opportunity to do ambulatory training. if you like it enjoyed, you were more likely to continue in that arena. we need to make sure that the dollar's fall the residence. -- that the dollars follow the residents. this bill would move doctors -- funded positions -- in the primary care arenas. as i said earlier on, that will not do any get unless you convince more of my graduates to go into primary care. it's not that there are not enough slots but not enough people willing to go into those slots. we have to address those other issues before the transition of bonds' fill positions is going to do any good. it's interesting that there are a pilot projects for training into disciplinary. we tend to train in silos.

even when we get out of practice, we all have to work as a team. the concept that this team will be more he dissent than any one of us deficient -- individually is an interesting concept but one that we do not have any money to train toward today. .

we're going to turn now to sort of a case study of how this works out in a specific place, that is to say, the commonwealth of massachusetts. we've asked our next two speakers to address, first, private sector approach, and then a public sector approach for dealing with the question of access. that means we're going to hear next from debra devoe, the executive director of community transformation of blue cross/blue shield of massachusetts. one aspect of her work is the dramatic new initiative on payment reform which was recently launched by blue cross/blue shield. the c.e.o. of that corporation, i was delleding -- telling debra before we started, he's

been describing this initiative at meetings of a commission he served on and that i attended meetings of and it is a fascinating experiment. while the congressional negotiators struggle with how to reshape health system payment for care in a way that encourages high quality and cost effectiveness, deb and her colleagues in massachusetts are actually starting to do it. we thought he'd ask her to try to explain a little bit of how it came to be and how it's working out. thanks for coming, deb. >> my role will be to talk about how payment can help support access. i'll be eager to hear your questions on how this will work the vision of massachusetts, similar to the vision of our

country, i think, is to create a system where all have access and it's safe and affordable. the challenge for the plan is when physicians, hospitals, and patients look at how we pay for services, what they could say is we do not pay for any of those things right now. we're not paying physicians and hospitals differently if the care is safer or more effective. we're not recognizing them if they manage to produce more affordable care. so we, as health plans, and blue cross of massachusetts feels strongly that we need to play a role in changing that and let's start to pay for the things we all want, safe, effective, affordable care. as you'll hear from sharon in a moment, our state took the first steps to try to provide coverage to all citizens in our state. but we immediately, once we

made access to coverage available, we immediately bumped into the issue that care was still not affordable, was not the safest care that we think we can provide as a system, and was not necessarily the most effective. we have grave concerns about losing the broad coverage if we can't a -- if we can't create affordable care. what we have begun to do is to offer an alternative contract to the providers that are in our network in the state of massachusetts to not -- it's not required for participating in blue cross. but what we are able to say to providers is, if you're prepared to accept accountability for cost of care, effectiveness of care, safety of care, you will be recognized. with greater revenue.

if you can produce that. so the basic structure of the relationship is that we've created long-term partnerships. of course in health care, long-term is five years. but the idea being that one of the barriers to physicians and hospitals being able to restructure the way they do things, that they live year to year, not knowing what their payment will look like. most payers make decisions about how they're doing to structure payment on a year-to-year basis. what we've done is say to providers who are willing to commit to a long-term, five-year contract, we'll guarantee their payment levels over that five years. which gives them the opportunity to think a lot more creatively about how they want to recognize the efforts within their system to change care. and the contract does, for both

outpatient care and inpatient care, pay differently, according to the results of that care. rather than just paying for each service that's provided. so this chart shows you the basic structure of the contract. the blue bar below the line establishes a budget per patient a global payment, that the provider is paid regardless of how many services they provide. they're no longer insented to do -- incented to do the m.r.i. or provide a service unless it's going to create the most effective outcome for the patient. and the provider is freed up to offer some services that might not be recognized or paid for in a traditional fee for service model. what we feel the global payment does is to get the insurer out of the way of doing mother may

i utilization review. is that admission needed? that decision is left in the hands of the providers, and if the admission to the hospital isn't needed and the providers can avoid the admission by offering services in a different way, they're recognized for that. the second component of the five-year contract is, there is a guaranteed inflationary increase each year of the contract. but this is where the benefits to those who are purchasing the care, the employers or the individual member, is realized because that increase, that year-to-year increase, is lower than the increase that we're experiencing in the rest of the system. so if the rest of the system is producing a 9% to 11% increase, the increase annually in these contracts is much closer to c.p.i. much closer to the level of inflation that we're experiencing for other services

in our economy. and then the final component, which is the component we're most excited about, is recognizing quality. and so, for us, putting significant dollars behind recognizing those providers who offer better quality of services is really the most important part of this contract. we'll -- i'll show you the performance measures specifically in one minute, but one of the key questions we often get for those that lived through the capitation models of the 1990's is, haven't we done this before? and why is the alternative contract different? we certainly have experimented with capitation previously in this country and with some disastrous results for certain physicians and hospitals. we feel there are a number of

differences that relate to how the budget is constructed and the fact that we are now able to better predict the expected health care costs of members than we were 15 or 20 years ago. however, we do feel that we need to continue to look very carefully at how these budgets are constructed because there's still things to be learned and we obviously, we're protecting the providers from unexpected insurance risks. so the cost of a neonatal -- a baby who needs neonatal care or someone in a car accident, those things that aren't subject to better management, insurance problems. so we feel that the global payment of -- that can be done in 2009 is a different one and subject to better predictive science.

so the -- i'm not sure if you can see these well on the screen, but we've established performance measures that are nationally accepted, well recognized measures of care. these are not measures that were uniquely developed by blue cross, partially because we feel that providers have developed measures that they believe are important and that can be measured in a valid way. partially because we want these measures to be able to be adopted by other payers, we recognize that any single plan, blue cross of massachusetts covers about 30% to 35% of the people in our commonwealth and we know that even if all our members were in this arrangement, that it's very hard for a physician to completely restructure their practice for 3030%, 35%, even 50% of the patients. we want to collaborate with

other plans, whether it's medicaid, medicare, the other commercial insurance plans in our geography to adopt similar measures so that the physicians and hospitals can perform across a common set of measures for all the plans. we think that's going to be the best way to move the dial. not to have different measures for different plans and, you know, cause the physicians and hospitals to be trying to move their performance across a broad variety of measures, but to limit that pool. so these are measures both for the hospital and for outpatient care that fundamentally address the structure, the process, and the outcomes of care. the other thing we thought was exciting about these measures is that we initially provided the same weight, financially, in our incentive plan for all the measures, because we felt

there wasn't any science around how to weight those measures differently. when we took the construct out to the providers, the physicians said to us, don't you care a lot more about the outcomes than you do about the structure and the process? don't you care a lot more about whether a patient's gotten a hospital-acquired infection that was avoidable or a complication after surgery that's avoidable or that their blood sugars are at the right level than you do about some of the clinical process measures. we said, sure, but we know those are harder to achieve. the physicians said, why don't you triple weight those. weight those measures so if they're achieved, you get paid three times more than those measures that are structure and process. and that made a lot of sense to us because, like many other people, i've bought an exercise bike. that's the structure.

i may have used my exercise bike. but unless i actually lose weight, lower my blood pressure and i'm in better physical health, buying the bike isn't really enough. that's what physicians were saying to us. even if we put in the right structure and the right process if the outcome for the patient isn't achieved, then there's a problem. so we have triple weighted the outcome measures. and then finally, we've created a scale so that those physicians who achieve the highest rates of performance that are possible, so in other words, we're not setting the highest gates at a level that is not achieveable, will be paid significantly more. and our belief is that with this type of payment system,

the incentives for the delivery system to restrubblingture, because the only reason for payment reform is to allow providers to restructure care will enable some of these fundamental problems and access, including fundamental care, to be reimbursed appropriately and -- in terms of care and efficiency and can help solve the problems of access. >> thank you very much, deborah. [applause] >> as i said, we're going to turn now to a look at what government in massachusetts and the people who are subjected to it have done about access questions, and we're going to hear from sharon long. sharon is a senior fellow the urban institute health policy center here in town. he's a health economist of

national reputation. she directs the urban institute's evaluation of the massachusetts reform initiative as well as the massachusetts household insurance survey for the state government itself. she's also doing evaluation work on a number of other state reform efforts, so she has a perspective that's uniquely useful to trying to take a look at the reform measures in massachusetts. there's a health affairs article, the gold standard that sharon has written on massachusetts, and it's in your packets. there's an electronic version available through our website at health affairs that updates that paper. i commend it to you. sharon, i'm very pleased to have you with us, tell us a little about what's going on in massachusetts on the public side. >> thank you. my job is to give you an update on a real world health reform

example. let me start by acknowledging the funders for this work, blue cross blue shield of massachusetts foundation, and robert wood johnson foundation. i changed my slides a little bit, i took one of susan's slides, i want to give an update to what she mentioned. as you remember, it was to improve access to care, cover the uninsured and bend the health care cost curve. as we look at massachusetts, i'll go into more detail on, but massachusetts has significantly improved access to care. this was before implementing all the elements of health reform. before the minimum credible coverage standards were implemented and before the small businesses could buy into the program. significant gains there. in addition, this was before what some are calling round two

of health reform in massachusetts which is, the state made the decision to address expansion in coverage and access to care first and then turn to costs, and that's where the state is just beginning to now address the costs. substantial progress for the first two goals, just starting oven the third. the work i'm reporting on today is based on a survey in massachusetts, we did a baseline survey in fall of 2006, our prereform world, then we did follow-up surveys in fall of 2007 and fall of 2008 and we're working on funding for fall of 2009. we're looking at how insurance coverage, access, use, and affordability has changed as it's been implemented in the state. one limitation is that we're looking at changes over time so we capture health reform and other changes other time. in this world we capture the effects of the recession and the impact of rising health

care cost as well. it's not a pure measure of the impact of health reform. what i would caution is those two effect the recession and rising health care cost would dampen the health care reform. we're probably underestimates what the health care reform would have got if the economy had stayed stable and medical costs had stayed stable. let's look at the findings. the impact of reform on health insurance. this shows insurance coverage in fall of 2006, which is the yellow, fall of 2007, which is the blue, and fall of 2008, which is the purple. the first set of bars are the overall population, the second set is lower income adults, and the third set is higher income adults. lower income is 30% of poverty, the cutoff for our comcare program.

there were significant increases across the overall population and the low income group and high income group. for the low-income group, it was at 96%, nearly universal coverage in 2006. this compares to 80% in other state, well above what other states were seeing. most of the gains in insurance coverage were among low income adults. there you can see a gain from 76% coverage in fall of 2006, to 92% coverage in fall of 2008. a substantial gain over the three years of health insurance reform. i should note here, i'm not showing it in the slide but the increase in coverage in the state is both gains in public coverage and gains in employer-sponsored insurance coverage so we don't see crowdout of employer-sponsored insurance coverage. we attribute this to the

individual mandate, we're seeing a takeup of coverage in the state. in addition to seeing gains in insurance at a point of time we see gains in continuity of coverage. looking at this slide, which shows people who had coverage for the full 12 months, you can see substantial gain there is as well, so less cycling on and off of insurance coverage which should translate to more coverage over time. when we turn to look at access and youth, -- and use, we can say the gains of coverage have translated to gains in access and use. the first set of bars is having a usual source of care, people who have somebody they see when they're sick or need advice about their health. as you can see, we see an increase in that under health reform. the next two sets of bars are looking at doctor visits, any doctor visit and multiple doctor visits. again you see a gain in access.

more people are seeing doctors and more people are having multiple doctor visits over time. to place these in context, 83% of dulls in the u.s. have a usual source of care, compared to 92% in massachusetts, in terms of doctor visits, 78% of adults in the u.s. have a doctor visit and it's 85% in massachusetts. so we see better access to care in massachusetts and gains in access to care under health reform in the state. wuven limitation of the survey we've done is we can't identify people who gained insurance coverage because of health reform. all we have are three cross-sectional pictures. what we wanted to know was whether the gains in access just from obtaining insurance coverage or was it from other people in the state because there were changes in the minimal credible standards. we looked at people who had employer-sponsored coverage for the full year and with that population we see gains in

access to care for that group as well. it looks like massachusetts reform effort expanded coverage and improved what counts as coverage in the state, so there are quains on both fronts. consistent with that, we see gains by income level, most gains in access are among the low-income population, that's the group that gained the most in insurance coverage. we also see gains in access among higher income adults. one of the things we see, people are more likely to get preventive care. that's one of the big changes when preventive care is covered before the deduckable applies. the gains are more broad based than those who gained coverage. another way of looking at access to care is to look at unmet need for care this slide is reporting on people reporting unmet need for care for any reason. we looked at a need for doctor care, specialist care, medical

test treatment and followup care, prescription drugs and dental care. i should note here, though these look high in levels of unmet need if we look at a survey with data from other states, massachusetts tends to be lower than other states. massachusetts has lower levels of unmet needs but still has unmet needs in its population. what you see is strong reductions in unmet need in fall of 2007. and then some offsets of that in fall of 2008. a bit of a paradox. we saw increases in access to care, more people going to the doctor, more people with more doctor visits but more reported unmet need for care. it's clear that there was a push up in demand for care in the state and people had a harder time getting care. if you look at the sources of unmet need on the far right corner, it's specialist care and medical tests and followup care where we're seeing the unmet need as people are trying to get care. what it shows is that people -- as people are trying to get

care under health reform in massachusetts, they were running up against the capacity of the provider supply and this was an issue prior to reform that's become more of an issue as more people have care in the state. we added -- because we've seen some indication of this last year, we added a question to the survey this year to gather information about difficulties in obtaining care. i can look at this in 2008 but can't tell you how it changed over time. in the far right hand bar, one in five adults in massachusetts in 2008 reported difficulty in getting care either because the provider was not accepted new patients or was not accepting patients with their type of insurance coverage. more difficulty -- some difficulty finding providers. this was reported for both primary care and specialty care, it's not purely a specialty care phenomenon. it's more common along lower income dulls and adults with public coverage than among

higher income adults and adults with higher coverage that may reflect the expansion of the coverage in massachusetts, a large part of it is in the public programs, and that was within four plan, it was a narrow provider network that had an increase. we are seeing some difficulties getting access to care in the state. the next issue we looked at was affordability of care. health care cos in massachusetts are going up as they were in the rest of the country. that predates reform, it's not a function of reform. we're seeing some effects of that on reform. here, as in the access measures we saw gains in portability in the first year by fall of 2007 and then by fall of 2008, some loss of ground on those measures. so that we no longer see the significant gains or significant improvements in affordability over time.

based on these findings, it does look like the trends in rising health care costs in the state are starting to undermine some early gains in affordability under health reform. i just wanted to -- part of what massachusetts was able to achieve was bringing together disparty stake holders to come together and agree on a the re-form initiative. everybody gave a little bit, everybody got a little bit. that support was strong in 2006 when we re-form passed and that support has remained strong despite much press about the cost of reform and unexpected higher levels of enrollment relative to the numbers before. when we look at higher and lower income, it remains strong, gender, supportive, different ages are supportive. it's amazingly uniform across the state that supports -- support persists for the health reform initiative.

let me recap what we know. there were significant gains of insurance conching in the united states. there's no evidence that private insurance is being crowded oout. there were significant gains in access to care as people gained coverage and kept coverage for the full year. there was some significant improvements in affordability. despite the sesses, there were some indications of problems over the last year. there's some loss of the early gains in affordability as health care costs have continued to rise in the state and limits on provider supply with the increased demand for care created barriers to care for some people in the state. finally, as i mentioned earlier, health care cost is really round two of health care reform in the state. massachusetts is just beginning to really address health care costs. it's clear that the sustainability of health reform in the state will be a function of their ability to bend that

cost curve, just as it will be at the national level. thank you. >> thank you very much. thank you, sharon. we've come to the part of the program where you get a chance to ask questions. as i say, there are microphones you can go to to ask them, you fill out a written question on that green card and hold it up, someone will bring it forward. let me just start, if i can, sharon, with one of the pointses you were making about what the rere-forms are starting to do to access even as people are having more frequent doctor appointments. there is a -- in the materials, there's a survey taken in a number of cities that seemed to say that folks in boston were having more of a difficulty over time than those in most other places in the country in

getting an appointment to see a physician. tell us what you think of that. and whether it's something we have to watch out as we work on access more generally. >> i think there's actually other evidence from the massachusetts medical association that is consistent with that, that there has been kind of more demand for care and more -- with that more waits for care. if you look at kind of the timing of the increase in coverage in the state, it's clear, enrollment happened faster than the state expected. it's a good thing, people got coverage, but it happened within a relatively narrow set of networks. there was a strong increase in demand. what we think will happen over time we don't have the data, will be that some of the pent up demand will beesed as people get care and get followup care and the demand should be mitigated. what we're seeing is people have coverage for the full year, it's in the cycling in and out.

as that happen we expect some pushback against that demand. >> susan? >> i think this underscores why delivery system reform is such an important component of overall reform. we all know the phrase, you get what you paid for. what happens now doctors get paid, when you come in to see them. if you look at systems that have moved away from fee for service, like kaiser perm nene the, a cap tated system we published a study that looked at what happened when kaiser put in place secure email capability between patients and their physicians and lots of other interventions so you didn't necessarily have to come in to see your physician. what happened? visits dropped by 25%. people, it turns out, don't really want to get in the car

and drive three hours to see their doctor, if they don't have to, nancy. i think you'd concur. the delivery system has been frozen around the way we pay it. as we think of new ways to pay the system, the system will break up these frozen blocks of turgidity and do things like use email and do other kinds of things that will make it possible to have more encounters, if you will, with individual patients and free up capacity to be used in those directions as opposed to just in the old-fashioned visit. >> we have someone at the microphone. identify yourself and let me ask all of you who come to the microphone to be as brief as you can to allow us to get to as many questions as we possibly can. >> al, a.m. media, how do each of you see abortion access and coverage affecting overall health reform?

>> you can see everyone's leaping to answer that question. and if we have no takers i'm going to have whiff on it. nancy do you want to take a crack at that? >> i guess i don't think it's going to have -- i think that it's another set of services that some doctors or providers will perform and some will not, some payers will pay for and some will not, i suspect that it's just not an issue that's going to substantially tip this one way or the other, though it does have the potential, i guess, to elicit enough polarization that it could perhaps be used to either push in favor or push against reform. but i would think we should look at it as a service as opposed to something that ought to define whether this wins or

loses. >> david, georgetown medical school. massachusetts, to begin with, isen in a far more favorable state in terms of medical resources, both primary care physicians and specialists and substantial community health centers. were there to be an analogous reform through congress, address the work force issue because it appears on the two years that that's already a serious problem and a very favorable, probably among the most favorable situation we have in the nation. >> one comment, i agree with you that there's some aspects of massachusetts that are very favorable. we had a lower uninsured rate than other parts of the country and as you point out there's

strong, academically, sources for medical education in massachusetts. however, there's also some big challenges, for example the cost of living in massachusetts and the ability to maintain a lifestyle in massachusetts, and as nancy was saying, as a practicing physician there, earn enough to live there. so we feel that while there may be aspects of the experience in massachusetts that are easier to achieve in our state, there are probably some issues in other states that are going in the other direction. but i think what is going to be similar is that creating access to coverage will immediately bump into the significant problem of affordability and that fundamentally, though that affordability issue may vary a bit between states, i do think

we all have that issue that the cost of care -- costs of care are grow manager rapidly than what we can afford to cover. i think the work around how to restructure the care so that it's more affordable may be more similar across the states. does that answer your question? >> if you're going to speak, you should speak into the microphone, if you would, please. >> i sense from the preliminary data, the issue of actual access, more physicians not taking people, particularly lower income people, therefore a greater discrimination in who you see and apparently from back d -- backlog of people able to get access to care they wish. >> i think what massachusetts is trying to do is address those issues to provide

incentives to see the patients in primary care settings and make adjust. s susan was talking about. health care costs are high for the massachusetts than the rest of the country and are rising fastener massachusetts. so that piece is not the positive picture in massachusetts that other aspects are. >> just to underscore what nancy aid earlier, the main focus is primary care. it's clear from barbara's and others' work, primary care is correlated with the most cost effective, highest quality care. if you've got access to a primary care physician or primary care providers, you're going to have better care overall. that we know. we have this crazy system, as nancy said, go back to, you get what you pay for. we take the people in the system who provide the best, most reliable, high quality

care and pay them the least. what's wrong with this picture? how did the system get this way? then we take the people for whom, frankly, specialists, many of them are wonderful people if you know much about the evidence base in medicine, the evidence base for a lot of specialty medicine is pretty thin. we take the people who are applying the things we have the least amount of evidence about and pay them the most. what's wrong with that picture? we have to undergo the process so that we're paying more for the stuff we have a sense provides better quality care and less for everything else. if we all think this is going to be easy, mention this to our average highly paid medical specialist. but over time we think we can make some progress. social security why the gradual reforms will be important. >> i do think it's worth

adding, though if you go back to the 1990's when managed care and capitation briefly held sway, it may not be -- it will be every bit as painful as susan and the others have said, but it may not take as long as we think it will. during the 1990's a decade of reform in terms of how we paid for care we created tremendous numbers of new primary care training programs, filled them, probably the only time in my history, with the top students in the classes, it was the place to be because we thought we were going to change the way we paid for care and what we valued in this country. so if in fact reform can begin to show that there's a, going to be -- going to exist for a while, not just a couple of year, and that we're going to shift what we pay for, i think we'll in fact find many

graduates who begin to look at primary care much faster, perhaps, than we had originally anticipated. the 1990's is the evidence i have to look at. gary krystoferson, former d.o.s., congress. we built an inner city, public-private community health system in one of the largest cities of the united states. we learned what you need to produce healthy people and healthy communities. the approach to health reform to date has been slices. good slices like primary care, health insurance, this kind of thing. speak to me a little bit about what we really need, what's missing from the health reform discussion about if you really want to build healthy communities and make that happen.

>> i think most of health policy experts and public health experts in particular agree there isn't a whole lot of emphasis on public health in the reform bills. there's system. there's -- there's some. there's more focus on preventive care, etc., etc. but we look at some of the situations we face now, for example, the obesity crisis, we know we need to bring more to bear on those problems than just insurance coverage. i think that the whole issue of the so-called social and economic determinants of health that is to say your health status is to a large degree going to be determined not at all by your health care access and the treatment you get in the health care delivery system, it's going to be determined more by fundamental factors like your income level, did you grow up next to a toxic waste dump or not, all those kinds of things. that will be a work in progress. i think everybody agrees, the public health system in particular, is going to have to

address much more assiduously in the years ahead. >> but again, to take a more positive perspective, i said earlier i'm a pessimist, but i don't want to be. there are pieces, in at least the house bill that increase building infrastructure for public health. there are specific sections that address the value by attaching payment for things like smoking cessation, things that have not been included in an awful lot of payment mechanisms. so i think that perhaps if you add that to the concepts of patient centered medical homes and accountable systems, we will in fact have opportunities for a number of these communities to begin to grow up, if you will, and then because we're very competitive we may find that we can use those communities to encourage others. that the cost of care goes down if you have the infrastructure

of public health and the primary care overlay and we begin to use those to put the next layer. i don't think we'll get this all done in the first cut. but we've proven, as you said, that the we take it a slice at a time, we don't make any progress at all. >> i'd just make the observation that most frequently i've read criticism that these bills do too much or try to do too much, rather than that they don't try to do enough. there are at least a substantial minority in congress saying, maybe we're biting off more than we can chew. we have a whole raft of questions about -- why am i blanking on the nonsexist word for manpower -- >> work force. >> work force issues. let me attack a few of them, they are related. one of them has a pretty simple solution for the shortage, why not make medicare and medicaid acceptance required of all

providers in order to close the access gap? sounds like a reasonable idea, doesn't it? >> didn't massachusetts try that? >> would your massachusetts people like to address that? >> i'm not sure exactly where the question is coming from, physicians are required -- >> one of the ideas floating around as these bills started to get marked up was the idea of linking participation in medicare to participation in a public option, a public plan as a way of making sure that access for that group of people , presumably more the subsidized folks, would be relatively guaranteed since doctors and hospitals couldn't afford to write off medicare. as i recall, it was not met

with unanimous approval. >> i'd say that's the understatement of the day. >> that's perhaps the answer to the question. >> a fundamental issue here is, are you going to require providers to do certain things, number one. but also, what are you going to pay them. now in medicare, obviously, the federal government has leverage to control what physicians are going to be paid. that's what we've been talking about, some of the payment reforms that would basically make it more attractive for pry prie mare care physicians in particular to see medicare patients. on the medicaid side it's more complicated because medicaid is jointly run between the states and the federal government and jointly paid for between the states and -- between the federal government and localities. to raise rates in medicaid means the states have to go along with that as well, and the states are in a pretty

injured state with their economic considerations and fiscal considerations. how we address that over time will be an issue. in the house bill, the medicaid expansion that would take place would be entirely paid for by the federal government. that's an attempt to address this notion. but it's not utterly obvious that that is going to mean that payment rates get bumped up in medicaid. nancy can probably say more about how low medicaid's raids -- medicaid's rates really are. but that's a serious barrier. until that's addressed, a access for medicaid patients will be an issue. >> they oftentimes are as much as 30% of what medicare pays which is perceived in most places to be probably 80% of what private insurance pays. so now you're getting down to a fraction of the cost it takes to drive the process. i would probably say the best reason, though, ed implied, is

that while physicians and other health care providers are not a big enough group to kill health reform on their own, if they in fact are incensed enough to try to get all their patients opposed to a bill, they can in fact at least seriously disrupt the likelihood of passage and mandatory participation would probably be adequate to get that kind of activity going. >> and this one actually addresses the same question at a state level and initially it's directed at you, sharon. how have state government payments changed since 2006 to doctors and hospitals and how has it affected or how will it affect access in your opinion? >> one of the things

massachusetts did was to raise medicaid payment rates for physicians and hospitals. they did address that. they're not as high as i'm sure the doctors and hospitals would like to see them, but they were moving those up to address the capacity issue. and i think, you knowing one state that's done this, along the lines of the earlier question, is minnesota, which says if you want to participate in medicaid, you have to participate in the state government health insurance program. ways to tie them together to come into medicaid. >> this one addressed to both of you who are familiar with massachusetts' situation, were co-payments, or are co-payments and deductibles included in these insurance programs and have they been at snerd >> they are still included. >> that's not affected by the changes in your payment ex-personality, then? >> in the blue cross blue shield contract, we are applying that contract to our h.m.o. right now and employers

and members can purchase different types of benefit packages but all of them include some level of co-payment or dedubblettable in the product and what we want to do, as an earlier question addressed, is to start to introduce some alignment between the members and physicians so that lifestyle issues, members who are focused on maintaining their health, either throw smoking cessation, weight loss programs, etc., on the other side do get rewarded for that, in addition to having co-pames and dedubblettables for medical services. >> one thing the state did with minimum credible coverage, setting the floor of what counts as insurance in the state, was setting limits for the out of possibility costs could be for the year. there are some pushbacks on out of pocket costs and for people eligible under 150% of poverty, there aren't co-pays. there are some limits on --

aren't subject to co-pays. but there are some caps on how high they can be. preventive care is now for everybody in the state, for the insurance to qualify it has to be outside the dedubblettable, so you've seen an increase of preventive care in the state. >> continuing on the same theme, this is addressed to dr. dickey, medpac proposed, that's the medicare payment advisory commission, proposed increasing primary care reimbursements and decreasing specialist reimbursements in medicare. many primary care providers objected to decreasing specialty reimbursements. what would your advice be to policymakers on this issue? >> well, i think that to the degree that there's a single bucket of medicare dollars to be used to reimburse providers, physicians and advanced

practice nurses and others, the reality probably is that some of the adjustment, if we want to attract more primary care is by adjusting it out of specialty payments. it may not be payment per service, it may be you reduce the numbers of specialty services which is part of that bending the cost curve many of us think will occur. so i'll get paid just as much for every coronary artery bypass i do, maybe i don't need to do as many of them if i follow evidence-based information. obviously, i would assume those primary care physicians who don't want to take a pay increase off the backs of their colleagues, assume that somebody will put additional dollars into the bucket and specialists continue to get paid at the rates they are and we'll raise the tide and if that's an option, we'll all go

for that. none of us want to be divisive within our peer groups. i don't think that's an option. i think we need to talk about the fact that the money that's in the system needs to actually either go to providing more care or somehow bend it so there's less money in the system suggest that we're going to have to take the dollars that are there and spread them around differently than we have. so it's nice that you want to take care of your colleagues, but i think the data says we need more primary care. >> ok. here's one that goes back to something that several of you have referenced, that is the importance of preventive care. the questioner states, 37 states currently require insurers to provide prostate cancer screening as a benefit. but then we'll lose that benefit in currently debated health bills because they are not recommended by the u.s.

preventive services task force. how can we ensure access to these important measures? if i can add a second half of that question, how do you judge what's an important measure if you don't take the word of the preventive services task force? is there some higher authority? >> let me reference the comparative effectiveness research that is addressed in the bills and has had a fair amount -- fair amount of conversation. about half of what we do in medicine today has pretty good research that says, this makes a difference, or it doesn't make a difference. and what's -- what the bills have attempted to do is say, for that 50% that we have pretty good data, we ought to practice based on what the data sells -- tells us is good practice. for that 50% for which we do not have good data, we ought to

be spending some of our research dollars to collect the data. one way to do that would be to say for the 50% we don't have data, if blue cross is going to pay for it for you, you should be enrolled in a study so that three years or five years or seven years from now we'll be able to give you data that says it either helps to get this care or it doesn't help. and so we could then begin to say, at least for insurance purposes, for which a third party is going to pay for your care, we will pay for those things that appear to make a difference in your longevity, in your quality of life, in the timeliness of your recuperation, and then if you want to by those -- buy those things out of pocket for which there isn't good evidence but which either your physician or someone has convinced you you probably want to have it anyway, that's fine. you can always write a check for that. you just can't ask your

insurance company to pay for it. but if we don't have the data, as we don't have for about half or a little more than half of what we already do, we have to find a way to collect the data and -- so we'll know where to put those things. is that a fair description of comparative effectiveness? >> and just to say about the specific case of prostate cancer, it sounds like a slam dunk. you want a test that tells you you have it, you want to know sooner rather than later. it's not that simple. prostate cancer grows very, very, very slowly. the odds are in many individuals that they will die of something else, not the 3r0s tate cancer they have. we are only now beginning to discern which prostate cancers will grow fast and which will grow slowly. several years ago, a study was done of young men who died in vietnam and a lot of them had the early stages of prostate

cancer. they weren't dead they weren't going to die of prostate cancer, they were probably going to die of something else. you have to say, does the screening test show what i think it does? does it show i have prostate cancer or not, not me obviously, but a man. then what's the intervention have? does it kill the -- does the intervention kill the person? does it require excess surgery? does it make me impotent when it didn't need to make my impotent because i could have gone to a different surgeon or could have undertaken watchful waiting. once those things get done to people, you find out what they die of. you have to follow them and see if they die of prostate cancer or of something else. it's not clear that prostate cancer screening is always a slam dunk. it is clear that some people get treatment that they don't

need and die of treatment that they didn't need for a disease that wasn't going to kill them. so as nancy says, until we understand all of this, it really -- it comes down to, are you going to recommend we take our precious health care resources and spend money on them, or are we going to spend money on things we have some evidence, while we gather evidence to figure out whether we should be doing these other things or not. >> there was an article in the -- i'm sorry, i'm not sure of the source, there was an article about british health care coverage and my legal counsel for my academic health center came in and thought he was going to start a fight, i think, because he said, the brits have put a dollar figure on it. they decided if the cancer treatment costs more than, i'll get the numbers wrong, i apologize, but more than $20,000 and doesn't extend your

life by at least 90 days, they're not going to pay for the care. so they began to say, we'll spend this much money for this much longevity. and i said, you know, i'm not sure that's all bad. we have treatment interventions that cost tens of thousands of dollars that we can't demonstrate extend your life at all and being a cancer survivor, i can tell you some of those treatments might make whatever extension of life you get almost not worth it. fortunately for me, i'm hopefully cured, but -- so we are going to have to start asking difficult questions about which interventions we do, whether we do interventions for some groups and not others because different groups of people respond differently, but we should do it based on science. on having collected information from an adequate supply of people that we can then sit down with patients one-on-one and give them information in which to make intelligent

choices. to do that, we'll probably move a lot of things we probably think of as routine care today into experimental models where we begin to collect this information. and there will be those who immediately scream, you're rationing care. but the reality is that if we're giving you care that costs you, or more likely someone else money and doesn't improve your life, then we probably ought to save those dollars for something that could make a difference in your life or somebody else's. it's going to be a tough time, i think, as we begin to explain to people that this thing we think of as great science often doesn't have much science at all behind it. .

>> i ask you to thank you for thinking our panel for a very well the discussion. [applause] >> excellent. >> o kahlah thank you. --oh, and keep. -- thank you.

>> sunday, eliis cose on his public radio program against the odds. q&a, sunday night at 8:00 p.m. on c-span. >> this fall, into the home to the -- to america's highest court, to those only accessible by the nine justices. the supreme court, coming on c- span. >> up next, a look at health insurance companies. this portion of washington journalism out 30 minutes. continues. >> keith epstein with business week magazine has the cover story, health reform, why insurers are winning. i want to show a little from the inside and read some of what you wrote. as the health reform shifts from a vacationing washington to c

congressional districts, more of the battle is over. likely victors such as wellpoint and unitedhealth. no matter what specifics emerge in the voluminous congress the insurance industry will emerge more profitable. how did it get to this point? >> guest: we've heard about townhall meetings being disrupted and ads suggesting insurance companies are like sharks and counter ads, you know, suggesting the insurance companies are the villains. meanwhile in washington the industry has been very hard at work providing numbers, data, meeting with bluedogs, really taking more of a partis partici

role. >> inside the lobbying going on, why health insurers are winning, who is this man here? >> guest: that man there is steve helmsley, he is leading the healthcare efforts by unitedhealth, one of the largest, the largest by revenue, insurance companies in the country. in our article we focus largely on their efforts and their lobbying team in washington. unitedhealth is a company that has largely taken washington for granted for years. derived a lot of revenue from government programs. but -- >> host: you mean the lobbying effort has not been that strong in the past? >> guest: no, in the past they have had almost a non-existent presence. starting in 2007 they hired a man from, a lobbyist from goldman sachs and they now have a 50-person lobbying force across the country headed from

the washington office, including corey alexander, a brilliant man who was chief of of staff and leader hoyer at one stage. they have outside lobbyists and strategyists like daschle and others. we tally $3.4 million that this one company has spent in lobbying this year. and that is inside and outside lobbyists. >> host: did they get a head start on this debate? were they able to get their views to the incoming obama administration to get inside the senate discussions? >> gue: you know, we've seen signs lately of this -- rather in 1993, you remember with clinton attempted reform and it was very combative and ins lar. the insurance companies opposed it it vehemently. >> host: they were left out of

the discussion? >> guest: people were left out of the discussion and people felt that was a problem. the insurance industry being left out placed that famous harry and louise ad. this time the insurance industry, we have seen signs of of the pharmaceutical industry and insurance industry have been adept at getting a seat at the table. the insurance industry early on said, look, we're going to be at the table and we're willing to agree to not cancel policies or raise insurance rates for people who have prior illnesses, prior conditions. and so part of of this effort to be assertive and constructive has been to supply numbers to sit down with aides, key members of the senate finance committee, for instance. >> host: and on that seat at the table you write unitedhealth relationship with the senator in virginia illustrates the industry's subtle role. former governor of virginia is a

healthy ex-businessman who received choice assignment as liaison to business. he landed in the center of of the highly visible political drama in a position to earn gratitude of health insurance industry that donated $19 million to federal candidates since 2007. he's a freshman senator, so how did he become so prominent in this debate? >> guest: senator warner is prime liaison between democrats and the business community. he comes to the table with an entrepreneurial background. high-tech entrepreneur. >> host: right. >> guest: and he's moderate democrat in many respects. he sat down with some experts at unitedhealth and other places and came up with sort of end-of of-life hospice legislation.

that is in a lot of way what is unitedhealth has suggested. he is among democrats we've been hearing about lately who say for instance about the public plan this is the plan that would be a government-r government-runway of competing with the health insurance industry as the obama administration would hope that would be something that would bring down the cost of insurance and compete with the insurers. anyway, he has said for instance this could be a trojan horse. he is a trojan horse for total government-run health plan. >> host: let's hear from our viewers. our phone lines are open or you can go to twitter.com. first up is peter of new hampshire. and alex on the republican line. >> caller: thanks for taking my call. i have three quick points. one, the c.e.o. blows the cost -- i'm sorry, reveals the

true cost, it will be extremely expensive. my second point, i and others have actually read this bill, sir, and that's why we are livid. and third, why are you demonizing insurance companies? you are acting like a schiller or somebody for this administration. we are angry, sir, because we have read the bill. i've read the provisions where they want to access my bank account. that's why people are angry. i don't -- the democrat party has to find a demon and you are just pointing at the insurance companies. don't get me wrong, there needs to be some reform. thank you and i look forward to your experience. >> guest: thanks for your thoughts. i am not demonizing the insurance companies.

they were adept at coming forward, as was the pharmaceutical industry, to work with proponents of reform. about when you say you have read the legislation, however, that's, you know, which piece is it? there are three committees in the house and there are committees in the senate, primarily the senate finance committee, which will decide how to pay for this thing. that is far from resolved. that is one complication that democrats have right now in discussing this when they go out. it's a lot easier to talk about as the president does, about health insurance reform or to vilify the insurers as sharks, as this ad on moveon.org has done recently, than to talk about the complexity of this stuff, such as reimbursement rates, how much should the insurer pay, how much should other pays? how do you come up with the money? it is estimated to be in the

realm of $1 trillion. whether that money is something that would add to the deficit is something that is definitely unclear. people right now are starving for facts. there are a lot of people saying a lot of different things fed by the internet, fed by perhaps by maclimation of people organizing campaigns and perhaps they're not. at any rate, it's hard to find much in the way of facts. i would recommend alex, you or anybody else upset about what they are hearing and maybe not thoroughly understanding maybe look at the "new york times" article today that goes over some facts about five critical aspects of health reform and there is you had bill adair on with political facts. he is able to deal with the mikts out there. >> host: back to the lobbying by united, picture a giant

tractor trailer van they brought to capitol hill. you just talked about five different bills and committees out there working on a bill. which committee is the lobbying money chasing? what are they paying the most attention to? >> guest: lobbying money chases the key players. one of the real focuses of the insurers and others in this battle, as in many other battles, like cap and trade. are these moderate democrat? are the fiscally conservative members of of the blue-dog coalition in the house and moderate senators in the senate. we write about jim master'son in utah, this is a man who has a district the size of rhode island that gos from salt lake city all the way down to moab and beyond in southeastern utah, i think. you know for somebody like that, they're thinking about how do i

balance these interests in my district? how do i go with my party in trying to perform with something like this? what about the small businesses that are hard hit in my smokey communities. and these people who around marching in line with pelosi and company and the president are the people being focused on, by the white house, as well. people such as matheson and mike ross, bluedogs like that are conferring regularly with lobbyists, with the white house, with all the players because that is where the key lies to dealing with this. >> host: question from darrell price. why should executives have a seat at the table other than the millions underinsured? >> guest: well, that is a fundamental question about our system that people have been talking about for decades. we're trying to grapple with

that. as former writer of "washington post," who wrote on the topic years ago, i can't remember the name of the book. he said, here in the city, outside of the window where is we sit on capitol hill are these gleaming facts of democracy. we have this elaborate special interest in washington and there are groups that represent consumers and represent not just the corporate industry. there are those that would argue that sways the process. >> host: here is chris on the democrat line. >> caller: good morning. thanks to c-span. i have a quick comment and i'd appreciate if i could get all of it in. it's a lot, but it's statements and i'm going to be honest with you, yes, i do demonize the

insurance companies. as a matter of fact, if you go to -- i watch both networks, all three of of them, but the main ones i watc@ give out some information that is pretty useful to mr. epstein, too. i was watching on pbs, the jourl with wendell potter. are you familiar with that, sir? >> guest: yes. >> caller: he had a person who appearod msnbc because fox won't

listen to them. he was vice-president of cigna, he told the truth. he was a whistleblower and talked about how they made more money by basically declining patients and it is their policy. that is what they do. now we have demons that are in the game. one called frank writes scripts for the republican conservative party. alex constelano -- >> host: chris, there is a lot there. we will get the guest to respond. >> guest: chris, there are things that bother people about insurance companies. there are probably thing necessary our story that you would when you look at it, you would say, my goodness, this is bad, this is terrible, perhaps you would be upset at something we have where we talk about some

discussions behind the scenes of the senate finance committee in which lobbyists are trying to make a convincing case for lowering the amount of reimbursement they would be responsible for in future health reform and us raising it for people, other people. but on your point about demonizing insurers, there is demonizing obama, the democrats for wanting a canadian style program. we live in time where is it is hard to get at that kernel of truth between all of this. what is going on here, it is easier to craft a negative message, a simple campaign ad, disrupt a town hall meeting and deal with symbol or shout something out that gets a lot of attention than it is to deal with issues and have a discussion about some topics here.

it it is particularly hard for the democrats. another issue is doctors and patients. we have a tendency to want as many tests as possible and we're not always efficient about how we use healthcare system. i'm saying we as patients. and doctors don't want prices set for them and that sort of thing. there are other issues here where it -- >> on the role of lobbying, you write the industry has accomplished its main goal of blocking new publicly administered program that could grab market share from corporations that dominate the business and then this morning in the "washington times" they have the comments of dick durbin, the senator from michigan writing: i support a public option, but i'm open to a bill without it.

excuse me, state of illinois. >> guest: right. there seems to be quite an erosion of support if there really was some for the public plan, the government-run system. people like senator conrad, has been advancing this idea of a cooperative in which people would you have croppers for all sorts of things and this is when people ban together as a non-profit, for instance. the government might oversee it, but the idea is people in a group would be able to purchase healthcare at lower cost versus -- you know -- that is something insurers would arguably prefer. >> host: you point out senator conrad met with united officials before he came out with his

plan. >> guest: that is right. conrad met with him and people from bluecross blueshield. he says he is independent thinker to give conrad his say. he came up with that independently. it is part of the cultural fabric of the culture he comes from. at the same time and image thing aside, he told me the story of when he was discussing this wo one of the lobbyists. i said, what reaction did you have? they neither cheered nor jeered. they sat there. this is not something the insurers want, but it sounds preferable for what we've heard to the public plan. >> host: does united want a public plan in any way, shape or form? >> guest: no. that is interesting how washington works. tom daschle, obama's initial pick to lead health reform and a mentor to the president, and ran

into problems with nomination. he is actually a strategic advisor to unitedhealth. as he was before he was nominated. >> host: is that a paid role for him? >> guest: yes tis a paid role. he says it is not lobbying, it is advising clients on the lay of of the land. other people at his law firm does the lobbying. tom daschle is a thinker and well connected player, has written a book on the topic, believes a public plan is the way to go, but he's advising a company that is resistant to public plan. >> host: utica, new york, good morning to lee. >> caller: good morning. >> host: good morning. >> caller: now we have giant institution, healthcare institution here in utica. >> host: uh-huh.

>> caller: what happened, they are giving notification on the doors, no more medicaid patients and they are quite large. i see nursing homes, they want to take medicaid people. what i see happening, they're going to start dumping people on medicaid. there is over 50% of the seniors in these nursing homes on medicaid and they are going to start throwing them out. >> host: lee, we will get a response. >> guest: lee, there is a lot of fear and anxiety and things are happening to real people, real problems and this is one thing that makes the august recess complicated for lawmakers as they go back. never mind whether the protests are organized or not. the fact of the and they are hearing a lot from their constituents about what are you doing about this crisis? so-and-so is out of work, what about healthcare?

am i going to lose coverage? isq3f3f3f3f3fl+uuuuuuuuuuuuuuuu kick me out? ads and things partisans are saying are playing into that anxiety and that makes them effective. i was telling so much is unresolved and these bills, this thing is happen iing as we spea. negotiations really still going on in some ways. four different committees. there is no clear legislation yet. democrats are out there pushing for something that actually has not taken final shape and so you don't know what the final outcome is. i recommend that story in the "new york times," obviously as well as our piece, if you want to get more behind the scenes and get facts about what is going on. >> host: good morning to roger, an independent. >> caller: good morning. thank you to c-span. i'd like to make a comment and ask a quick question. it seems like kind of funny that

you are talking about healthcare and lobbyists because it seems like it is a cancer that has been affecting our country for so long and i'd just like to say that i think it should be public knowledge about these behind-closed-door meetings between our hol tigzs apolitici lobbyists and i think february or march unitedhealth was found to be cheated customers and why no one was prosecuted or went to jail. >> host: thanks for the call, roger. >> guest: the last point, you may be talking about a unit of unitedhealth called golden rule involving data that was determined by the new york state attorney general we have an article in our magazine, our current issue, as well. i believe you are looking at it now. you might want to take a look at

that. in fact, unitedhealth did pay money, didn't admit wrongdoing, to settle the claim by the new york state attorney general. now the other point was about the -- i'm sorry, i can't remember the other point. >> host: you addressed his point about -- oh, about lobbyists. >> guest: that's right. and disclosure. as a reporter, as a journalist, i'm all for more disclosure. we have very little disclosure of others who influence a process. hopefully our work helps illuminate that. as far as a cancer, though, the lobbyist role is the role that is part of the practice of democracy and that in a sense everybody is entitled to a lobbyist. you know, whether you fully agree with that or not is

another thing. lobbying has acquired this sort of evil association. people like heather pedestra, she put scarlet letter "l" to highlight this new stigma. do they go too far? who knows. is it helpful? unitedhealth and other insurance carriers have argued that by participating in the process, providing numbers, actuarial figures, revenue projections and so forth, they are helping the profits. they are informing aides through member of congress who might not be so informed. >> host: you do write in your article, what people in washington tend not to discuss on the record is open secret that insurers are minimizing their forecast of the eventual windfall they will endure for expanded coverage from americans. the bottom line, health would

lead to profit for the insurance industry. >> guest: as with cap and trade, i don't think many people truly and as opposed to what you hear on the airwaves now and in the town halls sometimes, i don't think is a serious student of health reform and expect there to be full-blown revenue. it it is likely to be something that resembles swiss cheese, may be a mixture of things. and the insurance industry, if more people, you can think about this logically f. more people are actually brought into health reform and by whatever means given access to coverage or some kind of insurance whether through co-op or public plan or whatever it happens to be, that means more potential clients for the insurance industry. and they have provided projections to the senate finance committee we're told that speak to because of health

reform. there is belief they are low-balling it it, but there still are projections of increased revenue. >> host: one more call from new york on the democrat line. hi. >> caller: hello. i am so nervous. i had time sitting here to get nervous. >> host: that is all right. take your time and take a deep breath. >> caller: i've been wanting to call for years. >> host: glad to have you through g. ahead. >> caller: i've never had a problem with medicare, blue cross, blue shield, it's been wonderful. i'm a retiree so i got my supplement through the bank where i worked. but the first of january they called and they said they were taking that away from us and we had to go to unitedhealth.

it is expensive. every time i go to the doctor, i have a co-pay. they say they are all specialists, which they aren't. that is $20. >> host: we will well let you go there and get a response from keith epstein. thank you for calling. >> guest: you might go on the internet or have somebody help you, on national public radio this morning on morning edition, there was a report out of vancouver, canada about the canadian healthcare system. i was not advocating that system, but i was struck with the ease that people are participating and less of the worry. what you're experiencing are a lot of americans are experiencing.

but it is antipathy towards insurance curious who have struggled with those forms for instance. >> he has the lead article in business week. when insurers are winning. thank you for being with us. >> all this week, on c-span is washington journal, we are joined by some of the nation's mayors. tomorrow, it is phoenix mayor phil gordon, wednesday, j. williams, the mayor of youngstown ohio. later in the week, greg ballard of indianapolis and friday will talk to fort myers mayor jim humphrey. >> don capacity, why is congress continuing to hold hearings on fannie mae and freddie mac?

congress is trying to figure out what to do with them. they said whatever they do do, they are not want to look like they look to date. they're going to restructure them. they could make them a public utility. there are a number of options they are considering. >> does it appear that lawmakers are writing legislation to address these issues? can you give us some specifics? >> they are not writing legislation yet. they are holding a lot of hearings and they are starting an internal debate about what to do with the companies. there will be legislation some time early next year. a couple of the options include placing them in receivership. kind of like the lack companies are, but for your mortgage.

another option is creating a bad bank for the bad assets of the company. and rolling off the good assets into something else altogether. there are a number of different things they are looking at right now. >> how is the other legislation doing that congressional approval? . with the troubled asset relief program, they didn't do what they said. extended a $200 billion lifeline to each company and they have already used up about $100 billion of that. they are not faring very well. the we default rates on loans are somewhere around 60%. for every 10 people that are getting the modified loans, six of those people are falling behind and the program has only

been under way for a few months. they are not sharing very well. fannie just lost $15 billion and freddie just reported a profit, but most of that profit was steering from accounting changes and different games. they were paper gains, they were not actual gains. on paper, the company looks like it did ok, it is really very financially weak. >> has there been reaction from officials about what lawmakers are talking about doing? >> no. the only reaction is that they're going to cooperate with congress, foley. the companies are being run by the u.s. treasury. they ousted in the managers that might have put up a really hard fight. right now, they are busy executing the president's plan and do not have a choice in the

matter because, as they say in their earnings reports, they are completely dependent on the federal government for the financing, otherwise the companies would not survive. they would not produce enough cash to meet their obligations and it would default on their bonds if it were not for this treasury backing. >> he talked a little bit about the house. what can we expect from the senate? >> the senate is usually slower to act. chris dodd has a conflict. he had one of the vip mortgages through countrywide that may have had ties back to fannie mae. the senate is always a little slower. but i think he will see -- senator shelby cares deeply about it. i think that chris dodd will probably go along with whatever it is that shelby once. >> in the few seconds that we have left, what about field,

administration? what did they say? >> the same options are on the table for the barack obama administration. so, they are on the same table. everyone in washington pretty much agrees that these companies cannot continue to exist in their formal right now. you will see some dramatic changes sometime next year. >> thank you for joining us. >> the key. >> president barack obama met with mexico's president and canada's prime minister in guadalajara and mexico. the three leaders said that their companies will cooperate on climate change in the swine flu. there were also asked about the

june 28 to in honduras. that is next on c-span. after that, a white house roundtable on health care. later, the alliance for health reform. >> how does he spend funded? >> donations? >> of private contributions? >> honestly i don't know. >> i would say from commercials. >> advertise the? >> policies been funded? 30 years ago, cable companies created c-span as a public service. and a government mandate, no government money. >> from earlier today, that news conference with president barack obama and the mexican president

and the canadian prime minister. this event took place in guadalajara, mexico. president of, returns from the north american leaders' summit this evening. right hon. minister stephen harper, the prime minister of canada, right hon. barack obama, the president of united states of america, ladies and gentlemen, members of the press, the president's of canada -- the leaders of canada, mexico, and united states had completed a fruitful meeting. we have shared our vision with the only other regional

communities that are safe, secure, and can face successfully that challenge -- the challenges. hat in an age marked by globalization, the challenges can only be overcome jointly. thus the importance of keeping the dialogue, trust, and cooperation amongst our three countries. americans, canadian, and mexicans have reiterated that the values upon which our societies are founded, our commock -- are democracy, freedom, justice and the respect of human rights. our three nations have reiterated our decision to combat organized crime in order to bring about more security to our communities. the struggles we have led in mexico for the rule of law and

the security of our mexican people forces us to stop a traffic of weapons and of money that go from north to south that strengthen and nourish organized crime gangs. the notion of responsibility, accountability, the exchange of information, and the building of our institutions should be the guidelines for our cooperation. in this international crisis context, the three states that make up the north american region have to take the leadership and foster the necessary measures to recover our economic growth. in our task, we have had to implement countercyclical measures that have been put into action and in a coordinated manner, we can stabilize our economies and

bring about trustworthyness and certainty in regard to the future of the global economy. it is also necessary to build our financial international institutions such as the world funds, the international monetary funds, which are fundamental to guarantee the financial resources in the case of latin america, the support that will enable us to recapitalize inter-american bank for development will be the best action and commitment in regard to the poor countries in the region in -- on behalf of the north american countries. i am certain that at the next g-20 meeting that shall take place in pittsburgh, the united states, will be a great opportunity to build the necessary agreements to reform the organizations that are key in the recovery of our economies and our reprisal.

i thank president obama for fostering this meeting in pittsburgh and the united states, mexico, and canada have to restart our agreements. we recognize that it is essential to abide by nafta and to resolve the pending topics that impede us to reach greater regional competitiveness and it is important to see how we are going to fulfill our commitment in regard to the environment and in regard to our labor domains linked to the commercial agreement, the trade agreement we have amongst our country. i am convinced that only by tapping the investments, labor, technologies and natural resources, we shall be successful in the world that is ferociously competing. at this time, we have reached important agreements such as

boosting decentralization of regulations and certifications of our products as well as the sanitary procedures and -- sanitary procedures that can be simplified as well as increasing the economic competitiveness in our region. the objective is to have in secure and efficient conditions these procedures to be implemented with no bureaucratic or far-fetched red tape in our offices and this will diminish -- decrease the prices for the staples and food and improve the competitiveness of our economies. on the other hand, the bilateral aspects, mexico and the united states will launch modernization initiatives at our common borders with

determined termed in order to promote the regional competitiveness actions mexico commends and is pleased to say that we are going to inaugurate the first international bridge that is currently being built after so many years between the united states and mexico. the united states, mexico, and canada have coincided in the importance to face the repercussions of climatic change, the cost is high but the prige we shall pay for lack of action cannot possibly be calculated. we coincide we have to foster the global agreement in copenhagen and the instrumentation for a green fund to finance and support mitigation and adaptation actions in regard to the global scale of the climatic change. we need to make congress in regard to clean energies and technologies as well as the

development of our carbon bonus market in order to have a regional market. north america has to be recognized as a responsible region and must set the example for the world in terms of environmental cooperation amongst countries with the level -- with different levels of development. cooperation and solidarity amongst the north american region must prevail at all moments, thus it was demonstrated last april when our three countries faced the new virus, h1n1 and working together, we showed our highest expressions of responsibility, accountability, and transparency and because we alerted timely the other regions in the hemisphere, they had the opportunity to implement preventive measures to abate the propagation of the virus and avoid its lethal

repercussions. h1n1 as we know will be back h1n1 as we know will be back this winter. we will face these contingencies and debate these impacts for our people. mr. president, prime minister, ladies and gentlemen, at this summit, the representatives of the united states, canada and mexico have an open and straightforward dialogue in share values. we have been able to found a successful in value. we believe that in the north american region, it is united and prosperous and wealthy and is able to build a better future for the forthcoming generations. i want to give the floor, now,

to mr. stephen harper, prime minister from canada. thank you for the exchanges on our priority issues. it goes into the economy, and energy and environment and climate change. on the economy, because of canada's strong physical management, we provided an informed of voice at these meetings. as we approach the g toward the summit in pittsburg, we continue to emphasize that country's economic stem stimulus. we talked about our shared an effective response thus far to

h1n1. it is a cross border threat to wallace. -- to all of us. outbreak and we'll continue to cooperate. in security, we recognize the commitment of president calderon in taking on drug traffickers. we are supporting these efforts as it is a shared challenge for all of us in north america. also on international peace and security, canada supports ongoing o.a.s. efforts to find a peaceful resolution to the crisis in hon cure rass. we must restore both democratic governments and the rule of law. i just about missed energy and climate change. given the integrated nature of our economy we did talk at some length about the importance of working together on a north american approach to climate change and also on doing our best to ensure that out of

copenhagen going forward, we reach an effective and genuinely international new world protocol on greenhouse gas emissions. to conclude, can dark the united states, and mexico are good neighbors and good friends. as sovereign countries in a modern world, we are independent and interdependent. i am looking forward to seeing president calderon and president obama at the g-20 and looking forward to hosting both of you next year at canada's summit in our great country. thank you. >> good morning. buenos dias. i want to thank my great friend, president calderon, for his hospitality and for hosting

us at this important summit, as well as my good friend, prime minister stephen harper and i want to thank the people of guadalajara and mexico for the incredible warmth they've shown us on this, my second trip to mexico as president. here in mexico, the word is juntos. in canada, it's -- -- but no matter how you say it, we come together because of the challenge and opportunities we'll be facing together. like our magnificent surroundings today, this could not be a more fitting venue. here in guadalajara, we see the richness of mexico's heritage, its arts, architecture, vitality, and culture, and we also see all the possibilities of mexico's future, this innovation, high--- high-tech industries, and entrepreneurship that make this one of the most dynamic cities

in our hemisphere. we also see our continent coming together, canadians, mexicans -- mexicans, americans, each bringing their unique traditions, each bound by mutual respect. in the 21st century, north america is defined not simply by our borders, but by our bonds. that is a spirit that defines the very productive summit we had here today. first we agreed we had to work together to restore our common prosperity. the global recession has cost jobs and hurt families from toronto to toledo doe to tijuana. we renewed our agreement to work together, we agreed to continue to take aggressive, coordinated action to restore economic growth and create jobs for our workers, including workers in the north american auto industry. because so much of our common prosperity depends on trade,

billions of dollars bort of trade every day, we reaffirm the need to protectionist. we are among each other's largest trading partners as we work together toward lasting prosperity we need to expand that trade, not restrict it. i would note that our common prosperity also depends on orderly, legal migration. all three of our nations have been enriched by our ties with family and community. i think of my own brother-in-law who is canadian, i think of the many mexican americans from jalisco who found homes in los angeles, texas, and my hometown of chicago. at the same time, americans, mexicans, and canadians expect their borders to be safe and secure. that's why my administration will continue to work to fix

our immigration system in a way that's in keeping with being a nation of laws and a nation of immigrants. because our future prosperity also depends on clean energy economies, we invest in renewable energy and clean jobs. we recommitted ourselves to the historic goals announced last month in italy. countries like the united states and canada will take the lead in 2050 and work with other nations to cut global emissions in half. indeed we made progress toward the concrete goals that will be negotiated at the copenhagen climate change summit in the summer. i want to commend mexico for curbing greenhouse gas emissions and president calderon for his proposals to help developing couldn'tries build clean, sustainable economies. we reiterated our commitment to the safety of our people. in regards to the h1n1

pandemic, we have worked closely, collaboratively and responsibly. we will continue to make all necessary pro pre-cautions to prepare for the upcoming flu system and prefair -- protect the health of our people. this challenge transcends borders and is must our response. we must also continue to address the threat to our common security from drug cartels that cause so much violence and death. i heartly commend president calderon and his government for their courage in taking on these cartels and the president reaffirmed his commitment to transparency, accountability, and human rights as they wage this necessary but difficult fight. the united states will remain a full partner in this effort. we will work to make sure mexico has the support it needs to dishasn'tle and defeat the cartels and the united states will also meet its responsibilities by continuing our efforts to reduce the

demand for drugs and continuing to strengthen the security of our shared border, not only to protect the american people but also to stem the illegal, southbound flow of guns and cash that promote this violence. third, we reiterate our commitments to peace, democracy and human rights. we talked about honduras. we remain united on this issue. he remains the president, and democratic order must be restored. we will continue to work with others, especially the organization of american states to achieve a negotiated and peaceful solution. finally, we pledge to continue these efforts. i look forward to welcoming prime minister harper in september. i look forward to welcoming both my friends at the g-20 in pittsburgh where i hope to

reciprocate president calderon's hospitality, our progress today is a reminder that no nation can meet the challenges of our time on our own. our common aspiration can only be achieved if we work together and that's what the nearly half billion people in north america expect from us. so that's what we will do. thank you very much. [speaking spanish] >> good afternoon. there are certain questions about violation of human rights here in mexico and all these problems, fighting drug trafficking, are you going to certify mexico and how can we move forward with the initiative? we've also been concerned about

any attempt against felipe calderon's life. we know about certain threats and his security that prevails. this, of course, is certainly related to your country. we're concerned about the visa problem, too, but what comments would you have regarding these questions? [speaking spanish] >> what are your concerns regarding this. we'd also nike -- like to know if mexico will be certified and if you'll help in applying resources for the initiative. we've also heard about aterpts

against the life of president felipe calderon. do you have knowledge of this? we're also concerned about national security, about visas, we'd like to know is there any possibility that you might turn this around that we might not have any limit on visas? >> i'll just address the first two questions that seem to apply to the united states. number one, we have been very supportive of the initiative and we will continue to be supportive. we have already seen resources transferred, equipment transferred, in order to help president calderon in what is a very courageous effort to deal with a drug cartel, a set of drug cartels that are not only resulting in extraordinary violence to the people of mexico, but are also undermining institutions like the police and the jew dish

care system that, unless stopped, will be damaging to the country. now with respect to the conduct of this battle against the cartels, you know, i have great confidence in president calderon's administration. applying the law enforcement techniques that are necessary to curb the power of the cartels, but doing so in a way that's consistent with human rights. we discussed this in our bilateral meeting and i am confidence that as the national police are trained, as the coordination between the military and he call police officials is improved, there is going to be increased transparency and accountability and that human rights will be observed. the biggest, by far, violators of human rights right now are the cartels themselves that are

kidnapping people, extorting people, encouraging corruption in these regions. that's what needs to be stopped, that's what president calderon committed to doing and that's what i committed to helping president calderon accomplish, as long as he's president of mexico. >> we'll continue. >> on the question of visas, it's important to understand the imposition of visa is due to one thing and one thing only, that is the dramatic rise we have seen over the last few years, and this year in particular, in the number -- in the number of bogus refugee claims being made from mexico claims being made from mexico into canada. it is important to understand this has nothing to do with the actions of the mexican government.

the government has cooperated with the some efforts to stem this particular problem and to limit this particular problem and it continues to work with us. the underlying problem, as i have said, the underlying problem is in the canadian refugee laws. it is simply far too easy in canada to make the bogus refugee claim as a way of entering the country. we have to change that. it is unfair to those who are legitimate refugees and it is unfair to the hundreds of thousands of people who are working through our immigration system. we will continue to work with mexican authorities to try and limit this problem. in the absence of legislative change, it is difficult for governments to control this. . . our parliament to stem the flow of bogus refugee claimants and

also to have additional tools to deal with this kind of problem. >> alex panetta, canadian >> alex panetta, canadian press. >> the topics which were very important to us, first of all, my government has an absolute and categorical commitment with human rights. the struggle, the battle we are fighting against organized crime is precisely to preserve the human rights of the meck can people, rights to safety, security, personal safety, integrity and the right to have a safe family. the right to work without being really molested or perturbed and the struggle for the security, the safety of the mexican people, obviously we have a strong commitment to

protect human rights of everybody, the victims and even the criminals themselves and this is how it has been, this is how it will continue to be and this is how the federal police will act, the attorneys general and armed forces will act. all in all of these cases, there have been -- there has been a scrupulous effort to protect human rights in all cases. anyone who says the contrary certainly would have to prove this. any case, just one case, where the proper authority has not acted in a correct way, that the competent authorities have not punished anyone who has abused their authority. whether they be police officers, soldiers or anyone else. we have a clear commitment with human rights. we have met this commitment, and we will continue to do so. not because of any money that might come or come through,

through the initiative or what's set in the u.s. congress, because we have the strong commitment to human rights and i certainly in a personal sense for several decades now and i have alms had this commitment -- and i have always had this commitment, i have details about what you have pointed out but in any case this won't be the first or last occasion on which we might hear something about an attempt against my personal -- about my life, my person, but once again, the government just can't stop, it can't be disturbed. we know that we are destroying the criminal organizations, we're hitting them hard, hitting at the heart of the organizations. we're making them back away. and we know, they know, that we're not only taking an initiative in the struggle against crime, but we are

actually being able to protect, defend our country better as time goes by. this is not a type of vengeance, of getting back at anyone, but we want to make sure that mexico is a safe place to live in, that we will be able to move forward in this one, we're not talking just about this organization, but our basic objective is to provide security, safety for the mexican people, this is something -- this is something the mexican people are entitled to, they can go out to play, go to school, they can make progress and fulfill their aspirations that mexico be a free country freerk of delinquency, free of violence, that mexico be a safe country, and we're not going to be intimidated, nor will they put a stop to you are efforts. i hope mexican society recognizes all the efforts we're making along these lines,

the police force who have been victims of attempts and cowardly acts by the criminals, all the efforts carried out by mexican marines, by soldiers, different attorneys general's offices, because we are committed to this ideal to have a safe mexico a safe country. these are values that we believe in and they're certainly stronger than any threat that could be made against us about anything whatsoever. so once again, we have had dialogues with prime minister harper on several different occasions, as we did on this occasion, about the summit, and the matter of visas for mexican visitors. we've talked openly, frankly, and certainly mexico certainly feels very bad about this decision, about this rejection, even though, of course,s the privilege of the canadian government to stipulate this,

but it gets in the way of a good relationship of what prime minister harper and i are doing to have good relations between the two countries. the explanation that prime minister harper mentioned, it is a problem, with the bogus refugee claim problem, this has led to an abuse of the system. we're going to try to work together, collaborate together, we're doing this here in mexico to try to do away with the underlying causes of this abuse regarding the general system for r.v.ing refugees in canada. -- for revving refugees in canada. -- for receiving refugees in canada. i certainly have the obligation of assuring that a specific topic on the bilateral agenda not deter reaching our full potential of other matters on the agenda. once again, here lies the great opportunity in this particular area of economic complimentary -- complementry of the three

countries' economy, that is take our whole region up to a higher state of competitiveness. these are the lines we've been working along, i think we have been making great strides in a sense, and we certainly will continue to work along these lines. i'd like to open this up. >> i hope you forgive me for this being a long question, we only get one question each. this is primarily for president obama. >> use the microphone, please. >> i would appreciate if the prime minister could answer in french as well. buy american causes considerable concern outside the united states, i wonder what you discussed about it, what power you have to rescind

the power and if you intend to. on a not completely related topic, health care has been an issue of debate in your country, canadians have lock -- canadiens have looked on -- canadians have looked on with surprise, i'd like to wonder if -- i'd like to ask if you see any parts of the canadian health care system that are worth emulating. >> as to the buy american issue, the prime minister raise ths issue every time we see each other. i think it's important to note that we have not seen sweeping steps toward proctionism. there was a very particular provision in our recovery package, our stimulus package, that did not extend beyond

that, it was w.t.o. compliant, it was not something that i thought was necessary, but it was introduced at a time when we had a very severe economic situation and it was important for us to act quickly. and not get bogged down in debates around this particular provision. prime minister harper and i have discussed this and there may be mechanisms whereby states and local jurisdictions can work with the provinces to allow for cross-border procurement packages that expands the trading relationship, but i do think it's important to keep this in perspective. this in no way has endangered the billions of dollars of trade taking place between our two countries. it's not a general provision, but it was restricted to a very

particular aspect of our recovery package. with respect to the health care debate, we are having a vigorous debate in the united states and i think that's a healthy thing. the reason it's necessary is because we are on aurrently unsustainable path. we spend far more per person on health care than any nation on earth. the -- our outcomes in terms of various measures of well being don't rank up at the top. we're not doing better than a lot of other country -- than a lot of other developed countries that are spending much less per person. individual families are being bankrupted because of the lack of insurance. we've got 46 million or 47 million people without health insurance in our country and for those who do have health insurance, they are always at

risk of private insurers eliminating their insurance because of a pre-existing condition or because of -- if they lose a job or have changed jobs. so the final aspect of it is that our health care inflation is going up so rapidly that our federal budget simply can't sustain it. nor can businesses that are increasingly having to make decisions whether they hire more workers or eliminate health care. whether they stop providing kverage or force more costs onto their workers. the whole system is not working well. how do we change it? when it's 1/6 of the u.s. economy, there will be a lot of opinions. congress has moved toward and we are closer to achieving a serious health reform package than we have been in the last 40 to 50 years. but there continues to be a vigorous debate. i've said the canadian model

works for canada, it would not work for the united states, simply because we've evolved differently. we have an employer-based system a private-based health care system that stands side by side with medicare and medicaid and our veterans administration health care system. so we've got to develop a uniquely american approach to this problem. this, by the ways a problem that all countries are going to have to deal with at some level because if medical inflation continues at the pace that it's going, everybody's budgets are going to be put under severe strain. what we're trying to do is make sure we have a sensible plan that provides coverage for everybody, that continues the role of the private marketplace, but provides people who don't have health insurance or have fallen through the cracks in the private marketplace a realistic and meaningful option. we've got to do it in a way that change ours delivery system so we're not engaged in

the kind of wasteful, inefficient medical spending that's so costly to us. so i suspect that we're going to have continued vigorous debate. i suspect that you canadians will continue to get dragged in by those who oppose reform, even though i've said nothing about canadian health care reform. i don't find canadians particularly scary, but i guess some of the opent -- opponents of reform think they make good bookymen. -- bogeymen. i suspect once we get into the fall and people look at the actual legislation being proposed, that more sensible and reasoned argumented will emerge and we'll get this passed. sorry to take so long on the question.

[speaking french] [speaking french] >> on buy american, we did have a good discussion, as president obama said.

i'm happy to see our provinces and the federal government have recently come to an agreement to work collectively on this matter, which is largely, actually, within their jurisdiction since this@@@@@@@@) how respective trade ministers have been talking. we will be discussing this at greater length and are upcoming meetings. on the american health care debate and the system of health care, as we know, canadians support their own health care system. my only answer is that this is an american debate and the responsibility of the provinces. >> ginger thompson. >> i'd like to start with

president obama, please. given the fight you're having to wage for health care, i wonder if you can tell us what you think the prospects are for immigration reform, for comprehensive immigration reform which you said is your goal, and whether you think the blows you're taking now on health care, and that the democrats are likely to take around the mid term elections, will make it hard if not impossible to achieve comprehensive immigration reform in this term, and who what you told president calderon about that? president calderon, i'd like to hear a little bit about your thoughts on honduras. there have been some in latin america who have said that the united states has not acted strongly enough to return the hon duran president to power. i wonder if you can talk a little bit about how you feel about what the united states could be doing or should be doing to restore democratic

order in honduras and prime minister, harp -- prime minister harper, a few months ago, the homeland security secretary of the united states went to canada, or at least aggravated canadian sensibilities when she compared the canadian border to the mexican border and i wonder what you think about that and how you feel about the united states using some of the enforcement strategies adopted on the southern border in the north? thank you. >> that's all? >> that's all, mr. president. >> well, first of all, ginger, i don't know if you're doing some prognosticating about the outcome of the mid term elections, which are over a year away, i anticipate we'll do just fine.

and i think when all is said on health care reform, the american people are going to be glad that we acted to change an unsustainae system so that more people have coverage, we're bending the cost curve and we're getting insurance reform so that people don't get dropped because of pre-existing conditions or other issues. so understand, though, i'm not acting based on short-term political calculations. i'm looking at what's best for the country, long-term. if i've been -- if i'd been making short-term political calculations, i wouldn't be standing here as president because nobody calculated i could win the presidency. with respect to immigration reform, i continue to believe that's in the long-term interest of the united states. we have a broken immigration system. nobody denies it. and if we continue on the path we're on, we'll continue to

have tensions with our mexican neighbors. we'll continue to have people crossing the borders in a way that is dangerous for them, unfair for those aplaying legally to im-- applying legally to immigrate, we'll continue to have employers exploiting workers because they're not within a legal system and oftentimes are receiving less than minimum wage, don't have overtime or are being abused in other fashions. that's going to depress u.s. wages. it's causing ongoing tensions inside the united states. it's not fair and it's not right. we're going to change it. now, i've got a lot on my plate and it's very important for us to sequence these big initiatives in a way where they don't all just crash at the same time. what we've said is in the fall when we come back, we're going to complete health care reform. we still have to act on energy

legislation that has passed the house but the senate, i'm sure, is going to have its own ideas about how it wants to approach it. we still have financial regulatory reform that has to get done because we don't want a situation in which irresponsible actions in the global financial markets can precip kate another crisis. that's a pretty big stack of bills. what we've been able to do is begin meeting with both democrats and republicans from the house and the senate, secretary napolitano is coordinating these discussions and i would anticipate that before the year is out, we'll have draft legislation along with sponsors, potentially, in the house and senate, who are ready to move this forward and when we come back next year that we should be in a position to start acting. now, am i going to be able to snap my fingers and get this done? no. this is going to be difficult,

it's going to require bipartisan cooperation, there are going to be demagogues out there who try to suggest that any form of pathway for legalization, for those who are already in the united states, is unacceptable and those are fights that i'd have to have if my poll numbers are at 70% or if my poll numbers are at 40%. that's just the nature of the u.s. immigration debate. but ultimately, i think the american people want fairness and we can create a system in which you have strong border security, we have an orderly process for people to come in, but we're also giving an opportunity for those who are already in the united states to be able to achieve a pathway to citizenship so they don't have to live in the shadows and their children and their grandchildren can have a full participation in the united

states. i'm confident we can get it done. oh, excuse me, i know this wasn't directed at me, but i want to make one quick point on honduras because you repeated something that i've heard before. the same critics who say that the united states has not intervened enough in honduras, are the same people who say we're always intervening and we need to get out of latin america. you can't have it both ways. we have been very clear in our belief that the president was removed from office illegally, that it was a coup, and he should return. we have cooperated with all international bodies in sending that message. if these critics think it's appropriate for us to suddenly

act in ways that in every other context they consider inappropriate, then i think what that indicates is that maybe there's some hypocrisy involved in their approach to u.s.-latin america relations that certainly is not going to gut my administration's policies. [speaking spanish] >> many of the people who work in the united states who live in the shadow, live in the state or come from jalisco, the state. these are people who have migrated to build a better future for their families.

all of them, or most of them, have enormously contributed to the american society and the american economy and it is unthinkable to see that the u.s., the main power, the main economic power in the world, disvalues the contribution of mexican laborers and workers. this is not only a good will statement. during our meeting, we handed the delegation the benefits of north america and why the mexican population represents in terms of the population of the united states. the only way to have sustained progress throughout the north american region, especially, is for allowing for the natural economic processes so immigration can happen, this implies the labor mobility that cannot be determined by mandate or decree. this is what we have underscored with president

obama during this meet to keep on invoking the protection for the mexican laborers, whatever their migration conditions are in the united states and our highest commitment to the way president obama has tackled this migration issue. now aside from defending the rights of the mexican laborers in the united states, one day, instead of the mexican people having to leave their country because they're hungry, we need an economic scheme where we have great investments coming from the u.s., hailing from canada, and opening here the labor opportunities that the mexicans so need. i think president barack obama has responded to the topic, or to the issue on honduras. what we have discussed and agreed is what needs to be done .

to build the international action that was been taken in order to re-establish democracy in honduras, to strengthen the o.a.s. and the group that's going to meet, to build the mediation actions that oscar arias, the president of costa rica, is carrying out in order to re-establish the constitutional law in honduras. this is not about a person or another. this is not about the president of honduras himself, per se, it is about the constitutional and democratic lives that ought to be defended in regards to the international legal framework we have all agreed upon and one more expression, i coincide in the contradiction highlighted by president obama. those who have rejected or have argued about the intervention of the united states in the

region, are those who now are claiming for the determination or the intervention of the u.s. in the region no matter how legal this action might be. so we have to resort to international law and international instances beyond the intervention of one single state or even more. the intervention of one single person to resolve such a dispute and such an issue. this is a path to be taken. today we congratulate ourselves that president obama is leading the administration of the united states but in the past that happened, but in the future we don't know who might be president next. i am not of those who share the idea that the u.s. are elected as the ultimate judge and the ultimate sovereign resolvers through the intermediation of the affairs in our country yes, we have to have -- our

countries. yes, we have to open the paths to organizations, for groups we have formed such as rio group, groups that are friends of north america, countries that befriend honduras, that befriend central america, that befriend guatemala. these countries must act on our own account, but in observance of the international law and the rules we have settled ourselves. we have to perform a group of friends of honduras that through -- with the help of oscar arias and with the help of the o.a.s. and their forthcoming action. >> just briefly, minister van lauden and secretary napolitano and other initials -- officials have been meeting on the question of our shared border, i think we have good

cooperation in that regard. there's always work to be done. let me be clear, from the canadian perspective, we look at our border as a line between the two closest countries on earth. we have the largest trading relationship of any two countries on earth, but we also share security concerns. i've said repeatedly, i'll say again, there's no such thing as a threat to the united states which is not a threat to the security of canada. that's why canada has been a steadfast ally of the united states, nafta, and norad for many, many years. we want to address the same security issues the united states wants to address and we want to do so in a way that doesn't impede commerce and doesn't impede the great social interaction which has made our two countries so close over the decades. i'm just going to also weigh in a little bit.

as a friend of the united states, on the question posed to president obama. if i were an american, i would be really fed up with this kind of hypocrisy. the united states is accused of meddling, except when it's accused of not meddling. and the same types of -- the same types who are demanding the united states somehow intervene in honduras, the same type of people who would -- who would condemn long standing cooperation between colombia and the united states, which is being done for he jate in the security and drug traffic reasons that are in the interests of all the countries of this hemisphere. mexico and canada are involved in the mediation effort l efforts in supporting the mediation efforts of president areas -- areas. i think the united states has

forcefully articulated its concerns and its outcomes in that regard and has been supportive of those of us working in the multilateral process to deal with this serious issue in the hemisphere. so, you know, i think that's precisely what we want to see from the united states is the united states that leads on issues of values but is very supportive of multilateral attempts to deal with challenges that we all face. >> coming up on c-span, looking at at first to change that

nation's health-care system. we will look at the white house roundtable on health care. and after that of forum from the alliance from health reform. they will discuss the health care system in massachusetts. dollars on tomorrow morning's "washington journal," andrew exum will talk about the political and security situation in afghanistan. after that, linda douglass of the white house office of health reform joins us. and in phoenix mayor phil court and on challenges facing the u.s. cities. and later, an update on the economy with gerald seib of the "wall street journal." washington journal begins every morning at 7:00 a.m. eastern on cnn. and then a comments on retirement and social security from lawrence summers. watch live coverage at noon

eastern. >> and now health officials from government and the private sector discuss proposed changes to the health care system. they look at a range of topics looking at primary physician care, medicaid, medicare, and government sponsored health insurance. hosted by the white house, this is about 90 minutes. >> we're talking about primary care. as you know, we're committed to enacting health care reform this

year. [unintelligible] primary-care is really important. right now costs make it difficult for patients to off board acted insurance and comply with treatments and medications. it is a fault in our system and we need to do something about that. to many patients do not receive the recommended care. our goal and the thing that many of you have been working toward in vermont -- good to see -- and are around the country is to try to do that and address these challenges which we wanted to buy working with congress and with all of you, including doctors and state health leaders who have engaged in some of these reforms. this is going to require changing the way that we deliver

health care. we're really gratified that some of you have already been engaged in that difficult worker we need to focus on improving the quality of outcomes, making sure that we provide preventative care, and better coordinating care for patients with chronic diseases. those are all things that primary care has a critical role in doing and trying -- driving the transformation that our system needs. we have gathered some of the experts in the field and some of you who have been working to do this around the country, to discuss some advanced models a primary care if they can meet the challenges that confront our health-care system. we believe that the reform we are talking about offers a major opportunity to improve the quality and coordination care, leading to improved patient care and experience, but also lower cost. i let board to hearing what you have to say about your

experience in doing that. we aired joined by leaders who are addressing these challenges. we have representatives from state medicaid programs, from health plans, and delivery systems, and position societies. we're also joined by academic experts. we welcome you to share your expertise on how we can improve and expand the advance primary care models. we have people from all over the country and people who have traveled a long way. we appreciate you taking your time to do that. i'm also joined today by several colleagues were working on our team for reform. i think we will start off by going around the rim is introducing ourselves. and then the doctor will have some remarks. why don't you start? >> i am a policy adviser overseeing the office of public engagement and intergovernmental affairs. i'm a primary-care physician by training. >> and i am nancy-ann, the

director of the white house health care reform office. >> i am with health and human services, and i might doctor by training. >> i am with the special office of health reform. >> i am ibm's general manager on health care. >> i am dan fields, with the national economic council for health care. published on a family physician. >> and the policy director for the medicare program. >> i am a professor of health policy at emory university and the executive director of the partnership to fight disease. >> i am chief of staff at the first lady, and i'm also part of the health care reform team at the white house. >> i work on the national

economic council on health care policy. >> i am a family doctor and i chair the department of family and community medicine at the university of california san francisco. >> i'm on the council of economic advisers working on health care policy. the oilers i am a senior executive for strategic initiatives. >> i am the director of health care transformation an idea and corp. in that primary care collaborative, an umbrella organization representing 400,000 doctors on primary care. most of the fortune 500 helps to drive transformation in the white weave by care around a model of care. >> i and the ceo of the american college of physicians and an intern. >> i am a director of the national association of public hospitals and systems.

i will emphasize the health system's part. >> i work a public health reform. >> i'm currently acting as a consultant. >> i am the director for the vermont health reform, and a pediatrician as well. >> i'm a family physician who practiced for 17 years before taking on thin year-old running primary care for a number of years. now i'm the president of the medical groups about delivery systems. >> senior medical director and principal investigator project. i'm here today dick from cigna. >> i am not family physician and with cigna healthcare. >> i and the deputy director on

health care policy and financing. our agency administers our public health insurance programs like medicaid and our s-chip program. >> i am a practicing internist and medical -- i work on a model called care management +. >> i am a family decision and with carolina health care system now. i am formally the medicaid director. >> i work with the national economic council were at work on health care and i'm an internist by background as well. i want to thank everyone for coming. we are thrilled to have a tremendous cross section of innovative practices and experts to speak about primary care. islet take a few minutes and talk about the opportunity to advance primary-care and frame the discussion that will haunt

all. if you don't mind, cut to the next slide. as nancy-ann said, we're thrilled that this year we are tackling health or in ways that will reduce cost growth for americans and their families and businesses, increase the quality of care, and expand access and choice to millions of people. today's discussion will be about improving the quality of care. around the table we have folks who have done amazing things to improve care. reform will only improve the acceleration of improvement there. on a talk about the changes that we see coming that many of you embody. the first is quality emphasized. we want quality of care and thinking about ways we can align incentives in ways that you have. we won a major the preventive care to not add to costs.

we wanna make accessible the everyway because that reduces costs and improve quality and it is the right thing to do. coordination is something that all of you have thought about. we need a system on how to coordinate care such that patients with multiple diseases actually get the right care for their issues and for each disease and that the carotene, which is a team, knows who is in charge and who is doing what and what needs that happened. there is a lot that goes into that and that has to be improved. we make sure that patients get their right clinically recommended evidenced treatments. too often we follow -- we fall short on delivering evidence- based care. there are a lot of reasons that that happens. we wanna make sure that the it figures out when it is happening and how to remedy that and get patients back on the right treatment.

you have bought for ways to organize care to eliminate duplications. finally, the connection with community. we have a system of clumsy handoffs between hospitals, specialists, community resources, and at least a lot of frustration for families and patients. it is costly and today we're gonna talk about ways we can get the communities and families and patients to get informed and cooperative in the care. and finally, expanding access to million people who do not have access to date. we're talking about primary-care today because primary care is too often not in place for enough patients. what was referred to in recent primary care is a doctor and a practice any care team hopefully who is responsible for ensuring that a patient gets the proper

care, the patient knows who to call, but they call them back, and if you have questions, u.s. someone who can answer, if you have concerns about accessing specialists, there is a practice that serves as needs for you. most of you deliver those types of care to your patient. it's too often not the case. in the care system of the future, we will absolutely have a more primary care system. it will be what we talk about today. i want to point out that around the table, we have seven systems to a poll taken primary care in different ways of with similar results. we will hear a story about how north carolina has saved $250,000 already. patients who are different and s than the population that allen is going to talk about. how colorado has really improved

pediatric care and had remarkable improvement in compliance in state metrics. how group heal4h@@@@ @ @ @ @ @ r we have some compelling stories today, and what is amazing is that we talked with the records about them and it is things that can be done widely in many places. these are not limited example. they could all be scaled and we will talk about how we can actually scale the said that more patients will get the benefits that we will hear about today. next slide. there are many differences but there are four things common to all of these practices. first, this notion of care coordination.

after a patient see. whether there's a followup process to ensure that whatever has to happen patients are reminded, physicians are reminded. it involves not just information technology but teams to take care of patient. because there's no one person in charge, there's jobs that need to be done by a full team. there's a much more patient engagement in these practices than in a typical practice. so patients know what to do. they're followed up in some cases so the patients are rewarded for doing the right thing. but they're much more education that goes into the care of patients in these practices than in many around the country. easier access. so in these practices when you call them they answer. and you're likely to hear a phone call answered on the first phone call. that's not typical in many practices. so they've come up with ways to make it much easier to interact. in some cases the practices are open nights and weekends, there's alternatives to emergency rooms and it's much much simpler to communicate,

sometimes by e-mail and other ways to make it easy for patients. and finally they're data driven. so each of these practices utilizes information technology to ensure the practices are reminded which patients are high risk, that the interventions can be taken before -- need age-appropriate screenings so if the appointment is not scheduled it's scheduled and happens. so we're going to hear a lot about how information technology makes care better. so i'm thrilled that we're going to get these stories and that there are similarities but also tailoring that's happened in each of these practices that it leads to better care for the patients. allen is going to go first. in the interest of having a spirited round table discussion we're going try to be disciplined about five minutes. we're going to hold up a sign that says one minute warning. and i have to cut you off when you go over which makes me very anxious. so i'm hoping we'll stick to that. because the discussion you know about your practices more than others. so we don't want to go into great detail but talk about what

you did and what happened and all of you have data to share in that regard. i'm going to have allen lead off. we'll hold the questions untilled end and then we can use the round table for questions. >> i appreciate being here and talking about primary care in north carolina. it clearly is now time for reform. and we really must -- to be economically sustainable we have to overhaul a fragmented system. and i think the first must be an investment in primary care. and i think the values and principles outlined in the joint principles of patient-centered primary care is outlined is a pretty good first fundamental step for reform. community care is an example of the value of just such an investment. we started about 10 years ago with this project. community care is a public-private partnership between the state of north carolina and 14 not for profit networks that are comprised of the majority of the local

healthcare providers in the state. and it's built around primary care. it also includes all the other physicians, local healthcare providers and in particular our hospitals, our academic medical centers, public hospital systems, health departments, social services and other safety net organizations. this partnership delivers the patients that are primary care to medicaid and s-chip recipients and other low income adults and children in our state. and our networks have now grown to over 4500 primary care physicians, the majority of primary care physicians in the state and 1360 locations covering all of north carolina, all 1 hundreds counties and manages a little over 1 million patients. and next slide. and this is what the math looks like of how the providers have self-organized themselves. community care delivers improved quality care to our patients and cost savings to our state using

-- primary care physicians serve as a medical home or personal physician for our patients. second, local not for profit networks decree -- are created as a virtual integrated healthcare system that links the primary care physicians and patients to the rest of the local healthcare system and support agencies. it's like the glue in the communities. these networks provide the needed physician leadership and local collaboration in order to create a local solution to improve care management and quality. this provides a flexible structure that has proved to us to be adaptable in the rural areas as well as our largest areas including our largest academic health systems. third the state funds the primary care physicians through an additiol blended monthly fee and also fund the network to provide additional local resources to the patients and the primary care doctors such as case managers, care

coordinators, pharmacists, medical directors and some local quality improvement infrastructure to make sure that we improve the care. this assures that optimal support is provided to patients and the results are achieved locally. community care has demonstrated quality improvement and cost savings and obviously phenomenal growth since it's now statewide. and has documented significant savings exceeding $100 million a year since 2003. and in short, north carolina has successfully managed the cost of its medicaid program mainly through a clinical management strategy rather than just a price reductions and regulatory control mechanism. so community care is now kind of the centerpiece of healthcare strategy in north carolina, is enthusiastically accepted by both patients and providers. again it's a value-added proposition. and it's in the community. legislature has mandated its expansion to s-chip and inclusion of mental health.

and community care is now working with c.m.s. on a medicare demo that will allow us to continue to care for the sickest medicare fully eligible and at risk medicare. we believe north carolina's model serves as an important national model for health reform. local infrastructural work both in urban and rural areas as well as public and private systems. the path for our reform efforts i think can be really informed by a lot of folks around this table and a really high-functioning health system. but the problem is that most of our healthcare delivery system isn't in the system at all. and so i think some of the lessons learned from north carolina show the value of investing in patients in primary care and a road map for organizing local communities

regardless of size or quality and improvement of quality. so some of my suggestions for improvement would be making sure we adequately reimburse p.c.p.'s. a blended payment to support those activities, making sure we have enough primary care doctors to meet the needs of our folks. also aligning -- we were able to align some policy and payment decisions to get certain access in comprehensiveness equation like after hours clinics. we need to fund additional care coordination strategies both at the practice and community level and provide the ability for flexible ability for primary re physicians and other providers to link together outside of a risk model. the big thing we learned was that you have to reinvest the savings to get growth in strengthening local systems and get meaningful and lasting growth. and there's a need for preventative services. and clearly there's a need for technical support for primary care physicians to undergo this

transformation, maybe through an ag extension model or model i the local community to support primary care efforts. appreciate the opportunity to be here and participate in the discussion. >> thank you. david? >> great, thank you. as i said, i am an internist and i practice infomatics as well. we study the way -- i like to do this in the context of a patient. so i'm going to talk about our care management plus pilot that we've done at intermountain healthcare and our subsequent dissemination at oregon health and sciences. gloria is 75, she's seen at mountain. i'll show you her picture with her permission in a little bill. she's active. she says her health is fairly good. she lives at home. she's doing pretty well but she has five chronic conditions that kind of accumulated. diabetes, she had a little bit of depression, she had cardiovascular disease and she's having memory difficulties.

and so we know just from that that she'll probably see an average of 13 providers a year. she'll fill 50 prescriptions. she has 90 times the risk of hospitalization versus somebody with no chronic conditions. and the 5% of medicare patients like her account for about 42% of the costs. and so at intermountain where this was developed these were the patients who really wanted to target in primary care to keep them healthy and at home. and so the model is simple. it's a care manager in a primary care team that has specific health information technology to help them. and we use that to help do care coordination, education, motivation and other tasks. we've seen some successes around hospitalizations reduced, improvement in mortality, improvement in quality and efficiency. so a little bit about the background. we started doing this in 2001. and in seven clinics versus six

controls, we basically built this system with the help of a care manager. they saw about 70,000 patients in those clinics, the care managers saw about 4700. and we compared these seven to six control clinics in cost, quality and utilization. our patient population was really focused on patients like gloria although they could refer whomever they wanted. and we've since in the last few years done dissemination in 75 teams at ohsu. so the model is simple. gloria would be referred by her primary care provider to the care manager, actually usually the care manager comes to the room and joins the visit. and then they work out together what gloria and her family need to stay healthy. and so the care managers receive specific training to do assessment and cocreate a plan, and then they have technology to really back up that plan and make sure it happens reliablely.

and so the clinics were very similar to clinics. intermountain is a large integrated delivery network but they had multiple payers. most of their pay did not come from special pay for performance. a small portion. so the care coordinators did this because the primary care providers in the system thought it was a good idea for satisfaction overall. the care managers saw about 350 active patients on average in the pilot. and the health i.t. really helped them to do care coordination tracking, to never lose track of a population or a patient who's at risk, a person who's at risk. and had a centralized reminder system that had protocols that also had kind of the ongoing task around social and other needs that these patients so often face. so scheduling and access was improved as well as a connection to the community through the i. t. and the evaluations were regular in the program.

the health plans initially was done by the medical group, but since then we've worked with several health plans and different payment models which i'll discuss at the end. and we've been working with federally qualified health centerrers in our dissemination as well as medicaid. so what are the results? i hit them at the beginning. i will discuss them. we reduced hospital admissions 20 to 40% and we improved guide line compliance about the same. we reduced mortality. so the patients in these intervention clinics were living longer. people with multiple chronic conditions are at high risk of an exacerbation of their illness that could lead to death. all of this led to significant savings which led intermountain to double the size of the program in the medical group and per patient what we saw about 640 to $1,650 per patient per year savings. we also saw the clinics were more efficient and people were much happier. the patients and their families called this a life saver.

they really felt like they couldn't live without it. and the fizz eggses really felt they could work smarter and the pressure on their primary care was -- the hamster treadmill that many primary care physicians phil they're on with 20 to 30 visits a day was lessened. the care managers even told us that computer tools were an absolute god send which is obviously near to my heart. [laughter] >> so we really felt like that was successful. and what we've done since nen is rolled this out starting at ohsu at more than 75 clinics across the country. and a lot of what i'm going to say for the summary is really going to be focused on what those clinics told us. so next slide. first of all we found that care manager role was essential. most of our dissemination clinics had a thursday but didn't have a care manager. we found nurses and social workers were great at this, although some small clinics needed a combination team that did the