years and it's worse now than it's ever been with the understanding of the kids in high school and college today. i've been scratching my head again why is it that the kids today are so enamored by government power. they are such precious things. why do you want to give up your liberty to these politicians? it lies in what you talk about in this book, which is what happens is people have come to think that capitalism is cronyism and they associate capitalism as the left calls the crapitalism. he goes around the worldsame capitalism is a terrible thing. he didn't get it where pope john paul ii get it.

the answer is pope john paul ii grew up in poland in a communist country. he saw the ravages of big government. where did this pope grow up? in argentina. do you even consider that a capitalist country? he regards capitalism as cronyism and this may be a good point and on. your book is a good way to say above, capitalism and cronyism are exactly the opposite. it corrodes the powerful forces. we need free-market capitalism and thank you very much for your great work on this and please give a nice round of applause. [applause] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations] >> at the making of this discussion on improving economic conditions, go to our website,

c-span.org. we will have it for you later today. coming up life today a discussion on the zika via race it is just getting underway on c-span. also, donald trump will be speaking to the group tomorrow. we will have live coverage of that. and coming up tonight, donald trump will be speaking and offering his immigratiimmigrati

on plan in phoenix and then meet them at the next event president, president nieto ahead of that speech live on c-span and will include your phone calls. that is 9:00 tonight on c-span. >> i am reading a undocumented courage and ultimate sacrifice of seal team six special operator adam brown. this is a book that chronicles a flawed american who became an american hero, who channeled some of his cure your states, which led to risky behavior into what made him a great warrior in defense of freedom for our country. a

>> who recommended this book? >> a colleague of mine, congressman from the central valley of california. he's a good friend of mine. we were eating dinner one night and he was very emotional talking about a book he was reading. i was intrigued because i don't know my friend dave is a super emotional guy, but he clearly was impacted personally by this story. and so, i asked him more about the book in a described it to me and i have to get a copy. just like david, i devoured the book. it was absolutely a page turner from the very first paragraph, which began -- the story begins by saying on march 7th team, 2010, maybe seal team six operator adam brown woke up not knowing that he was going to be killed later that evening in the hindu kush mountains of eastern

afghanistan. 70,000 miles away, his little boy woke up in virginia beach, virginia worried about his daddy. from that compelling introduction until the very last word of the book, you can't put it down because this is a story about overcoming personal challenges. it is about an american hero and about the courageous service in the sacrifice of so many american heroes who are fighting in the global war on terror. >> i am reading a book by presidenpresiden t jimmy carter, his autobiography. i had the privilege to attend his sunday school very recently, and i was then nice congregation. it was amazing. after that i went to the school he attended. of course it's been turned into a wonderful museum and i purchased his book, if all life.

this man is an incredible human being. it continues to be a true moral leader and he puts it way ahead of this time. his book conveys that very clearly. it is well written and it gives a lot of history, but it actually tells you who he is in demand as the person who is a believer in god and a christian. but how he applies his christian values in his public life in terms of feeding the hungry and sheltering the homeless and all of the great values that are taught in the bible. >> at the present time i'm reading a book called president kennedy. profiling power or profile of power by richard reeves. i heard him speak about the book at a conference and thought i

want to read that book. it's pretty heavy reading but it's got information about the president and insights to him and his families in the challenges the space that never before, never heard of before. highly recommend the book. treated >> rdc or go to biographies? >> i like biographies, but there's so much we have to read, factual stuff anyway. i like peter schweizer's book. throw them all out. extortion. he's written some good books and i wish every american could read those as well. once i could master with a "new york times" bestseller about the ent threat that most people don't want to too much about in this country. about 20 good nonfiction books that i've written so far and recommend them all.

a not the effect of america's aging population on our health care system including the added cost of long-term care spiraling prescription drug prices, health insurance and end-of-life issues. public square posted this event in phoenix. [applause] >> thank you all for coming tonight. i will start out and introduce our panel and talk a little bit about the topic at hand. domain question we are looking at tonight is a simple one, but not so simple as the answer. our baby boomer is going to bust the health care system? are the most important question facing the u.s. these days although you may not know it from the presidential debates. public square's failure to fill

that void. currently the share of the population that is 65 or older to 13.7% but by 2030 the share will increase to more than one of five americans were more than 70 million people appeared around the same time the medicare hospital trust fund expected to run out of money. that's a major policy issue on the horizon. it's also very personal issue for all of us. it will directly affect all of us, parent and children and get the care that we want when we need it and how much will that cost us and our families? we have a great group of people here to tackle these questions. marjorie baldwin is a health economist and professor at the wp carey school of business at arizona state university. john rather as president and ceo of the national coalition on health care and organizations

working to achieve comprehensive health system change. he's also a longtime veteran of the aarp where he worked on issues for decades. their activities as executive director for long-term quality alliance in washington d.c. he was also recently staff director of the federal commission on long-term care. prior to that, he worked in the pharmaceutical industry and public policy issues including that merck. keith is the ceo of integrated sensations which includes hard than a thousand positions. currently there is on the market precedent partner and chief executive officer. say what you want about american health care. there is one area where no one can hold a candle to this country and that is they generate more acronyms than any other country. i've actually heard some people on the stage might be among them who can deliver entire sentences composed of nothing but acronyms. we will try not to do that

tonight. hoping we can declare this an acronym free sound. one exception that we are going to have to allow and i'll give you the definition up front for it is that i think we need to call the center for medicare and medicaid services cms. the medicare and medicaid programs as many of you now. that is one acronym you will hear and that is why cms stands for. hopefully that the only one we have. we are going to kick things off with the chicken little question. is the sky falling? how worried should we be about the population in the system should mark what are the worries we should have? maybe we can start with you and everyone else chime in, please. >> i don't think the sky is falling, but i do think that health care like global warming is something we better take seriously or we could get inundated. population aging is something we

know is happening. we know that we need to make health care more affordable and response we need to. we also know that there is so much today that's not beneficial some estimates, at least 30% of our health care. many, many opportunities to move this towards a more efficient system and if we can do that quick enough, we should be able to offset the rising people about what put pressure on the health system. >> marjorie, you are an economist. how bad is that? >> it's not a crisis situation now, but the thing is the sooner we act on it, we know the easier of the six days. our medicare system was designed when life expectancies were at least five or 80. now life expectancy is our much

longer. so we need to make some fundamental fairly easy changes to the system now. if we wait, it's going to be surgery. >> one qualifier at putting the demographics at their peak in this country, our percentage of the population 65 and older will be exactly same as for japan and germany had to say. germany and japan i don't think you see any, but i do think the fundamental challenge is that the very substantial health care cost of growth in this country, we haven't begun with the growth slow recently. we had the challenges they are at now per capita across the larger population but the significant and will have a very significant effect on federal

budget. it will affect everybody's private cause that we are going to have to deal with and it's really just a fundamental health care costs. >> i would add while the sky is not all in, we have an absolute tsunami warning. the tsunami warning will calm by the time 2030 times and there is a doubling of the number of american citizens in 65 and that will be over 70 million medicare beneficiaries at that point in time. estimates are 60% of those will have comorbidities. database that will have 5% comorbidities. the tidal wave is going to be an incredible increase in demand. so the warning as they appeared now we have to take that warning to heart. this is the time to put in place sustainable change.

>> if i could take issue with the tidal wave. to me it's more like rising the levels because the real pressure is going to be almost impossible to notice year to year. over time it is going to be compounded. particularly with the change from a few problems to chronic poor people have diabetes, arthritis, as metal limitations that require ongoing treatment. this is going to be fundamentally different type of help are challenged and we have had in the past. to me it is something that we know it's coming, but it is going to be very gradual. >> another aspect is this is the fastest growing part of the american economy and a major area for innovation and new development. this is a big part of the economy. how do we manage this and it's

really fundamental. >> along those lines, let me jump into my next question. the next question is can american seniors continue to have it all? traditionally people if they talk about health care do not like being told no. if they want a proton beam therapy, they want protein. their appeal. if they want the newest oncology drug, they are definitely want that covered and expected to be paid for. is that a model we can continue to have or do we need to think down the road about something a little more like what the national health service staff in the u.k. where there are choices made in judgment made about what is covering and maybe some things that are. >> i can jump in. the short answer is no. it's not sustainable and we can't continue to have it all.

rationing is going to come in some form. i think what we have to choose is if we want a system like the national health system where the rationing comes to the government, they make the decisions on what is going to be provided within the system or whether we want to make those decisions for ourselves. i can imagine in the u.s. we will be happy with a system where the government dictate the kind of care we get. we have to start making it possible for individuals to make those kinds of decisions and making it in their interest to make sure that the care they are receiving is quality and high-value care. >> we do have a budget -- a global budget function in our health care economy. it is broken up into individual managed care plans. we basically do the same thing that governments that provide government health insurance to in those countries. the global budget with decapitated amount, you know,

people get care within that amount and the urbanization is providing carers of risk. that is not a bad model. we have not proliferated that bottle. medicare advantage. >> on make >> on a two-point good. one, let's not kid ourselves. we ration care today. people who are poor don't get the same quality of where as middle-class people and people who are rich have much more choice and much more access to top therapies. so let's not pretend that there is a rationing going on today. the second point is their destiny to be rationing in the near future at least if we are smarter about web services are valuable and which are not. we have to match of some kinds of care and not enough of others. if we can be more clear about what provides value, what

actually contributes to well-being, it then we can marshal our asset in a way that i think would be adequate for all u.s. citizens, but we are not doing that now. >> i would add that we removed a very important part of the economic equation and health care. we isolated and insulated the true cost of care to the beneficiary. once we begin addressing that, at the same time making sure we have the effect of the communicated the clinical-based evidence that supports the truth and alter the dates that are available. we are all consumers and if we begin to look at the way health care is delivered more like a consumer-based business model, i think that will change the implicit help haitians make their informed decision.

right now we have put them in a very difficult position, where oftentimes they don't have information that is necessary and they don't have a care navigator to help navigate them through those complex equations. >> talking about giving the beneficiaries and they have quite a bit in some cases, but more financial skin in the game. larger deductible, that kind of thing. >> part of it is once you truly have protocols in place, if the option is to choose to go outside those proven scientifically proven guidelines, there isn't economic implication to take in that decision. >> one of the things that i think very few people understand is there is no out-of-pocket cap in medicare on how much you have to spend out-of-pocket. you can go bankrupt and be a

medicare beneficiary as a result of help your cause today i'm like most people who are insured privately under 65. out-of-pocket costs for someone who has chronic condition, who has the same condition on a regular basis and takes a lot of drugs can be quite substantial. the average income for people 65 and over is only 25,000 a year per family. we have to be careful when i talk about skin in the game that we don't end up taking off the skin from the people who need it the most. >> well, with respect to the structure of medicare, and it is really an odd kind of insurance. what we want his insurance will cover the catastrophic costs, the calamitous costs. when we totaled our car we want to replace the card. medicare, as you say, these 20% of the cost and these can be

huge cost less to the beneficiary. if we are going to guess again and again, it needs to be more in the up front. we don't need higher deductible, but at some point a maximum. most of our insurance policies will have a maximum out-of-pocket costs annually by lifetime. but now with medicare. >> deductibles to often present a barrier to care. if you want people to get preventative care, if you want them to get screened. if you want them to see a doctor early, did that book can be a real problem. >> you raise medicare at vantage, i wasn't going to last, but since you brought it up from a 30% of beneficiaries these days are managed, that there is a study published in health affairs last year that looked at folks who needed nursing home care. who needed homecare and they

were more likely to opt-out of medicare rather than the reverse it is always there as sort of a back drop. when there is talk of voucher systems, there was a lot of political talks about that. so how do you balance those things? >> went into medicare advantage does not cover long-term care costs. medicare doesn't at all. people in medicare advantage to our going into a nursing home, that is all an out-of-pocket expense for them. one of the things that i think we have to move to is a fully integrated in a fit in those plans. the other challenge we have in this country as many people want to maintain a relationship with their own physicians and a lot of times we've maintain the principle of medicare choice and people are choosing to opt-out

of medicare advantage when they are in the plans were to stay in paper service to maintain the relationship or the position. people often overrated the importance of their own personal relationship in this current system where those relationships that exist in the same way as they used to. >> i think the relationship long-term with a physician who knows you and understands he was really important. i think it is important to treat the whole person, not just the symptoms. if you have a relationship was him when to understands you and your situation, that is really worth something. so i don't think we should get in the way of that. but they tension between the choice of rhetoric that we've always used in health care and the need for continuity and coordination.

continuity and coordination are really the more important values often than choice. >> let's get to another issue. hot button issue in health care. drug costs. some then people in the states have been scanned with close at hand. the bill for pharmaceuticals in particular has been rising rapidly. no signs that will change. the total tab is likely to rise even more. what should we be doing about this? should there be direct negotiation? should there be some sort of government intervention? other drug companies the problem or the solution? what would you guys like to see? >> yes. [laughter] >> speaking at the economist,

the pharmaceutical industry is one of those industries we love to hate. they are not what is driving health care costs. the specialty is rising by rapidly than anything else. >> over the last few years i keep track of their proportion and they've been right around 10%. if we need to do something about health care costs, we have to look at hospital costs and physician costs. drug cost is not going to bring it down. the other thing is even the drugs may be expensive and many of them are and we pay a lot for them in the u.s., it is still a cheaper way to treat many conditions rather than having to treat them in the hospital with long-term care. treating heart conditions with drugs is cheaper than having somebody go in a hospital and having bypass surgery. drugs are actually lowering the cost of treating particular

conditions. i wouldn't say the pharmaceutical companies are the culprits. the >> there're two things going on. one is opportunistic pricing, which is just their organizations making the decision to go ahead and raise prices on pharmaceutical products because they can without too much regard for what the consequences are. particularly where we have drugs. the other thing is we are in a world where drug development is far more expensive because the level of science involved is far more complex than they've ever had before. we develop products that have very great utility, but for people with very specific kinds of characteristics. we have to get much better really measuring the value that we have and pricing to value. it's not a terrible thing to price a hepatitis c drug of $100,000 that is going to somebody who's definitely going to contract liver disease and

who will be able to hear the hepatitis c, virtually eliminated with one. the trade-in of $100,000. that is not a bad equation. when you generalize that treatment to a much larger population with the return on that treatment is not going to be as great. i think the problem is we have a lot of expensive drugs and we do not have good mechanisms with their diagnostics and things like that can enable us to get the value. >> i agree we need to pay for value. that is not where we are today. let's be clear. drugs are priced out of the company thinks the market will bear. since there is no functioning market that is practically restrained and we've seen drugs increased by 5000%, what more evidence do you need that we don't have a functioning market? i think there is a real need for

action. my organization released yesterday a comprehensive set of recommendations to move us towards paying for value and i hope we can move on that very quickly. but really, this is a dilemma in health care. we need an innovative, strong effort by the pharmaceuticals. we want the promise that drugs may come back and actually lower health care costs. not many of them do now. on the other hand, it has got to be affordable. if it's not affordable, what good is that if people can't take advantage of that? we are at the point now where it's simply not affordable for too many people. we have to have a better balance between continued innovation and affordability. one way to get there with you to take a look at the billions of dollars spent on director consumer advertising.

we are one of the few countries in the world that permits that. i have to question whether it is really valuable or not because other countries that don't have that kind of advertising are able to have much lower drug prices and people who need it can afford it. and yet we tolerate this in a way that i think is not helpful. >> i agree with you on the direct consumer advertising. i wouldn't support negotiating cms or lower drug prices with the pharmaceutical firms. other countries have done that. sure when he disturbed or pharmaceutical industry. australia did the same thing. the united states produces a huge majority of innovative drugs in the world. i is one of the representatives of the pharmaceutical companies

so you better like the drugs you have because you are not going to get new ones. >> just on the negotiation issue, we have a system in which we negotiate drug prices and its medicare part d and the federal government contracts with health plans to negotiate prices with the drug company. it has been relatively effective. if you replace that with a single governmental negotiator, you have to have the ability to deny access to the market. in other words, the plans that negotiate say we won't cover you. if we don't get a good deal, we are not going to cover you. ..

>> all right. a large share of medicare spending often occurs in the last months of life. since the tradition that has been paying doctors and other clinicians for fans care planning discussions. this is a limited move and this is still a sensitive topic. we remember the whole death penalty discussion of several years ago. what do you guys think the government, meaning cms or the government more broadly can or should you on this issue? if you like to touch on what they think the rest of us, i'm talking about physicians, clinicians, families can do on this front?

>> it's been a challenging topic because for decades it's been a taboo topic for the discussion of death. and dying with dignity. many of our physicians especially those that were trained 20, 30 years ago and are in the middle of their career have never been trained on how to have that discussion. and yet it's critically important. as you mentioned, i think so the estimates are 50% of the expense, health care expenses are spent in the last nine months of a patient's life. and oftentimes many of the clinical interventions actually expedite end of life instead of the expanding end-of-life. so from a physician's perspective, one of the new tools have been the stench of palliative care, nurses, only to

have -- palliative care positions and making no part of the care team. spirit it's hard to think of a more constructive public debate in the last few years and the term death panels, because we do need to confront the way people go feel good about not feel afraid of. the key is talking about with the family. because oftentimes the patient is not any position to make decisions for themselves, and the family has to be invited -- united on this an sms to understand what the patient wants. so that's something that each of us can do with our families. we shouldn't put it all on the physician. we need to recognize the inevitability, we all will die, but i don't think many of us

want to die in a hospital hooked up to a lot of machines. most of us would prefer to die in comfort at home. and yet that's not how we do it. that's the exception, not the rule. so there's a lot of opportunity there to do a better job for ourselves and for the people we love. >> on your question about whether there's a legislative health care, i think this is a big cultural issue. we have to all become much more comfortable with this conversation. i'm not putting in a book blog but if you haven't read being mortal, you should. it brings the conversation down to a level where we can have, feel more comfortable about it. the other thing is the way we do the discussion of this in public is wrong. we should talk about the right of patients not to have unwanted medical treatment, and that's a right to every patient should have. that right should be supported by an intelligent conversation

with your physician about the trade-offs, the risks, what can be done and what can't be done. there should be an opportuniopportuni ty to make those choices. right now that doesn't happen. right now those choices are made in the medical world, infrastructure without much regard often for what the patients really want is an opportunity to understand the issue. >> arbeiter was live in scotland and canada and california route, the scots the death is imminent. the canadian seed is inevitable. california see it as optional. and doctors are trained to fight that. it's the enemy. they're going to lose indian festival fight it to the end. that's what i think would've a lot of this care that's doing very little margin without you, and maybe prolonging someone's life a few months, maybe even a

your buddy don't think we think about the quality of that life. i agree. i think we got something worth the pain all the is that people need to think about what kind of care they want. i think physicians need to be very honest with people about exactly what he can and cannot do and what the treatment will and will not give the person so they can choose, don't want to undergo this treatment, or do i want to plan for the end and be home with my family? >> all right. point of agreement. good to hear. you raised this already but i'm going to jump in. long-term care. probably people in this audience know this but i can tell you as a reporter talking to a lot of consumers you'd be shocked at how few do. medicare doesn't cover long-term care. medicaid does if you qualify but medicare does not. it is a gap that affects a lot of people.

around 8 million needed long-term care in 2000. that's going to grow around 19 million by 2050. i'll ask the panel how should the tackle this issue? old at the policy level, meaning what should happen at the federal or state or other places, the government, but also do you have any jobs for the people in his audience or others who might be watching how to address th that issue in their n families? is something that can affect many of us. >> is the most glaring area of exposure that we've left our health care system for people is tough to bear on their own. most of the care provided in the training is provided but our own family caregivers. pager is a relatively small proportion of what's going on. we really don't tally the consequence of that for families but it's very substantial. i think we could tackle it on two dimensions. one is what i characterize as

service delivery reform. we are undergoing a substantial movement in the united states in the medicaid program we call rebalancing. which is, essentially transferring the resources available to support people who have great, functional limitations. what we're talking people, functional limitations that they need help with in the home or in the community, half are under 65 so it's not just seniors were taught but long-term care. many of these are services people need to be able to function day to day. medical care may be a part of their life and then maybe in and out of the physician's office a couple of times over the course of the year. day to day their living with this that they need that kind of support. we have to first of all i think to this rebalancing in getting away from an institutional focus which without for so long and try to do more to support people

in their own homes and in their jobs and in their lives. but i think the other big piece of this is financing. we do not have way to finance those people other than the people who become eligible for medicaid. long, long-term private insurance has not filled the gap and can't be we have to completely rethink the way we approach this whole thing and i would say one quick thing which is i do think through integrated plans and bring more of a long-term services to support and fully integrated health plans essentially would offer the opportunity to manage these these needs in a much more effective way. and will have a big impact on health care costs. >> when you safely integrate health plans doing something like medicare that would also include a long-term care benefit? >> yes exactly spent okay. try to keep things simple. speed at which comes to long-term care i think we all live in the same state and that's a state of denial.

it's a painful subject and one that is threatening not just us as individuals but those people would love because we could end up being a caregiver or we could have our children or ourselves give up everything else in order to care for us. it's a very tough subject and i think that, i agree with larry entirely. there's some hope in terms of more integrated approach is but given how much of this is dealt with within the family, it's not a matter of the medical system. it's a matter of are we prepared to step up when people we love need the help. i think that's a tough issue. we should set up on our employment law so people can have family. we can set up support in the neighborhood to get people relief from being caregivers. there's a lot we could do. it's not all about health care

and the medical sense but it's not even all about government. >> i would add to that that is also the opportunity for us to deploy nuclear delivery models as well. larry mentioned the movement from institutional base long-term care to home base. there's a lot of technology that can effectively be leveraged where someone could state in their home yet be wirelessly connected to a health care provider, and the ability to have care managers available adjunct to the family to help care for the individual at the home as opposed to a higher cost long-term care facility. >> now at risk of getting a little too wonky, forgive me, everybody. i'm going to ask about payment models for providers. i'm going to ask this because although it is difficult, it is

at the heart of the system, how people, their stated it shows how uk providers really quite close to fix the care that they give, not to be too cynical but just turns out to be the facts. so federal regulators, cms, have been trying to change how they pay hospitals and doctors, and a law passed last year is expected to accelerate that on the physician side. the idea to just try to keep it simple is that it would be health care providers each thing that they do, which is the predominant model today i would say, they're just going to a lot more of whatever that thing is. but the alternative means of income something like capitation which has at its most extreme, no matter what your the person gets the providers to get approximate the same amount of

money. or other versions of that that can reward efficiency, that can reward quality. there've been concerns about those models, particularly if you look back to some of what played out in the managed care industries in the '90s. what do you guys think needs to be done quick is cms plan the right thing? are they going far enough? are they going too far? what do we need to do in terms of how physicians and other providers are paid to manage our system adequate. >> there is no perfect reimbursement or payment mechanism. they all have failures. with that said, i am a huge supporter of the momentum that cms as well as cmmi widgets and for medicare and medicaid innovations have begun to

implement that type either the clinical outcome, which is also viewed as a quality indicator is being more on the outcome value versus how many widgets, revisits or how many units of service you can effectively provide. it is a step in the right direction. you mentioned capitation and that the prepayment to the hospital or integrated delivery system. that has worked very, very well. think about the payment mechanisms that are out there right now. anybody, a providers route is someone else's expense. so you see the insurance company as an example to the insurance companies rather is the premium, the hospital every time to admit a patient, every time they see some in the er, or every time the physician order to test it as a test, then that is the

expense to the plan. there's a lot of incentive to go the extra mile in order to save expense because the person doing the work, i.e., the physician, is not economically rewarded for the extra work. quick case in point. if someone calls and physician at 5:00 on a friday afternoon and if they're patient and then have congestive heart failure and they're having difficulty breathing, the physician can go to the er, and that's going to start what is going to be an 11 or $12,000 in counter starting at the our. most likely admission and then three days later a discharge back home. it easy for the physician to do that. what capitation does is that physicians face an extra half

hour, coming, or mrs. jones, i'm going to send my clinical nurse to your home. it may be as simple as an adjustment to their medication that just kept them out of the hospital. but the physician then get paid because under capitation you can change the rules and you can't invest in clinical resources and new ways to reimburse but didn't say the system $12,000. so from about how yo you a linee right economic and clinical incentives for the benefit of the patient, the patient patient often at home and not in the hospital. >> consensus in washington about this issue today, it is a move away from fee-for-service and move toward capitation. you can also think about what you like your physician to be paid just a salary and not have the incentive to either over treat or under treat? but the point i would make is no

matter what system you employ, i would want bonuses for good outcomes. i would want to report the physician to do the best job regardless of how we pay them. we are just beginning to the management system in place to be able to do that. i think this really important. >> that's the system they wanted to move do is what they're paid for the quality of care that they deliver. the problem is how do you get those measures of quality of care? part of it is going to the electronic medical records, so that we can monitor the outcomes of care. a lot of the outcomes are subjective. the physicians take time with the patient to discuss their concerns to talk about adherence to the treatment plan. this is a very difficult path but it's the way they should be paid, and the fundamental problem is the one who is receiving the care, the one who really knows the value of it is

not the one that is paying the bill. >> one of the best things to come out of the affordable care act was cmmi. and the opportunity to do a tremendous amount of experimentation, demonstrations, pilots about the right of different payment methods to test what might really align the incentives probably come what might get the results. then the discretion which we've never had before to be able to expand the outcome to scale the out in this country without having to go back to congress and passed another law. that's going to change the pace of innovation in medicare very substantial. >> i would like to add one point. to comment about the clinical quality measures while imperfect, they are at least a step in the right direction right now. i would tell you because they get to watch it every single day, the fact that these metrics and the outcomes are being measured, the physicians are paying attention.

we have seen a significant improvement in clinical quality and outcomes as a result. >> we've got a couple of minutes so i will ask, i mean, i have sort of covered stuff related to pay for performance and these kind of models and did you seen, they can be very challenging. i'm sorry. i think john has something he wants to say. >> we've been talking about health care as if the medical system was the answer. but really if we really want to save money and how could we be thinking about population health. we would be thinking about smoking, thinking about illegal drug use. we would be thinking about alcohol. those of what cost money. those are where the big opportunities to save, and by the way, keep our kids healthy. so we can jigger reimbursement and benefits all we want and health care system but investigates just about this

population health stuff we are not legally to change the course of what it costs or the cost of course of how well we do in keeping people healthy. >> how do you get people to take care of themselves and eat a good diet and exercise and not get diabetes? >> wear your seatbelt, all of that. >> i mean, is there an answer speak with the economist always a bigger part of the costs. so we move, we moved away from that with the affordable care act with the community rating. you can't really risk, you can adjust your premiums according to your health, your risk, the expected cost. so people are insulated from the costs of -- >> should people pay more for their coverage if they are obese or if they're eating lots of steak and soda? >> i don't know.

>> most of the population. >> choose your marriage very carefully. >> i think we're about where the audience gets to ask questions, right? >> we will take questions from all of you. there are some eager hands already. on the only one with a microphone tonight but there are plenty of cameras around the this will be recorded. please say your first and last name before your question in case we want to quote you and we have our first question right here. >> i'm a geriatrician and we've all communicated earlier on a panel discussion. two issues that shoul you have t addressed as far as rising health care costs are, number one, did mr. goss to deliver health care. you look at the administrative costs are medicare. are 27% compared that with someplace like candidate were

it's about 15%. each year it is gone progressively elevated. keep in mind that's 27 sent out of your dollar for health care is going to an administrative cost. the second question i'd like to ask you to comment on is that defensive medicine that is being practiced in the united states. we are talking about liability concerns and malpractice concerns. if you think what a patient comes in and i'll give an example of this, how communications are sending -- scented emergency room with heavy? the total cost by the time they get out is anywhere from two to $5000 for their ct scans. it's incredible the number of people that are going in there and ask the doctor why they do it. one answer is liability concerns. if you can address that i would appreciate it spirit i'd like to start on the administrative question. one thing to bear in mind about administered cost is then we spent on administration to actually do things like put in electronic medical records to do

quality, measure quality, that's all very expensive. if you reduce the benefit dollar, the amount of money you're spending on health care costs themselves, the equation result in a much higher percentage of the total amount spent being for administration. the more we move down this path of quality, improving quality and outcomes and measure what we're doing in accountability for practice and performance, it is going to be a much higher percentage of the total dollar we spend for administration. i would be willing to bet canada does not only have a lab or system that we have right now to build around quality. >> i'll speak to the other component of what you talk, defensive medicine the health economist come it comes to john don't agree on much but health economist agree that the single force that striving health care

costs and use is the technology. technologic it's expensive and the more it does, the more powerful it is the book they can benefit other people. and so we have mris, all of these available and then combine that with the possible of malpractice lawsuits, and yes there's a lot of unnecessary waste in the system. >> i think we can do more to protect physicians as we have better measures of quality, a physician can say i practice within approved guidelines. been issued be protected from lawsuits. sometimes you about outcomes even when you practice well. that doesn't mean that we should allow suits against the physician. >> next question. >> i'm a recently retired

teacher, and although i'm not come we don't use the word capitation, what i'm hearing sounds like what's going on in the education profession in which teachers are getting more and more pressured to graduate students to get in certain grades, et cetera, et cetera, et cetera. i'm also thinking about lawyers, for example, do we reward them if their clients don't go back to japan to commit crimes begin? my point is that for this outcome thing, the other half of the equation is the patient. how do you have a good outcome if the patient refuses to do part of your treatment. i mean, that's my worry about this capitation thing. could you address that? >> i'll start but that's okay. great question. patient family and if you want to call it member participation

is critical ultimately to a successful outcome. oftentimes patient compliance is more an issue of a lack of education and making sure that we provide not only the education but also the resources and the tools to be successful. with that said you'll never have 100% compliance and it's also built into the metrics as well. there's always going to be an error factor. >> we should clarify exactly what capitation means. capitation means her head. it's like, if you are a teacher you are paid per student that you have in your class. so the straight capitation payment would be a physician or health care plan is but a certain amount of dollars to provide all the health care necessary for these particular pools of patients and their paid according to the number of

patients they have. there's nothing is an outcome measure involved in a straight capitation system. >> what you're talking about pay-for-performance is also part of the submitters time to do and ensures our country do. the question was on point. >> i have a question you haven't touched on in its one that becomes relevant over the last several years. could you address any of the panel members, how burnout is affecting health care providers, whether doctors or nurses? this is something that seems to be occurring in could be affecting the system going forward. but a lot of things have changed over time, all the things she mentioned that some of those have had a negative effect on people providing care. one could say, move that to the family care. >> you used the term burnout? you're absolutely right.

there's been a lot of new pressures put on providers. least of that being the administrative burden that the doctor spoke about. i've often kid with my partner physicians where i said i that you didn't become a doctor to become a documenter. that's what they're spending a majority of their time doing. they're also spent the majority of the time when they're in an exam room not looking i to with patient and touching the patient. they are focused on a 13-inch screen. so we need to change that but you are right we've seen a number of physicians leave, retire early but don't want to put up with this. a lot of that is because we have become our own worst enemy by not providing the training, the resources and tools for them to be successful. that means new investments in technology but also in people.

>> i wonder if some of this is a generational thing. i think of a generation of physicians who are trained to trust their judgment and the knowledge and experience. after a while they get really good at, accusative this knowledge and accountable with it. the whole system of putting a place accountability is based on imposing extra design standards on physicians and then measuring their performance on that basis. i think that goes done better with the younger population, but i think it's been very, very difficult for the physicians who have been practicing for a long time. >> next question. >> i would like you to continue the theme started right at the end of the panel, when you called the idea was preventive medicine and to charge fat people, drunks, whatever you

want to call them, charge the more not for the health care but for the insurance. i would answer my own question that there are about three ways of doing that. one is to have the competitive insurance. number two is to eliminate the restrictions against preexisting conditions. in other words, the insurance company gives you a health evaluation and they charge you according to your actuarial costs. if they did that, would that not induce people to take better care of himself? >> if i can comment on that. one area of complexity around that is that people can have conditions or things that happened to them that is based a lot on the genetics and maybe

predisposed to things, and the other people just have really bad habits and don't care. but you're kind of making a uniform judgment about people and why they are the way they are and how they have gotten there. it's because you created as a form of punishment. i think would be hard for people to accept a system that's built that way where some people just for no fault of their own are in a situation where they are being punished spirit one of the things the affordable care act did was change the individual insurance market which used to be more like which are describing repeat were underwritten, paid more based on a preexisting condition. although the aca itself pulled results on this or decide on next, the aspect of people being able to buy insurance no matter what the existing conditions has both i think is a pretty popular, pretty popular aspect of the law. >> the point is the insurance is pooled risk. to the extent you start to experience rate people, then you

really eliminate the pool of the whole concept. >> but we experience automobile insurance, people have more accidents are paying higher prices. we don't cross subsidize them. there's experience rating and workers compensation insurance and that provides tremendous incentives to employers to make sure the workplaces are safe and they keep the number of accidents down. i don't know the answer to this, but i do know with the community rating now, anybody who takes care of themselves and us healthy is subsidizing the less healthy people in the pool. >> i think this is a tricky issue but i do think it's him. only answerable. the people who have to pay more because of some behavior stop

that behavior? no. so if it doesn't intend people to do the right thing, then maybe we should take another approach. i think that's pretty clearly what's going on in health care. people were not adopting perfect lifestyles as the result of experience rating. it has a role in some areas, i certainly agree but in health care it's just not producing change. i think taking other approaches is a better way. >> that's going to conclude by y program for this beauty to all of our panelists will be at our reception were all of you invited to grab a glass of white and speak further with a panelists tonight. i want to thank the council for co-presented tonight's program to take you so much and, of course, all of our lovely panelists for being here tonight and donating their time to us. thanks again. have a great night.

[applause] >> plane rides and presidential transparency is a sort of double online at nytimes.com by columnist jim rutenberg is joining us. thank you for being with us. >> guest: thanks for having the. >> host: for those in immediate some alarming parallels between the axis we're getting, or not from the clinton and the trump campaign's. what did you learn? >> guest: i think the thing that i found most surprising, i've been doing this a while, is that neither candidate is having the press on his or her

airplane. it is especially surprising with mrs. clinton issues when a much more traditional campaign. mr. trump is like his own but either way this robs the public of what it takes aspect and more importantly because some people say we don't care, its just code and it's all staged, with gentleness of agree with. it's symbolic of their approach to the press which can be very sort of controlling. lastly i would say that mr. trump has been at least far more accessible in terms of interviews and interacting. so this is kind of the owners of the colchis lemoore aren't mrs. clinton in this case. >> host: do you think is a precursor for what we can expect a neither a trump or clinton white house transferred absolutely. and again i would say the signals perhaps if i'd like to some erasers i think the signals from trump's camp are even more i think alarming the mr. trump

has done some frankly i would say horrible things in terms of media blacklist to talk about making it easier to see reporters. but again you know what's happening inside his campaign. you understand what he's thinking, as much as you can follow his thinking. mrs. clinton's case, she's very, very guarded. in fact, e-mail server story that we've all been so closely following this year if not only about how some very sensitive national study documents were handled. it started with an attempt to take certain e-mails, thousand of them out of the searchable public records. but then it is more important concert as important aspect of these e-mail scandal which all feeds into the same thing hosting what are the analogies you put in your piece, 1964, a campaign by nominee barry goldwater, is that a fair

comparison? >> guest: here is a candidate famously famous to talk with the press and made them talking point. yet he had been on his plate and became to like it. i didn't i think if you go back and i did this over the weekend, you'll read the coverage of these campaigns and gene what these candidates, what the atmosphere around them was like at key points in the campaign. in mrs. clinton's case this is a historic run. shshe's the first woman nominatd democratic party and we don't know what the fight was around her at the first check accounts from reporters wednesday she loses to michigan or any other challenges come along. i think it robs the story of important human details. >> host: you add in your column but this is about openness and accessibility. so two additional examples. november 1963 the ap report on board air force one when vice president johnson was sworn in as the assassination of john kennedy. and more recently went air force

one became what you called a flying bunker as president george w. bush traveled from florida to very start of the country before returning to washington, d.c. what the is your take the weighn all of this? >> guest: some people take issue with it like that was air force one, but again you have to distort candidacies and this could be moments when you want the press to be there. you don't want to rely on aids and family in these moments. not to denigrate them but they have loyalties in some cases in terms of age, they have loyalties but they are also paid. you want some objective mayor richard this setting is a lot of people think that press can't be objective anymore. i think that's false and they think what people would learn if they talked to reporters which is not easy to do, what reporters really do care and want to get the story right especially when they're in an observation about.

>> host: when you reach out to the trunk or the clinton campaign, what do they tell you? >> guest: the trump campaign did to make it with me but they did not have anything to say about the plane. the clinton campaign has told td reporters that it will have on the plane after labor day. very late for this process and by historical standards. otherwise they don't really provide a wide. they say she does a lot of interviews because the context of this is just not enough press conference in some nine months. she does interviews. she's out there enough. maybe some people would agree with her but by again historical standards she is not out there as much as any other presidential candidate before. >> host: this is a story that we can immediate talk about but do you sense the public cares about this? if not, should they? >> guest: i think they

probably don't and they see as some harping from reporters and to think in cases they say good riddance. i think what they will find is that they're going to miss us when we are gone, that it's not about us. it's about the information we get. you want to know that your presidential candidate, at least i think he should want to know that your presidential candidate is being transparent, that democracy is working to the transparency is in good supply. and so what do you care about this or not is beside the point do you care about the information we are paid to ferret out. >> host: what you think a trump and the clinton campaigns both have been so reticent to other reporters on the plane or also make their candidate available to the press? >> guest: probably two things. one is a mr. cobbs case his airplane is partly has been his own home for years. he probably doesn't want a ton

of press traipsing into where he she's having private space but i say to bed. believes a bigger plane. again better late than never. in mrs. clinton's case i think there's been an arms length relationship with the press for some time. and while that's always been the case, when she ran eight years ago she had reporters on her plane and was much more interactions i think she's just kind of gotten hunkered interacting she sees some strategic kind of benefit here that helps to run against mr. trump waste out there so much. let him slip around because he does that sometimes but that said, the public's right to know should not be second to the political imperatives and that might apply on but more you wonder what happens if she wins the white house. >> host: as you write in your piece is about something much bigger than eyewitness accounts and plane rides. the column by jim rutenberg enviable online at nytimes.com.

thank you very much for being with us. we appreciate it. >> guest: thank you so much. >> the white house is responding today to the interview with the hill reporting president obama's top spokesman today chastised me at times of giving the administration enough credit for taking unprecedented steps to make the white house more transparent. josh earnest wrote a letter to the editor criticizing a piece by media columnist jim rutenberg which knocked presidential nominees hillary clinton donald trump for their campaigns lack of transparency. press secretary complaint jim rutenberg did not acknowledge the important and unprecedented steps that the obama administration has taken to fulfill the president's promise to leave the most transparent white house in history. you can read more at thehill.com. coming up at 4:30 p.m. eastern president obama will be the keynote speaker at the lake tahoe summit focusing on water and environmental concerns. joining him will be harry reid, jerry brown and diane feinstein

among others. that will be live here today on c-span2. coming up tonight at nine eastern its donald trump as he outlines his immigration plan to peace meeting with mexican president this afternoon. president enrique pena nieto ahead of that speech. he would give his speech from phoenix, arizona, but it will be live on c-span tonight and, of course, we'll take your phone calls and your tweets. here's what we might see in here tonight.s >> good morning.ng me. what do we know exactly about the positions this speech willw take in air the debate by donale trump? >> guest: we really don't know much. he spent a little bit vaguely after the speech. we do know they have doubled down. we know you will still call

mexico to pay for all those her is going late last night he tweeted that he will be going to meet with the president of mexico before the speech, so they could always be some changes to the policy after m meeting which you can toggle in terms of compromise. we know that he's going to really double down on stronger enforcement and giving criminals out of the country. >> host: so talk about arizona. why they are? and specifically then, what's been the reaction may be from those in arizona about this speech? >> guest: arizona is a republican state. they are not actually -- he's ut not by a ton but by about five points, so it's accountable state for them to be and.it i he has the endorsement of sheriff joe arpaio it was very, very strong on stopping illegalv immigration. arizona has a growing hispanic

population, and so mr. trump has been going back and forth over there are with people who do noh like his policies at all. but democrats have tried to tap into that side of things. there's a mixed message but overall it's a republican state with an endorsement of a sheriff who is really strong on illegal immigration. >> host: there have been stories leading up to this speech about you mentioned the change in positions possibly that mr. trump might be taking with it comes to immigration. for those who are most interested in that out whether watching this speech? >> guest: what we are watching for debate is if there's any kind of quote-unquote softening from him. his team said last night that the government not happen, but the reason we're looking for that is because last week he met with a hispanic advisory board, and coming out of that meeting he said a few things. at one point he said he would be

open to softening on newsstands, which as you know was the strongest kind of -- signature campaign issue throughout the very strong on a. at one point he called for deportation of course. to softening would be a big deal. a the other thing he said is he would be willing to work with law abiding, undocumented immigrants who are willing tots pay back taxes. he came a couple days after that and said that's not true. i was just talking, soliciting opinions from people. i'm just as strong as ever. any of those things kind of come through, that's a change in his this. >> host: about the meeting people have with mexico'st president today, was it just donald trump invited? i imagine immigration issues with top that agenda but what else might be discussed? >> guest: we don't know very much. hillary clinton was also invited.hi apparently the present next invited them both on friday.

we didn't hear anything until late last night. i know that the trump campaign has been working to schedule this. it's a strategic schedule. not just travel wise because although mexico city is closer to arizona then say new york, he can go into speech saying i met with the president of mexico. we discussed this. we came out with these plans ane the deathly is a presidential move. it was not by any names just directed at donald trump or we don't know what they will be talking about besides that butnt it is just leading up to the election, our two countries are connected, let's talk aboutum things, then immigration is going to talk. >> host: this speech comeho anything else we should no anything else important for our viewers to watch from thisor? speech? >> guest: i think we are looking for details tonight. can talk about the wall, you can talk about giving criminals out but what about the 11,

12 million undocumented immigrants who were in the country right now? we are really looking for was could happen to them. he previously said give them all out. we are curious as to what -- witwould you be willing to let e of those stay. >> host: eliza collins talking about the speech by donald trump tonight. thank you. >> guest: thank you. spent live to a discussion on the zika virus with dr. anthony fauci, director of the national institute of allergy and infectious diseases. he will be joined by other specials to look at progress made on vaccines and treatment. >> that began in and go and is engulfing africa, and by the time we this mean we should know what the emergency committee's recommendations are because bears a vaccine shortage for

yellow fever and we're trying a portion those resources. so what i want to do is just put this zika conversation in context. in the latin america and caribbean region there are 45 countries that have reported local zika mosquito transmissions. there's been increasingly worrying data coming out of particularly problems with neurological disabilities among infants, and particularly microcephaly. at the moment there are two areas in the united states, both in miami dade county that are experiencing local mosquito transmission. there've been approximately 30 locally transmitted cases confirmed to date. and nationally the are a couple

dozen cases of sexual transmission and thousands of cases of travel associated zika infection. and as will be discussing today, we are uncertain what we are seeing whether this is a hidden epidemic whether or not there are other cases that we are not seeing and we don't know what the future will hold in the united states and beyond. there are also will be discussing not only the public health concerns but also the moral concerns because about the region, including in the united states, there's reason to believe that zika affects the poorest communities, it affects women and their babies. and because it involved such controversial issues as contraception and abortion and health care for the poor, it

raises the stakes in terms of our political understanding. so we will look at questions of health with justice. just yesterday, freedom, the head of -- tom frieden, ahead of the cdc said that the funds the president obama had allocated were virtually exhausted in the fight against zika, particularly in the miami area of the $222 million allocated so far. 194 million have been used. and he characterized that as the cover being bare. we are going to hear from the great leader in the united states tony fauci, globally, about what the funding implications might be. not only for zika vaccines and diagnostics and treatments, but also other nih priorities and

the biological research agenda. meanwhile, there's been congressional dysfunction. it's been about six months, a half a year ago that president obama in february the past congress for $1.9 billion zika allocation, much like congress passed the allocation for ebola. but as of now, congress went into summer recess without passing it. it's been a political football, questions we will be raising our should we play politics with the public's health and safety here in the united states? mitch mcconnell just said that he hopes to bring a built up next tuesday in congress, but again there are problems with

the democrats and the republicans inception of what we should be doing. so we will talk about that, the public health implications, mosquito control, the progress there, research and development, health care for pregnant women and the poor. and generally, is the united states and is the world health organization prepared. i couldn't be more pleased to welcome our panel. our featured speaker is very, very dear friend, tony fauci, who has been for many years the thinker, conscience of infectious disease in america your i can think of no greater tribute to somebody to say that he's really built the research and development agenda, and he

has served as the voice and the conscience for infectious diseases, and been a steadying hand for continual outbreaks. told me has told me never gets a summer off. not because of epidemics start in a summit but they start before and they linger on. and that's where we are with the zika outbreaks. .. international studies. he is -- i'm continually amazed of thinking. i had the privilege of serving with him on global health commission in the wake of ebola

and no greater thinker of national security, political reason for action or inaction and global health security. and then the part of this panel, he's a senior and i like to call him the micro hunter. wherever there's a problem in the world, he's there. he's there to treat patients. he's there to advocate for reform. he's a thorn on the side of margaret chon. [laughter] >> as he should be and just returned to africa working on yellow fever. i will turn it over to you. [applause] >> thank you very much, larry.

it's really a pleasure to be back at the o'neil institute particularly to join my colleague and dear friend lucy and larry in discussing this really important problem that is really described on the first slide right here, pandemic in process. this is not a retrospective analysis of what went on but a description of what's evolving more and more literally every week not only in the americas but what we see in the news in singapore they're starting to have a situation in singapore that's quite worrying and i'm sure we will get to that discussion. i will set the stage on discussion on zika. i show a paper that was recently published in january about a month and a half after it became clear to me that we needed to have an accelerated efforts. i chose the title zika virus in the americas, yet another threat

because i wanted to put it into context that this is not just a one-off issue that we are facing. if we look over the last several years of the virus that is were not an issue in the america that became issue like west nile in 1989. chikungunya in 2013, dengue back and forth and now accelerating over the last several years and now more recently zika. and so again this is something that we are facing and when i get to the discussion i will tell you it's not the end because we are going to see it again. i assure you of that and the reason i say that is because a year and a half ago at the end of talk that i gave to a large audience about ebola and how the ebola appear demic was ending, we got through that, that's wonderful. i said it isn't over and something is going to happen soon. unfortunately i didn't realize it was going top a month later with zilla but it actually did.

i'm going to divide my discussion in four areas that i will briefly touch upon. first zika background. many people right now are very familiar because of the public attention that has been put to zika. i show you this but to point one thing, rna virus that's of the family virus. why is that important? it's important because these are the viruses that we have a lot of experience with the flavi viruses include dengue, yellow fever, west nile virus. wife made successful vaccines against flavi viruses. i will get back to that in a minute.

why? i have a fair amount of confidence that we will have a vaccine for zika, when is really the issue. it's transmitted by a mosquito copious in the americas. that's critical. you heard in the last several months the more we learn about zika the more complicated and more disturbing it gets because not only it's transmitted with mosquito which flavi virus is transmitted by mosquito then we found prenatal transmission, and, of course, we get to that in a moment and then sexually transmitted, first to a man to a women and then also woman to a man. also blood transfusion.

i put other because we are waiting for additional surprises, i hope not that we will see with this. the history of this is a textbook case study. it really is. people are going to be studying this in public health schools for decades to come. it was first recognized and people confuse recognized with occurring in the sense of just evolving. this virus has probably been around ifever. it was recognized in 1947 in the zika forest of you --euganda hence accident in -- zika virus. we didn't know exactly what the impact was because if there were outbreaks they were unnoticed in africa and southeast asia. when you don't have an outbreak, you don't appreciate the extent of what a virus can do. as the years went by in 2007

there was a modest outbreak in the app islands and then in french polynesia working to what it might happen and worked nicely, not really nicely, unfortunately for us across the pacific until it landed to what i call the perfect storm. the perfect storm is a populist country that has economic and other conditions that make it conducive to have spread of mosquito-born viruses, multitude of mosquitoes that are the right mosquitoes in a country that has a healthcare system that's good enough to notice what's going on and that's really critical because it was the fact that although there are pockets of poverty in brazil, they have a pretty good healthcare system that can pick up things likes microcephely and other things. what about zika infection, it can be confusing to people.

putting pregnant women aside, it's a fundamentally relatively benign and somewhat inconsequential disease. it affects people and 80% don't know they're infected. 20% have symptoms that are usually mild, aches, pains, fever, it tends to clear in seven to ten days and then you're done except -- and we will get to the excerpt -- except in a moment. if you look at -- there are multiple things that tell you things about zika but i like this map because what it tells you is if you look at the areas that are environmental suitable for zika virus transmission, right climate, right mosquitoes, all the right things, this is the area so there are about 300 million

people in the may may -- americas where suited, 300 million birds per year and obviously we will get to in a moment the issue of microcephaly is an overwhelming compelling issue with zika. this is what i meant when the people in brazil first started noticing a dramatic increase in microcephaly over and above the baseline. you heard people argue, well, they weren't really looking for microcephaly. yes, it's probably an overcall but there's no doubt there's a major increase in microceplay associated with zika. we are seeing that in a number of countries. what is microcephaly,

abnormality by direct destruction of the brain. why do baby have small heads who get infected? it's a fundamental explanation. as the brain developing between fetus, the brain pushes up the skull so the skull is because the brain during development pushed it out and when normally developed it's a nice smooth contour. the head looks flat or small. there's another thing called fetus brain where the brain does well and what happens is the brain caves in and that's when you see pictures of children -- tragic looking, skin as if they had a normal size head and then it slunk again and there's a recent paper that show pictures

that are quite disturbing. we know now in one study but we still have a lot more to learn that in a study in brazil that if a woman gets infected during first trimester there's one and third chance that the child will have microcephaly, a baby could actually be born looking normal and have serious abnormalities of hearing and sight. there was a paper that came out three days ago that just showed the issue of visual and hearing abnormalities. there are also other abnormalities which is a contraction in cur lg -- curling up but it's likely from neurons.

it's a brain issue. now one of the things that just recently came about and everyone was surprised about it and i got a lot of calls from the press about it that babies who were born with congenital infection, we have decades of experience with rubela if you get infected because of the system is not fully developed, the baby interpret it is virus itself so it doesn't make a response against it and when the baby is born you can have prolong and it's not a surprise. influuenza.

what about zika in the united states. now the united states as you know also includes puerto rico and i learned a lesson that i was briefing president obama in the situation room and i was talking about the united states and puerto rico, time out, tony, puerto rico is part of the united states, oh, i'm sorry, mr. president. [laughter] >> the reason they're american citizens, they're having a terrible time right now. they're in the middle of an outbreak that's going to be bad. it's going to be a really serious situation because what happened with them, with chikungunya in 2014 is that 25% of the population got infected. now if you look at the potential importation, there are about 200 plus million journeys back and

forth from the united states to areas with local transition of zika, 34 million by air, a lot by land and by sea which means and this is something that are start to go appreciate now, the difference between a travel-related case and a local transmitted case, in the united states there -- there are at least 2500, closer to 25,000, namely someone who is infected elsewhere and either comes back to the united states or travels to the united states. if there are those many people in areas where the mosquitoes are transmitted, it's not surprising that you ultimately as we predicted would have local transmission. among the people who were infected in the united states there's over 500 close to 600 pregnancies and in the territories particularly puerto rico there's over 800. so we are going to start sees as

we already are seeing cases of congenital abnormality already here in the united states. now, you heard larry mention what is going on in florida is not unexpected. when you get local transmission and we know this from dengue and chikungunya, most of the time they're one off, single cases. bites someone who never left the united states, they get infected and a dead-end there. occasionally cases that cluster and related to one another. we have seen that in two defined locations, one in wynwood north of miami and the other is the south beach section of miami beach. so right now there are total of 46 locally transmitted cases of florida, several sexually transmitted cases. so i want to stay within my time

frame so let me close and spend a few minutes on looking at the role of research and development alike. you might expect the response to zika from hhs and other agencies very familiar to the response that we had to ebola which is accommodation to the cdc doing public health thing that they do so well. with zika it's infection control, for the nih fundamental research to understand the disease one and develop countermeasures in the forms of diagnostics and vaccines. you look at that, take a look at what just came out two days ago was the identification of some molecules purely by high-through screening that might have activity against zika. be careful because invitro

activity doesn't mean it's going to make it. we did study in south america and puerto rico looking at 10,000 pregnant women, not necessarily zika infected pregnant but following pregnant women perspectively to determine the incidence of zika and what's the incidence of malformation. also vaccine, and this is a combination of basic research with animal models showing that you can actually protect monkeys against challenge when you vaccinate them with a variety of candidates all in cue that we have now lined up for testing. now, i mentioned in the beginning of the talk that i was reasonably confident but i always say that with a caveat because one can be fooled, the reason we can have an effective vaccine against zika is that the

body makes a pretty good natural immune response against zika and whenever you have a mike robe in which the body tells you that it's capable of making immune response, the chances are if you try hard enough you're going to make a good vaccine. we can't necessarily say that yet with hiv because the body doesn't make a good response against hiv but the animal studies indicate that i think we are going in the right direction. this is a complicated slide. we have five or six candidates that are lined up for testing with the vaccine. the first one that goes into testing isn't necessarily going to turn out to be the best one. people need to understand that and that's the reason why you have a number of candidates, let me just pick out one as the property -- prototype with the

assumption other candidates are three months to a year behind that. the one that's ahead is one that was developed at the vaccine research center. it's a dna vaccine. we started phase one trials in humans on august the second. we will be testing 80 people. it will take frobly till november or december of 2016 to show that a, it's safe, and b that it induce it is response that you would predict would be protected. if we are successful in doing that, which we will be, and we will get into the discussion later, if we are given the resources, we will move forward to a phase two trial which will determine if it works as oppose to having 80 people, the phase two will have 500,000 people, 20 to 25 sites in south america, central america and the caribbean.

we mentioned the testing right here in the phase one trial. at the university of maryland and atlanta. i want to close with this slide to remind you what i said in the second slide yet again another virus infection is that we are dealing with emerging infectious disease. this is something that i refer to as a perpetual challenge. there have always been and there always will be new emerging and reemerging infectious diseases. i think it's becoming apparent to all of us that when we need to respond, we need to have something that's already in place and you heard many of us talk about the idea of an emergency public health fund so

that we don't have to go through appropriations process which is a good process but it takes months and months and months. so i will end with that and i would be happy to join the panel and discuss this further, thank you. [applause]

>> thank you very much. that was superb as always. why don't i begin with you and widen it to some of the other political and ethical issues. i think there are many people in the public, it's kind of a dual public reaction, on the one hand i am going to be talking about in the panel is that there's broad-spread among the population, something like 77% of a poll thought that there was nothing that significant to worry about, more difference to the public and political reaction to ebola but on the other i think the public is wondering, you know, is this a hidden epidemic, what aren't we seeing?

we know about the confirmed cases in miami-dade, florida, we know about some of the sexually transmitted cases, but in your sense, is this a hidden epidemic, are there things we can do in terms of diagnostic tests to enable us to have a better understanding of actual transmissions in the united states? >> well, if you say hidden epidemic you're going to find something totally transforming that we didn't know about it. i don't think that's the case. i think as we get more and more experience it's clear that when you have larger numbers of cases, you will see things that are rare events and there will be rare events that a person died, a benign disease that once in a while you'll have somebody that gets sick and ultimately dies. i don't think that this is hidden in the sense of a lot more people getting infected that we don't know about even

though you have to be careful that because 80%f e ople are without sympto. toour point of apathy it's veryntesng because you mpare ebola, there's somethg about the la of coecng the do when u have to convince the public that somethg rely serious if it essential is a mild meat trivial infeioin evebody eept pregnant women iyore not thinking in rmof you are women who is ofhild-barinage and you're a mawho has had a bynd deta h anxious you g during prean or ifou're a husbanwhha childn and you understand the risks in pregnancy, peoplte to not get upset about becau is like it's someing el's prleand whenever you get a situiowhe ople start to thk 's somody else'

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sense of comn purpe at ses above is? we don't know. [inaudib] the overlay of outbreak or ouay of ctracepon, abtion, and parentho, medicaid funding for pr me and their chdren. can you talk littlbit about at? >>ell, when you talk earlier aboudiercer inability to t people to see what is in fronofs, tnk, there are multiple factors tt ment play. e take puerto cowhich is e most dangerous and rapidly foldinsituation. most america dnoseputo ricos -- as part of amica in realy. tony mention it inis own conversation with the esent. i ink all ous in meayr

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