classical way look like a roman general. that was not entirely a popular decision with the people of north carolina. and probably the thing that shocked people the most is his legs and feet are completely bare. many people thought that was a little disrespectful to show a president with his legs and toes showing. >> more from the north carolina state capitol next weekend as book tv and american history tv wicked history and literary life in raleigh, north carolina saturday at noon eastern on c-span2 book tv and sunday at 5:00 p.m. on american history tv . >> next, a discussion about how the health care law will impact the medicare advantage program and the 14 million americans to use it. this discussion was hosted by

the alliance for health reform. it is an hour and 35 minutes. >> our board of directors. this program on the growing part of medicare, the medicare advantage program that enrolls more than one-fourth of the entire population of medicare beneficiaries, 14 million are so in a private health plan. that plan is then responsible for delivering all of the traditional benefits, and is sometimes deliver more services than those in the traditional medicare package. if you are on medicare, if you are on medicare and not in a major advantage plane you're in a traditional fee-for-service medicare arrangement to be very likely to have a gap policy to help you with the cost sharing. very likely to have a prescription drug policy that is separate from that. did i mention that this was kind of confusing?

medicare advantage plants have been around with one name or another for the better part of 40 years. in recent years they have grown enrollment and also they have grown as the source of policy issues. the payments at an appropriate level. how well they serve the needs of minority and low-income beneficiaries? what is the future role for the program? today we're going to look at those questions, what changes are coming to the plans and for beneficiaries enrolled them. what impact the changes might have on those two groups. we're going to let the future of the program, how much it paid and how that is determined which is itself, granular process that we all need to learn more about our copartner in this foundation

has been cranking out some of the best analysis of of medicare, including medicare advantage. tricia new menu is in the audience today heads that the foundation's medicare policy project and they produced some great analyses, many of which if you will find in your packets, one of which was just published today. but if you go to our website he will be able to find today's if version of their update on medicare and roman. medicare advantage in roman. so we are very pleased to have the family foundation. >> thank you. thank you all for joining us

today on the topic of medicare advantage. i really appreciate the fact that today we were able to pull together such an incredible panel to really look at the various aspects of how medicare advantages working, who enrolls in a canal is paid, but especially because not only other implications from the medicare advantage program with the medicare program itself into medicare beneficiaries, but also as we increasingly are looking through the implementation of the dca and the changes going on in medicaid and private insurance and a growing role for managed care. some of the lessons that we can take away from today's discussion that might help us if we move forward to try across the board to improve the way health care services are paid for and delivered. so i am very pleased that we have such a good panel to start off our discussion in such a great audience that i no will put related questions to them as

a move forward. thank you. >> great. thanks. if you are a member of the twitter verse or whenever one might college, you will notice that there is a hash tag that you can make use of in the course. in your package you will find an awful lot of information, some even not produced by the kaiser family foundation. including some speaker bios that are more expensive than you will get from us as moderator's. there is a one-page materials list in your kids, a power point presentation that we received in advance. there will be lots more background information available at our website. there will be a video recording of this briefing available over the next couple of days thanks to the kaiser family foundation on their website. you can get it through our website as well.

it will be transferred to a few days after that. if you are watching now on c-span and have access to the internet, you can call up the slides from our speakers as the golan by going to our website, clicking on the information link for today's briefing in them on the panelists name under speaker presentation. at the appropriate time those of you in the room can ask our panel question by filling l1 of the green question cards in your packets or by going to one of the microphones, one on the side of the room. at the end of the briefing we would appreciate it if you fill out a blue evaluation form so that we can. so, let's get to the program. as diane alluded to, we have for terrific panelists today that

will give us some brief presentations and then you have a chance to get in on the conversation. we will lead off with gretchen jacobson who is the assistant director of kaiser's medicare policy program. the foundation from the staff of the congressional service for she specialized in health care financing. but the foundation she carries out projects and iraq's others that shed light on medicare and the people who serve, and we are pleased to have you back. >> there you go. thank you. so i will provide a bird's-eye view of the medicare advantage program and how it currently works for the people on medicare . for decades now medicare beneficiaries have had a choice between saving and medicare benefits from other traditional fee-for-service medicare or through private managed-care plans known as a medicare avenges plan.

today there 51 million medicare beneficiaries, 28 percent of whom are enrolled in medicare advantage plan. medicare advantage enrollees can do between different types of plants. most people on medicare advantage, 65 percent are enrolled in hmo. the 30 percent are enrolled in local pbs are regional appeal. 3 percent are in private pay for service plans and 3 percent are in other types of plants such as demonstrations are medical savings accounts. when we look at the demographics of people enrolled in medicare in vantage versus traditional medicare we see some subtle differences. starting with the orange said you can see that a smaller share of people who are under the age of 65 and a smaller share of people who are ages 85 and older are

enrolled in medicare vantage. in the blue metal bar you can see that as smaller share of beneficiaries are enrolled in medicare advantage. and while there appears to be a slightly larger share of medicare advantage, this difference is not statistically significant. the differences are statistically significant. finally in the green said, you can see that the incomes are slightly lower among people with medicare vantage. changes will affect some groups of beneficiaries. and earlier you saw about 28 percent of beneficiaries are enrolled in medicare advantage. many of these changes in a roman , changes in policy. initially enrollment in private

plans is relatively low. starting in the early 1990's there was an increase in enrollment in private plans. then in 1997 that balanced budget act named the private plan program medicare and reduced payments. in the years following the enrollment decrease. renamed the program medicare advantage established the prescription drug program which was subsequently integrated into medicare advantage. enrollment has continued to steadily increase. in 2010 the affordable care act reduced payments and established a new quality based system for the plan that was subsequently expanded by a demonstration for 2012 to 2014 and partly off that

the reduction in payments are implemented in the apa. since the apa room and has continued to increase. 2013 more than 14 million beneficiaries are enrolled in medicare vantage. nationally 28% to beneficiaries are rolled. this varies greatly. ranging from 1 percent in alaska to 49% in minnesota. you can see them more than 30% to beneficiaries are enrolled in medicare vantage. compared to less than 10 percent of beneficiaries in the six states shown here in dark blue. enrollment also significantly varies within the state. so changes in policies that affect medicare vantage play at differently across states, but they often play out differently with the state's.

from the perspective of the beneficiary medicare beneficiaries can choose from among 20 medicare advantage plans on average. there are a lot of differences across the plan, but there are also some minimum requirements that all plans must meet. all plans are required to cover medicare. kashering that is actuarially equivalent to the cost sharing of traditional medicare. plants can also cover pardee prescription drugs. in 2013 most medicare advantage plans to. unlike traditional medicare, all medicare advantage plans are required to limit enrollees' out-of-pocket expenses to $6,700 less. vary greatly. finally, most plans provide extra benefits such as lower cost sharing or benefits that are not covered by traditional medicare. pinfish years may value in factor into their choices.

familiarity with the company or brand loyalty is another factor that may factor into beneficiaries plan and roll a position. most medicare advantage enrollees are in plans operated by one of five affiliate's which you can see your. and this is similarly true that the state and county level, albeit less than the different companies. so it is really a select number of companies that try the local and national medicare advantage market and have most of the room . another factor that beneficiaries plan choices, the plan quality rating. for less, the distribution of ratings among plans if you compared the orange said on the left to the ones on the right, you can see that while a quarter of all plants received four or

more stars, about 40 percent of enrollment is in plans. "beneficiaries seem to be disproportionately enrolling to live remains to be seen to what extent the ratings are influencing beneficiaries plan enrollment position. and another factor, planned premium. on average in 2013 beneficiaries enrolled in the medicare advantage plan with a prescription drug coverage. $35 per month in premium in addition to their part b premiums. this is about the same amount that they paid in 2012 and is a decrease from $44 for monthly payments and $0.20. premiums, as you can see, very across plant size and vary from one county to the next. there are many other factors that vary across plans,

including things such as provider networks or plans. looking forward, the outlook for the medicare advantage program is now entirely clear. most expect enrollment to continue to increase through 2014. after 2014, when you can see here in red, the projections differ. some say in room and will continue to increase other same room and will decrease. it remains to be seen how policy changes from the a.c. a in cms will change the landscape of the medicare advantage program and the coming years. and for more information, medicare advantage to conceal our resources. thank you. >> thank you. give mark the clicker there. thank you very much. here next from mark miller who is the executive director of medicare. most of you know that all things

medicare, including payment, access, and quality and is as non-partisan as you can get. mark himself has held senior positions in cbo and omb and at the centers for medicare and medicaid services. the non-profit sector. and i'm pleased to say he is a frequent flier on our panel. not as frequently as we would like, but we're happy to have you. >> thank you. i think it is going really well. >> not as smooth. what they asked me to do is to take you through the payment policy and the evolution and what is coming. that is what i'm going to try and do. i am from the medicare advisory commissions. that choice of managed-care

plans are private plan and traditional fee-for-service. we think that private plan is a tool that fee-for-service is not necessarily have to coordinate care and keep the necessary volume down. on the other hand, like every other payment we think that they have to be done carefully to be fair to the providers. also, to be fair to the taxpayer and beneficiary. some issues with respect to the the private plans. just to jump right then, the first thing i want you to get into your heads, managed care works like this. fee-for-service, its volume driven and uncoordinated. the supposition that managed care is we will come in, do a better job. with that savings we can offer the beneficiary extra benefits. extra benefits that were usually less cost sharing, and that will attract beneficiaries to go to managed-care and you will have this cycle of underbidding

fee-for-service and trying beneficiaries in. let me give you a sense of how that my work. this is of the old payment system works and how the new payment system works. of course obviously much more complicated because it always is . i just to work our way through this line, on your left hand side, let's imagine that there is an $800 monthly benchmark. the government says this is its benchmark. hundred dollars below it. under the old system they would keep 75 of those dollars. medicare would pay 775. and just working no way down the slide. the beneficiary would pay nothing out beyond their party premiums and there would be $75 of extra benefits. now let's pretend that also in the same county plan becomes and and its $840. in that instance there is no rebate, no extra dollars because they did not bid below the

benchmark. the government pays $800. then he has to pay $40 to join the plan and there is no extra benefit. you see the economics. the beneficiary should want to choose a plan als there is some superior quality. for the moment as soon quality is the same. they should want to pick plan a because the premium will be 09 it would get extra benefits. $64,000 question areas where is the benchmarks? now, to get this concept into your head now want you to get this picture. imagine -- not imagine, what is happening in this picture is that you take the counties of the united states and you are re them from low to high. basically what is happening up at the far right hand side is you have miami and mcallen, texas. everyone is going to hospitals and getting an mri and then down the left-hand side you have the northwest, the upper midwest for utilization is lower.

again, this is a stylized picture, but this is a managed-care proposition. they have a cost function that is not flat. it follows the line a little bit more, but to dramatize a little bit i wanted to make a crack. the point is, and high fee-for-service areas of the country managed care can be fee-for-service. in love fee-for-service areas of the country managed care may not be as -- may not be able to compete. i want you to and print this picture in your head because it is going to come up again. for example, in this light. let me back up for one second. the proposition this creates is where you set your payment. he said the payment to maximize the savings on your right hand side of the picture. or do you set your payments in such a way that you have plans in all parts of the country. in other ways, maybe you have to pay more than fee-for-service to get plans. well, the congress decided over

many years and over many pieces of legislation to actually plant those benchmarks well above fee-for-service in a low-cost fee-for-service parts of the country. the yellow line at the top. even in other parts of the country benchmarks were above fee-for-service pbgc the problem from a payment point of view is the plans stay below that benchmark. the gate -- those payments are, in fact, above fee-for-service. and so will we have for many years is a situation in which payments, given the payment away plans were paid to every time a beneficiary, at least on average, was rolled into managed care it cost the program might. suppling people out of fee-for-service into managed care cost the trust fund, cost the taxpayer. now, of course, plans offered extra benefits, and so this is very attractive. those extra benefits did not

come from the efficiency of that plan relative to fee-for-service . able to get the dollars and offer extra benefits. rapid growth in the industry. our concern is that it also stimulated love how you plans. we mean two things up plans that were billy -- bidding well above fee-for-service. we into the program anyway. clancy said at and say, i'm not even going to managed care. i will leave you with that thought and we kontakion question. we recommended that the p this. the payments system should be more neutral between fee-for-service the beneficiary could looked at these two and not be standing one single or

another that steers into managed care fee-for-service. it should be an equal signal for other managed-care or fee-for-service. i want to be clear. we don't think fee-for-service is a well functioning system. what we want is managed care plans to come in and do a better job. and soment congress took some action. we also said within the managed-care system if the plan does better on quality it should be paid more than a plan that those were some quality. those have more money to offer extra benefits and attract beneficiaries to the high quality plan. congress also acted on that. so the slide is the most complicated slight. i apologize. this is live set up the original one. congress is divided into counties of the country into four quartiles. this set the benchmark to different levels.

i am going to illustrate just two of them for you. so on your right in the light blue shaded area, these of the high-cost areas of fee-for-service in the country. miami, mcallen, texas. the benchmark is now transitioning to 2017 to a benchmark that is 95 percent of fee-for-service. in these parts of the country managed care plans have to bid below that in order to offer the beneficiary extra benefits. the program will save money in the beneficiary will get their extra benefits from the efficiency of the plan. however, far left, the dark blue, the benchmark there in 2017 was the transition to 15% above fee-for-service. the congress has made this decision that says in a low fee for service parts of the country we will continue to allow plans to pay court to be paid above fee-for-service. so in a sense they are giving

savings from the part of the country that has high fee-for-service and then they are using some of those things to subsidize plans in the low fee for service parts of the country. this is painful. we are almost done. agnon. i am enjoying this any more than you are. let's just be clear about this. so that is what congress did on the bench marks in the payments. and then not equality what they did is they said, okay. if you are high-quality plan -- by the way, high quality system that works on outcomes, intermediate outcomes, patients experience, some process measures. there are about 50 measures between na and the party part of the program. a couple of things happened if you are i star plan. you could identify it -- a bit of a higher benchmark. you give more money to provide and benefits.

and if you are of five-star plan , you get a greater percentage of that difference. if you're a five-star plan he keep 70 percent of the difference. if you are a three, three and a master plan you keep 50 percent of the difference. that means a high-quality plan will get more dollars to offer extra benefits to try and attract beneficiaries to them. there are some issues with the way this said been executed. i will stop here and take that unquestioned. thank you. >> thank you very much. a lot less painful than it seems c-span2 the inside. the extent we have the senior vice president. blue cross and blue shield association.

the 38 member of a plan in that association cover almost a hundred million americans including tons of medicare beneficiaries under medicare advantage plans. now elizabeth has been one of washington's help policy analyst for 25 years. ben l. envy, bin hhs. she's gone to tell us how medicare vantage works. >> thank you so much for that intervention. i appreciate the invitation to be here today to talk about medicare vantage. lacrosse is comprised of 38 independent companies across the country. plans offer coverage to individuals, small groups of

large groups. every zip code in this country. plans also participated extensively in the government program. medicare advantage, medicaid as well as the federal employees health benefits program. the offer medigap coverage. to use in the program. enrolled. the tune at million people, 17 percent of all medicare advantage beneficiaries. blue plans offer hmo coverage, pbs especially needs plans and we also have one in as a option. there is great value in the medicare advantage program, and i would like to outline some of the value. first of all, it is important to understand that medicare vantage enrollees receive comprehensive high-quality coverage and

benefits and services that go far beyond what people did in the traditional program. 2013, a survey found that nine out of ten medicare advantage beneficiaries are satisfied with their coverage cal and 94% believe that they receive very high quality of care. the feature of the medicare advantage plan is the coordinated care, and that is what is so important. in sure that people are receiving the right care at the right time with the greatest efficiency. fewer return visits to the hospital of. i would give you a few examples. from our own experience. medicare vantage. people want to make sure they're getting the appropriate preventive care and using the best practices said both treat medical condition and manage

chronic illnesses. the medicare advantage plans offer range of benefits not covered in medicare fee-for-service. c-span2 was that out of pocket cap which is a great value to make sure that you're out of pocket spending is captain you don't get that in the traditional program. but medicare advantage plans also offer many other additional services to improve in early coverage including medication management, health lines. just to name a few. finally it's really important to note that medicare is vantages service many low-income and minority individual. 41 percent of beneficiaries in medicare vantage make under $20,000 a year per -- compared to 37% in the traditional program. there's a very high percentage of minorities also receiving

care and medicare vantage. as a result of a coordinated care and these additional services and benefits, peer review research has demonstrated the high value of medicare advantage. i have several of the studies listed on the chart. i will just highlight a few of them. key findings include lower hospital readmission, better performance, better performance and clinical quality measures. in the last of the here by the national bureau of economic research shows a spillover effect to the community. greasy high penetration of medicare vantage, you can actually see lower hospital costs in the community. the traditional medicare program and to the under 65 population. so you are seeing better savings as a result of this care. finally now listed on this page,

but a study that i just became aware of a few days ago was a study by the boston consulting group which found a shorter hospital stays and better preventive care, and that was just released a few weeks ago. blue plans eyes seeing very impressive results. for example, blue cross and blue shield in massachusetts is ensuring that their knee and hip replacement members are returning home safely through home visits and phone calls to ensure they're getting the proper follow-up care. they are also seeing significantly lower remissions rates in both hmo and epo compared to the traditional program. fourteen blue cross blue shield plans across the country, a comprehensive program that identifies high risk members,

and sure they get the care they need to prevent hospitalization and keep them as healthy as possible. for example, congestive heart failure patients are equipped with wireless skills that set off alerts if the patient gains too much weight overnight. if so that patient is seen by a clinician and neck state to monitor and take care of that patient. clark did a great job talking about how medicare advantage payments are being calculated. what i would like to highlight our the ones that are ahead. there are accountable care acts including the direct funding cuts of over $150 billion over the next ten years. as you can see from this light, the cuts are being phased in with the largest cuts yet to come. in addition to the direct, they

include the new health insurance that is supplied to medicare advantage in release. the tax begins in 2014. $8 billion. it grows significantly each year and totals over $100 billion for the next ten years. the actuarial firm is not the person. it's a firm. they estimated that the tax will add $220 per beneficiary a year in 2014 growing to $450 billion by 20203. we think that tax is also unfair hmo, nonprofit hmo pay 50 percent of the tax while p.o., even non-profit a 100 percent of the tax. so there is a difference in the tax which we think is unfair.

in addition to the direct cuts that i mentioned, there are a lot of other cuts that are being phased in. the dca also included billions of dollars in cuts to other providers. because the benchmark is tied said fee-for-service spending, that means there is an indirect cuts being phased in to medicare advantage as well. cbo estimated $70 billion over ten years an additional indirect cuts because of this linkage. second, new year's eve also brought an additional $2 billion in cuts. and medicare advantage is also subject to the additional 2% because of the sequestration. and while not of funding reduction, starting next year medicare advantage plans are subject to new requirements for

a minimal medical loss ratio subject to 85%. .. >> on top of that regular

performance products with a lot of oversight for what it is paid for a and to make sure people understand there is a lot of oversight as well. private like to leave you with two points. first coming medicare vantage plan is committed to continuing to serve medicare beneficiaries and to build upon the current system to improve quality to rein in costs. we are proud of the job we doing that really think we can do better and we're striving to do that. we are concerned that already schedule funding cuts are likely to lead to increased costs and reduce benefits and access for beneficiaries. public for to talking about that. thank you.

>> thank you very much. says she was saying the medicare and advantage program is operated in the private sector and part of the answer to the question that is posed in that part of the briefing of the future of medicare advantage has to do with the private shareholders perceive that future and fortunately we have in my notes somewhere a perfect addition to the panel. final speaker is colonel mcdonald. he is a director and senior analyst, the managed-care industry for several leading firms to take a clear eyed

look at the future of medicare advantage from a business standpoint. >> great. i was tasked with the question whether or not medicare advantage is viable over the long term to talk about the finding challenges that we just walk through if they will be able to thrive and the answer absolutely is yes. the key factor to think about is competing against said an efficient program they have the it a bit -- ability to serve cost as the fee-for-service program is a big turnsole to give a specific example medicare advantage can make sure seniors have a primary care physician someone they can go to for care relatively inexpensive way as to showing up in the emergency room. the medicare advantage plan

with the fee-for-service that attempts to do with the melted success. of up one negative an example is constantly providing there -- reviewing their provider network if there is of specific doctor allowing more than ever betty else with no reason they can eliminate that doctor from the network these other ways that the companies can be more refashioned. i should be more specific but the way things set up now medicare vantage can absolutely be viable in urban areas like miami, los angeles definitely more of a question whether medicare advantage can survive some other role markets that in terms of the way it is set up as well as the ability to control cost. as you look at the last '03

years with the cost increase generally in the three or 5 percent range, medicare advantage cost increases have been close at zero or 2 percent over the last couple years. it has been a significant difference in across trend in the last couple years so as to think about where medicare advantages going to understand where it is today to give a summary today with 40 million people with risk plans the average payment is $94 per month taking about $155 billion of revenue. on average they pay roughly 85 percent of those dollars with hospital doctor drug costs that is close at 85 percent medical loss ratio. 10 percent of those payments

go to the sca, that ratio is in the low single digits the difference between the fee-for-service and the medicare advantage plan is spending some of that is salary is the rest is the care and management programs i was talking about to keep people at of emergency rooms , fraud abuse and that is what that is and the private plans on average earn a margin of five 1/2% what is interesting if you would get the pay rates of the medicare advantage plan over the last five years they have not gone up a single year. the base reimbursement has fallen with four 5% cuts and a couple of those years. this is not a totally new environment they are working for the reimbursement reduction everyone of the

last couple years. if you look at the period between 2010 and 2014 despite those cuts the enrollment has accelerated and margins have been between stable and better and the benefits of the plans offered to the seniors have been relatively consistent. another indication that the plants have been able to mitigate these rate cuts through the cost saving mechanisms that we talked about earlier. this is a chart from he amanda that breaks the enrollment into the four taming quartiles. up fifth -- of the left is 95% but the cream bar on the bottom is the people that have benefits that are better than fee-for-service. over that three-year period that benefits have increased to that point* despite the

rate cut the benefits have been stable to better that is relatively consistent across all quartiles of the urban areas. the ability that the plan has to save money does vary quite a bit. these are ximenes statistics and what it does is bring down the membership in terms of the provider reimbursement that they have so one-quarter of their lives is where the doctors and hospitals take on all the wrist. kim and is paid by the government and they turn money over to the hospital and doctor is up to the provider to give the managed-care. in those situations so that goes back to why it can be viable if you scroll to the

bottom those that have no incentives they can generate only 9%. so that would be the extra benefits so that helps to explain why companies like amanda doing everything they can to move more people into the hmo product where providers take risk. even to the point* that he man among other companies has started to buy up doctor practices. we have seen a couple of those acquisitions across the industry over the last couple of years. this is with the publicly traded companies with the products so they are significant differences on one end of the spectrum so

almost 70 percent is hmo product very little of the epo where somebody like him amanda has a little more of 40 percent is an hmo. if you look over the environment over the next couple years with the rate cut is much easier for united with a lot of hmo and risk sharing to work to the cost they and for a company like humanity or universal american to have a significant amount of membership in rural areas with providers to have no incentive to keep their cost down. one thing that becomes significantly important but the star bonus payments with the medicare plans with the increased payments. starting in 2015 you have to

get to the four stars to get the 4 percent bonus payment if you are a three-star plan then you get a bonus payment but if you don't get half for stars to get no bonus payments so that means if you are at three or 3.five start plan not only do not get the 4 percent bonus payment but as mark manchin and you also get less of a rebate if you bid below the benchmark. so roughly you could have a $50 per month differential between one plan that is four-star rated and one that is not. that is significant amount of extra benefits that the four-star plan can offer seniors. and these do become all-important -- more important here minute is one

example is just under four stars they are in relatively good position. somebody like welfare who is under three stars at this point*. it operates specifically in the hmo market in south florida as one big market and it will be extremely difficult for them to compete in that market in 2015 if they are not getting bonus payments and everybody else continues to. i will stop there. >> you now have the opportunity to join the conversation. if you are close to the microphone and keep the question brief. if you have a question to right on the green card, hold it up and someone will bring forward and we

will spring it on the panel must. i believe you were first. >> ellis said it is great job i'm sorry i am from wellpoint. she did a great job to compile the successes but one of the thing of the final call was to change the risk adjustment that it will impact particularly the low income and chronic needs folks that will need chronic care special needs to the eligible plans. and to the actuaries the impact is a reduction and reimbursement almost equal to the growth factor increase that was ballyhooed in the press.

has the medpac had a chance to look at the impact of the risk adjustment calculations ? >> we have done when cms put out the call letter we had a comment on that change and we were concerned about it to we were concerned cms had mixed the coating adjustment with the risk adjustment and really thinks that should be as accurate as possible and we felt there was mixing of the coding changes so we suggested they step back to not implement that right away and what we have done we have not gone to that analysis but to talk about in the june 2012 report we think there does need to be improvement for these types

of populations and we've made a set of recommendations rethink would tighten up the system. where did that guy go? here he is and we do think there are adjustments that could be made to take food distribution for those who need the chronic condition payments we have a set of recommendations which we have been saying that they should pursue due to go after that particular problem. >> this is already out june june 2012 i was supposed to say during my talks that they are in the march 2013 report but i forgot to tell you that. >> i am a primary-care physician. dr. poplin. with the 20 percent of the

medicare population is responsible for 80 percent of the cost. in the early-- medicare advantage there was a concern that cohort the population attracted to medicare advantage was healthier than the population of the fee-for-service section so that the cost would be lower and i was wondering do you check for that does anybody looked at that? nobody has mentioned it. >> i think there has been some examination of that issue that has found overall the differences has narrowed over time as with most recent studies have found although that will differ

across the white country so that is something to consider and i think more research is needed to examine that as well. >> initially there was no risk adjuster that has been added to the program and made a significant difference as well that appropriate payment is made for those of chronic illnesses and what you see with the medicare advantage plan is on coordination and emphasis on primary care to make sure those individuals get the right care. >> is there a discount? >> yes. lower payments because of the risk adjustment. >> i would have said the same thing. there has been narrowing of the differences but there are three recent studies

over the last year there still finding lower risk profile for the beneficiaries. >> i am with medicare advantage news of itasca the degree to which beneficiaries are using vestar ratings to make those decisions to be see any change in that and the most recent annual election period? and what is that likely to increase. >> basically zero. seniors don't care. the examples i would give with a low performing plan under the three stars they are a letter to give an opportunity for a of election period to move to a higher plan very few seniors choose to make that move so

'02 care about premium within zero premium plan and then drug coverage, a primary-care co-pay, , etc.. but the point* that i made in directly you get extra benefits to the fire plan and with those options out -- extra dollars you can offer lower premiums so there is in direct but generally the seniors don't care. >> you don't see that changing in the next couple of years? >> probably not. >> i will follow-up to the star rating system and that is what kind of measures of provider quality are included in net? is a system for the beneficiary to know about

the providers beyond satisfaction and other factors? >> part of what is included in the star rating system are measures better quality measures that measure things did someone get the appropriate tests they should have received? preventive care, and a measure such as that that should be correlated to the quality. other measures are those as patient satisfaction and also to administrative measures included in the star rating as well. so there are others in terms of whether or not they're doing what they should be. >> but not directly the position? >> i am familiar to its foundation i have a question

about enrollment in the future. and 2010 the hatchery said the ac a would receive enrollment by 50 percent. >> please stand closer to the microphone. >> enrollment would decrease by 50 percent but then the cbo said at the end of the tenure 11 million people would be enrolled in medicare advantage now they say it is 21 million in 2023 which is nearly the 100 percent increase of which of course, has the reductions. i know you're not with the cbo but you have any idea why they have changed the moment projection? >> they have not given an explanation that i am aware of what drove the change so i am speculating but historically cbo has not assumed any cost savings so all they have done is look

at projected payment rates for the future period of time to make assumptions about that enrollment so to have that kind of swing they have to be looking and efficiency that they can realize. >> my perspective is these numbers are directionally better although little optimistic given the payment challenges we will face over the next couple of years. >> i will take this opportunity not to answer your question i don't know why they change the estimate but i will pick up on what karl said that might be implied why people like him and others are looking out. i am often asked these things to be the unhappy guy and i am sure i accomplish that but what i want to say is actually is there is good news and i think from his

comments they get to it. under the old payment system where benchmark was set for fee-for-service now we're getting average bids of managed care 104% basically the private plans were saying i cannot provide this benefit as efficiently as the traditional fee-for-service and as a country we were paying 10% above for that privilege. now under the pressure of the benchmark and certain plants have been moved out of managed care environment in the private fee-for-service plan you now have much more focus on the plan that actually can deliver the benefit more efficiently the average benefit is 96% and managed-care plans can provide services less expensive than fee-for-service but the question is if it is a

program we take advantage of that. hmo average bid is 92% and this is why i think we try to move people into products to control the expenditure is why you see that have been. maybe that has something to do with people looking for with projections thinking they may be viable in that environment but that is not if -- officials from cbo. >> when you get your members together to you here optimistic or pessimistic views? >> when you look at the numbers that are out there in the years to come it is hard to see how you can keep the level of service, the level of cost sharing and benefits stable because they

are such huge cost ahead so it is a big concern how people will want to work hard for their beneficiaries because it is critical for older people they get scared. my parents were in the medicare plus choice in the '90s and they called me every day. it is a huge problem for people and premiums go up for they have to leave the program because of funding cuts so we looked at those numbers and they are concerned and looked at sgr in september and then they will have managed care again so it is a concern that tax is very significant so a lot

of work and we will continue using on what we're doing with the private sector to translate that into the managed-care plan. >> it is helpful to think about the existing program verses new seniors that could potentially come into the program. but for those that already in the program plans can do whatever they want and they will not leave prepare you can raise premiums as much as you want, cut benefits benefits, and time and time again it shows they will not leave and go back to fee-for-service they will switch to another plan but even then back in the late nineties or early 2000, the seniors left and went back when the plan pulled out of the market. as you think about the growth of the program and think of the cuts it is out

attractive medicare advantage is to the program now. >> george? >> i am with amblin health plan of new york. for better or worse rehabing contacting with medicare 186,000 medicare advantage members. with baffle background and modest yet have never heard so much i can disagree with. in particular, the tone of the optimistic enrollment forecast, if you forgive me come on page 13 of your excellent report, the optimistic sense fact that enrollment continues to grow. i am sure ginning that sentence. in your report you point*

out 35 percent are in high fee-for-service areas. and a high percentage of those are in what we call zero premium plans. most of these are in urban areas serving people who cannot afford medicare supplemental coverage. that is a big part of the constituency. the other part that you have not talked about is the employer members who ag and. as projected the rates of those urban areas to go down a 95% if you add to that if the data that alyssa gave you on the impact of the cut, several of the cuts cuts, we've just gone through the exquisite pleasure of presenting the bid to cms for next year.

how can you make these optimistic immelmann forecast? nineteen missing? the comment you can charge anything and people will leave? on sari. 40 percent of the membership is employer based. they are very price sensitive. they will leave depending on price. those low income people will leave depending on price. maybe somebody on the panel can tell me what i am missing but when we come back to the presentation the future of medicare vantage i have been doing this since 1971 i am very pessimistic so when reminiscing? -- what am i missing? . .

no overall most plants of looking at something in the vicinity of the 5 percent reimbursement that. in 2014. now if you're assuming that cost trends will rise a percenter to then these plans are facing some more in the vicinity of the 700 basis point headwind. down 5%. cost trend up. plans will be allowed to adjust the benefit in most of the region to be able to absorb the bulk of that. there may be of the bid of margin pressure as well, but the embarrassment