sharply. i will not accept that. i say we'll find potential areas that will make up that gap. let me say to them that we will overcome a bowl and the economy will bounce back. challenge me. >> madam president all of us want to thank you for your optimism and your tireless efforts in this time and for your courageous leadership in the past but particularly in this present time. it's an inspiration to all of us and we just want to thank you once again for taking the time to be with us this morning. thank you very much. [applause] >> it was certainly inspiring but also sobering to hear it directly from president johnson sir leaf about her challenges and their plans.

it was exciting so thank you to steve in particular for organizing that segment. f a forn what are the implications of what we've heard this morning and particularly what are the implications as we look ahead to what can be done? and so i'm really excited about group that we have here. and let me just briefly introduce the panelists going across from my left. first is superkemp. -- susan kemp. she is the deputy director of the o'neil institute at georgetown university. susan is trained in law, public health and business and holds jd, mp h&m ba degrees to prove it. she is, in 2001 she served as special consultant to the state department regarding reforms to the global fund to fight aids,

tb and malaria. super's also worked extensively on a wide range of health law issues including implementation of the international health regulations, pandemic response and infectious disease control. and so we are looking forward to susan bringing a legal perspective here to the discussion. next to susan we've already heard from dr. rat live, but just to give the broader background, dr. rattle is the distinguished professor in the practice of development in the donald f. mchenry chair in global human development at georgeton school of foreign service. steve has held senior positions in the federal government, chief economist at the united states agency for international development and deputy assistant secretary of treasury. steve, as you could tell from the earlier presentation, has advised the government of liberia among many other governments on chick development

issues -- on economic development issues. and then last but surely not least is dr. ron waldman who's the professor of global health at the george washington university: ron has had an exceptional and distinguished career in public health including service with the centers for disease control and prevention, usaid, the world health organization and the united nations. his resumé is very long and very distinguish thed, but it includes really an extraordinary list of initiatives including smallpox eradication campaign, developing a new center for force migration and health, pan pandemic preparedness for the u.s. government and lead roles in both the response to the indonesian tsunami and the haiti earthquake. with respect to the current crisis, he is the team leader for save the children's ebola response. and one thing i would say is i've had the good fortune of actually working with all three of these panelists in different parts of my career; susan with

the o'neill institute, steve at state and ron at hhs. and i think we are in for really a terrific panel today. we'll follow the same format as the earlier panel, we'll do some general questions, and then i'll pose to the panelists some specific questions that have been developed by students here. so let me just say that i'm just going to ask everybody to take a, ask a general question to each of you to kick this off. but let me start with susan kim. super, you know, you've -- susan, you know, you've heard this morning much discussion has been about roles and responsibilities of institutions both global and domestic, and the issue of law comes to bear here too because that's -- up, those are the instruments we use to decide who does what, where and when. so i guess i'd love for you to reflect on what you've heard and what you know about the ebola tragedy from the legal perspective, particularly, i suppose, with respect to the

implementation of international health regulation. so will you kicks off? >> sure. thank you very much for having me. and as john mentioned, i will sort of be speaking about, within the context of international health regulations or the ihr. dr. cameron, actually, spoke a little bit about them earlier this morning, and really what the ihr is, is a legal global framework to respond to -- todefect, respond and monitor disease outbreak to prevent spread of international disease. they are an international treaty under the purview of the world health organization, and they've been around for a while, since about 1969. but as dr. cameron mentioned this morning, they were revived in 2005 to more effectively respond to diseases that transsend national borders. so sars was a catalyst for this, but also hiv and also, ironically, things like ebola.

at its core it is a fairly complicated strum, but at -- instrument, but it establishes a mechanism for capacities at the domestic and international level. so countries themselves are responsible for implementing the different, different elements of the ihr which include sort of monitoring and surveilling local disease outbreaks. one specific criteria are satisfied in terms of severity, sort of the ability -- potential to transcend international borders novelty, then there's a reporting mechanism back to the who about whether they need to sort of sound a more international alert system. and sort of this would be at the global level what you have heard to referred to as something called a public health emergency of international concern. and what, essentially, that is, i guess the simplest way to describe it is a type of global amber alert for public health

emergencies. basically, it's a way to effectively signal to the global community that this is sort of an emergency, a public health emergency that will transcend or has the potential to transcend international borders, so people should pay attention and start to mobilize. in terms of resources whether it be financial, medical and also human. and i think sort of additional action can be taken when a fic is implemented, and these include temporary recommendations that restrict travel and trade. the declaration, obviously, has multisectorral implications. these can be very severe because -- and i think you heard from president sirleaf, with the suspension of travel and trade across borders, this has to be sort of a severe economic implication. the who doesn't tend to declare a fic very likely, and tins since 2005 they've only declared them three times. in 2009 it was h1n1, earlier this year it was the with polio,

and in august it was with ebola. so specific, i think, to the current outbreak, one of the questions is whether a fic was declared too late. it's hard to assess this, i think, overall, but i think the answer is probably yes in this case. the who declared a fic on august 13th. i think from some of the remarks made earlier today, ebola had already taken a foothold in countries and had begun to traverse borders probably around may or june. and sort of, as i mentioned, as a type of emergency alert system, the declaration sends a clear message that sort of the world needs to mobilize. and because they've done that too late, you've heard sort of the different, the very difficult, i think, consequences of this timeline. measure. >> susan, thank you. and let me turn, if i could, to dr. waldman. i think what susan did was lay out the architecture for the legal responsibilities of how

the international community should respond. dr. waldman, ron, give me your experiences both working in the u.s. government and internationally. welcome your sense of where we are now, but also particularly what lessons do we draw from this experience in terms of going forward, in terms of health systems that we've heard so much about but also the international response capacity. >> thanks, josh. thanks, john. is the microphone on? >> it is. >> thanks, john. i'd like to address the problem in two parts. one is what we can do about this horrible outbreak now, and then where we can go from here: i want to start by saying that in regard to dr. kim's statement, i would just -- every time she used the word probably too late, i would just take off probably. [laughter] i don't think it's really an issue that the world did respond too late. we allowed the outbreak to spread, and we allowed the

number of cases to grow to a point where it's very, very difficult to contain. the outbreak probably began as long ago as december, and the first instance -- the first cases were reported in the forests of guinea. doctors without borders announced in june that their resources had been overwhelmed and that they could no longer each try to contain -- even try to contain the outbreak from spreading. and the world health organization responded in august. the u.s. government announced its first major foray last week. so, yeah, we responded too late. there's no point -- at this time pointing fingers, that be be done as part of the case study that the president suggested. but at this point for all kinds of reasons ranging from the humanitarian to the very, very, very practical, political, social and economic consequences

that are yet to fully be seen, we need to do as much as we can. so let me just say i think that many of you if you're following this outbreak, maybe you saw a article in "the washington post" this morning that reports on a newly-evolving strategy that may or may not be able to have an impact on the situation. let me just go over very briefly the pranks of -- the planks of the strategy that most of the department, most of the partners now agree on. number one is the management of cases of ebola virus disease. basically, this revolves around getting people off the streets and isolating them for the duration of their illness. we to not want to allow people to have any opportunity whatsoever to transmitt the virus to others. it's a highly infectious disease. fortunately, it's not spread by the, through the air a, by the

respiratory route. one has to come in contact with surfaces contaminated by the body fluids of a sick person or with those fluids themselves. but still, when people are exposed, when they develop illness after an incubation period that can vary from a few days to a few weeks, the proportion of people who come down with this disease who die is scary. it's well over 50%. and as a result and the worst case scenario might have been mentioned earlier this morning that are going to be released by the cdc this week, the cdc is saying without further intervention, as president sirleaf said, the number of cases is estimated the surpass 500,000 which means we're very likely to see between 300,000-400,000 over these three countries. it's just phenomenal. they're numbers that are so big for an infectious disease outbreak that it's hard to get a

grip on them. so one area of intervention are the hospitals, called ebola treatment centers. steve mentioned that president obama had pledged to liberia 17 100-bed hospitals. i want to come back to whether or not that's the best strategy, what proportion of the overall strategy those hospitals need to play, it's up in the air. i'll come back to it. we've been pushing at save the children very hard to have an intermediate layer of care developed closer to the community with a little bit less strict isolation procedures so we know that what we're proposing in terms of facilities will be leaky and will be part of the problem of transmission. but we hope that they will be a bigger part of the solution of getting people out of their homes, off the streets and in places where transmission can be restricted to an absolute

minimum. but president sirleaf so right on -- is so right on. she stole my thunder, i'm sorry to say. this won't work unless the communities are convinced to take ownership of this situation and of the problem. and for all the reasons that the president mentioned, this is proving to be extremely difficult to do. but there are many people who are keeping their ill family members home, becoming exposed themselves. they are, if their family members or village neighbors should die, they're conducting burials in a very up safe manner -- unsafe manner. burials are kind of a superspreading event where people because of the traditional burial rites put themselves at particular exposure. crowds come, they touch the dead body, and these need to be carefully supervised.

so community action, attempts at behavior change, these are really the only things that will bring about relatively rapid end to the epidemic if that's even feasible at this time. president sirleaf also emphasized the fact that many people in liberia are dying of non-ebola disease because there are no health facilities that are currently functioning. so common diseases like malaria, diarrheal diseases, pneumonia, complications of pregnancy, people are dying because they have no place to go. and if there are facilities that are functioning, then mixed in with all of those people with those conditions are also people with the early symptoms of ebola virus disease because the symptoms are nondescript. in the early days of a person ill with ebola, it's characterized by diarrhea or a cough or a fever, the same things that are the characteristics, the symptoms of

the most common potentially fatal decides. so this is a real disaster and a difficult problem to overcome. triage needs to be done. ebola patients need to be separated from non-ebola patients. but our science isn't advanced enough to allow us to do that very quickly. there's no rapid test for the detection of ebola virus. there's only taking some blood, sending it from a peripheral area to a laboratory wherever it might be, doing a test that takes 4-6 hours to complete, getting the results back. in the meantime, all of the mixing of ebola and non-ebola patients has occurred, and health facilities also -- where are they functioning -- would be also super-spreading sites or amplifying sites of the outbreak. so we're really looking at some major challenges, and we're not sure how to overcome it. two other quick things. one has to do with the protection of children. there's a growing number of orphans, there's a growing

number of chirp in the streets. -- children in the streets. they're very vulnerable, and they need to be cared for and protected. it's very difficult to to convince people to foster, to take in children whose relatives had ebola and the children may be exposed. and finally, and this will tie in some with what steve is going to say, there are real hardships in terms of people's inability to pursue their livelihoods. there's no money coming in to households, and without money, there's no purchasing power even for the basic things like food. so food distribution is becoming a growing issue, a growing area of concern. of course, food, water and basic needs will be provided at the health facilities, the hospitals, the ebola care centers, but even now within the villages and communities people are having difficulty. as you might know, there was a lockdown for three days in sierra leone this weekend, and the biggest complaint that i've

heard from the population was their ip ability to store enough food to carry them through those days. people live from hand to mouth and don't have large reserves. the same is true in liberia, and foodstocks need to be supplemented either by the distribution of food itself or by other systems whether they're voucher systems or cash transfers. so i just wanted to say what are the constraints, we might be able to figure out what to do, but there are very severe constraints, and just in one minute, there's not enough money in this response yet. the response is okay. it's big, it's getting bigger. the world health organization, the u.n. have called for over a billion dollars in funding. that's not yet available. and i know from what's coming through the ngos so far that there really isn't that much money. and if we concentrate on the high level facilities, the 100-bed treatment centers that president obama promised, the budgets for those right now that are being submitted to the

government call for more than a million, million and a half dollars a month for their operating costs. so whatever money has been pledged is going to be exhausted all too rapidly. secondly, human resources. this is by far the biggest constraint that all of the responders are facing. there are no people available for this response. neither ex-pats who may not want to go there because president sirleaf said they're not sure would they be able to get out should they get ill, if there's a dangerous situation. but local staff also is very reluctant to sign up to work on this. and in any event, the numbers of health personnel and support personnel required are really high when we're talking about the needs for isolation, for water and sanitation, for disinfection, for burial purposes. these aren't good jobs to have. they're not nice. and people don't really want to

rush up and volunteer. and the final constraint -- we don't know very much about what's going on. these are uncharted waters. there have been ebola outbreaks in the past, but the responses have been more rapid than expected, and we've been able to contain them very early on. here we've never dealt with anything like this. even proposals like the one i mentioned of having the intermediate level, close-to-community care, we have no idea if that would be part of the solution or part of the problem. every action that's taken needs to be carefully evaluated in realtime so we can see the impact that it's having, and we can see whether or not we want to pursue that line of work. so i guess i'm coming across as not being quite as optimistic as president sirleaf. and by nature, i'm fairly cynical begin with, so that's not a good thing. [laughter] but the outbreak as the director

of the cdc, the director general of the who, theup special representative for ebola viruses, we've heard all of these people say the situation is out of control. it is out of control. it's going to take a gargantuan effort just to bring it back, just to bring it back to a situation that can be controlled. and that's what we're shooting for now. not even bringing an end to it in the immediate future, but rather, just getting a handle on what's going on, reducing transmission to the point where there's no more growth of the outbreak or only slow growth of the outbreak so some of our more traditional means of containment can be more effective. >> ron, thank you. it's sobering. and, steve, turn to you. i mean, i think ron's message is clear. as he said, it's been reiterated by global health leaders. the epidemic is out of control, and the control measures that we

are bringing in, putting in place or are being put into place by various partners are really in uncharted space right now. people are going to have to learn. we don't know what works in this context. so with that, it'd be terrific if you could build on the conversation you started with the president. but also where do you see the economic impact here, for the three countries, for the region, even more broadly for the continue innocent, and also how do we think about the kind of investment that's going to be needed to sustain economies while public health measures are brought to bear which will undoubtedly take a considerable period of time? so, steve? >> thanks, john. the first point i want to make is that this is an epidemic of poverty. this is not strictly a disease of poverty. anybody can get it, but it's an epidemic of poverty. just as low incomes and lack of

food and lack of water are all manifestations of poverty as is illiteracy and many other manifestations of poverty. the weaknesses and lack of capacity in institutions to be able to respond to a public health crisis is just as strong an indication of poverty. and through that, unfortunately, there's a self-reinforcing negative cycle that we're beginning to see here. that is, that as the disease worsens, that undermines capacity and undermines finances and economic ability and political systems and legal systems which in turn further weaken the entire economic and social system which are cutting incomes and leading to more poverty.

so it's a horrible crisis because for the last nine years, since the elections in 2005, liberia has been in more of a positive reinforcing cycle. that improvements in economic and political systems are leading to higher incomes, less poverty, increases in school enrollments, strengthening of democracy which in turn are reinforcing each other or had been reinforcing each other. positive steps in one area were reinforcing positive steps in another. and there had been so much progress since the end of the conflict in 2003 and the elections in 2005 in liberia, also in sierra leone. a little bitless of an extent in guinea because the political system just began to change more recently, in 2008. but we're seeing a sad reversal from a positive reinforcing

cycle back to a negative reinforcement cycle. and since this is an epidemic of poverty, one of the things that's really made me, quite frankly, angry is the blame the victim sip dream that had been around -- syndrome that has been around for the last several months. the problem is that these people are stupid in terms of their cultural practices or that the government doesn't have the competence or the capacity and, or, you know, they make dumb mistakes that this retrospect, you know, we can all see that these are mistakes, and if they just took things more seriously or were able to treat people, this would all end. and it's really quite sad that once again we see the kind of blame the victim kind of situation. this was not anyone's fault. this is ap act of nature. an act of nature. the deep unfortune is that it came into a region of the world that was very fragile in terms

of its very promising recovery and was overwhelmed very quickly. scott taylor said it, dr. bump said it earlier, who would have expected, who could have expected that they would have had the systems in place to respond in -- to respond? there is, as several people have said and ronnie just said, there are big lessons here for the future of the international system and its ability or inability to respond, because this isn't going to be the last ebola crisis, and this has really exposed enormous weaknesses in the global ability to respond to emerging disease threats. i'm not an expert on that, and others will comment op that, but i think there's a huge lesson going forward. in terms of a couple of comments on the economics and politics, president sirleaf outlined a lot of the devastation that's going on. it's really quite enormous. among many other things, i'll just highlight one she didn't touch on which is the impact on the budget, which you might not think of. but the government revenue is

way down because they rely very heavily on import tariffs, and trade is down, so import tariffs are down can. the mines are shut down, so their payments to the government are down. there's a big question as to whether the government's going to be able to make its payroll this year. if they wanted to reopen schools, are they going to have the money to reopen them? court systems and all the other kinds of thing that is government normally does. and among many other things, they need a big infusion of cash which, just to keep the government operations running, which the international community is generally very reluctant to provide. generally for good reasons in other circumstances. but we don't have the flexibility to respond in a set of circumstances like this when one of the things they need is cash and figuring out how to do that. usaid is providing $5 million in cash, and they were twisted in pretzels to figure out how they were going to provide $5 million

in cash. the imf is actually going to step up in the next two weeks or so and provide around $50 million cash to the liberian government and similar smaller amounts to guinea if sierra leone. so the imf, in of all situations, is going to be one of the first to step up in the crisis. but i do worry about the longer term impacts on the economy and the impact on investment going forward because i think it's going to be -- the longer this drags out, the more of a dark shadow is going to be cast on west africa in general, and the harder it's going to be to attract investors going forward. and this is having huge impacts on individual people. people are out of jobs, poor people are not being able to work on construction sites and retail shops as taxi drivers, working in hotels and restaurants. they're not working anymore. a lot of them have lost their jobs. so anger is rising both in terms

of the disease and etch's worried about that -- everyone's worried about that, but on top of that, people's incomes are down, and they're not able to provide for their family. so anger is on the rise. and alongside the economic implications, i worry that there are going to be longer term political implications and ramifications. all three of these countries are young and fragile democracies, quite promising democratses, and they had begun to deliver the goods. and i worry that among many other casualties one of them will be a lack of -- a loss of faith in the ability of democracies to provide, provide the goods. and already in liberia we're seeing former warlords and associates standing up and saying, you see? they can't actually do it. i should be in power. and with elections coming up in a couple of years, we'll have to see how that, how that takes shape. but i do believe that there are much bigger implications here on economic and political systems and people's belief in those

economic and political systems, not to mention their belief in the world order and international systems and their ability to respond. president sirleaf outlined the steps going forward. it doesn't have to all end in catastrophe. we're running out of time, but there sill is some time -- there still is some time. the key will be not just for the people in liberia to given to -- not to begin, they have been stepping up in a big way, to continue to step up, but for the international community to provide the cash, the people, the health experts, the other experts that can help turn this around and begin to make those investments in agriculture through the u.s. feed the future program to get farmers back to work, through trade to make sure there are trade concessions that outside investors will be somewhat more open to investing in these countries going forward, to investing in

infrastructure -- roads and power systems which will have a long-term benefit but which will get people back to work quickly. there's going to have to be another prong to this effort which so far isn't really happening in order to get people back to work to be able to care for their families and get these economic systems back going in a more process direction. >> steve, thank you. and -- okay. if it's okay, i'd like to follow up directly with you on the last point because it does seem to me that we've seep seen -- seen the global public health community responding slowly to this crisis. what you're laying out, though, is an economic agenda for these three countries, but for the region. and, again, the imf is to be credit with the the initial steps it's taken. but it seems to me the president also laid out a much broader aweapon is da around trade and around investment. who could take that lead?

do we have a global architecture to take the lead? that's for you but, also, all the panel its. who should be -- is this the u.s.' role? who needs to be the lead in this? >> so we have an insufficient global architecture on these issues. it's slightly different in each cub -- in each country. in liberia it's united states, in sierra leone, it's historically the united kingdom, and in guinea, it's the french government. that's not going the change, and the reality is that the united states is going to focus primarily on liberia and not so much on guinea. we might not like that, we might all hope there's a regional response. there should be, but it's not going to happen. we're going to need -- so all three of those governments are going to have to step up. and then several key international organizations. the international monetary fund, as i mentioned. who would have guessed, you know, darth vadar himself, you know, the age-old nemesis. [laughter] that's long other, but they still have this reputation.

far from the old, out-of-date image of strong conditionality and we'll never do it unless you do it our way, they're going to be the ones that are going to step up as part of existing programs and existing commitments that had already been made and that the governments were all in compliance with and will go to their board -- you'll see, it's going to be october 23rd, it'll be page 26, column c of the newspapers that the board will approve, i think it's going the to be about $48 million for liberia and other amounts. so the imf is a big piece of this. the world bank is going to have to step up. they have made many commitments so far. they sound like quite encouraging commitments. as far as i can tell, there's less actually happening on ground. and the bank is going to have to step up on the infrastructure side in particular and on power and roads as well as some of the cash to supplement the imf stuff. bilaterally, the u.s. response

so far is certainly good, as ronnie said, it's a step up. but if you look at what the president said in the white house press release last week, there's nothing on the economic side. now, what they are saying is that'll come, okay? fine. i hope it comes fast. but the united states -- and there have to be similar efforts by the united kingdom and france, they're going to have to support farmers getting back to work through feed the future, infrastructure investments. i hope the millennium challenge corporation is a bit flexibility in sierra leone and liberia, two of its partner countries, to move forward on infrastructure investments. we're going to need the ustr and commerce to step up on trade and think very creatively about the kinds of things that we can to to encourage trade; remove tariffs, open up the door cans. so it's going to take efforts from are a number -- from a

number of actors, and there isn't an overall coordinator to do it. it's different piece that are going to have to fit together in a puzzle to make this work and to get the economic response that we need as quickly as possible. >> steve, that's very helpful. i was going to turn to the public health response. super, or ron -- super, or ron -- susan or ron, do you want to -- if that's the case from the stand point of the global economic architecture, i'd like to go a little bit back to where with we started. susan, you laid out -- and i would agree with ron, i think you could drop the "probably." i think that people are -- and that's not a, there are people who are working in all these organizations incredibly hard to respond. it's just a question of whether we as a global community have the instruments and the to respond. -- and the infrastructure to respond. and it seems in this case we've responded too slowly and ineffectively. but i guess the question i would

ask you, your analysis, susan, is this a situation where the ihr legal instruments are essentially sound but in this case we didn't use them to their full potential? or is there -- are you beginning to see lessons emerge where we need to rethink the global legal infrastructure in which public health responses like this will be conducted? >> so overall, i think the ihr is, you know, in principle, a legally-sound instrument. i think it is sort of the execution and implementation of it. and i think it was said very well, it's very difficult to think about sort of what is the process and execution of how do you address a heart attack when you're in the midst of a heart attack? so i think dr. cameron mentioned this morning in the 201 assessment of whether countries had implement inned mare core capacity, there was around 20%, i believe, in the region. if 2013 report, i think, is more

positive, but these are based on self-reports, and for those of you who do surveys, take that as you will. also i think part of it is, you know, the institute was engaged, for example, in terms of resource allocation in a training course for folks on the implementation of the ihr. and these were primarily for middle and lower income countries to think about, well, what exactly are the core capacity requirements, how do you implement this treaty? but that was stopped a few years ago. so really, i think, what we found in doing that course is very few, i think, lower and middle income countries had sort of a lawyer at all in the my industry of health to sort of explain what are the requirements, how do you implement them. and it doesn't have to be a lawyer. a few of them had sort of anyone in the my industry of health that could actually explain, you know, what are we required to do? so when you think about do these countries have effective, you know, is the ihr an effective

mechanism? yes, if it's implemented correctly. has it been implemented correctly? no. [laughter] and i think, you know, with something like, for example, i said a public health emergency of international concern has been e declared three times. the first one was with h1n1. and i think the who assessed whether that had been working effectively. at the time overall they said yes, but one of the things they raised wuss, you know, we got a little lucky because it may have been diffuse and spread, but it didn't have sort of, you know, morbidity and mortality of sort of what could happen in a pandemic. and i think one of the questions is what would happen with sort of a disease outbreak that would have senate morbidity and mortality? and i think you see the consequences of that now. >> so, ron, if i could, i mean, if we -- even if we have legal instruments that describe roles and responsibilities, it still requires institutions and capacity to do so.

and i know we focused a lot on the countries, and i want to be cognizant of steve's caution that this is not about blaming the victim. i'd like -- given your experience, ron, in public health or global public health responses, what lessons do you see here that we can begin to think about in terms of the international system, including who? what do we need to be thinking about? because, obviously, we need to be thinking how do we avoid being in the situation again? >> yeah. i think who's made a number of proannouncements regarding the fact that they were underfunded in this particular area which may or may not be true. i think if you start at the macro crow level, we're seeing a shift in the global health priorities as countries are growing economically. we're going through something called the epidemiological transition which means that the disease profile in many low,

low-middle countries are starting to shift from one dominated by ip february white house diseases to one that has to put great or priority on the diseases that occur when people live longer and are healthier and societies are healthier. so people are trying to put a greater emphasis on cardiovascular diseases, cancer, mental disorders, so on is and so forth, and that means that the money is shifting from one area to another. so there has been some decline in attention to ip february white house disease -- ip february white house disease control in the global level, certainly like in the wealthier countries like our own. you don't have to learn far into the newspapers to learn about epidemics occurring in this country because we've taken our eye off that ball. but on the global scene as well, parts of who like the global outbreak alert and response network and the areas concerned

we merging pandemic threats, they don't have the same funding now as when we really had the imminent threat of not only h1n1, but at the time it was the h5n1. and because of that threat, in fact, there had been a lot of preparedness activities in a lot of countries in a lot of parts of the world. the u.s. was haley engaged -- heavily engaged as was the who. at that time, it was in the late 2000s, there really was a whole-of-society approach adopted to the control of these emerging pandemic threats. interestingly, the one part of the world where there was the least preparedness activity taking place was in this part of the world where this is occurring now. it just wasn't seen to be a very vulnerable area for the emergence of these pathogens. ..

and we are responding to the problem as it existed in june. as if we are doing what they should have been then we are doing it now and it's too late. we need to be responding now to the situation as it will exist in october and november. we need to get ahead of the curve and every time we spend is going to be another day that we fall behind alternately. so there are some fairly drastic solutions being proposed and we are starting to hear them but we don't know the legality of them both as an individual, community and national level and i hope it doesn't come to that, but for the control of the disease risk, who knows what happens. i tell my students they ought to

watch the movie contagion which i think is a picture of what might, although i hasten to add and i might repeat that there's really no threat. i want to build on what steve said actually. there is extremely little or no threat to the wealthy countries of the world. they have systems that can deal with it and we will know when the first case arrives in the united states and our public health service will be able to contain it very rapidly and that is the situation with most countries is an epidemic of poverty. but we have an obligation on many levels i think to continue to do our best to bring this under control now and back to the point where they are more conservative and traditional measures of containment that can be put into reverse the tide.

>> did he want to the law to comment on the human rights? in the midst of an emergency, you know, the intervening story has the ability to enact what can be extraordinary and coercive measures at the individual and the regional level. we send to the regional and global level this is permissible. it depends on the balancing and i think for those of you familiar with public of the law it is the notion of the power and restraint. the powder and the duty to react but they must also do so and i think these are outlined in the a. hr and international human rights instruments which is the principal principle and really i think with not just ebola is

looking at when they are directed at this directive and necessary to achieve the objective based on the scientific evidence and limited duration and most importantly the least intrusive and restrictive measure to achieve the overall objective. i think one of the questions folks have now and the experts are more knowledgeable of it but whether the regional quarantines is appropriate and i think even if it is completely possible to put someone in isolation and quarantine if it isn't the ghost restrictive measure to achieve the objective which is to prevent the case it might not be lawful to do so. >> i'm just going through some of the questions that we've got here but before we switch to these i do think this is an

epidemic of poverty. i do like that. it's the political will and the global community and we saw some actions last week in the u.s. security conference that's something that does not typically doing this kind of case that you can argue that the just a revolution. but it is likely that the future epidemics are going to have been in poor countries with fewer resources into the global and international community needs to be mobilized politically to respond if you are going to hope to be a head of this or in sync with it as an emergency. i don't know if the three of you want to share my think the u.s. has taken some lead later this weekend beginning of the local health security agenda but how do we fill the dialog that says this is a global public good, this capacity and is also something that is helpful,

particularly to people in poverty but also something we need to be globally. i think that is going to be necessary to whatever we do. >> part of the trick is to stop the fear mongering but at the same time continue to be serious about the potential impact of the epidemic not just in west africa but more broadly especially as it gets to spread. the fear mongering i think some people do it with the intention of we've got to wake people up to realize how challenging the situation is and it reminds me a little bit about, you know, i think some of that proclamation about the threats to international security were overdone in the years after 9/11 and frankly as a mechanism to get people to act on various

issues. the trick is to get the balance where we are not just scaremongering that we are getting the message out in clear ways that the threat of not just the immediate public health threat that to the international systems views on democracy and views on the international economic order and the others that have been taking a hit since the 2008 financial crisis and the invasion of iraq and we are seeing democratic recessions in a number of country and the beginning of the questions of the effectiveness of democracy and the minister of hungary calling for the liberal bloggers he for example and i wondered if this feeds into that part of what we have to do is to get get the narrative out of that can convince people of the seriousness of this issue without fear mongering.

but i do think that for all of the pessimism and challenges these are matters of choice. as much as this is a national disaster that comes out of nowhere that we cannot completely stop, there is a collective choice in the international of the international community to make over the coming weeks and months. you use the phrase political will. but we have the collective ability to at least begin to bring this under control if not to stop it in the months to come. before that happens there will be much more suffering that we have choices to make. can we get to a place where this is at least under control and stabilizing? yes. we've done it with hiv. it's not over by any shot but it is stabilized. we've done it with malaria after

escalating for decades the following very sharply because of international decisions to fight it and fight it harder. people finally made the choices, we did it with pouliot where it is almost eradicated but not quite there yet. this is similar to those. i remember in the early '90s i'd been thinking about the days when people are were finally recognizing the severity of the hiv crisis and it took the international community way too long to step up but when we did it have a big bag into the question for me now is whether we will collectively make that choice. and a lot of this goes to the united states not only by latter really because of its leadership in the united nations and the world bank and in the ins and other places imf and other places people still do look to

the united states. i worry a little bit because there are retired generals out there saying this is a bad use of that u.s. troops. obama is putting them in harms way and all that stuff .-full-stop don't recognize the bigger issues that are at stake. but the good news is that this is a choice and that we do have the brains and the resources and people to type this and to bring it under control. we are beginning to imagine a direction and we need to nudge more aggressively in the months to come and if we do that we can bring it together collectively we can bring this under control i think. i'm going to go to some of the questions now. let me start with one that we have been focusing on this question asks really if we are in a situation where this spread to surrounding countries where

it is synagogue -- can you describe do you think we will see more of what we have seen in the three countries that are impacted or are there greater and more dynamics involved if we see this spreading dramatically in the nearby countries? it is speculative. i'm a little bit surprised and i do not fully understand why the disease is not spread to other countries. one case in senegal basically traveled the length of the country to reach the capital city. a number of cases in nigeria and at least two sides we don't know what is going on with them. maybe it has spread to other countries but it hasn't yet reached the point of disability.

i know there are people looking on the alert in the other neighboring countries as well. i know that usaid is conducting regional preparedness workshops in the countries as we speak taking lessons from the pandemic preparedness plan that has had been developed for influenza. i don't think that we entirely understand the dynamics of the epidemic or how it spreads. i don't think that we heard the term's exponential growth. we've heard accelerated growth. i don't exactly -- it's really hard to model the spread of the outbreak even when we observe it up close because then bought even every county in the country before the cases. so the way that it moves isn't really clear it seems to move in spurts that it will reach a particular area and affect a lot of people in that area and that

we won't see it again and then it will occur in another area and it contributed to the lateness of the response that although we knew that the ebola virus was spreading in new guinea as far as december into january of this year there was a pure code that it became quite absent and they didn't react because if it appeared to be on the waiting end and many few cases were being reported and that it was an explosion again. so it isn't clear what the dynamics are. i can't answer that question except to say that it doesn't start affecting other countries and there is a chain of transmission that is payroll to the ones that we are seeing now, then all of the things that steve said about the economic consequences and the potential for the consequences will affect other countries as well.

>> next question gets to the issue of medical countermeasures and the question is what do you all the lever is there an appropriate economic investment as a global resource for this pandemic particularly of treatment and vaccines and also looking down the road and i know you've given some thought to this issue of how we create the right conditions for making therapies available for something that allows them to be available to address some of these issues. this is a question whether it should be a worldwide or global activity write-down to a great extent it is done by the united states and a few other countries >> of these types of things should be done, but i think that as doctor can attest to, when

things are framed in that they have to be in the local context, that requires as you pointed out that the hoa caldwell objects on investment but it's really not even just about the money but where is the money going to come from in terms of if these things are done, you know, how do you figure out the appropriate application and it really requires people like you to think about it before hand. so, absolutely. i think there is a place to think about making future investments in the medical countermeasures that folks need to give serious consideration into what to what that framework will look like. >> i just want to say one thing and to get it off my chest. the sad part of the outbreak is that we wait until these events occurred and then we start talking about how we ought to throw a lot of money into developing drugs and vaccines for ebola or worse the failure not so much of the outbreak

response community as it is in the development vanity into the real case study is what is the development agency has been doing for the last 60 years if we would have had stronger health systems in countries in the first place we wouldn't be where we are now but now i went to usaid very early on in the outbreak and they were talking about putting massive amounts of money into strengthening the health system in nigeria, which is fine and that ought to be done maybe not now, it should have been done maybe this is the right time to do it but i hope we learn a lesson and we don't have to wait for the next catastrophe to occur before we decide that we need to make the appropriate investments and development. >> want to ask you a question. >> we have all been involved and applauded the u.s. government efforts in the last ten years to

build responses on hiv, primarily malaria to a lesser extent tb. you know where my question is going. in terms of vertical responses to disease. and it's not just the executive branch. but the honest truth is that the congress loves it and the american people love it because we can explain that we are providing and antiretrovirals to agnes or whoever the person is is and we can actually bring agnes to testify in front of the senate foreign relations committee and say your money is keeping her alive and we can prove it because we are providing her with antiretrovirals. it's a very compelling case and we can do the same with a bad back bed nets. children live and weeks of the campaign's children in high school contribute $10 someone

will buy a bed net. so the political economy at its best level and is sometimes understanding the american people want a specific actions on specific diseases. jesse laid out very well and we all talked about the impotence of the health systems. you've been more involved in this than any of us. how do we square that circle of the congress is imperative they want results measurable knowledge of the need to build systems over time. >> that's the question that has been haunting me for the last several years. i've spent quite a bit of time on the bilateral response program that is focused to fight aids and malaria, three diseases. we had a considerable debate in the global fund about the extent to which countries should be supported to build the health systems and opposed to the systems to deliver responses to

those three diseases. they outlined exactly why it is so much more politically attractive to make the argument that an investment of u.s. tax dollars leads to a specific outcome with a specific person. i don't think that if the conversation is only going to be about a direct bilateral program versus a relatively nebulous investment in the health system i frankly don't see how that argument is going to be persuasive over time. i think you have to change the conversation and so one thing that this crisis provides is an opportunity to think about health systems as a protection for the world as well as for these countries that ebola illustrates because i do think there is an argument. people here in the united united states united states to invest

do invest and we do want public-health infrastructure. we may not think about it from day to day but we sure want the cbc functioning per example in 2009 with h. one and one. before we didn't know that it was a serious flu pandemic we forget about the constant news beat on cnn, the lines in the parking lot, all those issues. there was a demand for public action. can we change that and make that argument that the argument that we are going to be safer as a country if the world is safer and so i'm wondering if one would change the conversation. number two and i think this is the long-standing hope can you make the diagonal argument rather than the series of the vertical programs competing against an argument for war is awful, is there an argument that we can actually invest in systems with accountable countries such that when you come back -- a strong health system should treat people with

hiv, tb, malaria, ebola etc. effectively and then every other and better in life we know the systems that are well organized and share basic cost of operating. businesses don't operate -- wal-mart doesn't have a separate company for each product on its shelf so it makes sense to have institutions that are well organized. so if we can make the case that broad-based investments with performance measures that could give you the kind of maybe not exact way but something close to that specificity i think is the way that he would engage congress in and the executive branch into changing the conversation. i fear that that would be a much more difficult case to make. >> we are near the end. i didn't mean to speak.

that wasn't the plan. [laughter] >> it was my plan. >> i had a sense you are being so nice earlier that something was up. [laughter] but i do want to offer anyone a chance for a brief concluding thought since i ate up the last question. >> i have said plenty >> i guess i just wanted to say i would urge everyone to continue to follow this outbreak closely. it is a really important events. there are event. there are other things happening in the world but also extremely important, and sometimes those things get a little bit more coverage and attention because they are easier to understand and sometimes they have been there before. this is a very unusual events

that is occurring and one of major importance. for people that do the kind of work i do for a living living it's like an invasion from outer space and it really does require everyone's full attention and the maximum amount of cooperation as well. we are all under threat and have to rise to the occasion. >> i would like to ask everyone in the audience to thank the panel. [applause] i would like to invite dean anderson to come out and give the final remarks. >> i would open a session by saying that i observed that those of us have tried to teach that have tried to teach international affairs at the school of the foreign service we have come out of a period that is particularly i think enhanced by the cold war and post-cold

war era in which we thought of international affairs as a matter of relations between human beings. it's been the organization of the state, the threats to the state of about the alliance between the state that has made up the stuff of international affairs and we need to veto beyond the brink in which the questions become less of relations between human beings and relations between all human beings and the challenges that have come from global climate change, food shortages, water shortages and things like infectious diseases. as our panelists have observed today. the reality may be upon the recognition and ability to respond to that change. but i'm pleased to say that the community at georgetown and in the wider circle have come together today to deal with that issue in a way that the school of the foreign service is not

equipped to deal with and so i very some i very much appreciate those of our communities who have joined us particularly john and wednesday in helping us to think about international affairs in a way that may be more appropriate for the 21st >> good afternoon.

i am delighted to welcome you to the brookings's decision -- brookings institution. i am even more delighted to welcome sylvia burwell, burwell, tolvia this event at brookings. i have known sylvia a long time. over 20 years. sylviafirst encountered in the clinton administration, i thought of her as that friendly, competent young woman who worked for bob rubin at the national economic council. i learned that sylvia was the go to person and a can-do person. that was a useful person to have around. i also learned that she liked to

keep in touch with real people out around america, not just in washington. and that she grew up in west virginia. one day, i found myself in a hard hat, deep underground in west virginia in a coal mine with sylvia, barbara ven and rich trumka. i was not the only one who noticed that sylvia was competent and levelheaded hearing the president notice to that, president clinton. by the end of the administration, she was the director of -- she's had a distinguished career. president obama had the good sense to bring her back to washington to be director of

omb. i was delighted. affection forg the office of management and budget and i always feel better when i know the agency is in a strong, confident hand. a deep respect for the difficulties of that job because it is the toughest job i ever did. but apparently, it was not tough enough for sylvia. talked her president into an even tougher one. the department of health and human services is a vital agency of government that literally affects every single american at sometime in their lives, often many times area at any time in history, running hhs effectively is a huge strategic and managerial challenge. but this may be the most challenging time of all. it includes implementing the affordable care act. is a far-reaching,

much-needed piece of legislation that has -- that is already providing millions of people with affordable health insurance and will impact the way americans interact with their health care system for decades to come. it is complex. we don't things simply in the united states. it gives states a lot of flex ability. it will play out differently in different parts of the country. it will change as we gain experience with what works and what needs to sing. -- needs fixing. people in the academic world and at ring tanks like this one often imagine that the hard job in government is making policy. no, it is not. after the political battles are fought, and the compromises are made, after the bills are passed and signed, the really hard job is to implement the policy on the ground. and that is city of -- that is sylvia burwell's job right now,

to make the affordable care act work and she is here to give us a progress report. sylvia. [applause] >> thank you very much, alice. it is an honor to be introduced by someone that i have known and followed for so long. i am sure most of you all know that alice was the original director of the congressional budget office as well as the first woman to head the office of management and budget. to follow in alice's footsteps, she was someone who has climbed many mountains, both literally and figuratively, for those who know her, and for whatever reason, in trying to aspire to do that, when i left the clinton administration, i decided to climb mount kilimanjaro. aookings is a place that has

special place in the burwell household. we like to read to her children. our children are sex and four. it is a morning ritual over breakfast. sometimes we read the magic treehouse and sometimes we read brookings institution reports. [applause] when my six-year-old daughter found out that i was coming today, i don't seem all dervish, but i do have a message firm -- from my six-year-old. on the whole aggregate gdp eating a less good measure of economic progress, she does not agree. while i am not going to get in the middle of my daughter and a brookings scholar and academic leader, i do just want to skip to the fact that i have great respect for brookings as an institution and the work they do. examining all issues, they take both the long and the short term

view. they think about and analyze trends over time, conduct smart, systemic, empirical research. and focus on three words in the motto. quality, independence, and impact. as a former omb director, those words are music to my ears. i want to take this opportunity to apply that analytical framework to the issue of health care. as we think about the question of how is the affordable care act working. then i would like to share with you a little bit about how i am thinking of the steps as we go forward here i. i have come to believe strongly in the importance of measurable impact. when it comes to the affordable care act, i think there are three basic measures. access, affordability, and quality. our more people getting covered?

access and affordability. are middle-class families shielded from suffocating melba -- medical those? affordability -- medical bills? affordability. when you consider the law through affordability, access and quality, the affordable care act is working. and families, businesses and taxpayers are better off as a result. four years after president obama signed a law, middle-class families have more security and many who already had insurance have better coverage. if -- fewer americans are insured and come at the same time, we are spending our health care dollars more wisely and we are starting to receive higher-quality care. as we walk through the evidence, it might be helpful to add a little historical context. as a country, we have been

wrestling with these questions of how to cover the insured for as long as the brookings institution has been here. as a matter fact, even longer. in 1912, teddy roosevelt's progressive party platform called for universal health care along with priorities like women's suffrage and a national highway system. in the 19 20's, women got the right to vote during in the 1950's, president eisenhower delivered this nation a highway system. franklinago, president delano roosevelt succeeded increasing social security but was unable to make roberts on the issue of a national healthcare system. 625 is ago, president truman asked congress for a fair deal, a deal that included things like equal rights for all, an increase in the minimum wage, and universal health air. congress passed the minimum wage. 50 years, president johnson

signed medicare and medicaid into law. but a few years later, another president told the congress, "copperheads of health insurance is an idea whose time has come in america. there has long been a need to access tory american health care." that president was richard nixon. heftyuntry has paid a price for inaction on health care even though president ford come up harder, bush, and clinton made this issue a priority. cost spiraled out of control and health care became unaffordable for millions of families and businesses alike. taxpayers felt the effect as well. priced outo weren't of the health-care market, many were locked out because of pre-existing conditions. and many who were fortunate enough to have insurance did not receive a very high quality of care.

by the time president obama took the oath of office, our system had broken down to such a degree that we were spending far more as an economy on health care in both gross and per capita terms that all the other developed countries. in 2009, we were spending $2 trillion a year on health care. it was almost 50% more per person than the next most costly nation. these rising costs took their toll on family budgets. study led byrvard a certain professor with a very bright future, elizabeth warren, found that 62% of personal bankruptcies were due to medical problems. what were we getting for the higher health care costs that we shouldered? fund10, the commonwealth benchmark our health care system against six advanced

industrialized nations. in that the quality, access, efficiency, equity and healthy lives. we were dead last. while we were not scoring well in these benchmarks, we are doing a lot better on some measures of quality. by the time the affordable care act was passed, tens of millions of americans were injured. -- were insured. everyone felt the impact. too many americans relied on the emergency room for the most basic medical care. uninsured children statistically were more likely to have fewer immunizations and go without prescriptions. uninsured adults were more likely to have chronic health conditions, many of which went undiagnosed. the system was not working either for millions of americans who had insurance. went bankruptwho

due to medical bills actually had health insurance. just because you happen to have an insurance card, your carrot was not necessarily affordable. if you got charged several thousand dollars for an ambulance ride that was not covered. notng an insurance card did guarantee that you had access to the services you needed. having an insurance card did not mean your doctors were effectively coordinating so that you wouldn't end up taking tests twice or getting procedures that you may not even need. thanks to the affordable care act, things are changing for the better. let's consider for a moment the evidence on the uninsured where we are making historic progress. the affordable care act addresses affordable, quality, and access. coversat barriers to like pre-existing conditions as well as annual and lifetime caps . it allows young adults to stay on their parents' policy until

they were age 26. it created the health insurance marketplace. insurance companies now can provide affordable coverage to consumers through that marketplace. during the last open enrollment, consumers chose from an average of nearly he plans. i have some news for you when it comes to choice and competition. today, we are able to announce aat in 2015, there has been 25% increase in the total number of issuers selling insurance in the marketplace. there is already real evidence these plans are affordable. just last week, the commonwealth fund released a study showing that 70% of americans with marketplace insurance plans feel they can now afford their care. and a majority say their premiums are affordable. it is no surprise therefore that, when folks evaluate the success of the law, the marketplace receives much of that attention.

reportsmarch, news suggested it would take something close to a miracle to reach 6 million people. last week, we announced the that 7.3 million people signed up for marketplace plans, paid their premiums, and have access to affordable care. borrow aon people, to phrase from the vice president, is a big deal. but i am here to tell you i don't think that is the number we should focus on very yesterday, we released another number, a significant number, and that is that 8 million people enrolled in medicaid or chips since the enrollment date, an increase of nearly 14% in terms of the monthly increases before that time. that is a significant number. but again, i don't think that is the most important number we should focus on. the number that is even more important is that, in just one

year, we reduce the number of uninsured, adults that are uninsured, by 26%. 2013,nslate that, since 10.3 million adults are no longer uninsured. i firmly believe this is the key measure. we should look at it because it represents historic progress on something that has eluded our country for over a century. there isn't a business in america that wouldn't be ecstatic with that kind of growth. ultimately, every number tells a story. i want to share with you the story of robert mailer junior, a floridian who was uninsured. roberts coverage, he signed up for the marketplace and it took in effect on january 1. on january 2, robert went to see a growth he had on his tonsils

and i'm afraid the diagnosis was bad. it was late stage cancer. after prayer, perseverance, ration and chemotherapy, robert is now cancer free. without health insurance, those treatments that saved his life would be $200,000. under the affordable care act for robert, what we saw is he paid a $2000 deductible, $1500 in co-pays, and what was roberts monthly premium? $118. i want to read some words to you from robert directly. "i was not in favor of obamacare," he said. tost year, i was not going pay for health insurance and i was quick to take the penalty. i am one of the luckiest people in the world. i'm going to live and work and be productive. so i would submit that roberts story is not a story of the left or the right.

it is the story of affordability, access and quality. who it comes to americans already had insurance, i will be straightforward with you. those of us who support the affordable care act haven't done a good job at making the case that this was something that helped those people. if you think about a mom or a dad sitting at the kitchen table working out a family budget, it is a big deal that they are saving money, still getting better coverage, and have financial security. many middle-class americans have more money in their budgets because their insurance company is now required to spend at least 80% of their premium on their health care. families have saved an average of $80 that they can live on their electric bill or back in their grocery budget. meanwhile, millions of seniors are saving billions of dollars on their prescriptions as we phased out the donut hole. more than a .2 million seniors

have saved -- 8.2 million seniors have saved $5 billion. middle-class families are benefiting from the real security that comes from knowing your health care coverage will be there when you need it. to worryno longer have about losing their homes or having their hard-earned savings or anaway by an accident unexpected diagnosis. there is security in knowing that, if you lose your job, you can purchase market place coverage, even if you have a pre-existing condition and you won't lose your insurance just because you get sick or get caught off or if you need chemotherapy or some life-saving operation. a healthier and more financially secure middle-class is good for business who benefit from a healthy workforce and consumers with more disposable income. the bipartisan policy center reported last week that businesses lose $576 billion each year because of an

unhealthy population. as the new law makes our population healthier, we should be able to ring this number down. some of the biggest and most positive impacts that businesses and taxpayers feel from the law are in the area costs. since president obama signed the affordable care act, there is evidence that we have been to the cost are when it comes to health care. we have held down health care price inflation to the lowest level in 50 years. premiums for employer-based coverage have been driven down as well. earlier this month, kaiser reported that this year's cost growth is the lowest on record. that, hadprojected premiums ground at the rate we saw over the previous decade, instead of the slower rate of the past four years, employer coverage would be $1800 more today. thisu are an employer,

means it is easier for you to hire workers. if you are an employee, it means you can be keeping more that in your paycheck tomorrow. if you are a taxpayer, it means a healthier economy. improvements to our health delivery system are also having an impact on costs to taxpayers as we spend dollars more wisely. $160 billionyers in spending medical dollars more wisely. in a further example, the accountable care organization models we are testing through medicare are saving $370 million and counting. at the same time, they are delivering care that is more coordinated to beneficiaries and rewarding providers that do that. taken together, i believe the evidence points to a clear conclusion. the affordable care act is working. my job as secretary is to lead our efforts, to keep it working

and to help it work better. like anyone in business, we want to learn from the things we got right and the things we got wrong. we are taking that approach and we have a four-part strategy moving forward. first, improving access and affordability through the marketplace. in order to make sure that americans continue to get access and affordable choices, we have to get healthcare.gov right. to me, the formula for this is technology, management and prioritization. off thehecking outstanding items from last year's to do list, cleaning up the backend personality and adding functionality for inewing and enrolling coverage. we are prioritizing the most important issues and the areas to improve consistent with our deadlines. givingfocusing on ourselves the appropriate amount of time for testing and we are very focused on security.

anyone who can ever manage a wrought -- a large scale arctic knows that these are challenging and require tough choices. we are prepared to make those choices so that we can deliver the best consumer experience. second, improving quality for patients and spending every dollar wisely. we are testing new models in medicare and medicaid and reaching out to the business community to find solutions that we can all benefit from. changing incentives from volume-based to more impact-based systems come investing in tools that can expand our capacity for change in the health care delivery system, improving the flow of information so doctors can spend more time with patients and less time doing paperwork, so they can coordinate more effectively with the -- with one another. third, expanding access by expanding medicaid. one of the first meetings i did

with -- was a bipartisan meeting with governors and i said to all the governors we want to work with you. we want to work with you to be flexible, to expand access to medicaid. in the time that i have been there, we have added pennsylvania, a state with a republican governor, and we are hopeful that we can work together to do more in that space. consumerslping understand how to use their new coverage, including the role of prevention and wellness. many of the folks who are newly covered have not held health insurance in years and some never before. we want to make sure that folks know how to use their coverage and we are partnering with organizations across the country to help them do so. i would like to close with one final thought. as we work through these issues, i think we need a bit of a course correction when it comes to how we talk about these issues. it starts with collectively turning the volume down. surely, we can all agree that

the back and forth hasn't really helped those that we are trying to serve in terms of delivering for the hard-working families that we all try to serve. i prefer a brookings-type approach, quality, independence, and impact. a small business owner from texas wrote a blog for the hhs blog. what you talked about is what it was like to be uninsured. she talked about what it was like to be insured but not have a member of your family be covered because your son had a pre-existing condition. she wrote about, for her family, the affordable care act is working. i want to read to you a few of her words. "recently, i was able to enroll my family, my entire family. not only is my son finally covered, our premium is only half of what we were paying before. i was shocked to learn my prescriptions, which used to cost $280 a month, now cost five dollars. my dog -- my family now has the

financial security and jim and his peace of mind that comes with coverage. i don't have to work for someone else just for the health benefits anymore. i launched my small business and can focus on expanding it." families across the country are counting on us. they are our boss and they are looking for this to work. let's work forward together. iq. -- thank you. [applause] i am happy to take some questions. yes. >> thank you. i am from the american cancer society. people touched by cancer know have available insurance is. the challenge for all of us has been making sure that people who have not been touched by the disease or may be at risk for it

, how the law can help them. as well as those who have coverage through work, how the level stirs that. what will hhs and cms be doing to educate those people about the importance of the law. >> in .4, when i talked about the coverage and the covers, i think the point you raise is one not just for the newly insured but across all. i think many people don't realize the extension of benefits for prevention and wellness. i think that is probably what you are referring to specifically. one of the things we will do as we do our education for the uninsured is do that more broadly. the other thing is, in our conversations with the employers , that is a place where we are having a lot of conversations. i think many employers are

what we want to do is our own messaging, but we know in this case things will move more through our partners, the stakeholders on the ground,, people who are delivering to move that message out, and it is an important one. earlier, i dode not think we have done a good understand what the affordable care act did. yes? >> thank you for your remarks. hospitals were deeply involved in giving people -- getting people enrolled. for hospitals that were not yet engaged in that war have hesitated because they are in states where the aca is not as popular, do you have guidance for those in how they can work in their community and getting people signed up? >> thank you for the support and

help. with regard to the state where the aca is not as popular, one of the things is making sure states reach out to us. there are regional offices across the country for hhs, and with the hospitals, weather coming to our business organizations in washington or the regions, that might be more familiar with the challenges you are articulating, we want to work with those so we can enable them to do what they can do. now that people can see last time we did not have something we could point to. we did not have those stories, and we are hopeful that will be an element that can create a better environment, that where the environment is still out, we will work in ways that will work for the context that these hospitals are in. we are working with hospitals, insurers, stakeholders. this is an all hands on effort. yes.

one of the things as we think the number of latinos who are signing up for the law could be improved, and i am wondering your thoughts on how we can make a more concerted effort to get to that community and make sure their community is covered. place, and important we believe we can make progress, even more progress this year. one of the things we need to do is listen, listen to the feedback we received last year about a number of challenges. some of those challenges were technological, and some came and other forms, and we are trying to work through and make sure, whether through our navigators, to how we share information through language issues, that there are a whole suite of things we're working on to make it easier to engage in the system and, second, to make sure we are sharing the information so people can understand what it

means in terms of the benefit that it will mean. and then work with stakeholders that are closest to these organizations to help make sure, whether it is how we phrase something, explain something. often those kinds of things are making a difference. we have heard from probably some of you all here on the issues of our challenging. leaves keep letting us know. the ones we can fix, we will work to do that and do that as quickly as we can. in the back. thank you. i wish the national center for transgender equality. and with all the great things that have been done for years rules for thehave active civil rights provisions, and most people have not heard of those provisions, including providers i have talked to. we have delivered hundreds of those stories of discrimination to the department, and i would like to know, are we going to 1557 implement he

rolls this year's? >> that is something we are most focused on, making sure as we are getting the system up and running that if there are issues of discrimination that we are working through those. thank you for doing that. with regard to that question for the specific timing of the role, not something that i am at this to a ready to commit specific timetable on where we all and that. consider the issue extremely important. you know the administration's commitment on a number of fronts to the issues around making sure that there is access and that the access is not discriminatory, that cuts across a wide range of issue. we want to work to make sure we are enforcing the law and understand the importance of the issue of that specific provision . thank you. thank you very much. [applause] >> on behalf of brookings, i

want to thank secretary burwell and thank all of you for coming and listening out there. and good luck. we need this thing to work at hh s, and we are counting on you to make it work. thank you. [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute]