force and the army need in their reserve. because our first mission in our two missions are equal is our mission to support the federal reserve of the air force of the united states air force and united states army. so however the army looks, our however the air force looks, we have to be interchanging. ..

>> the real challenge is how do you balance this environment and not lose that edge or lose that equipment. and the air force mission is very unique. within 72 hours the air national guard unit can deploy and they have to be ready to deploy. this is my good friend here from the international guard. we have these tankers on alert right now that if something happens over the united states there are pilots and jets. and that mission of the air

force is unique. it takes more get up and going. the air force does a great thing and we have a great partnership. on the army message and transmission, depending on what skills that you need, if you need support personnel in my branch, for example, if you need engineers. most of our engineers have some civilian backgrounds. the wyoming guard came in and i think that we had 23 combinations and pulling people off the side of the mountain and went back later, which you probably didn't see on the news, after four states rolled in with

national guard and the army and they were engineers and i thought when i first went out there we finish the project about a month early. hoping that people could get back to their lives and i thought that i would drive that road and see a gravel bloat up alongside the mountain. so 18 major washouts outside this room that federal highway administration was funded and the colorado department of transportation did this as well.

and so this lieutenant colonel comes up to me from the colorado guard and he is writing with the colorado department of transportation and he says okay, i know i have a uniform on now but my civilian job -- i gathered up the colorado team and the department of transportation. so if you're going to deploy overseas you deploy that extra skill set and every job out there. and in november i went to afghanistan while i was there i met with one of the generals and he said i want to introduce you to something.

and he i said i'm a lawyer when he asked me what i did as a civilian. and those are the two skill sets that we always bring into every environment. depending on what you want and what you need and conflict and its an army standard that is 50 to 80 days that we can have a brigade combat team ready to go. especially when we will probably have 80 to 110 days.

and today most of them are certifying anywhere from 50 to 80 days of trading. and so the further we get away and we want to make sure that we end this is a unique structure with both being able to support the civilian government and to be able to support the president that we called upon. and we have created some opportunities in the future and if your member hurricane katrina and the unit of effort on command. i want to share that with you because we do have that unity of command and structure and

attention and weakly trained we pre-trained a certified national guard than in command and control is an active guard reserve force. going back to the colorado example. during the floods when they said that we have helicopters and people need to be rescued, mike edwards and others, he sent a note to us and says that he wants to figure out this dual status command. and this one commander commanded all of those 23 helicopters. we are doing that pretty

routinely and we've done it for years preplan events like the democratic convention or a republican convention. and that leads me to the last comment that i want to share to you if we get to the questions in this is all about partnerships. so much is about partnerships. and when we roll in to assist the community, we are not in charge. and it's a commander in the and the fire chief and the police chief and we want to make sure that when we roll in their that whether the guard will be the first one in and we want to make sure that everyone sure that everyone understands aware and supportive of first responder and our job is to relay this over and over. to make that first responder successful. so whatever they need, that first responder is in charge.

and so partnerships are what we focus on. and part of that partnership occurs inside the pentagon everyday. being a member of the joint chiefs, i have access organizations and i probably never would've had as a three-star. and i get called in as a member of the joint chiefs and to give you a couple of examples during the boston bombings i was called in immediately with the undersecretary of defense and to talk about what the guard is doing in boston. what was governor planning on and how is he going to shut the city down. verity had information from the general that he had 450 troops in the city at the start of the event over there for security and immediately the governor said that i'm going to authorize you to put them in the street now and let's start building a plan to back up the police force

in the markets market for vehicles out there that can escort this on team around as we begin to look for these two gentlemen that performed the terrorist acts. i was able to take that information immediately and get it to determine and also the secretary. during hurricane sandy i probably spend eight to 10 hours the secretary leon panetta over a two-week period where we actually briefed the president and he was on air force one and i was able to bring a perspective directly from the governor and about day three of us when i was with secretary leon panetta and the agency that did a great job. working very closely in case we were sure anything they would back us up. and what i found about day three was i wondered who was talking before we were on the joint chiefs.

because there is was no one in the room that had ever been on active duty or knew how it was organized. so at that point i realized the value of this. bringing that information to that level of government. because otherwise if you don't have that level of information for all of the right reasons you're going to react. if you don't know what he needs, we are very proactive as all of our agencies are. and so that is a partnership. and so other partnerships, and i will close with this, it's our state partnership with the state partnership program. sixty-five state partners right now that exists where we team up with a relationship with military relationships within a country and we just started in the fall of the soviet union and eastern bloc countries and we

align many of those countries and the number a number of them have just celebrated their 20th anniversary in 2013. continuing to add four more partnerships and we're working on those with combatant commands right now. bringing the teams together to build a long-term partnerships and we have helped those countries build capacity within their security enterprise. and i will just leave you with one bit of this. it just occurred not too long ago that an offshoot of the partnership program was the war started and many of these countries wanted to assist. the most recent one was a story out of bosnia and maryland who was a second partnership and we started this thing after 2003 where we would bring partner nations and we would plug units

into them or they would plug individuals or units into our formations and then deploy to iraq or afghanistan together. i don't know how many deployments we did with the illinois. but the one that was very unique kind of summarizes this and bosnia wanted to deploy -- they have been deploying this into a rack and they wanted to get in and deploy to afghanistan to assist nato and so 26 bosnian military police bedded in the maryland garden they deployed together to afghanistan. and i sent my political advisor to bosnia to be there for the welcome home this past fall and the minister said that this was a fabulous event and we were

consumers of security in the past and now we feel like we can produce security is a part of the international community. and what is next for us. what can we look to the future to support the peacekeeping operations of nato and other organizations. so that says a lot about what they have done over the years. we do that whole thing for total dollar figures. about $12 million per year and if you throw in some training dollars it is just less than $20 million a year. and that's the one account and want to mess with because it gives you so much great engagement and these countries that have deployed with us, 17 locations, i think. eighty-nine rotations in iraq or afghanistan where we plugged together like that. we are building capacity and capability for the future to be able to help nato. so thank you.

[applause] [applause] >> thank you. so what would you say is the biggest challenge -- funding or anything else? >> you know, there are two challenges. one is on the federal side and one is on the stateside but let me start with the federal side. this is a tremendous force that we have and i would encourage every one of you and we will work with you to get out and see this force. we have to keep the force employed and we have to find challenging missions for them. i mentioned 25 states and these young men and women joined because they think that they are going to deploy and these young men and women will not stay with

us. they want to take the skill sets and be able to apply that. so the budgets get tighter with the guy to get that right. and it worries me every day. we have gotten really good as a regional event was another hurricane sandy, even up to hurricane katrina. and our government and our response agency and we've gotten great activity and i know right now from hurricane season, we've gotten very good at that. that one we've gotten is earthquake in the reduction zone

it was a cat five hitting new york city and that concerns me. and we are spending a lot of time thinking through how we respond to that level. tonight you consider the national guard to be in direct controversy with defense dollars >> there is one defense budget. so we ought to work off that one defense budget. and we are not immune from the budget control act and as long as we have this budget control act we're going to take reductions and what we have worked on is how we could pay those bills and try to maintain a quality opportunity for anyone who wants to join the guard.

>> and has been widely reported including secretary hegel and his consideration. can you tell us about your plan and why you hegel and his consideration. can you tell us about your plan and why you consider it the best course of action? >> if you look throughout history throughout world war ii, the guard has been pretty stable about where we are at and one of the issues we are looking at right now is that we have to take reductions to pay those bills. what does that look like? and those are the numbers we have been working with and i think we're in a pretty good place and we're still working through on the discussions with the army. and i think that we know that we can take some reductions and maintain a quality course in the guard and pay the budget control act all. as we move forward though everything we do is tied to our

two services and the reason we have our federal mission and our federal equipment is to do that in the active component loses money, we won't be able to modernize. we won't be able to send pilots to the schools that we need to or as rapidly as we need to and we won't be able to get people into basic training and so we have to work very closely with the two services to make sure that we could win that battle and lose the opportunity to be able to train our folks because the training of the structure comes from the army air force. >> general odierno was our speaker here on tuesday and he indicated that we currently have balance between the army and the reserve and future cuts would likely come from the guard and reserve. do you agree with his assessment >> this is the hard part.

general dempsey and i talked about this when we were having a debate with the air force. and so right is the right mix between the active component is ready to go. it is the bulk of your national guard force and they can be brought up to standard pretty quickly and so what is that right balance? and that is what we are trying to fight right now. trying to discover that right balance. they are guard has been working with the air force and the air reserve on a mecca of that discussion. and i think that there has been a lot of studies off the shelf.

to get this right when we talk about an insurance policy in an unstable world and think we have a good opportunity for the future. >> general odierno says they train several days here. you have a response to that? >> welcome i will tell you that i have been trying to find the person that trains. i did train 39 years and want to become a leader as a sergeant, you may get paid 39 days per year. there wasn't a weekend away by and the idea of turning 39 days

a year, i'm not finding that anymore. and if you figure the schools that are folks have to go to come in many employers have been great to work with for most cases. and they have been able to go away for four months to a branch school on anzio development course. and the requirements that we have to get our folks to do. people are leaving their jobs and technology is changing so rapidly. not only that, with the widespread use of electronic media and electronic education, a lot of the folks are doing work on their own and sometimes they are doing college classes online just so they can be competitive. so the idea of doing this 39 didier doesn't exist anymore. >> the army and the guard are said to be in dispute.

what do you see as status of discussion on that topic? >> i think it starts with a discussion we're having right now. we will be working through this if we can afford a certain amount. what can we accept and what can we put in the reserve, the guard has an opportunity to also have this dual mission and be available to the governors. and so as we move forward we have to figure that out. and if you put everything active

morn. and at some point in the future it will catch up with you and we will be able to modernize. if you put everything into this regard come you won't have that force it's ready to use it because people have jobs and things like that. so somewhere is the balance we have defined. >> you expect to go to congress with a unified plan with the army? or will there still be debate on that? >> well, looking at the budget control act and some charts from yesterday, we have had to leave for a a few years. what we don't want to do is rush. we have some relief with a 9 billion added and that gives us a few years to look at us. i don't know if the general talked about it but it if we are

defining a forest, forthcoming i could look a lot different than it does today. it is totally different in how we do business. including what types of capabilities that we need in support to the air force and army. then as we look to the future, we stand pat with the budget control act and what is congress going to do and can we get to a point where we can find is to do the missions and the strategy and still do that within the budget. and so i'm very mindful that we are being hit by the budget control act. and as we look at today's we

will be looking very closely here as best as we can for the money and some of that will be reducing the size of the overhead. >> what role do you see the army reserve on this team? >> that's an interesting question because i get criticized sometimes. but jeff and i are good friends and i was a traditional guardsman with the corps of engineers when i work in the guard as well. jeff was an active-duty captain is a project engineering engineer and so we were together way back then. and i think there's opportunity here. the opportunity, i think, that we have right now i will give you the example of the dual status command and the reason that was designed was to avoid the confusion of unity of effort

and unity of command. so you have one commander who sees the whole picture and they are answering to the governor on one hand and i think as we shake out this discussion let's just say that if there is a new earthquake and if you studied it back then that fall down shook off and on and it rang church bells in philadelphia. that is how much disaster it can bring. and so much goes up and down those and that is where all the

power is up and down that river. there's so much commodities go up and down those rivers that if we have a major disaster in that, i think that we will need every voice that we can get our hands on to take your people in the united states and that is where the dual status commander comes in and i think that if we work with the reserves and with the department we can figure out a way so that those local units can come in when the governor requests. and the last thing we want to do is wait for somebody to get there. but the key is that the governor is out of assets because we are out and we want to be able to move in quickly. and that takes coordination and advancement to be able to do that. >> what is the potential for the

guard perform that? >> guess, in the first year of the job i have had a chance to visit with kosovo as well. and the mission fits so well for our guardsman and that was that one of the outposts and they're a great opportunity with a seven person team out there and he had a staff sergeant there and the staff sergeant allow him to run not and they were grooming him for the future. you know, he is going to go back home and he knows how to work a mission and he knows how to form his team to respond as we have

been doing for a long time. this will come in the same thing. even those above that because now you get into working in an interagency coalition warfare organization. the peacekeeping operation in the logistics of it takes to support that. one of the things that i saw in kosovo was the civilian skills that in what we do. and even before some of the humanitarian aid has been quite a bet in this consistently seen organizations coming on and then they would set up a humanitarian effort and bring forward one case with the computer system with some of the computers. ..

today there's almost 1,901,800 1,901,800 -- 19,800 guard mobilized today. we are almost 20,000. who would have ever thought of that? i think the right numbers going to be around 5000 every year that will keep give us those opportunities but what is even more important as we have the opportunity to capitalize on our training.

some of that may require a three week training. we have had missions where an exercise in an air guard platform and we were able to pull that out and help the air force. see how that these frequent deployments and activations affected recruitment and retention in the army and air national guard lacks. >> the deputy director of the director can tell you our strength is fabulous. our readiness, our personal readiness, our medical readiness is at a higher state than it has ever been in the international guard in the army guard. a lot of that is because we have to make sure the medical and dental kept up every year. so as those resources dry up we

are concerned that will be deployed at the time but it's priority we would have for the future. the recruiting piece, one of the concerns i have for the future is are we going to be able to have opportunities for those army and air marines and navy personnel coming off of active duty they want to continue to serve as the army, especially the army and marines draw and marines drawdown. will we have opportunities to capitalize on their skills and get them into the park wax why that is so important to us us from recruiting for spectrum general and grump and not so much on the air side because they continue to draw pretty good number from the duty but on the army side we were probably running closer to a 50% prior service and a 50% nonprior service when the war started. that meant 50% of our force was coming off of active duty into the guard for the war started. as we went into the war and everyone saw the guard

deployments, 760,000 army and air guard deployed a lot of folks have gotten off of active duty in starting their careers and their families. they knew if they join the guard they would go on another location and have two or three deployments already. so what happened as we shifted and today we are probably sitting at 20% prior service and 80% nonprior service. that is very costly and we could bring out a trained soldier or airman off of the street out of the services into our units we would save money and experience there. that would be a big help are the future but we are sending close to 20/80 and the other thing that will happen is if we can shift closer to a 50% prior and 50% nonprior we will save money and are recruiting and if you look at the population through

our report, three out of 10 high school students graduating today fully meet the criteria for the u.s. military without waiver so that's the competition in oka by the way let's send the same ones getting scholarship so we are going to compete with so we have to get that ship to driving -- drive more power. >> you think national guard soldiers and airmen and their families are being treated differently than active-duty soldiers on the return home? >> you no my wing man and battle buddy there and of course i will say one thing. chief rush is only as good as he is because blair his wife make sure he gets up in the morning so he can serve the chief brush will tell you we travel together working with the states and the guard and i think that i'm going to shift your question for a

minute that i think what we are going to see as we move forward here is that this force that we have is going to leave us if we don't challenge them first and that we are going to find and we have already found some up an older force going back in time. and i think bill you probably saw in the army guard definitely was the age as you get older you have more physical problems and things so the forest declines in readiness. we can't let that happen. the chief and i are committed to making sure that every soldier we have is treated properly no matter what age and we see as we go around to some of the transition units where people are recovering from an injury or a wound that the older folks take longer to heal. a younger force is always going to be more healthy.

when we hear about the treatment of the guardsmen or a woman different than an active we are right on top of that and to give an example we just had -- and the adjutant general sends me a note that says our guys got pushed off to the side. i said hey move out of the way. we have another unit coming through and the guard will have to wait. that was just one small incident by one person. we pass that up through the chain and that information gets to the army and gets to forces command and they will have first army commander tucker came out and spend the time with the adjutant generals. the first thing he did, he will go out and make sure that doesn't happen again. and the warrior transition units i have asked the chief to go out and spend time with them to make sure our folks are being taken care of and also to make sure that people are getting well and

getting back to their civilian lives and getting back home. so something we are definitely concerned about but it's not like it was when we first started mobilizing at all. we mobilized to support they said the same time we mobilized the or sis. >> two related questions that i will ask is one, first how are you able to persuade the five recalcitrant station national guard is to implement director for to provide equal benefits to same-sex couples and part 2 to that what is the status government -- governor perry refusing to abide by the mandate? >> let me just talk about what secretary hagel said. something that hit home for me in the process was we had a soldier, a same-sex marriage couple and she was killed in

afghanistan fighting for her nation. i watched how that state handled it. even though they didn't recognize same-sex benefits and they didn't recognize marriage about point. this was well before secretary hagel has said hey with that to make this work after doma. after doma was overturned. to me that was a soldier. i don't care you know, doesn't make any difference. it's a soldier and we have got to take care of that soldier. so, we called the adjutant general's on the phone about the phone and brotherman and said look we have got to fix this. we understand that we are in the middle of this and there are state constitutional issues and statute issues. there is attorney general that has to be involved. our legal framework within defense has got to be involved and we just worked every day to find a solution that did not violate state constitution and state laws. i have got to applaud the states because many of them worked really hard in very short order

to make it work so that we could extend benefits to whoever is serving in the military. >> what about texas? [laughter] >> actually we actually had a very good relationship. in right now we are not actually any problem. i don't know any situation where we have actually denied benefits. >> can you bring us up to speed also on the military suicide issue that of course has affected all branches? how much of a problem is that in the guard and do you think that the guard in the military overall need to take more steps to address its? >> you no, this is a problem and i have a serious problem within our society. it just bothers me. it really others me and i'm sure it bothers all of you. working through some of the school systems and where the armories are in the hometown and

what would drive someone to take their own life? i have a rear admiral who works on my staff as a liaison to services and she is on a fabulous job of reaching into the research community trying to get ahold of what's happening within the society. and the problem for the guard is we are so distributed out there that you don't see someone every day. you may see them once a week or over a weekend when you're deployed to spend more time but half of the suicides are not folks who have been deployed. so what has happened in our society and how can we partner with the community? we have one state right now that is working on that because of a couple of suicides that occurred in the suis -- school system as well as the guard. there's a problem within within society that we have got to deal with then of course we bring in that normal age group. whenever you touch america you

bring into the guard america you will have the same kinds of issues. we have psychological health professionals in our state and we are getting ready to make some changes. we have had contract psychological health to deal with this and make them available and make them available for hometown america, for the families as well as the servicemembers. and then educate all the membership that are available and if you see someone who is not acting right or someone who is having problems most of the issues we deal with our financial relationships and drug and alcohol depression. but we try to do is make sure everyone knows there are health care professionals that can, and you can talk to them and you can do it anonymously. the air guard that we shifted right now we were shifting resources and we are going to change those from a contract to a civilian position within the guard. so they are there all the time. they will begin to understand the community. they will begin to understand

the graphics and they will have the connectivity. we are looking at doing some the same for the long-term. i would tell you one of the concerns i have and i think the partner closely with the veterans administration is as we draw down the force, if we don't do anything else right now the environment is going to come down 70,000 from the growth that they had before the surge. they're marines are coming down some. all those individuals, those great americans that have served our nation in a time of four or coming back to hometown america. we don't know as a nation yet what 12 years of war does to people. what it does to families. 12 years of war, you have young 30-year olds out there that have had five years in combat. we won't know the impact so we have got to be prepared and we think our armories are good place to start working that distribution network through state headquarters.

>> we are unfortunately almost out of time but he for asking one last question i have a couple of housekeeping matters to take care of. first of all i would like to remind you of our upcoming speakers tomorrow january 10 will have joe boardman chairman and ceo of them track. january 15 we will have christine lagarde managing director of the imf and january january 21 d. murray smith the executive director of the nfl players association. secondly i would like to present our guest with the traditional national press club coffee mug son now with two of the joint chiefs he can bring this to meetings. [laughter] >> thank you very much. i appreciate it. >> one last question. our audience is curious about your first meeting once you got to the joint chiefs. it was a big deal to get the four-star and be there. was there any sort of hazing that one along with back? [laughter] >> as the chairman reminds me every so often, he says you

asked for this, right-click yes, chairman nye did. i couldn't ask for a better reception. they deal with very difficult issues and you know the history behind the position and when they went to the senate to testify. i have bounce things off of chairman dempsey. he has been a wonderful partner across-the-board. i've been to all the events of the joints chiefs. the thing that really catches you when you're sitting there the first time and thinking okay, any issues in the homeland today, anything on mobilization? all of a sudden there is this so one so what are your thoughts on syria? what really hits you at that point is you have to make sure you have created an organization that can respond to that level. and not just at home and because even though i'm an advisor i have to vote. i have to give my opinion to the secretary and the president on

all topics that involve defense. so you have to get your staff ready and it's an investment at times and resources and training and development and i would applaud both the army and air because they're offering us opportunities to put people into positions that will help us grow for the future. i will leave you with one thought. i need to do this if that's okay. this is who your guard is today and i'm just going to recognize a master sergeant, michael lance very. some of you have heard this on the news. this is truly -- even though he lost his life i could pick any master sergeant having get the same response. michael lance very sparks middle schoolteacher marine corps veteran nevada air national guard master sergeant lost his life protecting his students won when a 12-year-old walked in armed with a semiautomatic handgun and opened fire on the

school campus in october. that is who your guard is. thank you. [applause] >> thank you general grass for coming today. i would also like to thank the national press club staff including her journalism institute and broadcast center for helping organize today's event and finally a reminder you can find more information about the national press club as well as a transcript and video of today's program on our web site at www.press.org. thank you. we are adjourned. [applause] [inaudible conversations]

>> and new university of virginia commission report recommends that states play a bigger role in controlling the nation's health care costs. the report was cochaired by former health and human services secretary michael leavitt and former colorado governor, bill ritter. >> good morning. i am jerry baliles director and ceo of these miller center. the first announcement that must be made is a request for

everyone in the room who has a cell phone or electronic device to please turn it off because it may interfere with the c-span and other broadcasts being made at this press conference. i would like to welcome you here for the release of the millicent or state health care cost containment commission. in its report entitled cracking the code on health care costs. health care access, quality and costs have been at the center of the nation's public policy challenges for much of the past two years, and it is likely that will remain the case for the foreseeable future. while the rate of increase in the cost of health care has slowed over the last few years, it has still hit the tipping point and it is having a huge impact on consumer budgets. it is forcing major cuts in state and federal funding for education and infrastructure which are critical to the long

growth -- long-run growth of the u.s. economy. there are also questions about the extent to which the high cost of health care makes u.s. companies less competitive in world markets. the work of the commission is consistent with the mission of the millicent center -- miller center which has served as a central gathering point for nonpartisan policy discussion since our founding almost 40 years ago. other recent public policy issues addressed by the miller center include presidential war powers, federal transportation policies, immigration reform and the challenges facing america's middle class. unlike some policy issues where we know what to do but lack the political will, health care cost containment is in its infancy and so we must go through a period of accelerated state experimentation to determine

what really works. a supreme court justice william brandeis indicated in 1932 that states are the laboratories of democracy. the commission's report or bide states with a blueprint to follow during this period of experimentation. much like states have led and clean air welfare and education reform, they are likely the level of government to lead the transformation of health care delivery systems. not only our states very nimble in making adjustments to programs that work, but an health care most of the key policy levers belong to states. it is also true that health care solutions need to be tailored to the health care markets and the cultures of individual states. the commission met three times in the miller center washington d.c. office and has had numerous conference calls and developing

a strong consensus on the board and its recommendations. while we hope that the federal government's health care leadership listens and, this report was written specifically for governors, state legislative leaders and other health care leaders at the state level. the federal role as we see it in the area of cost containment is to support the state role by providing additional information to states and has financial incentives to encourage states and taking a more active role. states however have to take the leadership role in cost containment. let me introduce the members of the commission at this point. those who are here. first the two co-chairs. mike leavitt the former governor of utah in the former u.s. secretary of health and human services. and bill ritter the former governor of colorado. the private sector representatives who are here george halverson former chairman and ceo of kaiser permanente.

andrew dreyfus presidency of blue cross-blue shield of massachusetts. and glen steele president and ceo of geisinger health system. then we have bob restuccia and medicare -- reischauer a former director of the budget office said urban institute. rob restuccia with community catalyst. several other members who were not able to meet with us today includes simon stevens from united health, j. cowan with optimum, mike davis with general mills, john hanna and very former executive director of the colorado department of health care policy and financing and lloyd dean with dignity health. finally i would like to say a special thanks to our two major funders. first kaiser permanente and special appreciation to george

halverson. and second to the robert wood johnson foundation which is represented by andy. now i would like to turn the program over to governor bill ritter who outlined the role of states in health care cost control and the huge number of policy leaders available to states to both enhance quality and reduce the cost of rate increases over time in the health care field. governor ritter. >> thank you. good afternoon. prior to talking about the states role and its many policy levers to moderate health care cost increases i want to take a minute to make a few general points. first there are chapters in our report on the health care problem, the affordable care act and what the federal government can do to help states control costs. this press conference is going

to focus on two bottom-line issues, the state policy levers and are specific recommendations. second, although the title of the commission and the report itself talk about costs, increasing quality is of equal importance to the commissions. commission members believe that we can do both enhance quality and enhance the rate of cost increases over time. of although there are no silver bullets with respect to restraining health care costs the most important goal is to transform the delivery system as one that is fee-for-service to one that is comprehensive and integrated using payment models that hold organizations accountable for the cost and the quality of care. fourth, this report is written for governors, state legislative leaders and other health care leaders of the state.

this is because the transformation must be led by states. health care markets and differ from state to state and so solutions must be tailored to individual states. it is true that we are in a period of experimenexperimen tation attempting to determine what really works but if you look in retrospect to what states have already done they have a pretty good track record for experimenting, for being very good laboratories and being able to say what works and what doesn't. as a former governor i will admit that i have a bias when it comes to public policy in favor of states. but i think the commission members would agree with me that we are all surprised and really hearts and as we begin to dig into this issue and look at what states have at their disposal in terms of policy tools to control

health care costs. i want to talk about five different policy tools. first the purchasing power of state health care programs including medicaid, those first dates, to some extent local employees and individuals in state exchanges. medicaid, state and in some states local employees and individuals who are enrolling in the state exchanges. second state laws and authorities that govern insurance scope of practice provider rates and medical mal pratt is. the third update ,-com,-com ma state laws affecting market competition consumer choice, antitrust and price and quality transparency. fourth, the authority to invest in initiatives that improve population health specifically programs that help lifestyle choices and personal responsibilities.

the power of governors to engage stakeholders to and i will take a minute to talk about each of those individually. programs administered by state governments, the number of individuals eligible for health care coverage through stated minister programs is going to approach 80 million over the next several years. that is far larger than the 53 million enrolled in medicare. this includes medicaid patients which will likely have 70 million enrolled in the next few years but it also includes 3 million state employees. it's a potential of 11 million local employees that can be part of state programs. that includes another 6 million who will be purchasing health care through state exchanges so if you add up all those totals if the huge purchasing power at the state level which could be used to transform the delivery

system from fee-for-service toward one that provides high-quality, low-cost care. under the second category i mentioned, state laws and regulations that affect insurance. at all states regulate health insurance including a review of solvency, review of rate increases, contractual rules between plans and providers. while the fuse dates make rigorous review of rate increases and at times deny increases, most and not have the resources to perform a serious analysis. that said under state laws they have vast authority to do it. also, all scope of practice laws regarding what nurse practitioners and physician's assistants and other nonphysicians can do and how they are paid comes from state laws. many states are redefining these responsibilities so that nonphysicians can practice to the extent of their own capabilities. medical malpractice laws or

state laws. many states have ratesetting authority. maryland is the only state right now that sets hospital rates. therethere is a the whole abilin the part of states where rates are concerns and regulations are concerned to control health care costs. under the third category and the one that talks about laws that affect competition and transparency, all states have antitrust laws on their books although they are seldom used. increasingly however states are requiring providers and plans to make cost and quality information available to consumers on a timely basis. as governor of colorado to pass a law that talked about for cards for hospitals to increase transparency around quality of care. the fourth category public initiatives to promote population health. increasingly around the country these are being developed by states. some may be school-based such as exercise requirements and food and nutritional guidelines and

others are community-based such as grants for walking and bike paths that states are very much paying attention to their own ability to look at wellness as one index of controlling cost increases. the final in the fifth category is perhaps the most powerful. it's the ability of governors to engage stakeholders to create a stakeholder process that looks at change. the it will take a while for new governor to fully comprehend this power. it's not written in the constitution and typically not written in any law but correctly utilized it is a powerful vehicle for change. that is just a summary of the different policy levers and the biggest policy levers that states have. you can see that there are many such opportunities for states. if you look at all the ones put together, it came clear to the members of the commission and the governor and myself that

there are friday things that can happen where states can absolutely have an important role in controlling health care costs over time. i am honored to have served as the cochair on this commission with governor leavitt his secretary of health and human services and is steep and the subject matter area. it's such an important policy issue for this country and we are fortunate to have a man of mike leavitt's credentials. the part of this commission but also to have been part of this large or dialogue for such a long time. governor leavitt thank you and i then i invite you to the podium. >> thank you governor ritter. may i just extend some appreciation of my own to the miller center for initiating this project and raid for leading it and also the kaiser foundation and as mentioned earlier robert woods johnson and there will and to all of you for

coming to hear the report and for c-span for allowing those who are not able to be here to hear about it. this is an important report. could i suggest that three things i would like to make before we get into the recommendations. the first is this report was done primarily with the context that we believe market forces when utilized can reshape the health care system so you will see integrated into a lot of this a thinking that market forces properly constrained by the roles of government can in fact be the most effective way in which this is done and which plays very much into the sub text of this report which is states can have a tremendous impact on this process. states in a way to reflect a marketplace because there are laboratories of democracy. the second is that these

recommendations have been based on conditions as they exist with the affordable care act. if in fact the act begins to migrate or change over time, it won't necessarily change the opportunity for states that it could in fact change some of the things that were inherently placed in this report. and lastly could i suggest that this is a long-term process. this is a five to 10 year horizon we are talking about, not something that's going to happen quickly. governor ritter talked about the policy levers. within the context of those policy levers could i just briefly outlined the seven main recommendations that the report makes? the first is that states should create an alliance task force or a workgroup to transform the care system in their state. this is a classic collaborative

problem. it requires collaborative leadership and the collaborative leadership needs to be formalized. governor ritter spoke about the role of the governor and i would like to underscore that point. the governor in this state needs to lead. the governor in a state is in a unique position not just to use the levers of government but also to call upon the community. it is a unique role granted a governor. but in addition to the governor there are other state government officials who play a critical role. the medicaid director who typically would have responsibility for 15, sometimes as many as 25% of the lives in

the state being paid for through that mechanism. that is a key player in the function of state government. typically the insurance commissioner who regulates the vast majority of the market that remains outside of medicare and medicaid. very important player in the health reform, again a state official. another example would the the h.r. person or the benefits person in the state. typically the state government is the largest employer in a state and hence a significant part of the health marketplace. it falls under that person's responsibility. but it shouldn't simply be in this collaborative ross says. it shouldn't just be state officials. obviously it needs to be those patients and care providers. it needs to be insurers but the governor has the capacity to bring all of that together as a

convener was sufficient stature to begin to focus the state on this problem. recommendation number two, define and collect data to create a profile of health care in that state. could i suggest that there is no national health care system. there is no national health care market. there are 30016 hospital referral regions in 50 states and so states have the capacity to take the marketplace with in their state and begin to concentrated on its unique characteristics. so being able to gather that data to give the governor and the community a clear picture of what the system looks like in their state is a very important first step. recommendation number three,

establishing baselines and olds for health care spending for quality and other measures that are appropriate. states needed goal. they need to know what the status quo is producing and there needs to be a public commitment made to reducing costs within that marketplace. again and if you begin to look at the levers available to governors in states they are considerable. it's not only control 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 has mentioned it already and that's using the powerful leverage that the state has with existing health care programs such as medicaid, such as the employer, the state

status and employer and state employees. however there's a whole series of other levers that the states have. for example they have the capacity to promote regulation that will begin to drive the market. 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 is typically handled at the state. the scope of practice printers can practitioners and a physician assistants and other nonwas positions typically done at the state level. often that is the place were not only a scope of their practices determined that the limit to which they can practice is determined. another recommendation encouraging consumer selection of high value based on

information. having transparent information of cost and quality. states again have the capacity to harness that data and in nearly 30 states now we have all-payer databases where the state has accumulated information from all of the plans. those can be used to drive that kind of information. lastly the final recommendation help promote oblation health and personal responsibility for health. this recognizes that health is very much an ecosystem and it involves the health of people which can be everything from trails and having walkable communities to clean air and clean water. all of those things are part of what allows the states to have an impact. so in summary the governor should share and convene a process within states to attack the health care costs in their state. they should have dated the gets them a baseline from which to

operate. they need to have goals, goals that will in fact generally a period of five to 10 years to see the costs in their state overall notches the public sector but the private and public sector. they need to use the programs is 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 anything. 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 present for this report and then we will go to some questions from the

miller center social media channels. hu call on first for a question and? julie. >> i wondered if you could chat about whether you think massachusetts is an example of what you would like to see in other states? >> andrea have first-hand knowledge of that as the head of la cross shield of massachumassachu setts. >> thank you governor and it is a good question. i would first say i am always a bit cautious about recommending massachusetts solutions. one of the statements in the report is each state is different in each market is different but having said that, many of the recommendations mirror some of the actions that our state has taken. our state cost-containment law was only recently passed but it has created a climate in massachusetts that mirrors a lot of the recommendations in this

report. more collaboration among government and the private sector and a 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 i should say the growth in costs come down. another key recommendation and a report adopted in massachusetts has been widespread acceptance in changing the way we pay for care. the fee-for-service system which i think the report and other experts identify as being fundamentally inflationary is being changed in massachusetts and physicians and hospitals are voluntarily adopting and agreeing with health plans like ours at blue cross-blue shield and others to accept what we call global payments, payments that include incentives for quality and incentives to control costs. independent studies by experts have demonstrated that we are

starting to get to that holy grail and health care which is better care and lower costs. i think the massachusetts experiment is instructive and while i have a podium one or two other comments i would like to make. i do believe that if individual states of top did the vast majority of these recommendations health care costs would come down. there is some passing reference to the affordable care at that in my view is that the evolution of the affordable care act makes the recommendations of the report more relevant. the affordable care act has evolved than we have watched his states have made individual decisions to perhaps take a different path whether they have adopted to expand medicaid or not whether they have adopted two changes are not. some of the national standardization that was 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 promise of this report. so does that get to the question you asked? >> wait for the mic. >> manning of these recommendations sound like they need additional regulations in additionaadditiona l control by the states. how's that going to fly in some of the states who think perhaps there's already too much regulation? >> i think as the governor has a knowledge we need to achieve a balance between government regulatioregulatio n and oversight and market innovation. although massachusetts is often viewed as a state where government oversight is widely except that, in fact some of the most important steps we have taken to control costs have actually come from the market and have come from innovation together from plans and hospitals. i think there are some very --

states with republican governors have been innovated very successfully. i think each state has to settle where they are comfortable with the balance between regulation and innovation of the market but is a basic promise as you just heard, from our presenters, governments, state governments have a lot of authority even in states which have less of a regulatory climate or history. they are overseeing insurance regulation, public health departments, employee benefits so those are all opportunities to kind of focus on health care affordability. >> it i'm from the state of utah utah would likely be considered a different regulatory environment in massachusetts. but what is interesting to me is that both massachusetts and utah have achieved a fairly high-level of integration in the

health care systems by comparison to most other states. massachusetts, its background is well-known in reform. utah's back on them or form action start in. i happen to be government -- governor at the time and frankly we hauled together collaborative process that lasted eight years, where we put together collaborative process to every year put forward toward what we called our health plans moving toward a more integrated system so you have two very different cultures in terms of regulation but both move 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 unable to achieve. >> i would add our experience in colorado is interesting as well.

it falls somewhere between a massachusetts and the utah spectrum of regulation but it's another place where you see things happening in a bipartisan fashion. before i was was governor at the republican governor, governor owens and people formed this senate 208 commission. they came too late for governor owens but we wound up implementing many of those regulations some of them in a bipartisan fashion and some of them a little more partisan. after i left office in the states were left with a decision about health care exchanges one of two states i think in the country where there was a bipartisan agreement around the state health care exchange. colorado which is 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 the 20008 commission and ashley get them passed legislatively that it done overrated things to

help control health care costs to try and increase quality and provide greater transparency. there are states that the country and may think you just heard three different states that may have some nuances that have taken this on his estate in been able to navigate the political while 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 understana likely 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's packs of the marketplace. so the players, the responsible players in the insurance 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 regulations that will lead to a vibrant market that improves the well-being of people. >> i think that it's very exciting that states in the past have been really the innovators around access to health care and

i think innovation is moving forward and being taken up on a federal level is now shifting to the states to address the issue of cost. it is exciting to see across the country states moving on and developing a ceos and tool 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 agreement on. we have had some struggles around the balance between regulation and market forces. the idea that such a diverse group has come up with this balance with these recommendations if we all agree upon them is a reflection of what needs to be happening at the state level. we need to see action and we need to see people 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 am not sure how the commission regarded some of the things that are polarized the country so much on health care in the last few 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 and our collaboration 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. this was focused on cost containment and so we didn't spend a lot of time discussing

how best -- 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 and then 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 and bringing down health care costs. it is widely held back that in the u.s. we tend to be generous to the old and post him as to

the young. did you look at that issue and the costs involved? >> and 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 process. 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 that to the degree we can achieve integrated care we will begin to get lemonades the problem that you point to. not entirely, it's a long-term process that being able to integrate care while 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 and other health care systems. so not just speaking for myself as pretty matured to discuss rationing went today there is an efficiency and waste in the system whether it's at administrative inefficiency or clinical and efficiency that we can improve upon. and the steps that we have outlined in the steps in this report will do that. we need an integrated system in which we are paying for quality and not just for the volume of care. >> chris cartouche government magazine and a question for you governor leavitt. you mentioned that nearly 30 states have a database that collects provider data. what is the variance in making that more public way available

in a digestive way? they have that 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 began in a collaborative way but have as many as 70 million and 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. it isn't the creation. frankly it's not the technology that limits this. it's the sociology that limits this. if the capacity to get people together in a fashion that will begin to change the system. there 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. governor leavitt i don't mean to pick on you but i guess is the only representative of the deep red state here i have a question that i want to follow up on what julie asked. clearly your recommendations that are built in part on utilizing the tools that state government has whether it's the governor, the insurance regulator, the urges or state health plans. unlike utah there are a lot of red states where there seems to be a deep hostility to using those tools if you will to influence the health care market. 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 only resisting the affordable care act that seem resistant to the overall premise and some of the things you're suggesting. >> i believe there was a very significant event that occurred a couple of weeks ago or months ago now when the current administration chose to grant a 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 endemic that have been resistant to having so much federal involvement in health care. what i believe that the acceptance of that labor by hhs signaled was that perhaps the administration would be willing to acknowledge that states could

develop medicaid programs, could develop exchanges and to do other things in the context of what we have talked about that could represent their own culture in and their own value and their own view of what governments role ought to be. it was mentioned, i think rob mentioned the fact that health care is a very complex subject and frankly it requires 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 but we need the capacity to do so. i think ultimately the reason this report has relevancy is we are signaling not just states, we are signaling the administration to say if you want help in creating momentum

for reform, turn to the states because given the latitude and the tools they can lead, they will lead and they will be more effective than you can possibly imagine. in fact the exchanges have been quite a demonstration of that.