most comfortable in. transparency on its own as a risk of snakes in its wheels, disappointing people unless is hitched up to the perhaps harder policy to pursue where it plays a supportive role. why don't we move over here, and if you could please give your name and affiliation, please. >> i'm a primary care physician. rathera brief comment than a question. you have presented here what the consensus is among a wide swath of the policy community, but it is not among everyone. the focus in these proposals is utilization, that the beneficiaries need to have to mature skin in the game. commonwealth just produced a report saying americans have more skin in the game than anybody else in any other developed country. there is also great concern in

the physician community, the american of the american college of physicians, for example, does not represent its leadership but not necessarily represent its membership. whoe are health economists think the problem is not utilization, but the problem is prices him and it is not physician prices, it is at least under medicare it is prices of images, drugs, tests, the three we haveaccelerators in washington. none of these proposals do anything about that. by the time your proposals again, the accelerators are here and who is going to pay for them? that will be loved into what ever fees are charged, bundled, or otherwise. bundled intobe whatever fees are charged or otherwise. >> that is an important point

that we looked at a specified set of comprehensive proposals that certainly do not represent the totality of all of the ideas out there right now. i do want to clarify, though, and say i do not think that the proposals were limited to looking at limiting utilization, and i think in fact, that is a criteria for selection of the proposals that we looked at. we did not talk about all the provisions, but i think another key element that was in many of the proposals was a focus on beneficiary engagement. that is different than having gettingthe game, beneficiaries really engaged and giving them more choice. in fact, there is a significant agreement among even some pretty abstantial proposals in to different medicare-type benefit package. i want to clarify it is not just

all about limiting utilization among the proposals that we selected. ok, the other side. >> hi, national coalition on think thee and i commonwealth fund and the alliance for doing this. i wanted to return to a point that i think both paul and len made and sheila different a little bit about the notion wouldn't it be great if the sgr reform was part of a broader agreement, closer to a grand bargain, brought entitlement reform -- brought entitlement reform? i wanted to attack that a little bit. would it be possible, given where we are at now, we come to march, and for lack of that if folks kind of back away from attempting to do sgr now and pay for it in smart ways, wouldn't we undermine that

kind of confidence-building effect that that would have? i would like to tease that point out a little bit, from the folks. you do not want to have misunderstand. i mean, it would have been great had a grand bargain been available and if agreement had been reached on a whole variety of things rather than a relatively limited package that has moved to the house and is about to move through the senate and a separate sort of sgr conversations that will continue into next year. no question, a great many of us on both sides of the aisle had hoped that we would have a much larger conversation, certainly reflected in simpson-bowles, perfected in the work that paul and i were involved in at the bpc and other places, the presumption that the best scenario is the one that looks at this in a much broader

context. my reaction was simply that -- i guess too many years on the senate staff said that incremental is not always a bad thing. sometimes the opportunity to begin the conversation and make itself to as lends broader conversation. i think what it did was allowed people to come back together and work together in a bipartisan not seen that. i do not recall the last time the finance committee at a markup, but it has been quite some time. in talking to some of the staff and saying onto looking forward to it and a say i have never been to remarkable for, it was an interesting six prints. three or four years. if it does nothing more than get people get back to the table, get the sass working together, what i understood was a collaboration, both on the senate and the house sides, i think there is an opportunity

there. yes, would it have been great to get a grand bargain? want toly, but i do not suggest that what was done was not in fact important and in fact lends itself to a broader conversation. >> if i could say one thing. what i was referring to is really doing and sgr fix on its own, it seems the pay force have ors have tothe pay-f come for medicare. whereas if you do it more a fix., there is fors are easier if you have a context. i would second the point that learning to do bipartisan, even at a birthday party, is a really good idea. will turn to this question here, and then we will go to a question that came in on twitter. i want to remind our c-span

viewers that they can submit questions to us via twitter at ostconsensus or a twitter healthreform. >> one of the things we have talked about is a shift of paying from autumn to quality and value. one of the levers is quality measurement. i am a big fan of this. it is admittedly a science in its infancy, and some of the implementation has been a little less than ideal, and there has been a big pushback from from positions in prayer the writers. i'm concerned, are we creating a generation of physicians who are alienated from these sorts of repurchase the quality measurements and performance? >> i can answer part of that question. what i have seen over the last couple of years is a tension

between measuring quality or value at the level of a provider organization versus the level of an individual clinician. i heard a lot of these approaches are in never going to work. at the level of individual clinician. i am concerned with the attempt to try to do that. for me, i think the focus should be to encourage the development of organizations that can take on these responsibilities because we are never going to be able to build a direct incentives into the medicare program for individual clinicians that makes sense to them. >> i would just add that i agree with the individual physician versus group point that paul made, but i would add that there is a difference between ensuring quality for a clinician to continuously improve their organization's performance in measuring quality for the purpose of computing value as we

are talking about in these contexts. the dream, of course, is for you all to inform the idiots making the payment am right, and that is why you had a process. i think what all our proposals call for i think, at least one that mentioned it, was more standardization, alignment, i believe is a nice phrase rachel used, but a standardization of the quality metrics being required. i know an integrated system in virginia that is producing something like 249 quality measures or different -- i do not know what the right number is. it is not to 49. i think you got to have this process, but you got to start. we cannot feed paralyzed by the absence of perfection, and you know this, and so we will go from there. >> one final addition. the other thing that has changed is that more people now talking about not just the measure of quality, yes or no, but having a more informed conversation about

how is the data going to be used, and it is very different to get providers on board, and there are some things that people are comfortable using, quality out forms to make palin decisions, and there are some things you know as you make care decisions with the patient. so i think there is a more sophisticated conversation going on right now about quality measurements, aligning those, but also before you are just collecting measures to collect measures, what are they going to be used for from and this understanding that not everything needs to be tied >> >> to benefit decision-making. i want to underscore the point and i agree with richer. there is a more collocated question today and a more nuanced one. in all the proposals commensurately the work that we did at bpc, there is a sensitivity to the indicators that people breathe asked to track. the cost and the word in on individual providers as well as

on the systems, the desire to essentially simplify the process am a make it rich, but make it appropriate and morse and the guy said we can't agree on the uniformity or at least some kind of consistency that providers systemsrunning multiple and the burden of that. there is absolutely. nqf isho is now running invested in understanding cap and developing criteria can be best allies. there is a conversation taking place that touches on a very important issue you have raised. >> ok, from twitter -- one provider payment reform that could be instituted that would demonstrate a shift away from the for service? i would ask the panel to give us a sense of the level of consensus on this one provider reform, payment reform.

, i can't -- one thing i want to bring up is in the bpc report, there is a simple thing that providers that are part of and the medicare network or have episode bundling contracts yet higher payment rates. a big difference. >> that was great. >> that was i was going to say as well. there are commonalities among the proposals about -- we've been talking about the sgr's. exempting providers from a threshold per my -- threshold amount, 25%, of their asian practice, and these new provider arraignments, primary medical homes, exempting them from the sgr freezes or scheduled physician payment rates that happened under sgr repeal.

that is one element that sticks out. all the proposals address that in some way. they did not all agree on the level or for how many years, but they addressed how you deal with medicare providers. >> i think it is interesting that both of my very learned colleagues immediately talked about increasing fee for service for the good guys. it shows you how hard this is to move the ball really fall really fast. i will go out little farther on the limb and say some kind -- i do not know exactly what kind -- but some kind of pmpm to providers who are willing to demonstrate they can do coordination for all the good offf, and there is a start that in a kind of a cumbersome way in the enc on a bipartisan basis, and the senate has a

version where they can play pmpm 's for being certified. thaton the board of organization, but i think the idea of rewarding our merry care entities for taking on responsibility -- what i would like to do is link that to some kind of risk down the road, some kind of performance base. maybe the thing grows over time if you bear morris. the key thing is eating the clinicians to be aware of the total cost of care. that is really hard to do, believe it or not, in the current system for most american are. airs. what most pmph's is show that docs the data, and docs are usually shocked. i did not know that. hitting the data in the doc's ha ays, getting the pathw

to the solution and rewarding them for the infrastructure they're going to have to build, that seems something worth voting. i will say the evidence on pcm ih is not thrilling. costd evidence pretty -- evidence pretty mixed right. we have not designed the perfect a bee. that is what i would say medicare could do with a little more oomph. >> thank you. we have a question. a couple questions, actually, addressed to paul, if you would not mind kicking us off on this, and then sheila and len, if you could respond. this is a much broader cover station than -- cover station then we have time to get into today. what do you think is going on with this health care spending growth slowdown?

is it real, is it going to continue, and how much of it can we attribute to potentially systematic changes coming out of butbly not thea aca, the systematic changes at that level? >> that was a very tough question. for everything i have read and from panels i have into, i have been to, clearly the recession and its aftermath was a very large factor in this, and hopefully that will go away over time. i say hopefully because hopefully the economy will come back. there doesn't to be some evidence of some structural changes -- there does seem to be evidence of some structural changes that need to be made. not the aco's. what people look that when looking at aco's, they are not

saving a ton of money. there is evidence about how technological change has slowed down, and as it has slowed down because it is running and has things to do, or because of the recession, because the market is not there? i think some things we are going economy isonce the restored, is we are still going to have a much more payment of the point of service by paid patients, we will have incentives to use provider some more than others, there is a lot that is going to be continuing in a stronger economy, and i think that will have an effect. ofi am optimistic that some the slowdown in spending will be -- butned and probably probably will not be as extreme as it has been in recent years. >> i think it is fascinating to observe that the slowdown

actually began a couple of years in 2007, for the recession really hit. contributedecession to it, no question, but it already started. so what is the deal here, and what has continued? we're speculating here, so i would just say in my opinion it has to do with the fact that a critical mass of health care decision-makers had figured out we got to do something about our health care system's costs. i start with employers sending the signal, sending the signal that we got to find cheaper ways to do this. hospital leaders -- i have never seen hospital leaders unanimous in being aligned around this point. we got to reduce cost. before the aca. what the aca did was kick in and turbocharge it and really down a marker. we are not going back. let me tell you a secret ash

real.pdate reduction is it takes learning out of hospitals forever, basically, at an increasing rate over time. that ain't changing. the penalty on readmissions, which gets worse over time, these things have focused the minds like never before. there has been a system-wide ok, they are serious this time, and some of that is going on. i think everything paul said is right. i think the technology think maybe as important in the short run as anything else. >> i think it is both, a, nation of all things that have then touched on. there will be elements, that will be sustained. we are also looking in terms of the aggregate at this bubble of baby boomers that are coming to the system that will certainly put enormous pressure on the system. many of the elements that were contained in early work in the sensitivity -- and the sensitivity on the part of

players of employers and others about that is not going to go away come and many of those kinds of changes will be sustained. >> the good of this microphone. ok, let's go to this crime. ma media. what we know about increased costs for emergency care, also for delayed treatment of known and medical concerns and conditions? can we make comparisons with the solar health care costs and other nations? ownnt to mention in my personal medical experts this year, i got a referral in august from my general practitioner. i was not able to get an appointment with a specialist until the end of november. then when i needed to be treated in september, they told me to go to the emergency room. that had to be more expensive, i think. i made to a more jazzy room visits in september as -- i made two emergency room visits is ever as a result of that. >> i do not know if we know

anything more in terms of what you're asking than we have known for quite a long time. ishink what is fascinating part of your store is when you look at -- and maybe i am --if you look at what physician groups have to do to qualify for the private- cmh's, whichned p are by far the largest number, the first thing they have to do is figure out a way to give 24/seven access, and it could be that they have to have a nurse on call and call them whatever, but they have to find a way to address the question of a human theg who needs care outside nine to five situation. that is a precondition for been the payment bump up whatever you get to join the program. weis unambiguously true that have learnt because payers are 7illing to pay for it that 24/ access has a cost-reducing

effect. it also has a beneficiary having this effect because you're not just off if you do not have to wait and all that stuff. those things are holding consumers in their. we know going to the er, when need, isot k ridiculous. all that has been known for quite some time. i do not think anything new is there to learn. >> you asked about international comparisons. we know we are paying more than any other industrialized country for health care in total and per have, and americans are more likely to go to the emergency room room because they do not have access to the usual source of care that anywhere else in the country. have good emergency room metrics. >> one thing that i thought that might be a factor is the distortion in our fee schedule. the fact that we pay so much.

more generously for procedures than four visits. that may have something to do with you having to wait months for a visit with a specialist. will take exception to that as a specialist, if i may. >> go ahead. >> i do not want respond to that question, but i will. three or four months is ridiculous, i will agree with him, but i do not think the difference in pay has anything to do because specialists are overrun just like anybody else trying to do clicks. there is much a shortage of specialists as our primary care. one of the other things before we jump on the primary care bandwagon, look at the training of the primary care docs now compared to them 20 years ago. len as an antidote, and knows this, before i left washington i looked at who was coming into our clinic, and over a five-year. period, we had a 300% growth

in patients with functional disease that should have been cared for by the primary care. why did we have to see that 200% increase which ends up delaying the patient with real disease coming in? before we get into this, remember we have to get down and look at a few other things, and i will segue into my question -- a few other things is training. you got to look at training, of how they are being trained. second, it took us an hour and a half into this program before rachel tensioned data that len mentioned four more times, paul alluded to transparency, but without the data, why do we do it? comment about doing a manhattan project is great. being tovided in this, get schizophrenic -- being too

schizophrenic. equality aceson of what i did in 2013 and paid in 2015 is like what we are taught not to tell the mothers, say, johnny, you are bad, wait till dad gets home to spank you. you got to put it into the context of when you are doing it. how are we going to have a manhattan project? infrastructuree to get timely data to the physicians so they can make the improvement? i will tell you right now a lot of the associations that are doing the quality measures are starting to say, what is in it? where is our association? are stepping back from that. they do not make money for four or five years. i ring that up that l -- i bring

whenup that len said that physicians see the data, they will change. when you get physicians comparing what they do against their peers, locally, regionally, nationally, giving them tools to change, whether you do for any payment model or incentives. own wanted to add from my experience of a specialist told me later when i saw them a few weeks ago that if i was already in the system, they probably would have seen me. that was like a first-time referral. that was the reason they told me to go to the emergency room. that is what they explained to me. >> this is not meant as a political comment, but the likelihood of cms getting a lot of money anytime soon is unlikely. but i think there is a great deal of sensitivity to the timeliness of data. one of the issues that paul and i contend with in the work we age doing with bpc is the

of the data. this has been a longtime problem with respect to medicare. len is exactly right that one of the credibility issues with respect to the indicators in quality has in fact been the time lag between essentially the acquisition of the data and the analysis of the data and the practice. there's no question that we have to find a way to make things more relevant, more current month and a more credible as a result, so that people can essentially believe that what they have been given is the basis on which they can make change. in the near-term i do not see a commitment for a manhattan project, the but the point is a good one. >> so i got to say, there are many things i do not understand in life, and i would start with the american league and the chinese language, and how come it is that the private plans can g, andu data with a 1/4 la

let me be clear, the private plans to the processing for medicare, but somehow or medicare cannot do it in two years. i do not understand that. we do not need more money, sheila. you need different people. i cannot figure this out. speak,ou're going to join us at the microphone. understanding in medicare you have a year to split the bill and they wait until all the bills are in. >> the insurers have the same lag. are doing on a rolling average for medicare, which waits for averages. >> it turns out all i know what docs,te plans are giving and somehow it is enough to get a good guess here. it seems silly to me. >> ok.

>> i'm with the commonwealth. a couple of authorizations -- observations. one is on the distinction between the discussion of skin in the game and the distinction between rewards and punishment. i think one of the encouraging things that i see across all of these proposals that we have been talking about today is there is an emphasis on changing the payment system so you reward good behavior, and we need to think about the health care system like that. it is not about punishing bad behavior. good behavior. right now we reward bad behavior. it has be a change -- that has to be a change. we think about the trend in health care costs. i remind -- i am reminded about whether people are saying health care costs are slowing or what is causing the slowdown is i get the sense it is a spectator

sport, and health spending is not a spectator sport. it is something that is generated by millions of decisions every day and is an ongoing thing. whether or not health care spending has slowed because of a recession or because there were structural changes, we need to make sure whatever happens in the future sustained a level of health spending that we find sustainable, and that means action and not just sitting back and watching and waiting. and i think there is action on that front. they're both public and private initiatives that been shown to be promising. one of the private ones that we have done a lot of work on is the alternative all of the concert in massachusetts, which boost cross blue shield in massachusetts has done, and what they have done is one of the incursion things they have done is taken data and shared with her fighters to compare -- with

providers to compare their behavior not only with other providers in the state, but also perhaps fighters in their own practice -- but also providers in their own practice. blue cross blue shield will tell us how she goes into a doctor and point out that the bought dr. next door was prescribing a different much more expensive drug for the same condition that a doctor that she was talking to. and the doctor she was talking to just did not know. i think getting that kind of transparency, and i agree with paul that transparency that is hitched to some workable legislation rule situation has to be done. and the last point i will make is one of the things that drives me crazy about people talking about health for form is this notion there is a shrinking pie. people talk about blood running in the streets because providers are fretting about the shrieking i. if you talk about over the next

10 years, there are on the order of 50% or 60% more health spending 10 years from now than there is now. i would posit only in health care would that be called a shrinking pie. [laughter] great. i would go to one on the cards, and then we will come to you for your question. we will shift gears a little bit. len, you have a question about what you believed the role of antitrust should be, back to health care reform efforts, and what you may have meant when you said the need for more nimble antitrust? >> good point. i would hope that somebody would take that bait. it is mired in the past in that it really is focused on structure and predictions of performance. and basically, i would say there has been a tremendous emphasis

on organizations proving clinical integration efficiencies before a merger is approved, but they tend to lose in court. they have gotten frustrated over the years. my point would totally be this -- sometimes antitrust needs to be more in my view accepting of the newosition that indeed vertical integration and new virtual integration agreements may be more worthy of getting a pass than they have in the past, but also we need to be aware -- i mean by more nimble am a sometimes the antitrust remedy is just too cumbersome for current law. there is very little you can do about local market power if there is one hospital or no matter what you wish already one group of cardiologists

orthopedists, whatever, pediatricians, so they can hold everybody hostage. if you're in that situation, antitrust is a very cumbersome tool. you to think about this i hate to say it, but i will -- you need to think about regulation in that context. i think of regulation as the as i-case last door, but am an economist, but in the absence of anything else, what do you do? what you could do, and this is what i mean by allowing more nimble permissions, i think domestic medical tourism is greatly underused. i know a retired surgeon in the months into six retirement, got more out of his mind like most of us will, called up a mining owner he knew, and he said, let me help you? he looked at his data and picked 15 conditions that were the most in the -- expensive conditions, and with mining companies committed to shoulders, hips. he found the best places to get

those procedures done in the midwest, and, by the way, all of them had lower prices than a lot of places they were going and they had way fewer complications , etc. the problem was getting the minor from wyoming to go to denver or other places. they used cost-sharing in the plan from the -- a self-insured employer can do that stuff, but they threatened the local monopolies with i was in my group over here unless you come back. that is a brutal form of reference prices. in my view you have got to let that stop go on and encourage it. the guy told me the biggest problem he had was getting the guys from wyoming to go to denver, because they were afraid that they would get robbed in the parking lot when they came out. [laughter] >> if i can follow up. antitrust policy can be beefed up. but that is not going to be --

it is very cumbersome. it is not paying any attention to these combinations between hospitals and physician entities, which i think is a real concern to me. but there are a whole range of things that are market oriented was either come as len saying, can be done by purchasers, payers, or they can be facilitated to governments. for example, one approach is a tiered hospital network which is very difficult to get off the ground because prominent hospitals can say put us in the best or only one a contract with you. massachusetts passed a decisive to ban that. there are real opportunities at the state and federal level to not necessarily take a regulatory approach, but to take action which actually fosters, freeze up market purchase, and another is austrian physician

organization -- is fostering physician organizations. aco program, the it has special provisions to encourage he smaller physician led programs into the program. we need more of that. >> i'm with the international association of firefighters. the replicas concert is the cadillac tax rate when dr. ginsburg pension placing the tax, -- mentioned replacing the tax, with the exclusion of employer-provider health care, it was the first time i heard that idea, actually. i'm intrigued by that. on the theme of encouraging good behavior, discouraging bad behavior, actual effects on employees, insurers, what it means, i am interested in hearing about that. in addition to the political

realities of whether that is something that has legs or not. primarily, how it works. >> i would think from the perspective of firefighters, the problem with any of these approaches, the cadillac tax or a cap on the exclusion is that some employee groups due to the nature of their work or the nature of their workforce are going to have higher medical spending. that is a challenge of making these policies sophisticated, sensitive enough to adequately recognize that. and this applies both to the cadillac tax and to an bpc reporte, and the had that. one of the most concrete things is the difference between the two is the way it works out, the cadillac tax is effectively a de facto cap on premiums.

you give them the fact that the insurers cannot do that the would it is that they have to charge so much more for anything above the cap, they will not do it, and that is really much more limiting than the approach which is just dealing with the incentives and saying you can have the policy that the higher premium, it is just that you will do it without tax subsidies for that last part of the premium. >> there's a difference in terms of the impact, and as you pointed out, in terms of the employer and employee. as you might imagine, as paul suggests, depending on the cost of the plan, the industry, the group that is covered by the plan i'm at the nature of the plan, it does have a differential impact. you might imagine that a large employer plan, historically, large union plans, there have been a fair amount of opposition to these kinds of changes.

when you look at the political realities, those are stakeholders who would have some strong views on this question. great. we're down to our final couple of questions. of thishad the majority conversation focused on areas of consensus and have steered pretty clear from the affordable care act. -- let's bring it back to that specific topic. this russian asks whether the -- this question asks whether the addition of millions for under the aca poses an additional hurdle for health care cost control. i might ask folks to think about if there are additional opportunities embedded in there as well. now that we are enhancing the poll that will be insured under the aca, whether in the private marketplaces or in an expanded medicaid situations, what are we

facing additional -- in additional hurdles? >> rachel, i think a major positive of expansion of coverage is that i think there will be fewer concerns on the part of providers that if they do practice more efficiently, if they limit hospital admissions, this is an environment where you can do that and will not suffer as much. whenever providers are very busy, presumably they're much more receptive to ideas about having to practice more efficiently. you maybe see it in hospitals. if the hospital is worried about empty beds, it is going to be different than if the hospital is worried about i am bursting my capacity and i do not have the capital to expand. >> that is an excellent point. i would also suggest when you get right down to it, what the law does, in my opinion, is

not all, butmore, many more players in the system on population health as opposed to taking care of me and mine. toe your car all insurers take all comers, you have a different world. that world has not yet come to be. it will come assuming the website will come up in 2014. that will be a different world, a world in which insurers will have to change their business model, and their results model will move from partially, and maybe in some cases, mostly risk selection, to helping all enro llees five value in the system. there will be a live in aggregate spending. yes, total spend will go up in a blip. because we are going to face in medicare performance, it will take four or five years for the whole blip to begin.

the key variable in all of this discussion is the rate of growth of costs per capita, and in my view if you have more players the kazakh population health, -- more players focused on population of, you have more providers taking the lead because they will not go broke, and you have more plans focused on value, that allows the system to deliver value and you have more people interested in developing incentives for that value be to be sustainable by providers. it is easier to contain cost of the long run with everybody in. >> i think this is one of the areas where it is going to be an interesting scenario to watch between the state level and federal level and what occurs in ofse different pockets expansion. certainly, with respect medicaid among we have seen in recent years a large majority of plants for their existing population ine chosen to put them

managed care arrangements. in the course of the conversations around the new expansions in the states that have chosen to go with a different strategy, and with those that have chosen to expand, again, the states have thought out and are looking for opportunities to essentially organized and paid for services in a different sort of way. you might imagine with the increase, if we looking at 8 million people coming in successfully into medicaid expansion in the coming year, that there will be greater pressure on the states to look for those opportunities. the enrollment to the exchanges and the exchange-based fans lent itself for insurers to look for insurers to look for methods to finance care any more efficient way. one way might be the way to construct their networks. the point he made earlier that we are only beginning to see what these plans are going to look like, the rates they're going to be, how they are going

to organize services, what tools they like to be centrally organize that care and keep certainlys down, and the uncertainty about what that risk. to look like, because of the slope enrollment is going to because of the slow enrollment will complete things. it will be a couple years before we see things play out. the underlying insurance regulatory changes to put pressure on them, to figure out how dimensions -- how to manage this publisher differently. there are opportunities, but friendly some challenges. before i post less friends -- before i post the last russian, there is a blue evaluation shaped -- she. i would ask that you fill it out. the last question has to do with

30% of patients accounting for health care costs. the question is, how do we balance between targeting this high cost group first and benefiting the other 70% of the patient population so that they receive better outcomes in high- quality care? >> those are common themes and common strategies. if one can imagine figuring out how to manage that population that are sure nearly expensive, that that can only work to the benefit of the general population in terms of how we organize and think about services. there's no question that there is increasing attention on the duals, people who are eligible for medicare and medicaid. they are costly. there our efforts to look at the relationship between the state and federal governments in finding ways to finance those patients.

that can only benefit the broader conversation about how we think about the ways we organize and manage people over tinuum of care. >> i would look at what real plans are doing, and the medicare demos are doing. what you see is i would say three kinds of patients they are focused on. there are those that are really sick already and you do the best you can come and that is care management and full speed nurse manager at the side. then there are those who are in bid position that use a lot of services, but they can be much better managed if they were coordinated. that is where people are throwing the new infrastructure. then there are most of us who

are healthy most of the us who are healthy most of the time. we don't need much. it is about consumer service there and then about preventing that 70% from getting the condition or having the condition deteriorate. it is about monitoring. you do not want to ignore them, but they don't need near as much infrastructure as the 30%. but they are finding is that they do better on roi if they focus their infrastructure on those that are in that 30%. unmindful of not the ones that come in, and if something happens to you and you get in the group that needs more attention -- but you don't need that much attention. most americans would balk at that much attention. i don't think it's that big a problem, as long as we get the infrastructure. thanking join me in

our panelists for shedding light on areas of consensus when we talk a lot about differences in this town. thank you very much. [captions copyright national cable satellite corp. 2013] [captioning performed by the national captioning institute] >> good points. [inaudible conversations] [inaudible conversations]

white house press secretary updated reporters today on the implementation of the health care law. he spoke about the state of the union address in january. here is some of the briefing. first of all, i know i can confirm -- deliver the state of the union address on january 28th. so that is one. two, i have -- [inaudible conversations] >> yes. yes. he will be there. and second i have a topper related to implementation of the affordable care act. today we are highlighting the millions of uninsured americans who can gain access to affordable health insurance plans because of the affordable care act. nearly six in ten will be eligible for coverage at the cost of $100 per month or less. and if all states expanded the medicaid programs nearly eight

in ten of the uninsured americans would be able to purchase coverage for $100 or less per month in 2014. justice yesterday, iowa joined a growing number of state lead by both republicans and democratic governors that have chosen to politics aside in expanding medicaid under the affordable care act to reduce the rate of uninsured and help their states, hospitals, and businesses save on uncompensated care costs. it is an example of how when both parties are flexible and work together, we can move the country forward for the good of all americans. this stand in stark contrast to the congressional republicans plan. where every middle class american enrolled with tax credits would see the premiums skyrocket. and every american covered through medicaid expansion would be kicked out of the coverage. if? were ever a time for republicans to change course and help americans without their

obstruction would be able to gain access to hurricane in less than a month, it would be now. we'll bring you more on the health care law sunday morning. health and human services secretary testifies on the website since it launched on october 1st. you can watch the hearing starting at 10:235* -- 10:35 a.m. eastern on c-span. on the next "washington journal."

this is a train depot in georgia. the oldest building here. as you can imagine in 1976, the hustle and bustle of the activities here on the campaign. you would have tables going off and letters coming in and out of the area. she was helping run the campaign from the small building. this is where rosslyn carter helped with the campaign. it was basically a way to get the word out about jimmy carter using volunteers, going door to door. it was a method so effective it helped him get elected to the presidency. watch our program on first lady rosslyn carter on our website or see it saturday on c-span at 7:00 p.m. eastern. and monday our encore presentation of first lady

season two. 9:00 p.m. eastern on c-span. >> were in the which was a capital of bosnia which of a part of austria hungary on the tour. it was a big day. it was a serbian began national holiday. and so soviet, the neighboring country was furious they had taken over bosnia. seen as a provocation and islamic people within and they decided to kim them. they did it. they shot the arc duke and his wife. they both died next the chairman

and commissioner of the nuclear regulatory commission. they testified about the operations and management of their agency. they appeared thursday before a house energy and commerce subcommittee for about two and a half hours. [inaudible conversations] welcome, everyone. we would like to call the hearing to order and would like to welcome the commission here. and recognize myself for five minutes for an opening statement. we are holding the hearing today to conduct oversight of the nuclear overstory commission. chairman terry's bill reorganization plan climates act nrc's role in protecting public

health and safety in the environment is vital one and take over responsibility very seriously. thank you, commissioners, for making yourself available today. earlier this year, the u.s. court of appeals for the district of colombia granted a writ say, i quote, the commission must continue with the legally mandated licensing process. close quote for uk can -- yucca mountain. three months later they issued an order to proceed and resume the line review. while i largely agree with the order. i question why it took so long. given the commission's history on the topic, i wondered if the nrc was dragging feet on the issue. or if it's just the normal pace of operation. as it turn out, the nrc seems to be losing the schedule discipline in a number of areas

like new plant licensing, line extension, and power reviews just to name a few. that seems odd given the growth of the nrc's budget and personnel over the past ten years. the reduced number of operating reactor and decrease in material licensed and the withdrawal of new plant licenses. on november 21 tion we sent you a letter asking for more information to help the committee understand how the growth in your budget and decreased workload had not fostered timely or decision making. at this time, i would like to ask it be included in the hearing record together with the nrc's response. without objections. so ordered. thank you. going forward i will with the chairmen to bring scrutiny of the ability to manage the workload and make decisionses in a timely fashion. and with that, i would like to

yield the balance of my time to congressman terry from nebraska. >> thank you, mr. chairman. the independence of the nuclear safety regulators is paramount. it's one of the primary reasons why the nuclear regulatory commission is comprised of five commissioners not a single administrator. in 1980 during consideration of help us reorganization the nrc, one congressman raced concern about how tipping the balance of power too far in favor of the chairman could have crassic consequences. i'm going quote democratic congressman from his testimony before the senate government affairs committee, quote, there will be two situations in the future, those who are the chairman basic agreement with the majority, and those who are he or she is not. in those cases the chairman has a majority of commissioners with him or her is it's obviously

that the chairman will not need the extraordinary powers tucked away in his plan to work his or her will. the chairman and the commission can move in unit sob toward their chosen regulatory policy. continuing, quote, but what about the other situation where the chairman is in the minority regardless of party aflghts within the commission when the majority of the commissioner oppose the chairman. isn't it equally obvious that if it will be at that moment that the special powers will be most appealing to the chairman? isn't it clear that if these powers are ever to be needed and utilized at all, it is precisely bay chairman bent on going against the majority of the commissioners. during, end quote. and end of his statement. during the previous chairmanship, we witnessed that turmoil that mr. first saw.

turmoil documented at length by the nrc inspector general. while i know we are glad to see the commission functioning as it is now and should be, it is incumbent upon us as legislators to do what we can to prevent this type of turmoil from recurring in the future. that concern is what prompted me to draft this bill developed in large part from the inspector general's conclusions, and with the advice and counsel of the nrc itself. and i yield back. >> gentleman yield back his time. taking the last minute, without that. i will turn to ranking member for five minute opening statement. >> thank you. thank you, mr. chairman. good morning. and thank you to our participates at the within table. it's great to have you before the committee. we have quite a full roaster

potential issues during the course of the hearing. among these is the bill to amend the reorganization plan that lays out the structure and authorities of the nuclear regulatory commission, and define the role of the chair. the commissioners and the nrc staff, that being hr3132, which is authored by our colleague, mr. terry. ..

>> commerce subcommittee has focused on these and previous hearings. with the activities overseas by the commission arrived skeptical of the need of h.r. 3132 it does not address any real problems and some of the provisions they create new ones. the primary ones is to ensure the fleet of nuclear power plants operate safely in nuclear materials are accounted for in the end of safely there's room for error. the public will not tolerate this to maintain public safety and public confidence

are essential if we rely on nuclear power. as we proceed to consider h.r. 3132 that is what we should use to examine this legislation. a speedy response is oftentimes called for in addition to the central focus of safety i would observe the organizations may be productive as a test of her time and attention away from the main mission undertaking this task. i am skeptical with such a anyhow hot diversion given before this commission and i am understand the working relationship among commissioners that is a concern short operating those rules by believe we should concentrate our efforts to solve problems such require a legislative

solution. i am not convinced h.r. 3132 can pass that test. think you to use the commissioners to. >> in addition to oversight we are here to discuss h.r. 3132 mr. terry bill to modify a overseas organizational structure are to appreciate my colleagues i have concern which have already been mentioned which leads to the ability of the

commission in to respond to emergency situations. i am afraid the bill would hamper that and i would like to hear arafat is confirmed or not by the members of the commission in this speaker -- this morning also fund nrc from its facilities from yucca mountain be heard from secretary moody's said it makes is that it is important with public support and i agree wholeheartedly we need to do discuss straight -- state technologies for storage of nuclear materials of these issues are important for idi nuclear project in the future we should take every effort to make sure they are fat as we go forward. my time is expired civic we

now recognize mr. with field for five minutes tim mckyer also want to say killed and other members of the commission for being with us today and we appreciate the work that you are involved in. of a like 2.0 we try to setup this hearing beginning in august and everyone has busy schedules but i hope he will work with us in the future. we set some dates that were not agreeable to all commissioners and your staff cutback to wes to suggest a date we were not even in session but i hope we can work together to facilitate these hearings. i also read senator boxer was critical of your travel. i would say i think it is

important you do adequate travel because the expertise we have fallen the nuclear issue and safety is better than anyplace else in the world's what is important to pershare our expertise. buses fukushima you have been focused on safety issues as you should to convince the american people that it is safe and he must have in it but i do believe in additional regulatory

cost should be justified by high real safety of benefits. said general mentioned in a letter in november 2.0 staffing is 29% over the past 10 years and in the fees recovered has increased 58% and as we receive and this further be found in a duel review of a long-term safety trend to a and the nrc reported it has not had any significant adverse trends of safety performance. that is commendable and we are pleased with that but in spite of that there is 58 new regulations pending. then the nrc received applications for new reactors and licenses for issued to build for a and 62

licenses have been withdrawn or suspended but that nrc stock continues to cite budget constraints with their review. i do agree that there seems to behalf a disconnect between the resources they and what appears to. we look forward to your comments today and we certainly look forward to use the opportunity to ask questions and work with you as to move forward. i yield the balance of my time. >> i appreciate that. civic the minority has accepted mr. waxman shows up

to give his statement. life detector does he would be given as there are competing hearings. the pronunciation of the names is a challenge so with us today children mcfarland, a the commissioner maguey david so for my colleagues we will try to get that right. you'll how chance to europe grain testimony bill could. >> good morning. two distinguished members of the subcommittee. my colleagues and i

appreciate the opportunity to appear before you today on behalf of the u.s. nuclear regulatory commission and. nrc has a full plate of responsibilities from reactors from raised in security he continues to flourish and effectively. to dale like to share a few highlights of our accomplishments. with a licensed facility of materials in means our top priority. a vast majority aha -- are performing well while a few indians oversight to ensure the safe and secure operation but construction of the new unit is well under way under rigorous inspection in construction continues in the staff works toward the operating licence the decision.

we also anticipate the first design certification applications for small modular reactors. the shares of the reactors shut down or to cease operations as these plans transmission year-old adjust oversight accordingly to insure the steps are dressed while keeping the public informed for cody nrc is in compliance with of circuit court of appeals decision to resume the review of the licensing application. we reviewed feedback and budget deprivation from the nrc staff in the november 18 the commission issued order directing the staff to complete the safety by erasure report for the economic construction authorization in the application. project planning of the

capability is now under way. on several matters to the license application my colleagues and i may not be able to come into to pending motions have participants to the education they seek relief in federal court also to make progress in the waste confidence toward the proposed storage role in statements are out for public comment until december tortillas. we have conducted 13 public meetings in 10 states for feedback and questions. we have received over 30,000 public comments. in the interim nrc refuse all applications from we will not become final decision depended on the raised confidence decision intel it is fully addressed we continue to learn from

the fukushima accidents among others things licensees to put equipment had reactor sites did have a supplemental flood barriers and to develop plans to install the instrument pool and also several rule making is. to ensure this work is to distract us from the day today nuclear safety priorities. the highest priority enhancements will be implemented by 2016. the nrc has held with the manhattan 50 public meetings to get input of the fukushima work. the biggest of a year with the sequestration and cosseted the rapper's the impact how ability to carry out operations but if it continues it will negatively impact our new reactor were kindling divergency licensing activity among others.

the recent government shutdown had a detrimental impact on the safety and security commission included ongoing inspections at emergency response capability was never in jeopardy but we were able to live that the impact of relative but even the four day for low-cost agency more than $10 million of lost productivity. we have accomplished a great deal but the challenges are still ahead for the nrc. i am confident we can address these issues in the country goods and i would be pleased to easier questions. -- answer your question. >> al breaking them for waxman will give his opening statement. >> apologized for being late the other committee midinettes the same time started late.

they keeled and especially to chairman macfarlane for being here today and which use my opening remark to comment on a really bad idea of the bill of today a laundry list of changes 40 internal procedures of all disputes the commission has worked through. after the three mile island will tell congress and the carter of the industry should recognize the importance to centralize in emergency authority of domestic nuclear crisis. the planned 1980 addresses is concerned to establish basic responsibilities. the cherubim and the commissioners of the nrc. but to codify the plan every since the plan to from the

three mile island put tickets states needs as seeing gold clear decision maker to reap -- during a nuclear in urgency. the bill takes the opposite approach the requires the nrc to befall the other commissioners it either prevents the chairman from taking in the emergency action until she did a price of four commissioners and the general public and the congressional committee. i figure that is a troublesome idea if a nuclear meltdown is happening we don't need bureaucracy be need to the chair to act quickly and decisively. we should now required to call congress and commissioners along with the web site of the illustrator of public affairs officer for exercising a birch's the

authority the impact of this bill could be proving disastrous in the nuclear crisis. that is not feel the change. not long ago struggling with a nasty personal conflict while the commission seems to of moved past that with the leadership of chairman -- chairman macfarlane. but the republicans cannot let it go. and schuster the pot to reopen past disputes read the nrc focused on this 80 not refer id procedures. hit every proposed changes to shift authority from the chair to the commissioners even to the president or congress with any perceived violations by the chair. there is one nrc internal

procedure that should be changed. the commission revised policy for how handles the congressional request for non-public documents. previously. >> host: and provided documents from the oversight committees or with nuclear facilities in the district. as a policy of another fight on public documents to individual berbers and they withhold sensitive documents from chairman its drinking grabbers as well. this is misguided and dangerous if there is say document dated two b.c. then they should get a. they want and probation and they should get it is not partisan issue but institutional oversight responsibilities. i encourage all five commissioners to brief the

of the flawed policy and i look forward to discuss this issue today. i have to apologize in advance because i have another subcommittee at the same time that has fought and patience to sufficiently to be both places at one. >> genscher a lot of people are glad you're not able to be cloned to yet. [laughter] we will miss you. and i am sure mr. terry appreciates the ability to competent and his bill. [laughter] so return back to the commissioners again. you are recognized for five minutes. spectate year chairman and ranking member of the subcommittee for the opportunity to appear before

you today on nrc braddish rick the potential need for legislative reform. the chairman chairman macfarlane has provided a comprehensive description of key aegis your accomplishments in challenges to carry out the important mission of public health and safety of every nation and the circumstances that may carry out his mission in is constant patience of our approach this was a message said from the senior career official. to all nrc employees it was as follows our future will be dynamic and unpredictable the agency will need to remain highly flexible as we respond to events in the external pressures. we've got to fight the work we're doing giving careful

consideration how to use resources than safety and security. i agree. as senator organization that embraces the precepts were burning nrc seeks to improve the internal organizational effectiveness parker as the number i will for quebec colleagues in staff to support the agency to accomplish the work efficiently and effectively with the circumstances we face today. i am confident it the nrc members are up to the task as they have proven time and again. i think and pour their sustained commitment. i appreciate the opportunity to appear today in the live forever to questions. >> commissioner you're recognized for five minutes.

>> good morning. chairman of a raging rivers and distinguished members of the subcommittee's. of a bite to offer a few cuban live regulation. addressing concerns of cumulative effects for example, the nrc staff acheson in its midst of the rulemaking process for this is in addition to chitin's as well as specific solicitation of public common stock and cumulative effects with the publish proposed rules. aside from the enhancements to the staff is open to industry proposals for fukushima action when they testified.

ended to shinri were directed to come up with options to have their prioritizes has eat integrative set on a plan specific basis. the nrc staff are exploring in public duties the idea of this proposal. the rationale behind the first nuclear power plant risk is very specific and to focus on just one area are of regulation such as safety enhancements ignores other work of the agencies to me such as fire protection in closing we reviewed focused on the security mission in a way to of the greatest

impact on safety. think you very much. >> al commissioner backward -- teeeighteen. we appreciate your oversight because we think it is important we have to choose to share our thoughts about these issues. our printed comments capture the activities so i will much well of that but it has been a busy time for the nrc. evade progress and receivers including waste issues, and updating standards the first fukushima a plan -- the first player since the '70s but today attention is placed after the fukushima response.

march 2011 nrc harris learned important lessons from this tragedy as it takes action to enhance safety. we did not overreact or underreact and i think we have right. at the same time nuclear energy and fukushima has responded with strategies have will provide safety benefits beyond requirements. reported the -- more importantly, the two months ago all the officers of utilities travel to japan as a group to inspect the fukushima's site to talk with those of the disaster. there were big gains made on this trip. cover challenge now is to a absorb the post activity into our normal work and

prioritize. requires how with fellow probability extreme defense to protect against other areas. commissioner apostolakis talks this morning that we see growth of the resurrection but it is a big challenge. the steps we take one of significant implications for the years to come. the university bill have the benefit of us half than the highly experienced people this is too vast a pair of the commission has afflicted and do general counsel. by the ford to continue to work with you. i look forward to your questions. >> commissioner you're recognized for five minutes. >> 8q.

commissioner, ricky members in the rivers of the committee, the chance to be before you today to ted looks at the safety oversight role to ensure proper safe operations on a pledge hundred operating reactors across the country. nrc only seeks to have the experience is the guy right lessons learned and as initiated by the chair read where appropriate. i am confident of the decisions nrc has made it is functioning properly as a body intended by congress ian the frustration. others talk about po-faced told its i will talk briefly about the process that of every team in order issued

has sought and deliberation of the commissioners at his table happily there is some solid effort put out everywhere have sufficient funds to complete the safety reports which i think our report change. and he will keep them updated with of the reports. the nuclear power plants today operate under challenging conditions in the past. a cost of repairs in the low price of natural gas of lead of -- to the shutdown of four plates of this year and more have announced for next year because they are not economically viable proprietress of new reactors has weighed in the current economic climate. that said nrc will be made diligent the plans are operated safely to keep oversight with the

activities. as others have noted we also look to change our workload a and to insure our staff is the right size. i appreciate this hearing and the committee's role and i will answer your questions. . .