level though never entirely that he was not anything like that. so she had this sort of -- if you graph it. enormous enthusiasm and after a while if people didn't need her anymore, they couldn't love her and therefore she would move onto another one. at the end of her life she had a whole lot of them all sort of clustered around her mutually antagonistic i'm sorry so say. sort of a strange circle. all of them adored her and felt they had not gotten enough of her somehow. does that make sense? >> she couldn't cross a line. was that because -- >> i can't prove she didn't cross a line. i just don't think so. >> do you think that's because franklin hurt her or because of her childhood? >> i think it's because of her childhood. >> she was really devastated by the lucy mercer discovery? >> it was the same kind of confirmation about her father.

here's this golden person and then they turn out not to be golden. and most of us deal with that better than she did. >> they reject her. >> they reject her and of course they reject her because she's rejectable. >> there are pictures of her in this book when she was young when she was seeing franklin in the beginning. she's beautiful. >> she was. >> she was beautiful. she didn't know it. she didn't think she was. and of course pictures we see of her she's not. she was. that's something that surprised me. we're going to invite you all to come up to the microphones in the aisles and ask questions and while we're setting up for that, let me ask you one final from me. as you delved into the personal relationships of the franklin delano roosevelt wing, what's the biggest surprise for you? >> when we did this? >> what's the latest surprise

you came upon in the relationships? >> i guess my theory was that theodore roosevelt was terribly important in the lives of both eleanor, who was his niece, and franklin. and that was just strengthened. when i thought about it, the shear number of times you could see the connection. you could see fdr trying to be like t.r., rejecting t.r. he was a huge figure to both of them. she saw herself all her life as a member of that family. when she was very old, she said somebody told her to sit down and relax. she said i don't think i really

can. i can't sit and knit in the corner. i'm too much of theodore roosevelt's niece. >> he did love her. he was one of the few, right? am i wrong about that? >> he loved her when he saw her, but he didn't see her very often. his wife actually didn't want her to come to the theodore roosevelt home because they believed that somehow elliott's problems would be visited on her. there's an awful letter in which she said i don't encourage -- >> elliott being her father. >> pretty grim. that's why she's a wonder. >> you called her a wounded

person. >> yes. all right. please. >> good morning. first of all, the book sounds fascinating. i'm going to get copies not only for me but the other grandmothers. i share grandchildren with two other grandmothers. >> the child goes to grandparent day and brings eight people with them. >> we have a handoff system and everything. i was intrigued by what you said about eleanor roosevelt looking back and regretting the way she raised her children to the point where she considered killing herself. i never heard that. so i was hoping you could talk about that a little more. >> when she was an elderly lady living alone in new york, she had a very dear friend who was her doctor. sort of the last person to whom -- >> foreign i believe. >> yes. absolutely wonderful doctor and wonderful friend to her. they used to take walks at night.

she couldn't sleep. they used to take walks at night and he told her -- i'm sorry, she told him that she just didn't think she could go on. there had been yet another divorce or yet another something in the newspapers about her children and every time that happened, she felt that it was because she hadn't done the job. >> thank you. >> am i correct in this that none of her children could sustain a relationship? is that correct? am i going too far? >> i think the number is 19 marriages. i think that's right. >> among her children. >> yeah. >> that's a perfect lead into my question which is -- i think you mentioned this before, mr. ward, when you were here that they had something like 18 divorces or something. is that a result of eleanor being not the ideal mother?

>> i don't know. i don't know how you -- it must have been part of it. >> is there anything about presidents' children that suggest -- >> it's awful. >> something about the children of presidents. >> fdr said it's a god awful thing to be the child of a president. i think that's true. you know better than i. it really is -- especially now but even before. everything they do is news. that has a lot to do with it. also there's the business of you never know whether people are interested in you because you're you or because your last name is roosevelt. that's very tough. that goes on through the generations. it's very tough. >> you know, you bring to mind in my mind because i covered jimmy carter's white house, amy carter, who they put into public school. it was sort of a spectacle when she started at that school, the press and everything followed

her day in and day out. and she became kind of a solemn kid in the white house. they would make her go to the dinner party and she would read her book through the dinner party. i wondered how she would turn out. i met her a couple years ago. she is healthy. she is raising a couple of kids. she's got a strong marriage. she's lovely. so it's not 100% by any stretch. there's a history. >> i would like to ask you about fdr's father. i believe he was 52 when he remarried and sara, i think, 25. i've seen pictures of her. she was gorgeous. >> she was indeed. >> spoke several languages. had grown up in hong kong with her father. what was their marriage like and what kind of a father was james roosevelt? >> as far as i can see, he was a terrific father. he adored this kid who i think was a surprise and a delight.

he already had married a member of -- a rich family. i can't remember their names. i apologize. and had one son who was a sort of showy. married into the family and retired. i saw some form he had filled out. i think he was 23. retired capitalist. not a bad thing to be at 23. james roosevelt, mr. james as everyone called him, was a lovely man with a very good sense of humor and enormously fond of his son. >> franklin's strength of personality came from two loving parents. >> yeah. >> thank you very much for this wonderful discussion.

what kind of a grandmother was eleanor? because i remember when i was a teenager, a couple things about her. one, she took a european tour after the war, and she took one of her grandchildren with her on the plane, as i recall. is there anything about eleanor as grandmother considering her background and her rejection? >> i'm constrained by talking about her as a grandmother because i don't know much about her. i think there are people in the audience that do, but they're not going to speak. >> they seem to have a close relationship. it was a girl that she took. i don't remember who. >> yes. curtis was with her in united nations. i really don't know very much about her as a grandmother. that was not a period i was writing about. >> i write a little bit about it.

everything that i came upon was always describing her in relation to sara. sara was doting, loving, generous, and eleanor was distant. it wasn't that she was distant but in relation to sara. the kids talk and have written and have been quoted as saying sara was the one they wanted to go to and they called her granny. they called eleanor grandmere as jeff said. that describes the comparison. obviously she loved her grandchildren. you can't not love your grandchildren. >> something you said about her being beautiful when she was younger. i'll be very brief. i went to hunter college. i was about 17. they had, every christmas, some famous person would come to speak. that christmas it was eleanor roosevelt. she came down the aisle just like this. she was very tall.

she was older. she had white hair. she was beautiful. she had a beautiful profile. all this talk about her not being so -- and i was a kid looking up at her saying what is this stuff they're saying? she's beautiful. she was marvelous on the stage. >> she didn't photograph well. >> in person she was beautiful. >> lovely. >> part of the problem was that she did have very prominent teeth, which the theodore roosevelt family wrote letters about but never did anything about. they could perfectly easily have fixed that. >> there was orthodontia back then? >> yes. other members of the family had. they would say she had unfortunate teeth and then do nothing about it. >> i'm a big fdr fan number one. read many books. i wasn't going to ask questions today but what came to me while

you were speaking about the sons of fdr, they were really used by other people for business purposes. they were exploited for their name. i remember reading that some of his sons would go to him and they would basically talk about business deals and he seemed to be okay with that and would use his power of the presidency to help them along in some of these exploitative business relationships. didn't he see the moral difficulty with that? have you dealt with that? >> i think he was very sympathetic to his sons. i think he thought on some level that he had -- he had caused them trouble by becoming president. i think if they could succeed at something, i mean, i don't think he used the power of the presidency in any nefarious way

at all. but they were roosevelts. i do think he felt for them. i think he felt that he hadn't been home enough unavoidably, and that they had a tough road to hoe. i had lunch with james roosevelt about a year before he died, maybe a year and a half before he died, and we had lunch on the upper west side. he couldn't have been nicer and more helpful. at the end of the lunch he had tears in his eyes. he said, mr. ward, i hope you will be able to tell me why my father didn't come to my graduation. i don't know how many years after that that was. it shows you the price families pay for people going into

politics. >> you're suggesting that both eleanor and franklin felt guilty about not being more attentive. >> i think so, yeah. >> on the day that the president died in warm springs, lucy mercer was visiting him. do you know if the president requested her to be there or did he have some idea he might be in his last days? >> i don't think he knew it was his last days. he did ask her to come. she came often when she was in warm springs and daisy was there. another cousin was there. all of whom adored him and all of whom sat around and listened to the stories they heard before. the account of those last days is to me incredibly moving. at the very end they were feeding him some kind of -- daisy calls it gruel. i think it was porridge or

something. he would get in bed and she would come in and feed him, and he would pretend to be a baby. this is president of the united states fighting the greatest war in human history. he needed that maternal unqualified adoration. he deserved it at that time. >> he did. you know, you read through this book, and i was really struck by how indulgent sara was with him. how he could do no wrong. he suffered as a kid because other kids didn't like him very much. she kept him on that pedestal. reading through, i said oh my goodness, he came to need it so desperately. he came to need what his mother had done, which was just tell

him he was perfect and fabulous and make him the center. >> that's why i think he ran four times. i think he thought the natural order of the world was with franklin roosevelt in the white house. he had been raised to believe that. >> his father doted too. >> it happened so there you are. >> let me look for this. i pulled out a quote, which i always loved, which i put down here because i wanted to tell you. it's a quote from churchill who we all know kind of moved into the white house for a while to convince the united states to come into the war. and he said -- winston churchill says, "franklin roosevelt with his iridescent personality meeting him was like opening

your first bottle of champagne, knowing him was like drinking it." so he even strove to get other people to see him as the sun and come around and worship. i forget what side i'm on. go ahead. >> i'm one of those silent grandchildren that you were kind of looking at over here. my name originally was sara delano roosevelt so i carried that name for quite a while. i want to say it was moving to hear about our father that you had spoken with him. we didn't see a whole lot of him when we were children because he did go on and marry other people. i was thinking from the perspective of a grandchild, which you've described fully and well, that one incidence sticks out in my mind.

i was a student at boarding school and mrs. roosevelt was coming to give the graduation address to the then graduating seniors and i was a sophomore. she came to our house, the boarding house, and sat in a chair. i had been pulled aside for a moment by the head mistress to say hello to her in a private room, which is basically a kiss on the cheek. and so i came back and i sat on the very outskirts of this group of adoring girls. kate and i had another grandmother, a maternal grandmother with whom we spent an awful lot of time. we really didn't know eleanor. i think i could say that. she probably knew her better than i did. in any case, in this situation, i'm sitting and i suddenly have this revelation. i said i understand.

she's everybody's grandmother but she's not mine grandmother. >> oh boy. that's perfect. >> did you call her grandmere? [ applause ] >> no. kate and i called her grandma. i think we were the only grandchildren who called her grandma. >> lovely. thank you so much. [ applause ] that is wonderful. very exciting to hear. thank you. >> a question that's not totally unrelated to what was said. i was struck by your story on fdr's grandparenting style and then lesley you saying that

grandparents are supporting more grandchildren now. i wonder how social privilege and financial privilege shape grandparenting or is there some inherent -- income inequality increases significantly and grandparents serve such more of an active role in sustenance in the family. how does that shape the style of grandparenting? >> let me first say that i found that this deep loving, this unconditional love for a grandchild is universal. it has nothing to do with income, education. it has nothing to do with what country you live in. it's not 100%. i've been criticized because someone called in on a radio show and said i'm not like that. it's pretty much the norm that people fall in love with their grandchildren. going back to caveman times,

grandmothers raised the grandchildren. so there is something inherent in our bones, in our dna that grandmothers need those grandchildren, we're supposed to be in their lives with be we crave them when we're not, and we -- both grandfathers and grandmothers love them. it turns us silly. really, all of us. in terms of our contributions to their lives, obviously if are still suffering because of the recession, you can't send money because you don't have it. but the baby boomers and generations older, the pre-boomers, as we're called, are the generations with the money in the country. it's inverted right to you. in all of time, it was that senior citizens -- i hate that, senior citizen -- were the poorer ones and our children helped support us in old age. it's inverted. we're the ones with the money. we're the ones who still have pensions and social security and savings accounts and all of that, and the younger

generations need our help to probably -- young parents both working, not earning what one bread earner earned in our generation. so we are -- a great many of us -- sending money, if we have it. and we're forgoing a lot to be able to send the money. there have been surveys taken where grandparents put their grandchildren ahead of everything. ahead of their own financial well being, put their grandchildren ahead of traveling and seeing the world, and even change their idea of retirement if they realize that their kids in some way need help. so i hope that answered your question. >> yes. thank you. >> my question is about the roosevelts in new york city.

i work on east 65th street and i always stop to look at those two town houses where sara had one and eleanor and franklin had another. and i always try to imagine what it must have been like when they were there. i was wondering if you could just share a little bit about what their life was like when they were there in new york. >> sure. when mrs. roosevelt wrote her autobiography, she gives a pretty grim picture of that, of their two houses next to each other, doors open in between, and you never knew when your mother-in-law would suddenly appear checking on things. and it's usually made to sound very uncommon. it was not uncommon. there were lots of houses like that in new york. in fact, the roosevelts -- yes, the roosevelts were married in one of the parlors of a two-part house. i think it was -- you know, it was a very complicated place.

it is a wonderful sight and they've now -- they haven't exactly restored it, but you can see it. you can go through it which you couldn't do in the past. i find it very moving. one of the roosevelt children died there. he was brought back there after he had polio, and there is a wonderful picture -- it is one of my favorite pictures -- of him leaving the front steps of that house to go become president of the united states. and there are railings so that he can go down. he's just about to sort of vault down and his son james is patiently holding his cane at the end so that you can't quite see it but it is going to be handed to him. to me, that's a very emotional picture. that's a terrific place. >> you know, for all of time, until the mid 20th century,

families lived in multi-generational houses or compounds. again, this goes back to caveman times when families were structured so that grandmothers were an integral -- and grandfathers were an integral part of families and definitely lived together. and it is only in recent times with mobility and the urbanization really that we have broken that up. one of the things i say in the book is that it's unnatural. and there is a huge trend today, enormous trend, of grandparents, whether they retire, selling the house they've lived in for 50 years, and moving near their grandchildren. and more and more the children are accepting it because they want the help. they need the help. and the idea that the daughter-in-law and mother-in-law clash is as old as humanity. that's also built in to our

bones and our genes because the younger woman wants her husband to turn to her nest and break the connection with the mother. that went on even when they were all living in the same household. >> sure. just because you were the one that brought up that, there is a nice irony. at the end of her life, mrs. roosevelt shared a house with the doctor whom i mentioned before. and the lady who married the doctor, it was a friend, a lovely lady, recounts being in her bedroom with her new husband and mrs. roosevelt appearing in the doorway to say good morning, which is -- it's sort of irony there somewhere. >> definitely. >> well, i can see that we could go on and on and on asking fabulous questions about

franklin delano roosevelt. but i see someone with a hook. >> yes. and i have tons of questions myself. but some day we'll continue this. leslie stahl and jeffrey ward, thank you so much. this was a different morning. [ applause ] >> we're going to do it again. >> they will both be at the book signing table, so stay, pick up a book or two or three or four. and you can continue the conversation outside. thank you all so much for coming this morning. american history tv airs on c-span3 every weekend telling the american story through events, interviews and visits to historic locations. this month american history tv

is in primetime to introduce deuce cow to programs you could see every weekend. features include lectures in history, visits to college classrooms across the country, american artifacts, taking a look at the treasures at muse s museums, reel america, revealing the 20th century through archival films and news reels, the civil war where you hear about the people who shaped the civil war and reconstruction and the presidency focuses on u.s. presidents and first lady to learn about their politics, poll sis and legacies. all this month in primetime and every weekend on american history tv on c-span 3. alternative health delivery models such as telehealth. the group represents fortune 500 companies and their perspectives

on federal health care policies. good morning, everyone. my name is brian marcotte, president and ceo on the national business group of health. i welcome you to this 2017 large employer health plan design survey results. i should say to start, there are no pokemons in the room. i did a scan before we started. my son is obsessed with pokemon. just a bit about the business group before the survey. the business group is membership based nonprofit organization

about 425 primarily large employers who come together to share best practices, to learn from each other and leverage those learnings back in their own organizations to improve the health of their employees and health care management of their programs. they also bring their health leadership or thought leadership to the table to help advance delivery system reform, improvements in health care and the overall well-being of their employees. a little bit about the survey, if you follow along, there's a chart pack in your material that you can follow along with my remarks. the survey was fielded in the may to june time frame. we always do the survey in that time frame because by june it's when most companies make their final decisions for the upcoming year. so the results that you see are what employers are planning to do in 2017, not what they're considering or thinking about

doing in 2017. we ask questions about medical trend, around cost sharing and plan design, around delivery reform and even get into some other ancillary issues like private exchanges and some other things. we had 133 members respond to the survey. these are all large companies, average employee size of around 20,000. they're self-insured, multistate, in many cases global employers. and they provide or offer health insurance to over 15 million employees and independents. to put that in perspective, that makes up probably around 10% of all of the people that receive coverage through the employer sponsored health system, and it's more than people that are covered currently through the public exchanges. from a demographic perspective, this survey covers a wide range of industries from retail to hospitality, to energy, to manufacturing and technology, banking and financial, consumer

products. again these are large employers. three-quarters of the employers who responded to the survey have over 10,000 employees. 30% have over 50,000 employees. i'm going to walk through some of the key findings and then we'll go a little deeper on some of the issues. employers are projecting that medical cost trend will increase 6% for next year. 5% when you factor in plan design changes that they will be making. medical costs continue to increase at multiples of cpi and general wages. about three times cpi and about twice general wages. and the ongoing continued year over year trend that's running around six or so, 5% to 6% is really unsustainable from a cost perspective and it's still the number one priority for what employers are focused on.

and it really threatens the overall affordability, long term affordability of health care. specialty pharmacy is now the number one driver of overall medical trend, which is surprising when you go back even just three years, specialty pharmacy wasn't even in the top five. specialty pharmacy only affects 2% to 3%, 2% to 4% of your population but the number one overall driver at this point and we'll spend a little more time talking about that. employers are beginning to shift away from plan design changes and really moving more into focusing on the supply side of health care or the delivery system. we're seeing the emergence of more offerings of accountable care organizations, of select high performance networks, the expansion of centers of excellence beyond transplants into bariatric surgery, cancer,

even infertility. and when we look at where employer-sponsored health care is today versus the public exchanges, employer-sponsored health care is the most effective and efficient way for employer to provide affordable health care to their employees. when you look at the public exchanges today, there's still a fair amount of volatility in the number of plans come in and out, health plans come in and out of offering coverage. premium contributions are proposed to be double. and deductibles, when you compare average deductibles within employers, they're about a third of what you find in say the most common plan within the public exchanges, which is the silver plan. from an employee perspective, what can employees expect in 2017?

you will see pretty much a business as usual moment. not a change from a plan offering perspective, not a lot of change from a plan design or contribution perspective. contributions will be on par with what they were last year, probably 5%. they may see some expanded options in terms of coes, centers of excellence and other delivery models as part of their offerings but overall it should be a pretty normal annual enrollment or open enrollment period. if we take a little bit of a deeper dive into medical trend, you'll see that medical trend has been consistently running around 6% top line and around 5%

after plan design changes other the last three or four years. consistent or stable doesn't mean good, as i mentioned earlier. health care trend running at six, top line, cpi is below 2% and general wages projected to be 3% in 2017, you still have this challenge around the affordability question and how long will it take before health care from an affordability perspective is really a challenge or really a concern. 2015 cost actual came in at 4% for large employers, even thigh they projected it for 5. jury is out for 2016 but the forecast is still overall 5% and a net of 5% for 2017. so what are the major cost drivers for health care costs as we go into 2017? as i mentioned at the beginning, specialty pharmacy is the number one or top driver as we look into 2017. in the mix with specific disease

conditions, such as maternity, depending on the industry, or musculoskeletal or cancer or diabetes, high cost claimants are always up there as well. but in that group of three, specialty pharmacy has jumped to the top. and it's jumped to the top because the trends are expected to be around 17%. these are very expensive medications. they run in the thousand to tens of thousands per treatment. they are typically have challenging administration or dispensing. they require monitoring in often cases patient monitoring to make sure dosage is correct and maybe some care management wrapped around them as as well. they're expensive and complex. when we look at trends for 2017, a lot of that is driven in part by pipeline of potential break through medications. and some of the categories those medications are in is

hemophilia, gastrointestinal disorders, ms, oncology and diabetes. potentially seeing more drugs coming out in those classes that potentially could be expensive but very beneficial in many respects. when we look beyond specialty pharmacy or we try to look at what are employers doing to manage costs as we go into 2017, it's no surprise that focus on pharmacy management is number one, if you look at the next slide. full replacement consumer directed health plan is still considered the top way of controlling health care costs but we're not seeing a lot of movement for replacement as we look into 2017 and i'll show you data related to that. the big focus is specialty pharmacy management. if you look at the next slide, it gives you a shot of what are

the specialty pharmacy techniques employers are focused on as question move into 2017. we're seeing a number of companies -- actually the number of companies doubled from last year to 2017 who requiring medications to be obtained through a stand alone or freestanding specialty pharmacy. a doubling of the number of companies, up to 38% who require a fourth tier, a specialty tier for pharmaceuticals. we're seeing more in the way of high touch case management, again because of the complexities around these medications, some of the side effects and the dozing management. and we're also seeing a fair amount of site of care management. 30% of companies focused on that. you can see a 7x difference in price depending on the site of care that is selected. if there's a more appropriate efficient site of care moving

from hospital to possibly a stan alone infusion center or moving from an outpatient facility office to a physician's office or from a physician's office to the home, that there's quite a variation in price if it's appropriate to have care delivered in one of those alternative settings. so you can see that there's a lot going on in terms of specialty pharmacy management. but there's also some focus on opioids. a number of companies, 30% of companies are implementing restrictions on prescription opioids really in the form of pharmacy management, maybe requiring employee to go to a particular pharmacy to get opioids or managing multiple prescriptions. but the shift we see from employers is more towards looking at the delivery system for solutions, moving away from plan design and moving to the delivery system. and part of the reason for that is once you go to a high deductible plan, a consumer health directed plan which most

employers offer today, where do you go from there? the plan is already high deductible. you need to turn your sights on the delivery system if you want to control the health care costs. they're looking at alternative models for delivering health care. and one of the alternative models that has really grown is telehealth. about 7% of employers offered it five years ago. by 2017, 90% of employers will offer telehealth and by 2019 it's pretty much universally offered by companies to their employees. so what's the value of telehealth? telehealth is a much more convenient access point than a number of different venues. emergency room cost $700 on average per visit.

urgent care costs 150 on average per visit. physician office $100. telehealth $40. telehealth is not meant to be a replacement for primary care. it's meant to supplement primary care and give people access when they can't get after-hour coverage, when they have a long time to get an appointment or they didn't get off work to see a fen for a select group of services. telehealth is one vehicle to access health care. one of the things about telehealth is the mobile application. today if your strategy doesn't include mobile, then your strategy is not complete. 80% of the workforce has a smartphone and most of the information, both from a decision support perspective as well as access for telehealth and other services is being pushed to mobile. when you look at alternative delivery models, we're seeing growth in the use of accountable care organizations and the use of select high performance networks.

accountable care locations are when providers come together to ultimately take on responsibility for the cost and quality for a defined population. and i say ultimately because these are works in progress. acos when they first come together are not really going to take on risk or not be accountable to that extent. there's a lot they have to do to gear up, to drive care coordination, primary care at a high level, have the analytics to manage their population. and this takes, this takes time. and so there's a developmental period for accountable care organizations. but 25% of employers now have acos as part of their strategy, mostly through their health plan, some going direct. high performance networks fit in

the same category. they're a leveraging aco. and in about a quarter are of employers are also using those. but a number of employers are still unsure. most employers are still unsure, what do you get from these new delivery models, how do they differentiate from the market? how do i know that they are providing or delivering a better service or even a better cost than the market? one of the questions we ask employers -- look another the next slide -- is trying to get a sense of their their expectations were for aco performance versus the market. both from a trend per spec ty, how much can an ac objection affect trend or bend the cost curve and then an aco that's highly efficient, how much better than the market should they be for a total cost care perspective. for three levels of an aco, look at this as a journey map or as levels of maturity, an aco launching within the first couple of years, what do employers think the impact will be on trend, on lowering trend.

most respondents said no impact, that there wouldn't be much of an impact first couple of years out of the gate, won't be much impact on trend. for a developing aco, an aco that has established -- the care model, the patients in a medical home, better data analytics, better data sharing, the expectation is that they will bend between 1% to 3%. if send is 6, take it down to 5% or 3%. most respondents believe that was probably a realistic expectation of acos. but for a mature aco, an aco driving on all competency levels, whether it's network, whether it's the care model, whether it's technology, the financial model, that they should be able to beat trend by 2% to 5%. which means if it's 5%, then it's getting it in line with cpi o general inflation. but even 2% is taking it down to

4% without making any plan changes or the like. the other question we asked was about the maturity of mature aco, how much more efficient than the market should they be? in other words you have a well functioning aco in the market, what's their total cost of care versus that market? most employers said that it would be between 3% to 5% or 6% to 10% better than the market in total cost to care perspective. we're trying to get a sense of alignment, what do employers think and what do providers and health plans think and how do we align that thinking around expectations when it comes to the delivery of care with these more models. there will be more to come on this as more employers begin to move into this space. if we shift out of the delivery system and look at plan design and cost sharing, as i said, there's not a lot of change for 2017. as you can see, consumer directed health plans are pretty much universally offered if not

by today, 84% of companies offer them. certainly over the next couple of years it will be universally offered. we've only seen a small incremental increase for companies offering them for 2017. so we know that the focus is shifting away from plan design to the delivery system. if you look at the median cost sharing for employees for 2016 from a deductible and out-of-pocket perspective, for all plans, the average individual median deductible is 1425, 600 for ppos, 1600 for consumer directed health plans. employers pay, on average, 78% of the overall premium, employees picking up the difference. that's been pretty consistent over the last four or five years, it's a little higher for employees, a little lower for dependents, on average of 78%

and that really hasn't changed over the last several years. when you think of high deductible plans, though, employers contribute to health accounts. and 85% of employers who offer consumer directed health plans and a health savings account, contribute to the health savings account. on average they contribute $600 per employee, $1100 for a family for the health savings accounts. this is important because it helps offset the deductible. when you think about how that compares to, say, a public exchange, the net deductible is $1,000. so the average employee deductible nets out to be about $1,000 for an individual. when you compare that to the public exchanges silver plan, that deductible is around

$3,000. when you compare out of pocket maximums with an employer plan, it's around 4,000. with the public exchange it's around $6500. and when you look at the change we're see in the volatility around premiums right now, on average we said employee contributions would go up around 5%. we're seeing a doubling of that in what's being proposed for public exchanges right now. a lot of volatility in the public exchange and the employer based system is the best solution for providing affordable quality health care to employees. a couple of other considerations. when we looked at employer actions to the availability of public exchanges. we're not seeing a lot. we're seeing more early retirees moving into exchanges and part-time employees who don't have access to coverage getting access through private exchanges but not a lot in between. employers really haven't done

much to push employees to public exchanges. one of the tactics that has emerged over the last several years, as more companies have moved to high-deductible plans is wage based cost sharing. pla is wage-based cost-sharing. and one of the reasons far is employers are sensitive to the affordability and the challenges with the high deductible plan so 45% of employers have implemented strategies to balance that out a little bit. either by adjusting premium contributions based on wages or adjusting health account contributions based on wages. meaning lower-wage people get more into a health account than higher-waged people. or adjusting out-of-pocket maximums or deductibles more tied to wages to try to make these plans more affordable for a lower-waged employee. the other area we're seeing some resurgence, i would say, is in the area of mental health and behavioral health benefits.

we talked about telehealth and most companies offer telehealth today and we're seeing a growth in telehealth being offered among large employers on the behavioral health side. so 34% of companies are offering telebehavioral health services where it's allowed by states and we're seeing a resurgence of on site mental health counselors. a lot of that has become teleon theic -- telephonic, we're seeing resources going back on health centers, merging with primary care or making them available on site to give people access. access in mental health is a big challenge in this country right now to providers and by bringing them on site it's an enabler but also it makes it more convenient for people to access as well. just a few other comments, one on private exchanges, we've seen interest in private exchanges

decline other tver the last sev years. in 2014 it peaked at around 35% of employers were considering them for their future. it's dropped over people to about 10% this year and we've only seen 4% of employers move to private exchanges, at least large employers move to private exchanges. we've seen more activity on the retiree side where 26% of employers have moved their retirees to private exchanges and we'll see that 28% are considering moving them over the next several years. so it's a strategy that seems for most employers to make sense for retireers but it hasn't been for their active employees. if you look at the next slide it will give you some sense as to why. so the question for -- we asked in this survey and we've asked for several years now is "how confident are you in the ability of a private exchange to do the following better than you do today?" and if you look at the bottom of this slide it's really about

your ability to control costs better than an employer can, your ability to advocate on behalf of my employees better than i can and your ability to drive engagement into health programs better than what i as an employer can do today and that confidence is low in that front. most employers are not willing to take a leap of faith to jump into this until they can get a better sense of their ability to reduce costs and sustain that cost reduction over time. and in effect change within the underlying delivery system. that's what they're waiting to see before they're willing to -- more willing to move into private exchanges. excise tax. most employers still believe that they're playing with the highest enrollment in 2020 if the excise tax is implemented.

because of the way it's structured and how it's indexed to general inflation as opposed to medical inflation regardless of what employers do to control their cost they will trigger the tax if it goes into effect. so i wanted to close with what employees can expect in 2017. i mentioned at the start it will be more business as usual. they won't see on average a lot of change. a 5% increase in premium contributions, minimal changes to deductibles and co-pays. access to centers of excellent, bariatric surgery or infertility or heart or cancer or orthopedics. and they'll see more tools to help them navigate the delivery system and help support the management of their conditions. and that's pretty much what 2017 is looking to shape up into.

so happy to take questions. >> hi, jay hancock. consumer shopping tools. now that all these cdhps are in place, what is your sense of too t tools that employees and your families have to shop for care. those have been sort of wide ly panned in the past. are they getting any better? are employees able to make smarter choices and his price transparency going to maybe someday happen? >> i think they will -- they continue to get better. ful they continue to be a vehicle to integrate other resources so if you're searching for a provider of orthopedics, they're starting to leverage

those tools to push other resources an employer may be offering so maybe there's a decision support program that can help you identify best place to go for care as well as treatment options. so they're getting more sophisticated to bring other in addition to shopping on price. i think the challenge right now is engagement. if number one issue and this is not out of this survey, number one issue for employers is engagement. how do i engage people in using all of these resources? how do i optimize these resources i make available? whether it's transparency tools, whether it's telehealth, whether it's decision support, concierge services, employees are offering a lot of services. but it's hard to get them in front of people just there time just when we need them. i think where we're seeing the technology going is the emergence of engagement

platforms that you can plug all these resources in that use predicti ivive analytics to pus people at the time they need it and to drive engagement up. that's where it's going to try to leverage the usage so if some of these tools are great, whether they are decision support or actually web-based tools but it's getting people to use them which is more of a challenge and we're seeing an emergence of enterprise-based engagement tools that you can plug in these resources that are going to leverage claims data, farmsy data, consumer information to push information to a mobile, to ping them at the time that they need information to help them make a decision. do you have a question? >> tina reid from the washington business journal. you mentioned specialty drugs that are expected to come down the pike but what are the specialty drugs now driving major increases. >> if you think of the top

drugs, hue mar knehumira, remic that come to mind that are top users in the inflammatory space. if i think of other areas where i can give you a sense of class as opposed to actual drug, multiple sclerosis, oncology, hep-c which has become the poster child for pharmacy. those are the classes where you're seeing cost in specialty pharmacy. the other ones is where we see a lot of the new drugs coming out. other questions? >> what's your take on the election and who ever wins, both clinton and trump have said that the excise tax is not something they support so we're probably looking at big changes and how do employers has to respond to that unknown?

>> well, i think that if hillary clinton is elected it will be business as usual with the aca and trying to improve and drive improvements in the aca. if trump is elected i'm really not sure what that means from a health care perspective. i think there's a lot of bipartisan support to repeal the excise tax. will it will replaced with something? there's been talk of do you look at the taxation of benefits? what that could be on the agenda. as we look to next year, it's anybody's guess at this point as to what it ultimately means. but that's my best crystal ball at this point. other question s? all right. well, great, thank you very much.

>> while congress is on break this month, we're showing american history tv programs normally seen only on the weekend here on c-span 3. today, programs from our presidency series which looks at the politics, policies and legacies of america's presidents and first ladies. up next, two historians discuss the process of writing presidential biographies. that's followed by a look at the books collected and read by george washington throughout his life. later a discussion about franklin roosevelt's mother sara and her relationship with members of her family.