route? have we really change the behavior? maybe it did start with the recession. have a change behavior or are they so concerned about this? >> i would think that is a uniquely washington question. when you get out in the community, it is a devastating burden on employers, both public and private. my daughter still pacer increases in premiums for teachers this year. we have major trade-offs and what we'd invest in infrastructure education. it is a huge burden. being a public employees got flat funded. they haven't had raises in five years. it is absolutely challenging that beset her of our economy. >> i would add i think it is very not good to see between medicare costs are way, way down because it's not quite

sustaining forces. but it's no time to rest on our laurels. we have many others pressed that now is the time to keep the progress going, keep moving forward and not to expect the trend will continue, but to get ahead of it and keep moving down the path. >> i think from our good, certainly after the economic downturn, we did see a slowing in the growth of overall costs and medicine. do we believe, 18% of gdp is health care. the unchecked prediction as to be 25% of gdp by 2025. now is the time to impact occurs. although lucena moderation in growth were recently, we have seen a spike again. so i agree it is time to really focus after -- as part of the implementation of the affordable care to really focus on cost.

>> agreement on the send? >> yes, i think so. one of the concerns be seen as slowing the rate of growth in that occur in particular, we have allowed vb programmers in the medicare system right now. 65, 66 years old relatively low utilizer's at the population as a whole. 15 years or not, baby boomers will be older, needing more services. so i did or said that by bipartisan policy center of worried some thing now to change the trigger very. >> yeah, i agree with everyone and what they've said. we need to be explicit about what we are tackling. if it comes by that we start talking about it and get 3%, i know especially with other speakers before us we can do better. there are things that the plan level, provider level, patient engagement we can actually do better. >> okay, great.

frederick is here from the nga. he's going to join us. okay, so we are talking about costs. so what is in the aca that is going to reduce costs? what do you see -- i would like to hear from me should you just very recently, what do you see that you think holds the most promise to reduce cost, just very briefly. let's start out here with clifford. >> so i i think the big thing we talked about this morning is access. you get the ability to take care. but we have to focus beyond getting access and it's really the care we are giving it a lot of the panelists talked about that. how do we give good quality care, how do we measure it and how do we us to make it efficient and decrease the cost? it is going to be involved in public reporting, involving measures and measured about and

as different scales and what we have been doing until now. it is going to involve data and data will be a big issue in technology comes in. so it's really a collaborative effort of many different plants come in many parts health care to get the plan underway. >> and i would add to that, the provision is in the affordable care act. if you look at that language, give the secretary of hhs unprecedented authority to particularly see that as a driver of health systems change. provided for the first time the secretary of the authority expand demonstrations very abruptly at the medicare program if they both control costs and result in improved quality of care. a lot of folks look at the demonstrations out there and see some this may be more successful than others. this is really the start that program and the start of those

staffers. but those can evolve over time. the secretary does have the authority to change them. >> we will get back intact in greater detail about the cnn i is doing with his greater initiatives in detail. >> i would just say when you have 40 million to 50 million americans uninsured, now we have an need to bring the vast majority of americans into coverage, whether it be medicaid, a subsidized exchange, the commercial exchange, additional medicare advantage members. we have an opportunity to put them in a managed care model that truly impacts wellness initiatives, preventive care initiatives and excellent medical help and that's where you can begin to drive down costs. >> i agree fundamentally with that appeared to focus on value and accountability is the real, real change. this is not an easy thing for institutions to adapt to. its major change in health

systems in this major cultural change in the hospital or whatever the situation is. that focus on accountability, on value and moving towards focus on the person at the center of care and working to get costs down for you to equality up for improved quality is a major improvement. the affordable care act included a number of provisions, for example, and putting risk varied aspects of hospitals. hospital acquired infections, rid should, all kinds of things like that. those in combination or six as a kid. there is evidence on the hospital acquired infections with some incentives are actually beginning to these people to really focus on those problems and the infection rate has come down in some cases, at least in one study i saw in florida. but the hope is that will be -- the central theme will expand and that will keep moving over the next few years.

>> i think we've quantified over and over that up to 30% of what was spent on health care isn't improving health. we can change how we deliver care and pay for care and really reduce cost of delivering better care. as much as ever with talking about insurance coverage that's critically important, the real opportunity is the delivery system change and payment reform that enables better care. patient center is a great example. these are emerging around the country in part because the aca and cnni. we see up to 20% reductions in hospital admissions because people get the right care the right setting. they have data. they have support. so we can improve care of simultaneous improve cost. >> i would just pick up the same theme and say what we've seen is a real energizing a tivo for governors, discussion about this as a possibility.

aca provides new tools for governors. we see action around new policies like purchasing medicaid program, enhance quality metrics come at you like that. teaco's unbundled payments, sites that are also delivers governors kenya's to drive down cost improved quality. even more exciting than that is the energy of the state level is governors thinking strategically about their entire system and how we drive towards a system that operates in a more efficient way. you see a lot of the work going on at 25 states around the country is about really taking an honest and deep assessment of the health health care system wn the state in determining where are the right places to drive towards higher quality, more efficient care. at another level, were personally get the most excited

is governors are uniquely situated to pull a whole array of lovers. you see a lot of governments think about their health care system in the classic market distortions operating within their system. things like asymmetry of information or monopoly. they think about the lovers they can pull to increase supply or drive towards transparency so you have modern point consumers. so the conversation going on now at the state level has become something much broader than even the new policies that the aca, that's really about how do we take an honest look at all the problems and distortions we have operating in our health care sector and try to address them? >> coaches like to to add to that. health care reform can have there from washington. it's going to happen at the state level, regional level, working with physicians, employers and health land to change how they deliver care. i agree there is a momentum on

the ground that hasn't been there before. in addition to the state government, bringing all stakeholders together to say how coming you do this differently? so there is momentum for change. >> and i had to that? when you think about bringing different stakeholders, here we have the respect consumers of news and commentary throughout the country. the blue cross blue shield association tour is 37 members covering over 100 billion people in the country and the ama, the major advocacy group for the position at the very core of change coming together to have this transformation discussion. whether it was the aca for a moment in time, we see the opportunity to bring different groups from different perspectives together and figure out how to do this together. >> i couldn't agree more. everyone on the panel more or less agrees with the thrust and the basic notion of value person

centered and improving quality. you see it reflected across the board in our organizations, both catherine and i are concerned to touche and collect them in the curve in the focus on that. everybody in town, the bipartisan policy center, everyone on the health policy side is more or less in the same place on this. now is the time not to rest on our laurels, but move away worse models of care that and still more accountability, better quality. >> i think you see that across the political spectrum as well. i've been working out alessi for 25 years. both democrats and republicans. there's always been a focus more on the conservative side to control entitlement spending, but in particular you begin to see more focus on the left because they realize now with increased coverage there is even more stake here and it's more important to control costs in the short term and changed the weekend so that in the long

term, coverage is sustainable. >> you certainly see that in the governor's context as well. people like to say, there is no market anymore for high cost quality care. spend less and get more. governors probably more than anyone else feel the fiscal impact of their health care programs, strictly medicaid and are looking for ways to drive towards better outcomes for constituents, but lower cost to the taxpayer. i do have to say, this whole discussion about the migration to risk and payment transformation holds a lot of promise and we see early results were as a young release the payments on this fee-for-service vehicles into something that allows providers to become creative under a global payment, where you figure out what she did the right is. if you save money, he'll make money. if you spend our money, it will cost you money. that is a powerful concept.

we also know that there are some real market forces at work that are fighting that migration. you got a lot of competition issues. if you have markets where you have prepares consolidated or providers consolidated, that can really stand in the way of these things catching hold in transforming the system. so you need an actor like a governor to step in when they can and say look, we need to push past some of these classic competition issues. i give you a really simple example. data. right, everyone in the world thinks we need to be more interoperable so providers can make the right choice for the patient at the right time. the problem we have is there's a lot of competition issues around data. by the two competing share data? sometimes you need a leader to step in and say this is more important than political concern of the market. if we hold his hands together

and jump in and everybody shout that it was, were all the same place. you need some actor to get in their push people to move past the political concerns holding us back for decades. >> i would applaud the governors for that. but i think it's been driven by the private sector. what is happening is you've got the systems built on the provider side that have incredible patient medical records. you have all the claims another data. there's really out for that force by government, but because these different parties are coming together and saying how do they get, as you said so well, the right information to the right clinician to put the person the right care at the right time in the most efficient way. it is a combo between government led by governors in each state and also the private sector. >> elizabeth, as you jump in, can you please explain what it

is you are involved in? >> certainly. the regional health improvement collaborative have about 40 run the country, 32 of who are members actually working on the ground. their natural conveners, nonprofits to bring in the employers of state government plans, patients come in unions to try to solve this in a practical way to implement change. some of the governors who believe this, not everybody does. so we are also seeing private employers step up and say we can't take this anymore. you're absolutely right. people want to pay for value. how did they even know it? how do we know if we are getting high-quality appropriately priced care without transparency? that is another element of the aca that is enabling transformation, to really make sure we had data, that we have measures that are meaningful and people can use when they do try to push value. >> let me ask a question about

data. do we have -- are we getting the kind of data that we need? look, this conversation was supposed to talk about aco's. we look at there. as long as they talk about has the aca said it's up so that providers at the community, the health care community now has all the data it needs in the exact form that it needs to do what it needs to do? are we there? >> i will start off. i run a number of databases at the american college of surgeons from the cancer database that was talked about earlier from the american cancer society at 80% of the cancers in the u.s. are a bunch of surgical outcomes databases. a quick answer is no. we are not there yet. but we are getting there and we need to figure at how to get the correct data engadget without burden, without a lot of

resources needed and whatnot. but that depends on what we want to measure. that depends on what our vision is for the health care system should be. once we put a magic out there, what we found have found in health care and particularly in surgery is that if you put a number of their government people look at it or get hired. we have some measures nobody believes, but everyone is at 90% compliance. we know as soon as we put a metric out there and start collect and good, believable data, believable for everyone on this panel, believable for providers on the front line that that's where we'll get better. it will be predicated if we have the right metric for now. and we have to collect that data well. we have to do it accurately because if it's not accurate, people leave the room and we have to do it efficiently so that is quick -- we don't want data from two years ago to say how i did two years ago. we also have make a break adjusted the different

heterogeneity of plants and systems in hospitals need to have a level playing field so that we think it's fair. a lot of things are data issues. we are moving in the right direction. >> i agree completely. when you're from providers as if i'm in five-minute countable payment model, i need to know where i had on a real-time basis or as close to real-time as possible so i can make the adjustment i need to make to hit the target. the circuits are financial, but also equally important, quality. the development of quality measures to get the agreement on them and the ability to implement them quickly in a way that people can report and know where you are, these are critical. i guess i would: infrastructure. it's really necessary to move to the kinds -- [inaudible] >> i have to say this is one area, especially the commonwealth of pennsylvania where the senator has run the

charge. and really putting the money, public monies together to form health information exchanges to truly get to the point of everybody sharing the same data. i would agree, however, that at a macro level we are still struggling to put it together and have a totally real-time story. but if i can give it very briefly one quick example, we are at independence blue cross co-owners of two brothers and a company called the merits called now than it. now the net is their position portal for claims processing. that's how it started. now it's getting into some critical things. it is agnostic and other payers use it in providers offices. but we find is the new company that is the majority owner, they have -- they are health technology company. they have fought the acl tools that he positions physicians office needs. they put that in a practice,

which is a patient center medical on prospects, where people use data coming in and engaging members one other time. we see a significant impact on overall cost. people are getting care at the right level at the right time. >> i agree completely with the panelists. i might frame it differently. let's take a giant step back and say where are we at data? we have data systems that go along with this solid fee-for-service. we have data systems that do not communicate with each other. within a hospital or health we can have five different data systems. none of them can act as a system that rates prescriptions for the nick io, et cetera, et cetera. i think as katherine pointed out, earlier this is a terrific issue and is utterly bipartisan.

one of the big moments of the bush administration that has a real drive towards trying to unleash data with the office of national coordinator was conceptualized. you just saw the obama administration pick it up in area forward. the aca underscored what had our dependence started and kept everything forward. what we see this an actual paradigm shift coming out of the administration were we move away from thinking about data as some is simply used to pay a claim or some thing like that, but this is a tool we have to unleash and allow people to utilize in a meaningful way. i will say this, i think that there are a lot of smart folks out there who have a lot of concern about getting past some of the competitive pressures that stopping us from falling. we should all be really aware of the fact that at the heart of it there are two -- providers and payers are turned to serve their patients. they are trying to serve their

enrollees, but they also have competitive pressures. we need to make sure we set up a system that allows them to move past the barriers with an understanding of what competitive pressures are. we can't underscored this enough. if you happen to live in an area that's heavily consolidated, payer provider, you could have responses if people don't step up and put his past these market concerns. the >> so i lived through some of the samarra very real. you cannot sugarcoat getting people comfortable with sharing data in a competitive environment. it had been an advantage is correctly to have your data. you cannot have physicians to manage risk of that information. it's not fair they can't do it effectively. we have got to change how we think about data ownership. it must be about improving patient care. in the aca, there is a provision that is often a sleeper, but the

quality certification program is allowed communities to have access to use it for these reasons. there's a lot of opportunity there. >> one reason it's called a section 10332 -- [inaudible] what is that? >> transparency is the big issue of getting data out so everyone can see it. >> that's one of the big challenges coming from federal policymakers at their are so many silos that are health care system to begin with, but there is sort of the data system and the financing people. there is not a way to bridge those in an easy way, particularly when you talk to a federal policymaker, their eyes start to glaze over with health i.t. and data. one way to breakthrough that is to talk about how the data can be used and think about how it can be used to help consumers and other purchasers make meaningful decisions about what high-quality cost-effective care is. that's where we need to make a job. >> it can be done in a very hip

a compliant way. you are not drilling down so the specific member, specific patient has more population base. >> let's take a step now let's talk about specific initiatives that were created in the aca. let's talk about the center for medicare and medicaid innovation. it was created by the aca. it has $10 million over 10 years to quote come and test innovative payments and service delivery models to reduce program x amateurs while enhancing quality of care. so there are many different varieties of initiatives, but most of them fall to the accountable care or patient centered medical home category. several bundled payments and there are several varieties of

others. so i was hoping that the panel could talk a little bit about let's start with teaco's because we had some recent evidence, some findings come out from the pioneer aco that showed some savings, showed some quality, that had some quality findings. so what does this tell us? by the acs this answer? is this where he was absolutely headed? we had aco's better part of this initiative. we had aco is not part of the initiative. what part of the future do they hold for us and then again, i'd be going to be a big part of breaking down cost for controlling costs? big question. who wants to start? >> telstar. if aco's improved population

health, that great. a fuss about the structures in the outcome. i think what they have done is encourage people to really have peripheral vision. attack to cardiologists who are now talking to nursing home operators because they are responsible for the continuing care. that didn't happen before, so i do believe we are going in the right direction in terms to reorient into the egg dionne just the facilities, so i think that's positive. i also was struck by their reaction to the results of the pioneer because typically used by budget systems improve quality and reduce costs, that would be a great thing. i don't think we should understate the achievement started in the field. it's going to take time as a heavy list. >> it is going to take time because the economic model has to shift. if you look at a pair perspective, we have to be more comfortable sharing the management process, including data as you said earlier.

in the provider side comments got to be less about volume and more about collaborating, getting people to the right. it's a major shift. >> i agree completely. one of the things in bending the curve report was medicare comprehensive care. i think bipartisan policies envisioned almost the same thing. the idea is to moving in this direction and accept people moving to these bottles. you have direct maze is a fairly major adjustment for institution to do this. i had the pleasure of going through a rather large economic institution and much was happening at the position model can safely that is quite remarkable. i think the results i agree with elizabeth are a good more class households and glass half empty. 40% of these pioneers save money. almost all of them beat the industry benchmarks on quality. most of them are still there. this is done? no, it's not done.

we need data infrastructure improves they know where they are in a real-time basis are close to real-time basis and work and quality measures to keep it at full quality level one of the things we can contribute to this is to look for everything we can do to move in this direction. whether it is in preparing a substantial gain -- excuse me, the sgr system comes sustainable growth rate system and trying to use as a mechanism to help move us forward. wherever we can try and get this ball rolling. >> i think again i agree with the panel. it is interesting because what a good concept. we finally are getting off this crazy treadmill. talk to any provider operator in the u.s. right now and they'll tell you how fed up they are put to create a treadmill-based care. how many patients you see, it's

overwhelming the current system. so let's get away from that. that's created global payment, share risk and allow you providers to make your best effort to keep the patient healthy or get them healthy. we have some real problems to face here. first of all, as folks have mentioned, we talk about taking our system from fee for service to this whole new payment system. that means you have to change your entire cost structure. so for example, you have to stop thinking about yourself as a hospital in how to treat patients most effectively, most efficiently, create good primary care and outpatient services that are more efficient, et cetera. on the other side comebacker multispecialty group, but got to think about the competition. that's tough. ..

from volume to quality, right? switch id to population health. 50% isn't going to do it either. we are talking about to actually swap the fee-for-service economics and move to the health delivery system you need to have most of your business coming in through the risk base and right now we are nowhere near that across country. remember evin and payment systems like medicare we were we

might have them mco they are not paying most providers they are paying fee-for-service and medicaid most patients and the enrollees are managed care providers are still getting paid the fee for service. so we have got to actually give the aco's in the country the ability to go fully at risk for most of their patients. >> and i think that's going to take time. it will definitely take time. >> it will definitely take time across the country as a trend. but the one thing that a lot of providers out there in the particular health systems and large groups as well or jerry scared of is that one health system in a market that gets it right early, and if that one system gets a contract and that risk they are going to be the subject innovator. they are going to shake up that market. that is one strategy that might work which is to plant the market in tucson or chicago or

boston and allow those that are published and you have heard the stories. they are amazing, right? my mom had a whole character of around her. it's everything you always wanted in health care but we have to make sure when the providers are going full steam in the population we can get them in a multi pay your payment systems that support them on the commercial side and the public side unified to be dead market. >> i agree with everything the was said. my point is we believe it is more difficult in the reversing a lot of information on the large system level. but we think the next this point, where this is going to be driven in the physician's office and get back to developing a relationship with the patient centered medical home where you

have a set number of appointments and appointments that are open and an emergency situation that would have gone to the emergency room but now can come to the primary care physicians office and you begin to look at things from the more quality-of-care than sheer numbers and if the physicians get it and understand the payment model was reading those quality standards, meaning yes those efficiency standards, quality first that ultimately it will spread throughout the health care systems, which are for somebody focused. >> i think we are all pretty much cautiously optimistic. and i think it is going to depend like everyone is saying this is a new paradigm of the way we are thinking about health from the single provider in his or her office to the system and to the community. once we start to develop -- and i keep on harping on the metric because we all get measured. and if we don't get measured we

need to get measured because then we need to see how we are doing and provide metrics. my model is dementia or my brother that has diabetes. we need to collect that data and we couldn't agree more. again this is with insurgents and so that might be in now supplier. hospitals to improve the surgical care if you are going to improve something don't try surgery. a lot of things that happened the first year do not sustain the second year or things that don't happen in the first year it takes more than one year to do it. and so whether this is a call for not affect or it's going to

be better it is too early to tell. but absolutely, we are moving forward. >> i think we are all in agreement on this. i think the key point is it is going to take time. leaders came out with a report in 2013 and they rely primarily on the organizations i would call enhanced accountable care organizations because we have learned a lot. there is concern in the current model that there aren't enough incentives for providers to move in that direction or the beneficiaries, the existing model to which the patient or attributed rutka bayonet rolling it makes it difficult for certain groups to managed care when they don't have control or any way of communicating with other providers or even knowing where these beneficiaries are going for care and it makes it difficult so one of the things leaders recommended was an

attribution base model on dimond attribution based model accountable care organizations and again recognizing that this would likely be available over the next ten, 1520 years. it's not going to happen overnight but given the medicare beneficiaries a choice remaining in the existing fee-for-service program and enrolling in the medicare and advantage plan and providing an incentive to was a beneficiary and providers to move away from fee-for-service. the approach that we took in terms of incentives to beneficiaries is a reduced medicare premium for going into some sort of organized system of care. and to providers with the ability to share in the potential savings but at the same time putting a freeze on the medicare fee-for-service. they recommended fixing it, but for those patients that remain in the fee-for-service, you wouldn't see the update on the

accountable care organizations to encourage providers to move in this direction. but again you have to give the secretary the authority to provide updates and fee-for-service based on a variation from region to region because this isn't going to happen overnight. you have to give the secretary the authority to provide updates and fee-for-service over time but at the same time, we ultimately have to support independent physician groups and a provider's groups generally. physicians give them the tools they need whether that is some sort of administrative assistance to help them move forward and move. >> if people stay healthy and no one gets paid. we are asking them to shoot themselves in the foot for doing the right thing for patients. that doesn't make sense. so if we change the payment and to go to the global payments and there is room for innovation and

improvement, i think that is our only way to really enable the delivery system reforms we are talking about. but with the purchasers are concerned about is i'm going to write a blank checks. how do i know and that goes back to the metrics. we have to have transparency on the cost and quality and safety and patient experienced. we get the metrics out there and then i think you can get much more flexible about the structure. maybe it is a medical home or community care team. it's about are you improving population health and can it be demonstrated? >> does it not matter whether it is a patient centered medical home or if it is a bundle to payment i know that is a little different and that isn't the infrastructure, but does it matter? are they all going to reduce the cost? what should we be focusing on and what is showing the most promising evidence at this point? >> they are all tools that can

drive down costs and drive up quality. so, again for us we are looking for things that work. changing the payment model we have gone with our entire provider network and the pay for performance model and it speaks to the quality metric. it speaks to the outcomes and assure the initial up front payment is held steady and will reduce slightly what we found both in our individual clinician practices and the house system as a whole. if we do these things together because we are sharing the data we are seeing the data driven outcome than the payment is enhanced and therefore thinking slowly but surely shift from the traditional pay for service or fee-for-service. >> i would add not everybody is ready to get on the escalator at the top in the middle and at the bottom and a different places.

all medicine in this country is local. if you want health care market exchange and so that different places at different providers and different levels of this you need a variety of options to keep people moving but one to keep them all moving up the escalator and that is the point we all agree on. you want to keep people pushing up the ladder towards more accountable care and more personal focus, lots of metrics. metrics are the key to this. we have a long way to go in terms of the infrastructure. >> so, throughout all of this restructuring we have a lot of consolidation going on. does it matter who is in charge and who is managing whatever structure we have going on? and i would like clifford to answer the question first. >> who's in charge?

[laughter] i guess i can hold my tongue a little bit. as to what a lot of people are saying, one thing lesson we've learned in using a bunch of hospitals or system is exactly what you said. you see one system, and you see one hospital it's very hard to take something that works in the mayo clinic and even the cleveland clinic we just did a collaborative but it didn't work. i think it's going to be a different model and the system should support some structure but some individualization. and for who is in charge that is part of the individualization. >> the key is moving more and more of the payment system up the escalator in the direction of more accountable care. >> i think it is less of who is in charge and more about every spoke of the wheel having a say

in interest and sharing the same information and pathway. that is over simplification because it is a very complex health care system. but that's what it's about, everybody respecting each other's point and coming together to find the best way to move forward. >> that is the vision i think we all share. we are working with a lot of governors on building these systems in the state. it's interesting. i think who should be in charge -- i don't know who should be in charge but you know who's in charge? the economic incentives. should it be a multi specialty group for health system? there's a big war going on in the country right now by who is going to be the aggregate for of the rest and sort of managed the whole continuum of care and i think on that one is just as you said. we've got to keep this

competitive. let's make sure the options the open and who gets it right because as we were saying earlier there's strong incentives to not change because they have an entire infrastructure in the fee-for-service. however on bug group if you have a whole set of economic incentives for those other specialists and use a certain level of volume that is a very powerful driver if the system goes faster and relocates the structure and gets efficient, if a multi specialty group gets it right and really gets involved they are going to be in a terrific advantage .2 impact of a delivery care but the bottom line is it is the economic incentive that is going to lead the way. whoever gets the cost structure right and is ready for the transition those are the ones we want the land. one last question.

there are few economists out there who are talking about the formation of aco's and other arrangements that have because of the consolidation that has come from that, they are suggesting that this could and may be starting to cause monopolies to form that could actually cause the prices to increase as opposed to decrease. is that possible? >> yes, it's possible. again, getting back to the point that has been laid over again and again that you are in one market let's take the commonwealth of pennsylvania where blue cross is located and take the five county philadelphia region. there are any number of large respected teaching institutions. a university of pennsylvania, thomas jefferson, a children's hospital, the university health

system. and there are any number of community based hospitals either unaffiliated or affiliated. there are three or four very competent and commercial government focused managed care entities. that environment is one that if an a cl is formed it would be a total for the institution to help better manage and drive down cost. but because of the competition in that market place, i think it's one where a very high-cost region today we can have a significant impact on the overall cost. go to the other side of the state and you have you p.m. see -- upmc that has managed care into a sea and the market a terrific book cross blue shield acquiring western allegheny the two major health care system in the region. but the traces are limited.

whenever tresses are limited unless they focus on what's most important, you have a possibility of cost escalating. so, it depends market by market. and in our state we have two examples that couldn't be further apart. some economists see things working in practice - that in this case there is something real because we are seeing the health system coming together and suddenly they are increasing with the purchasers. and that is a real thing but there is a lot more complicated questions about, you know, how do we know if that is even worth it? if the care is that much better than we can have those conversations without having transparency. and the other question that no one seems to ask is if they save money where does it go? does it go back to the purchaser, the patient, the community and how do we know or is it just benefitting the same

players? so i think there's a lot more questions to ask. i think the risk is very real. but i think we need to understand the dynamics. >> in some cases you can't get the incentives for better quality and lower cost without more integration. so figuring out how you make the system is accountable for that is a tough one. i'm not a trust it is an uncomplicated area. >> let's take questions from the audience. if you have a question raise your hand. we have one in the middle. if you could identify yourself, please. >> i would like to bring you from 32,000 feet to the exam room. i am concerned about the payment for good outcome. we have terrific medications to get cholesterol.

people with the bad cholesterol that i can fix but then i have a patient with dementia and another patient with brain cancer i can tell you we don't have anything good for either of those. but i can get the cholesterol down and if that's how i am being paid then that's what i will do. but those people need care and what are we going to do about paying doctors who take care of people that are really sick? >> this is one of those exciting parts moving into the population which is this questioner is asking when you think about the problems the patient's face, there may not be a good medical solution for these guys but there are other solutions they need that we are currently not paying for and we can save a ton of money if we start to open our mind and think about other ways we can help these folks. we are at the center working with states on developing the

super utilize are basically implementing the plans in the states which are finding those really high-cost patients working on the whole hot spot and that whole trend and the big lesson of the super utilize terse is guess what i have a patient and this is something i have a patient who is admitted 400 times in one year. so on average more than one a day what if you went -- and it turns out he had a lot of mental health issues that wasn't being treated because we don't pay for its and some environmentalists health issues and the environment was really bad the of the substance abuse issues. if i go to a housing and say guess what we have 100 bucks to

spend. you can do anything you want. they could change his entire life. and just saved 90%. that is a holy grail. that is probably one of the most exciting parts is that we are having a conversation as you were saying we see the health system's talking to for the first time ever. when house that ever happened. come in and talk to us. how do you deal with patients? >> there's also a cultural approach of collaboration because if we are punitive and we don't have the right measures and this is a sort of gotcha for

the physicians who are trying to do the right thing we are going to stop progress. we have to bring people together like the collaborative 71 at the table saying we have a shared goal we may not know how to get there but if we do this together there's the right incentives, the right measures and transparency, i think that collaborative approach is promising. >> i think what's going to be important for this question especially is how we define what quality is. most of us look at the outcome of the patients did they get readmitted or not and if you look at the components of the quality much more so than the outcomes and we've gone through a lot of process measures it is going to include process measures and how we talk to the patient and it's going to include patient measures and appropriateness measures with overuse or underuse and what we need to develop for the metrics that really come by and all of the components into what the quality is and then incentivize

it with value because it isn't just one thing. it isn't just one slice. we have to get more of the policy of what quality is as a metric. >> i think of it in terms of primary-care physicians that have an ira of patience and there are those very sick patient that you identify where let's face it in some cases the outcome is not going to be good and it's going to be very costly to get to that end of the game so we have to make sure that as a humane society we continue to focus on the best care for those individuals but then we have an raf other occasions that come to see the primary care physicians but we can impact quality and put folks into the initiatives that drive down cost. for example, we were involved in a study with n.y.u. and what we are trying to identify is not

only the diabetic that goes undiagnosed and put them into a program that we are also coming up with a predictive model where a physician's office can see the trade and the signs are pointing towards someone being a diabetic and began to prevent of measures in place. you put those types of incentives and programs across the ed gray of the multiple diseased states that show and a traditional primary care office, you can begin to net the costs on the edges and keep people healthier. i believe that will lead to a larger pool to care for those high-cost, chronically ill, probably not a good outcome situation. >> one in the front pew at >> you were talking about costs

and i was wondering, the population that is going to becoming an to the exchange's and that are going to be eligible for the subsidies we get one out in pennsylvania but are they going to be different, are they going to be similar? how will they be with respect to the medicaid population because you have these people coming in that haven't had access to health insurance. i'm just wondering how those costs are going to be. >> that is a great question. if you look at the impact it has had whether it is a state run with federal support or by the private sector it has had a very powerful impact and you've taken folks that have traditionally accessed care in the emergency room and community-based clinics that they now have an insurance card and they now have an assigned primary care physician,

they are part of the patient centered medical home and they have a system of support. so it worked at the medicaid level. if you look at the next year, the folks around 100 of 33% of poverty who will have access to some side of subsidy they are also coming from an environment where they were not insured and from the environment the accessed care in the emergency room through a clinic but not a traditional medical home. so now those that are eligible for the subsidy are much like the medicaid population. and then managed care will be a new world for them. there will be an opportunity for the system to really get them involved just like a traditional commercial member involved in managed care practices. so, i see that above medicaid the folks that have some level of the eligibility for the subsidy under the subsidized exchange. it will be their first time or

for a long time the first time that they have had access to the capabilities and managed care. >> we have another question. in the middle. >> i'm with the national association of social workers. frederick, you are one of the few people who has mentioned mental and behavioral health as an aspect of all of this. i think it is a critical part of the quality-of-care and of the quality-of-life. but both rhetoric and others on the panel i've heard nothing but metrics and measurement or even take this into account considering he quality. can some of you address this?

>> i'm so glad we are making this point about the metrics because you said it perfectly. when this was being drafted and people were looking at the notion of providing they said look we are going to give providers a whole lot of freedom but we have to measure that because we don't want the worst outcomes so the measurement -- of course the worst possible outcome is i think in part if we are not measuring this right, then we are creating a disincentive for providers to take the most vulnerable complex patients out there and that would be a travesty. that is the opposite of what we are trying to do here. i do think we have miles and miles to go on how we measure this appropriately. frankly the problem we've had as you talked about earlier we have the systems that work for the fee-for-service in a way that we can measure equal the. so, one of the proxy's and it's a very in perfect proxy but it's

one of these that the administration has prepared for pushing so hard so the idea is until we can get to the meaningful metrics in the broad array of things including behavioral talf we have to make sure we are taking the pulse of the patient and understanding of the patient is feeling they are getting care for their needs are being addressed. we know they never know if they are getting good care so if the score should be used to say this is bad care or good care but it's some kind of barometer until we get to the point we need to on the quality across all spectrums of care. >> two things that i agree with, one man's good mental health care on a parity in the affordable care act that is an essential part of the benefits package so that's great news because many people will have access to care that they didn't have before and that means a lot of adaptation for the institutions.

but when you get into the medical homes every physician i talked to has told me that one of the central concerns or first place is they go is to figure out how to deal with the behavioral health component because depression is often a, a devotee -- co morbidity with many chronic diseases. so i think that this calls more attention to it. we have to measure it better and figured out how we hold people accountable for doing the right things here but i also think that this accountability brings people to focus on this issue in a way that they didn't before. >> if i might add until we have those measures i think that's why it's so important to look at the adequate risk adjustment and i have cms is doing work on this right now with respect to the dole eligible demonstrations going on. but until we get the point we have accurate measurements we need to think about the risk

adjustment in a very real way. >> one thing we try to focus on and thank you for raising that question i just did an op-ed letter to the philadelphia inquirer about health care reform just before i came on stage i read an e-mail from a social worker that said a great letter. you never mentioned behavioral health. so we are trying to number one, influence the provider community, influence the members at large about breaking down the old stigma. the other piece is making sure when we focus on innovation we find innovative ways to reach folks that might be on the verge of a crisis situation and if we have the right way of touching them through the system to get them the right level of

behavioral and physical care that they need. we have one company we've been involved with called one dot way fae u.s secure while the technology so that a psychiatrist, psychologist, social worker can have a face-to-face interaction with someone in an area near or at a crisis point impact the behavioral side of that initiative to get them to the closest possible care before an emergency turns into a crisis. winning to all be focused on yes the fiscal peace is important but unless you bring that behavioral peace, break down the stigma and make sure it is at least equally focused on that we are not going to accomplish our ultimate goal. >> we have one more question and that is the last one that we will have time for to the

estimate i met with the jewish federation of chicago. one of the expensive areas as long term care. i was wondering do you anticipate that there will be a replacement to the class act soon and if so, what might it look like? >> this is a big issue that is forgotten. we are working right now on a task force and one of the issues we are addressing as long-term care. i think that class -- given that we are sitting in the building in the federal shot down it's probably not great but there is too big pieces of this. one is under the existing system that we have can we improve the care for long-term services and how do we create a private

system that can help support all of us as we get older and might need long-term care and i think the second piece is where we are lost and it's going to be a while until that happens probably but there's a lot of things we can do within the system. we have medicare and medicaid so that in the programs currently there is a lot disconnect between the way the requirements and the programs so that it defaults to medicaid and where medicaid has to pay for something the state budgets are tight and it gets harder and harder but there's a way to share their responsive and the more there's a lot of folks that think that can shore up long-term care until we have a more cogent and well designed approach to health do we all take care of each other as we get older. >> i can say that is the next project the leaders of the bipartisan policy center are moving into and i expect we will have a report coming out in

december. i think early december of this year which is an agreement of what we think the problems are and perhaps the principles of moving forward with a bipartisan group of leaders on this and hopefully the report may be next summer, early summer that comes up with some recommendations for federal and state policy makers but at the same time thinking about it they just came out with a report on the delivery system reform but think about how long term services and support fit into the existing model. redican the thinking of it separately as a long-term care issue that the person centered existing model these things are covered bottles to we need to do to help support the person to keep them in their home and make sure that they are not falling back in the health care system for the services that are not necessarily of expenditures. >> many thanks to the panel for being with us today for fabulous

in sight. [applause] >> the federal government has entered the seventh day of the shutdown. congress will be in session today. the house will be taking that a short-term funding bill for the food and drug administration expected at 5:45 p.m. eastern and that continues the house republican plan to pass targeted short-term spending bills, that's a strategy of that majority leader reid says is a nonstarter and any recorded votes will be taken after 6:40 eastern. the senate gavels in at 2:00 eastern to start with a general speeches and take up judicial nominations at 5:00. as the government shutdown continues, today's senate majority leader reid past the statement reads speaker boehner has a credibility problem from refusing to let the house vote on a bill that was his idea in the first place to declaiming

the subsidies from the members of congress and staff that he worked for months to preserve to seeing the house doesn't have the votes to pass a clean see our current spending levels. there is now a consistent pattern of speaker boehner singing things that fly in the face of the facts or stand at odds with his past actions. americans across the country are suffering because speaker bone or refuses to come to grips with reality. tooby speaker boehner should stop the games and let the house vote on the senate so that the entire federal government can reopen within 24 hours. and the speaker's office responded this morning with a statement saying passing a spending bill at the level required by the law isn't a concession. so it's time for the senate democrats to stow their outrage and a deal with the problems at hand. the federal government is shut down because democrats refuse to negotiate and the debt limit is right around the corner. the increase can't pass the senate floor in the house. it's time for democrats to stand up and act like an adult and

start talking about how to reopen the government and provide fairness for people under the obamacare and deal with the drivers of the debt and deficits. to statements there from the leaders of the house and the senate and we will keep you posted on the latest on the shutdown on the c-span networks. we need some fundamental overhaul of how this government works. we vote on tuesday because sunday is church today and monday is market day and you ride your horse and buggy into town to vote on tuesday that is just ludicrous. we have 435 seats in the house of representatives basically because that is how many seats but in the building. despite the fact the average house district has quadrupled over the last 40 years, the mechanisms of the government are due for a dramatic overhaul and

the congress will not be given to navigate out of the current cul-de-sac they've got themselves into unless the understand and embrace the changing nature of our society and we imagine what the government might look like. >> reshaping power and politics and society on the communicators, tonight at eastern on c-span2. this is the school for the deaf where calvin met at the first time. she was a teacher and he was in the boarding house. we are now and grace's bedroom and her dormitory building and this is where she would have looked out across the courtyard at the next building and she would have put a camera in this window and the parlor room available for them to meet up. in this room is where calvin and

grace when they were courting would meet up and have some time together. despite him being in his 40's and her in her 20s they had to abide by the rules of the school and meet somewhere they were supervised and chaperone while they were on campus. as humans live longer lives than america foundation, sleet magazine and arizonan university posted a discussion how living longer can impact society and public policy. they gathered a panel of professionals who work on policies for the social security fields and examined the challenges of living longer and what that could mean for the economy and the potential impact on marriage. this runs about an hour.

>> good morning. if i could have everyone's attention a think we are going to get started. the government may be shut down but we are open for business here. i am jacob weisberg chairman of the slate group and i want everyone to the co welcome everyone to the future of longevity whole for the increased years we are going to systematically increased life experiences, relationships, careers and society. i want to say this is a future tense event. future tense is a partnership bit in the new america foundation, arizona university and sleet magazine that explores emerging technologies and their transfer much effect on society and public policy. central to the partnership or the defense like this one in

washington, d.c. but try to take an in depth provocative look that while not so well understood today are willing to reshape the policy debates in the decades to come. we want to thank the provincial financial for supporting this event. like all of you it's identified increased longevity to the it's one of the transformer that trends of our time and it's a major factor in the way that they are addressing their customers' needs and we are very grateful for the sponsorship of the series at slate. on behalf of future tense and provincial i want to thank the panelists, the moderator's we are going to have appeared today and all of the attendees for your meeting of the challenges and the opportunities of longevity. human longevity is dramatically increasing. in the coming years it seems possible that we are going to live out our extra years or decades and vitality and good

health. but will we as a society be able to keep pace in the age of the technological and scientific progress and communities and politics and economic institutions under prepared for the coming challenge of longer human lives. if average human life spans extend to 150 years pulse of the is we are going to be fleshing out today. what is that going to mean for marriage as an institution for the work force and for personal financial planning? what will it mean for the economy as a whole for entitlement programs? how can we plan now for the increased human longevity that we know is coming and the inevitable impact it's going to have on society and on policy? so these are big questions. and they are very much dependent on what form want devotee takes -- longevity takes. i want to introduce joel

garreau, the co-director, lincoln professor of culture and values at arizona state university. joel was a staff writer of the washington post here in this building for many years. when i lived in washington 20 years ago he was one of my favorite writers that would look for the byline. you didn't know what he was going to be writing about but you knew you wanted to read it. and he is going to take you through four scenarios that are different, but all the potentially plausible in terms of our future life's them. without further ado, please come up and welcome, everyone. [applause] welcome to future tense. we are glad you are here.

what i'm going to do for a few minutes is we are anticipating had a and stretching a conversation on what longevity means. what i want to do right now is give you a little stricter to think about this and talk about this, give you a framework of four possible scenarios that we think are important about how the future might be in the year 2030, 17 years from now less than a generation. what we are helping these will do is give you a free market can refer to as the morning goes through. for example, suppose you want to make the argument as some people have that you think technology is going to advance rapidly that it's not going to have much impact on the life span. that is as an example. if you make an argument like that if you could locate it in

one of these scenarios and say i feel the future is to be this scenario, then that will give us something to push off of because the object is to be signed what we should do today about this dramatic change that we are looking into into the future. humanities increase in the life span may be the greatest achievement. most of the world's children and their grandparents are going to -- are living a long and productive lives. even if you count the wretched of the earth a typical person today can expect to live to nearly 70. that is up from the 30's in the 1900's. the significance of the is that you have dramatically different futures. what does the future of

longevity hold for us? it's impossible to predict. but if you want to create strategies today the object of the game is to think brought about the future might hold because it is better if you are creating strategies to never be surprised by the future than to occasionally try to be exactly right with predictions that never worked. here is a pertinent fact on the ground about right now. first, life expectancy in the developed world has been increasing like clockwork. a quarter of a year every year for 160 years. clean water, child mortality, vaccines, and other audits and so forth. that is already baked in. second, the amount of computer fire power that you can buy for a dollar has been doubling every 18 months. this is all. that's why the smartphone has more computer firepower than did

the entire air defense command in 1965. third, the genetics, robotics and the man no revolutions are now exceeding this accelerated curved. that's why the first sequence in 2000 costs several billion and today the cost is approaching that of a comprehensive blood test. now, those are uncertainties. those we know. but there are plenty of critical certainties in this scenario. a few examples include how will the new public she's like the obesity epidemic affect the life span and the health span. as the wife who spanned increases what about the diseases that take on new importance like alzheimer's? what about the gap between the rich and poor? is it possible that technology will stall?

we don't know. let me introduce you to the stars of the scenarios. they are john and a.m. gramm. in 2013 they are 65-years-old. they are not wealthy that they have savings, health insurance and interesting jobs that put them in the top quintile and they have two daughters sarah, 28 and emily is 23. their close friends are a computer troubleshooter in his fifties who's already had a stroke, and with butress at&t man in his 40's that is a smoker. so here are four scenarios and how it affects them for human longevity in 2030 less than one generation from now. first scenario is small change. small change is the offical washington future. this is what policy makers

expect typically. in small change the exponential increases in the biologic genetic neurological information , a man no and implant technologies have only minor impact. the current trends continue and life span and health span, social security, obamacare, cost, federal policy is a straight line projection from the present. small but persistent change while the costs skyrocket. this is the official future. in small change, they can expect to work beyond 65. but in 2013 in their eighties they are going to be dead or close to it. that is just the way the demographics have worked. giles and butress may not be as lucky. meanwhile, in 2030, they are in their 40's and a decade or so their health spans will begin their long expensive slide.

and that is massively on sustainable by today's cost estimate. that is the officials future. here is scenario be the exponential advances in the genetic robotic information and nanotechnology succeed in increasing the life span, but they largely fail at increasing the health span. in 2013, john and and therefore are already in assisted living. where they can expect to stay for the next ten or 20 years they have these long lives but they are marked by one major intervention after another at tremendous cost. and none of these free them from the walkers and the dementia.

their lives are so horrible that suicide is among the top five causes of death among the aging in 2013. now, a drawing on their shoes is a difficult scenario logically. but it's a core nightmare for a great number of the american people which is why we have it in here this scenario assumes technology can pass up the great cost without addressing the underlying causes of decline. so in 2030 even the supercomputers are now on everybody's rests only moderate progress has been made on heart disease, cancer, brain disease and decrepitude. in washington meanwhile will balloon is up congressional budgetary memorial is a vast. drawing on their shoes is even more expensive than a small

change. and americans in a scenario in 2031 to know from the congressman what they got for the trillions that they poured into the national institutes of health, the national science foundation and science in general. they want to know why they should work more money down the research ratholes. scenario see if live long and prosper. it's built on the assumption that the first human to robustly live to the age of 150 is already alive today and is in this room. it's on a sober scientists and insurance company. in who live long and prosper, the program designed to attack death which was just announced works. we see advances in personalized madison, tissue engineering,

oregon region a nation, and plans and memory enhancement. early interventions are routine in heart disease, diabetes, stroke and cancer. even as personalized medicine grows exponentially however, the cost drops like a stone. that means it is because medicine and the scenario has become an information technology and it starts to obey all so that you see medicine, you see the drop in the technology costs that you have seen in your smart phones and everything else in your life. meanwhile, the very disease model of medicine is coming to an end. john and amine their 2030 adhern have an appliance called googled medicine. it's the size of a toaster. we have a prototype of this that's real. every morning they spit in it and the box analyzes the bob yo markers and sends the

information up to the club where today's sample is compared to all of the previous reports as well as all of the reports of everybody else using this network. so they detect health changes for weeks, months and even years before the symptoms appear. this means early, cheap, personalized interventions. the results are amazing. and live long and prosper, in 2013 they are feeling more youthful than they have for decades. the chatter about how many careers and marriage as well fill their long and exciting lives. but in washington guess what, the fights are going full board. hundreds of trillions of dollars with a baked in cost assumptions about aging are deeply challenged in this scenario.

what does 65 mean? in this area, chronological age and metabolic age have become uncoupled. so saying that somebody is 65 or 80 just doesn't mean that much. in 2013 mike jagger will be in 87-years-old star. why should he be pulling down social security? hospitals meanwhile are going away of the post office. they are serving the less affluent and sophisticated who still waits to get sick before he seeks treatment and even though the medicine boxes are getting cheaper and more widespread everyday. meanwhile our pal didn't live to see google medicine which is too bad. he would have loved this technology. immortality.

immortality is not as crazy as a scenario as it sounds. all it requires is for technology to be advancing faster than you are aging. so remember for 160 years we have had an increase every year for a very long time. so in principle all you have to do is curbed the line up a little bit and have technology advancing such that you have by a factor of four it's advancing one year for every year that you age and then you are looking at something like immortality for some people. in 2013, john and anne have to many miles on their chassis and they were born 14 years before the first computer chip. when they were young the state of the art was a polio vaccine. but who knows for their

daughters sarah and emily. their kids of course have never known a world in which cancer was anything but manageable. they shake their head at the history that they read. scalpel's, plays in, radiation, how barbaric. what were these people thinking? thank you [applause] >> thank you. i'm an optimist but not a utopian so i am with scenario c. i also find the most persuasive but one of the implications of that is if a person lived to 150 and had already been born baby in this room, the first people

to be married for 100 years are also that will happen even sooner. it would be a plutonium anniversary. our next panel is about exactly the subject. we are calling at death until death do us part with a question mark at the end and how to fund the family and social relationships. our moderator is liza mundy, the director of the new america's foundation working family foundation that seems to defame the foundation to the changes that have taken place within families, work places and the lives of men and women over the past several decades. liza is one of the last journalists on issues including the atlantic, time, the new

republic, slate of course, mother jones and lots of others and like joel she was a staff writer for "the washington post" and is the author of the excellent book the richer sex how the new majority of the female breadwinner's is transforming sex, love and family. liza is going to introduce the panel. >> thank you. it's great to be here. i am excited about the conversation. i will introduce the panelists. we are fortunate to have the great discussions of how technology and longevity are going to affect our personal lives and relationships. we have sonia arrison a technology analyst and author of the national best-seller 100 plus how the coming age of one djibouti will affect everything from careers and relationships to family and faith. if you all want to come up i

think i will sit in this one. she is based in san francisco where she was the director of the technologies to the department of the pacific research institute. she is a founder, economic adviser and a trustee at singularity university. she's focused on exponentially growing technologies and their impact on society. her work has appeared in "the wall street journal," the economist, msnbc and the today show and we are also fortunate to have chris, the recently retired director of humanities at the university of arkansas for medical sciences college of medicine. for more than a decade he was the woodrow wilson visiting fellow with the council of independent colleges and lectured at medical schools and college campuses around the country and abroad. he's written books and articles on end of life decisions and on the rationing and health care reform in the context of an aging population. he's currently working on social

issues and the use of genetic and reproductive technologies. so we will get started with what we hope will be an invigorating conversation and open up to questions after a 30 minutes. then we will open it up sooner. i am a former staff writer for "the washington post" and i want to just very briefly free in our conversation. one of the first story is -- one of the first articles that came to mind was a piece i did a couple of years ago for the "washington post" magazine looking at a situation of a man in this area, wonderful man, a federal worker, ordinary, living in the suburbs. his wife was diagnosed with huntington's disease which i'm sure as you know was a degenerative neurological disease. ..

that they were in it, you know, until death do us part and as his job to be her caregiver and her caretaker. there is no question that she is no longer alive, the extended through his caregiving her longevity. so we can talk about technology and robots and everything and that's all great but human caregiving in terms of extending our lifespan and the quality of our life is something we can't forget about. so people, everyday he got up and went to his job, he is

probably furloughed right now but then he came home every night to a second shift in which he was taking inspirational and extraordinary care of his wife and extending her lifespan come and extending for in the situation that he was living. so that's one story that i thought about that have a lot of personal meaning for me. in my own life my mother who is 79 and just the other day she called eric cantor because she's worried about --'s office. she married for the second time in her life 782 another 78 year-old man. and it is been an extraordinary blessing in our family to see the happiness and the companionship and a mutual caregiving that they have enjoyed together. there's no question again in my mind that through their loving, tending of each other that they

would also have an impact i hope on each other's longevity. and live long and prosper is the hope of them and everybody in our family. so this subject has a lot of personal meaning to me. just the final sort of framework. when we talk about why we are living longer, there are all sorts of technological reasons but there's also an interesting series called the grandmother hypothesis it also relates to this which is that when evolutionary biologists and anthropologists think about why two women lived past menopause, why do women live past their reproductive years, their ability to have children, one of the answers to this mystery is what they call the grandmother hypotheses which is again that one reason we live longer as a species is because we have grandmothers who can take care of the children while the parents are out there forging for nuts and berries or hunting or whatever, that the

grandmothers are taking care of the children and extending their longevity, and that long lived women thereby enable their daughters and daughters-in-law to have lots of children will pass along their genes. so those with genetically after their caregiving, grandmothers have had a major influence on extending the human lifespan. so i guess i would just like to keep in mind the importance of social relationships, companionship and caregiving, both at the beginning of life in terms of caring for children, as well as into our hundreds, what are going to be the marriage patterns? we're in a society now where people in the '30s increasingly are not getting married. people who are having children increasingly are not getting married. so like my mom, is she an outlier? what are going to be the patterns that emerge as people live? how will we ensure that these people have cared for us and extend our lifespan and

eventually ourselves are going to continue to have the human companionship and the caregiving that will make their lives happen as they get old. let's start with sonia. where are we going? how are we going to ensure that people continue to have companionship as they move into speedy's i think it depends on what scenario we're talking about. i think that was a useful, joel, that you this for defense minister in my book, 100 plus, people look at scenario c basically. what happens when human beings, again is or been done and not just life expectancy but health expectancy. people live healthy for longer periods of time. how does that change the world? that's essential what my book looks like. i have a chapter on families where it's like take a look at how, you know, i go back in time to say what happened the last time we roughly doubled life expectancy. well, what happened is age for

marriage went out. age first birth when a. but it hasn't gone up as much as you would expect. so in 1950, age at first marriage was around 20, for women. today it is around 27. it's gone up about seven years, which in longevity has gone up quite a bit since then. 1943, sorry, yes, in -- in 1950 -- i'm trying to get my longevity numbers here. there's two numbers going around in my head. so we come essentially from 43 years to eight years, right? we have roughly doubled life expectancy. but you would think that age of first marriage would go hop higher and you think people would have children later. but they have as much as you would expect. i think the reason is fertility

test stock. even with ibs. women are having children later but not, there's still this point between 40-50 were fertility really starts today. by 50 it's already don't have their own biological children. some women have had donated eggs and that the children come we've seen a 66 euros have a child and a 70 oh have a child using their uterus not their own eggs. so the question is what happens to fertility over the long run, i think it if fertility can be extended a in age for first virtual really pop up quite a bit spent it has gone up, i marriage. almost a straight line parallel. it has gone the rate of divorce. since 1990, the rate of divorce of people over 50 has doubled. so that's a think what we really need to deal with at this point. not so much the age at which we

get married but how long we stay married. that's the real difficulty i see. why are people getting divorced more? because they have longer lives after their children are gone and longer period to become a little bit board or, you know, and seek a new exciting and that's what's happening. if we lived to be 150, how many people in this room would want to say merry for 100 years? it's really, yeah, that we don't want to say that to our wives are sitting to us or our husbands, but in the general population that's going to be a real problem. sonia,-com,-com,-comma you really do with that, haven't you? you talked a little bit about -- >> you can expect is that they can future to be much more serial relationships, marriages, divorces or even not getting married and having a whole bunch of relationships, much more than we see today. so co-habitation.

>> and then if fertility pops up or women can have children come into, post 50 can you can imagine the different types of family types as well where a woman might have a child in her late '20s and then have another one in her 50s and have a different type of family. the extended family a lot different in that scenario. >> you know, your first story was so important i think frame the discussion because here's a relationship that's enduring fast him and the difficulty and so important for those two people. we can talk about those relationships and have a contract for 30 years or 25 years and move on. but that's difficult. it's not as easy as it sounds. these are intimate, important relationships and it's important we have these relationships. i'm not sure it would be the same thing to be married for 30 years and to go into it knowing that in 30 years you will be choosing somebody else, or having to decide -- these are

extremely difficult kinds of concerns that i'm not sure how we're going to do that. >> with this wonderful mandate, we had this conversation because as people are able to live longer with chronic illnesses, this is the marital caregiving is becoming more common. it was his absolute conviction that he was in it, but there are support groups for people are in these long-term care situations and i think most a new support group felt action when you're in an acute situation like this having a relationship on the side is okay. that was in his view. is you is i am married to her until death do us part. i think he departed actually from a lot of the people he was in the support group with about what is america contract -- what does a marriage contract mean

speak with you brought up the idea that if we live to be 150 and had children, generations apart, that is was going to change what the family looks like. currently it's pretty rare to five generations at the same time but i know in my own family, a young cousin, four times removed i guess, has a great, great grandmother. so that's what, for generations. but when you extend that further, the family to begin to look really top heavy. if you have for generations, you have, what, 16, 32 great, great, great grandparents, and then one more generation you have 64. so this family tree looks like this. what do you do when you need to send out graduation announcements? [laughter] we're going to need a new set of attica books to be able to solve these problems and how would bring people together, we bring together, who is part of them and who is not part of the family. one more point, the further we

get in age from those who came before us, the less intimacy there is in those relationships. how you relate to great, great, great grandmother really will be different than how you relate to your grandmother. this is all new stuff. >> we think the human pattern, we are descended from acumen and disaster and goes like this. you talk about a situation where it's like this. >> have a young person with two parents and those have to and those have to. it goes up exponentially and it's not long, six generations and you have 64 great, great, great grandparents. >> i can see that plays out in my own family. i have younger have ceilings but now with my mother's remarriage my daughter was talking to me yesterday and she said something about your sister. what are you talking about? what sister are you talking about? she meant the adult children of my stepfather come some of whom we've met, not all them we've met and it is, on the one hand it's wonderful to we really love

his family, but it is a whole new relationship to navigate -- navigate. as we have this really large adult period of our life, then sort of super adult period, we can move through through relationships that we end up with a horizontal family that can grow and the famine is going vertically as well. spent in a very specific direction. >> it is a lot to navigate. >> if we have three or four marriages and children with each of those, if we live longer, fertility, although we don't know for sure, it's possible to have brothers and sisters from three or four different marriages. what is that relationship going to be like, the sibling relationship? especially when you spread them apart by 60 years or so. it's going to be very different. >> it struck me also coming in that we haven't had -- has appeared in the -- were we are having a lot of world's oldest mother's news stories.

there was like a 70 something mother of twins in italy or where ever and it was a series where they seem to be surpassing each other but it seemed kind of quiet on the world's oldest mother front for a while. and i'm not sure why that is pick their songs a couple of fertility doctors who are willing to really push it. i actually wrote about reproductive technologies and it was an extraordinary thing. in the realm of reproductive technology, doctors really were winging it. one of the case studies that were so shocking was they were really not sure whether you could bring a woman out of menopause by giving her hormones, and then using a donation. they really didn't know. they were like let's try it. so they did and one of the case studies i read shocking, quadruplets and a 54 year-old mother. that was a case where selective reproduction was used at least to create a more manageable pregnancy for a woman in her

mid '50s. and the way in which the fertility industry has pushed that, the willingness to wing it and experimentally see what's possible, what's leading to these cases, you know, 72 year-old mother of twins, and yet i'm not so sure why this is. i am waiting for anyone to kind of -- maybe we've reached our limit. i don't know what the upper age was. under member ethics 68 or 72 but maybe we push that as far as we can. >> but maybe it doesn't seem that interesting anymore. anymore. >> maybe. and there are consequences. i mean, women who had children with a donation in her 50s, don't always lead to be 100. then you have cases of children who become sort of marooned and potentially -- >> carmine, she was one of the first older mothers who had come she was in spain an have a twint

66, which seemed really quite open to the 70 year old came along. you know, her mother lived past 100 so she thought she was going to, too. two years after she of the twins she died of stomach cancer. so it doesn't always quite work out. she was a little ahead of her time. >> right, right. but again i guess i do wonder sort of in terms of social policy, what we do, i mean, we have countries like japan where you have traditionally when a woman married it was the expectation that she was a caregiver not only for her husband but for her extended family. and so in countries in traditional societies like that you've got this aging population. you have wit with a no longer wt to enter into that marriage contract because they don't have the responsibility for taking care of extended a generation. we don't necessarily have those

expectations in our society, but how is it going to play out as people not only in terms of marriage but just as people get older, it's great to think of bill to fit into something and extend their own lifespans but they're going to be needed to be cared for. are we going to have institutional care or are we going to have family-based care? and how are we going to manage that? how are we going to get ourselves to where we want to be? >> i know one of my biggest concerns was i'm just now retiring and facing older age is towards the end of life who's going to take care of me? fortunately i have a younger wife so she could do that for a while. but i think as there are more people without people like him to take of from our institutions will have to develop. assisted living a sort of a new industry now, and my own father

just died at 95 a few months ago, and so i think the private sector will develop new institutions to help take care of people spent so that's what it's going to be, the private sector? >> it would be nice if we could have -- [talking over each other] >> i feel like we are talking back and fourth between between different scenarios but if we between different scenarios but if riveting and scenario c, then everyone -- you are 90 and you're still healthy. you don't need a caregiver at that point. but if you're looking at different scenario like scenario b or a, caregivers are really important. and so, which scenario is that? >> i was thinking about radically extending the last -- we would do that by slowing down human aging, and also was telling us about what causes aging and how to slow down is also telling us what's these days -- age-related disease. it related to the 150, it's not

we'll keep getting older and more frail and sector and sector. we will be healthy, for most of that time. at least that's the hope. >> it does depend on what technology allows human things to allow -- live longer and healthier lives. how does it happen and how quickly does it have been? the gold standard, the best way to do that would be to slow down aging, maybe do something -- that's a long way off but before that happens of the other things like personalized medicine and tissue engineering, so replacing human parts. so someone has a heart disease, today we manage it through pharmaceuticals and lifestyle and all that kind of thing. i mean, the future, scientists, which isn't that far off a bill to grow brand-new hard parse or an entire new hard for somebody in this just repair. so that fixes the heart within they keep letting and maybe alzheimer's. and what would be adequate would also fix their brain right away?

unclear. it kind of depends on which technology when and how quickly it happens. >> right. the thing i keep thinking if we're looking at people who are paired, when people might be healthy, you will be really lucky if you both track as healthy on each other going forward. but i still think there's always going to be a scenario if you're in a relationship where one people might be healthier than the other person and they will be caring, or the families, somebody will have to be taking you to these hard replacement appointments, you know? it's never going to be something i think that you're doing on your own. so why do we go ahead and open it up to questions? i suspect there will be quite a few. okay, you had the first end up. >> [inaudible] >> there is a mic coming around. sorry. >> hello, i'm bill.

i live in dupont circle. i'm 82 years old. i went to an internment at my church, st. mark's, capitol hill, last week. and we interred one of my ex-girlfriends. and it ended up that she had had three husbands. i did not know that when i dated her, and all three showed up. and i thought, this was a real good sociological study, because she had three sons, very well from the first husband. she had three more children from her second, and each of her ex-husband's had gone on and we married and had families.

and i was thinking, this was a large interment. there were a lot of people there that had never met each other. and they got along beautifully. and so i asked two of the husbands, because one sat on one side of me and once out on the other side of me, and and they each liked each other and they said what a great person she was. and i was thinking, this is the new world we live in, but you talk about multiples. when you take her, her children, her exes children and their children, you've got an enormous number of grandchildren from her. i can't remember, it was like 16 or 18, and her great-grandchildren, just an

astronomical figure. so that's the new world we live in spent what age did she die? what age where she when she died? >> [inaudible] >> i'm sorry? >> so i think that will become the norm. who your relatives are will become an extremely complicated -- because we're trying to figure out how do you explain relatives? and there are no turns out there. >> exactly. >> emily post. >> the other thing which is more important, even though i live in dupont circle, i am president of the board of directors, an organization that puts dupont circle together. and one of the organizations at dupont circle is called the village. now, before i explain this, how many people know what a villages? that's pretty good. because you talked about going

to these retirement homes. this is a concept -- i think in the long run, replace that. you've got a whole new concept that starts thinking about the village is you stay in your home, you get the same services that you get at a retirement home, but you stay where you are and where you know things and everybody knows you, and you keep the same friendships. and those friendships are really, really, really important. >> did you have a question? >> that gives a whole new concept of aging in place spent those are great comments. >> let me just say, my undergraduate college has just finished building a village that has all those advantages you talked about, plus a college, a vibrant college across the street where people can go and

sit in on courses and keep alive. i think it's a wonderful idea. >> american university -- [inaudible] >> sonia, did you -- did you have a comment also? >> well, i loved your comment about how there were so many different husbands and different people. that really is the beginning of the future. you know, you are 82. it's funny because when i go around and give talks on a book i like to ask condit, i like to ask the audience how long they think they want to live. life expectancy in america generally around 80 years. who here wants to live to 80? we note you want to live longer, right? who wants to live to 150? or indefinitely? spent longer, yes. >> so it's interesting because usually if we haven't had an 82 don't speak to a lot of people say ate sounds good.

until -- >> at least 100. >> so, the next question. the gentleman here. can we get a mic? oh, i'm sorry. right here, sorry. >> good morning. i'm john, i spent a lot of time working at aarp. so to fax and an observation. fact number one, most people who need support in old age are widows, and you can't really look for spouses for them. the men may be more fortunate, particularly if you have a younger, healthier spouse, but statistically we're talking about widows. second observation is that the studies that i've been for me with that look at quality of life show, unfortunate, that spousal caregiving is a major risk factor for shortening your

life. the stress is huge. and the lack of support -- so my observation is people who are going to increasingly be facing this need a loan are going to have to look to their communities and the public policy, not just their families for all the reasons we've been talking about. >> right, right. thank you. question, did you want to pick somebody from that -- >> good morning. i'm from the toronto national post. i wanted to ask john smart who is one of the founder of the idea of the singular the of a computer's processing speed exceeds that of a human brain. how do you think supercomputers will be with us? he said we will be there houseplants. my thought is, what you would think, why would we think -- can you extrapolate how dependent we are on our phones, facebook, on our technology. think of a sick show with his

hand-held videogames. whiteness in the wheel need human companionship at all? if you look at "the new york times" magazine store a couple weeks ago about the new poker machines, that virtually can replicate any singer of the human interaction over a hand of poker. why not assume that google will take care of that also? why do you think you'll be any need for -- >> so there will be something to hold your hand? >> which can speak and interact and have memories and all that. why not assume no need for human companionship? >> i think john smart probably made that comment, assuming that computing power would become more intelligent without our input. and i'm not sure that that really is an actuate of viewing the future. but ultimately human beings are the ones who are developing this technology. it gets created because we need it because there's a use for it and we want it.

john smart might say something like, well, at some point computers will just get so smart they will start developing themselves and we will -- and we will be out of the question. you can talk about that but i don't think that is anywhere in the near future. before we get there we will get to living to 150 before we get to his scenario. the technology that we develop will be technology that we want that keeps us healthier longer and that integrates with our lives. and in that sense nothing will change from the perspective of we do like companionship and we do like to be around other people. ..