saturday, what we've seen with the five star movement there the so-called pirate party in iceland, the second largest party in iceland, use of the internet by the prime minister of india. what we are seeing here is ability of parties and nontraditional politicians to go over the media and to run their campaigns through different means. >> thanks for having us. i appreciate the opportunity to have the conversation. i think the part i agree with most from nate there is the credit goes to the candidates. every campaign is a reflection, not just of the candidate as a person and their message and what they have to emphasize but their personality and management style and leadership tendencies

and all of that. those amount to a band of outcomes that affect strategy and personnel. one of the best parts about working for barack obama, his leadership style and personality allowed for a very special mix of the types of things you need to run a digital campaign and a big grassroots campaign really well. there is part of obama that is a cautious, rule-following very deliberate person who wants to get things right and be deliberate and measured about things. there's also the, what i do oppose is the dumb war community organizer who wants to shake things up and do something differently. i think those aspects of his personality and biography were reflected in the campaign. and in a kind of creative tension between operatives who

came from politics and a bunch of folks who came a little bit from the outside. i was 25 when i started on the campaign in 2007. and there were a bunch of us who were more of the insurgent side of the party of the discipline of the profession. and we managed to all co-exist together and put something together that was consensus-driven but in service of a different type of way of campaigning and a different approach to politics and the other campaigns were taking in that first race in '08. if there was a band of possible outcomes for obama, i think we operated high near our ceiling. now that being said, had we somehow lost in 2008, i would probably be in an institution somewhere because i know where we could have raised that incremental $100 million in 2008. we didn't think of things fast enough. we didn't innovate fast enough.

we were building the team as we went there was more we could have done there, but we did enough. and so when you think about the 2016 campaign, i actually think donald trump operated from a digital and technology perspective in the bottom half of potential outcomes. when you look at the campaign, for all the things you're pointing out, they did get started late. they didn't bother building much of that during the primary. what we know is like compound interest, the learnings and organization you put together gets more effective and more intelligent and more powerful as you go. in the end for all the hats and christmas ornaments with the "make america great" again on then, donald trump will raise as much in small dollar money than mitt romney, probably less. we'll find out with the last

round of fcc reports. we need to be, relative to obama who is in both campaigns up over three times as much as that. we need to be careful about what we are actually thinking about when it comes to the campaigns, specifically in the digital thing. from the outside there are a few things to look at. innovations in 2004 and 2008 and 2012 were very much within the campaign apparatus and control. that was one of the errors on the romney campaign. they had outsourced big parts of that infrastructure to the rnc and super pacs, so it didn't have the ability to control and innovate in a disciplined way. for the most part, those innovations were mostly around taking big dollar donations, and there wasn't this other set of weaponized outside forces the way there was in 2016. there's the wquasi-media source,

the fake media, the masadonian kids and robots and hackers. the actors going in trying to take down an organization through illegal activity. that is something we saw in the other races, but fought back and were able to repel. that became a much bigger operation this time. i think the other thing that's not mentioned enough about the digital campaign this time is that the weaponized outside forces, the hacks, breitbart, the fake media, but there's also just the machine sgrags of abuse online that i think had a toxic effect on the ability of the electorate to have a conversation with itself about the campaign. i think that is obviously related to the fake news, the

breitbarts and all the rest, but it's also related to the big tech companies being asleep at the switch and not necessarily enforcing what they would otherwise in terms of their policies about how their platforms ought to be as a public space on political content. i think that's something that was really unfortunate and not something that anybody had a good answer for outside the platforms, other than talking about bullying and all the rest and trying to appeal to the better angels of our nature, but the folks who had the ability to drain the swamp of abuse in the political conversation online, which was a very big force in this election chose not to, and choose not to currently. we are starting to see some of those reforms, but there does seem to be a level of denial. looking at the innovation across the different campaigns, you saw incremental moves from both

candidates and party in the general election. there's lots of things to nerd out on that. i think the big changes were in the outside of the campaign this time. >> echoing what joe just said. a lot of this discipline comes from the top down. at some point tech evolved and evolved and evolved, as to become part of the campaign. what i mean by the top down was, if you think about the obama social media program i had the honor of working with under joe in '08, we were creating the rules as we went. what we created was, we wanted these to be embassies of the campaign. we created sort of rules. if you said hateful, xenophobia,

racist, we kicked you off our platform. if you said things about our opponents, we kicked you off the platform. we gave you factual answers and links so that you could find the truth. the team created of "tell us the truth" or "fight the smears" campaign to actually do search engine optimumization. this year we saw the exact opposite. the ugliest corners of the internet being elevated by not only the candidate, but being talked about in the media and by everybody. instead of, we're only going to use social media to get it positive, social media has grown up, the internet's grown up and now we are elevating and retweeting the darkest corners of social media in a way that is not good for politics in my

opinion. as far as technology, i disagree with nate here on the panel that technology keeps evolving or i would be standing up here talking about how barack obama is a myspace guy writing books about how great myspace is. we are humbled on the tech side to figure out what's working, what's not and shed what's working. there was a race like there is -- if you go to south by southwest conference, it was the newest tech. now it's a bunch of venture capitalists and reporters looking for the new tech and there is nobody in tech working these conferences. you saw stories of this is the periscope election. this is the vinyl election, the snapchat election. people were racing to call it some new tech thing versus the

most evolution of tack was is more people on mobile, 50% of bernie sanders campaign came from a mobile phone. 42% of all of our contributions came from a mobile phone. is that sexy and is that headline-worthy versus it's the platform that you never heard of election? probably not. you saw this rush to be that. instead, look, the bernie sanders campaign we were scrappy. we didn't invent a lot of tech. we used a lot of tech. we used blue state digital, facebook. i disagree with you on facebook. we spent more money on facebook than hillary and were jumping up and down hillary wasn't spending enough money on facebook. [ inaudible ] >> it's incremental evolution and how it was set up.

i've got to give credit to david axelrod for allowing tech to sit in the right place at the campaign at the right time. everybody got paid equally. media consultants got paid equally. pollsters got paid. it was about winning which meant if i had a cool scrappy idea about ways to use something, and i could bring it to joe and we would do it and do it quickly. it wasn't 22 approval processes like mitt romney's campaign. it felt authentic and real. we were burning up laptop computers and leaving them on tarmacs in the rain doing live stream video. maybe the trump campaign did something different with live stream. i don't see it. the dodd campaign was doing live stream video.

>> i agree with all of that. i left bernie sanders for time reasons. >> he gets left out of all these meetings. it's fine. >> i was really just comparing the clinton campaign and trump campaign. bernie sanders, yes, not only the way they use facebook but fund raised also broke all kinds of records and methods. i don't disagree. i hope i wasn't minimizing the importance of technology. i was simply saying despite spending money on technology, having a sophisticated digital operation on the democratic side, nevertheless the sort of ramshackle organization donald trump was able to put through was successful. >> what does it say, 2016 barack obama showed up south by southwest?

>> i tend to agree with scott's analysis of this particular conference. even though that's the price of success of growing any kind of thing like that where people begin to come looking for the things that you're known for. i think the great thing about tech with the campaigns and this is more true on the democratic side, i didn't really perceive the republican, the crowded republican primary as a petri dish of innovation where people were trying out these different digital tools, techniques, approaches, structures, the rest. like it felt -- donald trump was doing something obviously very different which could be characterized as nothing. but that it wasn't really a different set of innovations. i think one of the unfortunate things about the democratic primary really just being these two big operations was that we didn't have the opportunity to

see a lot of different models play out behind different candidates. so if elizabeth warren had been in there, if joe biden had been in there, if a couple more folks had been in there, the campaigns would have looked and felt

>> and from a talent perspective, the barrier's never been lower, at least on the democratic side, a real sophisticated, meaningful campaign to be put together and play out as an experiment in leadership and organizational culture and innovation. i feel like we maybe missed a little bit of that opportunity by having a pretty small primary field. >> i want to pick up on something talked about earlier in the context of journalism. that's not getting too much into the trees of data and analytics. in that context.

and this ties into what you talked about, joe, as one of the things the trump campaign did was to outsource a lot. did the clinton campaign overlearn some of the romney mistakes, spend a lot of time developing their own model, their own tech nonology, the ad model, the more of computer science. and then have a model that allocated resources to other states and relied heavily on that model? >> ultimately, a campaign -- i learned this from down the road at american university is about

three things. that's time, people and money. ultimately, you're supposed to figure out the right equation of time, people and money to win. that's it. and so if you're able to talk to elders in the field and people in wisconsin, like a good friend of mine theresa velmain and chapman, they worked clinton '92, obama '2008 and 2012, and they're telling you there's a problem. you listen to your labor unions and they're telling you there's a problem. so i've been very clear in my assessment of this as saying, all the data and all the models and everything else in the world and the best tools, the best technology in the world don't mean anything if you can't actually have a real message that's connecting and resonating with voters. the models may have been genius and right and accurate, but they

weren't listening to voters. this is where the art and not science of campaigns comes in. as whether you should be building these tools inhouse or out of house, again, i go back to the original sentence of mine, it's about time, people and money. on the bernie sanders' campaign, we didn't build a csm system. it cost us $500 off the shelf to use his tools. that grows the bigger the list we get. eventually you buy your own servers and deal with the other stuff. that's out there facebook events tool is a powerful tool. if i had that tool when i was doing anti-war organizing, i wouldn't have done necessarily a website. i would have used facebook events. in time, people and money, i don't know these campaigns should be building warships and trump may have stumbled into that because he didn't have the time and the people -- clearly had the money -- didn't have the

time or people to build his own warship. >> let's talk a little bit about where things go from here. in some respects, campaigns don't change. abraham lincoln wrote a manual in 1840 that said states must be well organize d could be brough to the polls, divide into small districts, make a perfect list of voters, keep a constant watch on the doubtful voters, have them talk to by those in whom they have the most confidence on election day, see that every whig is brought to the polls. it's the same today. how does technology change that? what do you see next? what are going to be the innovations of the next cycle? pull out your crystal balls.

>> the great thing about technology and the sort of digital campaign and culture around the mideast from the campaign's perspective, it's a way to bring those things to life to do those things better, smarter, more efficiently at a bigger scale. i think that's going to be the question. i think the one that sticks out is that they hear from whom -- they hear from in whom they have the most confidence that. notion of trust and how people are willing to stand behind their candidate, the issue they care about and their role in the election is on the table from a civic perspective. the rise of abuse online and in the new york city subway is troubling and undermines the civic and political fabric of people's willingness to participate in campaigns in a

meaningful way. i think what we are going to see hopefully, even before the next presidential campaigns get started, is more politicians and more organizations working to build and reenforce that trust and asking more ordinary citizens who are concerned about the future of the country and issues they care about to take up and spend that social capital that they have in their neighborhood, in their family and their work place, and try to be out there standing for something and that the equivalent thanksgiving conversation next year and the year after that and the year after that is one where people are having discussion and hopefully influencing each other as opposed to the kind of let's just agree to not talk about it detente that happened at so many tables this year. >> where i see this going, i think there's a couple of things we can learn from the trump

campaign that are impressive if you want to tweet out emotion at 3:00 in the morning -- i don't agree with the tone or content of his sort of obnoxious ways, but the emotion, the raw emotion at 3:00 in the morning, in 24 hours to change the entire conversation during drive time is something impressive i urge every democrat that wants to be an opposition leader to be doing right now. i'm watching a lot of democrats with millions and millions of followers as assets not actually getting in that game and showing rage the way you saw joe biden earlier today talk about helps real emotion around leaving office, and we felt that. there were people in the audience tearing up. i would like to see more of that online.

evolving online ways trump did by spending 50% of the money i think is what you said roughly, is something very different. bernie sanders' campaign, a much as we did online, our spend was not to that extent. our spend was around 30% online. google and facebook and folks like that are saying, it depends whether it's going to be 20%, 30%, 40%. corporate america you're seeing spend 50% in branding and persuasion type tactics or mass communication. the final thing is i do think that the increase of ad servers and ad technology are growing. so people that used to say early money is like yeast, early ad money is like yeast. and that all of these things work like compounded interest. so the fact that bernie sanders when he first launched gave us enough money to do acquisition to then go and get repeat donors

of young voters, to give us $20 at a time was super important and is only going to grow more and more important as the ad technology quickly evolves. >> as i said, the trump campaign says they did 50% digital, 50% traditional advertising. we'll see. one of the problems in studying this is we don't have real good disclosure where money is spent outside of tv. we may never know. but i think the trends are quite clear, given how much money was frittered away either by jeb bush and his campaign or of hillary clinton on television ads that there's -- you know, the generational shift under way in campaigns. those folks are going to get older and more senior in the campaign. they are going to dominate them in four to eight years. we should expect that trajectory to continue. this sense which the boundaries

of the campaign are disintegr e disintegrating and how the, whether it's the platforms or media organizations in trying to figure out sort of more broadly how to integrate all those other kind of gray areas that are relevant to the campaign, if we are fighting them, the last war next time that that's where you're going to see the action. very few people are going to have the kind of immediate name recognition then twitter following and then ability to get media attention than donald trump did. t the $2 billion and free media was just in the primaries. it's probably double that if you look through the general election. very few candidates who just announce are going to be able to garner that kind of attention. the playbook, the loose playbook is there how you're going to try to use these new digital tools to get the attention you need in order to run an effective

campaign. >> let's step back. we should take up one more topic then questions. let's step back for the nuts and bolts. talk a little bit more about broader impact on democracy. 20 years ago the grateful dead lyricist wrote, we are creating a world where anyone, anywhere may express his or her beliefs no matter how singular, without fear of being coerced into silence. you brought up sort of some of what's going on in parallel around the world, joe. we heard a lot of discussion here today about some of the negative impacts of social media. to what stent do you see technology to blame or not to

blame for those challenges to civic discourse and to civility? >> as i said before, i think the platforms were so much of the discourse is taking place have more control than they are exercising over enforcing a basic standard of decency and their own codes of contact they already have. i think that's something that needs to be addressed. i also think it's important to note that more people voted in this election than any other one. so i think that's in spite of really concerted efforts by people to prevent groups from voting. let's just say, by republicans to prevent people from voting. right? sorry. so i think that's an important reality. so there are some silver

linings. things like automatic voter registration, the initiative that just passed in alaska is going to provide a really fascinating set of data for the academic world to look at the effect of brard voter registration on turnout. my hope is that the peculiarities of the electoral college and the emnity will hopefully become a focus of attention but become more of a bipartisan and less polarized issue. i'm not sure what the political path for that is, but i think that that's a key aspect and i'm encouraged by the fact that the fight is on on those things and we are seeing some progress on it. it's tough times out there for

civic life. the politics isn't helping with that. what i can see from where i sit, and we work with progressive and democratic advocacy groups part of the time, we also work with 501c-3 charities like museums and universities, but also folks like partners in hell, the u.s. fund for unicef, things like that. what we are seeing in the data across hundreds and hundreds of these organizations, both the political and advocacy groups fighting for civil rights and justice and everything else are seeing a big uptick as has been reported in the media, but also the 5013-c charities historic giving tuesday totals and end of year fund-raising. while the social media scene can be one depiction of civic life that feels like it's a bit in the ditch, what we can see on

the back end of the data is that people are sort of sitting bolt upright as a result of this election season, and in the aftermath are deciding to give to on the progressive side the causes they believe in but to folks they think will be at the front lines of whatever the policy consequences of this administration are. that gives me some hope. >> sounds like your wheel house. >> your question, i took, was where is this technology taking us as a democracy many? to go back to earlier from the earlier panel, it's unmediated democracy or the old mediators aren't there, whether talking about political parties or media organizations that is a very different situation when a candidate is able to talk to his twitter followers than when they had to talk through walter cronkite or pay money to get air

time. i think that has a lot of troubles consequences which we have seen. while there's always the utopian view, powered people, everybody has an equal voice, equal megaphone. the utopic side enables the racist fringe to have a greater megaphone, as well as the fact that democracy needs mediators, that you need someone to aggregate interest, you need political parties to effectuate policy that 300 million people yelling is not a way to run a government. the way i think about the consequences of the, the unique consequences of the move toward internet democracy, it's about

the effect of anonimity. one of the consequences, and one of the things that enables a lot of the hateful rhetoric online is the fact that unlike if you were to run a television ad to a mass audience, because the enimity twitter and other platforms allow you, you don't have to take responsibility for the speech. it facilitates the hateful language we've seen. sovereignty or territoryality when we are principally looking at television the way candidates are communicating to voters, you didn't have to worry about the fact that one of them -- only in the manchurian candidate sense would you worry there is foreign influence. now you don't know the origin of

internet communication. it could be coming from anywhere in the world. and third gets to the fake news, that virality is about the political currency. it's not about truth, but what's popular. the key fact, you try to get your message to get as much resonance and popularity as possible, and this really is the problem for the platforms which is that if you listen to what facebook says, when mark zuckerberg talked about saying fake news he didn't think was the problem, he said our purpose is to have an engaging experience. to promote engaging, a meaningful and engaging experience. that has nothing to do with truth. meaningful, engaging experience could have all to do with hearing all the kinds of signals you want to hear. same is true for search engines. their currency is relevant. figuring out whether the message is and the information you receive are relevant to other

characteristics about you, that has nothing to do with whether it's true or not. that's where we've come which is different than when the traditional media institutions were the moderators and political discourse. >> thank you very much for that. we have time for only one question from the audience because we have another part of the program ready to go. but it says because of its universal accessibility, social media is used at a high rate by people with disabilities. voters with disabilities are 36 million voters, but turnout at only 42%. do you see campaigns using social media to bridge this type of voter gap in the future since we're trying to look forward? and this should be a fairly quick, but i'd like your views

on this. >> it's an interesting mention. when i was doing social media platforms originally for obama, it was before facebook allowed you to have you need a dot-edu addre address, could only have a certain amount of followers for a presidential campaign. is there a platform called disaboom, the disabled americans social media platform. you could actually have intelligent conversations with people on these unique niches, niche-based platforms. we had barack pllack planet was largest african-american social media platform with over 500,000 followers for barack obama before any of the other platforms. i think you need to oregon and talk to niche-based communities in unique ways. now all these other platforms

have died and it's all on facebook, facebook algorithm or reaching or having a platform or showing, not telling, and doing videos that address these different communities and different niches is super important. it was almost easier when every community had their own platform, but now through much easier advertising networks that i talked about earlier, you can engage these communities. i think the biggest problem with this election is not that the technology is not there, it was, again, using a message and engaging these communities. the one thing i'd say different on video, whether it's viral versus engaging, is that, you know, if you're trying to organize people in iowa, you don't care if the video's got 200,000 voters on it. you've got 15,000 views in iowa.

thinking about engaging and thinking about views is way more strategic a lot of times than thinking about virality. >> thank you very much. i'd like to express our appreciation for this panel. thank you. and statisticians

with the group presented their findings at a news conference this 50-minute event was hosted by health affairs journal.

>> good morning, i'm editor in chief of health affairs. we are pleased to be releasing a paper that shows the national health spending for 2015. this is part of our ongoing partnership with cms office of the actuary. they produce, as you know, the gold standard estimates for historical and projecting in health spending, disaggregated along a few dimensions you'll hear about today by pay or 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 material is embargoed until 2:00 p.m. today. please honor the embargo until 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 changing 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 national health statistics group in the office of the actuary at the centers of medicare and medicaid services. michael hartman, statistician in the office of the actuary. they are joined by aaron kaplan in the office of the actuary and benjamin washington, economist also in the national health statistics group.

they are here as resources, as i know are other representatives from cms. let me turn over to anne to begin presenting the results. >> thank you, alan. thank you all for coming today. my name is anne martin here with other members of the national health expenditure accounts team to present to you the results of national health spending in 2015 and trend set we will discuss today highlights some of the important points seen in our article. it will be presented as a health affairs web first at 2:00 p.m. today. also at 2:00 p.m. all the data will be presented on our website. so 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 $9,990 per person, from $9,515 per northeperson in 2014. overall rate of growth 2015 was 5.8%. this was faster than in 2014 when spending grew 5.3%. in 2013 when spending grew 2.9%. it was also the highest rate of growth since 2007 or 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 are 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 increased at similar rates etch another from 2010 to 2013. then in 2014 and in 2015, after five consecutive years of historically low growth, health spending growth began to accelerate, increasing 5.3% in 2014 and 5.8% in 2015. at the same time, the economy grew 4.2% in 2014 and 3.7% in 2015. in this divergence in growth rates for the two-year period of 2014 and 2015, occurred outside of a recessionary period, and can be attributed to legislative changes closely associated with coverage expansions under the affordable care act.

so this graph shows national health spooend turs as a share of gross dome stek prstic produ. in 2010 to 2013 spending was relative flat. however, as a result of health spending increasing faster than gdp in 2014 and 2510, as he would saw in the previous slide, health spending share of the economy increased from 17.2% in 2013 to 17.4% in 2014 to 17.8% in 2015. over the 55-year history of the national health spooeexpenditur accounts, largest increase in health spending share of the economy typically occurred around periods of economic recession. the 0.6% point increase in health spending share since 2013 which occurred more than five years since the end of the last

recession coincides with major health insurance coverage expansions under the affordable care act, particularly through marketplace health insurance plans and the medicaid program. it also coincided with rapid growth and prescription drug spending. so on both 2014 and 2015, the faster rate of health spending growth and the increase in health spending share of the economy were largely influenced by increased insurance coverage, rapid growth in prescription drug spending and increased yut sga utilization of services. coverage expansions that resulted from the affordable care act affected private health insurance and medicaid. it affected 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 2014 and 2015, primarily due into creased

spending for new medicines, particularly for the new speciality drugs such as those used to treat hepatitis c. next, faster growth in spending was also experienced for hospital care and physician and clinical services and was primarily driven by increased use in intensity of services associated in part win creath increased insurance coverage. one of the biggest drivers 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 had an overall effect on the insured portion of the population. just as a note, these categories are not mutually exclusive and therefore not additive. people can have dual enrollment and some people may have previously had insurance coverage but moved to another

category. therefore, not all who gain insurance were previously uninsured. enrollment and private health insurance increased by 5.7 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, increased 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 directly purchased insurance. it was the net effect of changes among these different types of insurance that yielded a total increase of 9.7 million with private health insurance coverage. for medicaid between 2013 and 2015, an additional 10.15

enrollees were added and 9.8 million were eligible. medicare continued to grow at a steady rate as population ages increasing 3 million since 2013. the uninsured population dropped by 15 million. the insured share increased to almost 91% in 2015. on this slide we are and in 2015 the capital hill spending grew 5.5 percent compared to 2014, so is we're breaking down the factors in the medical price and use and intensity of services. medical price growth is indicated by the blue section of f the bar. that includes the overall

economy price inflation and medical specific flight inflation. in 2015 medical prices grew 1.2 percent and that was slower than the growth when it increased 1.8 percent. this was the fourth consecutive year where it was less than two percent. the overall spending was not drip by price. the age and sex factors and that's the red section of the bars account for changes in the characteristics of the population and typically make up a portion of growth from year to year and increase by 2015. finally the use of services as indicated by the green sections of the bar captures changes in the quantities and makes the services used and that increased 3.2 percent in 2015 and was the

primary driver in 2015. this is the strongest growth that we have seen in over 10 years for the category and including before 2009 or growth and health spending was. it increased for all it breaks up among the health care services and they tend to stay constrant from year to year and in 201530 percent of all we want to hospital and that's the largest category the third was

for retail and they kointed for 62 percent of all health care spending in 2015. this chart shows the goods and services compared to 2013 and 2015. in 2015 growth was faster for all services expect for the prescription drugs that slowed. however the rate of growth is still the fastest growing among all services for the second year in a row. especially those for the treatment of hepatitis c. hospital care and position and clinical services that account for 52% in total spending. and both continued the experience upward growth driven by intensity of services. that was approached in

part with the insurance coverage expansion and nursing care pa silties however growth is driven more by increased health care spending and for residential and personal care growth was driven by increased spending for home and community based waivers. the rest of the other services were largely influenced by the insurance expansion which is mainly through the increase of health insurance and medicaid spending. so looking more closely at the hospital spending, we're showing the growth rates from 2011 to 2015 and hospital spending accelerated for the second consecutive year increasing 5.6% in 2015 to reach $1.04 trillion. the faster growth in hospital spending reflected strong growth in private health insurance and medicaid spending associated with the expansions. it's primarily seen through increased

use and intensity of services or the quantities of goods and services used. for example hospital utilization is measured by the number of inpatient days and number of discharges both increased in 2015 to 2014. price growth was less of a factor and overall hospital spending growth as it increased at the slowest rate since 1998. here we are looking at spending growth for clinical and physician services. spending continued to increase in 2015 by 6.3% following 4.8% growth in 2014. reaching $634.9 billion. this was above 6% in ten years. the faster growth was private health care spending and an increase this the use and intensity of services.

because of the enrollment growth experiences and private health insurance and including position in clinical services. in 2015 pricing actually declined by 1.1% and driven by the exploration of increases to primary care physicians. as a result the entire increase spending for physician and clinical services was due to an increase in non price factors. primarily due to coverage expansion. for retail prescription drugs spending reached 324.6 billion in 2015 and increased at a rate of 9% which was some what slower than the increase of 12.4% in 2014 but still much higher than the growth experience in the last two years. the rapid growth experience 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 and cancer and auto ill immune diseases. in addition the number of new drugs approved for use in 2015 was the highest in any one year in the last decade there's also price increases for existing brand name drugs and since 2014 double price increases were reported for 2015. i'll now turn the presentation over the mika that'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 payer. as you can see health insurance is highest at 74% of the total in 2014. this category is expanded to the right of the smaller pie where we show private health insurance as the largest category at 33%. followed by medicare at 20% and medicaid at 17%. and then va, the department of defense and the children's health insurance plan also accounts for the remaining 4% of health insurance. moving back to the larger pie on the left. the next largest payer is out of pocket spending and the expenditure accounts includes co-pays and deductibles and does not include any payments for health insurance and finally the last category, the last three categories is other third party payers and programs and investments and the last in total health care spending. on this slide we show annual growth

in spending for 2013, 2014, 2015 and you can see that the most recent health care spending trends for all payers just before and during the affordable care act enrollment expansion. with private health insurance medicare and medicaid accounting for 70% of all spending in 2015 we'll discuss the recent trends for the growth in more detail on the next few slides. before we do, i'll focus on the out of pocket spending that increased 2.6% and 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. and the increase in high deductible health care enrollment and higher cost sharing for these type of plans. annual growth has

not been higher than annual growth in the national health expenditures account. and paid by out of pocket spending. and 10.5% in 2015. and as you'll note on the slide, the va and children's are increasing at double dig it rates and they account for less than four percent of the total and didn't have much impact on the overall trend. and focussing on private health insurance we see the spending increased 7.2% to reach $1.1 trillion total private health insurance enrollment increased 2.6% in 2015 and reflects the net impacts of marketplace expansion of 2.63 million employees and increase of 2.4 million in 2015. the faster growth and private health

insurance spending in 2015 was primarily driven by enrollment growth and faster for enrollee spending. had includes continued enrollment growth in market mace plans. a pick up of enrollment and increased in most goods and services and including hospital and physician and clinical services and due in part to the new enrollees that on average may have been sicker and had higher medical cost than previously ensured individuals. looking at the medicare program we see that spending increased in had 2015 and increasing 4.5 percent following 4.8 percent growth in 2014. more than accounted for the difference in the overall growth in the medicare program between 2014 and 2015. the trends remain almost

identical and at one point six percent and one point 7 percent. the overall spending includes hospital services due to reductions in dish payments and continued decline in resubmission and increasing in 2014 due in part to spending on hepatitis c drugs and due in part to a slow down on medicaid spending on behalf of spending that reached the catastrophic threshold and while there was faster growth for nursing home care and some types of service provided and pick up in utilization for nursing home care. looking at the medicare program in more detail, in 2015 we see it accounts for 68% of total medicare spending while the medicare advantage program accounts for 32%. and as

recently as 2011 fifa accounted for 74% of spending. the increase in the medicare advantage reflects the faster enrollment growth as seen on the slide. service spending reached 442.6 billion in 2015 or 1.9% growth. the slow down is being driven by hospital, physicians and retail prescription drug spending. medicare reached 223 billion in 2016 and it's due to a slight increase in medicare advantage spending. and due to benchmarking the payment rates to be more in line of fifa service costs. turning the focus to the medicaid program we see spending increased 9.4% in 2015 to reach $545.1 billion. overall spending growth was strong in

reach $545.1 billion. overall -- it accelerated in 2014 to 3.8 percent in 2015 and some of the reasons for the acceleration in 2015 were that many states adepartmented the higher rates for some providers, medicare payments were increased for hospitals and growth for other health personal care services were strong as nearly every state took steps to expand in the home and community. on this slide we show medicaid spending in total but also divided between federal

and state and local 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 to the affordable care act expansion in the program. new medicaid eligible categories are established by 100%. state and local spending increased 4.9% following growth of 1.7% in 2014 and it's due in part to increase payments to providers. at this point in the presentation we'll take a look at the sponsors of health care spending and we give you a sense of the impact of the recent health care spending trends and each sponsor. and how it's realigned and run through a couple of examples for out of pocket spending in the national health expenditure accounts that all that spending will be moved to the household category and

sponsor where as all is split between the employer portion of the premium and move to the household category and sponsor and the employer portion of a premium that will be moved to the private business sponsor category. so with that in mind the federal government became the largest sponsor of health care up 3% from 26% to 2013. it all remains relatively stable with household and state and local shares declining a small amount in 2014. even with the increase in share total federal spending slowed in 2015 in the medicaid -- due to the medicare expansion of medicare agent that slowed in 2014. you can see on the gravel to right and spending on the

premiums from the esi population or employer sponsored insurance and due to increased enrollment and private health insurance and state and local growth was faster due to the state portion of medicaid spending which increased the rates in the expanded care in the home and community. so the summarize the presentation, we see that natural health reached 2.3 trillion and 9,990 per person and for the 2015 and the spend counted for 17.8 percent of the economy and up from 17.4 percent in 2014. and increases of this magnitude occur around periods of recession. however the 0.4% increase occurred five years following the end of the great recession and reflects millions of individuals gaining health insurance coverage in 2014 and 2015. faster growth occurred in

2014 and 2015 as the affordable care act expanded through the medicaid program and private health insurance marketplaces and to a lesser degree in 2015 an increase in employer sponsored health insurance coverage. in all 90.9% of the total us population had some form of health insurance coverage up from 86% in 2013. in 2015 growth includes intensity and accelerated for hospital care and physician and clinical services. some of this was due to faster growth and private health insurance and spending growth picked up. federal health spending growth in 2015 maintained high and increases of medicaid and enrollment and all were fully financed by the federal government. at that point i'm going to stop here and turn the presentation back over to allen. thank you. >> we know this is is a lot to

absorb but it's your turn to ask questions. the floor is open. we have a microphone. >> hi, noah with the los angeles times. in looking at the historical table of the year over year percentage growth, that's the exhibit two in the health care article. it looks like the year over year growth returns closer to what kind of historical norms were before the rescission and yet there's obviously been a huge coverage expansion in the last couple of years. can you talk a little bit about if health spending growth had returned to historical year over year growth without coverage expansion. 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? >> 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 have seen in the history and historical accounts but we are coming off of the greatest recession in history and the health spending is historically low for five years before insurance coverage started to pick up due to expansion and we do expect to see a bump up in health spending growth and we cannot parse out what it would have been without coverage expansion.

>> hi, u.s. news and world report. first of all the share in the percentage of gdp for health care grew by .4% right. >> in 2015. >> there's a point here where it's .6. >> that's over two years. >> got it. >> 2014 and 2015 are unique because we're coming off of growth that was very similar for 2010 to 2013 and they grew it. and it's the same as the economy and it was historically low. we are seeing the pick up in 2014 and 2015 that shows a distinct story coming with the 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 the times of recession? >> 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. >> i just want to follow up on this question. so i want to make sure that i understood you correctly. are you saying basically that normally we 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 have seen. we have seen the divergence during and around period of economic recession. >> so this currently does not fit the usual historical pattern? >> correct. >> and my follow up question is to confirm and this 2015 is the first year that the federal government becomes the largest payer for health care? thank you. >> i had a question about the slow down. can you talk specifically about the readmissions and i think you said the prescription drug rate changes related to it. can you explain it a little bit further. >> overall medicare spending. and in a service portion we saw

the expenditures decelerating slowing it growing at a slower rate. so a lot of that was drive by hospital spending and physician spending and driven by prescription drug spending within medicare and within hospitals in medicare and reduction readmissions which brought down spending and also reduction disproportion share and hospital payments. there's other factors such as productive adjustments and reductions and there's other factors. they're the largest ones that we mentioned. when you get to physicians there was a smaller payment update in 2015 and then 2014 but the volume intensity of services continue to grow. so it's mostly driven by the the

payment update and for prescription drugs within medicare, and it's still a really high rate of growth. the fact that it comes down is coming off of a super high growth rate the previous year. all of that high rate of growth is due to the specialty drugs we have seen in the hepatitis c drugs. and the largest part of medicare approximate spending in recent years has been the the reinsurance part of where the threshold and it kicks in. that's because they have been using more specialty drugs that get them to the point faster. and medicare pays more. so that typically has been growing at double rates in resent years. i just came down a little bit in 2015. >> because there are patient out

of pocket paying? >> it's really not anything noteworthy other than the previous year was a lot higher because of the reintroduction of the hepatitis c drugs. >> hi. i'm going to take another cut at my question here. i'm looking at exhibit five in the article, and here it seems like your parsing the factors that are accounting for growth in the current period verses the decade earlier. if i am reading this correctly, it shows that a lot of the growth in the 2004 the the 2011 period was driven by price increases where as in the two years 14 to 15 driven more by use and intensity, right? >> that's exactly what we're seeing. >> so if one were to look further back into the past, are you able to say that the use in

intensity is the largest factor driving overall spending growth? >> i can't recall offhand all the factors for the previous years but i know that in the 80s there was a lot attributed to price. there have been years where price is definitely a bigger factor. this is definitely noteworthy that the residual use and intensity driven by coverage expansions has played a role in overall health spending growth. i would have to look some of that up. >> okay. maybe i can follow up with you. >> okay. >> hi. i'm with politico. i'm wondering if you 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 that we can really drill down to in these estimates. we take a broad look at overall spending and if something moves the needle, that's going to be the top line and i don't think that 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. i know that the federal government share and medicaid grows up gradually reduces with the medicaid expansion but i'm wondering why it grew. we saw it accelerate and then by almost 5% in 2015. is that higher than to

be expected and do we know whether some of that would be part of the effect in medicaid when people are enrolling in the program that 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 that we talked about in the presentation what's going on with medicaid was in the first year expansion you have expanding coverage for the population. the second year in 2015 we had three additional states participate with the expansion but some of the other factors that we talked about earlier in the presentation that

wouldn't be reimbursed fully at 100% with the expansion, higher rates for some of the providers and increasing payments for hospitals and then there was the other personal care services. so trying to provide more care in the home and community and a lot of the shift that we have seen in 2015 is not as strongly driven by the expansion under the affordable care act and was not as strong in 15 as it was on 14. that's on the enrollment side. >> [ inaudible ] >> basically, 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 changes and encourage access to care and other measures that they're

trying to do state by state so this was one of the years where when surveyed this is where 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 wonder if you could, since there's so much attention being paid to this issue if you could help us all understand where the rebates fit into the calculation of spending and what share of prescription drug spending is retail given that there are also other places that drugs are dispensed including in hospitals like -- >> we do accounts for rebates. they're suck substracted and not include in the numbers. so if the rebates are high, that's going to bring down the spending level. if we -- we -- i'm not sure of

the exact proportion of spending retail drugs verses hospital and physician, but i think it's a majority. approximate f >> yeah i think it is is majority. we do not have an estimate of this year that is retail versus those provided on the other side. >> our data comes to us strictly as retail and then whatever is provided in the hospital or physicians office is automatically included in the spending that we report on as categories. >> thank you. yes. >> just double check. >> let's get the -- sorry. get the mic. >> make sure what our understanding is. so the growth rate for residual use and intensity is that -- so more people having coverage and using the coverage or is it that more

people also have coverage more using more use of services. >> yeah. >> is that expected in terms of the bulk of the coverage expansion happened in 2014 was it anticipated that use of services will continue to grow a year after and that happened and just in 2014? is that how things are -- >> 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 multiyear effect for that intensity keeps increasing? >> yeah. >> yeah. >> typically does it? >> it was just -- the way our methodology is constructed we take the total top spending and we get that from bls and we also have national health expenditure to play here so we have a way of

measuring crisis and we take out the age and sex factor. and the rest is intensity, so it captures other things like measure and error and 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. >> let me just add and and that -- we typically don't have expansion of coverage on the magnitude and there was a big expansion in 14 and we had a number of individuals that gained coverage in 2015 as well. that's why you see the two year affect on the use and intensity. we will hopefully -- we hope next year to release the projections of ten years and we

can look at the trends going forward. >> can you explain again how you break down or you get some sponsors, right? how do you break down the private businesses and households. i think a lot of people may look at that and think that most of that is not households but employer spending on health insurance. how do you break it down? >> well, everything is in a cross law of categories. so for households it includes out of pocket spending and portions of premiums from an employee perspective. and for the federal government, they're looked -- the state and local government is looked at part employer on this chart. if the federal government is an employer, then the employer share premiums are going to go into there. so the private businesses are

employers as well, and so the private health insurance portion is going to go into the private business there. so there's a crosswalk that we take all private health insurance premiums and it goes into the different bucket. so i think mica was trying to understand the employer and employee breakout and so the employees share would go into household and the employer would be broken up between businesses and government. >> so what i'm paying for my employer provided premiums is counted as a private individual expend thur and not counted on the employer side? >> correct. your share is in the household. >> that's a way to track it and we want to take the premium

payments that come from the household and put those into households and then as federal employees, that's the same thing. the federal share of the prem m premiums would stay with the federal government. the amount that we pay goes back to the household. you can look at the burden of health care and the measures for the sponsors of income or revenue whether it's the federal government or state and local government. you can see the burden of how spending places on the sponsors of care. >> how important are the factors of age, sex and the level in patients? >> the age and sex factors are typically the same like every year. so it's about 0.6 percent of capital growth every year. they do not change much and they

take into account the change in the demographic and population. >> yeah. in the short run they don't change very much. in the long run they will change as the population ages but it's the index that we create in terms to adjust to the different composition of consumption that occurs as the population ages. so it's like .6 of a percent pretty much per year in the short-term. >> following up on that how is the distribution changing and which is or balance is more expensive? [ laughter ] >> so yeah, we have a study and we break it up by age and gender. it's not as current that this is as we're releasing today. we have estimates through 2013 on the website. what we do is we break it

into -- you can look at children, working age adults and then sort of the elderly, 65 plus population and in general women tend to spend more per capita on health spending than males. there are several categories with children and perhaps with drugs and children's consumption of drugs and they spend more, but i canal follow up with you on that. there's a study on that, but it does not take it through 2015. approximate >> can you talk a little bit about the factors that go into explaining use and intensity? you mention that obviously the coverage expansion is driving a lot of that. to what extent are you able to say the growth in the high deductible plans maybe depressing some of that. >> well we don't have really any data on the residual use and intensity because it's just the residual. it's what is left over. so we look for supporting

information on -- to explain the trends. i mean high deductible health care plans have grown in popularity over the last few years. because of the higher deductible, people may not use as many services because they're having to pay out of pocket until they reach their deductible. it may detour, but we don't know. we can't tie it specifically to the portion of growth that is use and intensity. >> other questions? we know there's a lot to take in.

just to clarify, so agent i think -- did you say that -- are some patients sicker. >> let me give a reference to what's going on in the marketplace and the reports that have come out recently and making some comparisons with this population as they just are getting experience with 2014 and 2015 about how they utilize health care, and one of the studies that we site talks about how they tend it to be sickerer and use more services and had additional chronic conditions compared to populations that were previously insured or had insurance. that's what some of the insures are starting to find with the expansion of the marketplace, and that's what the, you know, that's what our estimates show. >> thank you.

>> i did find in my notes some of the details from our agent gender study, this is for 2012 and this is for an older vintage of the historical data. females spent about 23% more per males on per capita spending basis, the only one where males spent more is children zero to 18 and they spent 9 percent higher per capita. >> i'm just going to wrap up then with a couple of comments, first is one that i make every year, which is that the data presented here are really critical, but a lot of the policy questions, why did something change or what was the effect of this policy change, those are sort of the stock and trade of the articles we publish in health affairs, those require regressions and other techniques that are not what the purpose of these estimates are. so there's no -- i don't want to detract at all from the values of these. this is sort of the raw material. some of the in depth analytics require time and

methods that are different than the ones that the health expenditure team uses, please continue to look from that material from us as it evolves. just remind you that in the press release, there's a link, it's not just to the -- it's to the entire paper. as i mention we have flash drives with the graphics. please, 2:00 p.m. embargo, please honor the embargo, it's under embargo until 2:00 p.m. today. thanks again to our colleagues for their terrific work and the effort they put into making these very complex data as understandable as possible. thank you for joining us and we are adjourned.

this week on c-span and prime time, tonight at 8:00 eastern president barack obama and abe visit the american navel base at pearl harbor. he is the first sitting japanese leader to visit the attack after world war ii. wednesday night beginning at 8:00 a very view from house and senate hearing on 2016 on topics like the flint michigan water crisis and the wells fargo unauthorized account scandal. >> seriously, you found out that one of your divisions created 2 million fake accounts, fired thousands of employees for improper behavior and had cheated thousands of your own customers, and you did not consider firing her ahead of the

retirement? >> we remember some of the political figures that passed away in 2016 including former first lady nancy reagan and friday night at 8:00, our program continues with paris, muhammad ali and john glenn. this week in prime time on c-span. join us on tuesday for live coverage of the opening day of the new congress. watch the official swearing in of the new and re-elected members of the house and senate and the election of the speaker of the house. our all day live coverage from capital hill begins 7:00 p.m. eastern on c-span or listen to it on the free c-span radio app. south carolina governor nikki haley was honored at the 2016 jack leadership award dinner in washington dc.

governor haley was chosen as president-elect donald trump's pick. the event is about 45 minutes. please take your seats. we're going to let the servers finish the coffee and get the dessert down. we want to respect everyone's time. so i want to agree with something that speaker gingrich said while up here. it is an incredible opportunity to focus on equality of

opportunity to have doctor ben carson as the incomie hud secretary. i am fortunate enough to work en the transition team on the hud issues, and it's interesting since i have been back in the hud building over the past couple of weeks -- a place where my dad reminded me that when you walk into the building it feels like you're in the eight floors or ten floors of basement. despite that fact, the people in here care about fighting poverty and providing opportunity for all. what you witnessed up here with michelle and speaker gingrich and senator mccain was the type of events that we have been h d holding over the past five

years, and it focused on three areas, policy and then the third is economic policy. one of the things that many of you remember my father saying is that people people don't care how much you know until they know how much you care. and to introduce governor nikki haley, we're going to bring up someone who cares. at the kemp foundation, we've been real fortunate to have political leaders reach out to us and want us to work with them and help them and this man has -- this senator has called us at the kemp foundation and asked for us to help and he's invested his time not only in his home state of south carolina but also across the river. the kemp foundation, i've been doing a lot of work r ron moton.

are you out there? i'd like you and all your young people to stand up real ron -- { [ applause ] >> you all can take a seat. but ron is working with those young people in a program that's training them for jobs and getting them ready to achieve all that they can be. and bob woodson, who's here, bob, would you stand up for a moment. [ applause ] >> many of you know bob. bob and my dad were good friends. bob took dad around the country when he was hud secretary. what we do at the foundation, a large part of it is encourage politicians to get in their communities. go to the places where people know the answers.

and bob talks about josephs, that there are a bunch of josephs out there and if we'll get out of our ivory towers, if we'll stop just thinking about theory but go talk to the people who are doing the change in communities, that's where the solutions come from. so ron moton is a joseph in d.c. he's a returned citizen and he's investing in young people's lives. tim scott said hey, jimmy, i want to meet some young people in d.c. who are trying to overcome a lot of challenges because i've overcome a lot of challenges and i want to hear from them. this was just in the last spring. so tim has welcomed them to the capitol, hosted i think 12 senators and congressmen who sat around for an hour listening to them. tim cares.

and young people, they care what he knows. his constituents care what he knows. i'm more than thrilled to be able to welcome to the stage one of our great young leaders for the american idea to introduce governor haley, senator tim scott. >> good evening. wow. it's a great day in washington, d.c. good evening. if you were from south carolina, you would realize that when governor haley stands up and she says it's a great day in south carolina, everyone says it's a great day in south carolina. the fact that we're in d.c., no one thinks it's that great of a

day in d.c. i have the privilege of introducing my governor, one of the greatest leaders in america to you. i thought about some things that would be funny to say and if you know my humor you'd realize it's best for me not to sing or tell jokes, so i will do neeither. i did think, governor, about the one joke that i thought would be funny that you would not find funny. i'm a gamecock fan. any gamecock fans in here? i can tell by the silence there's only one and she's in the front row. she doesn't want to be identified as a gamecock fan either. at 6-6 there's not much to celebrate. our governor went to clemson and i think she is personally responsible for the success of the clemson tigers going off to the playoffs. i see we're not in south carolina at all. anyway, jokes don't work outside of south carolina, son.

got it. yep. my pastor was telling me i have the right to be wrong. this is wonderful in front of all you nice people. seriously, our governor is a fanburg native who started working at 13 years old keeping the book in her family business. she learned very quickly the importance of hard work. and one of the reasons why i know that she is a person who deserves the award tonight is because she embodies leadership. not only is she a clemson graduate, but when you think of the success we've seen in south carolina think about this. 46 counties and during her tenure we've had over 82,000 jobs created in all 46 counties in south carolina. that's amazing. [ applause ] >> that's one of the reasons why it's always a great day in south

carolina. but think about some of the jobs that have been created and expanded under her leadership. the bmws of the world. $1.2 billion expansion. the michelins of the world. mercedes benz, 1,200 additional jobs. boeing, over 8,000 jobs and still climbing. volvo, the first plant in the country, south carolina. there's a reason why south carolina is the number two growing state in the country t.t. it's called good leadership. many of us would focus on so many of the positive things we've seen happen under her leadership and that is truly good leadership. but i think perhaps the most important form of leadership we see when times are hard. when everybody's running in the opposite direction. you see south carolina has had

manmade and natural disasters. i think about just less than two years ago. the flood. the 1,000 year flood. flooding in south carolina, not on the coast, but in columbia, and in the middle of the state, our governor rose to the occasion and led our state through a very traumatic situation. and then just this year, hurricane matthew comes through the middle of our state. again, parts of the state that was most impacted were not the coastal parts of the state. she stood up, rolled her sleeves up, and led. led the people who were d disillusioned and did not know where to turn. we watched her positive powerful leadership keep our state moving

in the right direction. but if those two were not enough, as governor, she led the charge to remove the confederate battle flag from the capital. i will tell you that when the decision was made to take on that fight, not that many people were clapping in south carolina. she had the vision to know that sometimes you do the right thing even when it's not popular. and the trigger -- let's give her time to clap right back there by herself. god bless you, ma'am. you just keep clapping for my governor. there's no doubt that the trigger for the removal of the

confederate was an incident that no governor, no person should have to live through. we are all familiar with the murder, the murderers at the emmanuel mother emmanuel ame church. gov m governor haley, who showed tremendous leadership as our governor, did something that i thought was far more important during those funeral, because i was there with her through almost every funeral. she was there. but she was not just there as a governor. she was there as a mother. she was there as someone who held hands with a state and people that were broken. if you ever want to know what leadership looks like, don't look at her record as a job

creator. don't even pay too much attention to the response to natural disasters. look specifically at the crisis of mother emmanuel and her response as a human being, as a mother, as a governor, but most importantly, as a bridge to a better future. south carolina remains south carolina strong because of the leadership of our governor. it is no question that when president-elect trump saw the resume and watched on national and international tv the leadership of governor haley, he chose her to be our next ambassador to the united nations. please help me welcome our governor, my governor, nikki haley.

[ applause ] thank you very much. thank you. this is just a surreal night on a lot of different levels. i have to tell you first of all, when i heard about this award, i thought really? i mean, it was just one of those that i just couldn't even comprehend or imagine and then to go and you have to understand as the wife of a combat veteran, to even hear john mccain talk about you is like overwhelming because we can't ever thank you enough for your service. and i am forever in your debt. and i don't know where newt is

or if he's still here, but i have to tell you when he was running for president a few years back, that will go down as one of the best dinners that michael and i had was with him and his wife. the man is a great dinner companion, because he iscan tal and talk and talk, but it's really cool things that he talks about. i want to thank him. it was really nieeat to hear hi talk about that. as i was planning for the speech, i saw that i thanked tim. i didn't know it was tim scott. i just thought it was somebody named tim that was going to introduce me. now i look back at that and it made it that much more special. i will tell you when you are a governor and you're elected to lead, you make a lot of decisions. some decisions you go back and you say i wonder if that was right. i will tell you one of the best decisions i ever made was appointing tim scott as u.s.

senator. so thank you so much, tim, for that great introduction. i appreciate it. thank you to joanne kent and to jack and joanne's incredible children, to the entire kemp family and to the kemp foundation. i am deeply, deeply honored that you would choose to give me this leadership award. it means more to me than i think i could ever truly express. i regret that i never met jack kemp. i know i would have liked him. in anticipation of tonight, i was reading some of the things that i came across and i came across this quote. there is a kind of victory in good work no matter how humble. my mother as tim said made me start doing the books for our family business when i was just 13, so believe me, i know that those words have meaning. but beyond what secretary kemp said and when i look at what he stood for in his life, and what

he did, i am in awe. in pro football. in congress, in the executive branch, as a national leader of the conservative movement, his accomplishments go far beyond any words. but it's not just his accomplishments that stand out. what is perhaps the most significant about jack kemp is his compassion. the compassion he always showed to those who had been left behind in our country. and the courage he showed in going against the grain of republican thinking when our party was wrong. jack kemp was often referred to as a bleeding heart conservative tiff. i love that. i love it because it's important to be conservative because it's the right way of thinking for our countrcountry.bu.

but it's also important to have heart for our country. some in our party. jack kemp never did. we can't afford to miss it now. we have an incredible opportunity in front of us to remind america that our approach will deliver freedom, an opportunity to all citizens, regard little of race, gender, or where they were born and raised. that is what drew me to the republican party. and what drew my parents to america. my parents left a wealthy lifestyle in india with just $8 in their pocket to come to america to start over. why would they do that? because even in 1969 they understood that no amount of

money, no lifestyle can compare to the opportunities we have in america. only here can you be anything you want to be if you just willing to work hard. only here do the circumstances of your birth not define your future. only here is anything truly possible. that is jack kemp's republican party. that is my republican party. and that at its core is the american ideal. i'm not an academic. i'm not a fills on fer. i'm a waive and a mother and a governor of a state who took a chance on me six years ago. i have spent every day since then working to prove to the people of south carolina to they made the right decision. to me that's making sure every south carolinian has the same opportunities i had.

the opportunities that allowed an indian american girl from a tiny rural town in south carolina to one day grow up and be governor. when i took office six years ago south carolina was struggling. jobs were scarce. economic anxiety was real and the american dream felt out of reach for too many. i remember not quite knowing where to start. and then i came across the quote from one of my predecessors, governor carol campbell, who was a contemporary of secretary kemp's. governor campbell said if you can get a person a job, you can take care of a family. well, governors don't create jobs. we can do a lot to make sure that when a business wants to grow, it can. we got to work. we cut business taxes. we passed tort reform. we wiped our regulatory boards clean. i replaced the chairman of our largest and most bureaucrat i

can permitting board with the president of construction company. we now build planes with boeing. we build cars with bmw, mercedes benz and now volvo. we have five enter tasinternati companies. for those who said bicycles would never again be made in the united states, we brought back a new jersey bike manufacturer from china and they're now operating at a rural town in south carolina. most of that doesn't exist six years ago. so more than 82,000 new jobs and $21 billion in investment have been announced in south carolina during that time. we've moved more than 35,000 people off of welfare and put them to work.

[ applause ] unemployment has been cut in half and more south carolinians are working today than ever in the history of our state. i've often been asked how we've done it. as if there's some secret formula that spurred our transformation into the fastest growing economy on the east coast. my answer is that like most things in government, it's not as complicated as some people think. it's about common sense. and a willingness to get creative and challenge norms. and a belief that all things are possible if you free people to pursue their own dreams. jack kemp understood that better than almost anyone. as vital as job creation is, lifting people up is more than just about finances. it's also about education. that's an area in which our state has lagged behind for many years. we're still behind.

but not for very long. more than four years ago i started a conversation about education in south carolina. i met with principals and teachers, superintendents, university deans, business leaders, and clergy. i listened. i learned. and we changed things. we now provide reading coaches in every elementary school in south carolina. we've ended social promotion. we are aggressively recruiting rural teachers and we are changing the districts. we're investing in technology getting every south carolina child up to speed in the world as it is today. not as it was three decades ago. and we did it all without raising taxes. [ applause ] we have made immense changes to the way we teach our kids in

south carolina. these changes are happening because of two things. a willingness to acknowledge a problem and a willingness to move outside of our comfort zone to find a solution. it was out of the ordinary for a republican governor to go to the teachers and superintendents to talk about education reform. that's usually democrat territory. but those conversations helped me understand where they were coming from. and that helped them begin to trust me. that built relationships that allowed us to push these changes through our legislature. everyone wants to feel heard and in this nation everyone deserves to be. for too long the leadership of political parties have written off large groups of our fellow americans. out reach and honest communication with have enormous positive effects. i've seen it in changes in our

state. i've also seen it with a change that goes much deeper. i speak of the mother emmanuel shootings in charleston and the removal of the confederate flag. when i first learned of the shootings, i knew this was going to be unbearable. nine shooting deaths in a church at bible study. a state senator and a leading figure in the local black ministry shot to death. we'd never managed something to horrifying. the next morning we captured the killer and it immediately became clear that this was the act of a racist motivated not by mental illness but by pure hate. the first thing we needed to do was lift up those families and celebrate the lives of the victims. i decided to taeattend each funeral. i met the families. i heard their stories and through it all i had the privilege to get to know nine

amazing souls. after each funeral i would head home and sit down with my two kids. i would show them the faces on the programs. i would introduce them to the person i met that day. i introduced them to ethel who despite losing her daughter to cancers two years prior was loving jay who sang her favorite song, one day at a time sweet jesus. that's all i ask of you. give me the strength to do every day what i have to do. i introduced them to our youngest victim, a 26-year-old budding entrepreneur anxious to hep his own barbershop who on that night stood in front of his 87-year-old aunt and said you don't have to do this. we mean no harm to you. i introduced them