called the religious land use and stalalized person's act, it's called rlupa for short, and since september of 2010, just in the last six years, we have opened 50, 50 rlupa land use investigations. we have filed ten lawsuits involving land use, and we have filed eight amicus briefs and private parties rlupa cases to inform the courts about the law's provisions and its requirements, and in the last six years, 38% of the civil rights divisions are lupa land use case, involved mosques or islamic schools. 38%. this is a dramatic increase in the percentage of those cases brought during the previous decade. now, of course, we all know that religious institutions are not the only vulnerable spaces that we are determined to keep free

of hatred and bias, because we all know in order for our children to learn and thrive, in order for them to do what they did so beautifully here today, they need access to safe and inclusive classrooms. earlier this year the civil rights division launched a new initiative with our u.s. attorneys offices and that was significantly advance our ability to address religious discrimination in schools. [ applause ] because the place where you go to school should be a place where our children's minds are opened to other ways of thinking, are opened to different religions, are opened to different cultures, not closed off and made to learn to hate other children. now i'm also so pleased the head of my community relations service of crs, paul montero, is here today. paul and the crs work so hard to

ease tensions and promote understanding in communities and schools that have been rocked by traumatic incidents. they go in not to do an investigation, but to help people heal literally. [ applause ] and by which of just one example, after a young student, a young woman was allegedly forced to remove her hijab in school in massachusetts, the school actually invited crs to come in, to work with them, to present its arab, muslim and sikh cultural awareness program to the school's staff, so they could better handle such situations in the future. we also, through crs, has just appointed its first ever national program manager for muslim, arab, sikh and south asian communities, and i'm so pleased that moka has joined us here today. thank you for taking on this task.

[ applause ] now of course, we're also concerned about the crimes against our lgbt brothers and sisters. in october, we commemorated the seventh anniversary of the matthew shepard and james byrd jr. hate crimes prevention act, which expanded the federal definition of hate crimes to include crimes based on gender, disability, gender identity, and sexual orientation. [ applause ] and here, too, we've been active. we have been active using this tool. we brought a number of hate crimes cases in states around the country, and i'm actually traveling to new york tomorrow to meet with lgbt youth, to reaffirm the department of justice steadfast commitment to the rights and the well-being of all americans, including our lgbt family members. [ applause ]

now these are all important efforts, where we are so proud to carry them out. their impact has actually been amplified by the outstanding partnership we have with our local law enforcement agencies from state attorneys general to sheriffs, to police departments across this country. in our efforts to work with them in training our local federal agencies in how to recognize and investigate hate crimes, how to engage with communities, and how to better encourage hate crimes reporting and data collection, and all of these initiatives have helped us tremendously to forge the partnerships i just referenced which are so important in bringing the communities needs to the fore, the partnership between law enforcement and the communities that we serve, and i am not only hopeful, i know that these partnerships will serve as a bu bu bullwark against hate crimes for years to come. now i am so encouraged by what we've accomplished together over

the last eight years, a few points i've been proud to mention today. but i also know, i know that we face challenges in the years ahead. we face challenges that will require the department of justice to remain an active force for good in communities from coast to coast. our federal hate crimes laws are among the most powerful tools we have for creating a more just and a more equal nation, and career justice department prosecutors will continue to enforce them. [ applause ] we will be here, the career men and women of the department will be here, but we also need all of you. we need you to be our eyes and ears. we need you to raise issues to the fore. we need you to work in

partnership with us, because i know that so many americans are feeling uncertainty or feeling anxiety, are feeling fear, frankly, as we witnessed this recent eruption of divisive rhetoric, as we note the hateful deeds that we've been talking about, and i know that many americans are wondering, are they in danger simply because of the way they look or the way they pray? and i know that some are also wondering if the progress that we have made at such great cost and over so many years is in danger of sliding backwards. i understand all these feelings. i see all of that, when i meet with groups and i travel the community, and i also know that as we continue to demand a nation where all people are treated equally and fairly, we will be met with prejudice, bigotry and condemnation. that is also a sad part of our

history. but i also know that we have come, as we say in my church, a mighty long way, and there was nothing preordained about it. there was nothing guaranteed about our march toward a more just and peaceful future, and there never have been guaranties. this has always been hard. it always has been hard. our centuries long project, this wonderful democracy, and we are all in the midst of our goal of creating a more perfect union. that's not fate. that's not destiny. that is the result of countless individuals, some well-known, some whose names we will never know, some famous, some invisible, they all made the choice to stand up to demand recognition, to refuse to rest until they knew that their children would inherit a nation

that was more tolerant, more inclusive, and more equal. ordinary people just like all of you here today. they were the ones who made the progress that we celebrate. they were the ones who gave us the examples that we use in the cases that we make, and that's why it is so fitting that we're here today in this beautiful house of worship, this place of deep and fundamental faith, because it has been the faith that have sustained this fight since the beginning. faith that a small upstart colony could take on the greatest power in the world and build a new country founded on freedom and equality. faith that this new nation could in fact survive. the original sin that it never resolved, and survive a divisive and bloody civil war, faith that

it could, in fact, overcome that, and live up to its ideals, and not just faith, but the works that made that faith reality, is what we celebrate here today, and that's what gives us the courage to move on, when there is no guarantee of success. that has been the harbinger of every movement in this country. people throwing themselves into the fight without a guarantee, but simply the knowledge that they were working towards what has, is right. and i think of examples even from my own life. two members of my own family who also happen to be faith leaders, i think of them often, my grandfather and my father, because they both lived in the southern part of this country at a time when this country regarded them as less than fully human, simply because of the color of their skin. and they both did their part to make this country a little bit

more free and a little bit more fair, but they had no idea how it would turn out. my grandfather was a preacher and a sharecropper in 1930s north carolina, where the middle of the night on a dark road, there were no equal rights. there were no miranda rights. there was no equal protection, and they used to hide neighbors who were in trouble with the law under the floorboards of his home until they could leave the state to safety. and a generation later, my own father, who had seen this, let civil rights groups use the basement of his greensboro, north carolina, church to organize sit-ins and protests at north carolina with the students at a&t. neither one of them knew the results of those actions. both of them lived in fear for the possible consequences, and they were acts of enormous courage, but also in that acts of enormous faith and hope,

because there were two men living in a country that, even years apart, still put obstacles in the way of them from even voting or living their lives, that told them they couldn't use certain drinking fountains, that told them when the declaration of independence said all men are created equal, it wasn't referring to them, and that's just their experience. there are so many other groups who have had those same words thrown in their faces as well, but my father and my grandfather knew what those words meant. they chose to act accordingly. they knew their portion of fear, they knew their portion of anger, but they also never lost their hope, that although this country was far from perfect, it was certainly capable of doing much about, and they both risked a great deal for that, never knowing how it would turn out, never imagining that the daughter of one and the granddaughter of the other would one day be the chief law

enforcement officer of this country. [ applause ] now my friends, that hope is still alive in this country. that faith is still here in this country. that ability to face incredible odds with nothing but the desire and the knowledge that you are entitled to the rights of every american is still in this country. because you and i know that when the declaration of independence says all men are created equal, it means us. it does mean us, and you and i know that when the constitution says "we the people," it means us, and that's the strength of this country, and the backbone of this country, and so as we leave here today, united in the

knowledge that those are our words, these are power ideals, this is our fight, let us leave here united in our confidence, inspired by our faith and strengthened by our courage. let us all leave here with a renewed commitment to demanding nothing less than a country that is true to its founding promises, and let us leave here in faith and in hope, the same faith and hope that has brought this country so far, two centuries and two score years, and it will carry us even further. now, is it going to be hard? yes. it's always been hard. will there be challenges ahead? we have always known that the price of freedom is constant vigilance. we have to work to maintain not just the gains, but to make advances, but of course, the

question particularly in these times particularly in these times of concern and anxiety i know, the question is, will we persevere? will we succeed? we always have. we have moved this country forward bit by bit, day by day, right by right, from where would we get the strength? allow me to quote from spiritual from my faith, made famous by the late mahaliya jackson. she used to say "lord don't move this mountain but give me the strength to climb" that call to a greater power. that call to the faith that is recognized by all people here today, that call to persevere no matter how high that mountain looks. we have accomplished so much but there is so much more to do, but

that's what we do. that's what we do as americans. that's what we do as people of faith. that's what we do as people of hope. we keep moving. we push forward. so let me thank you for letting me spend just a few minutes with you today to talk about the country that we all love, and the future that we all cherish, but the work that we all have to do. but thank you also for all that you are already doing in your congregations, in your communities, in your homes, in your classrooms, to vindicate the promise of american life. now my time as the attorney general is coming to a close, but to everything there is a season, but the work does not stop, and i pledge to you that my commitment to these values and these ideals in this work will not stop. i will continue to stand beside you in the calls of liberty and justice for all, sharing with

you -- [ applause ] -- sharing with you what justice brandeis said is the highest office in the land, that of private citizen, and the most powerful. thank you so very much. [ applause ] >> tonight on the communicatoco, verizon's executive vice president of public policy craig silleman talks about the company's changes over recent years, including the purchase of aol, and the proposed acquisition of yahoo!. there silleman also discusses the need for a massive fiber buildout, what could be part of the infrastructure program being considered by president-elect trump and congress. he's interviewed by john mckick

none, technology reporter for the "wall street journal." >> we're building the fiber deeper into the networks so the wireless signals are traveling a shorter distance. it means when we talk about our wireless networks, 90% of that is actually fiber. i mentioned the internet of things and smart cities, you look at what cities are trying to do, you need a massive fiber infrastructure to do all that. >> watch "the communicators" tonight at 8:00 eastern on c-span2. c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's cable television companies, and is brought to you today by your cable or satellite provider. now republican and democratic congressional leaders hold a ceremony to sign the 21st century kiers act. this is 20 minutes. >> i guess i put that up there.

right here, perfect. i'll get yours, too, when you're ready, okay? >> hello. >> good morning, how are you? >> wow. what a day and what a moment. i could not think of a better way to end the year than by signing this bill. this is exactly the kind of legislation that we need to be passing. this bill takes head-on one of the big challenges we face, curing what today are considered incurable diseases. i don't have to tell any of you that this moment was a very, very long time in coming. and we would not be here if it were not for the tireless, relentless work by so many people that are here standing today, like fred upton, and now we have a lot to show, i want to

say to all of the legislators here fantastic. you guys did such a good job. [ applause ] look what we had to show for it. more money for medical research, a streamline process for approving new drugs and devices, that means millions of patients will get the treatments that they need. i'm talking about people like our good friend here max schill, speeding up medical imknow vasion could mean fewer surgeries and less hassle for max. it could be millions of americans get to live longer, healthier lives. if that doesn't convince you we need this bill, i don't know what will. i would be remiss if i did not recognize the work of congressman tim murphy. tim murphy like everybody else works so hard on getting mental health reform to the finish line, crisscrossing america, doing hearings, talking about

how to fix these issues. he he's led to bring the attention and the resources to mental health issues, but all of you have worked very hard to put the patient back in charge. that's what this is all about. i am so proud of all of the accomplishments of these members and i simply want to say thank you, and job well done. [ applause ] thank you. >> well, the speaker covered the significance of this and there are a whole lot of people here who deserve recognition, but i'm going to single out one member of the senate who did more than anything i think to acquaint us all with the significance of this. this is i think the most significant piece of legislation passed by this congress. to have the greatest impact on the future, and the fellow who educated us in the senate republican conference about this was senator lamar alexander, and i want to single him out for

special recognition. [ applause ] i also want to thank the president of, this is a classic example of incredible bipartisan cooperation, the president had a particular interest in precision medicine, the vice president obviously in the cancer moon shot. i had an interest in regenerative medicine. we all kind of pulled together here, and when a bill like this passes with a very big margin a lot of times people think, well, that was easy. some of the toughest things -- leader pelosi i think would agree some of the toughest things to do around here actually in the end do end up passing by a very large majority but it was really hard to put all the pieces together, so everybody behind us here played an important role in this, and i'm pleased to be here today. i think this is an exciting way to end this session. thank you.

>> the 21st century curers act represents a vital step forward, one that is important to modernize and strengthen our nation's pursuit of life-saving treatments. the national institutes of health has the biblical power to cure. where there is scientific opportunity i think we have a moral responsibility to allocate resources. that's part of what this legislation does, we're providing reforms and resources that will accelerate innovative biomedical research, precision medicine, and in the interests of president obama, brain research, very important and i want to particularly salute vice president biden, because he really advocated for not only his moon shot, cancer moon shot initiative, but for the entire

bill, bringing clarity to its purpose and votes for its success. frank pallone, our ranking mental on energy and commerce and diana deguette have made this legislation their life's long work for a very long time. their knowledge, their persistence, their traveling the country, when it, to have the best possible input, working in a bipartisan way, as the speaker and the leader mentioned, which was very, very important, and i'm very pleased that, finally, we have the $1 billion in opioid funding needed for the epidemic of addiction. we're also making improvements in mental health and substance disorder services, and that was a very bipartisan initiative as well. i'm also pleased to have a letter from the speaker saying that, promising that congress will meet its responsibility to robustly fund these commitments in the years ahead, not just in

the 2017 appropriation. celebrating -- don't worry, okay? >> yes. >> you heard it. no worry. i'm relieved. accelerating the development of cures and protecting the health and safety of the american people depends fully funding the fda and the nih, and may i say that, when we make these investments, and we come forward with cures for interventions, we want them to be available to all americans. we will continue to try to work in a bipartisan way to champion the robust investment in innovation and r&d that powers new miracles, new miracles going back to that biblical power to cure, and i join the speaker in saying, i can think of no better way than to start the holidays and to be signing this legislation, which brings, makes america more healthy. thank you. mr. upton. >> well thank you.

i am fred upton, and this has been a great cuble of years, because that's how long it has taken. we have worked not only both sides of the aisle, but both sides of the country from north to south, from east to west. and we did something that congress is often accused of not doing, and that is listening. we listened to every group that was out there. the researchers, scientists, particularly the patient groups. clock's ticking. folks that have a disease know that it will take them without a cure. this bill is going to fix that problem because it expedites the approval of drugs and devices and is coupled with literally billions of dollars in more research that will find the answer for those curious years ahead of what it otherwise would have been. i want to thank may colleagues on my committee.

you'll remember this bill passed our committee 51-0. it was no easy task. republicans and democrats, particularly i want to thank my partners, frank pallone and diana degette, and those on both sides of the aisle, particularly lamar alexander as we cobbled this thing together to get the votes in the house, and just want to close saying, you know what really made this important, it's personal. it's personal that everybody out there, our colleagues, our staff, our constituents, it is going to find the answer. and it's important that we did it right. we also want to thank the administration because without them it would not be a reality

when president obama signs it into law next week. so, thank you, everybody. thank you. [ applause ] >> thank you, fred. and you and representative degette and pallone have site a remarkable example for the united states and we're grateful for that. >> say that again. >> i'll say it again next christmas when we do the same thing. dr. francis collins, the remarkable leader of the institutes of health, he calls it the national institutes of hope, predicted in a hearing before our committee that the following could happen in the next ten years. artificial pancreas for people with diabetes, medicine that would identify alzheimer's

before the symptoms are apparent, and then once identified, would help retard the progression of alzheimer's. a vaccine for zika, a vaccine for hiv/aids, a vaccine for univers universal flu which killed 30,000 people last year. heart transplant doctors like bill frist will be out of business because, instead, we'll begin to use regenitive medicine to use your own cells to restore your own heart. this is dr. collins talking. and the real answer to the opioid addiction which would be non-addictive pain medicine, which he seize coming in ten years. this bill makes those come true in two ways. first, funding for the research, and second to move those more rapidly through the regulatory

process into doctors' offices and into people's medicine cabinets so people can use them, hopefully at a lower cost. that's why the president said this is an opportunity we can't miss. that's why the vice president was making phone calls to the senators all week. that's why speaker ryan put this as part of his agenda for leadership and that's why mitch mcconnell said this was the most significant piece of legislation for the year. i want to especially think speaker ryan and senator mcconnell because they have so many, as they know, they have so many conflicting demands as leaders and as speaker, but they cleared a pathway for a very complex bill with many important differences of opinion. and without that, it simply would not be here today. last year we presented president obama with what he called a christmas miracle. after a long time, we helped effect the lives of 50 million

children by fixing no child left behind. this is a second christmas myrrh kashlg a medical miracle, the president will be presented that affects more people. it's the way congress ought to work. i'm privileged to have been a part of it. thank you. >> thank you, senator. i'm going to sound a little like senator alexander in what i say. first of all, i think this was a significant bill that became even more significant as the leadership, the very one here, got more and more involved. i have to start out by saying, first of all, fred upton and diane degette from the beginning were determined to go around the country and listen and knew and wanted our country to continue to be innovative. the feeling those two had was that there wasn't enough innovation, too many restrictions or wasn't enough money being spent at nih for research on diseases we haven't

found a cure and we can could do more as a country to accomplish that. so, that was 21st century cures. as time went on, we had these other bills that were just as important. mental health reform, dealing with opiates. some of you know we passed an opiate package and the president signed it back in july but there wasn't the funding. and also the cancer moonshot, which was a really innovative idea on the part of president obama and vice president biden. so, all this evolved into a package now that really is truly remarkable, that we're able to combine all these in one rubric, if you will, under the auspices of 21st century cures. i just want to thank the leadership. i have to thank nancy pelosi, our leadership on both the house and the senate side because there were many times when i met with nancy and, you know, there were the naysayers that said, we can't do all this, we can't put this all together. there's not enough time.

she said, there is enough time. we're going to do this. i hear the anyway say irz but they're wrong. this overall is a really great bill, and it is. i want to thank everyone here for putting this together. i think it's remarkable that we're able to accomplish so much in this last few days of the session. and now i'd like to introduce diana degette because if there was anybody who was saying, we're going to do this, every hour, every day in my ear, it was my colleague, congresswoman degette. >> thank you so much, frank. it was almost exactly three years ago today that fred upton came up to me on the floor and he said, you know, diana, i'm thinking about doing a little bill to help revise the way we do biomedical research so we can get cures much more quickly from the research lab to the approval to the patient. and i'm wondering, would you want to help me with that?

i said, sure, fred. then i went back to my office and told my staff. so, you can imagine three years later, as we stand here with all of our wonderful come padres on colleagues from both sides of the aisle how special this is for us. it's not just special for us, it's really specialty for all the patients of america. people for whom we need to have hope during this season. people like max, people like my daughter, francesca, people like so many other americans who have diseases for which we don't yet have a cure. and that's really when this congress can come together in a bipartisan way to bring that hope to those americans. everybody has said what a team effort it was. and it was a team effort. our friends in the senate on both sides of the aisle, our leadership in the house, speaker ryan, leader pelosi. i wasn't the only one who refused to say no.

there were those many late night phone calls with fred and his staff and, of course, everybody on this committee. i do think there's one group that deserves our thanks more than anybody else and that's the incredible staffs that we have on all sides. give them a big round of applause. just one thing in con kugs, some commentators have said this is the way congress used to work. guess what? i hope this will be a new day opening the door in congress working this way again to solve the very serious problems we have facing this country. i now want to introduce the star of our show, max. so, max. >> super max! >> yeah. >> max, by the way, he was with us every step of the way. he was. >> hi. my name is max. thank you for supporting cures.

cures will help people feel better. it's more than hope. it's action. thank you for working together on cures. cheers to cures. >> awesome. [ applause ] >> now we're going to sign some bills here. >> go over there. c-span's s

documentary contest is in full swing. this year we're asking students tell us, what is the most important issue for the new president and new congress to address in 2017? joining me is ashley leigh, former student cam winner in her documentary help for homeless heroes. tell us about your student cam documentary. >> in 2015 my partner and i produced a documentary where we covered issues of homeless veterans on the streets of orange county, california. we decided that these sort of people who are fought for our country, have given for our country, and the fact they are now living on the streets, not having family, not having anyone who care for them was not okay. we decided we are going to talk about this issue wiwithin our c and we made a c-span documentary. i encourage high schoolers and

middle schoolers to use your voice, to speak your voice, saying your generation deserves to be part in the government. if there is a better place to speak these issues, this is it. my advice for students on the fence of starting this documentary is to really look into your community and see what is affecting those who are around you because they are the ones who you love. they are the ones you see the most. they are the ones you're surrounded with almost every day. so if there is an issue that you see happen every day on the street, that's probably where you can start. be a part of this documentary because you want to be a voice for your community. >> thank you for all of your advice and tips on student cam. if you want more information on our student cam documentary contest, go to our website, studentcam.org.

follow the transition of government on c-span as president-elect donald trump selects his cabinet and republicans and democrats prepare for the next congress, we'll take you to key events as they happen without interrupt. watch live on c-span, watch on demand at c-span.org or listen free on our c-span radio app. today a look at the challenges for incoming trump administration. panel lists clue josh bolton and staffers from the george w. bush and obama administrations. that's live at 3:00 p.m. eastern on c-span. now the centers for medicare and medicaid services review the findings of the 2015 national health expenditures report. they talked about the increase in health care services and insurance coverage. this is 50 minutes.

good morning, i'm alan weil, editor-in-chief of "haelt fairs," we're pleased to announce we have a paper for 2015. this is part of our ongoing partnership of contract ms of the actuary. they produce, as you know, the gold standard estimates for historical and projections in health spending, disaggregated you'll hear about, by payer, by service type and the like. for the media in the room, you have a flash drive with all of the materials, the press release has a link to the full report. i will remind you now and again

the material is embargoed until 2:00 p.m. today. please honor the embargo of 2:00 today. i don't think it's very complicated to introduce the importance of this material. estimates of health expenditures in the united states are extremely valuable in their own right, but, obviously, at a time that congress and the president-elect are contemplating major changes in health policy, having a solid baseline, understanding of where we've been is critical as well as what you will see today, beginning to document the spending effects of some of the recent policy changes should give us some insights into the possible effects of changes those recent policy changes. so, we have a team effort on the health affairs side to make this publication work, but i particularly today want to acknowledge the team effort on the part of cms. we'll hear today from anne martin, economist in the centers for medicare and medicaid services. you'll then hear from micah

hartman, statistician. they're joined by aaron catlin, deputy director in the office of the actuary and benjamin washington, economist also in the national health statistics group. they're here as resorry, as i know are other representatives from cms. without further ado, let me turn it over to anne to begin presenting the results. >> thank you, alan. thank you all for coming today. my name is anne martin. i'm here with other members of the national health expenditure accounts team to present to you the results of national health spending in 2015. and the trends that we will discuss today highlight some of the important point seen in our article. it will be presented as health affairs web first at 2:00 p.m. first and also at 2:00 p.m., all the data will be presented on our website.

to start off with some of the overall findings on national health expenditures, total spending for health care in the united states reached $3.2 trillion, up from $3 trillion in 2014. per capita health spending reached $999 per person up from $9,915 per person in 2014. the overall rate of growth in 2015 was 5.8%. this was faster than in 2014 when spending grew 5.3% and in 2013 when spending grew 2.9%. it was also the highest rate of growth since 2007 where since the beginning of the great recession. health care spending is a share of the total economy, or gdp, increased to 17.8% in 2015 from 17.4% in 2014.

as an acceleration in health spending was accompanied by a slowdown in overall economic growth. on this graph we're showing the annual rates of growth in national health expenditures compared to overall economic growth as measured by gross domestic product. following the great recession, which extended from december 2007 through june 2009, growth in health spending and the overall economy increased at similar rates each year from 2010 through 2013. then in 2014 and 2015 after five consecutive years of historically low growth, health spending growth began to accelerate increase 5.8% in 2015. at the same time the economy grew 2.4 in 2014. in this divergence in growth rates for the two-year period of

2014 and 2015 occurred outside of a recessionary period. it can be attributed to legislative changes closely associated with coverage expansions under the affordable care act. so, this graph shows national health expenditures as a share of gdp. from 2010 to 2013, the health sharing portion of gdp was flat because they grew at similar rates. however, as a result of health spending increasing faster than gdp in 2014 and 2015, as we saw on the previous slide, the health spending share of the economy increased from 17.2% in 2013 to 17.4% in 2014 to 17.8% in 2015. over the 5-year history of the national health expenditure accounts, the largest increases in health spending share of the

economy have typically occurred around periods of economic recession. but the 0.6 percentage point increase in health spending share of the economy since 2013, which occurred more than five years since the end of the last recession, coincides with major health insurance expansions you should the affordable care act, particularly through marketplace health insurance plans and the medicaid program. it also coincided with rapid growth and prescription growth spending. so, in both 2014 and 2015, the faster rate of health spending growth and increase in health spending share of the economy were largely ininfluenced by increased insurance coverage, rapid growth in prescription growth spending and utilization of increased services. first, coverage expansions that resulted from the affordable care act affected both private health insurance and medicaid.

it affected both enrollment and spending primarily because of the number of people who gained coverage. second, prescription drug spending increased at a high rate of growth in both 2014 and 2015, primarily due to increase spending for new medicines, typically for the new specialty drug especially those used to treat hepatitis c. next, faster growth in spending was experienced for hospital care and physician and clinical services and was primarily driven by increased use and intense services associated with increase in coverage. one of the biggest drivers of the health care spending in 2014 and 2015 was coverage expansion. which had an impact on enrollment trends in both years. in particular, the aca affected enrollment for private health insurance and medicaid and also had an overall effect on the

insured portion of the population. just to note, these categories are not mutually exclusive and therefore, not additive because people can have dual enrollment and some previously made had had insurance coverage but moved to another category. therefore, not all those who gained insurance were previously uninsured. as you can see on the top line, enrollment and private health insurance increased by 7.9 million people over the two-year period from 2013 to 2015. in this category includes employer-sponsored insurance, which accounts for the largest portion of private health insurance and increase by 3 million people over the two-year period. it also includes other private health insurance which increased by 6.6 million. other private health insurance is mainly marketplace enrollment but also includes medigap and other purchased insurance. it was the net effect of these

insurances that yielded a total increase of 9.7 million with private health insurance coverage. for medicaid between 2013 and 2015, an additional 10.3 million enroll yees were added. of those, 9.8 million were newly eligibleable under the aca. medicare continued to grow at a steady rate as population ages, increasing just 3 million since 2013. and the uninsured population dropped by 15 million. as a result, the insured share of the population increased from 86% in 2013 to almost 91% in 2015. on this slide we're dividing up the factors that account for per capita health care spending. in 2015, per capita grew 5% compared to 4.4% in 2014.

we're breaking down the factors into medical price growth, age and sex factors and resillial use and intensity of services. medical price growth is indicated by the blue section of the bars. in 2015 medical prices grew 1.2% which was slower than growth in 2014 when it increased 1.8%. this was the fourth consecutive year. the overall increase in per capita spending was not driven by price. the age and sex factors, the red section of the bars, account for changes in the demographic characterization of the population. they make up a consistent portion of the growth year to year and increased 0.6% in 2016. finally the residual use and intensity of services as indicated by the groan section

of the bars captures changes in quantities and mix of goods and services used. that increased 3.2% in 2013, up from 2014 and was the primary driver of per capita spending growth in 2015. this is the strongest growth we have seen in over ten years for this category. including before 2009 or before growth in health spending was visibly impacted by the recession. growth and residual use and intensity in 2015 increased for almost all personal health care services but most notably for hospital care and physician and clinical services. so, this pie chart breaks up the distribution of the 3$3.2 trillion among health care services. these shares tend to stay relatively con stanlt from year to year. in 2015, 32% of all health care spending went for hospital

services, which is the largest category. second largest category is spending for physician and clinical services at 20%. and the third single largest category was for retail purchases of drugs. in total these three services accounted for 62% of all health care spending in 2015. this chart shows the growth in health spending among goods and services for three years. 2013 compared to 2014 and compared to 2015. in 2015 growth was faster for all services except for prescription drugs, which slowed. however, the rate of growth for prescription drugs was still the fastest growing among all services for the second year in a row. this was largely due to the introduction of the new and expensive specialty drugs, especially those for the treatment of hepatitis c.

spending for hospital care and physician and clinical services which together account for 52% of total spending in 2015, both continue to experience upward growth that was driven by increased use and intensity of services. that was associated in part with the insurance coverage expansion and increased spending in private health insurance and medicaid. for nursing care facilities, however, growth was driven more by increased medicare spending and for other health, residential and personal care, growth was driven by increased spending for medicaid, home and community-based waivers. the rest of the other services were largely influenced by insurance expansion, which again was mainly through the increased private health insurance and medicaid spending. looking more closely at hospital spending, showing growth rates from 2011 to 15. hospital spending accelerated for the second consecutive year, increasing 5.6% in 2015 to reach

1.$1.04 trillion. the faster growth in hospital spending reflected strong growth in private health insurance and medicaid spending associated with insurance expansions. it was primarily seen through increased use and intensity of services or quantities and mix of services used. for example, in 2015, hospital utilization as measured by the number of inpatient days and number of discharges both increased in 2015 compared to 2014. price growth was less of a factor in overall hospital in 2014 as it increased at its slowest rate since 1998. we're looking at spending growth for physician and clinical services. spending in this category continued to increase in 2014 by 6.3% following 4.8% growth in 2014, reaching $634.9 billion.

this was the first growth rate above 6% in ten years. the faster growth reflected stronger growth and increase in residual use in intensity of services. because of the enrollment growth experience in private health insurance, this impacted growth in many service sectors including physician and clinical services. in 2015, prices for physician and clinical services actually declined by 1.1%, driven by the expiration of temporary increases in medicaid payments to primary care physicians. as a result, the entire increase in spending for physician and clinical services was due to an increase in nonprice factors such as use and intensity of services, primarily due to coverage expansion. for retail prescription drugs spending reached $24.6 billion and increased at a rate of 9%,

which was somewhat cloer than 12.4% in 2014 but still much higher than the growth experienced in the last few years. the rapid growth experienced in 2014 and in 2015 was based on similar factors. primarily increased spending on new medicines, particularly for specialty drugs such as those used to treat hepatitis c, cancer and autoimmune diseases. in addition, the number of new drugs approved for use in 2015 was the highest in any one year over the last decade. there was also price increases for existing brand name drugs. although moderating somewhat since 2014, double-digit price increases for brand name drugs were reported by industry sources for 2015 i'll now turn the presentation over to micah, who's going to talk about the payers of health care.

>> thanks a lot, anne. so, we're going to take a look at the distribution of health care spending by payor. as you can see health is insurance is the largest in 2014. this category is expanded off to the right with a smaller pie where we show private health insurance at 33%, followedably medicare at 20% and medicaid at 17% and then va, department of defense and the children's health insurance plan also accounts for the remaining 4% of total health insurance. moving back to the larger pie on the left, you can can see that the next largest payor is out-of-pocket spending at 11% of the total. out-of-pocket and national health expenditure account includes all co-pays, deductibles and direct pays from individuals and does not include any payments for health insurance. finally, the last category --

last three categories is other third-party payors and programs, public health activity and investment at remaining 16% of total health care spending. on this slide we show annual growth in spending for 2013, 2014, 2015. presenting these three years, you can see the most trending health care spend tours for payors during the affordable care act expansion. with private health insurance, medicaid and medicare accounting for 70% in all of 2016 we'll discuss the recent growth on the next few slides. before we do, i'll focus on the out-of-pocket spending which increased 2.6% in 2015, or close to the recent average annual growth of 2.9% from 2011 to 2013. just following the end of the most recent recession, but just before the start of the enrollment expansion in 2014 and

2015. in 2015, out-of-pocket spending continued to be influenced by the mixed effects of the affordable care act expansion, decline in uninsured and increase in high deduct able enrollment with higher cost sharing for these type of plans. annual growth in out-of-pocket has not been higher since 1998. as a result, a share of the result of out-of-pocket spending has declined steadily to 10% 5% in 2015. as you'll note on the fly, va and children's health insurance program are increasing at double digit rates in 2015. however, they account for less than 4% of the total and didn't have much impact on the overall trend. we see spending increased 7.2% to reach 1$1.1 trillion in 2015. total private health insurance enrollment increased 2.6% in

2015 and reflects the net impacts of marketplace expansion of 3.6 million enrollees. faster growth in private health insurance spending in 2015 was primarily driven by enrollment growth and faster per enrollee spending. a pick up of -- increased ut zalgts and most goods and services, including hospital and physician and clinical services and an acceleration in per enrollee spending due in part to the new enrollees that may have been sicker, used more services and had higher medical costs than previously insured individuals. looking at the medicare program we see spending reached $646.2 trillion, increasing 4.5% following 4.8% growth in 2014.

in 2015 enrollment growth slowed 0.4 percent ang points which accounted for the difference in the overall growth in medicare between 014 and 2015. per enrollee growth trends remained almost identical in 2014 at 1.6% and 1.7% respectively. the stable overall spending growth for the medicare program includes slower growth for hospital services due to reductions and d.i.s.h. payments and declinement in readmission. medical retail increased substantially in 2015 due to expansion on hepatitis c drugs but slowdown was due to a slowdown in medicare on behalf of medicare. while there was faster growth for nursing home care and holme health care due to an increase in payment updates for some types of services provided and a pickup in utilization for nursing home care.

looking at medicare program in more detail in 2014 we see fee for service accounts for 68% of medicare. as recently as 2011, fee for service accounted for 74% of spending. increase reflects faster enrollment growth in medicare advantage you see on the slide. fee for service spending reached $442.6 billion in 2016 or 1.9% growth. the slowdown in per enrollee spending is being driven by hospital, physicians and retail prescription drug spending. medicare advantage spending reached 203.6 billion and the faster growth in per enrollee spending is due to a slight increase in medicare advantage spending. however, per enrollee spending growth has been slower due to

benchmarking. turning focus to medicaid we see spending increased 9.7% to reach 545$545.1 billion. overall spending was strong in 2014 but slower than growth of 20.6% in 2014. spending slowed in 2015 as enrollment slowed and a payment increase which expired at the end of 2014. however, spending per enrollee accelerated from 30.4% to 3.8% in 2015. some of the reasons for the per enrollee acceleration in 2015 were that many states adopted higher reimbursement rates for some providers, medicaid supplemental payments were increased for hospitals and growth for other health residential and personal care services was strong as nearly every state took steps to expand

care in the home and in the communi community. on this slide we show medicaid spending in total and divide it between federal and local and state spending over time. federal spending increased faster than state and local spending for the third year in a row, although the difference between the two levels of spending was much larger in 2014 and 2015 due again mainly to the affordable care expansion in medicaid program. new medicaid eligible categories were established that were fully financed by the federal government at 100%. state and local spending increased 4.9% in 2015 following growth of 1.7% in 2014 and the pick up in 2015 is due in part to increased payments to providers. at this point in the presentation we're going to take a look at the sponsors of health care spending and we present spending in this way to give you a sense of the impact of the recent health care spending trends and the relative responsibility of each sponsor.

to give you an idea of how spending is realigned, i'll run through a couple examples. for out-of-pocket spending in the national health expenditure accounts, all that would be moved to the category sponsor whereas all health insurance for private businesses is split between the employer portion of the premium and moved to the household category and sponsor and the employer portion of a premium, which would be moved to the private business sponsor category with that in mind in 2015 the federal government became the largest sponsor of health care at 29% up from 3 percentage points from 26% in 2013. the share of households, private businesses and state and local governments all remained relatively stable with household and state and local shares declining a small amount in 2014. even with increase in share, total spending growth slowed due to slower enrollment growth in

the medicaid -- due to the medicaid expansion under affordable care act which slowed in 2015 but spending growth accelerated slightly for all other sponsors in 2015, as you can can see on the graph to the right. household and business accelerated slightly mainly due to increased spending on premiums from the esi population, or employer sponsored insurance, and due to increase in enrollment in private health insurance. state and local growth was faster due to the state portion of medicaid spending, which increased reimbursement rates and expanded care in the home and community. so, to summarize our presentation, we see national health expenditures reached 2$23 trillion in 2015. spending accounted for 17.8% of the share of the economy, up from 17.4% in 2014. increases of this magnitude typically cure around periods of

recession, however the 0.4 percentage increase occurred five years following the and millions gaining health insurance in 2014 and 2015. faster growth occurred in both 2014 and 2015 as affordable care act expanded through the medicaid program, private health insurance marketplaces and to a lesser degree in 2015, an increase in employee-sponsored health insurance. in all, 98.9% of u.s. population had some form of health insurance coverage in 2015, up from 86% in 2013. in 2015 growth in price factors accelerated for hospital care and for physician and clinical services. some of this increase was due to faster growth in private health insurance as enrollment and per enrollee picked up. mainly due to continuation of the increases in medicaid enrollment and all of the newly

eligible adults were fully financed by the federal government. so, at that point i'm going to stop here and turn the presentation back over to alan. thank you. >> we know this is a lot to absorb but it's your turn to ask questions. the floor is open. we have microphones. >> hi. norm levy with "los angeles times." in looking at the historical table of year over year percentage growth, article 2 in the health affairs article, it looks like the year over year annual growth of 5.8% sort of returns closer to what historical norms were before the recession. and, yet, there's obviously been a huge coverage expansion in the last couple of years. can you talk a little bit about

if -- if health spending growth had returned to historical year over year growth without the coverage expansion, would -- would the -- would we normally expect that to be even higher? i'm sorry. i'm not phrasing this quite as artfully as i would have liked but do you understand what i'm asking? >> yeah. unfortunately, we can't provide estimates of what it would be without coverage expansion because this is what our data came in as and we report what it shows as far as the current law. so, it is, obviously, lower than we've seen in the history, in historical accounts, but we are coming off the greatest recession in history. so, the health spending was historically low for five years before insurance coverage started to pick up due to

expansion, and so we did expect to see a bump up in health spending growth, but we cannot parse out what it would have been without coverage expansion. >> hi, kimberly leonard with "u.s. news & world report." so, the share in percentage of gdp for health care is -- grew by four percentage points, right? >> in 2014. >> there's a point in the report where it says 0.6. >> 2014 and 2015 are unique because we're coming off of growth that was very similar for 2010 to 2013 and they grew at essentially the same rates of growth as the overall economy. it was historically low. so we're seeing the pick up in

2014 and 2015 which shows a distinct story of coming with insurance expansion. so, some of the numbers are a two-year time period. >> okay. can you help me explain to readers why we expect the share of health care to be higher during times of recession? >> because during times of recession, typically health care spending remains at a level that is higher than that of the economy. the economy reacts quicker to changes in jobs and the health care sector takes a little time for that to happen and for contracts to be renegotiated. so, usually, health care spending comes down after the beginning of a recession. >> with ap. and i want to follow up on this question. i want to make sure i understood you correctly.

so, are you saying basically that normally you see the gap between gdp growth and health care spending growth open up during times of economic recession and not so much during times of economic expansion? >> according to the history, that's what we've seen. we've seen the divergence during and around periods of economic recession. >> so this divergence currently does not fit the usual historical pattern? >> correct. >> okay. my follow-up question was just to confirm, did you say that this 2015 is the first year that the federal government becomes the largest payor for health care -- >> correct. >> okay. thank you. >> hi, shannon firth. i have a question about the slowdown in medicare. can you just -- the hospital. can you talk specifically about

the readmissions, the -- i think you said the prescription drug rate changes related to the catastrophic funding. can you just explain a little further. >> okay. overall medicare spending on a per enrollee basis remain kind of flat but in the fee for service portion we saw per enrollee expenditures decelerating, slower at a -- growing at a slower rate. so, a lot of that was driven by hospital spending, physician spending and prescription drug spending within medicare. so, within hospitals in medicare, we have overarching themes such as reductions and readmission, which brought down spending and also reduction in proportionate share. there are factors such as productivity adjustments, reductions in health insurance technology, bonus payments. so, there's other factors, but the largest ones are the ones we've mentioned. and then when you get to

physicians, there was a smaller payment update in 2015 and then 2014, but the volume intensity of services continued to grow. so, it's mostly driven by the payment update for physicians and for prescription drugs within medicare. it's still a really high rate of growth. the fact that it comes down, it's just coming off a super high growth rate the previous year. all that high rate of growth is due to the expensive specialty drugs that we've seen, hepatitis c drugs. what micah was talking about is the largest part of the medicare spending in recent years has been this reinsurance part where when the beneficiaries reach the catastrophic threshold, medicare payment kicks in, and that's because they've been using more specialty drugs that get them to that point faster.

and medicare pays more. so, that typically has been growing at double digit rates in recent years. they just came down a little bit in 2015. >> because out-of-pocket -- >> it's really not anything noteworthy other than the previous year was a lot higher because of the introduction of hepatitis c drugs. >> i'm going to take another cut at my question here. so, i'm looking now at exhibit 5, i guess, in the article. here it seems like you're parsing the factors that are accounting for growth in the current period versus the decade earlier. if i'm reading this correctly, this shows a lot of the growth in the 2004 to 2011 period was driven by price increases, whereas in the two years, '14

and '15, driven more by residual use and intensity, right? >> that's exactly what we're saying. >> so, if one were to look even further back into the past, are you able to say how unusual it is that the radio siddial use and intensity is the largest factor driving overall spending growth? >> i can't recall overoffhand all the factors for the previous years, but i know that in like the '80s there was a lot attributed to price. so, there have been -- there there have been years where price is definitely a bigger factor. this is definitely noteworthy residual intention has played a role in overall health spending growth. i would have to look some of that up. >> okay. maybe i can follow up. >> hi, i'm with politico.

i'm just wondering if you all can say anything -- if we can assess the impact of the shift of value-based payments overall. can we say what kind of effect that's having on national health care spending? >> that's not something we can really drill down to in these estimates. we take a broad look at overall spending and if something moves the needle, you know, that's going to be the top line. i don't think anything stood out to us regarding that topic. we would have to look into that a little further. >> i want to talk about the state and local spending jump. and i know that the federal government's share of medicaid grows -- gradually reduces.

with the medicaid expansion. but i'm wondering why it grew -- so, we saw it accelerate by 1.7% in 2014, but then by almost 5% in 2015. is that higher than would be expected? do we know whether some of that might be part of the woodwork effect in medicaid, where people are enrolling in the program who would have qualified before the aca? >> yeah, i need to bring up the growth rates, but i do think there was some effect of increased enrollment that was not expansion-related across some states. >> some of the factors we talked about in the presentation, what's going on with medicaid was in the first year of the

expansion you had 26 states expanding coverage for the medicaid population. in second year 2016 we had three additional states, you know, participate with the expansion. but some of the other factors we talked about earlier in the presentation that wouldn't be reimbursed fully at 100% with the expansion, higher reimbursement rates for some of the providers and a lot of states increasing supplemental payments for hospitals. and then there was the other health services. so, trying to provide more care in the home and community, so moving that care. so, a lot of this shift we've seen more recently in 2015 is not as strongly driven by the expansion under the affordable care act as the growth in the expansion was not as strong in '15 as it was in '14 on the enrollment side. [ inaudible ] >> basically, you know, states have a lot of control over how they allocate resources within

the medicaid program, and so at different points in time, they try to make payments and, you know, other measures they're trying to do state by state. so, this was just one of the years where, you know, when surveyed, this is what states responded that they would be looking to do in 2015. >> i'm going to interject with my own question since we're covering so much ground. i just want to seek some clarification around prescription drug spending. so, the numbers reported here are retail spending. i wonder if you could, since there's so much attention being paid to this issue, if you could help us understand where do rebates fit into the calculation of spending and what share of prescription drug spending is retail given there are also places drugs are dispensed, including in hospitals. >> we do account for rebates. they're subtracted so they're

not included in our overall number. so, if rebates are high that would bring down our spending level. we -- we -- i'm not sure of the exact proportion of spending of row tail drugs versus hospital and physician, but i think it's a majority. >> i think it is a majority but we do not have an estimates of the share that is retail versus those provided in institutional and our settings. >> our data comes to us strictly as retail. and then whatever is provided in the hospital or physician's office is automatically included in the spending that we report on those categories. >> thank you. yes. sorry, i want to get the mike. >> make sure i'm understanding this. so the growth rate for residual use and intensity, is that --

so, is more people having coverage and using the coverage or is it more people also who have coverage have more use of services. >> both. >> both things are happening. is that expected in terms of the bulk of the coverage expansions happened in 2014, was it anticipated that the use of services would continue to grow, you know, a year after that had happened and not just in 2014? is that how things -- >> it's typically expected in that type of scenario. and after the recession, there was probably a lot of pent-up demand, and with the insurance expansion it was expected to see more use and intensity of services. >> so, any idea, this is expected to be a multi-year effect or that intensity keeps increasing? >> yeah. >> typically does it? >> it is just -- we -- the way our methodology is constructed,

we take the total top spending and we take out the price effect because we get that from bls, and we also have national health expenditure deflator. we have a way of measuring prices. and we take out the age and sex factors and the rest is -- that's why it's called a resid you'll -- the use and intensity. so, it captures other things like measurement error or -- or -- it can be a mixed bag, in other words. and so it's hard to make a prediction on what would happen exactly to that category. >> i would just add that, you know, you asked if we typically expect that, so we typically don't have an expansion of coverage on the magnitude that we had as a result of of the aca and that in -- there was big expansion in '14 but we also had a number of individuals that gained coverage in 2015 as well.

so, that's why you see that two-year effect on the residual use and intensity. we will be -- we hope to early next year release our to early next year release early projections that will go out ten years so we can look at trends going forward. >> can you explain again how you break down where you get sponsors, right? how do you break down private businesses and households? i think a lot of lay people might look at that and think most of that is not household but employer spending on health insurance? >> everything in the national health accounts is crosswalked into a category of sponsors. so for households, for example, includes out of pocket spending, the portion of premiums from an employee perspective. and for like the federal government, now the federal

government is looked at, state and local government looked at as part employer on this chart. so if the federal government is an employer, then the employer share of premiums are going to go into there. so private businesses are employers as well. so the private health insurance portion is doing to go into private business there. so there's a crosswalk where we take all private health insurance premiums and it goes into the different buckets. so i think micah was just trying to explain the employer/employee breakout. and so the employees share would go into household and the employer would be broken up between businesses and governments. >> so what i'm paying for employer provided premiums is counted as a private individual expenditures and is not counted

on the employer side. >> correct. your share is going to be in the households. >> sponsor estimates are a way to sort of track who ultimately finances the payers and programs that we have discussed previously. so we want to take the premium payments that come from the household, put those into household. as federal employees, it's the same thing. the federal share of our premiums that the federal government pays on our behalf would stay with the federal government but the amount we pay would go back to the household that way we can look at revenue, federal governments, state and local governments and see the burden that health spending places on those sponsors of care. >> how important as factors are the changes that you mentioned in the age and sex and the level

of education. >> the age and sex factors are typically the same like every year. so it's about 0.6% per capita growth. every year they don't change that much they take into account demographic population. >> in the short run they don't change very much. in the long run they will change as the population ages but it's an index we create to adjust for different composition of consumption that occurs as the population ages. in near term, 0.6 % per year in the short-term. >> how is distribution sex changes and which sex object balance is more expensive? [ laughter ] >> yeah.

so we have another study where we take historical data and break it out by age and gender. we have estimates through 2012 on our website. what we do is break it into -- you can look at children, working age adults and elderly, 65 plus population. in general, women tend to spend more per capita than males. there are several categories, i believe it's with children and perhaps with drugs, children's consumption of drugs where they spend more. i can follow up with you. we have a study that looks at that, it just doesn't take it through 2015. >> can you take a little about the fact thaers go into use. you mentioned coverage expansion is driving a lot of that.

to what extent are you able to say the growth in the high deductible plans may be depressing some of that. >> we don't have any data on residual use and intensity because it's the residual, what's left over. we look for supporting information to explain the trends. high deductible health care plans, they have grown in popularity have grown in popularity over the last couple of years. because of the higher deductible, people might not use as many services because they are having to pay out of pocket until they reach their deductible. it may deter but we don't know. we can't tie it to the portion of growth that's residual use and intensity.

other questions? we know there's a lot to take in. >> just to clarify, age and sex is not that important. i think -- did you say -- [ inaudible ]. >> a reference to what's going on in the marketplace. what's been going on recently and making comparisons with this population as they just are getting experience with 2014 and 2015 about how they utilize health care. one of the studies we site in the report about how they tend to be sicker and use services and have chronic conditions compared to populations that already had insurance. that's what some of the insurers

are starting to find with the population on average that's been alexandered with the marketplace that's what our stems show. >> i did find in my notes details of age and gender study. in aggregate, this is for 2012. this is for an older vintage of historical data but females spent approximately 23% more than males on per capita spending basis. the only category where males spent more than females was for children 0 to 18 and they spent 9% higher per capita. >> okay. i'm just going to wrap up with a couple comments. the first i make every year, which the data presented here are really critical, but a lot of the policy questions, why did something change, what was the effect of this policy change, those are sort of the stock in

change we publish in health affairs. those requires aggressions and other techniques that are not what the purpose of these estimates are. i don't want to detract. this is raw material. but an elects require time different from the ones that the health expenditure team uses. so please continue to look for that material from us as it evolves. just remind you that in the press release there's a link. it's not to the abstract but the entire paper. we have flash drives with graphics. please, 2:00 p.m. embargo, please honor the embargo, this is under embargo until 2:00 p.m. today. thanks again to our colleagues at cms for terrific work and effort we put into making very complex data as understandable as possible. thank you for joining us and we are adjourned.

today a look at the challenges for the incoming trump administration. panelists include former white house chief of staff josh bolten and staffers from george w. bush and obama administrations. that's live at 3:00 p.m. eastern on c-span. >> abigail fillmore was the first first lady to workouts the home teaching in a private school. her love of hair styles and pink was marketed as mimi passenger. they sold clippons to mimic her

style. jackie for white house historical association. nancy reagan as an actress saw her name on suspected communist sympathizers. she appealed to screen actors guild head ronald reagan. she later became his wife. these stories featured in c-span's first ladies, c-span historians on 45 iconic american women. the book makes a great gift for the holidays giving readers a look into the personal lives of every first lady in american history. stories of fascinating women and how their legacies resonate today. share the stories of america's first ladies for the holidays. first ladies in paper back published by public affairs is now available at favorite bookseller and will as an ebook. >> the u.s. council object competitiveness recently host add forum with corporate executives, journalists and politicians about the role federal and state governments play in advancing u.s.

competitiveness and future of manufacturing in the u.s. first we'll hear from kansas senator jerry moran. >> ladies and gentlemen, please welcome back to the stage council president and ceo, the honorable debra smith. joining her to discuss impact of policy recommendations over the years and set agenda for future insights former chairman and ceo of international dr. craig a barrette, president emeritus georgia tech and secretary emeritus of smithsonian institution the honorable wayne cliff and dr. william goldstein. [ applause ] [ applause ] thank you. i hope you all like or quick panoply of council. we couldn't highlight everything but gives you a snapshot of where we've been and what we've

been doing for the country. we have a wonderful guest that's arrive. jerry moran, senator there kansas who is the co-chair with chris coons from delaware on the democratic side of bipartisan senate caucus. senator. >> deborah, thank you very much. i just came from squawk box interview where i must not have been saying the right thing about me stiffness because in the middle of the interview, breaking news, president of coca-cola. i listened to the news and thought schurrle they are bringing me back. having failed to have full time in front of squawk box audience i decided to visit with you and tell you something i would have said had i had more air time this morning.

senator coons and i are honored to serve in capacity trying to bring members of our congress and staff together for purpose of promoting an agenda that is about competitiveness. as i was explaining in that interview, competitiveness is a nice word for jobs, for better jobs, for higher paying jobs, for job stability, an opportunity to find policies that create the chance that more americans can achieve the american dream. and so while competitiveness might sound like something technical or policy oriented it's more basic to the country and economy. let's make the opportunity for every american real and let them have the chance to pursue it. so thank you for your efforts. we will continue to try to find ways to work together. i am hopeful. i look at elections as similar to new year's day when we create

our resolutions. a hope good things happen in the future. senator coons and i are committed to helping our colleagues, whether republican or democrat, finding the sweet-spot in the agenda that increases the chances the united states will remain competitive in the global economy, that certainly means front and center for congress and administration in the future, the tax code, repatriation, the regulatory world markets, technology advancements, education and training workforce that is highly motivative and innovative. those things matter greatly as we try to make certain good things happen in america today and in the future. one of my agendas as i came to congress mostly related to coffman foundation in new york city, foundation on entrepreneurship. how do we restart opportunities for someone that has an idea they developed in their backyard or barn, take it to market. become a country of startup businesses that our country historically has been.

my pleasure to be with you today and thank you for efforts to make sure congress has an agenda that will achieve the things that are important for our country. again, thank you for the efforts. we look forward to working in 2017. >> thank you so much. >> well, i think many of you know that innovation and technological leadership and the nation's position in research and development has really been that the dna of the council on competitiveness since our inception 30 years ago. we did some of the first critical technology lists. we had a great report that our first distinguished fellow eric glock who just sadly passed away did on reinventing r&d. and the list continues. i wanted to start this conversation about with three tremendous leaders at the forefront of technology throughout their careers, about what really was the genesis for

some of the work that you all did with the council. i might start with you, wayne. as our vice chair for industry and even before, when you were president of georgia tech, you were really doing some very innovative things on the regional front and then ended up leading one of our major projects on regional innovation clusters. tell us a little about that story and the impact of it for the country. >> thank you, debra. again, congratulations on the 30th. i think when i was president of georgia tech, i knew i had a lot of things to do. one of the things i felt lacking was connection between what we're doing in the context, national context. so i talked to some people who i felt were friends and mentors and they all thought council for competitiveness was where things really happened and you brought together industry, government, labor, and private industry to do things together. so i had to explore that myself. it was a real positive

experience for me. a lot of time invested in the council and every bit of that came back to me, more than i invested in it, then had the wonderful opportunity to work with deborah and to be vice chair of the council. it's been continual, all these great leaders that continued to add to our national fabric on competitiveness. we had the great honor to coach here, national innovation initiative in early 2000. i think people forget about what led up to that. the lead up to that is a very important part of the work on the council. michael, who we saw last night on the video, worked on the cluster study. we did a cluster study in atlanta. it was a seminal study. it helped atlanta for the first time understand its economy and how to redirect it so you would get the desired result.

the council has been important to me personally. it's been important to my institution, which is obviously actively involved in these issues and also very important to atlanta and all of georgia and that region about, you know, making it successful and anticipating what's coming down the road. >> i think in that study also, you really presaged a lot of leadership atlanta has across many sectors of the economy, from logistics moving into biotech and health and nano and so many others. did you think at the time we had a vision into the future that your city was going to be the dynamic global city it is today in these critical sectors of the economy that were just beginning there? >> not really. i don't think anybody can anticipate these changes. atlanta had good fortune to have good political leadership as well, good civic leadership. we described this.

the council works on national policy. national policy set the framework that allows you to succeed. that's where the federal government's role is. but innovation is local. innovation is regional. we were very fortunate to be rebuilding something called technology square, which we thought would be a great way to get corporations and government and industry working closely with the institution and with the city. with the help of a lot of people it worked. my successor, bud peterson, has done a terrific job with that. today that area is full of not only startup companies but major companies with research components locating their health care, retail, doesn't matter. logistics, they are all there. it really has been a core of the development of atlanta and the technology innovation sector as it's called, the council was -- you were there many times. you know, i think this idea we -- that everyone could work

together was not really understood until the council got involved. >> of course we were so fortunate to have great leadership dwayne ackerman chairman of the council when he was chairman and ceo of bellsouth, he was your partner in all that. craig, you've been in technology through your whole life, having come out of stanford and go on to lead one of our greatest high-tech companies in the world, intel. but you've also been passionate about the investments and basic research and people and s.t.e.m. and everything. we were so honored when you and bill brody, when he was at john hopkins took on leadership to move our national agenda on innovation forward. move national agenda on innovation forward. just share with us a little about the history and why do you think back in 2004 or 2006 we had a moment where we could jump-start and lead to america competes legislation on innovation capacity. >> i think two things came together in that timeframe,

deborah. again, congratulations on 30 years. the beauty of the council is it's a continuing entity. a lot of these programs and national reports rising above gathering storm, we talk about they appear, but then there's not a whole lot of follow-up. the council gives follow-up. innovation in my mind has always been driven by a couple of key things. some of them are in your report card. it's really driving basic r&d budget, federal r&d budget, you know, just i'll paraphrase my assessment of where we are in each of these as we go along. federal r&d budget we've been crying to double that forever. it doesn't score very highly on your report card. put that in perspective, the

company i worked for intel has a way bigger r&d budget than the national science foundation and probably the department of energy combined. one company. so it's critically important we've been pushing that. the other one is education. you heard people talk earlier today, michael, very eloquently about education. i have a very simple model there, which is the earning power per capita gdp in the u.s. is going to depend on the average level of education of the workforce. these are the results of our k-12 education came out this week. we are mediocre to bad in all three categories. even though we have the best research universities in the world, the fraction of our folks with postgraduate -- post secondary schooling, we're now something like 15th in the world and we used to be number one. and then the government

environment set up to promote innovation. you heard today talking about tax rates and things. sometimes i think it's important to look at the big picture on all of these, which is what we try to do in the council. don't get excited about little line items where you have success where if you're failing overall mission you have to admit you're failing. maybe we'll get a corporate tax simplification incentive to do things in the united states out of this administration. we've had disincentives. give you a simple example of a disincentive. intel builds these massive manufacturing plants to make silicon chips. at present value one of those plants in the united states or in a low tax environment is well in excess of a billion dollars different. doesn't have anything to do with

labor rates, has everything to do with u.s. tax code. it's very difficult to explain to shareholders you're going to take a billion dollars away from them just to put the plant in the united states. we haven't succeeded in that area at all. i'd look at those three categories. education, we're not succeeding, folks. building federal r&d we're not succeeding. the current incentives structure to do things in the united states, we're not succeeding. a good message to give the president. >> i want to come back and talk about infrastructure and education. but on the education front, in your post ceo life at intel, you've done some amazing things, doing some innovative pilots around the education in the state of arizona. do you think that some of these new ideas and opportunities that you're incubating can scale up, or do

we really need to be thinking more at the local, state level to get a handle on some of these education challenges? >> well, i mean, you look at this whole issue of raising standards in common core, backlash of the federal government associated with that. education has to go on at the local level, driven at the local level, but there's some very key aspects of that. take washington, d.c., good example. we're in the middle of it. it's historically had worst k-12 system in the united states, maybe in the world. it is now the fastest improving educational system in the united states. the reason is that half of the kids are now in alternative education charter schools, not public schools. charter schools are competitive, innovative, got to raise level of public schools up. without that competition, d.c. would be zero in education. i'm a big fan of competition wherever you might be. it makes the whole system better. we've had great results with

charter schools and they are absolutely scalable as long as the local state government invites this alternative competition in and supports it. there's still eight or nine states in the united states that don't allow charter schools. >> we're seeing arizona an innovative state on many front in terms of education. >> arizona early adopter of competition the public school system, roughly 16, 18% of the kids in arizona are now out of standard public schools and in public charter schools. the public charter schools are kind of like the top 20 schools in the state. so competition works in that space. the entrenched beaurocracy doesn't like that concept but it works. >> so bill, you're a physicist. so i know if we were having a glass of wine, i wouldn't

understand three-fourths of what's going on in your mind as an advanced physicist. i do know, of course, you are leading one of our great national laboratories in an unrivaled system of labs in the department of energy but also in other federal agencies. innovation and rapid technology development to solve big complex national missions is at the heart of what you're doing, but you're also leading the forefront in advanced computation and super computing. how do you really see in your role as a lab director, you know, the value of your participation with all of us here in the council and what are some of the thoughts you want to share on this critical component of the national labs in america's innovation ecosystem? >> thank you, debra. first thing i'll share, you're doing better than me understanding what's going on in

my mind. also, just note that looking at the distinguished members of the panel, i've seen the only one without a former or emeritus beside their names. i may have more of a historical perspective on this than others. but i would like to add my congratulations on 30 years of exceptional service to the nation of the council on competitiveness. i think from the point of view of national laboratories, it's notable the council is the only forum that i'm aware of that brings together the system of national labs with industry, with labor, and academia, the only organization period. i can't think of another place where that happens. and in doing so, the council has been to common cause. the system of innovation in this

country from knowledge creation to application to scale up to commercialization, again, a remarkable accomplishment. in fact, in some sense, the council is the bipartisan policy equivalent of silicon valley in that sense, if you will. national labs, i think, are a critical ingredient for this. in fact, earlier, there was talk about capitalizing on the nation's competitive advantages. i think that the system of national labs that exist in this country is without question one of the competitive advantages that exist here and that can be brought to bear. in fact, we find increasingly other nations looking to the national lab system here in the

u.s. as an exemplar and looking for ways to reproduce it. i've seen that personally in places ranging from brazil where there's an initiative under the council that we've been participating in and also including china, which is looking very explicitly at the u.s. for how to adapt or how to develop the kind of national lab system that they see as so successful here. the mission of the national laboratories and not to mention the 25,000 scientists and engineers is to perform long-term research and development in the national interest, driven by applications, though, in energy, national security, environmental stewardship. it compliments and is fed by academia's more curiosity driven approach and can help to bridge a potential, in fact, often

realized gap between basic research and commercializable innovation. as you, i think, have noted, national labs being government owned contractor operated entities also bring public sector explicitly into the mix and open the door to i think a much richer set of public/private partnerships than are possible otherwise. the capabilities that are offered by laboratories are publicly financed, publicly funded to serve enduring national science technology needs. my laboratory lawrence livermore has as it's primary mission to provide the technical basis for ensuring the nation's nuclear stockpile remains safe, secure and reliable in the absence of nuclear testing.

however, the facilities and not to mention the know how that's required to do that, which includes the most important lasers in the world, as you know, debra, the most powerful computers in the world are available for a range of national needs and national missions. explicitly among them is the mission of transitioning technology and know how from the national laboratories to the private sector in the service of actually enhancing national well-being and increasing national competitiveness. this role, by the way, is explicitly recognized by department of energy. it's one of the missions of the department. i'd say the council has had remarkable success over the years in leveraging opportunity represented by its recruitment of the national lab into its circle. examples include initiatives on high performance

computing, which was so successful. here an example, by the way, of where i think council and laboratories played an important role in moving things forward for the nation but also in what that initiative did for the laboratories and us. recently in the area of advanced manufacturing where a very productive, explicit partnership has been formed by council of department of energy and national laboratories to make available the most advanced new developments in advanced manufacturing and 3d manufacturing. in particular, to the private sector, and in particular to the entrepreneurial sector. so i think those are some examples, and general how the laboratories have enhanced, i believe, and played a role and will continue to do so in the future. >> thank you. i would just add that you know,

one of the things i'm committed, going forward in the council, is to really deepen the relationship between our labs, our companies, and our universities, and i know there's some congressional barriers to some of those things, how money is appropriated and things, so that's something we want to work on. but you know, you've brought up manufacturing. of course, at georgia tech and under your leadership, you were one of the early universities having major infrastructure and research on manufacturing, and nanotechnology and the frontiers and craig, i mean, intel has been the innovator in the electronics manufacturing, and continues to do so. so let's talk a little bit, you know, from your perspective, about the future of that, because just looking at our time, i want to talk a little bit about that advanced manufacturing enterprise and what it means for our competitiveness, given the automation and all the transformation under way, and then have you all be thinking about what we should be doing for the future, the next 30

years. so craig, you talked about the cost and the scale and scope of the infrastructure that intel has in each generation of fab. there's a concern right now that perhaps we don't have enough of the next generation in america, so tell us a little bit about how critical this manufacturing technology enterprise is to the nation's competitiveness. >> well, it's critical. i mean, ultimately i think if the u.s. wants to have a healthy economy and growing economy and growing jobs, you need manufacturing here in the u.s. i mean, the facebooks and the googles are great, but you don't employ that many people in those companies and you don't -- googles