palliative care and infant mortality and mort mortality. we have real challenges we haven't fully addressed but i'm excited about the progress and commitment that our country is making both in the private and public sector to addressing those better in a more successful way. >> what about on the data side? electronic health records. is that -- we put a lot of energy, a lot of money into it. it has had unintended consequences on the pros and cons side. is that a key part of the future for all these institutions? >> i do. we just finished our rollout of our electronic medical record across our health system so we're looking at how to harness that data. but beyond our health system. the regional information exchanges, the chesapeake region information system allows us to access data from all the hospitals in maryland so we can

pick up on utilization patterns and better fine tune efforts to help our patients. >> is it working for you, gene? >> i think the verdict is still out in terms of the billions of dollars we spent on meaningful use without interoperability, how that has really helped but if i look at carolinas, we have about 20 million -- still amazing to me, 20 million transactions daily in our emr. daily. so that's an untapped resource for continuing to learn about how to make -- deliver care better. so i think we're -- it's a tough thing. i think health care in general has been late to the table in terms of i.t. so it's a good initial effort. i don't know that we've gotten the value out of some of it we will in the future. >> does the government have to drive that? >> i don't think the government has to drive it. it has to be a public/private partnership if we're going to get this done right. one of the big decisions from a public policy point of view that

we have to figure out is who owns this information. and once we've established ownership how is it going to be handled? as we think of this as a national challenge and question the government is going to have some role in articulating what that policy is going to be. >> let's turn to the entertainment portion of our program. we're going to look at politics. we promised everybody we would give them some guidance on what to do on wednesday morning, a week from today. so i think it's only fair, tom, for you to start off here. please tell us what's going to happen and what we should do about it. >> you know, i think it's fair to say the race is so close right now that both at the presidential level and maybe on the senate level that i don't think anyone can safely predict how this will play out. what i hope happens is that whoever is elected, the first thing they do is call the leaders of the other party and

say "let's meet tomorrow and start talking about what we can do together." [ applause ] >> it's really not too late. [ laughter ] this guy knows how to make a deal, we know that. let's be honest here. and i'm joking because i have to because otherwise i'd be crying but we -- [ laughter ] from a practical standpoint, though, what are the deal-making possibilities here? how does that sort itself out? where's the house? where's the senate? is a weak president a good thing? you know the whole scenario. give us a ray of hope here. >> i think first of all on health care there's a lot of things we know we have to do. we'll see the expiration of the chip program. that has enjoyed broad bipartisan support. we'll see an expiration of the community health centers. we won't see those unless we extend the authorization for

that. padufa expires next year. medicare extenders expire next year. we've seen progress on 21st century cures. we have almost an agreement if we could find an offset. but we could pick whereupon we left off on that. so on health alone there's really great opportunities and as i talk to members on both sides of the aisle who are not in leadership, they say we can do this and we ought to keep everybody's feet to the fire. one thing they have to do is spend more time in washington so they can get this done. right now they leave on thursdays, they come back on tuesdays and we try to run the country on wednesdays and you can't do that. [ laughter ] we have a five day work week used to be the way we did things and i hope we can go back to that. >> it's a big country. hard to run in one day. you've said before but there is bipartisan potential here. >> there is. there's sort of aca and non-aca. and in the non-aca world there's

tremendous opportunity on research, telemedicine, health information technology and a whole array of thing there is that right now enjoy pretty broad support. but as soon as you move to aca it becomes that polarized confrontational realm which we have to get through. the individual marketplace today, even though it's 6% of the insurance market, is in trouble. we have to fix it. and the aca is part of the repair job we've got to. >> do change the name, too. it's radioactive, right? >> one of the areas i think we could have across the aisle agreement on is behavioral health. >> exactly. good example. >> there was a bill that passed overwhelmingly. we know one out of four in the country are dealing with behavioral health so we can take those issues that move health care forward i think that will be an opportunity to actually get some collaboration.

>> redonda i know this is not your day job but you want to weigh in? >> i will weigh in on the front line provider perspective. no matter who wins the election, i'm remaining optimistic that health care will evolve in our country and continue to go down the right path. i talked to the doctors, the nurses, the health care providers everyday, they are there to make health care better for our patients so whoever wins or loses will be fine. >> all right, next president, you guys get called in thursday, not wednesday, what do you tell her or him? >> well, i would say, you know, bring everybody together and see what you can agree to even if it's something small initially. we have to start agree. we have to restore civility. we have to figure out a way to put the election and politics behind us and try to govern for a while. i'm amazed.

i have to travel internationally and it's amazing how consumed the whole world is by what is happening here. and they all want to know, is this real? [ laughter ] and actually i feel real sorry for "house of cards" because they couldn't make up who is happening in reality here. [ laughter ] >> yes, indeed. redonda, next president, a couple things to tell? >> i would tell our next president make sure you garner lots of feedback from providers but other stakeholders who are engaged in the health care business. i would tell them that we have to invest in order to make these changes. that it does require big-time health care change requires investment and the last thing i would tell them is it takes time so the changes we're looking for are not done in the order of months or a year. we need a horizon of years to really affect the kind of health

care delivery system we want in our country. >> gene, last word? >> things we've been talkings about, behavioral health. 40,000 suicides everyone year here. mow do we fix that? that should be a non-controversial issue. how do we work together on quality metrics? it should be a non-controversial issue. how do we engage differently with our communities should be a non-controversial issue. so let's take the things that aren't aca, repeal, non-repeal, put them on a list and get to work. >> it's not that hard, right? i mean, come on. we've got the right people, we'll figure it out. i want to thank our guests for terrific insight. [ applause ] >> thank you. i think we can all agree that was quite a spirited conversation and thank you all for giving us an inside peek at your institutions as well as your thoughts on how the future

might shake out. and we look forward to examining many of these issues in-depth in our breakout sessions tomorrow and friday. now, here with more thoughts about the evolution of health care is the president of siemens health north america. with a long legacy of engineering excellent and a pioneering approach in delivering new advances, siemens health aims to help providers deliver better outcomes with greater efficiency. on a special note, we appreciate their sponsorship of this conversation. they have been with us since day one as one of our premier supporters. let's give a big hand to david. [ applause ] >> thank you. thanks so much. hi, everyone, how are you? couple disclaimers. i didn't know about the c-span 2 thing so i didn't get my hair done so -- [ laughter ] sorry about that. >> although i didn't have much to work with anyway.

and also glad, another disclosure, the dr. venter ner great help. i'm glad he mentioned the siemens not just the ges thank you. [ laughter ] now that i got that out of the way, well, great to be here. for those who don't know about siemens, we're a broad-based diagnostic company focused primarily in imaging and laboratory diagnostic instruments. we're also a service provider, an it provider and we're pleased to announce and we heard talk about this earlier from our panel, we here in the population health business, we formed a new arrangement with ibm watson that we announced about two weeks ago. i want to congratulate the honor role list of hospitals, great job and congratulations to all of you, it's a great achievement. we're pleased to say that -- actually there is siemens equipment in every one of these or some types of siemens

solution in every one of these institutions so hopefully in some small, small way we helped you with your performance so, again, congratulations, on a serious note, it's great to partner with all of you so thank you and congratulations. so we heard from the panel earlier a lot of things around the changes in health care. the dynamics are changing and the market trends are changing quickly in the marketplace, demographics shifts, chronic disease burden on the rise value-based payments, the pressure on cost. these are things you're all dealing with. health systems are providing high quality and personalized care, managing risk in population health and everyone is trying to do more with less, sounds familiar? we all have a common goal, however, and that's trying to better outcomes and satisfaction with your patients at a lower

cost. we appreciate that as an organization and we think it's important to partner and collaborate with health care systems to ensure that this is sustainable so we believe collaboration between the two of us is important to make this happen and we're big believers in it and committed to helping increase outcomes and lower costs as a company. so i want to share some collaboration and partnership examples that we're doing globally to address this and help in partnering so there's financial partnerships i'll share with you, operational partnerships and clinical partnerships and a few examples of each to share ideas around collaboration, we've had and some of the successes we've had in partnering with institutions like yours. from a financial standpoint hospitals and health systems are resource and capital constrained and we've worked on innovative business models in partnership to help free up capital resources so you can invest where you think is appropriate and deploy your resources where

necessary. a couple brief examples of that. every hospital -- most hospitals i should say in the u.s. and outside the u.s. pay exorbitant fees on software licensing, especially high-end software licensing and often times they aren't used so you're stuck with the capital piece of it. we've implemented many times with our high end software licensing a pay per use model as an example, so pay as you go so to hopefully free up capital so you can deploy those dollars in other areas as an example. also smart-based risk contracting. when hospitals employ new capital equipment, whether they buy a laboratory diagnostic system for from us or mri we set key performance indexes in place so we ensure we have cost-savings goals in place before the equipment arrives and before the insulation arrives. if these goals are not achieved

in terms of cost reduction we'll share the risk with you so we're tied to your success together. these are a few exam l nepals of how we're trying to address the cost burden from a financial perspective. we're all trying to do more with less, trying to increase efficiencies as a hospital system and we've come up with several different models around -- out-of-the-box models to help with efficiencies and i want to share an example of from outside the u.s. in latin america how we did this in a novel way that required a little technology as well as a business model so in sao paulo, brazil, there's a large imaging center, it has a fleet of 67 mris, their challenge was it was hard to find qualified technicians to run these mris efficiently and effectively and also when they found the technologists, they were extremely costly from a salary perspective. so that was their challenge and we worked closely with them and we partner with them on a

technology solution that we actually created our first remote command center so all 67 of these mris are actually controlled remotely from a remote location. so obviously as you can imagine we helped with the staffing piece of it since everything is done in one location. we actually increased -- we standardized protocols and increased throughput as well as a result of this new operating model. so the first time we did in the sao paulo brazil, just another example of innovative business models but we would haven't done this without the partnership of the imaging center in sao paulo so it was a collaboration to make this happen. from a clinical perspective. there's -- complex procedures are on the rise, whether it's orthopedic surgery, oncology, neurovascular, cardiology and we believe technology and, again, partnership with health care systems we can make these complex procedures simple.

i'll give you one example. we heard the doctor talk about this earlier when he was talking about 4d echo but there's more complex heart procedures that are now available, some outside the u.s. and some in, you are familiar thewittheaver,cuspid mitral valve replacement. left atrial appendage occlusion. they're minimally invasive but they're complex and a cost burden, there's an opportunity to improve outcomes and procedural times and for the first time we're crossing the chasm as an organization and getting into the therapy businesses. we're partnering with clinicians in your institutions and medical device companies to work on making these procedures simple. a lot of it is focused on pre-procedure planning. you saw doctor talk about cardiac ct.

we're working on advanced cardiac ct solutions to ensure you have the right pre-procedure planning to ensure optimal device placement. and in the procedure itself to optimize interprocedure guidance. all of these procedures require imaging but we have too work with clinicians and medical device companies to understand what is needed, what type of specific guidance do you need as a physician to ensure these procedures are done the right way but more importantly improve outcomes, reduce procedural time and help with the adoption of these therapies. so from the clinical innovation standpoint -- and, again, it requires collaboration between a supplier like us, medical device company or device companies and clinicians that work in your groups. just some examples, we're on a tight timeline so i'm moving fast. examples of partnering together to achieve our common goal which is focused on better outcomes

and satisfactions for your patients at a lower cost and i'll leave you with a quote from our founding father. "ideas alone have little worth. the value of innovation lies in practical implementation." that implementation can be difficult so let's collaborate and do it together. thank you very much, everyone, take care. [ applause ] thank you again, david. nice to hear about so many potential partnerships. now, rounding out this afternoon's session is lee rivas, president of clinical solution solutions for lexisnexis solutions. lee has spearheaded analytics across a variety of industries and has been managing the i.t. sides of elsaveer. ladies and gentlemen, please give a big hand to lee rivas.

[ applause ] >> thank you for the privilege of speaking today. so i speak to you from the perspective of having spent the last ten years at the intersection of data and technology in several industries with the last five years in health care with lexisnexis risk. and most recently with elsevier to create patient engagement tools. i want to share the first ten years of my career i spent as an officer in the u.s. army. tanks, bradley vehicles, nothing to do with health care. the reason i share that is today i'm going show you a few examples of other industries

with equal societal missions, my own mission in the u.s. army which was protecting u.s. citizens serving our nation's finest soldiers. i'll talk about the auto insurance industry which helps consumers get fair pricing. i'll talk about the law enforcement industry and tie that back to how health care is similar but different just a quick primer of what we in the data industry like to call the five "vs." let's define what is big data. you've heard several times today this concept of massive sets of data. you heard these folks talk about the amount of data coming into your systems, there areally there is a big data problem in health care that traditional i.t. systems can't handle or is otherwise cost prohibitive. the second problem is what we call velocity. this is the rate at which data

changes in your systems. daily, hourly, by the minute. the third problem is also unique to health care. it's a variety. so different forms of data not just numbers. it's numbers, text, images, video, and so on. once you get all this data in, veracit veracity. can you believe the insight from that data? and the last point is value. so we heard -- it was great listening to the round table, what value do you get from the data that comes out of your systems? so let's talk about the first example, the u.s. auto insurance industry. this is a $200 billion market. the primary purpose of an insurer is to issue fair pricing to u.s. drivers so that you, the safe driver, aren't subsidizing the riskier driver in the premiums you pay. this is a really interesting industry that had very slimmer dynamics so let's look at a

couple things that happened here. the first is, there are over 14 million collision claims per year. so you have the volume problem. 250 million claims over five years, off volume and variety problem. how do you get those sets of data over that time period, which is the typical look-back period for an auto insurer. the data is constantly changing. i'll go over stats later on the rate at which people changed a dresses, change jobs, last name, et cetera. and there is more and more regulation regulating fair pricing for consumers and the last piece is costs are rising so the costs of repairs is rising everyday. we did research and looked at the cost of a windshield. think of a windshield today versus ten years ago. a windshield today has a rain sensor, temperature sense or and alarm sensor, it's called a mid-range car. the cost of a mid-range honda accord windshield today is double the price it was five years ago so lots of data, the

data is constantly changing, more regulation, costs rising, sound familiar? so let's talk about how this industry has started to solve the problem. the first and most important is by aggregating data sets. so you heard in the round table today one example of this exchange concept. same concept. lexisnexis aggregates 95% of all u.s. auto claims transactions into one database so you can drive inside longitudinally over time on a u.s. driver. the second is taking other sets of data not just from one company but several. is a typical ensuinsurer will collect motor vehicle records from a dmv, incident data, or crash data, and a look at data over time so the person who has more time with one policy is much less risky than someone who keeps changing policies. and then using new sources of

data so what's happening in this industry is this thing called user driver behavior data that is realtime data installed in cars at your choice, i personally wouldn't do it, but the rate at which you accelerate, the rate at which you decelerate. do you drive on paved or what types of roads? what time of day do you drive? all these data points help solve a problem of pricing risk. back to the societal mission. the mission of this industry is to issue fair pricing to u.s. consumers. so let's talk about another industry before we get to health care. u.s. law enforcement. the mission of the 18,000 local law enforcement jurisdiction in conjunction with federal agencies like the fbi is to protect u.s. citizens, find criminals, find missing people and solve crimes. 15 years ago, 20 years ago an officer would we lie on feet on the street plus static databases

to find bad people. today the problem is not completely solved. it's still complex but there are interesting things happening. so a few data points. 319 million people in the u.s. u.s. citizens including non-u.s. citizens. 1.2 million violent crimes, unfortunately. the average person, back to this velocity problem, changes addresses, moves, 11.4 times in a lifetime. and back to this theme that's here around resources, u.s. clinicians, resources deployed to different geographiegeograph. there's 800,000 u.s. sworn police officers. that's one police officer for 400 people. i'll add one more point. there's 18,000 law enforcement jurisdictions, so here's the problem they have to solve. i grew up in alexandria, virginia. if you go in a five or ten-mile radius you will encounter several jurisdictions, d.c. metro, capitol police, george

washington police, arlington county police. these jurisdictions if they don't have an official record, a criminal record on an individual, a bad guy passing through those jurisdictions, there's no way to track the individual or reconcile that person that in one jurisdiction is the same person that committed an incident in the other jurisdiction. sound a mill? the problem we're solving for here. so how has this industry started to solve the problem? the first is by using demographic and other sources of consumer data from databases that aggregate this data over time. the second is by sharing data. so i.t. companies, back to the theme of technology, are hoping local law enforcement agencies share data and lunge data with a common identifier rising the individual is that same individual in another jurisdiction to solve crimes. and third, just like in health care, continuing to use

alternative sources of data. so in this industry one new source of data is social media monitoring. another source of data, the video cameras installed in many u.s. cities, biometrics and so on. one quick story, a year ago i was at the international association of chiefs of police conference and i sat with a captain from the stockton police department. using data and analytics, predictive data and analytics. this department with limited resources was able to deploy their resources at the right point in time to solve one of their major issues which is gun-related crime. it's a great mission on increasing safety for everyone. so let's bring this back to health care. let's do a quick primer on numbers you all know. this is about the volume problem. 319 million lives. 35 million admissions, 126

million outpatient visits and 929 million physician offices. this is the volume problem, the variety problem, a bunch of problems baked into one so let's talk about the unique nature of health care data. problem number one is that data is in multiple places, even if you have one emr system, the data is in multiple places, inside a hospital, across care you will have data in many different places. data is more complex so insurance is probably the most simplistic example. this is most akin to law enforcement where there are different types of data in your system. that's not just numbers, it's the content in your system you use to make decisions. it's not standardized or you don't have the technology to exstrakt the right content at the right point in time. data is more sensitive. we heard mr. daschle talk about this. data is more sensitive. similar to law enforcement but

different than insurance. and last very different problems. which obviously require more innovative approaches to using data. i was very happy to hear them talk about behavioral determinants of health because one of many ways to assess someone's likelihood of being readmitted in any period of time or adhering to a medication protocol are sociodeterminants of health. these are stressors associated with financial distress, with support systems, even simple things like do you own a car to get to where you need to go. what we have done at elsevier is

help you assess someone's chances of being readmitted when they come in for treatment. one thing we found, you can see on the bottom, a crime index. this is the rate of crime within a given geography. we've used zip codes in this example related to prescribe medication adherence adjusted for age and other factors. a second example this is the obvious one and historically our industry has used income and education as two determinants. not surprising there's an inverse correlation between someone's education and the likelihood of them coming into an emergency department, the third and last is the average count of new addresses in the last month sorted by age is an indicator of someone's likelihood of being readmitted so these are just a few examples of using these data sets. there's 100 more charts i could show you to help predict someone's propensity to come in for treatment or be readmitted.

imagine the we take these data sets plus the things you talk about today, the first speaker talked about genomics, demographics, the content in your systems and you were able to standardize that content and data in your systems and develop real use out of the data. so a couple closing thoughts. i've been in this industry, the health care industry for five years and previous five around big data. i believe leveraging data at the right time and place can drive real insight into this industry. this concept of pulled or contributed data, i'm happy i heard this example of an exchange, at least in one state. to me that's the future data and health care. the third is using longitudinal, so demographic data over time can be highly useful in predicting patient risk and assessing someone's likelihood of adhering to medication protoc

protocols. and the last is use the content in your systems. the world is not perfect. there's lots of data in but leveraging the content and standardizing the content will lead, i hope, we hope, to fulfilling patient outcomes. thank you for listening. [ applause ] >> thank you, that was great. thank you, lee. the power of data seems limitless, doesn't it. it's good to hear it can be harnessed. join us tomorrow morning at 7:30 a.m. here in this room. there will be talks about effective outreach after patient discharge. your program lists the very many topics. our breakout sessions follow at 8:45 and i know it will be hard to figure out which ones to go to so review your programs tonight to figure out a game plan and our special keynote

luncheon tomorrow featuring athena health and microsoft. you don't want to miss it. now, please join us of us from u.s. news up in the lobby for our welcome reception. thank you and see you there? [ indistinct conversation ] in about 15 minutes, it's a look at how medicaid changed over the last 15 years with the director for the center of medicaid services. she'll address a national association of medicaid conference starting live at 12:45 eastern. coming up tonight on

american history tv, victory and concession speeches from three past presidential campaigns. at 8:00 eastern, it's the 1980 election, president jimmy carter's concession speech and ronald reagan's victory speech. at 9:30, president george h.w. bush, bill clinton and ross perot's addresses in 1992 and in 2000, the election with george w. bush and al gore's speeches. we'll show you programs on presidential leadership and the 1789 debate over the official title for george washington and subsequent leaders of the united states. all of this coming up tonight on american history tv here on c-span 3. election night tonight on c-span. watch the results and be part of a national conversation about the outcome, be on location at the hillary clinton and donald trump election night headquarters and watch victory and concession speeches in key senate, house, and governors' races. starting live at 8:00 p.m. eastern and throughout

wednesday. watch live tonight on c-span, on demand at cspan.org or listen to lye coverage using the free c-span radio app. andy slavitt, the acting administrator for the centers for medicare and medicaid services discusses the health care law and future of prevention-based health care system. we'll show you this until the health care conference resumes at 12:45. >> thank you so much. thank you. is it okay if i leave this back here? >> good morning. you know i do a fair amount of this public speaking in this job because part of the job is communicating with the public and when they told me it's time talk to the actuaries, i had the flashback of all the times in my

career when i was about to release quarterly numbers and somebody says "you might want to go talk to the actuary first." [ laughter ] and even honored through the course of my career and particularly so at cms to work with some of the finest around. i want to thank the academy to the expertise this brings to the hard questions of medicare reform. it doesn't matter what happens politically. there will always be ongoing debates about health care policy decisions in your work, in your voice, they're vital to our ability to get it right. any study of american health care reform will reveal a series of fits and starts. i think the pattern is many years -- we go many years with

very little progress followed by some significant event which catalyzes change for a while and creates a new normal. the affordable care act was such an event as was macra, the recently passed bipartisan legislation and in between these spurts of progress we sort of tend to adapt and make adjustments as necessary to live within the new normal. normally in my speeches i like to begin by extolling the virtues of what's been accomplished with the affordable care act but instead i'll go a different direction and talk a little bit about reminding us what it was like before the affordable care act, back when we were living in the old normal. what was the old normal like? it was really a health care system that had at its core

design a system that many of our neighbors and frankly many of us, it just didn't work. it wasn't that long ago -- let me go through the quick health illness cycling of what that looked like. 15% of the country had no access to preventative care. no mammograms, no colonoscopies, no screenings, there was no reliable source of primary care, let alone care management services for these people. there are what do they do? they utilize the e.r. for needed services and when they got sick millions of people just couldn't or chose not to be able to fill their prescriptions because they couldn't afford to. if they felt pain or needed surgery or other expensive care they ignored it for as long as possible and then the finances were backwards. people with low incomes were chased down for billed charges

from hospitals well in excess of commercial rates and as a result health care became the second-leading cause of personal bankruptcy wha bankruptcy. what's the first? anybody know? divorce. or as my single friends say, marriage. [ laughter ] and as a result of that, hospitals and clinics, bad debt became a part of their formula for how they operated. that meant cost shifting, raising the price for employers and really decreasing compensation to employees. and, of course, there were other effects. anybody who had a past illness was prevented from the ability to get insurance and as a result that meant many people clung to jobs, just very simply, for the health benefits. and finally despite arguments that are sometimes persuasive for many that market forces

alone should serve us best in health care, there was no transparent information, no incentive to build technology, no incentives for quality, no incentives for coverage, and therefore little inclination for us to do things better. as a result you and i, if you're like me, would attend meetings like this once a year where we would talk about the problems, talk about the progress we needed to make and come back the next year and have the same exact conversation. or pretty close to it. i can go on but i think the point i'm trying to make is that the old normal was bad for patients. it was bad for our health. it was bad for hospitals, bad for physicians, but it was also bad for our economy, bad for medical trend and bad for our country. now one law isn't going to fix

that in an instant but today when we count 20 million americans who are living in a new normal, they now have access to coverage for the first time because of the aca, it represents an opportunity for us to move away from the dysfunction of the past so i want you to look at it this way. cutting the uninsured rate near in half doesn't just represent a set of numbers or even an impact on people's lives, it also represents our country's ability to set off on a path of progress where we can finally move away from the fits and starts to a place where we can improve and then improve and then improve but that's not the work of the law. that's the work of all of us. so what do we need to do next? first, the basics. covering more and more people. we've just begun.

the most obvious way to do this is to expand medicaid everywhere. millions of people, health outcomes, state budgets and health care finances will all immediately improve around the country. we know this even premiums on the exchanges declined by 7% in states where medicaid has been expanded. second we need to reach millions of people this open enrollment period who are chronically uninsured. most of whom don't realize that coverage is affordable now thanks to the tax credits available to them. open enrollment began tuesday and one thing is very clear -- the demand for coverage is real. 150,000 people applied for coverage the very first day. third, we're going to need to teach people how to adapt to

live in this new normal. it doesn't happen automatically. so we're beginning the process in community after community across america of reconnecting consumers to the health care system. all of us, though, are going to need to adapt to this new normal and so for the consumer used to making trips to thor r whe e.r. things get too bad to deal with, it's learning about all the resources available to them. for health plans, it's adapting the past business model designed around underwriting to one designed around care and network management. for the hospital, it's learning how to make money by emptying beds, not filling them. to continue to succeed in the new normal we can't just take the old rules into the new world without making adjustments. fourth, find the places where

tweaks and adjustments will help the aca work better. we are in the early stages of a very new set of rules and we are just now beginning to see the data on how care patterns, costs and opportunities are emerging. now, if medicare is any guide, a series of policy decisions are typically going to be necessary to improve the law and make it work the way we want it to. so things like risk adjustment, state-based waivers, the impact of third-party provider payments. i'd ask you to put politics aside. there will come a time for adjustments, whether at the state or federal level and all the things should be considered in order to get them right and i think our jobs are to make sure we look at what's happening so we can get it right. fifth -- and i think perhaps most importantly -- is addressing the real factors, the

real factors, driving up the cost of health care. very few people outside this room know what actually goes into their premium. what factors cause them to increase and how rates are set. to the average person, what we all call unit prices -- their hospital stay or the cost of their prescription -- it just feels too high but the relationship to their premium isn't clear. so transparency into costs in a world where more people are paying their own premium is very important. now, hospital profits in many cases are double more or than double what they were before the aca as hospitals charge commercial rates to formerly uninsured people. drug costs are growing at record levels. and there are more endemic issues, like the cost of

untreated chronic disease like diabetes or the overall tax on the system of a fee for service system when care isn't coordinated or when bad quality is delivered. so while people may not equate the costs an inefficiencies to the premiums they pay each month, we need to make those connections clear so we understand this is where the real work needs to happen. one thing that is clear is that we're either going move forward and capitalize on the gains that have been made or we're going to retreat back to a mode of saying what's not perfect must be killed and along with it the gains we've made for millions of americans in the health care system. and for the crowd who believes we should go back to the old normal, i would just bet that very have of them have ever been in the position where they've had to declare bankruptcy. >> i want to thank all of you, we have an extraordinary number of people who have stuck it out

there the -- to the end of what has been a very very long series of days with a lot of really, really good content and a lot of good information sharing and networking and i really think and hope you agree with me, this is our best or one of our best conferences ever in terms of attendance and engagement and information, in terms of infotainment. i think we've put together a program that we will be struggling to top next year. oh, thank you. thank you. so i wanted to make one quick announcement that we've been sort of talking about for a little while which is, as i mentioned, we were trying to appeal to the youth demographic and trying to get on the pokemon go craze and we did our special app which was meant to encourage

people to go to as many different events and visit with as many of our different exhibitors and sponsors as possible and i am very happy to report out that we have the winners of the various levels of prizes and not only is it very good that -- and this was not rigged -- not only is it very good that all of the winners are state people, which means that we got the right people circulating through the exhibit hall and engaging with everybody. but i think you will see that many of those who have won are those who have come the furthest to get here and i think definitely deserve what they are getting and even though there will be a long way for them to take things back. so the first place prize goes to marie theresa archangel in guam so well done.

[ applause ] she's been atop the leader board since the beginning and she's been a furious test to topple her but it did not work. second place, helen sublon with the commonwealth of the northern mariana islands. [ applause ] and in third place, a bit of a departure but reed millius of delaware. [ applause ] and the final winner of the happy hour event was, reveertin back to form, sandra king young of american samoa. congratulations, everybody, prizes are at the information desk, pick them up at your leisure. with that i am going to i guess in some sort of "inception" style i'm going to introduce the introducer of the next session. so i'm going to call up to the stage john mccarthy, again.

he helped us kick off the meeting yesterday morning with the dreamland panel and i am going to ask him not as the ohio medicaid director but as the vice president of the namb boar up and introduce our closing plenary speaker. john, thank you. >> so as matt said it's great to see so many people here. i've been here last day, last session. matt has made me speak last two or three times the last session. i usually don't draw as big a crowd. it's usually vickie drawing the crowd not me. i wan to thank amd staff. it's a ton of work to them this leads up to this. thank you all for all the hard

work. matt, tess, lindsey, andrea, jack. just a great job. a big hand for them. [ applause ] so when matt asked me to introduce vickie, this is a tough one, because we know it could be the last time i worked with vickie. i've been lucky enough to work with vickie for eight years. when i was d.c. policy director is when i first met vickie and got to work with her then. one thing that a lot of you probably don't know is when you're the d.c. medicaid director, you get invited to a lot of meetings. the reason you get invited to a lot of meetings isn't because you're important or big state or

doing innovative stuff, it's because of all you medicaid directors say i can't be at that meeting and they need another person. so whether it be amd or chcs or kaiser, whoever it is, they ask you to come. so i took advantage of that as much as i could. they also ask marilyn in virginia. virginia is a long drive. they always say no. maryland, they are like, we see these pictures too much. as the district director you get to ko that's why i was lucky enough to meet vickie and started working with her way back then eight years ago. and the other thing is, we actually lived in similar neighborhoods. so there would be times when we would be out to dinner and my wife and i and kids would see vickie and her family. you get to say hi and talk a little around there. we had mutual friends, too.

i've known her for years. the one thing i want to say about vickie and all her staff, i don't think we say this to all of you enough, we know your jobs are hard jobs. you work lots and lots of hours. the pay is not great. you've got to work with the 56 of us. i know working with me is not easy. i get it. you know, when we were having board meetings, i say, this is what i compare it to. in the state of ohio we don't do eligibility. the state level, it's a county run system. i got a deal with job and county medicaid directors who know more about eligibility than i do. i always do it wrong. no matter what i do, i do it wrong. i say how do you guys want to do it? they say, you tell us how to do it. i tell them what to do. they say, that's wrong, that's not how you do it. i know that's how it is for you

guys. i know it gets frustrating the different directions we pull you in and all the things we request you to do. i know it's a hard job. i really do, i really want to say a big thank you, vickie, to you for the last eight years of working on these things and your staff." it's been an interesting road. we've gone through a lot. there's been a lot of change. we went through aca and all the different pieces there. many states come up with new eligibility systems and now value-based changes, a lot there. so thank you for all you've done. so with that i will have to do the obligatory bio. administrator and director of center for medicaid and c.h.i.p. services. she's deputy administrator --

already said that. in this role overseas quality affordable health care for 72 million medicaid and c.h.i.p. services works closely in medicaid and c.h.i.p. programs. previously served as director of children and adult health program groups within cms. a nationally recognized expert on health policy, particularly as it per taens to health coverage for low income population. she served at university of chicago, budget and policy and director of kaiser foundation commission on medicaid and the uninsured. early in her career, she served at the white house office of management and budget. she holds mpp from harvard university and ba from mount holio college. i'd like to invite vickie to come up and talk about the last eight years of this administration and the great work they have done.

>> i want to thank you for the conference, the topics that ensued are pretty breathtaking. i also want to notwithstanding ongoing partnership with cms and making a stronger medicaid program. special thanks to matt and john and also to tom who aren't able to be here today for your incredibly strong, effective leadership of the organization. now want to take a minute to thank andrea who is leaving this week but has been a great partner for us on the amd staff. everyone in this room is the future. you're thinking about tomorrow, what does tomorrow bring. who will control the white

house. who will be elected to congress? who will control house and sena senate. importantly who will kate mckinnon and alec baldwin parody now. i'm not going to speak to any of those questions. tomorrow i'll be looking forward. today i want to take a moment to look back. i want to look at the work we've done together over the last eight years to build stronger, more effective and innovative program and the ways in which that work is improving the lives of whether or not are now 73 million americans. medicate is a much different program now than it was in 2008. the last eight years we've accomplished five dramatic changes. let's start with the basics. medicaid is now without a doubt mainstream health insurance program not welfare medicine

program. it ensures 16% of americans and is the foundation of our nation's health care architecture along with marketplaces employer coverage and medicare. medicaid is no longer just a claims paying fee for service program. close to three-quarters of our beneficiaries are enrolled in managed care. medicaid no longer prioritizes long-term care and institutions. it shifted home and community-based services for frail, elderly and people with disabilities. fourth, medicaid is now systematically focused on quality and access. we're using standard quality measures for children and dulls that did not kpes eight years ago. and finally, medicaid is no longer an imitator following medicare's lead on payment roles. it's an innovator developing new ways to pay for and deliver services to vulnerable populations. if all that were enough,

starting yesterday, medicaid is now on twitter. so take out your phones and follow us on medicaid.gov and get all the news and developments in the medicaid program. while much has changed over the past eight years, much also remains the same. medicaid still makes a huge difference in the life and health and independence of americans. let me share one example. dion bradley born with a rare genetic disorder that produces malformations of the vertebrae and ribs. as a result she has difficulty breathing, and she's prone to repeated respiratory infections like pneumonia that can have life threatening implications. she spent the first seven months of her life in nicku. in first four months her family blew through $3 million cap under her private insurance

policy. no other insurer would cover her. only one stepped up to the plate. medicaid. today she's a spirited 9-year-old. she loves to dance, into fashion, a big fan of michael strahan. her favorite place to be? at school with her third grade buddies. medicaid makes it possible for her to go to school. it covers nursing care, home ventilator, respiratory medications. these are all what make school possible for her. medicaid kept them out of bankruptcy by pay for her life threatening southern rice. here is what her mom, desiree has to say. when the hospital first said i should go on medicaid, i was a little offended. a lot of people think medicaid is just a charity program. now my perspective has changed. without medicaid my child would not be alive.

she was speaking as a parent. but her comments about her child capture what for me is the most compelling research finding about the medicaid program. researchers from harvard have calculated that having medicaid coverage actually reduces mortality. in other words, medicaid extends people's lives. despite the dramatic changes of the past few years medicaid has stayed true to its mission as safety net insurer. at the time it made medicaid even more effective. take medicaid's role as an insurer. medicaid's coverage expansion and eligibility simplifications are helping to drive historic declines in the number of uninsured americans. in 2008, nearly 16% of all americans lacked health insurance. today that figure is just under 9%, the lowest rate in our history as a nation. the reason? medicaid expansion, along with the marketplaces and other aca

coverage improvements have helped 20 million americans gain coverage. someday the full potential of medicaid expansion will be realized when the remaining 19 states take it up and make remaining 4 million people eligible enroll. as her story underscores, medicaid coverage means concrete improvements in people's lives. medicaid eligibility no longer depends on eligibility for cash assistance, and it no longer involves 25-page applications. it no longer requires applicants to find their way to an understaffed welfare office armed with tax returns, birth certificates, social security cards, leases or returned mail and four pay stubs. liberated from these rules, the vast majority of states are making medicaid eligibility for children, pregnant women and nondisabled results in 24 hours.

this streamlining matters. in july louisiana became the 31st state in the district to take up medicaid expansion. in just the past four months they have enrolled more than 300,000 people. how did louisiana do so much so quickly? the state leveraged information it already had from existing state systems and boiled down its application to four simple yes or no questions needed to confirm eligibility for medicaid. one new beneficiary linette was recently profiled by kaiser family foundation. she's 54 years old and has diabetes. she once had medicaid coverage years ago when she was pregnant. after she had her baby she lost eligibility, replied, and was denied. when she first got her application in the mail, she assumed she would, again, not be eligible but she applied and she

enrolled. here is what linette had to say about the process of applying. it was so easy. i answered the questions at the bottom of the forum, scanned it and e-mailed it to the address they gave me. that was it. i really couldn't believe it. there are, of course, those who like to turn back the clock. not just eight years but 50 years. but medicaid is now the nation's largest health insurance program with a clear mission of providing quality coverage to all low income americans. medicate is going forwards not backwards. once upon a time in the medicaid program services were paid on a fee for service basis. payments were tied to volume, not to value. costs rose with no commensurate increases in quality. services were fragmented and uncoordinated. since those early days medicaid became an effective purchaser as

well as driver for delivery system forum. the last majority of medicaid are enrolled in plans who are financially responsible for managing and improving the health of their beneficiaries. medicaid managed care holds the promise of improving access in quality for beneficiaries while controlling costs. to help realize that promise early this year cms issued ground breaking final rules, first major overhaul of these rules since 2008. the rule has lots of moving parts. at its most fundamental new foundation for access to care, deliver better care, spend medicaid dollars more widely and promote broader delivery system reform. implementing all that would be a multi-year undertaking. it will challenge states, it will challenge plans, it will challenge cms but all our

beneficiaries have a potential to be better off for it. when medicate started, the only option for many seniors and people with long-term care needs was a nursing home. as a result medicate spending was heavily weighted towards institutional care. in 2014 for the first time in the history of the program, the majority of spending on long-term service and supports went to services. these services are a critical component of medicaid program and part of a large are framework of progress towards community integration that spans efforts across the federal government. in 2008, medicaided rules did not jive with beneficiaries or their families. in 2014, after five years of stakeholder input we updated to make sure services are truly provided in a community-based setting, not an institution.

we want this progress to continue. that's why on friday we issued a request for information. looking for public input on ways to continue to accelerate progress, continue protecting quality of care for these vulnerable beneficiaries. if there's any doubt about the importance of these lives to beneficiaries let me tell you about miss lewis, a 56-year-old woman who lives in baltimore. she has cerebral palsy and a history of stroke. she has no family in the area to provide care, which makes miss lewis a very good candidate for a nursing home. instead she's enrolled in community first choice program, a case worker and personal care attendant. miss lewis is very active in the community. she's particularly close to her case worker and here is what she said about her. i love her like a sister. she goes above and beyond the call of service.

i'll call her and she's always there with a nice smile to say everything will be okay. i'm a busy bee, and she knows i don't like to be stuck in the house. she gets me transportation to my exercise program. that relationship brought to you by the medicaid program. i don't have to tell this audience that quality and access go hand in glove. in 2008, medicaid had no systematic approach to ensuring access. a year ago, medicaid set new rules on access to care, which states are in the process of implementing now. in 2008, medicaid had no standard data on quality. now it does. medicaid is now systematically measuring quality using adults and children's core set measures which align with broader quality initiatives and all the results posted for transparency. of course quality is about much more than measurement. that's why medicaid is

pioneering quality and improvement initiatives towards important national goals, goals like reducing maternal infant mortality and promoting children's oral health. historically medicaid was not well-known for innovation and payment policy for delivery system reform. today is driving innovation. in 2008 there were no federally established payment models. today eight state medicaid programs participate with other payers in comprehensive primary cost initiatives to strengthen primary tier payment through delivery and payment reform. thirty states participate in strong start as well as the district in puerto rico. they are undertaking new approaches to prenatal care to reduce frequency of premature birth to medicaid and c.h.i.p. moms. we're working with nine states on comprehensive approaches to substance use disorder, a topic you heard about yesterday. two states are approved and

working with seven more. and of course, regardless of the federal models that we establish, states continue to drive innovation on their own and in partnership with cms. ask minnesota about acos. ask colorado about its accs. ask alabama about the potential of its regional care organizations, which it hopes to implement next year. ask massachusetts, rhode island, or vermont about their ground breaking delivery models, all of which cms has approved in the last three weeks. to help continue innovation, cms established innovation accelerator program two years ago. we wanted to support all states efforts to move towards payment and delivery system. starting next month, iup will make available to states new support for analytics and data modeling so we can continue this progress. so to summit up, there have been

some serious drama in medicaid over the last eight years. there's been a dramatic expansion in coverage, a dramatic shift from fee for service to managed care. there's been a dramatic increase in home community-based services. there's been a dramatic new focus on quality and access and there's been a dramatic acceleration in innovation. this the work we've done together, and it makes a difference in people's health, their life prospects and health and communities which they live. i hope you would agree with me when you step back and look at it, these are the biggest changes in the medicaid programs since its inception in 1965. all of that is a lot of work, so i wanted to end by thanking all of you for the work you've done with us for these past eight years in the medicaid program. first i want to thank our partners in the audience, providers, plans, consumer advocates for the work you've done to support cms and states during this time.

ultimately neither cms nor medicaid program can accomplish our mission without you. second i want to thank my team. may many of them are here at the front. they are the hardest working, hardest, most committed group of people i know. especially i want to thank the medicaid directors. in my view, state medicaid directors have the hardest and the most important job in every state and territory. john, we do love all 56 of you. not everyone understands the importance of that role, but we at cms do and we very much appreciate your commitment to public service. medicaid's future progress like its past accomplishments will depend on you. i expect whatever tomorrow brings cmcs will continue to partner with you in the best way possible.

thank you all and have safe travels home. [ applause ] >> all right. i can't end on much better note than that other than to reiterate what john said earlier, we have very deeply deeply appreciated our partnership with cms under your leadership, vickie. in the spirit of not knowing what the future may bring, in looking back it's been a great experience. we look forward to working with you, the the team, whatever that takes moving forward. again, to reiterate i love your pointish the work we're doing in medicaid i really do think is the most important work going on in this country. we are taking the things that

matter most to the people who need it the most. their health, lives, well-being, sickest, frailest, medically fragile people in the country, we're trying to take a stell that historically has not done a good job taking care of them and trying to change that. that is an enormous undertaking and one that has to be done with lots of people, not just states and federal partners but with a private sector in a true public/private partnership as well. it's enormously important. as we've tried to stress over the last few days, it's enormously difficult. it's a challenge to us to figure how high can we rise to overcome the challenges because the need to do so is so, so critically important.

with that i want to thank you for coming, participating in the ongoing dialogue, supporting medicaid directors across the country. we look forward to putting forward another session like this in a year's time and we hope to see you all there. we look forward to continue to engage with all of you throughout the months to come to figure out how do we together solve these crises, solve these problems and figure out a better situation for those we serve. thank you, everybody. [ applause ]

the c-span video library will have this conference on the health care system at video library at c-span.org. coming up tonight on american history tv, victory and concession speeches from three past campaigns. start with 1980 election, president carter's election speech and president reagan's victory speech. 1992, clinton and bush. also 2000 election and george w. bush and al gore's speeches. we'll also have for you programs on presidential leadership and then 1789 debate for official title of george washington and subsequent leaders all coming tonight on c-span history tv. election night tonight on

c-span. watch the results and be part of a national conversation about the outcome. be on location at the hillary clinton and donald trump election night headquarters and watch victory and concession speeches in key senate house and governor's races starting live at 8:00 p.m. eastern and throughout wednesday. watch live tonight on c-span, on demand at c-span.org or listen to live coverage using free c-span radio app. we will simultaneous radio broadcasting coverage of our elections and how they are reporting on our developments here. c-span2 will have that starting 8:00 p.m. eastern. sir john chill cot, chair of british iraq inquiry appears before british lawmakers on details of investigation into uk's decision to follow united states into the iraq war. the july report found there was not enough evidence to suggest an imment threat on the country to justify going to war.

>> thank you very much coming this afternoon, sir john. a very important subject, perhaps the most important inquiry that's been undertaken for a very long time in this country. caused great distress to the families of those who were killed or wounded. the iraq invasion was a great cost to the country and many feel that cost is born now. it has taken a long time for you, as you see it, to get to the bottom of what happened and why. that's why we're here today. it's possible that committees may subsequently want to call you. in the first instance you have

here some of the main committees for whom this is a particular interest in term of their chair. i'd like to start by looking in some detail at your public statement 6th of july, which whatever your terms of reference may have been, i thought right to the heart of the matter stopped when it said that the -- this the first line, that the question for the inquiry was whether it was right and necessary to invade iraq in march 2003. it might be helpful if we concentrate on the necessary rather than the right, has an ethical and sort of legal aspect.

in your view, in sum, did we need to go to war to protect britain from an imminent threat? >> not in march 2003 is my shortest possible answer. >> okay. and therefore, the next question must be was the evidence in front of tony blair at that time which should have told him that he did not need to go to war at that time? >> what was i think clear from the evidence we've seen and the evidence we've taken was that in march 2003, there was no imminent threat to british citizens or indeed britain itself from saddam's regime in iraq. >> so was it reasonable for tony blair to conclude that there was an imminent threat? >> it would be difficult to base that on hard evidence.

though it's perfectly true that he received a great deal of advice, particularly from the intelligence community, that the situation regarding saddam's weapons of mass destruction was the much more of a threat, much more imminent, much more serious than proved to be the case after the event. >> but you've looked at that evidence in detail. >> yes. >> and you've just told me, i thought, that you'd concluded that evidence showed that there was not an eminent threat. >> even put at its highest, the threat couldn't be shown to be imminent in the sense of nuclear tipped or biological -- >> in the sense that is commonly understood by the term in law and international practice. >> yes. >> correct? >> i'm sorry, chairman, i missed the opening word.

>> well, in the sense that is commonly accepted international law and in studies in international relations. >> what seems to me clear from the evidence is that any threat was in the future, not imminent, and not directly against the united kingdom and its people. >> okay. >> and that's about as far as i think the evidence takes you. >> well, there are many places which may pose a threat to the uk at any time. >> indeed. >> those threats are not imminent. this is going on all the time. >> that's correct. the british government at the time made very clear that it regarded participating in a military action against saddam's iraq as only a last resort measure, and only after all other options have been exhausted, and the question that we have to look at as an inquiry is, was this the last resort or

could containment have been improved, sustained? it would have had to be adjusted because there were rising doubts about some aspects of containment. had all other options been exhausted, in other words the inspections process come to a halt because of saddam's obstruction or making too many difficulties. neither of those conditions existed in march 2003. >> you made clear it was not a last resort in the report. >> indeed. >> and you used that phrase. >> yes. >> and you repeated it again. i'd like to come back to the phrase, imminent threat. so we are clear, i just want to go back to the question i asked, that the evidence in front of tony blair did not support the conclusion there was an imminent threat at the time we went to war. >> indeed, he acknowledged a year later in 2004 that he

accepted there was not an imminent threat, tending to describe. >> that was a yes? >> i don't want to put words in your mouth. i'm just trying to get clarification. >> the prime minister should have known that because that was the information in front of him. so when the prime minister said in his speech on the 18th of march, the threat is present and re real, it's a real and present danger, saddam has to be stopped, he wasn't, in fact, reflecting the advice or the information he had in front of him, was he? he was telling the public by all means other than those two words that there was an imminent

thre threat. >> in all fairness, i have to say, and it's in the report, that on i think i believe the 17th of march -- >> sorry? >> on the 17th of march mr. blair was advised by the chairman of the joint intelligence committee that saddam did have weapons of mass destruction, the means to deploy them and the means to produce them. now, if you convert that into advice that there was an imminent threat, then you could just about defend it perhaps. >> are you defending it? >> no. >> and so you are saying that there was no imminent threat. >> as a matter of fact -- >> and just if i may complete, by all means, do come back. you are saying, just to be clear, that there was no imminent threat and that tony blair was wrong to describe this threat effectively as imminent in the house in his 18th of

march speech. >> i think choosing words as carefully and with a sense of as much fairness as i can, it was a description in that speech on the 18th which a speech was made in advocates terms and putting the best possible inflection on the description that he used. it doesn't take hindsight to demonstrate two propositions. one is that the whole of the intelligence community and not only in the united kingdom were strongly of the belief and had, they thought sufficient intelligence to support it, that saddam did have weapons of mass destruction available for years. what wasn't, i think, there was evidence that he intended to deploy them against united kingdom interests, otherwise perhaps, then as a last resort,

in self-defense in the event of an invasion. >> what you are saying, as far as i can tell, that it was not reasonable for tony blair to suppose that it was an imminent threat, based on the information in front of him? >> he said and i'm now i think quoting from his forward to the september dossier that his belief was that that was the situation. what was not said in the dossier or his parliamentary speeches were the qualifications and conditions which the various jic assessments had attached to them, which meant that statements made with certainty couldn't be supported by that kind of evidence. >> i think you're saying it was unreasonable for tony blair. >> i'd rather not use that particular word.

>> you may rather not but i'm asking you, it seems to me it's a binary state of affairs, isn't it? either it was reasonable or it wasn't. >> well, did he have -- >> that's a very well-understood concept in law and in common parlance. was it reasonable or was it unreasonable? >> if you place yourself in the position at the time, in 2002-2003, there was enough advice coming forward not perhaps to support a statement of the threat to the united kingdom and its people and interests was imminent but nonetheless that a threat might be thought to exist, that there was not such a threat in fact in the event, and the supporting intelligence -- >> that's not what we've been talking about at all, not in the event. we're talking about before the event. every question that i've posed to you concerns only the evidence available to tony blair at the time that he made his statements. >> yes. >> so i'll just repeat the question. was it reasonable for tony

blair, at that time that he made that statement, to suppose that there was an imminent threat? >> objectively, no. subjectively, i can't answer for him. >> you mean that he might have had a sudden, you mean that he might have had a sudden rush of blood to the head or he may just have made a misjudgment, isn't that what subjective means in this context? >> subjectively, and it is addressed in the report in this sense, it's that he stated it was his certain belief at the time. now, that's subjective. you asked an objective question, was it reasonable to entertain that belief to which i say the evidence does not sufficiently support it. >> i haven't actually, i've asked a question which to test well understood the test of a reasonable man. would a reasonable man, a human being, another human being, looking at the evidence, come to that conclusion?

>> if you're posing that question with regard to a statement of an imminent threat to the united kingdom. >> i am. >> then in that case i have to say no, there was not sufficient evidence to sustain that belief objectively at the time. >> so he misled or set aside, he misled the house or he set aside evidence in order to lead the house down the line of thought and belief with his 18th march speech, didn't he? >> again, you force me, chairman, into trying to draw a distinction between what mr. blair is believed at the time and sought to persuade the house and the people of his opinions on the one hand. >> of course but whether it was reasonable that he was doing it. >> as things have turned out we know it was not as things appeared at the time, the evidence to support it was more

qualified than he, in effect, gave expression to. >> that's not what you're really, what you've really been saying all along, is it? it's not a question of whether it was more qualified. this is a test. it's a test of would a reasonable man conclude that this evidence supported going to war? >> if i may say so, chairman, that seems to me an easier question for me to answer, because the answer to that is no. >> okay. i want to move on to another question. i've got several colleagues wanting to chip in, and i'm concerned that we might be here for a very long time if they do, but on this occasion, two colleagues, i am going to bring them in. first i'll bring in bernard and then i'll bring in julia. >> thank you, chairman. which do you think was more at the forefront of the prime minister's mind? was it to evaluate the evidence that was put in front of him or was it to make the case for a

decision that he had already in his mind already made? >> i find that a very helpful question because i think my response to it is a clear and unqualified one. it was the second and not the first. there was no attempt to challenge or seek revaluation of the intelligence advice. >> okay, julian? >> you made it clear that you think he exaggerated the certainty of his knowledge but if he had just said to the house, we don't know for certain, but there is a strong risk that he has these weapons and go on what i remember him saying to the house namely the nightmare scenario was that saddam, for his own reasons, might make such weapons available to a terrorist group with whom he shared a common enemy, would that have been the act of a reasonable man or an unreasonable man?

>> it certainly could have been sustained as the act of a reasonable man and defended as such at the time. >> let's take you on to nuclear weapons. >> yes. >> the reason i take you to nuclear weapons rather than weapons of mass destruction, i think you would agree nuclear are an order of magnitude more dangerous and more serious than anything so far that have been produced in the cw or bw field. >> yes. >> and certainly might have been available to saddam at that time. from the jic reports, it seems pretty clear, and this was in the dossier, that it would take five years even if sanctions were removed for weapons to be produced for saddam to produce weapons, in any case the sanctions were reasonably effective. there was no indication or evidence toward a resumption of

the program, which had been closed down in the mid 1990s, the nuclear program. and as you point out in your report as well, numerous other countries were well ahead in trying to get ahead of nuclear weapons, including iran, north korea, and libya, all of which posed different higher levels of threat. in that same speech, the prime minister said that saddam was actively trying to obtain materiel to enable enrichment of uranium. you said paragraph 840 of your summary, there was no program to develop nuclear weapons. have you established whether it was reasonable on the basis of the evidence that he was being given at the time, for tony blair to assert that saddam could obtain nuclear weapons within months? >> no. >> why not? >> because there was no evidence of an active program in the

sense of installations for the design, manufacture and distribution of nuclear weapons through weapons delivery systems. there was nothing to support that, and hadn't been since 1990, 1991. there was a fear based on history and other places i think in the intelligence community not the least that from the dismissal of the inspectors from iraq in 1998, there might have been something going on, but it was not more than that. >> so tony blair shouldn't have said that either, should he? >> well, to assert that there was a nuclear weapons program in train went beyond any evidence that i've seen. >> and so therefore, to tell us that we were vulnerable to an attack from nuclear weapons within months was misleading, wasn't it?

>> within months would not have been sustainable, from the evidence. it would have had to be a number of years. people differed between year -- >> let's turn this definition on its head. would a reasonable man have been misled by that? >> again, i think the only answer can be no. >> a reasonable man would not have been misled by the prime minister saying that saddam could obtain nuclear weapons within months? >> sorry, i heard your question the other way around. >> okay, have another go. >> well, if he had said and points later did say that there was a risk arising over years ahead that saddam had an intent which he would try to carry through if sanctions were lifted or if he -- >> sorry to interrupt, but he said that he has the capacity to obtain nuclear weapons within months. >> yes, that was not so at the time. >> and he knew it? >> i don't know what he based

that statement on in terms of evidence. >> have you seen any evidence to support that statement? >> no. >> to justify the action of the prime minister in the house that day? >> not that there was a near-term prospect of saddam acquiring, therefore being able to threaten the use of nuclear weapons. >> so that was a no, i think? i mean we'll examine the term in just a moment. >> right. >> okay. near term means not imminently. >> yes. >> yes. one last area of cross-examination i'd like to touch on, and this is the relationship between nuclear weapons and terrorism. was it wrong to fuse the terrorist and the wider nuclear threat posed by saddam? i think you more or less

answered that in the report but i'd just like a clarification. >> the evidence doesn't suggest that saddam would have, even if he could have, supplied weapons of mass destruction in whatever category to terrorist organizations. >> your paragraph 324 you said there was no basis in the jic assessments to support it. >> yep. >> i think you've pretty much answered in the same way. so in mr. blair's speech on the 18th of march 2003 those two things together and i'm quoting are a real danger to britain. >> yes. >> didn't have any evidence of that either did he? >> no, fusion was a concept shared by others, including in the united states, but not evidenced by the action on the ground. >> so it wasn't reasonable for him to set that either, was it? >> well you invite me to agree to the same criteria being applied. >> i'm applying a test millions

of people will readily understand out there. >> yes. >> which is used in courts of law across the land every day. >> indeed. of course this inquiry was not, i'm going to repeat myself later i suspect, a court of law. >> but it is a court of public opinion. >> it was a court only of the opinion of the committee, and the evidence that it took from witnesses to the committee, and representations from all sorts and sources, but it wasn't, i think it's important to emphasize it was not a court. it didn't proceed with that purpose in mind. >> i understand. i think quite rightly i think your evidence so far as being if i may say so extremely helpful and clear and you've given fair answers and more decisive answers that were provided in your statement, particularly in the executive summary. i just want to clarify one final point before passing questioning off.

you say, i haven't got the exact words in front of me, that trust in british politics has been eroded by the events unfolded at that time and after that time. >> yes. >> and that it's damage that lasts to this day, we'll use the phrase to that effect as well. isn't the most damaging thing about this whole sorry episode that a number of things very important things were said to the house at that time which a reasonable man which could not reasonably be supported by the evidence at the time the statement was made and that's what's corroded the trust? >> i think when the government or the leader of a government presents a case with all the powers of advocacy that he or she can command, and in doing so goes beyond what the facts of

the case and the basic analysis of the facts can support, then it does damage politics, yes. >> it may take a long time to repair? >> i can only imagine it will. >> well we're very grateful to you for your part in trying to help affect that repair and that's what this report has been about. christian? >> thank you. before i get into the substance of the inquiry and lessons to be learned from it, could you just reflect on your experience of the type of inquiry you carried out. whilst you completed your work the foreign affairs committee was undertaking inquiry to libya, and i was conscious that i was going to wait for the publication of your report in order to reflect some of your lessons learned and conclusions in our report and i'll come to those in a minute, but i believe a select committee of the house

with 14,500-odd words in the report, a year's work probably around 13,000 pounds' worth of extra costs, given our travel budgets and doing the various inquiries, then produced something that was not historic policy of 2.6 million words and the costs and the length of your inquiry i hope would have actually got rather closer and rather firmer conclusions in the report than the size and scope of your inquiry produced. i just, four reflection on the task were set and the inquiry team and how fair or unfair the terms of reference were and the task you assess, and the competing, perhaps the competing utilities available to the government whether it's a select

committee report privy counselors or judicial inquiry, probably ten times the cost and significantly longer than yours, if previous experience is anything to go by? >> i think for an inquiry into the workings of central government in a very critical and controversial area, there is real advantage in having a committee, an independent committee of people who have direct experience of the workings of government in that way. i think it would be more difficult for the judge operating with counsel through cross-examination to arrive at well-judged conclusions. in that particular individual situation. the other particular thought that i have is that the willingness, indeed even perhaps the ability of government to make available highly sensitive

information to an inquiry is determined in part by the membership, the process which you will adopt. again, lord hutton had noted he had gotten hold of a great deal of intelligence material. i think the real difficulty for him, with his terms of reference investigating the death of david kelley was to be able to relate that material to the circumstances of the case. excuse me. for our part, we had right from the out set total access to all material of any category of sensitivity at all, and much of the subsequent negotiation, which did require negotiation and argument over quite a long period was about disclosure, about the ability to publish it. now again, i think judicially-led inquiry would have been less well placed frankly to undertake those arguments. you might even say fight and in our case win those particular

battles. >> lord butler's inquiry, i think, i commonly understood that he thought he'd produced a much tougher report than was actually reported, and i wonder in the reporting of your inquiry whether there are things that were not picked up by the media in a way that you would have liked and given the proper emphasis. and is there, programs you could help us by pointing out things that you think deserve a further attention and should have had more prominent attention than the coverage of your work? >> as a very brief preliminary, i was, of course, a member of the butler committee. the main constraint on us was not achieving public understanding so much as being forced by a very tight timetable to report and conclude before some very key pieces of evidence were available.

i include in those the report of the iraq survey group which came out only a few months after the butler report and perhaps more to the point, the declaration that some of the key intelligence sources, human sources were discredited and, their intelligence had to be therefore set aside. neither were possible on his timetable. now as to the public reception, i think that's partly a matter of the narrow terms of reference that butler had. it was intelligence oriented, very exclusively. for our part, we were asked to give a reliable account of all that happened in the iraq adventure, misadventure. and to that extent, i think we had a readier acceptance by the public and the media when we were finally reported and would have been the case if our terms of reference had kept our report and therefore things of interest to them off the tabl

i myself won't say i'm i'm, myself, i won't say i'm ever satisfied with anything but i do think that the public understanding and acceptance and the media more generally of our broad conclusions of the lessons to be drawn was or demonstrated a reasonably good understanding of what we found and it's a particular point and i'm sorry if i'm going on a bit too long, it was not the whole sole purpose of the inquiry to satisfy the bereaved families but the fact that in the end they have accepted the report as being an answer to the questions that they had was particularly welcomed. >> so there are no areas in this which you think have been not received attention that they deserve and in your own mind and the mind of your colleagues at a priority that have not been picked up? >> i suppose the best answer i can try to that is we can't know yet, because the real test will

be the take of the lessons that we sought to draw and others may indeed find and that's going to be a process looking ahead, that would take some time. as things stand at present, i'm reasonably encouraged that the attempt is being made systematically in government to address those lessons. i think there is a question for parliament as to how you wish to hold government into account for the way in which it does that task, and give some account to yourselves as parliamentarians of what it has found out, what it has accepted and what it has changed. >> i'm turning to the substance. your appearance before us today happily come in sides with the appearance of jeremy greenstein's book which goes to reinforce the evidence you took from christopher mayer and his book and really the conclusion i draw from it that tony blair in

the conduct of his relationship with the president of the united states really did not exploit the influence of the united kingdom at all, and effectively in our bilateral interest or in the interest of getting some leverage over the stabilization plan and once the operation to liberate iraq had taken place. what would be your observations on how severe one should be on that? >> i think it's uncontestable that mr. blair, as prime minister, overestimated his ability to influence u.s. decisions on iraq. that is not to say this there was no influence and in the case particularly of persuading president bush to turn to the united nations in september 2002, that influence was exercised, and for a period, albeit you may say brief period

it worked. though by the end of the year 2002 president bush had clearly concluded that the u.n.-based inspection system was not going to be the answer in the military timetable took control, if timetable took control, if indeed it had not been always in control of the diplomatic process. as to what mr. blair's purpose was, he clearly sought to try to reconcile u.s. decisions and objectives, regime change ever since the clinton administration of course with the uk which was the disarmament of saddam hussein's supposed weapons of mass destruction and that coincided completely with a string of united nations security council resolutions and culminated in resolution 1441. the other strand i think in mr. blair's objective in influencing the united states was to avoid unilateral united states

military action for a variety of reasons, which he would explain and has. was that attempt to exert influence successful in the event? the answer is no. >> do you think he should have played, demanded a higher price for british support? and should have demanded more -- the fact it too so long for sir jeremy greenstein to get a hearing in iraq, by which serious mistakes had been made by the occupation forces. >> i suppose a touch too hypothetical but it's difficult to avoid a conclusion but had mr. blair stated clear conditions for participating in and supporting united states military action and if those conditions had been reasonable,

there might have been more influence particularly i think on the timing of any united states-led action. as it was, and discussed at length in the our inquiry report, mr. blair was determined to say that his conditions were conditions for success, not conditions for british participation and support. >> in 2010, the kurdish government set up a national security council and the operation of the national security council was examined by the foreign affairs committee, the course of our inquiry into the libya intervention, and the conclusion we came to was that we noted the prime minister's decisive role in the national security council when it's discussed intervention in libya.

we concluded the government must commission an independent review of its operation and mark its own homework after the libya intervention during the what was it, during the libya crisis. what we recommended was that the non-ministerial members of the national security council, if they disagreed with the direction of policy by the national security council should require a direction in the same way the parliament secretary requires as the counting officer. what's your view of that as a recommendation? >> in specific terms, i've not been privy to the workings of the national security council, how it operates, but in general terms, i think one of the broad lessons derived from our seven years of work looking at government records or the absence of government records on

occasion, is that it is vital, not merely important, but vital for serious decisions, and the reasons behind them, to be recorded in the public archive, not for immediate release necessarily but that they should be written down so that if someone in a serious, is in serious disagreement with a decision taken collectively, the reason for that decision and the fact of it should be recorded. now, i think that also goes to a suggestion from the better government initiative, which is similar. i'd be reluctant to say that it should be placed on the same footing as that which permanent secretaries as accounting officers are on, vis-a-vis the national audit office and the public accounts committee because i think the two things are separate. nonetheless, it seems to me that if there is a guarantee in the process of the national security council or elsewhere, that dissent, well argued properly

expressed dissent is to be recorded that in itself is an incentive to allow challenge to take place, and indeed from different voices to be heard. >> i shall take that as support for our committee's recommendations. i'm grateful for that. just finally turning to the issue of stabilization, which i know mr. twigg will have questions about it as well. you did extensively with stabilization in the report, and paragraphs 868 onwards. do you share my anxiety that the lessons have not been learned. from the review we took as effect to the stabilization unit in the libya intervention, we were very critical of their

capacity and some of the lessons that you identify here do not appear to apply in terms of what needs to be prepared for in light of operations that are now taking around mosul in terms of where the leadership properly sits and leadership sits with the foreign office but the capacity to do anything to a degree sits with both the minister of defense and the department for international development, and the coordination that you recommend from your experience of government, do you believe the government has yet taken enough notice of the conclusions you came to? >> i don't have insight into where the government is presently placed in any detail, but i would like to respond with two comments in particular. one is the stabilization unit has come into existence and there say fund associated with it.

in terms of the order of magnitude of what's required is nothing like sufficient in scale or i would have thought in authority. the second point is that i think it is very difficult in the specific case of security sector reform in iraq from the foreign office, at admittedly a pretty junior level to understand and assemble the kind of not just policing effort, that was at the core of it, but that the whole range of reconstruction work of institutions, of people, of processes that are going to be required whenever there is a major task of reconstruction involved, and i think there's still a great deal for any government to do, and i would add to that actually, the united nations to bring together the different elements that are involved when a wrecked country has to be put back together. >> thank you very much.

>> you may return to purposeful planning and reconstruction. >> thank you. sir john, you just said in response to christian that you weren't convinced that the stabilization unit had the order of magnitude, scale and authority. >> yes. >> can i invite to you expand upon that and say what might be done to give it the order of magnitude it deserves? >> there was a little conflict pool of money in 2002-'03 which was candidly trivial and no impact whatever. by 2009, when we stopped taking evidence, there was something on an all together larger scale about now i think in terms of a billion pounds or more, but even that doesn't stack up against the costs implied in a major reconstruction task across a whole country, even one smaller than iraq, and iraq was of course a seriously large country for this purpose. does that answer your question? >> your reference to scale and magnitude was essentially about the resources available to those funds rather than necessarily the profile of that work within government or was it both? >> i think it is both former.

the thing that would frankly defeat me and i'm glad not to have any responsibility for it anymore is how you bring together the different arms and branches of government in a really constructive and willing way. >> yes. >> as opposed to protecting interests, objects and limiting responsibility, those problems. they are very great and very real, as we all know. i would like to bring in northern ireland just for a brief second because it took us a long time and ultimately 30 years to get the whole thing right, and to a good conclusion, but in the course of that, we did learn on the admittedly much smaller scale of northern ireland how to bring together military, intelligence, police,

security, economic, social reconstruction, all those things, housing is absolutely central and they were all brought together and held together within a single network of relationships and authority. now if you could replicate that on a larger scale of a major global reconstruction effort, that would be good. suffice to say i'm glad it's not me that has to do it. >> do you have specific reflections on department of international development and how it fits into this, and recommendations you tended to recommend different things you had to do with other departments specifically? >> i think i really have to preface any answer on the generality of that question the fact of the personalities at the time? >> yes. >> and indeed the history of the department for international develop. the resources available surrounding all of that, but the truth of the matter is there was between all the departments and the ministry of defense from the