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>> i think what will happen, i mean, it does depend on how quickly people start to live longer and healthier lives, right? i mean, if it comes on really fast, people won't know what to do right away, and they'll keep following whatever patterns they're following. you know, i think what it really means in the future is that we're going to have a lot more diversity in relationships and in, you know, when people get married. i mean, even when it's established that people can live to 150 in a healthy state, there's still going to be people who get married at 20 and then divorce at 25 and keep going, right? i mean, they'll just have more time to do that. but then they'll also be the people, i think probably a more general trend because what we've seen in the past is age of first marriage keeps going up. instead of being 27, it'll pop

up to, you know, 35 maybe. something like that. and keep growing. and i think age of first marriage will continue to increase, for sure. especially if fertility -- i think it's really linked to fertility, was a lot of -- because a lot of women feel pressure to get married and have kids so they can meet that 40-year mark. although increasingly we have egg freezing in ways that can push it -- >> you can push it, but not your own biological -- >> right. weeing freezing, you can. >> but egg freezing doesn't work very well, because eggs have a high water content, and -- >> i know. >> there is new technology now where scientists can freeze pieces of vain tissue -- >> right. >> and it's full of tiny, tiny little miniature eggs. and we've always known that. but the problem scientists had after that is how do you get these immature eggs, how do you mature them so you can actually go through an ivf be cycle. >> right. >> and that breakthrough actually happened a couple years

ago. >> -- [inaudible] under the skin so they can be be -- >> in fact, there was just a news hit a come months ago, so ovarian tissue, if you take it out and reimplant it within the woman, the eggs mature on their own just naturally, but it was always thought you had to put it back. but just a month ago or something, they took that tissue and implanted it just in the stomach, and it still worked. so biology's sort of magical. >> and then you can solve your work-life balance problems because you can work and have your children recruiting a tiring -- [laughter] and then the whole cop seventy of -- concept of, you know -- >> this kind of technology brings up an issue that we haven't talked about yet and that a few people have mentioned to men me when i talk about this technology is baby factories. if you can take out immature eggs, and it's a crazy kind of term, but if you can take out immature eggs and mature them in

the lab which is possible, then maybe you can just create the whole thing outside of someone's body, and women don't have to be responsible for it anymore. i mean, that would change a lot. >> you could even have a deceased father, sperm donor, and have a deceased mother who has donated the eggs and have a baby born and incubated in a little box, they're being developed so that the baby can be incubated outside the body. >> a lot of ethical issues. >> no father or no mother. have we done something good or not? [laughter] >> question. i'm sorry, you've had your hand up for quite some time. right here in the -- yes. in the open-collared shirt. yep. >> hi, thank you. don kaley. you've talked about the quantitative regarding marriage, but my question is about the qualitative. it seems to me that when we're agrarian and early industrial, it was really an economic institution. it was something that we relied

on for our own longevity. it's shifted in the last 50 years, you can tell me better than i know, into more an emotional institution -- >> right. companion -- >> do it for pleasure or for their enjoyment. what is -- is it going to shift again to something different than that, or is that going to mature in a way that we haven't been able to observe yet? i'm just curious about your thoughts. thank you. >> i think you're right, that the reason for getting married has changed. it used to be a religious commitment or a social or a family kind of thing to bring families together -- >> and property. >> and property, right. now it's for personal happiness. i think in almost -- at least this countries like ours. and as the purpose of marriage is personal happiness, as people become unhappy and have longer periods to become unhappy, you have unmarriage or divorce. so that was the trend we began with, and i think that maybe helps explain it. >> i think the big change

because of that is there will be a throwback to the past, a throwback to the extended family which we haven't seen that much of, but, you know, the more that people get married and we see different families being created and they're all together, families just get bigger and more diverse. and that was part of the same-sex marriage debate also, and part of the opposition would say, well, that's the procreative purpose, and then you can point to these older marriages and say, obviously, it doesn't. obviously, for many people it's about companionship and happiness. so i think we have time for maybe one more question. >> james sag. life expectancy is a number derived from distribution. as you talk about life expectancy getting longer, do you expect the whole distribution that we have right now just to shift upwards, or could you imagine that, for example, this room might -- people in this room might represent a small peak at one end and a large tail going down? and if that's the case, what

kind of social pressures would you expect? >> i'm sorry, what do you mean by distribution? or do -- what do you mean by -- >> [inaudible] average of that. and i can imagine a situation, in fact, you sort of talked about that in scenario b where it's a small group of people who benefit from from all the technology, get very long lives and then i think, you know, the one guy who died before everything happened because he smoked and stuff like that. so you wind up with a bimodal distribution or a distribution with a peak at one end, peak this this room, they look affluent, and a long tail and maybe a peak that hasn't moved at all from now. and i'm wondering what the social implications of that would be. >> right. right, right. if there's a longevity divide where you have some people living a lot longer than other people. which we already have, by the way. within the u.s. there's a

30-year gap between some of the people that, i think it's north dakota and native american man there lives to be around 50, and in new jersey an asian-american woman can live to be 91. so there's already big gaps within our own country, and internationally they're even bigger. it's like a 50-year gap internationally. so if that gap continues to grow, i mean, the question is how quickly does technology roll out, right? do life-extending technologies roll out quickly like cell phones and the internet did, or are they slower? and if there's a slower period of time, then there will be those big gaps, and i think there will be big social gaps, changes, differences between groups. and that could be really destabilizing. >> and distances across national boundaries, too -- >> right. >> in wealthy countries such as ours, it may be rather widely available, but in sub-saharan africa or southeast asia, it's not going to be, and that is really the potential for a

destabilized world order, and let's take that seriously. >> okay. well, on that note -- [laughter] well, thank you so much. did you have a comment that you wanted to make? >> oh, really i was just going to say we've talked about marriage and family to this point, but the current political situation makes me realize that our politicians would live longer, too -- [laughter] and we would have members of congress sitting on committees for maybe 40, 50, 60 years or supreme court justices -- >> the supreme court, right. >> we may have to replace constitutional issues at a certain point because we wouldn't want people sitting for that long. >> the quarreling could just go on forever. [laughter] >> okay. thank you so much. this has been a great panel. thank you all so much. [applause] >> and turning back now to congress and the u.s. government shutdown entering its seventh day, congress is back in session today. the house live now on c-span, our companion network. they're in, they'll be taking up a short-term funding bill for the food and drug administration

and safety with the fda. that should be taken up about 5:45 p.m. eastern, and it continues the plan of republicans in the house to pass targeted, short-term spending bills. that's a strategy that the senate leader, harry reid, says is a nonstarter in the senate. any recorded votes in the house should happen after 6:30 p.m. eastern, and the senate gaveling in at 2:00 eastern time starting with general speeches and judicial nominations at 5:00. as the shuttown continues -- shutdown continues, senator reid issues a statement today saying: speaker boehner had a credibility problem from refusing to --

>> speaker boehner's office respond with a statement of its own saying: >> a clean debt limit increase cant pass the senate, let alone the house. it's time for some washington democrat to step up, act like an adult and start talking about how do we reopen the government, provide fairness for the american people under obamacare and deal with the drivers of our debt and deficit. those statements, again, from the leaders in the house and senate, and we'll continue to bring you updates on the shutdown and congressional action on the c-span networks.

>> we need some fundamental overhaul of how this government works. i mean, we vote on tuesday because sunday is church day 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's how many seats fit in the building, despite the fact that the size of the average house district has quadrupled over the last 40 years. the mechanisms of our government are due for a dramatic overhaul, and congress will not be able to navigate out of the current cul-de-sac they've got themselves into unless they understand and embrace the changing nature of our society, of our world and reimagine what government might look like in the digital age. >> reshaping power and politics

in society on "the communicators," tonight at 8 eastern on c-span2. >> this is the clarke school for the deaf where calvin and grace met for the first time. she was a teacher living in a dormitory here, and he was a tenant in a boarding house on the property. we're now in grace's bedroom in her clarke school dormitory building, and this window here is where grace would have looked out and seen calvin across the courtyard at the next building, and she would have put a candle in this window here to signify to calvin that the parlor room below them was available for them to meet up in. in this room was where calvin and grace when they were courting would meet up and be able to sit and talk and have some time together. despite him being in his 30s and her her 20s, they still had to abide by the rules of the school and needed to meet somewhere where they were supervised and chaperoned while they were on campus. >> meet first lady grace

coolidge tonight live at 9 eastern on c-span and c-span3, also on c-span radio and c-span.org. >> more now on longevity and public policy with the new america foundation, slate magazine and arizona state university. they'll talk about retirement and financial planning with professionals in the field examining the challenges of living longer lives and what that could mean for the economy, entitlement programs and personal financial planning. this is about 40 minutes. >> going to say this is the week that no one is going to support the idea of politicians living longer. [laughter] chris, thank you for that fantastic discussion. this is such a great subject, and i just want to give a plug that this whole session is kind of a preview of what we're going to be doing in slate starting in a but weeks. so there is going to be a lot more of this discussion going

online starting later this month. so if you think that dozens of great, great grandparents creates an etiquette problem, think about the social and economic problems that could come from all of those people having nothing to do all day. and our next panel, can we ever retire, would we ever want to, is going to consider workplace and financial implications of increased longevity, especially for people who are planning and thinking about retirement. and to moderate the panel i want to introduce to you matt yglesias. where are you at? matt is slate's business and economics correspondent. before he came to slate, he worked for the atlantic, tpm media and the american progress. his first book was called "heads in the sand," published in 2008, and his more recent book was "the rent is too damn high."

the brief bio would be that if you want to sound smart about what's going on in washington about business and economics, you read matt, and it works particularly well because he writes many, many times a day very concisely always adding some fresh point that you haven't thought of. in his money box column on slate -- and his column, i should add, is a finalist for the 2013 online journalism award with. welcome, matt. [applause] >> do i have my panelists here somewhere? otherwise it's going to be, it's going to be difficult. but we should be joined by mark warshawsky with towers watson as well as a former vice chairman of the federal commission on long-term care, lisa mensah who -- i apologize if i'm mispronouncing everyone's names, this is a whole panel of people -- myself included -- with slightly odd names.

and jaime ca ma' december, of course, our sponsors here. at any rate, to sort of kick things off, i think it's worth -- you know, i think the idea of living longer, of greater longevity, it's very optimistic. i think, you know, most people don't really want the die, but it places sort of significant financial challenges on people to know how to save and how to save for a longer retirement and what that ought to look like. particularly if we're thinking of a world in which people may need to work longer because savings won't necessarily extend that far but also may need to financially plan for certain kinds of transitions in life. and so i wonder, i'm may, you know -- jaime, when people are thinking about what sort of savings they're going to need to retire, how much does it matter what kind of a life you're envisioning for yourself?

are you just going to draw those savings down or supplement it with work? how should people be thinking about this? somewhere well, i think the definition of retirement itself is actually changing. i think that oftentimes we think about retirement as that 1950s definition of withdrawing from working environment. and it turns out retire comes from the french word to draw and redraw is probably a better definition of how millennials and many people are thinking about retirement. when we ask people what they're going to do in retirement, the number one thing they say is work. which sounds counterintuitive, but it's -- they want to do what they love. and, in fact, i think that most individuals who are young and not yet ten years within the retirement age that we normally think of, 65, 67, they can't envision retirement.

and they actually procrastinate. and they have a really hard time thinking about saving for retirement. people who are closer to retirement, ten years or so, have some sort of life event that makes them start thinking about retirement, and most people start building a retirement paycheck in their mind from all their sources of wealth. hopefully, they've been autoenrolled, and they've started saving in their 401(k) or their workplace, but we're finding that today's work withers are facing a challenge -- workers are facing a challenge about 10-15 years in advance of retirement. >> absolutely. and, lisa, you know, this is very much, i mean, there's a lot of inequality in the united states economically, and this sort of continues into the retirement space and our more working class families and people who may have, you know, jobs that are more physically arduous. how do they need the think about this, and how do policymakers need to think about those sort of class-bound challenges? >> yeah, thanks, matt. i think that jamie's right, we're reenvisioning retirement,

but everybody's going into this not the same way, and you're right to think about this as well. if you've been hoisting up people or working on your feet or greeting at wal-mart, one you probably often you weren't in the system. you weren't building the retirement all along. so much of america, and it's a stubborn statistic, it's a stubborn statistic of about half of the work force that hasn't been amassing private savings. but for all americans, the social security system is the financing tool that really sustains the baseline. so i think many workers no matter class are still counting on both a row bows social security finish robust social security system and they want more. and i think that's where the real policy debate is. if you remember anything, it's really that we're heading into this question how would we ever retire, how would we pay for it with a two-stroke system which

is our social security system. and then everybody, even that greeter at wal-mart wants more than that, wants a private savings system. and that's where the challenge has been, how do we build that on top of the social security system. >> i remember when i was first taught, you know, public policy in college they spoke of a three-legged retirement stool, of personal savings, of social security and of pension plans through the workplace. which have, obviously, gone into substantial decline. but do you think that still has any kind of role to play? >> well, i think there certainly are still roles for the employer because the employer has an interest in providing a retirement plan because at least in certain industries and in certain organizations they do want to see a natural turnover in younger workers coming in and an ability of older workers to leave with dignity, and that's particularly many those type of -- in those type of

industries where there's a physical element to leaving. however, with that being said, there are yet -- there's a range of experience, and there are other organizations and employers that just, they don't really -- it's not that important. it's not important to the organization. it's important to the employees -- >> right. >> and so some response to the employees' demands, but there are other ways for employees to get what they need, and that could be through private savings or working. so there are other ways of dealing with those issues. >> what would we need to do to sort of get more participation from people? i think it's about half of people are in workplaces where they're eligible and about half aren't, right? >> so that's a really important public policy issue of how do you get people to have more access to savings. we know that the best determinant of whether or not someone's prepared is whether or not they're saving at the

workplace. and more organizations, companies that have workplace-based savings tools, participation tends to be fairly high because of new public policy solutions that allow companies to automatically enroll their employees. so where is coverage not available? it's not available at the smallest employers, those with less than 900 employees -- 100 employees. and who did they hire? they hire mostly women, mostly people of color and mostly low to moderate income individuals compared to mid-sized and large-sized organizations. only 25% in some measures of small businesses offer workplace-based retirement plans, and we see three barriers for why they don't. there is -- they are perceived to cost too much relative to the retail alternative, they are administratively difficult to administer because of the rules that we put around them, and

small business owners are individually fiduciaries. that is, they are personally liable for the or workplace-based retirement plan. the good news is there are a number of initiatives and ideas about how do you allow small businesses to pool their purchasing power or simplify the fiduciary responsibility. >> i think jamie really noted what is our big, a big policy challenge, and many in this room know it, but it's how do we build a system where everybody can be in? >> uh-huh. >> and i love the word simplicity and automatic. there's a great book out calmed "scarcity," and it talks about our bandwidth and why everybody's channelinged. this isn't, you know, you talk to anybody on the street, and they'd love to try to build their nest egg. but somehow the reason workplace savings works, it's where the money is. we make our money at work. somehow we need systems that are more simple and automatic. and those are the big trends of

the policy movement. can we make it more automatic, and especially for people who are working in small businesses or self-employed. ask any cab driver or anybody who cuts your hair, what's your plan? we know if it's not structured and made simple and so, you know, the president proposed in making it all automatic, making it optional for the individual so they can opt out, but making it payroll time just so when you get your paycheck, you're saving a little in a private, in a private account. and i think that the trend, it's hard to back away from things that are automatic. >> right. >> and automatic to your favor. >> right. >> somebody could to that with my diet, i would really love it. [laughter] >> yeah. i've had a similar experience. it's hard to resist the bagel. >> i want to add another viewpoint, and that is although the 50% number in terms of any one point in time of people who are covered by retirement plans is a steady number and it's

certainly been true over many, many years, it's a little more complex than that when you look at the number of when people retire -- and particularly when you look at it as a household, a a couple -- how many have retirement assets, formal retirement assets. it's a higher number than that. it's more like 70% because people do go from job to job. sometimes they're covered, sometimes they're not. but they still keep those assets with them when they retire, and certainly when you consider relating to the prior panel that many people are married and they stay married through retirement, it's about -- and the laws sort of recognize this -- it's the couple, not just the individual worker. >> right, right, right. that's a little more of an optimistic take, but at the same time it's certainly been my experience, i've been in the work force ten years, and i've had, i think, four different jobs, and i've always been fortunate to have some

retirement provision at three of those employers. and yet even just the logistics of keeping track of that can sort of get very complicated. i mean, is there things we can do to sort of make the policy account for the fact that, you know, the savings comes through the workplace, but also people are going to have many different workplaces over the course of their lives and integrate. >> i'm familiar with private organizations that have been popping up that deal with exactly that issue. so i think even within the realm, the rubric of current law there is a possibility of aggregating those savings. >> uh-huh, uh-huh. >> and i'm sure organizations like prudential are interested in that type of thing. >> into do. there are -- indeed. there are methods to headache sure that your savings are aggregated over time, but there is continued work to be done on a public policy basis for any sort of coverage solution to make sure that as people switch

jobs, they don't cash their money out. the, there is a behavioral issue that we as human beings have, and that is a bird in the hand is worth more than two in the field. so if you see a large savings amount and you switch jobs and someone says would you rather have the check sent to you, would you rather have the check sent to a future savings account, the vast majority of people take the check today and, unfortunately, are sacrificing their future financial security. ..

what was lost in a private pension for those that have them and there were women and minorities that never have them and lost a piece that is still there. so in one way it is the most powerful that america has. however it could be a boost. and polling shows us that most americans on both parties would favor improvement particularly at older ages. so we are more sympathetic to the 80-year-olds getting a bum but when they can't work anymore or they are not drawing a big salary with many private savings. and i think the truth about the social security system is how beloved is. not just from the people receiving it. the kids that don't have to pay for their parents or grandparents, too.

so that really is clear. >> i was going to say with social security it really provides an important base and does establish the concept of retirement. the increases on how long devotee we want to retire even the traditional sense eventually in the 70's and 80's and people have to also retire social security provides that base. i will use the word old-fashioned program. it reflects the view of the 30's, 40's and 50's in terms of marriage which we talked about before in terms of when you retire and the ages are red and wall from 62 to 70 and that was true in 1960 when the was designed. so - we need to update social security to reflect what already

has happened to say nothing of what we could expect to happen in the future. we also need to educate individuals after approaching retirement about the traces are today. too many people are doing that and taking money at 62 as opposed to giving themselves the range using the savings today and the proponents of social security until 67 or 70 which gives them a greater immunity for their lifetime. that is a hard financial burden to get over to say i'm not going to take social security right away but one that might optimize their financial security for their lifetime. >> i think that speaks to one of the larger point about the retirement which is. in addition to people may be don't save enough that they don't always save them the right kind of ways.

they panic of things are down or they all wanted the band wagons when it is too late. what can we really do in the media and in the private sector to help people understand the landscape. >> on the accumulation side and on the savings side both because of the private sector initiatives but also because of the policy there is the innovation target date funds and balanced funds that make the investing of a little more automatic and if they do address the issue of jumping on or off the bandwagon so people are -- can take a little less attention and fell you about the investing i think what is needed and hasn't really been developed it is something similar when people retire particularly when they don't have the defined benefit plan. it is actually needed both need

to encourage it and the private sector needs to step up to it. >> that is exactly right. how do you have defaults so people love wade making the mistakes? >> what we have seen as windows lifetime solutions become available -- and it doesn't matter what sort of available, they have the availability during the accumulation and save 38% more when there is lifetime income available. they don't comply ha iowa nsl perlo in the markets. the metaphor is you approach the largest bridge you've ever seen in your life. of the loved ones are in the car next to you. as you approach the bridge, you see that there is a commotion and realize there are not guard rails on the bridge. do you drive over slowly, do you

speed up and drive over quickly? malae will last another question. have you ever hit a guard rail going over the bridge? what is the purpose of the guard rail? it is to make you feel comfortable and the appropriately. the interesting thing is we have seen on the industry and the public policy point of view the accumulation. there isn't widespread use of a lifetime in, product and savings plans. we would assert that is the guard rail on the bridge allows people to feel more comfortable. there's nothing that stops people from putting it in right now. there's a lot of behavioral hurdles to put them in and a lot more information would continue to happen at this area. >> to me it seems like several didn't get a car. [laughter] what you in the press can help

us do it's really hard when you are working three jobs. we need help getting over this big coverage turtle. it should be more automatic. that is the duty of social security everybody is in. helping with automatic most of us can't do it. we can't follow the funds and even when we do it, we are bad debt. so why not admit the defeat on this level and at least be part of an automated baseline whacks the biggest innovation would be starting the whole savings thing and that is tried in the u.k. and amazing people came into this. i always say there is no shame or blame when you are just born so we haven't done anything wrong yet. so starting there just needs to be a bigger american by an to the seating side of this

equation. growing consumer is probably best in the world. we've got to consume the savings of little more in our dna and that has been a big mess. everything that is more is better. more savings is better if we had a few things -- >> people rarely find themselves regretting having saved too much. you can always do something fun with your grandkids if you end up in that situation. i think it is about time if people have any -- any in the audience. >> i wanted to ask you all to respond. i know that a lot of my friends

and a lot of people that i've worked with our concerned not just about savings and retirement, but also dealing with college loans and graduate school loans that they have taken out. i think that the idea of trying to make that a balance between how to have a fulfilling work life to save for retirement and do all the things you have that is now becoming sort of astronomical how you balance that and how do we as a society respond to that? at some point obviously there have been lots of thoughts out there about of course the cost of college, the cost of advanced degrees will have to go down and that will happen. but there is one, too, possibly three generations that will still be experiencing that and that will be as a society will have to address that.

i was wondering if you could speak to that. >> i love your question. i think it is all of the peace and we think of it once we have our first bulging disk after 40 we miss the first phase. i think your question is because it shows the key assets that we need are challenged at every life and what we do is policy on this town we reward and prosper the things that we value the most. so, we have choices about how we bring down and subsidize the cost of college and how we help people prepare for that but also how -- this is also the way if we need 10% contribution to the retirement funds every year that is the secret we should be putting away biblical 10%. so how we get there, one way to get there is matching people's

savings and if your employer can't do it especially if you have a small business or you are a hairdresser that's where you need the tax credit and savings. some of this should be automatic and not even, you know, you just turned and stalked away a thousand dollars and we reworded you 500. so some of the left would be taken from you. so why can't retirement and college we could do a lot more to protect and subsidize and accelerate how you got those. so i love your question. >> i agree that is a very important question. both in the current wall i think it sort of helps you to address it in one way or another. it makes it difficult because again if you are thinking of it from the point of view of a very long lifecycle you may need to spend a lot of money in the early years for college and

graduate school and therefore you have less money available for retirement but there is something called a catch of contribution that you can make in their retirement plan after age 50. so that is meant to solve that problem. so that is a good thing in the current law. the problem in the current law is that there is also the minimum distribution requirements which started at age 70, you know. and those -- age 70 was picked in 1960. that was really old. 70 is not old now. so it has a lot of judgment to make in that regard. and i think it would help. when you to college or graduate school you are thinking of your whole career so it's best to think of these things in terms of the lifecycle. >> over here. >> hello. thank you so much for having this amazing panel and for each of you being here.

i am one of the thousands that are furloughed. we are not allowed to work. i was told that we will not receive any salary for perhaps three to four weeks or more. many of us are looking to our retirement savings for hardship loans which is the absolute worst thing to do. but we have no other option. i've wanted to ask what do we do? and what can we do to turn congress upside-down so we can get back to work? we have work to do. i just had to say that. thank you so much for your reply. >> thanks for the question. we have identified three areas for big savings to the house, education, retirement. when you sit down with financial planners they always start with a force as well and that is a set of emergency savings.

financial planners will tell you to save three to six months of salary for the financial emergencies. they were not envisioning the situation at the federal level when they were suggesting that. that's not the task, but that is what the financial planners suggest. the challenge with that is that those numbers seem daunting when you add up all of those things. so, the implication is to start on that and save what he can and then adjust your budget and lifestyle and then pay yourself first when you get a raise. don't take it out of your paycheck. but instead, pay it to your savings and keep accumulating it over time. that is what the behavioral finance experts suggest is the best way to anticipate that over time. >> everyone should ask ted cruce if he wants to give you a loan

for a couple of weeks until he can sort of get this started out >> with of the futurist magazine i just want to briefly ask in terms of the comments jaime said which is young people don't think about retirement, i recently sat down with a group of about five or six people under 30 and i asked them actually if there was a financial planning but that they particularly liked and they all said the four hour workweek by timothy ferris. we laugh at that but it's an early retirement by creating a passive income the hinkle online and there is a lot of -- it's a very optimistic manual. but i think it is sort of fascinating. and so, that group wasn't necessarily represented as the whole budget does speak to a mistrust on both the private sector and the government to

provide financial safety leader in life and so this is for the whole panel. do you perceive a growing sense among young people but entrepreneurship is supposed to take the place of conventional family planning among young people? >> i think the popularity of that work people retire very young tends to show that there is a certain benefit to finding ways to score every frame the idea of savings. it's a little more positive but it often sounds like a bomber someone saying don't get that tv now, put it in your 401k and that's really boring. obviously this is like the provincials trying to deal with marketing but it's to make people be more excited about the idea of saving for retirement and we look forward to it and think of it as that. a benefit for yourself.

this goes to lease the's point about realistically what do people have access to in their lives. the most acute problems people are facing difficulties in. it would be great if everyone could start successful companies, but that's three barriers higher. >> i think the question and your comments respond to the need to refrain the question about retirement to make a positive, to engage everybody in thinking about positive aspects of deferring pleasure today having spending money for tomorrow. and it's difficult. 80% of individuals aren't involved in their financial planning. it doesn't matter what age perspective and what income level. we find that almost half of individuals don't look at their statements on a regular basis. either out of fear or about its

interest. and the issue is how do you get those individuals engaged in thinking about positive action today and avoiding the downside mistakes today as well. >> i think not we will have a transformed relationship with money as we look forward. and i think your generation is going to help us manage a day to day. thinking about the future aspect i think there will be ways to connect in the way we spend they came up with keep the change. a radical idea contributing and lighting that is the whole transformation is coming. i think that it's got to be simple, automatic and put us on the right path.

>> a lot of us have enjoyed other things that simply see what's happening in your life. >> i'm with the kaiser family foundation and i work with the medicare policies. nearly all of the medicare beneficiary of savings and putting retirement accounts and other financial assets including savings accounts but there is a huge disparity between the beneficiaries about half of whom have $86,000 in savings compared to black and hispanic. something like half of the beneficiaries of $12,000 of savings this demographic factor in putting education is also projected to persist well into 2030. i was just wondering do you see

the disparity as life expectancy continues to increase and what can we deal with the policy sense to target and reduce that disparity? >> one issue of course i'm not familiar with the specifics but in general is related to the lifetime income, lifetime earnings so there's that disparity that it just sort of continues on into the retirement years so i think it relates in terms of the discussion about the lower income folks whereas it isn't intended with the maine retirement vehicle for people in the upper income so when you add in the house and other sources of value it is a rather complex

story we need to be free flexible to respond to those. >> i want to thank you for raising the numbers and even the difference between 86k and 12k is extreme. but it's also reachable and i spoke to the asset funders yesterday concerned but when you think about it as a financial matter the difference between getting someone from 12k to 86k if you have time and you have a different way of financing the financial assets, we have too many people without a car in the first place. i know if he has 20 years of people putting in even - k or free que at the beginning of work he can close a lot of that gap, and i think that's first of

all we have to be appalled, we should be appalled and other research on what is driving the limits goes even beyond the life time and come and people didn't invest in the higher yielding assets not ever being in the stock market ever. we actually know how to deal with the 70,000-dollar gaps in the work life. >> there are small changes in the public policy that make big differences. there are inequities money to fix as well to tackle this problem. if we start having coverage among the low to moderate income retirement savings accounts against food stamps. it counts as an asset that disqualifies you for food stamps. we can fix these sort of public

policy inequities along the way. [laughter] >> what level of retirement savings to the need to engage in and what do the payroll taxes need to be if retirement is 100 years long? we keep rationing the age of retirement but there is a? life expectancy at 70 is really variable as the previous question after it is pointed out that tends to track heavily white income or difficulty of the sort of work that you are engaged in and it's easy to say let's ratchet up the retirement

when we have the mental jobs but that's really unfair to people who have really physical strenuous jobs and different health expectancies. >> differentiate the retirement system for people's actual circumstances. >> it's hard to answer the question in specific terms and general terms if we have the scenario in general i think it is reasonable to expect people on the average for most people would work longer and it just seems natural to think in those terms. with regard to the specific question i think it is both a the individuals and the response of the body of the employer and the response of the body of the society to deal with those i would call them out lawyers but the complexity of the people who may need retraining or they may

need an employer plan that recognizes the are going to retire earlier so that's what we need to respond to the general trend and the vast majority of people as well as the specifics of the situation. >> i think that you identify where the responsibility is shared the social life insurance system america didn't choose your representative's path. it is sold at 75 but we chose a system that was intentionally not a complete picture. and if we live long and prosper and if we have a long, much longer tail our social insurance system there will be a piece of it, there will be a societal role because we are not all the same and some peace of social insurance does something private insurance doesn't. we've got to pick up more of that. so i would predict we are all

living long and prosperous i would predict we are still going to need a pretty strong core of the social security that marks other pieces of what we do privately. >> i have been signalled to assure everyone off the stage. thank you very much for the discussion. [applause] a look at congress as the federal government is in its seventh day of the shutdown the congress back in session today the house will be taking a short-term funding bill for the food and drug administration at 5:45 eastern part of the house republican plan to pass targeted short-term spending bills. it's a strategy majority leader harry reid says is a non-starter in the senate. any recorded votes will be taken after 6:30 eastern.

the senate gavels in at 2:00 eastern general speeches with judicial nominations considered at 5:00. lawmakers will vote on the nominations are on 5:30. you can watch the house on c-span and the senate right here on c-span2. later today a hearing looking at suspected fraud and abuse in the social security benefits program. the senate homeland security governmental affairs committee will take that at 3:00 eastern on the companion network c-span three. a look at the supreme court where the justices began the fall term today. some of the high-profile issues to be considered include cases dealing with abortion and religious freedom and c-span will be continuing to monitor the court actions and have same-day audio of the oral arguments as they are released. >> 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 tuesday. that is just ludicrous. we have 435 seats in the house of representatives basically because that is how many fit in the building. despite the fact the size of the district has quadrupled over the last 50 years. the mechanisms of the government are due for a dramatic overhaul and congress will not be able to navigate out of the current cul-de-sac they've got themselves into unless they understand and embrace the changing nature of our society and we imagine what the government might look like. this is the school where calvente and grace met for the

first time. she was a teacher living in a dormitory and he was the tenant in a boarding house on the property. we are now and who grace's bedroom in her dormitory and this window here is where grace would have looked out across the courtyard in the next building and she would have put a camera here in the parlor room and below them was available. in this room is where calvin and grace when they were courting they would meet up and have a talk and have some time together. despite his being in his thirties and her in her 20s they still had to abide by the rules of the school and meet some where they were supervised at the chaperone level on campus.

a look at the affordable care act and its impact on patient and providers including quality issues and efficient access to care. as we look at the potential for the shortage of providers. tuesday was the first day the state's health insurance exchanges opened for enrollment. coverage begins january 1st and enrollments' open through march of next year. this is about an hour. >> the next panel is what means for patients and providers. the affordable care act will expand health insurance through a combination of measures including expanding medicaid eligibility, tax credits for employers, rules for insurance companies and requiring individuals to buy health insurance and more. this conversation is going to look at those changes from the perspective of all stakeholders examining costs, benefits and the changes on the health care system. the panel was moderated by maryland who is the

communications tractor and health policy adviser for the alliance on health reform. she previously was a distinguished fellow and senior correspondent at kaiser health news and was also an award winning health care correspondent for the national journal magazine from 1995 to 2010. joining her on stage for this discussion are kirsten for world wide policy and public affairs, dr. jean johnson who is the chair of the board as well as the nurse practitioner health care foundation and the dean of the george washington university school of nursing. the board member of the arlington free clinic, because alyssa of the american society for clinical laboratory science, thomas the president and chief exhibit officer of the sinai

medical center and dr. john the chief degette officer of the american cancer society. a quick reminder please do tweet all of your thoughts and comments at #mj. with that i will turn it over to you. >> thank you. we have a lot going on. millions of people are about to become injured in january. we saw the phones ringing off the hook a day before healthcare.gov and salles the system slowdown. the politics regardless of the republican and democrat conservative, liberal, regardless of people are believing, people are interested and they are going to sign up. there will be more injured people even through the private insurance or premeditate. at the same time many people will be left on injured.

so what will be the effect? we have a great panel with us today. and this is a pretty straightforward question but with different answers for just about everyone on the panel. so, we are going to start off with an insurance question. there are many engines changes in law. so john with the american cancer society can you give us a sense for how insurance is going to change, what are some of the differences in the rules in this law we are talking about changes with pre-existing conditions. what does this mean for the country's sickest patients and for all patient squawks? what does this mean? >> the word transformation for this conference is highly appropriate lead this is true for all the patience but particularly i would suggest

cancer patient. for the first time in the history of the republican people will have access to the survivorship. my organization is the largest organization of the world with 3 million volunteers and a billion dollars of revenue. when we got started 100 years ago there were virtually no cancer survivors. today two out of three cancer patients are survivors. the point is the third loses is to be to his or her life because of the lack of access to health care through insurance. so when the american cancer society started the american cancer database was the american colleges are assertion to show during the debate on the affordable care act following. it has stated diagnosis and whether you have insurance or not. so we were able to show the american public that a woman with stage 2 colin cancer with

insurance had a bitter five-year survival rate than stage 1 colin cancer who got treated. a very important points. if you don't have insurance you are likely to present a later stage disease. it's a surprise to see even if you get diagnosed at stage 1 you are more apt to die because you don't have insurance, so it would be difficult for me to exaggerate how important the portable care act is because for the first time in history of the citizens will have access in the case of cancer and access to survivorship. >> so what are the most important instruments changes in law? >> for the cancer patients in particular, think about my wife is a breast cancer survivor couldn't get health insurance. now anybody who needs health insurance can get it. there are no annual lifetime caps. children can sometimes exceed a lifetime cap in one year of

treatment. and then i think what's really important to remind everybody that however we build this out the centerpiece is an to be accessed in the preventive services and we now know that over half of all human cancer is preventable during a normal human life span. so if people now have access to colonoscopy at age 50 when they needed or some other kind of test we can actually prevent colon cancer from occurring so this is huge and transfer metcalfe for especially cancer patients. >> we know that a lot of people will have access to coverage. what about access to care with a lot of people entering the system the question becomes will there be enough providers especially primary care providers and the talk about a potential workforce shortage.

james johnson do we have been of primary -- do we have enough primary-care providers and in what areas? we are not just talking about physicians. a lot of states are talking about the scope of the practice law but by so that they can create new opportunities for the advanced practice nurses. for one, tell us what the prognosis is for the work force issues and then help us understand what's going on in this case right now. >> i think the workforce issue is certainly a challenge and we don't have a quick fix in terms of having an adequate primary care work force. but there has then the affordable care act and the

funding to expand the work force through training ships the programs have been successful. there's been i think about 1600 nurses now to the service corps because there has been significant funding added to the national service corps to get people into the very underserved areas. however, you know, even with those kinds of capacities and efforts on the financial incentive side in terms of the 10% bonus payment for five years to the primary care practices, paying for the fee-for-service and managed care and medicaid patients, the medicare rate and some other financial things such as paying for the care

coordination, i think that there may be a greater viability, financial liability for the financial care practices. however, even given the financial incentives and the work force expansion efforts we still have a problem with the practice for nurse practitioners. nurse practitioners are a major work-force and primary-care. there are on hundred 30,000 nurse practitioners and that number will continue to grow. there can be more practitioners produced on the pace for physicians and by not saying that we don't need physicians or that nurse practitioners will replace the positions because i am a firm believer in the professional practice, but unless nurse practitioners can practice for the full scope of their education and their

decision making skills, that is going to limit the services that the patients will be receiving and right now 17 states plus the district of columbia have allowed independent practice so basically on supervised practice and all the rest of the states require some supervision specifically for prescriptions were treated diagnosis treatment and prescribing. one of the things we do know in the states where there are limitations, you know there is also a pretty great need in terms of primary care. recently the health service administration has recently noted that there are 57,000 geographic areas in the primary care shortage areas, and that's

significant. that is current with the additional folks trudy aca the demand will become even greater. just to address those needs in the primary care providers that are needed and we just really don't have the protection capacity. and with the speed of the members of 45,000 additional primary care providers it has an estimated and we don't have that capacity. >> so, what you've done is up to the rest of the panel. who are the patient is going to be seeing when they get this new coverage and they want to come in and see are they necessarily going to be seeing a doctor, who else are they going to be seeing or where are they going to be getting their care? >> you found that people are going to seek out care wherever they can find it and you may find of the folks coming to the

pharmacy. the pharmacies all over the country are dealing with laboratory work and on a contract basis that gives a patient access to information that they currently do not have. the laboratories in this country are already trying to figure out how they can get better at giving a patient access to not only the care that they need but then also the information. and in fact they are supposed to change at hippa so they will be sharing patient results with the patient and it will enable the laboratory community to fill in some of the gap in the primary care buy also being available to explaining and then refer or give the patient some information so they can move on to the next caregiver because they're just isn't going to be enough time for what we traditionally call the primary

care givers, the nurse practitioners to cover all of the case. >> so are you saying that the folks at beau lab are going to have new of devotees? >> they've always had the abilities they've just never exercised them as well as they should have in the past because they always defer to the primary care provider. but with the system the way that we believe it is going to be false, there is not going to be enough -- there isn't going to be enough to go around. so the laboratories of all levels are going to have to step out and help the patient better than they have in the past. >> how are the lab is situated in terms of work force? there are going to be so many people in the system are there enough folks in the lab to handle the influx? >> that is the concern we have. there is no way to know yet how many folks we will need.

in our profession we have the ability because there are levels of entry to be able to help with some of the gaps. but once you get to the level that you need scientists and ph.d., then add that shortage is going to be riveting. >> we don't know exactly what the provider work force is that we need. if they reengineer how we do things, you know, and we don't do that population care very well. we are still in primary care doing one on one and we are not looking at the system, looking at the population and saying how old do we best destroy the variety of health care workers that we have?

the physical therapists, pharmacists, everyone. and i think that that is the key and the centers for medicare and medicaid innovation are really looking forward to seeing what kind of things come out of that. >> go ahead. >> we expect a lot of the patient will be seen -- we have a free clinic. we don't get federal funding or we received very little. >> the differences between the clinic and the community health center. >> the community health centers and the quality health centers get the federal funding and they have gotten support for the affordable care act in particular. so, a lot of them are expecting to see the newly injured patients. our clinic like many get to know the state and federal funding so

we are supported by the private donations and worker donations and they are a product of community trying to fill gap to provide care to those that don't have access. and we think very much will still be needed during and beyond the implementation because there will be millions of patients who still won't have access to care. they will have coverage but they won't have care. >> i agree with the observations that especially the people are going to go to the places they are familiar with and so i think in the early going even people with additional coverage now even the free clinics they will continue going to the hospital emergency departments given and the hospitals are actively working to redirect patients in that regard and trying to get them into a primary care kind of setting. but whatever point of entry, your opening question about the adequacy of the provider network

is a very real and legitimate concern. i think that the experience with that has indicated that and i agree with the observation oftentimes the question is posed should it be nurse practitioners or primary care physicians and the reality is in order to accommodate patients today even in the redesigned system we are going to need more votes of those kind of practitioners from the physicians standpoint there is a problem in that regard because there are restrictions on a number of the residency positions that are available. so this past year american medical schools were not able to get the presidency position. so there were limitations on the medicare program now and the available training spots that medicare is willing to pay for. so that issue has to be examined as well. >> from the health system perspective is this something that you were able to -- what is your role in trying to oversee this?

>> the major medical education research center around the country including my own at cedar sinai today actively support a number of training programs but what is paid for during the federal government has lost offering advanced nurse practitioner training and advanced for missing training for example in order to facilitate the growth of new providers into the system. so those positions frankly are being paid for through the commercial insurance side of things as well as the philanthropy that comes into the institutions in order to support those kind of training programs. >> so that is a medium term, longer-term approach that should be able to help down the road. what do you do starting january 1st as you mentioned this was a problem in massachusetts where we sell long waiting lists for people getting in to see a physician. so how do you deal with this if you have people that can't get

in to see a physician they show up at emergency rooms and your clinics and they show up and you have new working relationships between what the hospitals and the physicians and your clinics and system. what are you doing to prepare for the short term? >> the passage of the affordable care act i think really turbocharged a lot of work that was already under way to provide more integrated and coordinated care in the system about breaking down thus lilos of the existed traditionally so what's happened i think throughout the country would be a lot of different kind of partnerships that are developing with partnerships between hospitals as well as between hospitals and physicians. those are small partnerships and capital partnerships both kind of reforms. and i think how it plays out in every community is different responding to the particular dynamics and the needs of but

local community. one thing to keep in mind is as the health reform is moving out, as mentioned earlier, medicaid expansion as an example of things in which this is a federal law but it's not really being implemented for wally throughout the country. so that is just one example in how the exchanges are rolling out around the country is very different as well. >> back to you for a minute to the of how close are we with some of the state scope of practice law or some of them i believe are already passed and in a place that when a patient go into a physician's office that we may start to -- they may instead of seeing their dr. max they may be seeing a nurse practitioner or when they go in to see the pharmacist, the pharmacist may be doing more. are we going to see a system starting next year where the

patients may be getting up more than -- instead of relying so much on the doctor that we may see a different system where we are seeing more providers where are we actually in the process? >> we are already well under way because there was a recent study done by some really good colleagues who was a family physician and ten years ago around 10,000 only about 40% of family physician practices practiced with a nurse practitioner today repeated the study in 50% a little over 50% of the practice is now in a family physicians practice and that is a big change. plus we are seeing in the health care landscape the emergence of

retail clinics which were largely staffed by nurse practitioners and there has been a big investment in terms of establishing the clinics for the convenience and a very specific kinds of problems. but i wondered when they first emerged. my adult kids take their kids there won the have your infections -- ear infections and the understand the corporations that are supporting visa. >> okay. we talked mostly about people getting insurance. there's going to be many people who do not get insurance either because medicaid has not expanded in their state or because people choose to pay the

penalty or the cost is that they will not be required to pay a penalty so they will not get insurance. so we will be left with a level of insurance in each and every state. what happens to these people? where are they going to get their care and how is it going to affect the various provider areas that we are talking about in the health system and free clinics, how is it going to affect the cancer patient whom may be left on injured. how is it going to affect your individual areas and providing pharmaceuticals for these folks that are left uninsured and still are not able to afford to provide them. do you want to start us off? >> patients are either paying cash for the medicine or getting

assistance through the patient program companies. we will continue to provide patient assistance for people who have difficulty meeting the medication need. the way they provide patient assistance after medicare part b was passed there were still seniors that have trouble getting access or reporting their medicines. >> what is going to happen to the uninsured because we are still going to have on injured people. >> they will continue to go again where they have gone historically. they will go to the free clinics and community clinics and they will continue to come to the hospitals in the cases of hospitals that are both obligated by law but also the charter and by mission in the emergency departments they have been treating these people for quite some time, and we are expecting that that will continue going forward. >> you are obligated to basically stabilize them, but they are not going to get

extensive treatment. >> they go through the stabilization process and then hospitals have until now the continuation of the ongoing care after they are stable and able to be transferred. >> can you tell us how hospitals are going to be able to handle this financially because as part of a law, hospitals are losing funding that they traditionally gotten that is government funding that helped make up some of the uncompensated care. so some of that money is lost because the people are going to be covered and now some of these people are not going to be covered. >> it goes back to what i was saying earlier what is being implemented around the country differs. so medicaid expansion for example is a good example of that.

and when alana was originally passed the concept is that there would be reductions over time and the dish funding for medicaid and medicare as new people were added into the system and that is the approach that the association supported at the time that it was on the concept that medicaid was going to be expanded uniformly nationwide after the supreme court decision that's different. so from the american hospital association standpoint, one of the issues that we believe need to be addressed to come up with a way that is consistent with the new enrollment that's taking place and again how that is going to take place will defer state-by-state. >> what is the chance of the federal government or the state government stepping in to get back some of that money in the hospital. >> i gave up trying to predict the decision making a long time ago from the state standpoint i think that the states don't have the kind of funding to expand that in any significant way. the consequence is the hospitals

will continue to provide a significant amount of charity care as part of the mission. >> going back to the uninjured, this is why we know that the free clinics will still be very much needed in every community and why we don't expect that our patient demand a workload while decreasing with even more support because we have seemed more need in recent years and we know the situation is different in every state and every community. in virginia we are in arlington virginia. virginia hasn't yet decided to expand medicaid so the majority of the patients don't have any new good options yet. we hope they will in the future. but right now, those who are 100% of poverty or above may have access to subsidies in the marketplace and we are excited about that and we want to get them connected to new options.

but those that are under the poorest actually don't have any new support right now without the medicaid expansion. we are just as busy as ever and we need as much support as ever. and most "freakonomics" are in the same boat. >> are you concerned about the continued support? is there a perception that the "freakonomics" will no longer be necessary? >> there is that perception out there that there's the affordable c.a.r.e. in the expanded coverage that the free clinics won't be needed anymore and that just isn't true. there will always be gaps in care whether again we know that there will be so many that continue to be uninsured. again, there are those that decline coverage to are not eligible still and those that have coverage but not access to care so we are committed to the gaps and continuing to provide care for the neediest patients no matter what the situation is.

>> your folks how do you deal with the clinical lab with the uninsured population? >> well, in this country the laboratory community is a range that is not homogeneous. we have large laboratories and what we call in the big reference labs. they already have built into their business plans the absorption of some uncompensated care as do all of the hospital based laboratories. we know in the hospital based laboratories and number of our patients that we see are never going to be reimbursed for what we do. and that in the past has extended itself to even people beyond insurance because cancer patient tend to always overspend

their cap and we watch them, we worry about them as everyone else in the health care continuum and we know there is going to come a time they will be running with folks who won't be able to pay. about will continue especially for the population that is not documented in this country but will still need to access health care in emergency situations. in addition, there are a lot of small neighborhood laboratories. a day already do a lot of medicare and they will also see the same level of uncompensated care as the care gets shifted away from the private laboratories. >> i wanted to get back to you because we haven't talked a lot of the pharmaceuticals and yet there are affect when it comes

to pharmaceuticals of the law so walk us through what some of these affect all are. what is the impact? >> like all of the pharmaceutical companies started to help pay for the expansion starting in 2010 through the new fees and discounts included in the law. all of that notwithstanding we believe this is the right thing for pfizer that helped enable longer and better lives at every stage of our lifecycle and that's difficult to do when you don't have a predictability that interest brings. no one plans on getting cancer or rheumatoid arthritis. when you get insurance elsewhere you through that very difficult time. we look at how innovation in medicine have turned cancer into a chronic disease. but in order to be a will to stay on and maintain the cancer regimen, you'll need both of the predictable access to insurance

and other reforms that are in place that means your insurance can't be taken away from you. so these are all important things. the coverage expansion this year for both medicaid and the health insurance exchange brings new people into the marketplace, but also new people getting the discount and so from sort of the revenue perspective that doesn't offset the new fee to the industry but again it's the right place. the goal of the affordable care act are not just coverage of expansion but also improving quality and reducing the cost. and those are two places where the pharmaceuticals are instrumental. pharmaceuticals are effective in avoiding the more expensive health types of interventions like hospitalizations contract, the congressional budget office recognizes that and has and uses cost of setting methodology when they consider the cost of medicine and medicare.

they are known to reduce other medical costs. and then quality is another area where the pharmaceuticals it used effectively can really improve outcome prevention. one important part, pharmaceuticals are key to prevention. part of prevention being effective is you don't just get the screening that you can also fall with the doctor asks you to do in the screening. ..

spent at new ways in which providers will be working with patients. >> just a follow up on what kersten was saying. one of the things we've been doing at pharmaceuticals and the laughter have been working together for a while now, as new drugs are released to the market there are also contain and diagnostic tests that are released that help to monitor the therapy so that you can either determine compliance, whether or not you're approaching toxic levels or whether patients within the therapeutic range. and this has helped to move diagnostics not only diagnostic's but pharmaceuticals forward because you now have people using drugs at the appropriate level at the appropriate time and not over utilizing or possibly experiencing complications because they did not comply properly with what they were

told to do a source their drugs were concerned. and the laboratory is very keen in helping divisions -- physicians decide when that drug needs to be prescribed, when it shouldn't be. we also in the laboratory started to the a lot of molecular testing that helps to get up and whether or not a patient will even respond to the therapy, which has helped pharmaceuticals direct their research. all of this, will in the end, make us much more efficient than we were in the past, and i think that this will happen or continue to happen, as long as we all are working together and looking at nation outcomes, rather than look at our own initial silos like we used to. >> hospitals and physicians are working together between those two entities and then those two entities working together with

patients on this whole question of quality and efficiency. and so both in hospital setting as well as in the physician office setting, hospitals and physicians are working together to first make sure things are developed on a professional basis, based on the individual physician groups themselves. what is the right to the right place and the right location to make sure the patients are getting everything they need, but also avoiding things that don't make a difference. we all recognize part of the problem have been things that haven't made a difference. there's active going on hospitals with their medical staffs, hospitals and physicians working together in the ambulatory setting to identify those kinds of things. and then importantly, creating a system of the ability to the use of information technology but also providing the physicians with information they need to have a conversation with the patient based on their particular diagnosis and their issues. those range from the management of chronic disease to what happens in the cute sitting in

the hospital, up to and including the very difficult things that physicians have to do with an offices when it comes to things like discussions around end-of-life care. and issues with her to hospital care around end-of-life. that whole panoply of issues i think has risen to the surface and are getting an level of attention that just never occurred before. and i think as we look at some of the early indicators i think we are seeing some of the results commentaries things like hospital infection rates dropping. i think the data with regard to the cost, i know there's a lot of debate about how much of that is structural in terms of real change and how much of that is related to the recession. i can tell you from those who are watching -- practicing and feel that there's no doubt that some portion of that, some significant is the kind of work that i was just describing. >> yeah, i think there's going to, hopefully, be a transformation between how health care providers really interact with patients.

i think that maybe, you know, one of the biggest areas, and i think that we are only at the very beginning of understanding how to use social media, how to connect with patients through electronic means, and those kinds of things. and also working with groups of patients rather than 11, you know, when you have a group of people with chronic illness and the same chronic illness, having group visits are proving to be, you know, reasonably effective. so i think that how providers really work with patients is already changing. i mean, i think that many of us have experienced patients coming in and they've already explored the websites and know a lot about what may be going on within. they're basically looking for confirmation and some additional information. but they're also wanting to be

really engaged in the decision-making, and that is something that the aca has recognized in terms of patient engagement, you know, that is a very major issue. and so i think providers are going to know and learn how to better engage ourselves, you know, with patients and not necessarily expect patients to be engaging with us. it's going to be a very interesting transmission in terms of that relationship. >> how is that happening, john? >> i wanted to pick up on what was said by relating the following. right after president obama sign the affordable care act in the white house he came over to the interior building to speak with the vice president to an auditorium full of people who are engaged in the affordable care act but his first words out of his mouth were, now we've got to get this right. the point of like to make here at this juncture is the incredible, historical opportunity we have to build out health care system that really

works. it's so difficult and we want to focus on what's not working right and so forth. but we also have to appreciate for the first time we really do have the opportunity to build out the best health care system in the world and accidentally to the healthiest nation, which we are not. as the institute of medicine report shows last january, the united states compared to 16 other competitive countries, we are last or next-to-last on all of 10 variables reflecting a sickly societies health or the public health. life expectancy, infant mortality, obesity, you get the idea. yet we spend twice as much per capita as the next nation on health care. we have a chance, we have a chance to build out something that really makes a heck of a difference and build the healthiest aside in the world and there's no reason why we can do it. >> connect that to the law. how exactly is the law going to help us do that? >> well, the law, basically everybody has access to health

insurance. they can get it and and, indeed, there's an individual mandate they must get it. so obviously the dynamics change dramatically overnight in terms of the number of people that can get in the system. the key point that tom points out is that we focused, my organization in particular, about people not getting the care they need. i have to report to a board, as tom does, and a decade ago i report instead we get make our 2015 goals in last three things happen. we have to redouble our research efforts, public policy and we have to provide access. and the last when we discovered is the only one that could keep us from ever reaching our goals. so now we have solved that problem. not completely solved it yet but we have a chance to solve that problem, and i think it's an extraordinary opportunity. we do have to worry about overtreatment. and so the key point is people get what they need when they need it, where they need it, not too little and not too much. both of those issues have to be

solved. >> if i could add to that, the law put in place in addition to the coverage expansion is an emphasis on quality and paying for outcomes and we embracing, not reimbursing for bad outcomes. that's something that puts all of us, all the different health care providers in this boat together. it means effective use of diagnostic testing, counseling, using preventive medicine. that's something that there are portions of the law that kids in motion. to your point is getting that right. it's making sure that we reimburse and reward and identified and put the right quality measures in place and figure out ways to track and use them. the combination followed by the affordable care act really creates infrastructure to do that. but it's making sure the data is used, available, and analyze properly so we can have a continuously learning health care system. the health care system is constantly evolving. while the measure of possibly balding just like medicine and

diagnostics. for the first time really, the right things are in place for them to do that. >> there are a few things were doing at the free clinic that adequate general themes in the affordable care act. one is, we've been doing this for years, is really trying to keep patients out of the hospital. and reducing unnecessary we ignition is a big theme in the aca. i know that when -- i volunteer and see patients in free clinic so i know when my patients with diabetes and where adequate controlling their blood sugars. that we are keeping them out of the emergency departments and we are reducing hospital admissions. and when we also have spent a lot of time focusing on health education and prevention. another theme that we've talked about. we have a robust vaccination program. we do group health education. all these things are investments

that will save money in the future, and promote good health. >> we've heard a number of people talk about things like, as kirsten said, putting providers in the boat together. we've heard not as many sides oh, we've heard coordination. and the word that comes to mind for me is consolidation. so we've seen consolidation in the industry in a very rapid fire kind of way. since the law passed in 2010. and you know, i would like our panelists to talk a bit about what had been the effects of that consolidation, where exactly we see that happening, who is consolidating, and where we are now in relation to where we were in 2010. who exactly is consolidating? how much do we see that going on? how much more of it are we going to see happen? and what are the ups and what are the downs of that

consolidation? >> maybe i'll start. in terms of the hospital and physician community, as i said earlier, it there's been a series of different relationships that are emerging, both between hospitals as well as between hospitals and physicians. i think all of them oriented towards developing systems of care. so if we want more integrated, coordinated care in order to achieve the kind of things we're talking about you really need the capacity. unique and organizational capacity for the capital investment that's required, information technology represents for many of these organizations, and expenditure of several hundreds of noise of dollars in or to have the information systems in order to deliver the kind of care we're e talking about as was the manager capacity and the capacity to manage the risks that's associated with the new payment models that have been described for today that all of us see as a great step forward.

what you need the organizational capacity in order to do that. hospitals themselves are very, both labor-intensive as well as very capital intensive. one of the concerns in many committees unnecessary duplication and things of that nature. if we want to bring those inefficiencies out of the system, i think some degree of consolidation and partnerships need to occur. again, how this will play out whatever locality by locality, but that i think is an important part of developing the kind of system we're talking in the future. that kind of consolidation i know has raised some concerns in some quarters about this whole question are the providers have more influence in the system or do the insurance companies? if you step back and look at what we are trying to achieve in terms of a more efficient system, i do think we are coming up on a kind of a decision point on this issue. and that is that we have to decide is the creation of more organized systems of care, for example, in california the

kaiser system is oftentimes held out as an example of what the country might want to move to. the kaiser system is an enormous integrated, consolidated system. but now it accounts for some 40% of all commercial insurance in california. but again what they've been able to do with that kind of system over time is develop a lot of efficiencies that many of us are talking about today. so i think there are, i understand the concerns about consolidation but i think there are regulatory solutions to that as well so hopefully we can get the benefit of the kind of partnerships that are being developed, but also provide the protections that people are concerned about. >> i would like to echo to an extent. the affordable care act and the establishment of accountable care organizations has, i think, pushed a community that was already looking at consolidation during the managed care days, one step further, but, but

centered on a different, for a different reason. instead of just to cut costs, it is now to provide quality care and access across a large continuum of places where you would give care. not just the hospital, not just an academic medical center. so the thoughtful consolidation or coming together, different care sites so you're seeing in california, you are seeing in minnesota, you see in the shenandoah valley in virginia where they are not just doing hospital to hospital, but doing hospitals and clinics and physicians practices, and then taking a look at how are we doing things in this whole system to make sure that no matter where the patient is seen, the quality is still the same. and so in my profession, in laboratory, what we did is started to look at how a patient

specimen is handled and tested in one sector as opposed to another. because there are differences in methods in instrumentation, and maybe through standardization no matter where the patient is seen, the physician will get always the same quote unquote results. and that would be good for patients. no matter how you look at that. if no matter where they go, that glucose means the same and the value is the same, you will be able to compare. it will make us more efficient how we are today. it will also eliminate a lot of redundancy that we currently see when a physician doesn't know whether or not the patient was seen in the clinic, and reorders everything and say they can't see anything. our hospital, our laboratory system can bridge most of the ers and systems and bring that information to anybody no matter where they are. so this is a kind of thing that i think the act has done.

the impetus is different than it was in the '90s, and i think the cooperation will be different. >> yeah, and i would like to just sort of jumped in and mention some the changes in financial models, and one of them being the notion of bundled payment. bundled payment won't sit for every, you know, problem, health care problem, but by having bundled payment everybody has a stake in the game. in terms of primary care, rehab, kids care. you know, and that is, that may prove to be a powerful consolidator of people with shared interests and wanting to do well, coupled with sort of the outcome measures, you know, that would be attended to that still. >> okay, why don't we open up to questions from the audience? i believe we have some folks

walking around with microphones. i see a hand up in the middle ear. if you could please identify yourself. and if you have a particular panelist you're addressing your question too, just let us know. >> i'm a primary care physician, i volunteer at the arlington free clinic. my question is for the gentleman from cedars-sinai. we heard earlier this morning that cedars-sinai is not going to be part of the network for any of that care plans that are going to be offered on the california exchange. >> right. >> i was wondering how that is for you, and if you're planning to make any changes? >> sure. yet, i appreciate the shout out earlier in the program. [laughter] >> but i think the question is a good one. because again, a couple of things. one, it illustrates the point i was making earlier that how the law is being rolled out is going

to be different state by state. and so we need to recognize those kind of dynamics. number two, with regard to the california situation, your observation is correct. it's not just cedars-sinai. the networks that been put together for the california exchange are more limited than the traditional commercial insurance market. and you know, i think we should recognize, we are embarked on a grand experiment here and we're also embarked on establishing new markets. and new markets by definition come together over time. and so what's happened here today in the beginning, you know, likely will not be how things will play out over time. it also raises i think another important issue with regard to things like narrow networks, and that is the issue of how one determines the issue of efficiency.

because efficiency and costs are not necessarily the same thing. you can be, you can be high cost institution, like my own, admittedly, then the question is how efficient is it are you at what you do? so in the case of my own organization we provide more of the most advanced medical care of any hospital in the western united states. we have a significant teaching and research mission. societal goods that benefit the entire system. we see more than twice as many medicare patients as almost twice as many as the next largest provider of hospital service in california. we are one of the largest medi-cal provided in the state of california. that collection of facts come together to impact what our cost is. and i think as we go forward with the implantation of the affordable care act, and how this plays out state by state, the question of understanding efficiency versus cost, the

question of how are we going to pay for societal good, the question of how are we going to provide access for people who have to live near these kind of institutions, and other institutions. i'm just using my own as an example because it's what i know. those kinds of questions have yet to be answered. and help we will get answered as we move forward. >> yes. right here. >> joe coopersmith. i just recently, the director of the medical research program at the va. one thing that everybody agrees upon is that costs have to come down, and no matter how that's done, whether it's redistribution or efficiency or whatnot, it's going to think there's less money in the system for hospitals and other aspects, less people employed, and a certain amount of economic change for both institutions and the community because hospitals are among the highest earners,

or highest employers in many, many communities in the country. i wonder how you see that aspect of it? >> do others want to go first? you're absolutely right. the change that's going on in the american economy is such, and the growth of the american health care system is such that in communities around the country, hospitals are the major employer or one of, sort and one of the major employers. cedars-sinai is the sixth largest private employer in los angeles county, just as an example. but at the same time all of us have to recognize that as organizations we're going to have to be more efficient. we are going to have to figure out how to deliver care in ways that we haven't thought of until now. i think there are technologies that are coming along, whether that's technology in the form of new discoveries around the molecular medicine and other things that will allow total cost of care. the question is, we have to work

on the issue of total cost of care, not just unit cost. we have to work on both, but keeping in mind what the total cost of care. over time, using the international comparison that i think john mentioned earlier, if you look at what are the reasons for that, i think your observation is correct. those who work in health care system, whether hospital executive, nurse, physician, pharmacist, those who work in the pharmaceutical industry, all the related industries, the compensation level in the united states compared to other countries is much higher. and so the question will be, as we solve this problem what will the impact on those kinds of things be? >> is little hard to see with the lights. >> i might just add a point to what tom just said. we can get some efficiencies very quickly. we now come a month ago with 35 sponsors. we now have over 135 sponsors of

a bill, the two bills in the house on retaliation. we have good study showing that patients with cancer and other chronic diseases get better outcomes, it costs less and they have a higher quality of life. so we need to implement and make systemwide things that we already know how to do. if we do that we get real results. if you reflect the total cost, you'd our talk about the costs that occur at the very end of life. we have to have an adult conversation about that and determine what people really want. we have good evidence and they want -- they don't want to die in intensive care. >> do we have another question? >> okay, yes. one more out there. >> i am from the potomac research group. could start with pfizer to go down the line.

just one in haiti think the new law will impact innovation, particularly striking this week in the drug industry that mark, powerhouse and researchers is cutting back on research but there's been some points made up there that suggest there are some incentives for innovation. >> thank you. you know, this longer acts as an excellent to change the robbery going on in the market place. the market place has been demanding more value at less cost for a while from all of us. and so layoffs in our in c. have been happening for a while across the board, most pharmaceutical congress including pfizer, exclusivity loss, and with tha that goes wih las vegas to invest back in r&d. but yeah, the recent event of the merck layoff is another good example. there are parts of this law that really encourage innovation. the fact that health insurance marketplaces are competitive,

patients have choice, that's something that we saw through medicare part d. encourage people to look for value. we believe when you look for valid to look for valley the medicine as well as other services. and quality. quality demands in demand more value, but measures ca can alsoo in a way that are shortsighted and purely cost-based. so if it continues, or develops an emphasis on quality and value for medicine that pfizer and other pharmaceutical companies will be well-positioned to deliver and we can their investment on r&d with the medicines we bring to the market. but it's a challenge and there's pressure. you know, that's across the board. spent the c-span video archives is the true modern record of congress. the c-span archives are amazing.

>> it's easy, here's how. spend go to c-span.org and go to video library to watch the news video go down to the most recent tab, click on what you want to watch and press play. you can search the video library for a specific topic or keyword or you can find a person, type in their name, hit search and go to people. go to their bio page and scroll down to their advances. you can also share what you're watching and make a clip. use the set buttons or handles, add a title and description and then click share and send it by e-mail, facebook, twitter or google+. the c-span video library, searchable, easy, and free. created by the cable tv industry, and funded by your local cable or satellite provider. >> and a look at the u.s. capital. the senate is about to gavel an. they will start their day with the general speeches and

judicial nominations at 5:00. votes on nominations at 5:30 p.m. on the other side of the capital, the house working on partial short-term funding bills that senate majority leader harry reid says are a nonstarter in the senate. we want to take you live now to the floor o of the house for lie coverage here on c-span2. the presiding officer: the senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer.