predecessors. the team that appeared to be likely to get around a long time. the other end will have a lot more of weather is not kindly called the old will people who are above 85. and so it will be financing, but the actual provision of care and figuring how to take care of chronic care populations with the help care system that is still very much focused on acute care. ..

to the physician payment reform i think lance for the optimism to my belief that they will be avoided change the way that there going to get in such a way that help to close some of those even as new people become eligible. and, of course, we will also be bring in more people who better coverage throughout the lifetime. i think we have reason to believe that can make a difference and helping us of the people who are becoming eligible for medicare which also has an

impact. the ben keating preventive care their entire lives, not even getting access to the kind of care they need to prevent hospitalizations. that will make a difference. we've also made huge strides in quality of medicare. and the past few years reduce the admissions rate by 10%, reduced hospital record conditions by i think 17%. all of those things make me optimistic that we were able to work together to deal with the next changes are we need to make to accommodate the bulk of the senior to be joining medicare. >> talk for a few minutes, medicaid. in this video i talked about before the did for the kaiser family foundation, it's been updated to effect the changes over the past decade, available online if any of you want to see it or use it at conferences our

classrooms. but -- [inaudible] makes the point about medicaid that for many years we've seen medicaid synonymous with welfare. the words are almost interchangeable. that linkage has really been broken in recent years. so i would first like what you to take that issue on and give us an long view of how medicaid has transformed itself quite radically. >> bruce was the head between us. if you think back about how medicare was set up, it was explicitly tied to the receipt of welfare. so it's not an accident that people thought about medicaid and welfare as being synonymous. it was a major reason good medicaid. when i was around, i'm sure when

nancy-ann was around also, people would complain to me about all of the low income people, sometimes poor, very poor depending on their state and with the income cutoff was, as to why medicaid was such a bad program like that. my response was that it's not fair to criticize medicare bring something nobody structured it to be, which was a java program to support people because they were both income. that they can to change noticeably in the late 1980s very active work by henry waxman who was head of the health subcommittee of energy and subcommittee, commerce, a passionate supporter of medicaid, to use and what was regard as not a very friendly hospital period. all the strategies he could think of to break some of the

linkages. initially by having women who became pregnant become eligible for medicaid up to very high income level. having all the children who were under 100% of the poverty lines become eligible for medicaid coverage. it's that gradual change with a big push during the time that nancy-ann was there was what is called a tanf program, the welfare reform -- for program the president clinton signed into law in 1996 where that for the changed between welfare and eligibility. but it's obviously the affordable care act which expanded medicaid coverage to those who are 130% of the poverty line, the respective of other characteristics to be eligible for a program like

medicaid that really most transformed this to the program that is not in the books for people because they're looking come. i would have personally preferred that as a senator one point allowed to people about the pakistan have a choice about whether to be on the exchange or in medicaid be able to take their money. but the fact that we now as a country allow for coverage if the state buys in, then surely the file decoupling of medicaid and welfare reform, welfare receipt as i see it. >> the other thing that happened, less ago stock interested in was writing his dissertation about medicaid, was writing about 1115 waivers which the people in the show know what they are but just to explain, it's a provision of the law that allowed for states to give

experimentation in consultation with approval of the hhs, the agency running medicaid. that provision was around since the beginning of the law. it was in there in 1965 but it really wasn't used until the 99. it allowed states to quite a bit of experimentation which they used to build on some of these changes, and expanded the coverage. medicaid dollars were used in tennessee to cover more uninsured people, got pushed to the eligible for medicaid. that led to things like massachusetts connector and that health care reform. you can draw a straight line between that and the affordable care act your service take experimentation, the state laboratories of health care

really was enabled by the medicaid program. that is part of what led us to where we are today with a much broader program that is really an indelible part of the fabric of a great society. >> what are the implications of ethnic secretary sebelius never forget as a two-tiered system, with some states expanding medicaid under the aca in about 20 or 22 other states choosing not to. what are the implications of having a system like that in place? especially for the recipients. >> we had something like that with the beginning of medicaid in that it took, it's only been a volunteer program for states to decide whether not they can decide whether to adopt the medicaid. they had a financial stake in. it took 10, 15 years for all states define decide to have a medicaid program.

even with the state children's health insurance program thought helped to put was passed while i was there. that took a handful of years for every state to find decide they would adopt an epic children's health insurance program. so some of this is just what happens with these new programs. it's part of the passions around the issues, around health care that you talked about. but look, it makes a huge difference. i'm not going to go to fight all the study but we are already seeing evidence that makes a difference if you live in a state that has expanded medicaid and you are getting early lab test to determine whether you have diabetes or not. that makes it different in your life. it makes a difference for hospitals insurance other uncompensated care. that's why i'm confident that over time all the stitch going

to have this program. program. >> it sounds like that which you believe, that over a period of time all the states will sign onto this. do you think in a decade, dangers? >> i don't think it will take 10 years. >> we are clearly seeing more states that are signing on. i thought as angry as governors and republicans were, i think is almost impossible to understate the level of anger. i've been in a few meetings what it is bubbled over and i was somewhat taken aback. that i assumed it was so much money on the table they would take it but i was wrong. in 2014 came and went and -- but you are seeing in their own way a number of the red states. if the legislation as well as the governor is willing to find ways that are acceptable, and i

agree with nancy and i think you'll see this continue and it will depend a lot on what happens in 2016, after which i would assume most people that look out will trigger some significant modifications that are going to happen to the affordable care act. not necessary bad, but modifications, or they are not depending on what the election produces. and maybe then settle down and looking at things as they are. but not have it expanded coverage is a problem. it's a problem for the people who are uninsured. it's a problem for the communities where they live, for the physicians and hospitals that ultimately provide and services because among other things medicare says to a hospital turn someone away and are not medically stable and we will teach you. medicare doesn't enforce all of

its rules but the so-called, which is what is under, that's one of the ones they vigorously enforce. and trying to get coverage in we can debate how much coverage and where you should buy it and who should fund it, but the coverage is really important. and i think that is becoming more accepted with a lot of debate about how either it should be or should have been, but at some point it is now clearly the law of the land and people are going to move on. spirit you asked what we learned from the original medicare and medicaid. the one thing was the flexibility those built into medicaid to allow state extreme edition and you see that happen with a number of republican governors who are choosing to try to work with the british

asian to expand coverage. asking folks to do things like italy whether come and democrats, whether it's offering private plans or some variation in co-pay and that kind of thing. i think that's healthy and that will continue. >> give the admission credit for being more flexible in some of the requests that come your way that i thought might be the case. trying to encourage interest. sometimes republican governors take the rap. people ought to look in some cases the governors would like to make expansion by the legislatures are adamantly opposed. fact to be responsible for 10%, this tempest in a big expansion? that's not a relevant issue. the question will be can you find a way to expand coverage as much into as many people as possible.

>> i want to open it up to the audience right after this question. you mentioned 2016. we are entering an election season. what are your expectations about whether parts of medicaid, parts of medicare would become part of the political discourse of the next year? >> of course. they always have been. one of the guarantees that anybody has been involved in running medicare and medicaid has is when an election comes up this will be an issue. it has been as long as i can remember. it's hard to accept that we are already into the 2016 election cycle quite as much as we are. there's no question that medicaid, affordable care act, the health care system in the u.s. will be an issue. whether it's as much a niche in

the primaries as it becomes in the final election, the regular election or not, that depends on the parties as to whether not that's really what's motivating their candidates -- >> and how this up in court both. >> that's no small issue about what happens there's going to be a scramble in washington if the supreme court supports to defend the plaintiffs. and if not there will still be a lot of response but it will be a somewhat different nature. >> i guess i disagree a little bit. health care is always an issue in an election. it's just something that people care about and it will be an issue. i don't think that the candidates once spent a lot of time talking about medicare. i just don't. i think except to say they support. look, give a program that has on

with the approval ratings are but they've got to be two or three times any politician recently. it's a very popular program. >> that is a low bar. >> perhaps. is a very popular program and should be. people have stable, affordable for the most part coverage. provided a changing in ways that i think are helping to bring down the rate of cost growth. the program is solvent until 2030. there is no house on fire here. we need to work together on a bipartisan basis to make sure that we are improving and strengthening medicare for the future. and i believe we will. medicaid could be an issue and agree with gail, the affordable care act seems always be the issue of the day. i don't think medicare except to say i am for it.

>> any questions? very quiet audience. you i'll need some lunch i think. no? okay, then let me wrap up and ask you each a final question. the previous panel speculated about what folks would be sitting on this stage be talking about 50 years from now. i think that's too far out. let's talk about 10 years from now. what do you think will be said about these two historic programs. >> ten years from now we will know a huge amount now about this tumultuous period in health care than we had just gone through. i think actually in 2018 we were no a lot that we don't know now. in terms of how much of a slowdown that we've been seeing

which is very important for medicare as well as health care in general is a drag from this very long, very deep recession, or some early successes, some of the changes being tried. but not necessarily is a sustainable or sustained. by 2018 i think we are likely to of seen three or four years other robust economic recovery. and then we'll have a much better idea about whether some real change going on. that second thing that we are going to know by the end of the decade is whether or not most of the savings in medicare which are not because medicare cost less but because medicare is being reimbursed at lower rates as a result of the affordable care act, it was built into the legislation. legislation. adding some and get paid less, does that mean that cost less? hope is it will drive hospitals and physicians to figure out how to do it for less money with some of the pilots, whatever.

but we don't know that. it's why the actuary in 2010 says he's not sure that these reductions that are legislating, are going to be able to play themselves out because you begin to have too many access pressures for seniors that congress will not tolerate. acid, won't in the future either. so by the time we get 10 years out, we will have had a lot of baby boomers retiring. they would be very impatient demand as they always have been as we have gone through every phase other like putting a lot of pressure on medicare. we will have a much better idea about whether we really have figured out how to slow down in a sustainable way the rate of health care spending the most people forget we spent the whole decade of the '90s, 10 years. that's like a lot longer than since 2008 or 2010 yet, with

health care spent at about 13% of the gdp. very close to spend and robust economy. after that decade it all went away. that was because the kinds of changes that driven out of were not sustainable. we are trying different things. i'm hopeful that leaves some of them will, maybe because i'm older and have been around longer, just want to monitor, i will mention the reason we have the uptick in medicare rates, medicare advantage rates announced a week or two ago because medicare, the actuary says spending is going up just a little. not a big issue. just a reminder we don't know yet what's happening. i think a decade have nothing much better idea. i assume people have gotten over the affordable care act one way or another. we will have modified it until

just accept it as effectively. >> no more repeal though. >> exactly. so i think the deal is right that the economic and fiscal issues will still be with us. celebrity sitting on the stage in 10 years, big years will be talking about that. and also about quality and how we make sure that our medicare beneficiaries and our medicaid, the working comes to receiving medicaid are getting good quality care. all these issues will still be here. i can't get the specifics but i will guarantee one thing. we will still all be celebrating the creation of medicare and medicaid and the brilliance and compassion that led president johnson and the other leaders at the time to bring these two programs to be part of the fabric of our society. >> think you both so very much. really appreciate it.

[applause] >> thank you all very much ethics to all of our speakers, panelists and moderators, and to yes, robert wood johnson foundation. please join us for lunch on the second floor. and thanks most of all to all of you for attempting to be. thanks again. [applause] >> julian bond, a leading figure of the civil rights movement and former chair of the naacp died over the weekend at the age of 75. mr. bond had a long career in politics serbia and the georgia state legislature and was cofounder of the southern poverty law center. an interview in 2011 he was asked about the state of race relations in america since the election of president obama. >> what has it meant for the civil rights movement, which you've been involved with, for

your entire life, and still are, as chair emeritus of the naacp, to have a black man elected to president of the united states speak with it means the work we've been doing since 1909 has been worthwhile. we were talking together and joked upstairs about the headline in the onion today after obama's election. black man gets worse job in the united states. [laughter] but it means that the work we've been doing for all these years has paid off. it doesn't mean that work is over. there's more work to be done, but no one can believe that barack obama would be president of the united states had it not been for the work of the naacp and many of our positions, groups and individuals of the work done by the people in these groups over the last several years. so is like vindication for all of his labor, all of this effort has been worthwhile ever happy to go to do it and see the

results of the. he spoke at our convention in 1909 -- i'm sorry, 1999, our centennial convention, is that right? 2009, thanks. my wife is here in the front rol -- [laughter] -- and she said many, many wonderful purposes. [laughter] one of them is correcting me. >> i'm glad she did it because i couldn't get it rightñl either. >> at any rate, he spoke to our convention in 2009, and we were so happy to see. he spoke to us as senator obama. he spoke to us as candidate obama running for the presidency. he spoke to us as nominee of the democratic party and have him come to us as president was a great quick thrill to all of us. >> when he was first running and even as he was nominated, there

were civil rights veterans, members of yours and mine generation who seem to be resentful. particularly because he had not lived what they regarded as the black experience. i think jesse jackson was probably the front runner of those who seem to be unhappy about it in that respect. is that important? >> is important, i think it's important to note that also important to note reverend jackson became a strong supporter and is a strong supporter today, campaigning vigorously for him, i'm sure the campaign taken for him when he announces his campaign to win undertakes his formal campaign for reelection. many of those people who felt that way, i felt that he would make a wonderful president. has friends in chicago get on with this great state senator,

he will be president some day. i think you to be a u.s. senator, is going to be president and we was a shrewd. he began to run and what a couple of primaries and said oh, sure. then he won in iowa and to me that was, if they can win in the widest of the states, if you can run all the way and become president. i became a convert in the had not been before. i didn't not supported because i dislike them anyway. i just didn't think is possible and it wasn't going to waste my vote.ñx he proved to me he could win and i was happy to support him then. >> and to have an african-american, and the white house, african-americans and the united states are stillñl disproportionately suffering from poverty, ill health, poor schools, all of the otherñl illness.ñl that you've worked so hard to correct in many ways, succeeded in cracking but not in everything.

is it harder now to argue for affirmative action, argue for issues, argued issues of that kind? >> it is a little bit harder because the feeling in the population that had elected a black man, these problems have all been solved, gone away. the remedy to solve these problems are no longer needed anymore. of course, that's false thinking. that's that you. the fact that white men -- a black man is in the white house does not mean the country has become a wonderful place where everything is happy and everything is fair and equal. but because many people to believe that it is harder to argue for these things, we will argue for them nonetheless. >> you can watch the entire interview at c-span.org. president obama issued a statement on the death of julian bond saying in part michelle and i have benefited from his example

julian bond help change this country for the better.

>> tonight on "the communicators." >> usually into computers and the sci-fi and i pushed him and then he always heard about silicon valley and drink of getting to america. so from a very young age that's what he pointed to end at 17 he just went away from home and david. >> bloomberg businessweek technology reporter ashlee vance on one of silicon valley's most inventive leaders, elon musk. >> in silicon valley today he is seen as this next steve jobs kind of figured. he's got this attention to detail. he pushes his work is really hard. i kindly more to more of this edison kind of idea although i think elon has a lot to prove. what i taken what is he is a guy who gets these thousands of engineers, the brightest of the bright, it is very hard-working individuals and really is able

to get products out of them that can be commercialized and that every change industry. if you look at today he is the guy who has come his combined software and hardware, this idea adams and it's in a way that nobody else had. >> tonight on the community on c-span2. >> with vista in its august break we will feature booktv program weeknights in prime time on c-span2

>> more now on the 50th anniversary of medicare and medicaid. the aspen institute, lbj presidential library and robert wood johnson foundation teamed up to host this discussion with former health and human services secretaries kathleen sebelius and michael leavitt. this is about 45 minutes. >> [inaudible conversations]

>> i think we're ready to reconvene. welcome back. our next panel is on the front lines, to hhs secretary's and state governors put medicare and medicaid into action. i'm going to turn things over to ruth katz, executive director of the health medicine and society program of the aspen institute. but before i do i just want to say thank you so much for all you've done to organize a wonderful conference. so thank you and welcome to ruth katz. [applause] >> good morning, everybody. as you just heard on ruth katz, director the health medicine and society program at the aspen institute. we are going to move quickly into our next panel because we talk about the front lines of medicare and medicaid and what it takes to programs to welcome both the federal and state levels, there's a lot of ground

to cover but i'm sure you would agree. we brought together the right people to do just that. walter isaacson is your detail you'd more about those folks. walter is president and ceo of the aspen institute, my boss. as media is also a subtle but a journalist and biographer. he has long been interest in leadership and creative people make things happen. benjamin franklin, henry kissinger, steve jobs and albert einstein are just some of the great thinkers and doers who have been the subject of this approach. walter, thanks for guiding us to the next panel. walter isaacson. [applause] >> then let me have the great honor and pleasure to introduce governor sebelius and governor leavitt. they've also both been sectors of health and human services, but we all agreed that if every job in america, especially of

all jobs that lyndon johnson never actually held, the job of governor is the kind of you where the rest until it because you can't a whole lot accomplish. having said that as sectors of health and human services, both michael leavitt and kathleen sebelius also got an enormous amount accomplished. mike leavitt, george w. bush in 2005-2009 and, of course, governor sebelius was under president obama, 2009-2014, specially during the affordable care act years. but also oversaw the center for medicare and medicaid services, and thus we're going to talk about some. governor leavitt was deeply involved in implementing medicare part d are both were vigorous proponents for the reauthorization of chip, the children's program, and got it

done. in some ways i think your perspective as governors having to administer especially things like medicaid will bring a particular insight. so it's my pleasure to introduce to very close friend of the aspen institute both with, whether last summer, while the help will be there again this summer. governor sebelius and governor leavitt. [applause] >> thank you. thank you very much. you once said, governor leavitt, when you were the secretary that use of medicare and medicaid may be drifting towards disaster. how did you help stop that, and our we still any problem that could have been? >> at the time and make a statement we were moving toward a breed of time with the trust fund would be insulted.

everything about this time the trust fund, trustees meet, governor sebelius and i both had that experience and would go into a room at the treasury at a very unheralded meeting but would all sit around the government actuary would host the results. the reality was we were moving in a way that the trust fund would become insolvent. while the date has been delayed some that still the fundamental problem that we are spending more than we take in, that trust fund is slowly being depleted and doesn't make medicaid anything but good. it's but good. it said remains with to deal with that problem spent its mailing medicare your talk about which the trust fund has been deployed. how would you solve it if you could do that with just the stroke of a pen? [laughter] >> we are in a fantasy world here. >> it is a very complex question but i would think there are

things that need to be done. the first is the whole incentives of medicare and i think sector, governor sebelius would agree, that come unstuck, kathleen would agree with this, that all of the incentives and medicare are base of the around more. providers gain more money if they do more procedures. the patient is the incentive for anything other than that. of those who are paying you have this thing. so as being able to align them to begin to reward volume -- value instead of volume, the sister of the commercial market but medicare is the largest player. i would say that if i'm learned one thing as the secretary of health, it would be if you want to reform health care yet to modernize medicare. it's the only system that literally is indeed an entire system of health nationwide. >> governor sebelius, i'm going

to give you this magic pen, what would you do to reform medicare? more broadly, the whole health system. >> i would agree with my friend and colleague, mike leavitt, that reforming health care really is and starts with reforming medicare. because it touches every hospital, every doctor, every provider, every drug company, a medical device company. so what ar heard over and over again when i first came in from both private employers and the best leaders of health assistant is we live in two worlds. we are trying to move, trying to shift medicare is from the plant in the 20th century. total fee for service. the more you do the more they get paid. our comes are not looked at, measured. i think actually, walter, maybe

this in the most important frame of the affordable care act, a lot of attention has been paid to the marketplace. and expansion of a portal coverage for people who didn't have it, and that's critical. but there is a provision that for the first time in history allows us and for medicare and medicaid services to test these kinds of protocol that are designed to decrease costs in the children's insurance program, and medicaid and in medicare. and if they find and certified by the actuary that it is a cost reduction and quality is at a minimum maintain or ideally increased, they can bring it to scale administratively. no longer a demonstration project. so they are on a very aggressive timetable. >> keeping an example of what that was. >> okay. so one of the focus areas was in

the last couple of years -- well, i'll teac give you two --e on hospital with heart conditions where -- >> infactions? >> infactions, wrong drugs, wrong surgery, whatever, not what brought you to the hospital but what happens to you in the hospital. and 50, 60,000 people a year die, and millions more are injured and have longer hospital stays. so the federal government and cms said what pay attention to this, have a baseline and you hospital systems have to take this very seriously and we're going to begin to deduct payments if your infection rate doesn't start to drop it for the first time in history there is a 17% drop in overall hospital-acquired conditions nationwide. that is roughly $12 billion in savings, and millions of people who are spending less time and

did encounter the same with readmissions. those on the minus side, people who circulated right back in and didn't see a provider. but if it there's a lot of plus side going on. then you accountable care organizations and different climate of doctors and patients in medicare with the goal of keeping people healthy and the first place spirit in other words, dictate the whole population -- >> they are risk-based. but if there are savings from reduced hospitalizations, from the people staying healthier, that doctors chair and part of that cost and the patience clearly are better off. and the government shares. we have the lowest health inflation for the last five years that we've had in 50 years. that includes medicare and -- >> what proportion is because of the affordable care act? >> i don't know. i think it's impossible to guess at this .5 years out that it is not part of the framework. certainly the recession started

it, but whatever is going on for the first time, health care costs are training with a gdp, which hasn't happened. medicare went from six to 8% year in year out increases. last year it was .2%. so the cost increase in medicare are not because of health cost going up it's because the population is 11,000 people a day are turning 65 and coming in. we have a per capita cost have never looked like this before. >> just a punctuation point on this. there was a provision in the law about five years ago that if medicare ever got to the point that it exceeded, that they support for medicare it exceeded 45% coming from the general budget, that there was a responsibility of the secretary to notify congress and to present a plan to remedy it.

i happened to be the secretary when we crossed 45% of the support medicare coming from general tax revenues. and so i met that obligation by going to congress and sing to them, you know crossed this threshold are either obligation to present you with an alternative, and i have great a list of $168 billion of options. and the deficit is 3 billion. so your job to solve this would be to take they wanted $68 billion left and select three of them, $3 billion to satisfy it. it was, they just change the law. they can have a requirement to heal that. the reason that love and the reason that it's important on the 50th anniversary of medicare to talk about this is because the affordable care act in order to pay for it requires that we find $500 billion in savings from medicare in order to fund the affordable care act.

where is that going to come from? it's going to come from is not found in medicare, come from the general fund which competes with everything else. so my point is, your question about drifting towards disaster. we ar do so with the 50 annivery and to recognize that it is vitally important that we find ways to fix this because it's such an important part of the fabric of america. but if congress is enabled on its own to find $3 billion, how are they actually going to find $500 billion? you can put it on the skeptical side on that one if you will but think what kevin is because of the system that has to become more efficient through means of changing the way we approach this becomes important for the next 50 years of medicare. >> and that's the underlying solution as opposed to just congress making a few fixes is to have it changed the way

medical care providers speak with in my view, the political will does not exist to solve this problem legislatively. >> that's what so important about that piece of legislation is spirit congress has to create a mechanism by which the marketplace begins to prioritize what's done in begin to find ways of making the system more efficient. >> medicus often thought of if they should be inefficiency is it isn't that we can't issue a check is officially. medicare issues a billion checks a year and doesn't cheapen anyone else in the world. what it doesn't do as well is to find ways in which we are healing the overutilization in care and beginning to squeeze out the inefficiency that is very much -- >> you and i had but i felt was a fascinating dinner in a restaurant a few blocks america which on a napkin, we don't have enough cancer, -- we don't have

a napki napkin here. you sketch out a different type of model for how you would give population care make things more affordable. please explain that to us. >> for those who don't follow this as closely, currently there anyone who gets a hospital bill will see that it is itemized in a thousand different ways and there's a bill for the aspirin and go for the tylenol and a bill for the bandage and a bill for the search and so forth. there's no coordination. it's an uncoordinated system. if there's one thing you can get republicans and democrats to agree on, i think they're a couple of things, uncoordinated care is not as good as coordinate care and the second is a system where talk about that we have both spoken of, this fee-for-service system is the enemy of efficiency. you have to create instead is a set of the candidates were summit is taking responsibility to coordinate the care and to provide, to keep patients happy

and keep it within balance. that's the essential direction i think you get republicans and democrats to agree upon spirit that was grading both coverage and supply of health care within the same organization? >> there's little doubt that it is widely held american aspiration for every american to access to health insurance. i don't think that has changed. there's differences of opinion on how that should be accomplished but having the risk of care aligned with those who are providing critical part of the. right now what we have are people paying for care who have no reference. like any other part of the economy that creates misalignment. >> i would say that's what governor leavitt has just described is exactly what is in the framework and exactly what is being tested for the first time all over the country.

with accountable care organizations, with paying for bundled care. for instance, you or i going to have my knees replaced it and in the past there's a series of special is that i would see up until the point of the surgery and then there's somebody is selling this device and a surgeon, anesthesiologist and so my days in the hospital and rehab and i might get an infection come back in. each of those was described as a separate stream, each separate olympic and me a minute talk each other, may or may not coordinate. i may have a duplicate test run. i may be kept in 14 different drugs. that system now is being looked at as one payment for a knee replacement. and actually the payment going to both the doctor and hospital accounts or not what happened to

me in the hospital but for 30 days after i get out of the hospital, recognize its very critical data to my rehab and delicate confection and somebody checks on these i don't come back into the hospital. and actually outlining payment with a strategy battled integrates and coordinates that care because they payment stream is all the same, but we now the base of electronic health records that did not exist prior to 2008 where all hospitals and the vast majority of doctors can now see charts and see friends and share information. and, finally, the payments are online with keeping people healthy in the first place are so if i get out of the hospital faster, if i go through my rehab on and were expedited basis, if i don't get an infection, the pain is the same. as if i were to go back in. and so that is finally beginning of an alignment of paying for

really more efficient or more ordinary care, expedited care. you don't want to get more test because fo frank if you run 100 test you would get paid the same as if you run to test. you need to do the appropriate care and there's a risk adjustment for sector patients. but the kind of system that mike is talking that is actually what people are testing and trying right now. in cms has said in the own timetable there was 0% of the payments out the centers for medicare and medicaid services in 2011, have any value proposition at all, 0%. we are not 20% in 2015. it's going to get a 30% next year, and by 2018 the 50%. that's an amazing shift. and for the rest of the care

there will be quality measures attached to it. so the new system is at least being framed right now. and with medicare, $580 billion a year in health spending. at that move is made, private employers make the move. health systems make the move. it changes the whole way we think about. >> do you think medicare will make that move if you had your pen right now? >> medicare will likely be among the slowest to do it. the private sector is moving much more quickly to adopt this. could i say i think what kathleen has said, there's ver little disagreement among republicans democrats on the point she's making the site i think you can clearly argue that when the bill was written, that the recent disagreement between republicans and democrats because many of the ideas were things of which there was agreement before. but if you take the affordable care act you could break into

four basic a box effectiveness against edwin insured. the second is what calvin is talking about and find ways in which we can make the system more efficient. the third box would be shifting wealth to pay for getting a foot in sugar and a fourth and who gets to make all the decisions about this. there's little dispute on the peace we are talking about. that is agreement on how to get people insured, not if and there's a lot of disagreement on how you pay for this entrance of how much can be afforded at about disagree on how much the role of government should be in place. this is an ongoing discussion. that is to say, rarely is there legislation that simply solves an issue is complex. this is an iterative process. i think were going to see another round of discussion over time, and it just has to be that way. >> speaking of iterative processes and lyndon johnson, your father wasn't there in congress during this period we

talked about where people could gather together, make the compromise, do everything with the stroke of a pin. is it possible now to do what governor leavitt said, which is that democrats and republicans come together to make the fix is? >> i think you've seen recently some encouraging news out of, particularly out of the senate. well, in the house, too, to have leader pelosi and speaker boehner negotiate and sgr fix that is sustainable growth rate fix that's been talked about forever, and probably it's the single biggest threat to medicare existing. but it hasn't been solved. it looks like the senate will adopt about bipartisan measure the past the house. that's very good that the contentious issue that has been solved. the recent announcement after -- out of the foreign relations committee that there's a

unanimous vote on the senate side around a structure for oversight of an iran treaty, potentially. i think there is clearly conversation going on, engagement going on, but i think that this is in me talking, the our a lot of people who say this is the most polarized congress. it doesn't look anything like now in 64, 65 when my dad was there. to resume democrats you didn't really have to compromise with many people, although it was an effort to bring republicans along. i think this is a changed congress were both on the democratic prize -- site and the republicans are because of redistricting and because of the way lines are drawn, particularly in the house -- >> not to correct or put back too much, but there were a lot of democrats, but she needed to,

because richard russell's not going to on a civil rights bill, for example. we are now more ideologically split as opposed to having both parties have shifting alliances. >> i think that's right and i think the kind of gifted and extraordinary hands-on person by person political skill to lyndon johnson had, that was pretty unparalleled before or since. i would say it's not one of president obama's strengths but he would be the first to say that. i think restarting, trying to engage, but he has not been a hands on relationship builder in the way certainly, no one has had the where lyndon johnson did it i would suggest, but there've been lots of others have done a lot more average. undertake that is one of the issues and problems. >> especially your father. i'm going to turn it over, and

the people who would rather ask questions then hear me do it. but here's a tough one. suppose the supreme court, you know, not the underpinning of the coverage part of the affordable care act, what fix would you suggest as, i will call you a moderate republican who cares about this issue? >> well, i think the first thing that will settle in as a realization is that this will have an effect on millions of people. so they will have to be some way of being able to find a solution to this. there will be those i suspect who will say this is a great opportunity for us to just blow this whole thing up and, therefore, we ought to do it, it's important for america. then there will be those who say we can't do with the problem of 11 or 12 many people would be affected by. i expect if it were to occur that would be some form of solution, legislative on regulatory that would at least

bridge repeated during which time a solution need to come up. i think this is part of the iterative process that we go through as a society. speaking of iterative processes, i was just remembering, 10 years ago, i don't think it was to the day but 10 years ago this month when we were celebrating the 40th anniversary of medicare, as secretary i went to the harry truman museum and i sat on the same stage and i used the same desk. and as a republican i signed an order begins the application of medicare part d. we went there for purpose of celebrating an american ethic. and it is one of great caring for those who are elderly and who are in hardship. and as we celebrate this today,

i think what we are celebrating is that ethic. it is not simply the process that medicare has been perfect or that medicaid is the way it needs to be. we are celebrating an ethic of caring. and part of that carry i think has to be finding ways to solve problems that will perpetuate that ethic at the same time acknowledging that there are serious problems that have been created by our excess consumption of those programs that we have created very serious challenges that will require significant change. it's going to require the kind of hopefully not crisis driven change, but it will require change. and if the crisis gets enough that i think clearly they will respond. >> walter, i think that's a good point. the same ethic that compelled multiple president and finally

ended with lyndon johnson's success to broaden health care coverage, particularly at this point for seniors and the most disabled people, i think it is the ethic that carried forward and compelled this president to put on the table a bill that provided the financial security and some sort of way to expand coverage to the portion of the population. that didn't have affordable coverage in the workplace and were not 65. they were dying to be 65 but were not there yet. and that ethic of, you know, it is fundamentally unacceptable to let people go bankrupt because they get sick or just some people of great health care and other people have access to is one i think republicans and democrats do share. they may have different ways to get up i think it continues on today. because you saw, between the

time president johnson signed this bill and the time president obama in 2010 signed the affordable care act, president after president put forward another kind of step and comprehensive health reform to continue to move. so that ethic continues. >> that's a very inspiring talk. the notion of us all being part of an american ethic, it really does require not only iterative process the real partnerships and collaboration. i really can think of no better than the two of you, and i'll give a plug to the aspen institute, those of you who are here today but also get involved in this, and i think ruth katz is critical to also governor tommy thompson and to be kind of great if we could just get people of good faith like governor thompson and the two of you to help work these things through. let me open it up, if i may. yes, sir. stand, shout, we will repeat.

>> thank you very much. my name is keith martin. firstly, secretary sebelius, i want to thank you for your work on the aca. our thousands of people to be alive tomorrow and in the arc of their lives are changed because of the affordable care act. thank you for that. my question is, you are a sea of people wandering in the city enemy other areas whose lives have fallen through cracks of life. public health is where the big bang for the buck is introducing the cost for health care in this country to vastly improve outcomes and to change the inequalities within of this country. can you share with us how you see the low cost high impact public health interventions that can dramatically affect and improve health care in this country and health outcomes? how they see this thing and committed? we know what we need to do and how to do it. thank you.

>> well, i think first of all you are right, and there are some pieces of this that clearly need further iteration. i am deeply troubled and disturbed by the result of the supreme court decision on medicaid, now we are growing a sort of two-state solution with our lots of people in this country were actually too poor to qualify for financial help without medicaid expansion. we are seeing the result of that. there is an effort, anything inappropriate effort to double the size of three health centers which have been essential entities to deliver low-cost, high quality primary preventive care, and bring doctors, not dentists, mental health professionals and others into

the host -- the most underserved communities. that's been a great success and that's on its way to being expanded. but i think public health is also very, i don't know what governor leavitt situation was in utah. i ca get to ethic of in kansas t was almost impossible to get funding for public health. it's an unseen constituency. we were terrible. we put money in the budget every year and it would be taken out and we would have big battles. so preventing something from happening, keeping people well in the first place, having an ability to mount a healthier population i think is intangible to the point that it's difficult to allocate resources. having said that i think there's a great focus and a doubling down now on the two primary underlying causes of a lot of chronic health conditions, which

is smoking and obesity. and effort at the state and local level among providers, among families, business owners, a lot of people in the private sector to see what it is that we can do here in the united states to actually dramatically decrease the number of new smokers, and help people stop smoking cigarettes, but also deal with obesity. >> let me see if i can get governor leavitt on the very specific community health, public health alternative. >> i had the pleasure of reading the apartment of protection agency mid-america for a while. and i came to realize it is a public health entities. and i came to recognize that many of the fans is in health and longevity that we've had in this country came during a to we cleaned the air, the water and the land. there's a direct reflection on our health.

that's public health. but i also think it's important in this context to recognize that there's a limit in the way we can do this. we don't have any public health money in our country today. status of an appropriate e-money because they are paying for medicaid. their budget is just simply being used with medicaid. we are investing less in art education to that at any time during the last three decades. tuition is skyrocketing. student debt is skyrocketing. why? because it's all going to medicaid. it's not an ecological concern. -- ill logical concern. ..

and i just had my plane delayed for the second time and it was clear i wasn't going to leave until 11:00 and get home until midnight or after. all i could think about was a big mac and fries. so i went to the golden arches in the airport and it listed the price but it also said i would be consuming 1350 calories if i had the big mac and fries.

but rather than just write a check maybe they ought to put response ability on me and i got to make a decision about whether the big mac and fries or the lettuce wrap. but my point is we can't separate medicaid and medicare without recognizing for it to be here another 50 years and for all of the good things that we have reached we have to do this better. it isn't a function of celebrating and moving on the way we have in the past. >> questions please. while we wait for the next question i would like to - i'm

sorry, there is a microphone. go ahead. i'm sorry i have trouble with the lights in my eyes. >> i wasn't around when this was a sign that i was around for the long. but now involved in virginia i regret to say that first of all, our community center has had to close down because of the financing. and second, i am delighted to hear that you are trying to control the use of tests. let me tell you what the hospital in my area is doing. they are sending out mailers frequently saying come and be tested and we will perform tests to help you avoid stroke and cancer and whatnot.

if you check the list of tests that prevent the task force recommends as appropriate for people you will find there is a poor match what the hospitals are doing and this is in the only place it is being done is to say the buildings themselves will get test results and that is to do further testing. also it could have an adverse health effect. i am just concerned about how effective the affordable care act is going to be because of the system that is going on. i'm sure that the text and early but it is a money driven proposition. and i just wonder your comment.

>> let me use that if i made to get the governor to drill down a little bit further the whole notion of a different type of health system that would try to make healthy populations rather than send them to try to rack up tests in the reimbursement. >> a good analogy to describe this might be thinking about what would happen if we bought a car in the same way that we buy healthcare. we would go to the dealership and we would say i need a car. we see you do, go pick one up and we will send you the bill in a few weeks. so we would drive off the lot and then a few weeks later we would get a bill from the tire maker and the manufacturer who installed the windshield.

we would get a long list of different bills and no one would have had the responsibility to package up the car and to deliver it. the way we buy a car is there is a contractor in the car company who works with the people that do the windshield and the tigers and'. they bring it all together and deliver it in a way that we have accountability as to whether we think it is a good car for a goodbye and we have a sticker that says this is the amount. the system now does not allow for that kind of coordination and that kind of accountability. what kathleen is describing and i've worked to describe as a system where there is greater accountability because there is a contractor whose job it is to assemble the parts and be responsible for the result. they refer to this as beginning

to to rework the value as opposed to volume. and i think that is a system that you described as a situation where we get one part that is manufacturing to many steering wheels if you like and there is no one out there trying to put it all together into a picture of health. i hope this helps. >> and i think the government isn't the contractor. the government ultimately in the situation with medicare and medicaid is the payer to the providers become the contractor. somebody takes primary responsibly for the care and is typically would be the primary care provider. the doctor that would then have not only the ability to share information and coordinate care, but also to have a financial incentive to get you through the

system. and i think that it potentially has a huge buzzword in a lot of the center is at the patient centered care. and i think that it envisions a system rather than you as an individual trying to find all of the people who might improve your health and particularly for somebody that has a chronic disease, there are multiple people and multiple appointments that that's part of your health care. >> showed that system be connected to the insurance system so that you have an online interest? >> that is the whole point is to shift the alignment. the government spends $1 trillion a year between medicaid and medicare. that is a third of the health spending that comes out of the government entities and shifting the financial money to the

outcomes that people feel are better for the patience to patient to coordinate care to pay for the value to measure what's happening across the system and seeing who the outliers are is a very different way of doing business as opposed to pay for the tires. most cars have four tires and one in the trunk, sophia tires. in the old days you could actually pay for 25 because somebody thought that was a good idea and put 20 of them in the garage and then pay for six steering wheels. none of which drive the car. but hopefully those days are beginning to be realigned with finances and outcomes. >> can i also say that part of this regime has to be an acknowledgment that this isn't just the system.

is this a social change, it's what we eat, how we exercise, it is ultimately the high-risk behavior that we engage so we have to be part of the solution. it isn't just a piece of legislation or a new design of care. this is a social change. now back to medicare. we mentioned medicare part d.. that was the most significant addition or change to medicare since the 50 years of its existence. but it was important for two reasons. not only did it provide do they provide prescription drugs to people, it created a new delivery mechanism. except for the first time we think consumers actually could have a role in choosing the plan and benefits that they need and want and that they could make better choices than if we just had one medicare program that

everybody had exactly the same. you might be interested to know that there was a default plan under which seniors could just take the default. it turns out that only 6% took the default and 94% concluded if they could choose the way that it was all lined they could be better job than what the government would do. that didn't mean they didn't have an obligation or that they were not involved. it means the government was organized to use a marketplace where seniors could make these decisions. there were people that were skeptical about whether they could. we now have integration of health consumers who are making very thoughtful decisions about what they want and need and if they don't get what they want and need a committee go, they go somewhere else. and what we are seeing is that people are happy with the system and that most everyone now has

enrolled and we have a lot of satisfaction. i am of the view that will be a big part of the future in some form of medicare as we begin to see consumers take a large role in guiding the system in terms of the way that they interact. our time is about run out. if you have a quick closing thought if you want. >> i want to actually think the aspen institute for organizing this and i think it's we have a uniquely american health system, insurance system, delivery system that is launched all over the world. a lot of people are confused about some of the pieces of what we do but there is no question it is by and large working for a lot love of people and celebrating these important frameworks is important, but i think it is as mike suggests

also finding ways as we move forward to continue. it is a work in progress and it's a continuous work in progress that needs to continue to be improved upon as we go forward. >> i would like to end by saying i am more optimistic than i have been about the chances the united states is actually going to create an american solution to this problem. my optimism frankly isn't based on the affordable care act. we can have a long discussion about that and many of the good things that happen are unintended consequences as often as. i am optimistic because i'm beginning to see people do hard things that they have not been willing to do in the past. maybe it is because of the financial pressure. maybe it's because we are finally getting the picture. but i'm seeing people walk up

and we are now choosing by his lettuce wraps more than big macs and we are starting to think about that war. we haven't succeeded yet that we are starting to see combinations in the healthcare system where people are making decisions that are financially driven but absolutely required for the system to become better. so with optimism we are not there yet. we are a long way from that. we have to remodel and change the things we are doing in medicaid and medicare to be about 50 years from now. but i have optimism that we will because americans have had this map of when the chips are down, we make changes and i think that is what we are talking about here is a big change and as far as i can see there's only three ways we can deal with it. we can fight it and be overcome. we can accept and have a chance to fix it or we can leave it

right and if we do we will prosper and i'm optimistic that 50 years from now somebody will be sitting on the aspen institute stages of the rating 100 years of these great programs but they won't be the same programs today. they will survive because we modernized and changed along with the times. >> governor and secretary, thank you all very much. [applause] it's a long-standing tradition were each presidential hopeful gets 20 minutes to speak on the stage and grand concourse and then take questions from the audience rated sucker this afternoon south carolina senator lindsey graham will be there to read c-span very c-span will have live coverage at 4:00 eastern. tomorrow senator marco rubio will explain why he should be

the republican presidential nominee. c-span will show that flight 11:30 eastern. and ohio governor will take the candidate soapbox stage of the iowa state at the iowa state fair tomorrow afternoon at five eastern. c-span will have live coverage. and find stages of the candidates that stopped by on c-span.org. >> teen was into computers and that pushed him and then you always heard about it and so from a very young age that is what he kind to do and he just ran away from home and did it. >> the technology reporter on one of silicon valley's most inventive leaders. >> it was seen as this figure and i - they have this attention

to detail and push them really hard. we tend to lean more towards this edison kind of idea although we have a lot to prove but life taken away is that he is the type that took these thousands of engineers and kind of the brightest of the bride and bees very hard working individuals that are able to get products that can be commercialized and then the changed industry if you look at - to me he's combined software and hardware in a way that nobody else has. while congress is on break we are shooting booktv in primetime.

the idea behind the tour is to take the program from american history television and booktv on the road beyond the beltway to produce pieces that are a little bit more visual and provide a window into the cities that the viewers wouldn't normally go to that also have a rich history and his rich literary scene as well you can make a lot of people have already kind of heard of history like new york and la, chicago. but what about the small ones like albany new york. what is the history of them?

>> we will have 95 cities in april of 2016. >> most of the programming is event coverage and these are not the type of peace. they take you to a home in the historic site. >> we partner with affiliates to explore the history and the culture of the various cities. >> the key entry is the cable operator who then contacts the city because in essence it is the cable industry bringing us there. so we are looking for great characters. you want your viewers to be able to identify with these people that we are talking about. >> it is an experienced program where we are taking people on the road to places where they can see things and learn about it's not just a local history because a lot of the local history plays into the national story. >> if somebody is watching this it should be enticing enough that they can get to the idea of

the story but also feel as if this is just in our backyard lets go and see it. >> we want them to get the sense that i know that place just from watching one of the pieces. >> the mission as we do with all of the coverage believes in what we do out on the road. >> you've got to be able to communicate the network in order to do this job. so, it is done the one thing that we wanted to do which is build relationships with the city and our cable partners and gather some great programming for american history tv and booktv. general ray odierno has retired after 39 years of service to the army did it last week that last week the pentagon hosted a ceremony held for the

army chief of staff. this is nearly two hours. ♪ ♪ ♪ ♪ ♪

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>> once again, good morning and welcome. today united states army represented by the soldiers of the third united states infantry regiment, the old guard, and the united states army band marching sewn bid farewell to general ray odierno, the 38th chief of staff of the on and welcomes general mark milley, incoming chief of staff of the army. participate in today's review from left to right is the united states army band, persian zone. united states army band is the premier band of our senior service. pershing's own provide musical support for ceremonies and special events in our nations capital and throughout the united states. the united states army band is under the direction of colonel timothy holden and led by drum major scott little. elements of the old guard include charlie company commander by -- and led by first

sergeant josé barrera. next is delta company commanded by captain. since the days of the american revolution the colors have been one of the most important elements of a military unit. as soldiers kept the position information by dressing on the colors come at the center of today's formation and their international, is the third infantry's continental colorguard. next online is honor guard company. following is the commit and she's regarded patrick at the unit cleared by general george washington in 1776 to be his personal guard. the last elements online dress in the content of from is the old guard. during the american revolution

decisions were the reverse colors of the. infantry unit. the men and women of the old guard maintained a tradition by wearing red coats instead of the infantry blue. the court is led today by james hay. to the right of the formation is the presidential salute gun battery. to the rear of the formation on the 56 state and territorial flags of the united states. stomac[inaudible]

>> would like to take this opportunity to record is undistinguished gas after independence today. general and mrs. eric haitian subsidy, former chief of staff retired and former secretary of veterans affairs. the honorable and mrs. buck mckeon united states senate retired. the honorable and mrs. chet edwards, united states house of representatives, retired. the honorable patrick j. murphy, united states house of representatives, retired. the honorable robert work, deputy secretary of defense. the honorable paul wolfowitz, former deputy secretary of defense. ms. christine fox, former acting united states deputy secretary of defense. the honorable and mrs. -- former secretary of the army. the honorable francis j. harvey, former secretary of the army.

admiral and mrs. jonathan greenert, chief of naval operations. lieutenant general -- captain, lieutenant colonel, chief of staff, german army. >> general, former united states army chief of staff, retired. general gordon sullivan, former united states army chief of staff, retired. general and mrs. frank grass, chief national guard bureau. the honorable eric k. fannie, acting undersecretary of the army. ms. lisa disbrow, acting under secretary of the air force. the honorable and mrs. joe wieder, former under secretary of the army. the honorable les brownlee and ms. susan, former undersecretary of the army. mr. raymond dubois, former acting undersecretary of the army. the honorable and mrs. scott

casper, mayor, city of colleen texas. general and mrs. john paxton junior, united states marine corps, assistant commandant of the marine corps. general and mrs. daniel allen, vice chief of staff of the army. lieutenant general joseph lyndale, vice chief, national guard bureau. general austin iii, commander united states central command. general and mrs. john campbell, commander, resolute support nation. general and mrs. -- and mrs. heather, former united states army vice chief of staff, retired. general john keane, former united states army vice chief of staff, retired. general and mrs. richard cody, former united states army vice chief of staff, retired. the honorable joe darcy, assistant secretary of the army civil works.

the honorable heidi shue, assistant secretary of the army, acquisition, logistics and technology. the honorable deborah swatter, assistant secretary of the army, manpower and reserve affairs. the honorable and mrs. robert cyr, assistant secretary of the army, financial management and comptroller. mr. philip park, senior official office of general counsel. the honorable not -- former assistant secretary of the army. general and mrs. david m. rodriguez, commander united states africa command. general and mrs. dennis -- commanding general united states army material command. general and mrs. david perkins, commanding general united states army training and doctrine command. general and mrs. joseph the film, commander, united states special operations command. general and mrs. robert abrams,

commanding general, force. general john s. kelli kuehne states marine corps, commander united states southern command. admiral and mrs. michael rogers, united states navy, commander, united states cyber command. director of nsa. chief css. admiral william gorby, united states navy, commander, united states northern command. general retired and mrs. william buck kernan, board member, patriot foundation general john foss, yes these army, retired. general total, united states army, retired. general and mrs. crosby saints, united states army retired. general larry ellis, united states army, retired.

general john -- yes these army, retired. general done what he, united states army, retired. general -- done what he. general carter ham, retired potential and mrs. robert foley, united states army, retired and the army recipient. sergeant kyle white medal of honor recipient. sergeant major and mrs. brian battaglia, united states marine corps, senior enlisted advisor to the chairman. sergeant major of the army and mrs. daniel daly, sergeant major of the army. chief master sergeant and mrs. mitchell brush, senior enlisted advisor national guard bureau. sergeant major of the army retired kenneth preston, former sergeant major of the army. ladies and gentlemen, the history of the third united states infantry regiment reflex the growth and department of our nation. 55 well-earned battle streamers,

to ballot aboard, three meritorious unit accommodations and five superior unit award attached to the old guard action and achievements during peacetime. in 1922 the war department granted permission for the old guard to pass energy with bayonet sticks to the old guard one of the fix bayonets to the additional beat of the drums. [background sounds] [background sounds]

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[background sounds] >> ladies and gentlemen, movie and position, colonel johnny davis, commander third united states infantry regiment, the old guard. [background sounds]

>> order arms. >> ladies and gentlemen, taking the reviewing stand is the host for today's ceremony, the honorable john mchugh, secretary of the army, a company by the secretary of defense, the honorable ashton carter, the

chairman of the joint chiefs of staff general martin dempsey, the reviewing official general raymond t. odeo, the 38th chief of staff, united states army, and general mark miller, and, chief of staff united states army. ladies and gentlemen, please stand for the arrival of the official party can remain standing as honors are rendered. >> present arms. ♪ ♪ ♪

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