there needs to be a public commitment made to reducing costs within that marketplace. availableu begi look at ..rol of the marketplace but it's also control of the regulatory environment. that really gets to the heart of our recommendation number four. and i think perhaps the most important. governor ritter mentioned it already. that's using the powerful leverage that the state has with existing health care programs such as medicaid, such as the employer -- state as an employer, state they have the capacity to promote regulation that will begin to drive the market, and that gets us to the next

recommendation which is that we reform health care regulations to promote a system effectively. malpractice is often brought up. that's typically handled at the state. the scope of practice for nurse practitioners and physician assistants and other nonphysicians did typically done at the state level. often that is the place where not only is the scope of their practices determined but the limit to which they can practice is determined. another recommendation encouraging consumer selection of high valued based on information. having transparent information of cost and quality. states again have the capacity to harness that data. in early 30 states now we have all-payer databases where the state has accumulated information from all of the plans. those could be used to drive

that kind of information. and lastly the final recommendation, help from a population health and personal responsibility for health. this recognizes that health is very much in ecosystem. it involves the health of people which can be everything from trails and walkable communities to clean air and clean water. all of those things are part of what allows states to have an impact. so in summary, governors should share and convene a process within states to attack the health care costs in their state they should have data that gives them a baseline from which to operate. they need to have goals, goals that one fact generally have a period of five to 10 years to see the cost curve in their state overall not just in the public sector but the public and

private sector. they need to do state programs as the basis of that. they need to encourage consumers to shop for value. they need to use the regulatory leverage that they have and then look at this as a state ecosystem. subtext, states can have more impact than you think. with that i would like to encourage the members of the commission who are present to join us on this podium because we are going to now take some questions. and i would like to first of all have questions come from those from the media and others who are here who are present for this report and then i will go to some questions from the miller center social media channels. who may i call on first for a question? julie. >> you number of states are doing things and one of them is massachusetts and i wondered if you could chat about how the

bare cost control in massachusetts is an example of what you would like to see in other states? >> very good. enter you have first-hand knowledge of that as head of blue cross-blue shield of massachusetts. >> thank you governor and it's a good question. i would first say i'm always a bit cautious about recommending massachusetts solutions. one of the statements in the report is that each state is different in each market is different but having said that many of the recommendations mirror the state of massachusetts. a law that was recently passed has created a recommendations in this report. more collaboration among government and the private sector, his sense of shared commitment in the state that we need to lower costs while we improve quality and as a consequence we are seeing costs come down or should i save the

costs come down. another report adopted in massachusetts has been widespread acceptance of the change in the way we pay for care so the fee-for-service system which i think the report and other experts identify as being fundamentally inflationary is being changed for massachusetts and physicians and hospitals are voluntarily adopting and agreeing with health plans like ours the blue cross and blue shield and others to accept what we called global payments, payments including incentives for quality and incentives to control costs and independent studies by experts have demonstrated that we are starting to get to that holy grail in health care which is better care and lower costs. i think the massachusetts experience is instructive. while i have the podium one or two other comments i would like to make. i do believe that if individual states adopted the vast majority of these recommendations, the

health care costs would come down and there is some passing reference to the affordable care act but my view is that the evolution of the affordable care act makes the recommendations of this report more relevant codes as the affordable care act has evolved we have watched as states have made individual decisions to perhaps take a different path whether they have adopted to expand medicaid or not, whether they have adopted economic changes so some of the national standardization anticipated in the affordable care act has not come to pass at the same level which i think is but a much greater focus on states as the locus of accountability for health care which is exactly the kind of premise of this report. does that get to the question you asked? >> many of these recommendations sound like they will need

additional control by the states. how is that going to fly in some of the states that there is perhaps already too much regulation? >> i think it's both the governors acknowledged we need to achieve a balance between government regulation and oversight and market innovation and although massachusetts is often viewed as a state where government oversight is widely accepted and in fact some of the most important steps we have taken to control costs come -- from the market have come from indication together from plans and from hospitals and i think there are some very -- states with republican governors that have innovated very successfully. each state has to settle where they are comfortable with that allen's between regulation and innovation of the market but is a basic humus as we just heard from our presenters, governments

have a lot of authority and even in states which have less of a regulatory climate or history they are overseeing insurance regulation, public health departments, employee benefits and so those are all opportunities to kind of focus on health care affordability. >> i'm from the state of utah. utah would likely be considered a different regulatory environment in massachusetts. but what's interesting to me is that both massachusetts and utah have achieved a fairly high level of integration in their health care systems by comparison to most other states. massachusetts, its background is well-known in reform. utah's back on them reforms started during the 90s. i happen to be governor at the time and frankly we held together a collaborative process that lasted eight years, where we put together a collaborative

process to every year put forward what we call their health friends moving toward a more integrated system so you have two very different cultures in terms of regulation but both moved them forward and frankly long before the federal government did. making the point here that different states with different philosophies can move the state forward toward integration in their own unique way in a fashion that frankly the federal government has not yet been able to achieve. >> i would add our experience in colorado is interesting as well so falls somewhere between a massachusetts and the utah spectrum of regulation. it's another place where you see things happening in a bipartisan fashion. before i was governor or republican governor governor

owens formed senate will 20 a commission to lead to a variety of recommendations that came late for governor owens but we wound up in cementing -- implementing those. after i left office and the states were left with the decision about health care exchanges the exchanges one of two states in the country weather was bipartisan agreement around the state health care exchange. colorado which is sort of a purple state on the political spectrum has been able to do a variety of things in a bipartisan way and take these recommendations from this 208 commission and get them passed legislatively and have done a friday things to help control health care costs to increase quality and provide greater transparency. there are states that the country and as you just heard three different states that may have nuances to the approach would have taken us on this estate and been able to navigate the old shows why doing it.

>> just a general comment on regulation and health. we often use the term regulation in a negative fashion but health is a very complex product, very hard for consumers to understanr lightly or unregulated market to produce pernicious results. excluding certain people, not covering things you thought were covered and all that. what we see in regulation is defining the terrain over which competition will occur, competition that improves the well-being of the consumer while preserving all of the positive aspects of a competitive

marketplace. so the players, the responsible players in the insurance market and the employer market no the terms on which they are competing and it is defined in such a way as to enhance the benefit for individuals. i think what we have done here is point in the direction of the types of regulation that will lead the market that improves the well-being of people. >> it's very exciting state innovations moving forward and being taken up on a federal level. it's now shifting to the states to address the issue of cost and it is exciting to see across the country states moving on, developing a ceos around dual demonstration projects.

a number of the recommendations that we have made here. one of the reflections i have to say is this commission has been not just an easy thing to come to an agreement on. we have had some struggles between regulation and market forces and what needs to be happening at the state level. we need to see action and it means people need to come together and really have an agreement to move forward around an action plan. i think the commission report has reflected that. >> we will move to another question. another question. >> i am jim landers of the "dallas morning news." i'm not sure how the commission regarded some of the things that have polarized the country so much on health care in the last

two years, whether or not we should universally ensure the population and whether that would have an impact on the cost of care. did you address that? >> we concluded early in our deliberation that there is a universal aspiration for everyone in our country to have access to an affordable insurance policy. we recognize that there are many different philosophies on how to get there and concluded very quickly that states can in fact have an impact but this was focused on cost containment. so we didn't spend a lot of time in discussing how best to. we did it in the construct of the affordable care act as it has been written, recognizing that if it does change that will change the situation but in our judgment it probably means that more and more responsibility will go to states as it does begin to change.

governor do you wish to comment on that? others'? we will go to the side of the room in the back. we are following the microphone. i have lost control. >> i was wondering whether you contemplated the difficult issue of allocating resources, who gets what, sometimes known as rationing in bringing down health care costs. it is widely held that in the u.s. we tend to be generous to the olden plus team as to the young. did you look at that issue is a cost involved? >> in response i will just remind you that our task was to take the environment as it now exists through the affordable care act and to be able to say what role can states play in that ross's?

we came to the conclusion that an integrated system of care will clearly be superior in that process to a siloed system of care. and to the degree we can achieve integrated care, we will begin to eliminate the problem that you point to. not entirely. it's a long-term process but being able to integrate care will ultimately cause fewer of those decisions that have to be made. i will invite others to comment. >> one thing i would add is i think there was an agreement among the commissioners that we are not getting sufficient value out of today's health care system. and you will see and hear some comparisons with other european nations, other health care systems. and so just speaking for myself it's premature to discuss rationally when today there is an efficiency and waste in the

system whether it's administrative inefficiency or clinical inefficiency that we can improve on and i think the steps that we have outlined and suggested in this report will do that. so we need to focus on getting more value out of the system from an integrated system in which we are paying for quality, not just for the volume of care. >> chris cordish governing magazine and the question is for you governor leavitt. you mentioned that states have database that collects extensive and wider data. what is the barrier to making that more public and available in a digestible way? we have it but it doesn't seem to be available. >> there is actually number of different sources of data. states have created multicarrier databases. many health systems have now begun in a collaborative way to

create large data systems that can have as many as 70 million lines. i think it's safe to say we have gotten to the point that the aggregation of data is not the challenge. once you have 70 million lives you can look at cohorts of people and draw conclusions necessary to drive value. so it isn't the aggregation of the data. frankly it's not the technology that limits it. it's a south -- sociology. if the capacity to get people together in a fashion that will begin to change the system so it really isn't the aggregation of data. it's now the application of it and that is why we think this collaborative effort at the governor's level is so important. it's to draw conclusions and to drive action. do others want to comment on that?

>> hi. i'm with "the los angeles times." governor leavitt but i don't mean to pick on you but the only representative of the deep red state here the question i want to follow up on what julie asked. i mean clearly your recommendations are built in part on utilizing the tools that the state government has whether it's the governor, the insurance regulator, the purchaser of state health plans. unlike utah there are a lot of other red states where there seems to be a deep hostility to using those tools if you will to influence the health care market and i wonder if he could talk a little bit further about how these recommendations could actually be sold if you will to some other states that are not all me resisting the affordable care act but seem resistant to the overall premise of some of the things you're suggesting. >> i believe there was a very significant event that occurred

a couple of months ago now when the current administration chose to grant medicaid waiver in the state of arkansas for the purpose of allowing for premium support to be done in the context of medicaid expansion. arkansas like many other states both republican and democrat had been resistant to having so much federal involvement in health care. what i believe the acceptance of that waiver by hhs signal does that her hats the administration would be willing to the knowledge that states could develop medicaid programs, could develop exchanges and could do other things in the context of what we talked about that could represent their own culture and their own value and their own view of what governments roll out to be. it was mentioned, think of mentioned the fact that it

requires, it requires the government to bring order to it. that isn't the issue. the issue is what should the role of government be? should government operate the system or should it simply organize the system? states like arkansas are saying to the federal government we are prepared to use government. we are prepared to step in and lead that we need the capacity to do so and i think ultimately the reason this report has relevance here is where signaling not just dates, we are signaling the administration to say if you want help in creating momentum for reform, turned to the states because given the latitude they will lead and they will lead more effectively than you can possibly imagine. in fact exchanges were

demonstration of that. if you look at the number of lives that are part of the system and look what part of them have come through state exchanges and what part have come from the federal it's a very serious conclusion in my judgment that states are critical to this entire process. you didn't ask off that but -- and others may have a similar view. >> i think the question was some states are reluctant to get deeply involved in this kind of fact to the end how are you going to convince them to join the team? i think as this report rightly points out at the very beginnine successful through efforts like these to moderate the growth of health care costs in that state will see their economies grow faster, we'll see employment gains larger than other states, will see him minimum wages of

employees rise faster and the health care of their citizens improved. as the governor suggested this is a two or three three-year program. this is the five, 10, 20 or kind of effort but as you go along and you see the states that have successfully pursued these recommendations others will come along as they have on other issues in this country. >> other comments from panelist's? >> why do we check and see if there are social media questions after that. >> and i'm wondering there has been a dramatic reduction in the increases in health care costs in recent years including a reduction in the share of gdp. i think there is minute debate about whether that is a reflection of economic downturn in the recession or the

affordable care act is playing a role and i'm curious what your view of that is? >> others may have a comment that i will give you mine. if he were to go back back to te late 80s he would seek health care costs biking at a level that was unsustainable. unit health reform that the clinton administration did not pass but health care began to read constraints primarily because of what we knew then has managed care. people were uncomfortable with hearts of that and we had another political called the patient bill of rights. integrated care essentially evaporated as a result in health care costs by again. finally we got to 2000 -- 2008 and we had another election of health reform and we have seen a debate with a bill passing this time. ironic lee is about trying to integrate care and even before

its implemented we have begun to see the marketplace drive cost containment. i don't think we ought to have any illusion about the fact that if we don't continue to see markets constrained and pushed downward at the same thing will happen. we will see an explosion of costs and we are still at 18% of the gross domestic product. so i think there are lots of reasons to point to as to why health care costs have begun to bend. let's all celebrate that but we are not in a position at this moment to take our foot off of the reform paddle because we are in a very serious situation. we have an economic imperative now and i know there will be comments on this from others. >> two thoughts. first i think if we thought we were getting sufficient value in the health care system we would feel less urgency but let's assume for a second that your

first statement is correct in that there has been a more permanent easing of health care inflation. even under that scenario if you talk to governors or legislative leaders or for that matter small business owners today they would say health care today is taking up too much of household budgets, city and town budgets and other priorities in public state the are suffering as a consequence. we in the health care community have an obligation and responsibility to try to continue to slow the growth of health care costs and other priorities are important to the nation that can be funded. >> i'm going to echo your comments because medicaid for and since it's now 20, 25% of saeb budgets. that has grown pretty significantly. it is caseload driven so there's a certain amount of money that states are required to put in

that and as the cost goes up the states are required to balance their budget on an annual basis. in your wearing from peter to pay paul and you are not doing other things so very much an education budget, infrastructure budget, transportation and other kinds of, higher education budgets as well. another point i would make was to appoint the governor leavitt said, we still as a percentage of gdp spent far too much on health care with far too low-quality in a global economy and increasingly global economy matters a great deal to employers in deciding where to put businesses in something they take into account from state to state to state so in the global economy states compete for jobs and for job growth and this is an arena where an employer will let to a governor and ask them what they are doing to control health care costs and what kind of the system they have set up and what does not state as a percentage of gdp so all those

mitigating favor of states paying close attention to this as being part of constraining costs over time. >> there are a lot of different forces that influence the pace at which health care costs rise. and it's certainly true that 2008, nine, 10 a week economy had a significant impact that the economy is recovering. employment is recovering and other forces have contributed as well. some of them legislative in the sense that we have passed the affordable care act and it has imposed a a number performs of performance and restraints that have moderated the growth of costs. the fact is that employers have begun tightening up the generosity of the programs that

they are offering to their employees. on the other hand we see at the same time market consolidation going on among providers which has a tendency to push up costs. the population is aging. that tends to push up costs. the research community is hard at work developing new interventions, new pharmaceuticals. we have been somewhat of a lull over the past few years and what this just is this is a continual battle. as the governor suggested there you aren't coming up with new ideas and the orange driving for increased efficiency every day of the year we are going to see things cost naturally rise because all of us want improved health and we believe that is related to the interventions we received from the medical community.

you don't look at this as sort of one factor affects the rise and fall. it's many many factors in that mix of those factors that will determine whether we are successful in the long run and as the others have said can actually begin bringing down the fraction of our gdp that is devoted to health care while maintaining the quality that we expect. >> i think one of the clear senses from the experts in increased cost-sharing is one of the reasons that help care costs have gone down and consumers are paying a higher tonnage of the cost of health care. it's clearly a two-edged sword. in some sense it may make it that consumers are more in like we to be thinking about the value they are getting from it. we are also seeing lots of

consumers are not able to afford the care that they need. they may have coverage but the coverage may not be affordable. i think we have to be very careful as we move forward in implementing a costs agenda and the impact it has some on real people particularly low-income people. >> hi. soapy with "national journal." i'm wondering if you can speak a little bit more to kind of put the federal government's role in this is. there is the example of the arkansas waiver but what kind of sub order input is necessary or possible from the federal government in order for the states to really take the reins reins on the successfully? >> let me just give my thoughts. i think we have seen a reality set in on the administration and those implementing the

affordable care act and that is how limited their capacity is to implement a national strategy. it would be true of the federal government generally. it is the reason, having been the head of hhs and the environmental protection agency i will make a comparison. it's the reason we delegate environmental regulation to a large extent to the state. that's the same reason we have to delegate medicaid administration to the state. it's because they're different conditions in different markets. if you look at exchanges and i made this point earlier, the administration over time has begun to grant greater flexibility to the states in order to incentivize as many as possible to become involved. we saw that and the essential benefits. it essentially say let's grant the state some flexibility in

how they can implement that. we have seen them in the exchanges. begin to allow more flexibility among the states and how they implemented those. we have seen in medicaid and the example i gave in arkansas and many others saying if we are going to get reform is going to happen at the state level and way to get them more flexibility. so there is this ongoing struggle between states and the national government and the states wanting more flexibility in the federal government trying to hold onto the control. the more they hold onto the control for less able the states or to implement and reform comes to a grinding hault. that's the reason that this report is not just aimed at the states and the governors. it's aimed at the administration and states saying the formula here is if you're going to have national standards you got to

have neighborhood solutions. if you are going to have national standards the neighborhood stations is the way implement is anymore to provide flexibility for the more effective the federal government will be -- becomes. >> again back to the recommendations. on the report there's a recommendation that change in the way we pay for care and deliver care is perhaps the most influential way we are going to control health care spending in the country and states can be an important locus of that. however the medicaid -- medicare program the federal government pays for 40% of the acute care in the country. one way that the federal government could support the recommendations for states is to accelerate the adoption of innovative payment models to the medicare program. we have obviously seen through the affordable care act the

creation of the pioneer demonstration projects and other projects but to the extent that states start to take the lead in both the states and private industries within the states that the federal government which has sometimes been a little slow to adopt new payment models i think that what the an important way that the federal government could partner with the states to slow the growth of health care spending. >> one more question if there is one and if not we will conclude. i see no further questions. i say to the commissioners thank you for your hard work and again to the miller center and governor do you have any final words? >> thank you all very much for being here. i would point out that after lunch at 2:00 at the national press club there will be a roundtable discussion on federal versus state health care cost containment. i think the commission members who are here today plus some other important figures in this

field of health care will be very very stimulating participants in this important subject area. and you mentioned just a minute ago that how we pay for care and how we deliver care are the two most important things that we have to consider. let me point out as the court does, that the cost of health care in this country hatch reached attempting -- tipping point in spending by individuals, by governments and businesses that grown steadily not just in recent years over five decades. the report points out that in 1960 when some of us on this platform may remember that year, health care cost per individual averaged $147 a year. $147. by 2011 that figure had reached

$800,860. the projection is that if the system is unchanged that in the next seven years i've 2021 that figure will reach $14,000 per person. so that is the scope of the kind of issue that this commission has sought to address and i think they have done a splendid job in preparing these recommendations for consideration by governors and federal officials as well as individuals across the country. at 2:00 we'll convene here for a roundtable discussion and i invite you all to return. i think you'll be a very worthwhile and illuminating discussion. again might angst to the two co-chairs governor leavitt, governor sub-the members of the commission for their role in this important point. thank you. [inaudible conversations]

[inaudible conversations] 's being me i have attention please? may i ask everyone pleased to turn off cell phones and all electronic devices as leaving them on and having our discussion interrupted would create havoc at c-span. thank you all very much for being here. i would like to welcome all of you here for the roundtable as well as the press and other members of the audience. this session is being cohosted by the miller center and the bat batten school of leadership and public policy, both at the university of virginia. this session is being videotaped and will be available on the

miller center and batten school web sites and i'm reliably informed that this session will then be played tonight in prime-time on c-span. as you know just an hour or so ago we released the report of the health costs and health health care cost containment commission which was cochaired by our esteemed co-chairs former governor's bill ritter and mike leavitt. i must admit that most of us particularly those of us in the former governor category have been quite surprised at the number, the huge number of policy letters available to states to enhance quality and reduce the cost increases of health care overtime. these include as we heard at the press conference the huge purchasing power of states as they will be administering health care programs with a total of 80 million individuals enrolled. this provides states we think

the significant power to transform the current fee-for-service system to one that rewards integrated in and according to care where organizations are held accountable for meeting cost and quality goals. the policy levers also include malpractice, the scope of practice in price of quality transparency laws as well as the power governors to convene stakeholders did develop a consensus for action. given the importance of cost moderation to individuals as well as to both state and federal government budget is important for us to talk about the federal versus state role in cost control. some of those questions might include what do we do about the so-called dual eligible population which is not only costly but receives more quality of care wax is it necessary for states and the federal government to agree on the

definition of accountable care organization's? should the federal government provide financial incentives to states for cost control given the potential savings to the federal government in medicare and medicaid costs? with those questions in mind and there are many others that will be discussed during this roundtable, let me introduce the panelists who will provide all the answers and then i will introduce susan dentzer who will spend a few moments defining the scope of our conversation and we will then facilitate the discussion that follows. first governor's leavitt who is one of the co-chairs of the commission and former governor of utah former secretary for health and human services at the federal level. second, governor ritter the other cochair of the commission as well as the governor of colorado. and then joyce halverson the former chairman and ceo of kaiser permanente.

andrew dreyfus president and ceo blue cross-blue shield massachusetts. robert reischauer former director they urban institute and current medicaid medicare trustee. he robert, the executive director of community -- mark mcclellan senior fellow at wrecking sensitive shin and administrator of the centers for medicare and medicaid services and hhs. alice rivlin the founding director of the congressional budget and former director of the office of management and budget. joe lantos health care and retirement research scholar at the enterprise institute and then finally but not last, the project rector of the commission and a fellow at the miller center and a professor of practice at the batten school. now let me introduce susan dentzer also a friend of mine at

the miller center who will facilitate the discussion. susan is currently a senior held at wiser to the robert wood johnson foundation. there she provides policy and communications strategy to the nation's largest philanthropy and is devoted exclusively to improving health and health care for all americans. she is a renowned health policy expert. she previously was a policy analyst with the "pbs newshour" and is the former editor-in-chief of the influential journal of health affairs, the nations leading journal of health. with that introduction, susan take it away. >> thank you very much governor and you are indeed my friend. i'm a friend of the miller center and many of the folks on the table today. i'm very delighted to be leading leaving this conversation so thank you very much. the excellent report is called cracking the code on health care costs and what i saw that title i thought, cracking the code, that could be an allusion to our

current discussion about the nsa and other spy like activities or as i think more from a standpoint of health care and health policy i thought about the genetic code immediately, cracking the genetic code and how interesting an analogy that potentially was. because if you think about our problem with health care, health spending and health costs it is like that mysterious double helix. there are a lot of intertwining factors that we have done thank you as we come to grips with health care and health care spending. as we know a dollar of somebody's health care spending is a dollar that is not devoted to something else. it might in fact advance health care but it also means there's an opportunity cost and we can't use it for something else that we might value. it's also true the other side of the spiral is a dollar somebody's health care spending is a dollar of somebody's health care income and that is a very powerful reason that is difficult to do much about health care spending.

so separating the strands of dna, and tangling this relationship is very hard if not impossible for the united states but as we know as our spending grows also are health health status of the country seems to fall further and further behind the health status of many other rich nations so that gap to train what we are spending on health care and our ultimate health outcomes becomes wider and wider than ever. so we have got a very important task ahead of us to disentangle these strands and crack this code. as you said governor, this rep port essentially pitches right to the states and the leverage they have and to mix metaphors now and jump to levers from biotechnology. the levers the states have to come to grip with this are very important dimension what they are, the ability of states to govern health insurance, to deal

with issues like scope in practice, provider rates medical malpractice and so forth and so on to promote consumer choice, to advance transparency, to invest in public health and so one. what i hope we will do today in our conversation is look at some of the specific recommendations in the rep court, talk about the advisability on moving forward on them at different rates, which of the recommendations rise to the surface as being most urgent for those of you around the table and then talk very candidly about some of the obstacles that will have to be overcome in order to get these recommendations in place and actualize whether in terms of new laws and regulations were just the relationships forming in states to tackle these problems. in the interest of refreshing everybody's memory let me just encapsulate what the key

recommendations coming out of this report are. first and foremost was the recommendation that in every state -- to transform the health care system and stakeholders from all the key sectors, from government, business, education, industry etc. everybody who has a stake in health care reform and restraining the rate of growth in health spending and advancing the health of the population needs to be at the table and articulate the next set of reforms that will go on at the state level. the second recommendation was to create a profile of health spending in the state. as the old line says you cannot manage what you don't measure if you don't know what the actual spending is in the state and where it is coming about. where the dollars are being spent and where the dollars are going. you cannot do anything to manage that.

the third recommendation was to establish statewide baselines and goals for spending as well as quality and other measures including spending benchmarks and goals for the next five years and also to evaluate those on an annual basis and set long-term goals for tracking improvements in population health, and health care. the fourth recommendation was to use existing programs to accelerate the trend for coordinator risk-based care to create standards for what the coordinator care organization in a state might look like and as we know some states actually have those now. oregon and its medicaid program. use those existing structures and tools to transition medicaid more broadly across states to this model. the fifth recommendation was to encourage consumer selection of high-value care based on cost

and quality data to essentially adopt policies that were fire insurance plans in the state to provide these data so that people really can put together what is health care costs, what does health insurance costs in what is the quality that i get out of it? as we know consumers today tend to correlate high cost with high-quality even though there is very little evidence that relationship holds. make more of this knowledge more transparent to consumers so you understand more fully but the cost is of care and what the value is being purchased. and he is state action and antitrust powers to promote an official consolidation in the health care system but also to be mindful of things that can drive up cost for the six rickman issue is to reform health care regulations to system efficiency in areas like

insurance, scope of practice and medical malpractice and particularly to look at allowing providers to practice to their full range of competencies speaking to the scope of practice issue. and then timely promote better population health and more personal responsibility to health care. educate individuals about what they need to do to retain their health and improve their health. educate individuals about end-of-life issues as well, since schools and communities to adopt policies that support the preservation advancement of health and importantly another very important tool that states have, work with your own state employees and make sure they are as healthy as possible as well. with that what i would love to do is go-round the table starting first with the commissioners and then with our additional stakeholder members at this table and ask you of all of these recommendations which

one leapt out at you as the most salient and potentially the one that was the biggest burden potentially for a state to fall off? governor leavitt i would like to start with you but could. >> one is the need for this to be a collaborative solution. this is a classical problem that requires collaborative problem solving and collaborative leadership in the need for governors to embrace this problem as a state issue and a place they can make a substantial improvement in their state generally. the second is very closely related and that is the importance of governors in states using the tools that are available to them starting with medicaid, starting with their own state employees, starting with the fact that they regulate

insurance, that they are involved in practice patterns so in summary governors take charge of this. recognize that as a collaborative rob him. you have got to use the capacity and then start with the foundation of those things that you do such a share on employees, medicaid and other legal authorities. >> use the tools in the toolbox. >> governor sub five. >> we use the word surprised a few times this morning in the press conference and over lunch some people talk about their surprised at the breadth of things that the state really can do and you analyze it. i think the most important part of this report is talking about payment reform and is a former governor i had some sense about the difficult in-app. i am happy that we were able to stress how important it is and it's interesting what governor leavitt just talked about is the

things we would like to get to this place when we look at fee-for-service and we asked the hard question, we transition at the state level to this other way of integrating accountable care, it's risk-based and the answer lies in can we do the things the governor leavitt talked about? formed this alliance where you have stakeholder groups understand the need for us to do that in order to contain costs and the ability to do that really at the same time you are improving quality of care. so while the alliance -- the governor taking a leadership role and that's in saying there are millions of people who either our employees are part of health care exchanges or medicare patients so we have this patient base to do that. what we really need to do is change the way we serve that population. i think that's the most important thing in the report is transitioning to this different way of providing service i'm paying for that service but

doing these other fundamental things first. >> thank you so much. andrew dreyfus what stands out is the most important recommendation to you? >> both governor leavitt and governor leavitt and governors ritter ticked off a couple of my favorites, the collaboration and delivery reform but i might suggest a theme that emerges from those recommendations you cited is in every state they will have to create rob lee a unique local balance between an important role for government regulation and an important goal for market innovation and we often in health policy circles set those up as opponents of one another for his choices, one versus the other and i think it's a false choice. in fact half of all health care is funded by state and federal governments at least if not more in the other half by the commercial market, mostly employers but also individuals and households. i think with the sub report

suggests is there a regulatory tools at the disposal of state government and important market innovations that we want to encourage. those two work hand-in-hand of individual states and if we do that we will get to the heart of the report which governor ritter suggests is payment reform. that is ultimately where we have to go if we want sustainable slowing of the health care cost growth. >> thank you. bob reischauer? >> there is a natural order to them but what impresses me the most about this report is the clarity of its call that governors and states should accept a role and a responsibility in the fight to control health care costs and to

engage in this battle using the resources at their disposal. i think to be honest this hasn't been viewed as something that governors were states played a leadership role when. they are concerned about it and they are word about it but it's not until you look at all of the material in this volume and realize the tools that are available and the opportunity that only governors really have those leaders, as convener's that you realize that this is not a battle that is going to be won by federal policy. it's not going to be a battle that is won by insurance executives and it's certainly not going to be won by academics and think-tank experts. >> present company accepted. >> well we have tried. it's just going to be won within

marketplaces, within states with an understanding of the nature of the provider groups, that desires the community and the patients and use all of these tools that are laid out in this volume in an enlightened way to achieve the objective. >> robert, your sense of the most important recommendations. >> we need to start with the knowledge meant that i grew up in the -- district and all politics is local. i don't want to make a recommendation for a governors. i think they have to look at their particular circumstances in their particular states. just building off of what other people have said though, i want to look at the aca has a really important opportunity to move forward. there are a number of innovative drug grants that governors can take advantage of.

the office of innovation, cmmi, the tool demonstration programs and even the marketplaces are opportunities for governors to experiment and we are going to need experimentation. i don't think -- i think this report is very clear the answers are not totally there. the process to get there is so we know the process that we need some governors to really step up and take leadership on this. >> i want to take a moment to give -- an extraordinary role in pulling this report together. i know picking recommendations is like asking you to pick one of your favorite children but nonetheless what would you say? >> i think the collaboration is very important. the way i think about it is there are four ways that you can get things to happen and the state to pass a new state law which is oftentimes consuming in terms of running time.

you could do it through a new regulation or through an 82nd of order or you can get a consensus around the table. i would argue for example when it gets to payment reform if you can get all of the warfighters and pundits around the table to agree and have a consensus on they can implement that much more rapidly than you could do it with an executive order or regulation. so i think the consensus or part of that can be very powerful and once you get everybody to agree governors are pretty good about that. and then i think you could do it much faster than through any of the other vehicles. the other point i would make is i do think changing the delivery system is very important but i do worry that that means you have got to provide incentives for integration and consolidation. we have party scene consolidation and the question

is can we get the right balance with the threat of using antitrust laws so if we get positive consolidation that reduces quality without leveraging the marketplace. ..

has not, mentioned up to now. and that is the last one. it is promote health in the population. it's not just about health care, in fact, health care has relatively little to do with how healthy we are, and one of things that states can do and emphasize is if you eat better, if you exercise more, if you live in a safe community, you can be healthier, and that will make more difference than anything do about health care. >> what struck you?

>> well,, i have a feeling that alice is probably chiding me about my lunch today, but of course you're absolutely right, alice. but i think from the perspective of this report, the other obvious concern is how do we get through this year. how do we get through next year? , i mean, the sorts of thing that really promote health are very long-term investments. and by investments i mostly mean what al slice talking about. personal investments in behavior as opposed to necessarily financial investments in buildings or technologies. although those are obviously very important. one of the things that you asked us to select -- i selected several. i look for a theme that encompassed nearly all of them. i thought information a major theme here.

and i think that's an important part of the state's opportunities to take action and promote sensible judgment. as you have said, susan, if you don't measure it, you don't really know what you've got. but it goes beyond that. beyond setting some sort of standards to really giving the actors and the health sector more information about what they're doing and what the results are. by that, i mean, -- i don't mean just doctors, hospital, health department plans. i mean parent -- patients, consumers. i think it's an important theme here. i think the one of the big issues is how do we square the circle between providing appropriate confidentiality and

protection of personal information with the very important social function of measuring what we're doing and learning from it, and doing better. i think that is very difficult question. i don't think the states can necessarily answer that, but they can certainly act as a force to try to get some reconsideration of the issues with federal level as well. >> and mark. there are recommendations, i did give want to give a special thanks to the governor, ritter, and the rest of the commission for putting this together. as you've heard from the other commenters, the report really lays out how states can lead in reducing health care costs by improving care and improving health. as alice and others have mentioned, this is not the place that most people look first in

addressing the nation's health care problems. ting should be. perhaps the most important question going forward is why is this not happening more? there are some good examples around the country of governors and govern lev visit, governor ritter in colorado took steps like that outlined in the report that made some difference. but if we're going see it happen in a impact of our health at the national level and the health care cost at the major level it's got to catch on a lot more intensively and quickly. i think the truth of the matter is, it's hard work. ray laid out how even building consensus can take time and effort a lot of times governors and the legislatures, the work with feel like they're under a lot of time pressure, a political of pressure, a lot of need to get savings in the short term. these are four-year or longer term projects. probably good things to think about if you're a governor when you're first coming to office

and trying to laid out an agenda that will last and outlast your time in office. but hopefully this report is going to make it easier. it lays out a toolbox how to make the changes together to transform care and health in a state. it draws on some examples and growing set of examples around the country. the miller center is working on many of them. are collaborating with a number of states and local regional efforts to improve care. and thing are all sorts of way the federal government can support these efforts. robert mentioned the opportunities in the form of new medicare pilot programs. or innovative medicaid waivers to drive support for these kinds of reforms. i do think there probably is more the federal government can do from a legislative stand point support them as well. but i think the big challenge from here on out is how do you take the ideas and turn them to health care transformation lead by the state.

>> i want to capitalize on a couple of things that have been said. i don't think health reform is still about just health. it's become about economic reform. it's now about the economic equation of the united states, and the marketplace is seeking out a place where solutions can be accomplished. i think one of the thing about the report is the gridlock in washington will inevitably begin to channel these problems to a place where they can find a solution. not -- if it were just a political problem, it could linger. but there's an economic imperative about finding a solution. this is being driven by forces far bigger than the affordable care act. far bigger than just what is

going on in washington. this is being driven by a glacial force that is going find a solution somewhere, and the question is how chaotic is it? or how orderly is it? and i think ultimately this will be a place -- states will be a place where order will begin to be found in many ways before washington. >> well,let talk about some specific ways of achieving that ideal order. and in particular, i wanted to come back to a point i think andrea, you made about trying to sort our way through what seems like more regulation, more government influence. even if it's government at the state level or local level versus the federal level versus market innovation. one of the recommendations, as i mentioned earlier, the report that states start by doing an assessment of health spending in the state, and setting a baseline. a five-year baseline. now, that is going sound, to a

lot of people, like oh my godness the government is going to decide what we're going to spend on health care. curious, those of you on the commission, how the commission members thought about that. because that doesn't get us all the way to health care planning when we talk about just setting a baseline. there certainly states already well along as massachusetts and yantd as it discusses its new waiver with the federal government on medicare program. but nonetheless, for a lot of states, this would be a big step. t not something that is historically -- it's a per view of the governor's office or for that matter anybody in the state to do that. so how if the commission grapple with that recommendation? why did it come out with that recommendation? governor levin. >> establishing a europe. -like global cap.

bring all the resources together. and we also acknowledge there are few states and governors who could say in my state this is where we are today. and it's a bigger share of our spend than we can afford what did we do? this is about public leadership. we believe governors and states are uniquely positioned to be able to begin to exercise that kind of leadership. >> and it's interesting an earlier conversation talked about this being the 109 or 15-year proposition. in most states in america, governor is going serve at the most two terms. some states there are not term limits. other states where it is one term and you're out. so really governors have to take the long view on this, and understand that they're not committing their successor to

some cap. what they're doing is saying -- this happened in my case. my predecessor, governor owens, put together a commission, inherited the commission. i added to it. and the commission gave me a seventy goals and we passed legislation that came out of that. there was an overlap between my predecessor and myself. and we both had the same goal in mind, which was to do what we could to try and, you know, keep equality where it was or improve the quality. look how it was encroaching on every other part of the budget. our health care budget and understand the need to not let that happen to, you know, education resources, higher education resources, infrastructure resources, and so we both -- two different parties. we both have the same goal which is to citied this. and this wasn't ever a hard cap put in place. there was a consensus among people at the table developed in the commission that we needed -- at some place, to get our arms around this or the state. the budget for the state was going to suffer at the in a

tremendous way and in a sustainable overtime. i think the report reflects that. it's not saying think of a 20/20 cap. but have a goal in place can be embraced by members of the commission, and then work toward that goal. i think, you know, there are some 20 some recommendations, most of which wound up being legislated during my term. >> i want to remember that governors are not without incentive. the entire budget is being eaten up by medicaid. the capacity to invest in infrastructure, their capacity to do -- build higher education and public educations. all being eroded by this. so had -- this is not just a bid of governors doing good. altogether it would be good. it's an impartive for governors as well to get a handle on to. >> i i suspect 30 years ago, if you were talking to a major manufacturing company as a governor, trying to lure them to

your state. that's something governors do. you were talking about health care cost as a percentage as a budget. as limited budget -- as increasing medicaid costs and decrease your ability to dot other things and they have to be -- companies care about a grail great deal. they care about health care and health care spending, health care cost. they care about infrastructure spending and higher education budgets and k-12 system will be sustained over time. and so it becomes part of that conversation and certainly was with me and is knead a bigger way. >> so andrew, to come back do you as a person who heads a private sector company living in a state, now, that is actually engaging in this precise activity. charting a baseline for spending and what spending growth should be. how do you see the private sector entities financing health care, and delivering health care living in this new world? >> yeah, well. it's still yearly and we have a lot to learn.

i think some of our lessons will be help of the to other states. i would say the state setting a goal as the governor said was a galvanizing event for the health care community. not just health care community, business community, consumers and others who participated in the conversation. it's already having an impact. when we sit down, for example, and negotiate contracts with hospitals and physician groups, it's in the background that we've made a decision as a community that we're going try to lower the rate of growth and health care cost in part so we can liberate funding for other sources. just bring the conversation that the governors issue that alice raced. most of the social determine nabt of education are like -- as medicaid and funding for

state employee insurance and other aspects of health care have consumed greater share of the budget. so i would say in massachusetts it was a gavel needing event. i think we're going learn a lot and optimistic that the rate of health care spending was slow top to trigger our new law in montana was the fact we passed coverage reform, you know, in 2006 and 2007. we realized if we were to sustain the reforms, we had to slow the rate of dwrowt in health care costs. i think as individual states under the aca expand el -- e eligibility for coverage. >> i want to move on to a point again, a number of you made. which is using the tools already in the toolbox. not just the ones that represent the powers of states to regulate

or what have you. but specifically some of the arraignments already praying tout reform the way we pay for and deliver health care. in particular i want to table the dual eligibility. with know there is already a considerable effort to try to find new ways to integrate, coordinate their care, lower the cost, and ideally improve the outcome for them. one of the representations in the report was to accelerate the existing demonstration for the dual eligible population. there was a note that cms really -- the center for medicare, medicaid services should work more closely with states now to address ways to overcome some of the obstacles to those experiments playing out more quickly. i want to draw you out on that. it's a case where something is already playing out, but clearly

there was a strong theme in the report that it's not happening fast enough. what can be done to expedite those kinds of changes and achieve not just the improvements in delivery of care but obviously reap some cost savings as soon as possible. this is bowling right up your alley as a former head of cms. >> i want to remind you at being at the right side side of governor working with him and a number of states on medicaid reforms while i was at cmf there are a number of of programs available today that are relatively new that build on some things that the last administration started and the aca to make it easier for states that want to develop more integrated care for system to coso. this is a huge opportunity for improving health and saving

money. these are some of the most expensive patients in the u.s. health care system. and because of the way their care traditionally has been delivered through a fragmented system that including some long-term care and other funding for medicaid and medicare, some they have to get on their own. through other programs. it's been very fragmented. the people who benefit the most from steps to help them stay out of the hospital and steps to coordinate care get the least of it. the programs that are around now are starting to change that. there are some good examples in massachusetts that i know andrew and robert are very much involved in. some things that could help on the cms side along the proposal along the line of proposal in the report are, first of all, recognizing a lot of reformats in care delivery called for on the report talk about giving people more accountability and savings when they take steps to reduce cost. we can extend that same

principle from health care providers like the ones that andrew works with in montana to states themselves. if a state is taking big steps and investing in all of the effort to bring people together to improve coordination of care, right now most of the savings go to the federal government and the form of medicare savings and the federal side of medicaid savings. well, the federal government would be better off and states would get more support in implementing these reforms if they got a significant share of those savings. that's the proposal that the governor worked on together with us. similarly, there are some thicks to be done through legislation to support it as well. >> can you want to speak a little bit more about the particular proposal, also? >> i think there was a fair amount of optimism when cms announced the demonstration fellowship of things. but i would argue on the state

side now they really do believe that it's gotten bogged down. and it's largely sort of federal government seems to be taking the attitude of no risk at all as we move forward on this. i think to accelerate you have to accept a certain amount of risk going forward. >> and the risk, here, of course, is the concern that the frame sometimes even -- mentally ill individuals will be disadvantaged by reforms that might move too quickly. >> it's a legitimate concern. if there was tracking quality, and nobody disagrees with that, it seems to me they can move forward a little faster. >> it's gotten bogged down. i think the other thing that mark talks about, which the federal government never seems to admit they have a share savings at some point, you know. this is clearly an omb problem as women.

-- well. [laughter] but not only have to get they have to go through omb and any sharing of savings with states is a problem there. i think it sends a signal they're more open to the sharing . >> thing is an area the next six to twelve month we're going see a lot of activity. because states are so desperate for savings and desperate to repair model -- a number of states are moving dramatically and rapid will to things you couldn't have imagined they would have attempted to do three years ago. so i do think we ought to acknowledge there's a lot of activity we have to learn a lot from this. >> one of the plans in massachusetts. i was president of one of the boards of the board of one of the plants were very intimately involved in it. i think it's an exciting opportunity with at lough

risks. one of the -- to actually implement this kind of reform. we talked a little bit earlier about the lack of staff on the ground who understand that. that's going to be a barrier. i think on the federal side, quality metrics for dual eligible are qoped sufficiently to really help people choices. staying on the theme of building on some of the tools we already have available as noted by the governor and others. there's a recommendation we

should add a third factor which is all the private activity which is are the like. the alternative quality contract in montana you've been involved with, andrew, in your company being a case in point. what is the potential for this group of stakeholders to get together and agree on what they will call an aco, how they will measure an aco. the achievement of the aco. how they share savings with an aco. how necessary is it to have that kind of harmization, and how much should we do to let a

thousand flowers bloom here? >> well, i think first of all, there's a broadening realization that the term aco may not in fact reflect what we're talking about just on the report or generally. i prefer that the term risk-based provider entity because there are so many of the business that i'm involved in tracks these. i've identified well over 600 of them now. when you begin to drill down on the govern innocence process and the amount of risk they are taking and the relationship they have with other entities. they're all different. there are two fundamental changes occurring. woo is accepting risk. second, how we pay people. when you strip health reform down, those are the two big changes in the path it's always

been taxing entity that has born the risk. it in the future it's people who provide care. and the result of that is we're beginning to see a substantial reshuffling of the deck. insurers are buying hospital systems. hospital systems are forming insurers. states are delegating -- the assumption of risk to private entities. all of that is being driven by this requirement brought about by risk bearers. and the business of how we actually pay for care is dramatically important. i think that is something we are beginning to see states experiment with much more robustly. >> there are different ways with the governor emphasized for providers to bear risk or take on accountability for better health and lower cost for the

people they serve. one common issue underlying all of this, which is at the core of the report is the need for measures. what make -- matters for patients. states historically in the medicaid program have done a good job of manufacturing how often people got doctor and which drugs they get and how often they got hospital and try to keep cost down by squeezing down the pricing for those thing. it habit worked to transform care to put the emphasis on keeping people healthier and getting it right. one thing states can take the lead on is measuring what matters in a way that the private sector and the federal government can work with as well. it's an area where states do not need to reinvent the wheel. there are some good measures to build on and benefits from collaborative effort not only within a state and across state lines and coming up as robert was emphasizing. better measures of coordination of care, better measures for

quality of life of frail, elderly individuals. it's all can be and is being cone. and can be done quickly across states just to get some common measures in place. >> one of the other things we haven't talked about. a difficult time some states have had attracting providers to rural areas, and if you think about the rural versus urban or suburban district in this country, rural, we've seen examples where aco are risk-based provider entities that have had a better experience in providing higher quality of care, and being to be manage that care for the ?urnd insured or uninsured. places are not medicaid eligible. we've seen rural communities say we need to do something to support our doctors. you'll see organizations develop

really on a whole clothe as opposed being driven by a state program and ability to mangt care better. we have seen medicare costs come down in so. places in rural areas, but also a broadening of coverage. and so again, the narcotic that case, because they were losing docs all together. i think there is a variety of things that are going move this not just states and governors. but the need to sort of insure -- ensure we don't lose the part of the population in rural areas and not care for them or not find a way to care for them somehow. it's this other dynamic argues in favor of risk-based provider care happening so you actually wind up covered all the areas rural, suburban, urban. >> the fact we have a tendency

to want to overspecify when we don't actually know what works. we are certainly seeing this with the aco demonstration that medicare is running. and so -- i think what we don't have to worry about getting everybody to agree on all of the ways they are supposed to work. we can count on the market forces to wind l up ones that don't work. but we have to allow them to operate. we have to give some flexibility so that entrepreneurs, doctors, hospitals, and others can put together something that fits the local community -- that's the other thing people often forget in washington. health care is delivered very locally. >> if you talk to a lot of provider groups around the country, doctors, hospitals, they will express increasing frustration that different payers want different things, want different measures to be met. want to pay people in different

ways, and we're starting to see, at least in some areas, a consensus that all payer kinds of approaches. getting all the payers on board private and public. .. >> in our program we have only been adopting these measures that have been approved and we are now working with other

people and state government to have a set of measures that not every entity have to use all of those measures, but when we talk about any measure, it is the way that we have talked about it and find it on the telly talk about the statistical validity and etc. i think that will reduce the burden on the physicians and hospitals. >> what would be the role of states? states they really don't have to do anything in the measures are our eddie albert. >> i think that there is a lot that the governors need to do. they can look to the resources that are available to help them put these measures together. in massachusetts is a good example of that and you don't

have to be a blue state and their quality of care issues. whether they are having complications of care and readmitted to the hospital and other things like that. there are measures with not only getting standard measures that helping providers and it can even help address some of the privacy issues that joe has mentioned and raised earlier. so there are resources to go to. measuring and making progress on improving this. >> i want to move to a tantalizing recommendation at the tail end of the report and

it builds upon what we were talking about with respect to their key witnesses that the federal government shares the savings in some of the expansions. and this included the quality of care and through that by incentivizing this hold this in check, including in medicaid through a target rate. and this gets complicated, i recognize that. and the federal government would negotiate a rate and states would get a bonus in terms of an increase in the federal support from medicaid if they managed to slow the actual rate of increase down relative to the negotiated rate. it is the notion of putting dollars on the table to

incentivize that to take the kinds of actions that we have been discussing to help that's. this includes and this proposal wouldn't have it any other way. >> i think it's a very sensible proposal and something that is extremely difficult to do. we have two issues here. one is the growth and the other is part of this as well. and we are given part of this and they can hold their spending to 4% and i have spent a lot of this below california.

and we have taken several years to figure out this average wage in all the things that were affected. especially expecting to get their with a lot of contentious decisions. and we did a simplified office version which we have been over the past five years and the average growth rate has been per person. and we are bringing it down. and i think that this was part

of the something where more work is needed to figure out exactly how you could apply this. >> i think that we also refer to the waivers and i agree with bob. there are places where they get bonuses both on the education side and a medicare delivery sides. and a far better thing to do is to have the state come for a waiver request with the assurance that they will accomplish those goals and manage them. because that is what states like more than anything. the ability to have greater flexibility. >> and indeed that is kind of

like the approach of the state of maryland in the current medicare waiver. >> i would like to make a point. one of the reasons that we talked about that was to change the intent of the state. right now it is how i reduce my medicaid budget. and part of that is increasing the cost and other parts of the health care system. so how do you change this to focus on total health care? i agree with bob that i was on the other side of these negotiations and so on and you're absolutely right. every state is unhappy with this. but this would be a voluntary thing and you either comment or you come out.

but i think the concept of changing the incentive is a very important one. because right now it the total incentive is on medicaid. >> not only isn't medicaid, but states are insulting a lot of mr. drawdown the way that the federal dollars are going as well. >> rate. >> let's go back to the waivers. in the other aspects of the recommendation was that states and the federal government should work together maybe to identify a process in which this can be advanced and negotiated more quickly with a common template and etc. clearly you all agree that that was a good recommendation and how do you advance that? >> i think that a good thing would be the federal government

and various entities within the federal government expedite the process. and one of the things that happens is that you submit a waiver and states are pretty firm on budgeting year-to-year and some of them unless and you can submit a waiver and not get an answer in a timely fashion and it can be a couple years later and you have not yet been able to understand what the future looks like in terms of the medicare delivery of what you need to do to broaden the population. and that is kind of a thing that we are looking out we were considering this waiver request list. to do it without costing us a lot of money and having the federal government say that this is an okay restriction. and so that is the number one thing from my perspective, to set up as a and get an answer in a timely process.

>> i would like to tune to two areas and we thought a lot about these issues. some were guilty of pulling no punches and so let me bring those to you and ask you to stand on whether i am right about this and why and if not, tread lightly in these areas. one of which was the end of life. you talk about the importance of educating people on end-of-life issues and those materials about the importance of hospice programs and palette of care and is the end-of-life still a political taboo to speak about that you couldn't address that warhead on.

>> there's probably a consensus if we had some of the discussions that we recommended and we could probably have better results and we also recognize that the federal medicare program was near the recommendations in other areas as well are we had a more immediate role. but there are good examples of the state-based end of life commissions that have done important work and it can be and i think it's another area where it will very from the particular environment in the state.

>> i think that you see the conversation project organizing the community discussions. >> just elaborating with cheaper health care improvement and others to talk about this? >> yes. and i think increasing mess that there is an agenda that the community needs to be talking about. and most of those balls to medicare and we didn't think it was necessarily specific in that regard. >> the other thing that i thought about his maybe there is a punch that is going on. and specifically the issue about this a including their ability to regulate in the health care

arena. including the types of providers, whether nurse practitioners or other nonphysician providers and limited the scope of their practice including some of the more efficient delivery systems that we need now are we need to engage others in the nurse once said to me that it is like calling an apple not a pair or a peach and so i recognize that the terminology is odd. nonetheless we know that the scope of practice is very pronounced and probably does limit the effective use of the health care labor supply. including a recommendation with some of the alternative delivery provisions and not really recommending that the states go

head-on with some of these protectionist laws that protect the certain types of providers against other types of providers. >> i don't think our conversation could be characterized in that way. but i think that you're talking about putting together the governors association and they are all part of that as well. so you're really speaking to the leadership in those areas as well. and this varies a great deal and it has political conflict and is a tough thing to do when you get involved in the conversation because interest groups become creole peel with what they want to expand with and it's the typical thing to do. so we mentioned that where this can have an impact, the thinking

that we mentioned before in some states have done very well and say they do the tort reform to get to the place where you're going to have a better health care delivery system and entertainment system is one way were states can actually make an impact. and i think that that is one way. i do think it is important for a governor to think about the scope of practice and legislative leadership to understand that it is a part of the conversation and should not be taken off the table. >> like our other recommendations we are not so quick to do that. but here is the array of what is going on including what would work best in your area and don't say that we can have the impact because we do have that and i

was on the future of nursing panel that came out with a strong recommendation with respect to expanding the scope of practice are the greatest extent possible. and i felt that this was sort of in the same type of situation. >> we have also made some strong statements as well. because it is pretty clear guidance out there from a lot of places that this is a way to improve the care or at least do the same. >> a basically tackle this. >> if we expand in the number of people insured or underinsured, it is going to have to happen and by necessity it will happen

particularly with nurse care or physician assistant karen those kinds of things are going to be necessitated by the people as well. >> this is where really comes up to the first recommendation of the governors taking the lead in getting all of the stakeholders together to solve the problem of that particular state. and it is going to come up there and it will, very forcefully. >> the heart of the report is part of this organization than they are themselves redefining the scope of practice in the absence of state or federal guidance with the concept that you're practicing and it is redefining what it means to be a nurse practitioner.

>> right. >> as i remember, the numbers have acted over the last several years and having that many states as a positive sign. >> so as we wind our way towards the close of an excellent discussion, let me ask you a potentially difficult question. he said that this goes well beyond the affordable care act and this is all about a set of urgent national problems that the national scope has been talked about locally and at the state level as well. and it's impossible to talk about health care without having the affordable care act being

the elephant in the room. as we known a number of states there has been a tendency not to engage in a lot of health care reform because of the tax write up with some of the structures of the portal tracked. sometimes it is perceived that if you do something like the affordable care act from your endorsing the portal tracked at your own exchange or what have you. so do you think that the times that we are in order both can come together to create a new paradigm of human activity in the country regardless of what is going on with the affordable care act, and nonetheless recognizing that their tools on the table because of the law and additional forms that need to be undertaken that might even go beyond the law. could we get to a new era of consensus of moving forward with

joint partnerships between the state and the government and those who are representing this around the table to really make progress, or are we going to be bogged down for a lot longer. governor? >> i actually think that we will settle and. we made the point earlier in a press conference that we were careful to make a recommendations at the beginning of the implementation of the portal tracked to the extent that that were to change and change to radically. there are recommendations that may change and quite frankly before the affordable care act past before it was debated, states were already doing many of the things that we recommended. and you said that we had a series of reforms before the affordable care act not even

think about what it would look like, but understanding that we needed to do it. and so i think if the affordable care act were to go away tomorrow, the states would still have to do this including many of the things that we recommended. and we might have to change the recommendation to define the constants that we operate within. but they would still need to do these things and it is not going to go away. we are going to settle until way of understanding the power of the exchanges and the other powers as well. and i think particularly with the passage of time and the politicization, we would do so over time and states will increasingly would increasingly understand the need for them to do this so that they have the ability to have resources with things that other states should deliver. >> dating back to the supreme

court decision and the decision by many states have actually made this more important. more of the focus of accountability on health care than what we probably could anticipate. so i agree with the governor. i think that this has an even greater urgency as a result. >> you have a perspective on this? >> i can only agree. the states have no choice and none of us have any choice and it is not a question of seeing change from high-level in the federal government. we have already made changes, states have already made changes and they will continue to make changes. so for example if you look at this, it is a good example of

something that the state would like to continue on and modify and this is something that in some sense it seems to be limited by the aca and i would not bet on it because the administration has already talked about this, saying that we will let you do other things that were written word by word and i'm honest. >> okay, to wrapups here. some of you are old enough to remember an ancient television show called queen for a day. i propose that we have a new one called governor for a day. [laughter] [laughter] and nonetheless i'm going to ask each of you just briefly if you

are each nominated governor for a day of the state of your choice, based on this report, what would be the first thing that you would do when he went home to do. having thought a lot about the underlying issues and recognizing that as a governor you are in a position to take some executive action. it doesn't have to be a formal action. what ever it is. what can you do on the basis of this report? >> i would start with the first recommendation and get together many individuals, including the stakeholders and i would define the stakeholders quite probably because everyone cares about this together. to say whatever happens at the national level, we have to make

this state healthier. and how do we do that? here are the things that the report has reminded us that we have at our disposal. let's talk about how to make the state healthier. >> we took the first step. >> yes, and you have to do that. >> fair enough so i guess that i would start it with an education effort with prices that are more transparent and encourage consumers to augment the exchange and website for

everyone at the state. >> right. >> what you're going to get is the physician groups around us. >> and to tackle this is the state has a malpractice reform, talk about the refinements of that? >> and there are some other models. >> where one committee actually decides that if there has been providing a certain amount of money for it.

and so i think that there are some other ways that you can take on the practice and that is one that no one has tried. >> i think the things that the government can't do, but harnessing the consumer decision-making is probably the most important. >> especially when it comes to enlisting citizens in an effort to have better quality health care.

and by golly, the providers to make sure. >> some of the hospital raids for real. and we built a business case for reform. because that was actually part of the reform. so as you are doing this and you expect your staff is really important. >> other governors for a day, as they have done, i would like to focus on the report that maybe

ties together the importance of spending and medicare covers half or more to look at the issue payment rates for different kinds of services, we would think about this measure of medicaid effectiveness based on how much kids on the program are in school or preschool. and this is most effectively part of it. ..