child needs an abortion, at a minimum before that series medical treatment, that a parent has the right to be notified. 38 states have that law and yet this bill in congress would imperil every one of those laws. and if i may, finally, if i may have another 30 seconds to just share some of the stories from women in texas. ..

>> that abortion ruined think chanf me giving birth. as a result, i've had five miscarriages. three of them have been tubal pregnancies requiring emergency surgery and were very near death experiences. i have suffered from bouts of depression and attempted suicide, self-mutilation. my experience of emotional trauma after abortion is the same as millions of other women and their families. i havebe 317 statements -- i are 317 statements, each as powerful as that in terms of the human consequences of what this legislation would produce. thank you, mr. chair. >> thank you. ms. northrup, would this legislation prohibit the use of ultrasound when a patient requests them? >> oh, no, not at all. this law, again, is just very focused on those underhanded type of restrictions that are treating abortion not like

similarly-situated medical practices that don't advance health and safety and are harming access to services. >> in's sense, it would be irrelevant to the instance that senate be cruz has just described. >> yes, absolutely. it also very explicitly does not cover the question of insurance funding. it's not addressing that. it has nothing to do with minors. it specifically says it doesn't address issues about parental consent. >> doctor, have you ever performed an abortion? >> no, i have not. >> dr. parker, how many abortions have you performed? >> i don't have the numbers right off the bat, but i can tell you that over 20 years of patient care i've seen thousands of women, and some of those women have needed abortion care. and in your -- >> and in your experience other how many years? >> twebt. >> twenty years, has the width

of a hallway in those clinics where you have performed your medical services affected the quality or expertness of those medical services? >> no, senator. >> has the admitting privileges within that state affected the quality or effectiveness of your medical services? >> only to the extent they provided me from providing care to women. >> they barred you entirely, but admitting privileges ar irrelevant to the quality and excellence of your medical services because anyone in need of a hospital will be admit today that hospital. >> correct, senator. >> and the waiting period, is that relevant to the quality or effectiveness of your medical service? >> the reality, senator, is that women are extremely thoughtful, and most women that i meet when they present to me to be counseled about their options, they've been thinking about what they're going to do about their pregnancy from the minute that they found they were pregnant. so i know women to be extremely

thoughtful, and i've not seen any woman's ability to make this complex decision enhanced by being forced to wait longer than she's already thought about it. >> thank you. ms. northrup, in response to senator graham's questions, you essentially said that the limits embodied and incorporated in this bill were constitutional standards, is that correct? >> that's correct. for example, most states under the supreme court's constitutional rulings can ban abortion later in pregnancy and do. and as long as they have an exception for women's health and life, those laws are on the books now, and they would still be on the books. >> in effect, this law basically enforces the constitution. >> absolutely enforces every woman's constitutional right to make the important decisions for herself. >> and finally, in those countries -- and a reference was made to a number of them where abortion is made illegal -- is it made safer?

>> no. around the world many of the places where abortions happen women are terminating pregnancies where it is illegal, and it is unsafe. and whether you see this country before roe v. wade or you look at places in latin america and sub-saharan africa today, when women don't have access to safe and legal abortion, they are harmed. >> you made reference, speaking about the state of texas, to women in texas going across the border to mexico so that they could buy on a flea market drugs necessary they thought for abortions because they could not get that service in the united states? >> yes. as the clinics have been shrinking in texas because of laws that -- again, i commend the american medical association's brief in the fifth circuit talking about the medically unnecessary laws that have been passed in texas. that's the ama, very mainstream medical opinion.

because it's taking clinics from three dozen cut by a third and it will be down to less than ten if it's allowed to go into effect be, women have been going over the border in mexico, they've been buying medication on the black market. they've been trying to self-abort, and the situation is going to be worse. women are hurt when they can't get the medical care that in their decision to make, decision about their pregnancy that they need. >> ms. taylor, in your experience in wisconsin have the restrictions on women's access to reproductive rights made abortion safer? >> no. no, mr. chairman, they have not. >> have they, have they created confusion, in fact, discouraged women from seeking to exercise their rights? >> absolutely. and they have sent women out of state. >> thank you. we are voting, so i apologize, i'm going to have to close the hearing. my colleagues are on their way

there. i want to enter into the record without objection various statements including planned parenthood in southern new england, a statement that's been submitted for the record. as is our custom, our record will remain open for one week in case my colleagues have additional questions. and i, again, want to thank every one of our witnesses for participating in this very, very important hearing. thank you all for attending. [inaudible conversations]

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[inaudible conversations] there>> general motors' ceo mary barra will testify at a senate hearing about gm's recalls of nearly 26 million vehicles. we'll also hear from ken thet feinberg who heads up gm's victim compensation fund. live coverage starts this morning at 10 eastern on c-span3. and later this the evening, new jersey governor chris christie will be in davenport, iowa, for a fundraiser for state government terry branstad. it's part of our road to the white house coverage. that's live at 7 p.m. eastern also on c-span3. >> forty year withs ago the

watergate scandal led to the only rez nation of an american president. throughout this month and early august, american history tv revisits 1974 and the final weeks of the nixon administration. this weekend, opening statements from the house judiciary committee as members consider articles of impeachment against president nixon. >> selection of the president that occupy the very unique position within our political system is. it's the one act in which the entire country participates, and the result is binding upon all of the states for four years. the outcome's accepted, the occupant of that office stands as a symbol of our national unity and commitment. and so if the judgment of the people is to be reversed, if majority will is to be undone, if that symbol is to be replaced, then it must be for substantial and not trivial offenses supported by facts and not by surmise. >> watergate 40 years later, sunday night at 8 eastern on

american history tv on c-span3. >> the nation's governors met in nashville last week. one of the topics was the health care costs facing states. [inaudible conversations] >> this room got quiet real quick. well, good morning, everyone, and welcome to this session. we're -- i'm very pleased that so many of you would get up early on a saturday morning. i hope you enjoyed last night's entertainment and are enjoying your nashville experience. we are loving having you all here. want to call to order the meeting of the health and be human services committee, and let me given by saying we have a few administrative items to take care of. the governors should have all received briefing books in

advance including the agenda and nga updates. next to me is melinda becker, legislative director for health and human services for nga, and she'll be available after session if anyone on the panel or thin else needs further details of what we're talking about. reminder that the proceedings of this committee are open to the press and all meeting attendees. i would ask ask you to silence your cell phones and other electronic devices. today's discussion will really focus on two key issues that i know every governor spends a lot of time thinking about and working on. first, given demographic changes, rising costs of health care and a range of other factors, how can we expect the u.s. health system to evolve over the next decade for all of us, i'm willing to make the safe bet that health care costs are a major factor in our budgets and a major part of our jobs. second then would be how can governors harness these forces to improve health care in their

states also while reducing the financial burden for state goths, for our employers -- state governments, for our employers and families. whatever changes may be on the horizon, we can be certain governors will be dealing with them because, again, a lot of what we have to do has to do with dealing with health care. in tennessee we recently launched a statewide initiative to better with reward patient-centered, high-valued care. the tennessee health care innovation initiative will shift a heart of health care spending both public and private away from fee for service to three outcome-based strategies. the first aligns financial incentives to promote be successful outcomes for a joint replacement or a pregnancy. the second strategy focuses on primary care transformations that encourages prevention, coordination of care across providers and involves the physician in the total cost of care for their patients.

the third incorporates over value-based approaches and supports providers as well. with these efforts it's our hope that tennessee will be at the forefront of a national trend that is expected to gain momentum in the coming years. many governors are immomenting or -- implements or considering statewide plans. the central government is supporting many of these governments through the state innovative -- innovation models initiative or sim initiative. tennessee received a model design award in the first round and in the second round will compete for a model testing award to support implementation of our state innovation plan. despite sim and other efforts, successful statewide transformation will require a new era of collaboration between states and their federal partners. this enhanced state/federal partnership is a key for states to continue moving'b(hguz needle toward higher quality, more efficient care and better health

status. to this end, at the last nga meeting in february governors approved a series of recommendations developed by the health care sustainability task course. the governor of oregon and i had the privilege of leading that task force and to work with the administration on a number of key issues including streamlining the process for be state innovation proposals, creating a path to permanency, and allowing states to share in federal savings resulting from their efforts. be achieving these and other goals outlined in the task force report will give states the flexibility and the resources they need to transform their health care systems and respond to the future be challenges and opportunities we will be discussing today. i would like to turn now to the vice chair of our committee for any be remarks he may have. governor? >> thank you, mr. chair, thank you, governors. looking forward to hearing from the panelists. i've got to say, i don't want to get myself in trouble here, buttive i've got to say this hau been the most fun, successful

summer ng a a meeting that i've been to, and last night's entertainment show was just one example of how overgetting this right. thank you for everything you're doing for us, governor haslam, for the nga, for all of us, governor. [applause] and it's going to make it tough for any of us to host future summer meetings. [laughter] maybe we'll just shut 'em down here going forward. listen, i want to thank you all for being here. governor haslam's doing extraordinary work this tennessee. this is an area, health care, where we all agree that we've got to get costs under control. and today's discussion is really critically important to the work that governors are doing around this table and around the country leading in our states. and when it comes to health care, we're all working to stop skyrocketing costs that are hammering businesses, hammering job creation, hammering middle class working families and threatening our ability to invest in other priorities such

as education, roads and bridges, public safety, job creation. i know in vermont as an example, and this math is probably no different in other states, today vermonters spend 20 cents of every dollar they make be on health care on average. and if we were to see health care costs rise just for the next ten years at the same rate they did for the last ten years, that number would double. what i often say to vermonters is, you know, raise your hand if you think that's a prescription more job growth, for economic be prosperity, for a great future for all of us. so health care costs is where it's all, where it's at, containing costs. as governor haslam just noted, there's broad alignment that outcomes-based payments, moving from quantity to quality, is the wave of the future. and we governor governors are prepared for potential challenges that lay ahead from a rapid, aging population as the governor just mentioned to increased consolidation of our

health care industries that we're seeing in all of our states. there are many other trends that have implications for health care transformation in our state. in vermont we're focused on containing cost by covering health care providers and payers with funding from the state innovation models grant which has been a huge help to us. we are one of the states that got a sim grant. so just for a second imagine a health care system where health care providers, everyone in the system, our docs, our nurses, our hospitals, all the other ancillary services are totally driven to keep you as healthy as you possibly can, as they possibly can as a team and don't have to use as many expensive health care services to achieve those goals. second, imagine the a system where providers have the health care records at their fingerprints in an i.t. system that just can't be beat through american innovation, and they're there when they these them, and, third, where providers work with

people outside of the health care system to make sure you have the support you need to stay healthy once you're moved back into your communities and your homes such as good housing, good nutrition, active preventive care. i often say eating good vermont-grown food. getting off the smokes, exercise be, all the things we know be we should be doing. >> does maple syrup help you that much? [laughter] >> maple syrup is definitely the sweets you want to use, and it's got to be vermont syrup. that's important to know. [laughter] the inshow vegas project -- innovation projects support three times of work, the first is changing provider payments so that we pay for outcomes of care, not volume of care. that's going to be a major transformation in our system. and where we reward providers and patients for achieving that, for doing the right thing. second, where we're completing buildout of health care information systems that i just mentioned that link our providers together. and, third, designing a statewide system for how we

target and coordinate services to keep folks getting better. so how do we achieve -- what have we achieved so far in vermont in our innovative, innovation project? we've created shared savings programs for providers. the obvious question is, have you achieved -- how do you move from the model of payment we have to the new one that goes toward? shared savings programs are the first step away from volume-based payments for health care providers towards value-based payments. we've launched one program for medicaid and one for private insurers. vermont's the first state to launch that kind of program on a statewide, all-payer basis so that everybody's in. we've got our health care providers, our hospital execs, everyone around the table trying to figure out how to get this right. we've also invested grant funds in health care information technology, as i just mentioned, continued buildout of that interface between health care providers and the state's health care information exchange system is critically important. that includes establishing

connections between hundreds of health care sites across the state. we all face that challenge as governors. and finally, building an electronic gateway that will route health care data for quality reporting, care management and improvements to patient care. we have all of our major payers and providers in the state talking about collaborative hi a common approach to health care improvements. everyone knows the health care system won't be affordable or effective unless we focus clearly on keeping vermonters healthy. so for all of we governors, first prior i think is -- priority is quality of care, keeping our people healthy. second, right now everyone's taking their own approach to health care improvements, and that's what we need. we need an all-out, coordinated effort across the state. and finally, this is what we're building in vermont. so i look forward to the presentations that we're going to hear from the other folks on this panel, the other comments of the other governors.

i really do believe that the governors working together in a bipartisan spirit with the states as the models for innovation and change in health care is where the rubber's going to hit the road in bringing about quality affordable health care that los us to -- allows us to spend more money. thank you so much, governor haslam, i'm delighted to turn it pack over to you. >> let me introduce our distinguished guests. we have a great panel, and what i'd ask is all the governors to do is if you can hold questions to the end of the presentations. we're going to set aside a chunk of time for questions and answers at the end, so i would ask you to hold those questions for then. let me begin by introducing tom latkovir, director at mckinsey and company looking to improve the performance of the health care system. tom leads mckinsey's payer sector and co-leads the state's local and government practice.

he also founded health care value analytics, a special division dedicated to supporting, designing and implementing payment and delivery system innovation. tom, welcome. >> thank you very much. >> also with us today is andrew dreyfus, chief executive officer for blue cross blue shield of massachusetts. prior to becoming the ceo, mr. dreyfus spearheaded the development of the company eastern quality contract, one of the largest commercial payment reform initiatives in the country. mr. be dreyfus also priestly led the -- previously led the massachusetts hospital association. and he held numerous senior professions in massachusetts state government. welcome. we're glad to have you with us. >> thank you. >> also found out his son is an aspiring singer/songwriter, so you're in the right place. [laughter] finally, i would like to welcome bill rutherford of the hospital corporation of america or hca as they're known here, one of tennessee's and the nation's leading providers of health care services. they're based here in nashville. during his 24-year tenure, bill

has served in a variety of roles from staff auditor to chief operating officer of the clinical services group to his current role as chief financial officer and executive vice president. in 2005 he tooking a brief hiatus to start his own training and education company and then served as chief executive officer of the behavioral sciences, behavioral services provider psychiatric solutions. with that, mr. latkovic, i will ask you to lead off for us. >> thank you very much, and very much appreciate being here with you today. as governor haslam shared, i'm a partner ott mckinsey and company probably better nope for our work -- known for our work in the private sector, but we also do quite a bit of work with governors and with states across education, economic development, technology, etc. and working with a number of states on health care, health care payment innovation, medicaid performance improvement, technology, etc. so today my perspectives will be

both from our research as a firm as well as my personal experience working in both the public and the private sector. i should also clarify that we're not a political organization, we're pretty much nerds. [laughter] and we come at things from an organizational and operational and technical standpoint but not from the political one, so none of my comments today will be referencing any specific policies or legislation including the affordable care act. what i'd like to do is take a step back and actually make a bit of a case for the kind of nichives going on in tennessee and vermont. and there's really four things i'd like to share with you today. one is i think we have a unique time and opportunity to fundamentally change the trajectory of the health care system in this country, and that's very exciting. i think the next five years are going to be critical for the next 25, but that change is going to be quite difficult. second thing is we think the performance of each state's health care systems could quite likely diverge over the next 3-5 years. some states will be on her of a success path, other states may

not. third, i'd argue that governors and states' actions and inaction will be very consequential not just in the public sector, but also the private sector. another way of saying that, i think there's a huge opportunity for what states and governors do to encourage, enable and accelerate private sector innovation. and fourth, i would argue to be on the success path several shifts are going to be necessary both from the private sector as well as the public sector, shifts in agenda, shifts in capabilities and shifts in governance. so to start with, and i do -- i am a consultant, so i did come with two charts. although two is pretty good. [laughter] so i won't belabor the point, but despite its many strengths, there's an enormous and well documented opportunity to improve our health care system. there's a number of studies and analyses including some done by mckinsey that would suggest hundreds of billions of or dollars, we spend hundreds of billions of dollars more than we need to for the outcomes we get.

that's true across medicaid, medicare and across the public sector. in fact, last year i published a paper documenting how intelligent changes in our payment system could literally lead to saving a trillion dollars over the next decade. i think there's pretty strong consensus for, we're experiencing a number of real discontinuities or massive forces affecting the system, some of which were mentioned; increasing prevalence of chronic disease, growing provider specialization, increasing role for consumers. and across all of this, an affordability crisis with consumers, with employers and with taxpayers. so by the way, these forces were all in play prior to the affordable care act, they're all going to be in play regardless of the affordable care act. if harnessessed effectively, i believe they present an opportunity to capture the opportunity in front of us, however, if ignored or addressed unfavorably, it could make things worse. so the challenges harnessing

these forces are quite difficult. there's a great many stakeholders in the health care system, it's extremely fragmented, and that brings me to my second perspective which is we anticipate even greater performing differences. the innovation that's needed ultimately will play out at a local level. it will depend on the actions and behaviors of literally thousands of physicians, hospitals, mental health professionals, managed care companies, employees, consumers, etc. some stakeholders in communities are going to make changes more effectively than others. let me here light a few areas where i think there's a lot of consensus on what the elements of success include. one of those factors is that there's productive competition amongst stakeholders, both providers and health plans, that encourage greater value. the competition is actually based on what matters to both consumers, employers and other purchase beers. on a failure path, productive

competition is limited because few purchasers or competitors actually understand performance in ways that matter. the second thing to comment earlier on a success path, i think health care providers will be rewarded for delivering better outcomes at a lower cost, on a failure path, we'll largely continue to pay providers for activity. and last example on a success path, most consumers would have adequate both insurance and savings, agnostic of the approach we use to get there. so the good news is that i think that states or communities that get on and stay on this success path actually have a real opportunity to experience moderated health care cost increases more in line with inflation, including in the medicaid program and greater productivity and well being of their citizens. so in other words, we say being on the success path has a really strong return on investment to use a business term both for states correctly in%=uúu+aey tef their budget to medicaid as well as in a broader societal sense.

so if i, if much be of the actual change will occur in the private sector, why do i say government actions are so consequential? states regulate infrastructure, those things have a profound effect. but the state isn't just a referee in health care, it's an actor. so i think there's a two-way linkage between the actions a state takes as a health care participant and a private sector that may be underappreciated. just as an example, medicaid spending is in large part a function of the performance of the swire -- entire delivery system in a state. it is incredibly difficult to sustainably improve from a cost standpoint without the delivery system this that state fundamentally improving performance. that includes physicians, nursing homes, mental health professionals, etc. and it's incredibly difficult if not impossible for those providers to change and improve their performance only for medicaid enrollees.

thus, medicaid enrollees and private sector ebb roll lees are linked together from a performance standpoint. so in that way, the two interact. so let's assume you want to be on a success path, right? that sounds a lot better x. let's assume you buy the argument that states can make a positive difference in accelerating private sector innovation. what can you do? a few suggestions here at a high level. the first is, i would argue, to start to measure success based on what you influence as governors and in states, not on what you directly control and from the perspective of citizens and employers. for example, did employer premiums go up or down last year in your state? did people get healthier or not? how many health care related bankruptcies were there in your state? are patients more or less stayed with their health care? -- satisfied with their health care? be second would be to shift focus on enabling private sector innovation where most states need some help getting over the hump.

one of those areas are performance be transparency which is fundamentallal for productive competition. another is payment innovation or leading the transition of all payments from fee for service to outcomes-based payment. i'd include capitation, a number of different models. most health care stakeholders, by the way, agree that's the right direction to travel, but it's really difficult to get done without critical mass of both payers and providers to do it which is why the efforts in tennessee and vermont are so terrific. we need better infrastructure, both human capital and technology, and lastly, i think there's an opportunity to encourage widespread, efficient and optimal levels of both insurance and savings. the other thing to consider just in the way of doing that is, i think, to consider the nines of the state of health care -- so the question there is both in medicaid and in providing benefits for employees in a

state, are those programs designed and managed in a way to put you on the success path, a way that's neutral to it or a way that actually causes it to be more difficult. the last thing i would say is along with shifting focus in the way you influence things, i think affecting this change will actually require adapting your governance model with even more integration across the various agencies that affect health care and its programs. another way to say that is who's accountable within each state, in your states for overall health care inflation? not the medicaid budget, but overall inflation. is there such a person? and lastly, i think you'll need to either develop or partner to get stronger capabilities both with perhaps be a stronger view from a private sector standpoint be as well as people that really understand these modelses, health care technology and large scale change which i think is a pretty different skill set than running and administering a program. and the last thing i'll say just in a few seconds here is a couple very tactical things. who's on point for this in your

administration, name somebody. invest a little bit of time learning what's going on. my observation's the last couple of years there's been more difference at a state level than there has been for a long time, so i think there's a real opportunity to learn what's working and what's not from other states than there has been. not just on state programs, but the whole system and use that to build a real action plan. and the last thing, a number of states are participate anything the state innovation model, so i think we agree that could be a really strong catalyst for the type of change we're talking about. so thank you. >> thank you. very helpful. mr. dreyfus? we'll let you bat second. >> great. thank you very much. you know, the most important point that i want to make to you was actually made by governor haslam and by governor shut shun when they spoke because here you have governors from two very different states geographically, ideologically and in terms of their health care markets. they say, well, you know, but

they both focused on the same solution; to change the fee-for-service system to an outcome-based, value-based system as central to the solution for both improving care and promoting affordability. and i'm going to tell you a very short story about how massachusetts over the past five years has done just that and what some of the results have been. before i do so, you might step back and say is the experience of massachusetts really relevant to our state? after all, aren't you a deep blue state with one-party rule, unified on your progressive views of social and other issues and in a health care market centered on large academic medical centers? is well, what i'd tell you is we're actually a much more diverse state ideologically, politically and in term of our views of markets than you might think, and so there are some surprises in our story. from the diverse views within our state, we actually have

forged the kind of consensus that the governor spoke about, and in doing so we've tackled some of the thorniest problems in health care. and we've done it by balancing these issues that we just heard about is the role of government versus the role of the market. how do you balance those two, how do you constantly recalibrate those two forces, and how do we make sure that the market can continue to innovate? so let me tell you about what we've done in that respect. i think you probably mostly know the story, the progress we made on health care coverage. and so we passed our version of the aca back signed by governor romney in 2006, implemented in 2007. so what the nation's experiencing in 2014 we experienced back in 2007. and as you can see, a dramatic reduction in the number of uninsured in the state, the number's even lower now. there are no uninsured children in massachusetts today ask just a very -- today and just a very

small number of uninsured adults. but we had a second problem, we had a cost problem. some people say you started from a stronger point, we started from a weaker point here because we are the locus of the most expensive health care not just in the country, but perhaps in the world. so we had a lot of work to do on cost. so at our plan at blue cross blue shield in massachusetts, we stepped back back in 2007 and said how do we tackle the cost problem, and our answer, as the governor said, was to fundamentally change the way that we pay physicians, hospitals and other health care givers that moves us away from our volume-based, activity-based system towards one that rewards quality and outcomes. we did it, we designed our own system. it is not the solution, it is a solution, but it has proved both surprisingly popular and surprisingly productive. so we started with what you might think of as a pilot or

demonstration project in 2009. we had about 1500 or so physicians covering about 300,000 of our members in massachusetts agree to accept rather than fee-for-service payment a global payment for each of the blue cross members that those physicians cared for combined with very significant quality incentives. not just a little point or two of pay for performance, but up to 10 on top of what we -- 10 % on top of what we paid them they could earn if they performed well on agreed-upon incentives. these are transparent incentives that are nationally recognized. these were voluntary contracts, but we rapidly were successful. and very quickly almost 90% of the physicians in massachusetts now accept this form of payment. it covers about 700,000 of our members making it the largest, one of the largest payment reform initiatives in the country. at one point our own governor,

governor patrick, asked me, he said, andrew, how can we move this even faster? i said to him, with all due respect, governor, it's not going to be elected official or certainly health plan executives who are going to persuade physicians to change something they've been doing for 75 years, it's going to be other physicians who say i can take better care of my patients under this system. and that's what they started saying. now, this is not only the largest, also the most carefully evaluated payment reform initiative in the country. so from day one a team of independent researchers, health economists and physicians at harvard medical school were hired by the commonwealth fund to evaluate it, and they published in the new england journal of medicine, health affairs and other academic publications the results that showed us approaching what i think we all think of as the holy grail of american health care; better care at lower cost. we have the first two years of results, years three and four

should be publish ared this fall -- published this fall. not allowed to talk about them because they're not yet published, but i'll just tell you i'm happy about them. so what else did we co? not only did we ask physicians and hospitals to change that they did, but we had to change. governor shumlin talked about having data at the fingerprints of the practices, so we put that data at their fingertips. these are just a sample of some of the dashboards and benchmarks data that we gave to physicians. some as simple as saying did you know your patient was admitted through the emergency room to the hospital last night? many doctors don't know that unless they're on a system. but a lot of it is hutch more about did you -- much more about how did you know your diabetic patients are faring remtive to other diabetic -- relative to other diabetic patients. here are some ideas about how you can get better. and what happened when the

physicians started looking at this is they started changing the way they provided care to their patients. one of the leaders of our large physician practices talked to me about we're going to get liberated from the tyranny of the office visit. we've constructed our health care system for a hundred years around the office visit and, obviously, many times very important. but most health care takes place between visits. so what are we doing between visits? what did these practices start doing? they started hiring social workers e embedding them in the practice to deal with the patients who have mental health or family issues. they start sending pharmacists out to people's home to look in the medicine cabinet are their drug-to-drug interactions. they start communicating with their patients online through telemedicine through a whole variety of different efforts, and they like practicing better. as a consequence, we now have close to half of the physicians in massachusetts are accepting this form of payment not just from us, but as you heard, you

need all solutions from our other private payers and increasingly from our public payers. to also say this works in rural practices, yes, there are rural parts of massachusetts, urban practices u practices that serve low income patients, practices in the suburbs, practices affiliated with large academic medical centers. but i said it's not just the private sector, it's also government. and so in 2006 we passed our health care reform law, but every year, every two years after that we passed, our governor signed a cost containment law. and each law started to ratchet up the pressure until 2012 we passed a law that governor patrick sign that actually says state health spending in montana shall not grow -- in massachusetts shall not grow faster than the overall state's economy. and you probably know we've been growing about double that rate. but it's not government that's

going to enforce that law, it's really the private sector. back to that balance between innovation and government involvement. and just finally, i think repeating some of what you heard, what can states do? and i served on the university of virginia miller center's panel, co-chaired by two governors, one republican, one democrat, that looked at these issues. i encourage you to look at those results. convening a broad-based conversation within your state on costs, quality and value, promoting the kind of innovation and experimentation that we're hearing about both in tennessee and vermont, investing in prevention and wellness. we haven't emphasized that as much, but i know, governor haslam, you have a wellness institute you've established and worked hard on. obviously, governor shumlin has done so much on the chronic care issue. 5 percent of our patients are driving half of our spending, and their almost all people with multiple chronic illness. and then understanding technology and the key role it

can play. so, again, from what appears to be a single deep blue state, we actually have had a diverse experience of market innovation, balance with government involvement resulting in a dramatic drop in the rate of growth in health care spending and a dramatic improvement in health care quality that's been embraced and supported by the physician and hospital leaders in massachusetts. thank you very much. >> thank you. bill? >> thank you, governor. good morning, everybody. by name is bill rutherford, and i am the chief financial officer of hca. it's my pleasure to be with you today. i'd like to spend just a few minutes sharing with you our perspective as a provider of what we're seeing with the health care landscape across the country and three key observations. you may know hca is a the largest nongovernmental health care provider in the united states. we operate 165 hospitals, 115 surgery centers, havemmmmáb k of over 35,000 affiliated physicians, and we operate in 42

markets across 20 states. be annually across the hca system we'll see seven million emergency room visits, deliver 250,000 babies, have 1.7 million inpatient admissions. 80% of our hospitals have been recognized as top performers by the joint commission, and about 8-10% of the patients we take care of have no health insurance. we account for about 4-5% of all hospital care in the united states, so we think that gives us a fairly unique perspective on the health care landscape, and we see more health care than just about anyone across a range of diverse marketplaces. so i wanted to share with you some observations of what we're seeing. clearly, what's dominating the discussion in our industry is health reform, efforts to help people gain access to care and delivery system reform improvements that we've heard about this morning. those efforts are clearly continuing to unfold be, but we are encouraged with early signs

that we're seeing with the impact of that across many of our markets. when we reviewed our first quarter results, we have about five states across the hca footprint that have elected to expand medicaid. and be those states we actually saw about a 30 be % decline in uninsured activity as those individuals gained access to care either through medicaid or through the health insurance exchanges. when we look across the broader network and look at the activity with health insurance exchanges, about a third of those patients are newly insured or that they were previously uninsured. so momentum is clearly gaining on those efforts to help people gain access to care, and we think those are positive developments. so i'd like to share with you really three key observations based on our experience across the marketplace. the first one i'll share is hca and provider systems we see across the market are investing heavily to create what i'll refer to as high value integrated delivery systems. and there are certain --

[inaudible] delivery systems that are important prerequisites for preparing for changes in the evolution of care and reimbursement methodologies. obviously, continuing to advance key quality initiatives and focusing on improving health outcomes. focusing on collaboration and integration of what historically and largely still is today a fragmented delivery placed between hospitals, physicians and various ambulatory settings. we are investing heavily this technology, on electronic health records and other integrative platforms that will allow data to transition through the continuum easily. a continued focus on reducing the cost of health care that we talked about today. that's either through consolidating of administrative services, reducing variation, sharing best practices and a host of other efforts. and importantly, continue to focus on improving the patient experience as they navigate the health care system. all of these efforts are, in essence, to bring together a

hospital network, a physician network and an outpatient ambulatory network tied together with technology all in an effort to improve health value, to improve outcomes over cost while improving the patient ebbs appearance. experience. what we believe are three key ingredients for success and prerequisites as changes in the health care system occur. the second observation i'd like to share is the value-based purchasing is garnering appropriate attention, we see those models being implemented relatively slowly across many of our markets and in varied form. there are new payment models being introus cooed by governmental and commercial entities. we have pay for performance metrics in many of our relationships that largely provide incentives for the achievement of certain quality or other objective measures that we heard about in massachusetts. and we think those will continue to progress in the market and are important as we continue to

look at delivery system improvement. we think it's really a prerequisite and necessary for providers to continue to strengthen their delivery system capability through integrating, through technology, through focusing on cost and improving the patient experience. they're all important success factors that will survive and be important under an array of different payment mechanisms that might be in the marketplace. and lastly, the third observation i'll share with you as you may know, there are still many administrative and regulatory hurdles that likely will slow the pace of some of that evolution and integration in the marketplace. you know there are many regulations that govern the relationships between hospitals and affiliated physicians. and as we search for ways to provide incentives and align key objectives, often times you have to set up administrative and complex structures that require time in order for evolution to see in the marketplace. we also know there is a lot of

administrative cost within the health care system. the advantage of hca is we're able to leverage our scale across that, continue to work on reducing those costs and-to -- and many of those are redundant, so continue to edger -- search out how to' deuce those costs. -- reduce those costs. so in summary, you know, it is an exciting time. health reform, efforts to help people gain access to care are going to be important developments in our marketplace, and we are encouraged with early signs that we're seeing with that. health systems across the country are continuing to invest and creating these integrated delivery systems, bringing hospitals and physicians together, investing heavily in technology to be able to transport data and information that will help reduce the cost structure. payment reform is occurring. it's unfolding at a varied pace, at a little bit moderate pace across the country. we think that will continue to accelerate and will be an

important component for delivery system reform improvement, and there still are administrative and regulatory activities that are real and operationally that we have to deal with as we think about evolving the marketplace that will da sill tate our move -- facilitate our next move to the next generation of health care. my pleasure to be with you this morning, and i look forward to discussion points. >> thank you, bill, tom and andrew. i'm going to open it up to questions from the governors. ann dry -- andrewing you talked about this. health care costs are driven by folks dealing with chronic disease or end of life. and as we talk about payment reform and, you know, moving away from fee-for-service, how does the fact that, you know, the cost -- i don't know what, somebody here might know, what is the cost of those two? i think you said -- >> well, 5% of our members and the residents of the state probably account for about half the health care spending, and

the vast majority of those have chronic illness, multiple chronic i'll mtionzs. >> so if yaw add that to -- you add that to end of life, you're talking about a big chunk of what health care is costing us. so given that, as we talk about payment reform, fee for invest, begin those two realities, how does fee for service impact -- >> yeah. >> -- the world? >> relate me start on the chronic illness side. almost the first be thing the physician practices do when they are given be a different set of incentives is they focus be on those patients with chronic illness, because those are the patients who they see the most, who are hospitalized most regularly, and most of the time those hospitalizations could be prevented if the patients' chronic conditions were managed more effectively. i actually sat earlier this week with a practice from california that has eliminated admissions for their patients with con questions tiff -- congestive heart failure because they have a payment model like this in which their monitoring the

patients in the home, remember tronic scales tied to the physicians' offices, making sure the medication interactions are working appropriately, having a lot more home-based care, and this is something common to both end of life care and chronic illness, trying to move the care out of the hospital. with all due reference to the hospital representative on the panel, i'm sure he would agree that we only want the patients in the hospital who must be there. and most patients with chronic illness you can avoid hospitalization. and then when if they are hospitalized to prevent them from being readmitted to the hospital, so there's a huge opportunity there. many patients with chronic illness also have psychiatric or mental health diagnosis, and managing those much better. we know that patients with a chronic illness with a mental health issue will consume a lot more health care services. so getting the clinical team focused, and i say clinical team because health care is moving from an individual sport to a team sport. and be as a team sport, it's nurse practitioners and

physicians assistants and pharmacists and social workers and care managers who are making the difference with these patients with chronic illness. my mother had a variety of chronic illnesses, and she would often call herring if up, and she just had a little question about a symptom, he would say come to the office and see me, i'll take a look. she didn't need to be seen. she needed to have someone say, mrs. dreyfus, let's change your medication a little bit. so it's a great opportunity and a great question. >> no, i think it's a great question. from hi view, i think it deals with this concept of evolving from an episodic manager of care to managing a care and that's most prevalent when you look at chronic diseases. you have to bring that system of care together because, as you mentioned, it requires a lot of different settings in any community. your primary care physician, specialists, hospital, postacute and a lot of other activity. so the first effort, i think, is to be able to collaborate what in many communities today is

still a fragmented delivery system. so investments in technology, to be able to transport data across those different continuums and provider settings is, i think, a very important prerequisite to occur. creating structures that allow flow of informations and other information to flow among so we can better manage those patients for the right condition. >> other questions from governors? i can keep going, but, yeah. >> thank you. my question is for mr. latkovir. you mentioned in your presentation you thought one of the essential first steps toward moving toward a quality of care payment based on outcomes versus service, services performed was a transparent, fact-based measures. could you give some examples of some fact-based data systems that the public could see? >> sure, sure.

of it's a great question. and the -- i think the, there's two things i mentioned. one is simply there's some overall health care statistics in a state like premiums or health status, things like that, that are useful to track. but in terms of what will help actual providers make better decisions or compete on value or what will help consumers that are trying to make a decision about which health care provider to go to, i think the trick is most of the data that's provided today is similar to the way the system is structured today. so as bill described, in any, for example, episode of care, let's say you have to get your hip replaced or it's an elective surgery, there could be a dozen or more different providers that you interact with over the course of that episode of care. anded today even the data that's released typically even if it exists -- which in most cases it doesn't, but if it does exist, you might get a glimpse of each of those ten providers. what you don't get a glimpse of

is any sense of -- particularly the surgeon who's doing the surgery, how does their performance look in terms of that entire episode of care? so that would be a slightly different way to share transparency. another example be would be as andrew described in their model, if you have a primary care physician or primary care team that is historically would just see you in terms of office visits. as a consumer, you actually, you know, you almost have no way to know which of those teams or individual clinicians will do a better job in helping you manage your chronic illness or a worse job. at best you might get a little bit of fee information on them as individual providers. and so the real trick again with the performance transparency is not just the data itself, but however it's accomplished whether it's private sector or public sector, framing it in a way that's actually usable for consumers, employers, etc. >> so let me follow on that,

tom, where andrew said it's moving from an individual sport to a team sport. so you're moving from playing baseball where you're up at bat or the ball's hit to you at shortstop in, how, how ready is our entire provider community to play what looks like a fairly different game? >> yeah. i think, you know, there are in different states of evolution. it's interesting, in some cases there is a generational divide in that some older physicians who are used to practicing the way they practice and maybe, you know, a decade or less to retirement have said i want to keep plaquing that way. but -- practicing that way. but mostly both the younger physicians and the older physicians that have come to see it really like it a lot better. they actually see they can spend more -- so these chronic patients, you cannot have a ten minute be visit with a patient who's on eight to nine medications and has multiple chronic illnesses; they have cancer and depression, they have serious arthritis and asthma.

you can't manage those patients in ten minutes. and so once they see that they can be, again, liberate ad from those kind of ten minute office visits, they do like it better, they see the value of their nurse practitioners. and this has been going on in pediatrics for, you know with, 20 years and needs to happen more regularly in adult medicine. so i think it's in a stage of e louis, you know -- evolution, you know, what governor shumlin said having the data at fingertips, it is important we have some rural practices that are not yet wired that are performing fabulously in our new payment model, you know, through other means. so i think the teams are really being embraced and enthusiastically. >> i would just offer, i agree with andrew. e different communities across the country right now. i think there are certain places

that are both culturally from an infrastructure standpoint and from a, you know, formal sense the way that providers aggregate with each other or relate to each oh is very, very different community by community, and i think that's part of the reason we all agree there's no single solution that'll work everywhere, it's going to require some differences in local markets. ahead.vernor herbert, go >> well, thank you. i appreciate that the watercooler topic of the day in most states is of care, and bill, you said it is an exciting time in health care. i guess that is the understatement of the day, because i think it has become and has been very divisive. it is a complex issue, and we appreciate the fact that you are coming here to shed some light on the issue for all of us. utah thatm a state in

is generally considered a healthy state, one of the healthiest in america. been rated as the lowest cost for health care in america with about the fifth rated asked quality -- the quality. so, we are doing very well. we are below the national average and those that do not have average -- access to health those couldlf of have helped her, but chose not to, for whatever reason. care, but chose not to, for whatever reason. mandate,we have this the concern is will go from a good system to the average. cost and lower quality will say this is good, we are moving to the average. in massachusetts, you are grateful you are slowing the rate of growth in the highest cost health care in america, or

the world, and we do not want to be that high. so, my question for all of you is a simple, basic philosophy. one, i think we all share the same goals, although i did we do not define the goals very well. is the goal for health care reform in the future to be dues the cost of health care? -- to reduce the cost of health care? is it to improve the access of health care? is it to have better quality of health care? maybe it is all of the above, or additional things. where we how we get there. what in fact is the process to get there. as you look at the history of america and our tradition of a free market system, free market competition, individual choice and making those decisions,in coupled with individual responsibility some are concerned that we're moving away from that. >> yeah. >> and so why, if we think

historically that free market competition, individual choice and opportunity has given us the best products, the best service and the for the most people at the lowest cost, why do we seem to be moving away from that and think that somehow in health care it is a different animal? so that is a philosophical question question. i'm anxious to hear -- >> governor, governor, it is the question of the nation right now. so you put it really well and i have a couple of thoughts. first of all, you're right about all the comparative information. some of the reasons why utah is so successful that they have systems like intermountain system which was one of the early adopters of some practices, integration we're talking about and obviously had one of the first exchanges in the country though it was private market-oriented exchange. when the aca was passed i think

it anticipated a kind of uniform, national set of standards and activities that the nation would adopt and as, as a result of the supreme court decision, resulted actions by individual governors like yourself and others, we actually will end up with five or six flavors or variations of how the aca is going to play out in various states. i actually think that may be a really positive thing because it allows for different models for different states that have different markets, different sense of what that balance is between private innovation and governmentn involvement, different, you know, political cultures and different delivery systems and beliefs in that delivery system. i think that state experimentation and variety is going to take us very far and i think governors canri take the lead in that and that's why i said initially that the statements our co-chair said coming from two very different states but both showing extraordinary leadership in

their states is in some ways evidence that can work and state experimentation and, to answer your first question, i think we do want all three. i think quality and cost, combine, the best care at lowest possible cost. we want efficient system. you have a fairly efficient system today.ys our system has a long way to go to promote the kind of efficiency you've established. i do think however i think getting people, we know people who have coverage, get better health. not just they have aw ha card, t is important for the card, is just a start. actually getting them to better health again, respecting individual choices that peopleg want to make. so i would say let the state p experimentation flower. >> governor sandoval? or go ahead governor branstad. >> a lot of the focus has been on changing the provider system, moving from a fee-for-service to

outcome-based services that rewards quality and outcomes. we have set a goal in eye becoming the healthiest state in the country by from where we began, i guess 19th and we'rare 10th today, but one of the concerns that i have is, i think only way it works is you could get the patients to take basically, for people to take ownership of their own health, instead of looking to their physician or healthcare provider to have all the answers, to get people to make healthy choices whether it's, not using tobacco products, exercising regularly, making good choices in terms of nutrition and all of that. and then, trying to align the provider reimbursement so that also rewards and supports that. but, my, i guess i would like your reaction to that. i don't think all of these

efforts work unless you get a buy-in from the patient and i think there are too many people historically looked at it, that i just look to my doctor for answers as opposed to taking ownership of my own health. and we're trying to lead by example and do a lot of things and get communities involved and we, have these "blue zone" communities and we're setting all this focus on that and i guess i'd like the reaction from the panel to that strategy that we're in the process of implementing wherein our goal is five-year goal to go from 19th to 1st and i think we're in about beginning of the third year of this. >> governor, first i'm familiar with the strategy, john forsyth, my colleague, who is colleague of yours and speaks highly of the commitment you made.

blu e-zone. blue cross-blue shield hikes the idea of b-le zones even they we dent invent them.di you heard thisca before. the best piece of technology is not the scanner but physician's pen because they're ordering all the tests that cost so much. i have a piece of technology strapped to my belt which is a pedometer. >> we gave those out at des moines university when i was president. >> right. competition and all that. so we need to engage patients at multiple levels, first in the health, sounds like you're doing setting ambitious goals, people participate and both co-chairsoc talkedha about diet, nutrition, exercise. those are all important. the second piece you heard earlier how do we design insurance products that place some responsibility on patients to think about their own care.

and how do we couple that with transparent public data thatbl allows them to make choices, governor, to making choices and how do we steer patients or encourage them to encourage high value sites and care? that is advantage of so-called consumer driven products which patients have some skin in the game and have financial responsibility. we know from early results when that happens they make different choices. >> i would also ask about health risk assessments. we're trying to really incentivize to do health risk assessments so they know their own risk factors and they can work on those. >> that is essential. first of all that is big role for employers, especially large employers are embracing that in a different way. wellness at the worksite is big incentive. you have to understand your own health before you know whatth actions to take in collaboration with a physician or another.

we have a program where we're paying the parity, the doctor andnt giving incentives to small business owners together to promote the health of, not big, 1,000 person companies. these are small, 20 and 30-person companies. we find if that circle, all three, focused aligned around health and wellness we'll start to see actions. >> i couldn't agree more. i would build on that with some specifics. ion think, many respects consumr incentives are actually ahead of incentives of the delivery system where you have, let's assume you have a consumer that is empowered. they have some financial incentive to care of themselves and their health. issue in most parts of countries the incentive for providers in some respects are at odds a bit with consumer incentive. at minimum i would there isn't incentive for provider be it a physician or hospital to actually spend the time to equip the consumer with the information and guidance they

can use to manage their own health. a specific example, if someone at a hospital being discharged, the hospital, most parts of country today, many of them do it out of just general goodness of their hearts but they're not really compensated to spend time helping patient understand the medications they're on. make sure get back with the patients at their home with the care team. we need to catch up a little bit with the consumer and make those two things are aligned. sandoval. a >> thankli you, governor. really appreciate your presentations. listening to gary's comments about utah, that is veryts impressive. - in a little different decision. we made the decision to opt in with regard to the affordable care act and we are, we were 49th in the country in uninsured. we'll be adding 300,000 insured lives within a year. and so that's, an immense amount of people coming into our health

care system on a regular basis. many of whom have chronic diseases, about a lot of things that you talked about. as we c look, i feel like we can bend the curve with regard to utilization and healthier living but the place, where there is going to be a challenge is bending the curve with regard to health care costs. and i'd like to hear kind of your thoughts and on vixs --th regard tons with those costs. 80% of these lives will be in managed care in nevada. i'm trying to do everything we can to do that. implement those wellness programs. we're putting these little, these bands on to pass those out so that people are living healthier. as i look what we're facing in terms of costs for that i don't really knopaw what to do and soi would like to hear your thoughts

>> i'll tell you, that is such an easy question i'll take it. that is incredibly difficult in some respects the challenge of the western world, frankly how to control health care costs. i think the truth of the matter is, nos. one really understands the full answer. i do think a couple ingredients there is reasonable consensus on and can be a helpful start. in many respects the activities that both andrew and bill described in theew states i thik are great starting points. some of the ingredients include, both believe there is both opportunity to reduce some inefficiencies in the current system, but i think most people also believe to change actual rate of growth, it will require more permanent changes, especially in the payment incentive system. because, there is some things you can do in the near term, care management programs. things like that, that can reduce some costs in the near

term, but to really get costs to change over type. you have to change how consumers think and behave. change a bit of health of population overall. you really need to create long-term incentives for stakeholders, health care providers and others to be inventing new ways to do things better overtime. that is longer term challenge. that not just requires short-term changes but permanent changes how we pay for and reward health care. >> if i can just add a couple of thoughts there because we're trying to make some advances in vermont on this. in plain english, when you look at big picture, what is happening across all of our states in varying degrees, we're spending more than anyone else on health care, in the world, for less good outcomes. that is sometimes we don't talk about. we live less long than the countries that spend a lot less than us. we have higher infant mortality, than countries spend a lot more us. than we continue to have health care

costs rise at rates higher than our incomes. so, since i believe that money drives america, that is what we do best. we're the best entrepreneurial place in the world, you've got to bring your providers around to the thought that they can do better financially with a different payment system. and i fundamentally believe that, that is true. and that when they actually sit down and work it through they realize that is true. maybe it is different in urban states but in my little rural state, most of ply hospital administrators and providers believe that the current system isn't sustainable. that is kind of a big one. we're not talking about the corner grocery store going out of business or the dry cleaner around the corner. we're talking about our health care system. i had an experience a few months ago, i go down to the southwesth

part ofer my state, my hospital administrator down there is flipping out because the monday before the nearest hospital next to him, a big one, after 160 years of business, just said we're out of business, we're done. so all of a sudden, folks over the line in massachusetts. i thought at first it was governor patrick's problem but i realized they were having heart attacks, they were having strokes, they werere having babs and they were getting cancer and they had nowhere to go except to my hospital. so what we have done is put together, this is really important, what we call a blueprint for health, where we literally in our small rural communitiesa we're giving technology to providers soit they're all getting on one uniform system where they can measure outcomes and integrate delivery with each other. the i.t. piece of this is huge. as they do that, they see that they can get better outcomes for less moneyat for their patients which we sometimes forget is what health care providers want to do. docs, nurses and team are

actually trained to make people better. not to navigate a complex n payment system we currently have. i think the way a you get the buy-in and i think andrew pointed this out, governors can't tell their docs and their providers hey, we're all going to do this together and you're going to love it. what we can do is have a very deliberate and carefully designed partnership that allows us to facilitate, providers figuring out that they can do what they love to do, which is make people healthy, in a payment system where they get rewarded forhe less quantity and better quality. and then measure those outcomes very carefully, so that those who are doing chronic care, don't end up getting punished for a system that provides, that pays for less quantity and more quality. and it's doable. you have to have those three

pieces, i.t., buy-in from providers and agreed upon measureable outcomes so you're improving quality as you spend less money. >> governor dalrymple. >> yeah i have a question for mr. dreyfus. in my state, 85% of the health insurance coverage is provided by blue cross-blue shield of north dakota. why can'tta i just tell blue crs that i would like them to offerh the massachusetts alternative quality care contract and save myself years of groundwork you trying to develop something? >> first of all you will get me? a lot of trouble from my colleagues. we have our great friend from blue cross-blue shield tennessee here. don't get t any ideas, governor, they have their own innovations they care a lot about. >> we were trying to be nice hosts but go ahead. >> they're texting north dakota

blues right now. actually, governor is not that far off because the entire blue system is working on a model. the reality is, that the model i described works great for the people who work, live and work in massachusetts but we insure a lot of companies that have people who work across the country, in north dakota, in vermont, in tennessee and we have to be able to link our payment model to payment models that blue cross-blue shield of north dakota, tennessee and vermont have. sobl we're working on national system won't be identical to this. again markets are different. we have to respect that. that will link those two together. having said thatma i think this idea of, as a governor, setting a direction panned pushing your, in this case, largest payer to accelerate their work around payment and delivery reform i think is an appropriate role and it's a role you don't have a write a lot of new regulations, you don't have to create a lot

of new agency or government bureaucracy, i will insist the private sector do it. i got calls from my governorme like that. i didn't like them the first time but maybe we got moving. can i also respond to governor sandoval's question too. i want to make the point to preach a little patience. we, tens of thousands of americans turn 65 every week and they enter the medicare system. there is one thing we know that doesn't get a written about enough, some of them come in having insurance because they work for companies, and some of them come in uninsured. well, it wouldn't surprise you the ones come in uninsured are more expensive for the first few years because they haven't been seeing a doctor and have had chronic conditions andno after a few years they even out some these 300,000 new, newly-covered people you have in nevada, some of them probably haven't hadhe insurance for yearms and for the first year or two, they will probably be a little bit more

expensive and we learned that in massachusetts and don't assume because they're more expensive for a year or two, they will be more expensive forever because if we do get the right systems in place we can then get the health care inflation down. so there is going to be a lot of attention to premium increases in the fall in different states and whylo is that and how much s the aca to blame and i know we'll have a lot of debate, appropriate debate about that but if we push these kind of payment delivery reforms and focus on chronic illness and wellness prevention like in iowa you get the results you want and your health status improve and yourur costs should not start to skyrocket. >> a okay.ro we need to move to a wrap.o gary, ifyo you want to add something? >> i know you will close us off and i want to make a observation and editorial comment. i think everybody here recognizes, andrew, you're

right, utah learned from massachusetts with your exchange. we put in a exchange in place a little different than yours. i know it is more of a culture f and ourit desire to get better health care in utah so we learned from massachusetts. i hear great things coming from vermont here. i'm very concerned about the approach of a one-size-fits-all and i think as a committee i think one of the things we ought to be pushing to give states the opportunities to find their own way with their own unique demographics, their own unique challenges they have, which are all different.ch utah and nevada are similar in some ways and different in other ways, and so our needs are different, our challenges are different. the solutions will be different. so let's make sure we give states the opportunity to be, laboratories ofwe democracy whee we can learn from each other and probably graph state towards a similar area but we'll learn from our successes, we'll learn from our i will call them failures but maybe they're not

as successful, but we'll find the optimal place, as a country and get to the place where we want to be for health care reform. >> thank you. i will ask governor shumlin, if you would make some closing comments on this. >> thank you, mr. chair and your great work and my fellow panelists and governors. i think gary gave the best summary we could give. j i think weus all agree at a time not much is happening in washington, d.c. governors actually have to make decisions to get things done. we're working together in bipartisan spirit to do that. i want to thank the nga staff for putting this panel together. i think as gary just said. we are going to be the laboratories for change in health care to improve quality,a reduce costs, get better outcomes. and if we can use this forum and conversation we just had here, as the fuel for that transformation we're all going to win and which can get this rightve but i really do think it

boils down to governors having the courage to work together with our partners to push where we need to, to pull where we need to and to share common discoveries whereee we need to t this right. it is critical to job creation. it is critical to quality of life. we've got to find ways to reduce the cost curve or we're all dead economically in terms of what we want to achieve, prosperity for those that elect us. thank you, chairs, panelists and thank you governors. i thinks, this is area where the nga canth make a difference, helping us be tools and lack tories for change. >> what you heard from governor herbert and governor shumlin why we have nga. two fairly different states and two different ideologies and two different approaches to aca. i think you hear a whole lot more agreement than disagreement in terms of what the key issues facing us are. i really appreciate that. i do want to thank our panelists. you guys are terrific and very

helpful and practice cam and specific and that sometimes is hard tero do on a panel so thank you very, very much. [applause] all right. before we, before we break we'll have a 1 1/2 minute update from fred sick assi, from center for -- frederick asasi for center on best practice. frederick, thank you very much. >> i'm the health division director at national governorsio association. this covers was perfect segue what we want to announce for all of you. which is after the hard work of this committee and health care family tasf k force earlier this year, one of the requests that came out of discussion is there a way for the center to work, to give individual states the ability to move forward with the federal government and negotiate individual authorities under

medicaid around statewide transformation. so we've been working for the last few months to secure funding. we want t to thank the robert wd johnson foundation in agreed to fund this project. we will be announcing in the next week or so an opportunity for states to come forward to work together to negotiate with the federal government new broad authorities in their medicaid programs around statewide transformation. t authoritiesvidual for each state. so. each state one size for that state and not, sort of one size fits all approach at all. the funding will allow us we'll hire leading national consultants to assist the states. expert panel will work with the states and the federal government. we havee received confirmation from leadership at hhs they will bring their a-team to bear on this, so we can have really constructive conversations. so the rfp to the states will be released in the next week or so and states will have six weeks to respond. the launch will be in october

and we'llut work over the next year with hhs, with the individual states, and with our experts to try to reach agreement in concept on broad, new, broad statewide authorities in medicate. i think one of the most exciting parts of the project, after its over we'll work very hard to basically build a template for other states interested in receiving these kind of authority so that we can kind of accelerate and move past very laborious back and forth we see so often in these discussions. there will be a template built and a lot of discussions at hhs, is the there ability to let states jump ahead a little bit in the discussion so they can get to yes faster, if they use these templates and these new processes. very ambition, very excited and please, if you guys are interested, have your senior folks reach out to us, and let's get busy. >> high-stakes, high reward. we like it. thank you. all right, linda, are we good? okay. i really want to thank everybody

who attended, our panelists and the governors. this was a great session, very helpful and thanks as always to nga for making it happen. thanks, everybody. we're dismissed. good job. well-done. [applause] >> c-span2 providing live coverage the u.s. senate floor proceedings and key public policy events. every weekend booktv for 15 years the only television network devoted to non-fiction authors. c-span2 created by the pro. watch us in hd, like us on facebook and follow us on twitter. it's a thursday morning and we'll go live now to the u.s. senate where members will continue working on legislation,

rethor requiring the terrorism risk insurance act. beginning at noon eastern the chamber plan as series of amendment votes which expected final passage street to come. after that senators go back to debate on judicial nominations. live now to the floor of the u.s. senate here on c-span2. the president pro tempore: the senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. eternalfather, hear and answer our prayers, from your holy hills. we sleep each night in peace, sustatined by your grace and mercy.

arise, o lord, and use our lawmakers to fulfill your purposes. empower them to make the rough places smooth and the crooked places straight. give them the wisdom to commune with you throughout the day, leaning confidently upon you for wisdom and striving to be responsible stewards of their calling. keep them from becoming impatient when anything or anyone causes them to wait. lift the light of your countenance upon us all.

we pray in your holy name. amen. the president pro tempore: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. mr. reid: mr. president? the president pro tempore: the majority leader. mr. reid: i move to calendar s. 2569. the clerk: a bill to provide incentive for businesss to bring jobs back to america. mr. reid: mr. president, following my remarks and those of the republican leader the senate will proceed to the consideration of s. 2244, an extremely important piece of legislation. there will be 30 minutes for debate on the coburn amendment and ten minutes on the flake

amendment and 30 minutes on the tester amendment. any remaining time until noon will be for general debate on this legislation. at noon the senate will proceed to a sew ris of up to -- a series of up to five roll call votes, expected in relation to the coburn and flake amendments. however, we expect voice votes on the vitter and tester amendments. upon disposition of the amendments the senate will proceed to a roll call vote on passage of 2244 as amended. we expect to reach an agreement to vote at 2:00 p.m. on the motion to invoke cloture on the executive calendar number 849 the nomination of julie carnes of georgia to be united states dj for the 11 circuit. senators will be notified when an agreement is reached. mr. president? the distinguished president pro tempore of the senate who just opened the senate has been for many, many years the chair of the foreign operations

subcommittee on appropriations as chairman of the judiciary committee. mr. president, i, during -- and i wanted to note that while he's on the floor. over the past two weeks poker players from las vegas have -- poker players have flocked to las vegas because there's an annual world series of poker. it's on espn. i don't know how athletic it is but it is on espn and it draws a lot of attention. poker is very important and popular game now, a game of chance. and this tournament, the world series of poker is the most prestigious high-stakes tournament in the world. 2,400, 2,500 miles away from las vegas here in washington, d.c. senate republicans are playing a high stakes game of their own with a humanitarian crisis. instead of poker chips, they're using kids, children. last night the junior senator

from texas upped the ante and announced that any legislation to address the humanitarians crisis in the rio grande valley must also include the termination of president obama's 2012 deferred action for childhood arrivals program. in other words, mr. president, before republicans help our broarp -- border patrol agents and all the personnel trying to do something to handle this humanitarians crisis, they want president obama to deport the dreamers who are already here, legitimately here. these are children. but instead of considering a thoughtful, compassionate solution to a real-life crisis on our border, radical republicans are trying to hold these kids ransom. mr. president, these people, i've heard senator durbin speak here on the floor.

he visited one of these centers in chicago on monday. and there are mothers who have babies there, who have been brought as the law requires to chicago, to try to unite them with their families. as we learned last night in a senators briefing, more than 50,000 of these children arrived at the border, and we have to do something to address that. the people who are required by law to take care of these children, some of whom are babies, don't have the resources to do it. these are not children sneaking over the border. they come to the people in uniform and say, here we are, and we have an obligation by law to do something about it.

but it takes a lot of money to take care of this. we can't do it unless we have added resources. and what the junior senator from texas said, we're not going to do this unless we deport all these children who came here before, the so-called dreamers, once again we see there are no substantive solutions being offered by the republican party. instead of doing something about these children who are at the border, they want to deport hundreds of thousands of people who are already here. president obama's deferred action plan, which is widely popular in the country, mr. president, because it is the right thing to do, and obviously republicans want to get rid of it. this is all about, his deferred action plan, is about keeping families together and grants immigration officials discretion in considering cases children who have lived most of their

lives as americans. let me give an example of a young woman from las vegas. her name is astrid silver. ast ri d -- astrid came to the united states as a girl in a boat across the rio grande river. her mother was with her. she was in her -- i want to get this right. she was in her dress, confirmation dress or whatever; just a tiny, little girl. she had her rosary beads and a little doll, and she floats across the river. mr. president, she knows no other country than the united states of america, and now because of what happened, because of the president's action, she can now fly in an airplane. she's done that. she's working on getting her education completed.

it's a wonderful, wonderful involved woman in what's going on in nevada. and the junior senator from texas wants to shernd tbak to a -- wants to send her back to a place she doesn't know: mexico. mr. president, astrid silva is an american. it is the only country she knows. it would be cruel and unusual what the junior senator from texas wants done. the deferred action plan is a positive step forward and we should not go back, especially not as a ransom for helping our border personnel care for desperate children. i would hope my friend, the republican leader, can rein in these extreme elements of his caucus so we can achieve a real solution, one worthy upon -- of the ideals upon which this nation was founded. these children are real, little kids, real human beings. they shouldn't be used as pawns in the republicans' high stakes game of chicken with president obama.

mr. president, i ask unanimous consent that i, the statements i'm going to make now appear at a separate place in the record. the presiding officer: without objection. mr. reid: mr. president, when i first came to the house of representatives, i had the good fortune of serving on the foreign affairs committee in the house. it was wonderful. i served under chairman sblaki from wisconsin, chairman fascell from florida. it was a wonderful experience to get a view of what's going on in the world and i enjoyed it very, very much. but i learned there -- and i think we all know, maybe i should have learned it sooner -- that our national security depends on the qualified men and women who serve as our ambassadors throughout the world. our foreign service corps, when i travel overseas, mr. president, i always make sure that i get the staff of these embassies together and tell them how much i appreciate what they do for our country. they're not all ambassadors.

of course there's one per country, we hope. but when, mr. president, to apply to be a foreign service officer, it is hard. you have to have a really, really good grades. you have to pass a written examination after having graduated from college and maybe with graduate work. some of them are ph.d.'s. and then after you pass a written test, you have to pass an oral test. it is very, very difficult. these are some of the best and the brightest in the world. and their ultimate goal, as we had the all-star game on tuesday, is to be an all-star, to be able to play as they did on tuesday in major league baseball in the all-star game. that's what ambassadors. they are the all stars of the diplomatic corps of this country. right now these ambassadors are on our front lines.

they're fighting to defend our interests abroad, our security interests, our national interests and our economic interests. right now there are gaping holes in our nation's front lines. mr. president, let's look at who ambassadors really are. here in the senate i had the good fortune to serve with one of the really distinguished ambassadors. daniel patrick moynihan from new york. prior to coming to the senate, he was ambassador to india, and he left his mark in that country. he did a remarkably good job as ambassador from the united states to india. the republican leader and i attended a funeral a week or so ago in tennessee. the funeral was for howard baker, who had been the majority leader in the senate. a fine man. he married another senator from

kansas, nancy kassebaum, and he became, after retiring from the senate, ambassador to japan, distinguished himself there again with the remarkably good job he did. mr. president, we can go back and look at the beginning history of this country. what do we always learn about thomas jefferson? we know how smart he was, how he wrote brilliantly. but we also learned in every history lesson about thomas jefferson that he was ambassador to france. john adams, ambassador to england. they have set the standard for how important ambassadors are. mr. president, here in the united states senate, republicans are stalling ambassadors. 25% of all the ambassadors to the continent of africa

unfilled. there are gaping holes on our nation's front lines. approximately 30 ambassadors are waiting to be confirmed, and waiting and waiting and waiting. senate republicans who have been so quick to accuse this administration of poor leadership on world issues are obstructing the confirmation of ambassadors who are desperately needed at embassies all around the world. the republicans are abdicating the senate's constitutional role to confirm ambassadors. mr. president, in previous years, ambassadors were just approved so quickly. there would be once in a while something controversial would come up, but it was once in a great while. as i said, a quarter of u.s. ambassadors -- embassies, i'm sorry, in africa don't have an ambassador. we don't have an ambassador in bosnia. we don't have an ambassador in vietnam, and on and on. can't we all agree that it is important that americans be represented in these places?

the answer: we can agree. the republicans don't want these ambassadorships filled. when can these people who want to play in the all-star game be able to play in the all-star game and represent the interests of this country? they worked careers that are very difficult. they don't start out as ambassadors. rarely does that happen. and each day that goes by, more ambassadors are unfilled. ambassadorships are unfilled. all the ambassador nominees will pass out of committee unanimously, with rare exception. they are noncontroversial, with rare exception. i'm talking about career ambassadors here, mr. president. these are not political appointees i'm talking about. i'm talking about career ambassadors. what does that mean when i say career ambassadors, career diplomats? these are good men and women who will work for decades for the united states state department. in most cases, these diplomats started working at the lowest

levels processing visa applications, asylum requests and then become an economic officer, a political officer. by working hard and acquiring this area of expertise, these career diplomats have readied themselves to be ambassadors. it's hard. career ambassadors don't represent political parties. they represent our country. these long-time professionals have worked for both democrats and republicans, and they worked for several different administrations, and it doesn't matter if you're a foreign service officer, whether the presence of democrat or republican, you do your job for the country. now these professionals are needed to fill posts in some of the most volatile regions in the world. republicans have slammed the brakes on these nominations. at the very least, the senate should confirm these noncontroversial career diplomats. if they want to play games with political appointees, they can do that, but, mr. president, these career diplomats aren't

political appointees. they are qualified diplomats who have performed admirably for the state department for a long, long time. we need their experience. we need their expertise at embassies all over the world. some senate observers say that republicans are stalling these nominations as payback for rules changes instituted by the senate. well, let's see if i can kind of figure this one out then. republicans are stalling executive nominees vital to our national interest to get back at democrats, to get back at me? how is that one? stalling these nominees is jeopardizing america's interests abroad. it's damaging our nation's role in global affairs. it's damaging our national security. it's conjured up political retribution for the united states? of course not. mr. president, there was a "new york times" article in the last 48 hours where secretary of

state john kerry said i have 52 important state department officials who are waiting to be confirmed in the united states senate, 52. i was stunned to read in that same article a quote from the ranking member of the foreign relations committee over here, the junior senator from tennessee. here's what he said -- quote -- "rather than filling vacant embassies to alleviate the national securities raised by secretary kerry and others, the majority leader, mr. president -- listen to this one -- who controls the senate floor has chosen to spend this week on a sportsman's bill and previous weeks confirming judges." why? that's the end of quote. mr. president, criticizing bringing up the sportsmen's bill. this bill was sponsored by a majority of the republicans. 26 republicans cosponsored that legislation, and the junior

senator from tennessee's complaining that i brought that up? i guess he's also complaining that i brought up raising the minimum wage, which the republicans have filibustered. maybe he is also complaining about we have student debt in this country, about $1.3 trillion, and we brought that up to alleviate the pain to families in america with student debt. maybe he is complaining, mr. president, because we brought up here on the senate floor something extremely important. that is that if a woman does the same work as a man, she should get paid the same amount of money. not different work. the same work. she should get the same money. i guess he is complaining because we brought up something that addresses the need that americans have. that is, the hobby lobby decision of the supreme court. we think that's wrong. women in america, families in america with some exception believe that's wrong. so, mr. president, i agree with the junior senator from tennessee. there is an urgent need to fill

these diplomatic posts as soon as possible, but for heaven's sakes, mr. president, how could he complain about the substantive legislation which is so important to america that i have just run through? and then he complains about judges, we are confirming judges? mr. president, i have been here a while in the senate, and until obama became president, with some exception, these nominations went through unanimous consent. we weren't holding up ambassadors. there would be a spat on a judge here and there but not holding up all the judges. the reason it's taking so long is we have under the rules of the senate what we call postcloture time, and that is a time, mr. president, that was originally set up so after you got on a piece of legislation on a nomination, you would think about it for a little bit. they think about it a lot and do nothing. 30 hours on a lot of nominations

postcloture, eight hours on others. judges only two hours. we have gone through a lot of judges because of that rules change that we made. mr. president, i thought it was an urgent need four months ago when i came to the senate floor to talk about the growing logjam of our ambassadors around the country. senator corker is claiming that these ambassadors appointments were unnecessary by judicial confirmation is a little weird and a little strange. and it's strange and weird for a number of reasons. i take issue with the notion that the senate somehow wasted time by legislating and confirming judicial nominees. these are our constitutional duties. we're going to confirm in the next few days a post in georgia. we have two to be filled there. one of them has been waiting for more than a thousand -- mr. president, more than a thousand days. so i think it's important we do this. why? because it is our constitutional duty. and we only have to take -- we only have so much time to

confirm judges because, as i indicated, the filibustering nominees, they do it to everybody. we are working through the judges quickly because we changed the rules, and thank goodness we did, mr. president. the senate did consider senator hagan's sportsmen's legislation last week, i repeat. that important bill affects the one that the junior senator from tennessee said we shouldn't have brought up. it affects 40 million americans who hunt and fish. mr. president, something i used to practice law with has a place in montana. he took his grandson there and had a wonderful time fishing. no hunting but fishing. his place he has, a little stream goes by there. he said it was the best time he ever had with his grandchild. that's what 40 million people do, mr. president. that's what we brought up. that's what the junior senator from tennessee says was such a bad idea. 26 republicans cosponsored that legislation. it contributes $200 billion

annually to our nation's economy. and my friend from tennessee thinks it's a waste of time, we shouldn't have done that? the junior senator from tennessee was a cosponsor of the legislation. he's going to go back and tell the people of tennessee that he made a mistake, he shouldn't have been cosponsoring that? earlier, he voted to proceed so we could work on the legislation, and then he voted to filibuster it. this is the same tactic we have seen so much over the past six years. republicans obstruct when asked why they are not accomplishing and then they blame democrats. they blame me. the truth is senate democrats have continued to press for more and more ambassador confirmations while also introducing legislation that helps working families. i came to the floor in march to highlight the backlog of ambassadorial confirmations. the senate has considered an increase in minimum wage, equal

pay for women, student loan refinancing, extension of tax cuts, cost-cutting energy legislation and a number of other things. these are all important bills to give working americans a fair shot at major prosperity. republican filibusters blocked every one of them. another issue i have with the senator from tennessee is that undoubtedly know the senate traditionally does much of its business through unanimous consent. in fact, most of our business. republicans agree there is an urgent need to get these nominations done and give their consent. we could confirm all these ambassadors in a single afternoon, and that would be a -- it would only take a few hours in the afternoon. we could do it today. but it's clearly not a priority for republicans. otherwise, they would expedite these confirmations. their behavior on these ambassadors nominations reminds me of a quote by gandhi. quote -- "action expresses priorities." republicans' lack of action on this matter illustrates that they have no priorities in this

regard. so enough with the stalling and enough with retribution. the senate standoff isn't good for this body and it's hurting american interests abroad. let's get these ambassador posts filled. our national security depends on it. mr. president, i ask unanimous consent that notwithstanding rule 22, at 2:00 p.m. today, the senate vote on cloture on executive calendar number 849. further, that if cloture is invoked at 5:30 p.m. on monday, july 21, the senate resume executive session, all postcloture time be expired and the senate proceed to vote on confirmation of the nomination. further, following the 2:00 p.m. cloture vote, the senate proceed to consideration of the vote on calendar number 709, that's made r. if confirmed that the motion to reconsider be considered made and laid on the table, no intervening action or debate, no further motion be in order to the nominations, that any statements related to the nominations be printed in the

record and the senate immediately resume legislative session. the presiding officer: is there objection? mr. reid: mr. president, with this agreement, we expect -- the presiding officer: without objection, so ordered. mr. reid: with this agreement, we expect roll call votes beginning at 2:00 p.m., and two additional voice votes, as i have mentioned. i apologize to the republican leader for taking so much time. i usually don't do that. i won't do it much in the future. mr. mcconnell: mr. president? the presiding officer: the republican leader. mr. mcconnell: yesterday, the american people actually scored a victory in the ongoing battle against government overreach. they literally rose up, spoke out and they forced the obama administration to withdraw the latest gem from the department of terrible ideas over the environmental protection agency. and they showed two things in the process. first, the need for constant vigilance when it comes to protecting our liberties, especially with the current

crowd down at the white house. and second, the impact ordinary citizens can actually have. the proposal in question was a uniquely awful idea. the goal was for the e.p.a. to grant itself the authority to garnish the wages of private citizens without even giving them a day in court. imagine, you receive a letter from the government accusing you of violating some obscure regulation, a regulation most likely you had never heard of and didn't even know you were violating. the government then hits you with massive fines, sometimes on the order of tens of thousands of dollars a day as you weigh your legal options and whether to fight it in court. and if you can't or won't pay

these fines in the meantime, bad bureaucrats in washington will just take them out of your paycheck anyway. out of your paycheck anyway. without even the option of contesting the government's actions in court beforehand. this is certainly government overreach at its very worst. that's why i join senator thune, vitter and barrasso in speaking out against it, and that's why we developed a resolution of disapproval to block it. but the real key to our success here was the action of the american people themselves. they got our help, but they didn't sit back and wait. they let their outrage be known. they fought back against this brazen power grab. and thanks to all these efforts, the administration finally literally threw in the towel yesterday and certainly we were glad to see it.

but look, the fact that the obama administration's e.p.a. even introduced this rule in the first place should concern all of us. it was truly outrageous. but it's also not surprising, because this is the same administration that just proposed a so-called waters of the u.s. regulation that would expand the government's authority so broadly that the agency could regulate and fine almost every pothole and ditch in our back yards. and this is the same administration that's been waging a costly war on coal jobs in my state through similarly ownous -- onerous and arbitrary regulations aimed at pleasing hard-core activists here in washington, without any regard for real-world consequences. it's like these distant elites in washington view their mission

acido logical warfare, and they don't seem the least bit concerned about the casualties they leave behind in the process. i've tried to get some of these bureaucratic foot soldiers down to kentucky to see the impact of their efforts firsthand, but of course they're not interested. they're not interested in people like the 32-year-old unemployed miner who walked into a pregnancy center to ask for baby clothes. an employee at the center wrote to tell me what this miner had to say. here's what he said: i don't come from a family that has ever had to ask for help, he said. i feel humiliated, but my baby is suffering. that pregnancy center employee wrote that the look on his face broke her heart, but this is the plight of many of our families in eastern kentucky. she wrote, their livelihood is being taken away from them by the war on