here. >> thank you for coming. welcome to the best program in the world. >> i agree. [applause] i am glad you said that. in a few words, because a lot of people do not know about this, this will be seen all over the country -- tell me why you said what you just said. why did you say what you just said? just briefly, ok? >> i screwed my life up. i knew at some point that i needed some structure and i needed some direction. the other thing i mean to tell you if i used to refer people here. ok? i'm a vietnam vet. i've retired from the va in d.c. for 35 years. i know how to give back. i'm not appear to ask you for

anything for me. i'm here to ask you for something for this program. i need for you to network with your people. i need for mr. smith and mr. garfunkel to network with their people and open up these jobs, doors, open up some profit opportunities for people like this to be available. because we are here to save our lives. . >> this is about life and death. a lot of times i think people do

not realize -- and the reason why i have this sense of urgency is because that i know that somebody needs it bridge at a certain moment. without that bridge at a certain moment -- it is interesting. talking about bridges, i got a letter today, it is in my car, she is in prison and this is a lesson for all of us. this lady is in prison and she wrote me a letter, saying, congressman cummings, i wrote you and thank you for writing me back. because, she said, the day i got your letter was of a i had already planned to kill myself. -- was the day i had already planned to kill myself. you do not know what your action will do to affect someone else. and what you just said? i will remember that until i

die. and more importantly, it ain't nothing to remember. he gives me the incentive to act on it and i hope it does the same for my colleagues. [applause] >> mr. congressman, it is a pleasure to have you here. what i wanted to address -- a lot of us in here have done things to mess up our lives. we had injuries and other things going on with us that we need to address and what not. but then there are those of us in here who desired to do things to access some of that money, those financial funds, that have been released by the government, ok? but we don't have the educational skills or the training or the finances by which to get those things to learn how to write those grants

so that we can open up businesses and put back to work. if you give a man a fish, you can feed him for a day. if you teach him how the fish, he can eat for a lifetime. what i am looking to do is an organization that is teaching people have access that money, man, because you know, it's no good if you are out there. >> again, i am glad that you are bringing this to our attention. one of the things that is frustrating, i sit on the transportation committee and we are about two in 18 months or less put out this bill will $600 billion -- with $600 billion. has the disadvantage component, which means a substantial amount has to go to businesses owned by minorities and others.

but the thing that is frustrating is what you just said. although the money may be designated, the question is, had you prepare -- first of all, in four people, and then how you make sure that they are able to access it? so that they can dream big and achieve those dreams? i need to sit down and try to see exactly what we have with regard to that type of preparation. there are all kinds of folks that we could help, if they do not already have it here, work with the men and women here about finding those opportunities and preparing proposals and respondents, those kinds of things. i would be happy to do that because of that maybe -- do we have something like that already here? you do? you need help.

>> i am just talking about getting a job. >> i know. >> taking the next that up. doing a businesslike and but some other people to work. i'm telling you. >> because you are where i want you to be, all of you. we will talk about that. i will talk about that in a minute. i promise i will sit down with them and figure out if there are things that mean to be supplemented -- that need to be supplemented and try to bring the power of our office to that. and let me say this. the gentleman was so eloquent when he said -- you remember what he said when he started off? this is a great program. [inaudible] but, but, but.

he said something else. he is not satisfied with the program being a great program. he is saying, we can go to higher heights. that is what he is saying. and that is what we have got to be about. how do we take this to higher heights? and that is what i thought. i promise we're going to jump on that. we've got the staff member on long from the united states army. [applause] and see, believe me, believe me, if you have a super ally right here. she is so wonderful. [applause] last question and then we're going have to wrap up. the general public is invited to share dinner? oh, ok.

what is on the menu? all right, i know why he started laughing when i ask you about the menu. [laughter] stand-up, you are the chef. [inaudible] [laughter] [applause] >> good day afternoon -- that evening. my name is derek williams. my question is, what can be done to help veterans who had fallen by the way in the judicial system and got caught up and don't have any idea about the programs that are available? no, a lot of us had made poor choices, and several of us have mental illnesses, and some do not even know that they exist.

and be done to educate those people about the programs that are available to them said that they can seek the help that they really need, that they desperately need? >> first of all, tell me about this. dollars can i say one other thing? i came up with this question because i was incarcerated about a year ago in hartford county detention center. they do not have any knowledge about these programs. i am specifically about va programs and they gave me a paper they gave me no information about this program. his detention centers in the same state. >> how did you find out about the program? >> by going through baltimore behavioral health. >> interesting. you think we might need to do a better job of getting the word out about this program? [applause]

>> and i might add just one other thing. if i did not look through their entire resource manual, i would not have seen mcvets. it was on the next-to-last page. >> it is one thing to hand a resource and another thing to know about it. hello? we have to work to make sure that that happens. i want my friend a comment. and then i will close out. >> very quickly and thanks for your question. the dea has two programs and i don't know that we get to that facility. if not, we should. we have two programs to deal with this issues. incarcerated veterans, where they go in and talk to the veterans and tell them about the aid programs and tell about what is available when they get out. the second program is a new program that just started, working with the courts so that

a veteran gets arrested for drug use -- rather than putting the veteran and a jail, we work with the courts and say let us put the matter and into a be a facility and we have the veteran -- into a va facility and rehabilitate the veteran. [applause] thank you. so we have several programs that we are working with. a second one is just getting off the ground. i'll look specifically about hartford facility and see what is going on there. but is not expanding programs and over the next period of several months, we should be in those facilities and in the courts and maryland and d.c., western virginia, all of those courts. thank you. [applause] dollars i am very sorry. i was standing in line. i was waiting for the line to

get shorter. islet of last person but i was just sitting down. >> ok. >> i want you -- not want to thank you for coming every year. you give us hope and everything. i have made some bad decisions four years ago. i need is a mental health. i want to thank va, and neither could do everything but they took care of what they could not do, and they made sure that they took care of it. in all, i got all the schooling. i got all the help. i got mental health, and i don't have any benefits but i waited -- there is no way that mcvet will let nothing slide. i waited and i sat here. and this is my only time i get a chance to say thank you to both. all of my bad decisions

[unintelligible] they picked me up enough that that is my boss right there. i am telling you. [applause] and i had to wait a long time. i had to trust that they were going to do it. they kept saying the 02 n -- a setback sec -- they kept saying to go to mcvet. i wanted a chance to say thank you. [applause] >> there is a lesson in what he just said. sometimes we go through some hell, but we need to tap that sensitivity said that we don't look the other way art just at white people don't matter, because we have been for something ourselves. hello?

did the register? so we may be going through some things right now but we will get through this. we're going to get through this. colonel williams was to introduce one person and then i will close out. three minutes, and then there when have this chicken breast dinner. [laughter] for some of us. [laughter] >> thank you very much. i know most of the folks but we have women here, too. would you please come forward and give us some of your history? [applause] >> thank you. nice seeing you.

>> good afternoon, mcvets. ok, all right. [laughter] as most of you know, i'm a combat veteran of the iraqi war. i was over there in 2004-2005. many of you also know a little bit about my experiences, as it was posted in one of the annual reports. it was a little rough. it was a little rough in the beginning. i was still sort of new being a female veterans, finding out a lot of things, most of -- most of the time with you all. i am getting services like you all. there is no difference. benefits as well. i find out with you all. i no way back, when i was in the

military, things were a lot of different to see women out there. when we weren't fighting, we weren't carrying any weapons. were we even in the military? [laughter] and the lot of people really do not know that the women are out there doing the same thing that the men are doing, on the front lines. everything is green, now. nothing is you are a man or you are a woman. everything is green. right there in the trenches, you are out there on the dangers convoys, if you are out there manning the bridges, the same thing, carrying a rifle, shooting at targets and seeing

the same things men are saying. -- seen. going through the same thing, and to be honest, men and women are a little bit different. we have different things that we have to deal with. but out there is the same. i want to represent other women veterans and think the va -- and thank a va as well. there was a lot of education that i received. but there is a trick to it. everybody is not going to tell you everything. of course, you know that by now. if you want the information, you have got to go and get it, pretty much. and a lot of the information is available. some people, you are not going to be waiting. -- they are not going to be waiting when you trip to say, here is the place. i know that there were some

changes in me. i was a different person, period. my family, my friends, i was just different all the way around. i held that for two years. i knew that there was something wrong but i did not know how to address it. one day i just decided coming to know, there has got to be something in place for this. you cannot just go to war and they send you back home like nothing happened, you know. i cannot even walk to the clothing store straight. that was a problem. i sought the information out on my own. it took a while, about two years for me to be where i am now. [laughter] but i definitely want to encourage you to come to our one

for program. i encourage you to stay and to continue. don't forget those who are still out there. the information is here. do not give up on yourself. everyday that you wake up, that is a blessing. that is another opportunity. you're not where you could have been. a lot if you know where you could have been. thank god for these opportunities to know that, being low and being down, the only way to go is where? >> up. >> good for you. [applause] >> miss hunter, i want to thank you for doing that. i know you had not planned to speak. but i think you because you made me think about something else. how to sit down and talk to you

to make sure mcvet -- there are things that they need to be dealing with regarding to -- regarding women. you said yourself, things may be a little different in certain areas. and sometimes we need that sensitivity. i've often said that i would hate to imagine that congress of united states without women and i mean that. there are certain issues that we might not deal with effectively. i want to thank all of you. let me just close. i want to remind you -- they did not put this in my notes. this must be a serious meal. [laughter] >> we need good here, sir. >> please remember that the general public is invited to share dinner with the veterans. $5, and for the veterans -- [laughter]

please note that our experts will hang around until 7:00 in the veterans resource room. and i hope -- i hope that you listen to what she said. i hope you listen to what she said. it is not easy to get up and talk about this. but to business out in the street. i think the reason why she did that was one reason, not to make yourself feel good, but she knows that a lot of you are going through the same thing and she is trying to say, dyes, we have got to get you through this. and maybe we need to get through it with some help. so let's go and get help. am i right, ms. hunter? i am going leave you with this. back in 1988, another friend of mine, and jesse jackson sr., ran for president of the united states. everyone agreed that he did not have much of a chance for

winning. but the values he advanced in the campaign had been taken up by millions of american. and that led to barack obama being elected president of united states in 2009. so it is worthwhile to lick -- to remember what jesse jackson said back in 1988. some of you will remember this. jesse reminded the delegates that if an issue was morally right, it would eventually become a political force. he talked about how rosa parks did not have majority support when she refused to move to the back of the bus, but that rosa parks was morally right. he spoke of how dr. king was advancing an unpopular view point about the morality of the vietnam war, but how more laborite dr. king was. and that was the key. and then jesse jackson talk

about the courage to do what is morally right. come on now. what is morally right. even in the face of adversity. it raises as up and helps change the world to a better place. understand, all of this, the discussion we have had today is trying to get us to a point where our country does what he needs to do for you, and we are getting there. but that is what is morally right. that we do what we're supposed to do for you. jesse ended in these words, and they are written, and i think about this all the time, because it means so much. sometimes i think that we get a little down, ms. hunter was talking about going for some difficulty. sometimes we have a tendency to just quit. i give up. we cannot afford to give up. we need to twist our thinking a little bit and jesse said is. i am tired of sailing my little

vboat are inside that harbour park. i want to go out in the deep were the great ones are. and should not frail craft prove too slight for the waves that sweep those below is over, i would rather go down that way than drowse to death at the shelter short. but mr. hunter was saying that his brothers and sisters, we have to go where the big boats are. we may think that we need to be in a little harbor and not go well were the big boats are because we have gone through some difficulties, because we gave our lives, our sweat, and our tears for our country, because we have a low moments, because we may not have a job right now, because the economy is going through what the economy is going through, but

that is why we have programs and you coming to get it at talk about this. i did not ask to stand to be here. but the thing that you are saying today, they will be broadcast all over the country so that other folks can get to where the boats are. at get to where the bid boats are? your comments will go in the people will hear them, probably the president of united states will hear the comments because it was all meant to be. we did not even know this until a few days that we were even doing this. it is not just about what is happening in this room but about protecting and out into the world's said that we can get to where we have got to go. don't give up. i am begging you, i am begging you, please don't give up, because we need you to much. you've got too much to offer.

you have got too much to get. she said. ms. hunter said it. the experiences that you have, most people do not have. you bring with that, again, your education, your experiences coming your hardships -- don't forget your hardships. and the fact that you have compassion, there is no way you could have done the job going into the mallet to it -- the military unless you have the compassion. so let's go with the bid boats are. and while i am meeting -- [laughter] my chicken breast. and my wings. [laughter] i want to thank you all for coming. may god bless. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009]

>> up next on c-span, a conversation on health care costs in massachusetts. after that, more from the new director of the national institutes of health, dr. francis collins. and later, white house adviser valerie jarrett talks to bloggers and internet journalist about the health care debate, dtv interrogation practices, and gay marriages.

on tomorrow morning's "washington journal," a conversation on the detainees at guantanamo bay. after that, thomas schatz with citizens against government waste. "washington journal" begins each morning at 7:00 a.m. eastern. and later, remarks from health and human services secretary kathryn sebelius on medicare fraud. this week and she said that a government-run health insurance option is not essential as long as the measures increase competition. live coverage begins at 10:00 eastern. >> as the health-care conversation continues, c-span

is health care of it is our key resource. go online and follow the same -- the latest week's end video ads and keep up-to-date with health care events like town hall meetings, senate and house debates, and even up lead your comments with a citizen video. the health care hub c-span.org. >> now report on massachusetts' health care system. it requires all residents to obtain health care coverage. a report issued last week looks at the program so far and how to control future health-care costs both in the state in the nation. from the rand corp., this is 40 minutes. most of the policy options that we've considered are being currently discussed in the national health care reform debate. and in addition to the fact that policy options for cost

containment are being discussed in the national health care reform debate, there's also massachusetts has been one of the first states to ask health care reform. to see major components of the health care reform in massachusetts included a mandate requiring all individuals to maintain or pay a fine. a separate mandate for employees also requiring to offer health insurance to residents or to their workers or pay a fine. also state regulated options became available to make it easier for people to purchase health care if they didn't have access to a policy. the uninsured rate in massachusetts fell to 2.6%. this is a big achievement. however, it's worth noting that

going into reform, massachusetts has relatively favorite demography for reform. it was 8% compared to 15% nationally. the median income is higher than united states. and the poverty rate is lower than the national average. so far the reform has been successful at achieving close to universal coverage in massachusetts. but there's a question about whether or not the form is going to be sustainable. and a key issue relates to the sustainability is the cost of health care in the state of massachusetts. so here we have projected trends in health care spending in massachusetts starting in 2010 and moving to 2020. in 2010 we project the health spending will be $43 billion and will reach $82 billion by 2020.

one question is all sectors of the economy are growing over time, or at least that's the general pattern. so there's a question of how does it compare to other sections. it turns out we were able to constrain the health care cost to match the anticipated growth of gdp. we see it raising at a lower raise only to $71 billion. this is a substantial different, there's 7.7% cumulatively over the 11 years. one of the reasons we would think about benchmarking it if health care cost were to grow at the rate of growth of gdp, we wouldn't see health care consuming a larger and larger share. nationally health care consumes about 16% of total gdp, i'm sure you've heard that number a lot. do we want to see it larger?

probably not. this is trying to make growth match gdp growth. in order to address this we were asked by massachusetts to evaluate the effects of various potential cost containment options. our project involves three steps. first we had to select the options. then for each of the options that we selected we had to conduct and review to understand the background, the evidence, and the theory supporting the effects of those policy options. and then finally for options that showed promise and for which there was sufficient evidence and data, we then did a modeling estimate of what the effect of those policy on health care spending in the state. so the first step was selecting the options for analysis. and in order to do this we interviewed state holders in the state and we came up with a list of 75 different cost containment options. 75 was too much for us to do in a single study. so we narrowed it.

the way we did that, we grouped th reforms into five categories, payment reform, redesign health care, reduce waste, medical behavior, and medical malpractice. we grouped those, and with the client, we selected options a total of 21 options that reflected all five of those categoried to do more in depth analysis. and the options were selected to select the one that had the most momentum. one of the challenges we encountered in conducting this analysis that really to have an option that you think is going to be a very promising option, you really want to have two criteria. we like to have strong theory. but in addition to theory and logic, we'd like to implementation and experience or

evident to suggest that it has worked in practice. and so broadly speaking, the kinds of reforms that we considered grouped into two different categories. the first is regulatory reforms. and for regulatory reforms we have a lot of theory and logic about why they might work. we also have a strong history about implementing them in the u.s. in the 1970s and '80s. we can draw on that experience to determine how likely these options are to work currently the other set is market based reforms. we have a lot of theory and logic, but we have less experience with these kinds of reforms. a challenge with the regulatory reforms that were implemented in the test, it didn't necessarily show in implementation a very strong effect on health care spending. we want to think about considering these reforms again we have to think about reasons

why they might work better this time. and then for the market-based reforms, there's a lot of logic to support the idea that they might work but we don't have as much implementation. this has been a challenge, and it's not really a fair fight. one we have experience to draw on and we can sort of draw conclusions based on that experience and the other is relying more on logic. okay with that i want to go through the different reforms that we did select to consider. and out of the 21 options that we did the in depth review, we ended up with 12 for which we created model estimates. so the first four we considered grouped into the general category of reforming payment system. so i've listed them here. the first two reforms are more market-based orientated reforms. and the second two are more regulatory. and the very first is bundle

payment. and i'm going to through what bundle payment is and give an example later on in the talk. the second two policies relate to pricing for academic medical centers in the state of massachusetts. so this is actually, these two policies are very specific to the state of massachusetts. massachusetts has a lot of academic medical centers and they tend higher prices than community hospitals. these policies would be trying to reduce spending at academic medical centers that are not necessarily relevant for the u.s. overall. the fourth one is hospital all payer rate setting. that's a regulatory, and one of the reforms that was adopted in the '70s and '80s, and has been abandoned by all states except maryland. the second group of reformed that we considered fell into the category of redesigning the system. the first three are all about expanding primary care and

increasing the efficiency of primary care. and the last is disease management which is obviously about better managing chronic illness. the third group of options that we considered had to do with reducing waste in the health care system. we hear a lot about reducing waste as a potentialolicy for -- for health care savings. so the challenge here was articulating which policies used to reduce waste. we came up with three that might be promising, eliminating payment for some events. and finally accelerating the option of health information technology. and then finally we evaluated one reform that was in the area of encouraging consumers to maintain health. and that reform is called value-based insurance design. i think that bared a little more explanation. value-based is setting propayments for medical services so they reflect the value that a patient receives for that kind

of care. so they are frequently discussed in the context of pharmaceuticals, and so the idea would be for the someone with a serious illness who has a need, they would get a lower copayment than someone using for a less serious condition or something. and then before the modeling, i would say there were originally five categories that we considered. when we narrowed it down to select options for modeling, they fell into four categories. the categories that was left off was medical malpractice. we developed health care spending projections for the state of massachusetts from 2010 to 2020. and these projections adjusted for population change. and they also allowed for health care cost inflation. and we projected that over this time period massachusetts would spent $670 billion on health

care. an then we model what would be the likely effect of implementing policies on the health care spending. and for each model -- when we model these policy options we created an upper and lower bound estimate. upper bound lower bound takes a more pessimistic view. i want to talk about medicare before i move on to the results. so medicare spending was included in the $670 billion of total health spending projected cumulatively of 2010 and 2020. however, it was kind of challenging to determine how we incorporated medicare into our estimates. the reason that our charge was to think about policies that could be speed limited by stakeholders within massachusetts. and medicare is of course outside of the massachusetts in general.

and so for many options we assumed that there would be no medicare policy changes. and if that was the case it would not -- medicare would be unaffected. however, there were a few exceptions. the first exception was that we thought the waiver could be obtained and a particular type of policy. this really applies to hospital rate regulation. the evidence from past experience has just that medicare has been willing to participant -- participate in those options. we had medicare within the rate regulations. we also allowed medicare to be included either medicare enrollees or providers to make sure of the system changed. so an example of this is health information technology. we think the providers adopted health information technology, they would use it for all

regardless of who was paying for that care, and so that case medicare was included in our estimates. okay. so now i'm going to move to the results. and first just to orient you to how i'm presenting this, the red star here on the graph representing the 7.7% that we'd like to see deline between 2010 and 2020 in order to achieve a production that would match the rate of growth in gdp. the difference was 7.7% this is the target we're trying to achieve. the option that turned out to be the most promising for reducing spending at least in upper bound estimate was a policy balled bundle payment. as a payment we project would lead to 5.7 reduction in accumulative spending. so before i was -- before i go

with the rest of the policy options i'm going to go through what we did for bundle payment in a little detail. just to tell you what it is, and how we conducted these only analysis. with these service, providers are reimbursed to the service they provide. that could lead to the overuse of care. the total cost of caring for a condition and providing a particular procedure would be calculated and that bundle payment would be given as opposed to fee for service payment. the idea would be that all cares of the patients condition would come out of the bundle. the bundle amount is usually reduction for the condition or procedure. it would be applied across multiple providers and care

settings. and well this is one of the market-based reforms for which there is not tons of evidence. the limited evidence suggests that it would save money. okay. so we considered bundle payment for ten different conditions and four procedures. they are listed here. the conditions are chronic conditions such as diabetes and high blood pressure, colts procedures like hip replacement. there's a payment reform system called the promethus system. we were able to draw from that data in order to figure out how much it would save the state of massachusetts. so walk through the example of how it works, for a typical patient with diabetes, the average spending for that parable is about $6,000 per year.

but promethus has gone back and looked at evident-based guidelines. and they determined that 39% of payment for care is for evidence-based guideline recommended care. and the other 61% is for care that was potentially avoidable. and by potentially avoidable, i mean it could have been a test that was ordered twice so you got the same test results back for the same situation. or it would be something that became a -- became necessary but could have been avoided. an example of that would be an emergency visit for hypoglioseem ya. >> and in this situation we've said that the reduction on potentially avoidment payment would be 50% sop this causes the

payment for diabetes to fall from an average of $6,000 to $4200 per patient per year. now the reason that this is this gives providers some cushion, and it also gives an incentive to participate. if you are a provider and you can get your care level to level where you are only provided recommended care, you can make some money off the policy. we just multiplied that difference out between the $6,000.40 $200 that we expect and bundled payment, and we came up with an estimated saving. -- the $6,000 and the $4,200 that we expected in a bundled payment. mostly for coronary-artery bypass

conference. the lower bound estimate included only hospital-based conditions. and you can see from the side that there was a specially a 0 effect, so this was marginal reduction when you include only the hospital-based conditions. so chronic illness is really the biggest cost saver, and we don't have enough evidence at this point. who owns the bundle and allocates the payment? in an integrated delivery system, it might work well. but in a more traditional setting where they don't interact were communicate with the hospital or the specialist, it might be hard to figure out how that bundle is going to be allocated. there's t they are also difficult to develop in price. they used this from prometheua,

and it took 10 years to develop prices. and then there are unknown effects on value of care. one concern is by capping it the amount, providers would pull back not only on the unnecessary care but potentially care that could have been necessary. okay. so this just kind of goes back to the slide and shows the original estimate for bundle payment. turns out to the four options that were the most promises in the upper bound at least were options that were related to former payment systems. one of the options that show the most promotion are captions aimed at changing the health care. we also had three options in the middle in terms of the likely savings potential, health information technology was one, and two others are options that are aimed at improving the efficiency and expanding primary care.

and then there were three options grouped at the bottom. these options are creating medical homes with, and also encouraging disease management. if you can see the slide, for these options, they cross the line at 0, which means that in some estimates they can increase as opposed to decrease. all of these three options that they are about better managing illness for patient. and so in order to do this we have to invest in better management for a wide group of patient. and then the savings come down the road. hopefully some people end up using less hospital and emergency care because they managed it better in the first case when something started to develop. so the reason these might provide uncertain savings is because the spending that you have to give in order to better manage care is a certainly and a savings that come down the road are very uncertain. okay. to summarize. we have limited experience with

most policy options. the policy that seem to be the most promising at least in the upper bound are all used on reforming payment system. and the policy that were aimed at better managing chronic illness, they require investment that may or may not generate savings. weaver looking specificically at health care spending. we're not thinking about the value that's added in terms of quality of life that would come about. the we don't mean to suggest they are not good ideas, but from a spending prospective, they are not necessarily going to save money. the final conclusion that no single policy a magic bullet. bundle payment was the most promising option in the upper bound would leave to 5.7% reduction in the 11 year period. the target is 7.7% reduction in

spending. so we're not getting all the way to the target with any one of these policy implemented alone. and obvious next step would be to think about combining options. it turns out it's more challenging that you might imagine. we don't think in terms of projecting the likely effect. we don't think these effects are likely to be additive. for most of the policy options they are addressing the same sources. many of the policy options that we considered are about reducing spending that occurs within hospitals for conditions that might have been avoided. and so you can obviously only save that money once regardless of the specific policy that you'd use. we can't necessary add these together. we think it would be possible to come up with an estimate of how combined package of different reforms would effect health care spending but we haven't done that at this point, and it would be another project. so in terms of the next step we

delivered to the client earlier this month. the findings were released. about three weeks before we delivered our reports, they recommended global payment as a strategy to reduce health care. global payment is extreme form of bundle payment where all care for a particular patient would be bundled as a specific price and the provider would receive one payment per patient per year. it was provided by the payment reform commission is that bundle payment could be the first step on the road to global payment. i should mention that bundle payment at this point is not a lot of implementation. we are currently evaluating in four different sights. hopefully with that evidence we will have something to say about the bundled payments. okay. so that concludes the reported portion of this believing.

-- briefing. at this point i'd be happy to take questions from the audience. yes? [hushed conversation] >> how reliable would it be if you were to have a disease and you were to get a price on how much to pay for that disease, what would happen if other diseases came about as as -- because of the former disease you have. how would bundling be able to excel sate, and how would you compensate with the cause of different health care : this make sure that the quality

of care does not suffer. and the second question, additional villainesses -- illnesses, they would be risked projected. it wouldn't matter for a different patients. -- it would depend on different patients. yes, tony? >> 10-year note -- explain the difference between us to terms? >> a little payment is for one meticulous care. we also think the bundled payment or global payment being coupled with a different performance incentives. that makes sure that the quality of care business ever. that is not necessarily the case with capitation. >> the emphasis on the bundled payment for chronic care

patients, it might be reducing their use of the e.r.. most of the bundling i have seen talked about in demonstrations are opposed to acute-care. is anyone evaluating the pre- acute-care to keep them out of the hospital and the first place? >> i am not aware that is under way. this is my co-author who might be able to answer that. [inaudible] >> in the back. >> could you describe how the bundled payments is evaluated with different.

[inaudible] >> so the bundles are based on those 10 conditions that i presented earlier so they were payments, they were intended to be payment for chronic conditions that would be an annualized payment per patient per year. for each payment with that condition. and then there were also four different bundles that related to sort of acute episodes of care like a geriatric surgery. it would cover all of the care that went along with a geriatric surgery, whether it occurred before, or after that was related to that episode. [inaudible] >> with bundled payment we would assume it would take three to five years to get fully operationalize and then after that we would see the savings accruing overtime for the period between 2010, 2020.

[inaudible] >> no, we only look at the original case, the state regulatory board. yes, was there another question over here? >> is increasing prices charged such as pharmaceutical questions or manufacturers of medical technology, increase their pricing play in projected costs of spending in massachusetts? and our price controls off the table? >> we didn't evaluate either of those off options. i can't speak to that. >> why didn't you? >> we had the school to evaluate

about, we started with about 75 different options and we narrowed down to 21 based on what stakeholders and what our client our most important to consider. that's how we narrowed it to 21. the ones we left off the list weren't promising, they were just options we didn't have the scope and resources to evaluate. >> the bundled payments that they have come up with, taken into account geographic area asian? >> that is a good question. i will ask peter. is bent and baltimore with the prometheus analysis. >> where they analyze what the prices in a particular market, but also potentially avoid the use. so they are tailored for the

program. [inaudible] >> they are in now. [inaudible] who does the bundled payments go to? is that the hospitals or providers? how does that work? >> that's a good question, so if it were -- i think the model would be typically two integrated so that the primary care provider for the patient was holding a bundle but how that would work in practice is difficult to say. we could see it working well in integrated delivery system but mormore challenging temperamentf there wasn't a link across different providers.

[inaudible] [inaudible] that is not one of the things that we considered. it turns out that the three options are in the middle, and two of those are delivery reform. for example, substituting low- cost -- lower-cost primary-care providers for indies. . -- md's. . [inaudible] >> so as we modeled it for that option we really only considered it fairly narrowly to focus on substituting for primary care dividers to see more nurse practitioners and physician assistants as opposed people with mds.

we discussed that could be implement more broadly to encourage the greater use of primary care physicians over specialist and there will be other examples of how that might other examples of how that might work as additional questions? follow-up? [inaudible] >> and now safety net providers are able to adopt if it isn't? >> so i'm not sure that the analysis that we did spoke to either of those specific questions that you raise. the way we talk about health i.t. is having savings across a number of different dimensions, including sort of reduced paperwork, reduced or better drug prescribing so there is less redundancy and unnecessary drug prescriptions. i'm trying to think about the other areas. nursing time, so that would be a savings to nursing time from having a health information technology of a low.

we had several categories of savings that we consider that went into the health information technology kind of pricing. yes. >> so notwithstanding the estimates that you got from the changes to the health care delivery system, given that bundled payments scenes, upper bound at least, estimates seem to work in the case of integrated delivery system, at that point in argue for the medical home concept or some other concept that does integrate the delivery system, vertically, horizontally, however you want? >> we did discuss that a little bit. in order to implement the reforms you might need a structure like a medical home structure underlying. in the payment reform report for the state of massachusetts where they talk about implement global payment they discuss it in the context of accountable care organizations which will be similar to linking dividers.

>> ended with the global payment without having these kind of other delivery systems? >> i think the idea would be to implement them in tandem, yeah. yes. >> consumers slash patients, what are some of the costs of downside of the bundled payments? >> i think the biggest downside would be if quality of care could be negatively affected in some way by capping the bundle at a particular amount. so the way that would hopefully be dealt with would be by implementing performances and synods alongside bundled payments to ensure the care was being delivered appropriately but it is a little bit unknown at this point. it is something we need to study further. >> bundled payments are a new concept. they started 20, 30 years ago i think when managed-care was first introduced in california. can you think of, for instance, can you give a concrete example of a bad outcome for a patient

because of bundled payments? >> i can't necessarily get a concrete example, no. other questions? yes. >> he thought about how some of these estimates may change at the national level? like for instance, does massachusetts choose nurse practitioners for a lot of care already? >> that's a good question. we have actually started doing some estimates at the national level and are hoping to develop a white papers in. i think that sort of the biggest difference is the national level we can certainly envision medicare playing along. so that would mean the savings potential for many of the different reforms is bigger because medicare consumes such a big portion of total spending. >> in your modeling, how did you assign a role for medicaid? because at the state level, that's the big consumer of state budgets.

>> right. we use data from the medical expenditure panel survey and we used the dissolution of the medicaid spending that was in an altered that spending basically in the same way we altered spending for other payers. okay. are there other questions? all right. thank you very much, everyone, for your time and i would be happy to take questions afterwards if you would just like to contact me personally. thanks again. [applause]

as the health-care conversation continues, the one line and follow the latest police, the deal adds -- the latest tweets and town hall meetings and senate debates and even up load your opinion about health care with a citizen video. the c-span health care hub at c- span.org/healthcare. >> tomorrow morning, an update on the afghanistan elections and security support. we will hear from the security assistance force. live coverage of this pentagon briefing begins 11 eastern. letter the day, and -- later in the day, the president of the national emergency management association is at the heritage foundation. live coverage starts at 3:00 p.m. eastern.

now dr. francis collins, the new director of the national institutes of health. shoot for release but -- oversaw the human genome project to provide a complete map of human dna. this is the first news conference since august 7. we begin with some of his priorities as director. >> in my presentation to the town meeting this morning, i tried to outline five specific themes that i think are useful in terms of betraying particular areas. i will do that briefly for you now and then i will be glad to answer your questions.

these are broad strokes themes. i was worried about bringing up anything with an area of interest if someone doesn't hear their favorite technology specifically. this is not a laundry list. this is a higher level. i think these are right for even more vigorous explanation. that is to apply the truly remarkable opportunities that are coming forth through high throughput technology such as nanotechnology, chemistry, energy, computational biology, an environmental science. all of those areas undergoing abortions and their ability to collect that. sometimes, something goes wrong and disease occurs.

in the past, investigators were limited in the kinds of questions they can ask and how they could approach biological problems. we had to study this particular physiological phenomenon. we ask what all of these are. what are all of the ways the development did you away from a single cell there are areas that are ripe for this. we cannot determine all the reasons that a good sell goes bad. -- that a good scell goes bad. this is something that is ripe

for expansion. the same thing can be said about autism. there is great concern for parents and the administration for all of us to understand this puzzling and frustrating disorder. some of the environmental science and some of the economics are poised to be able to answer this. things like the micra bottom. this effort funded by the road map. when balance property, they are -- properly, they are good for a spirit of this approach to a controversial -- comprehensive understanding has never had a better shot as it does right

now i would like to see that be one of the things that we try to apply. a second team will be a focus on translation, to take the basic science discoveries that are bursting around us and bring those to bear in the direction of the development of diagnostic and preventive strategies obviously, this is an area where public/private partnership is crucial. we have seen the beginnings of efforts to empower academic investigators these are things like the small molecules program. many investigators in the past assumed someone would pick up the ball and run with it after they make a discovery about a rare disease and they are now taking that next up, themselves. i think that nih colin in investing in those

opportunities, the cook partnership with the private sector. even if the market is not particularly large, it becomes more attractive for pharmaceutical companies to pick up a particular product a long way. i think that it's nicely with were the science is going. we will come up with those puffball along the lines, there is increased investment, given the fact that we now have final guidelines about how to review the embryonic stem cell lines.

and that we have the new development of the potent stem cells for the application of a long list of diseases. this is clearly what we want to see push forward. the first two areas are applying technologies. the third one fits very much where we are right now. i think that nih should be right in the middle of that by not providing political advice. that is not what we do. for less evidence that will be useful in this decision makers about directions that we need to go in to produce better health care for our nation and also to try to rein in that scary kerf

of reducing health-care costs. that means putting science to work for the benefit of health care reform. you have probably heard quite a bit about this to assess when there is more than one possible intervention. phew hoops i am not sure that it was called by that label. we already are as part of the stimulus. this would assist in the process of making wise decisions about american health care. there have to be -- you would not want to lose the individual

in this mix, but there are always to balance that. along with this area of science would be varco genomics to reduce the number of adverse events and to increase the effectiveness of the drugs that we have. along with that, there needs to be focused on how to implement preventive that will require good science and focuses on that equation. what is it that motivates people to receive this sort of information. help disparities will also need to be a major focus of this conversation on how to practice therapeutics and that is

something that i am personally interested and. -- interested in. a fourth team has already been invested in considerably by other organization and that is global health. our national effort to try to exercise soft power as part of diplomacy and as part of our american personality to exercise benevolence to the world has been very strongly promoted. it has that same motivation as a central part of who we are. we do support a lot of global health. particularly in areas like tuberculosis. there are attempts to look at non communicable chronic diseases. i think there are opportunities to look at some of the diseases i have not -- that have not -- [unintelligible]

there were new ideas about therapeutics. in the same way that rare diseases in the u.s. may need some help to get them boosted along the development of a therapeutic pathway. not so rare diseases suffer from a compelling economic motive and could be a benefit by investments that nih could make. i personally, for some time as a volunteer position, see this as a great and compelling opportunity. finally, the fifth team is about reinventing and reinvigorating and towering the research community -- and in powering the research community. to emphasize the diversity of the workforce and frankly to try

to achieve something in the term of [unintelligible] it is intensely disruptive and demoralizing to our scientific work force and we can no longer just assume that america will continue to flourish regardless. you see lots of other countries that are achieving much more impressive and predictable funding trajectories right now and perhaps have been doing so in the past few years. in that regard, perhaps the concern that i have that wakes me up already is what is going to happen after the two years of the american funding expires. that funding has to be spent and is being spent in a very creative way and you'll be hearing a lot about that in the next couple of months in terms of what we are doing to invest

those dollars in highly innovative signature initiatives. what happens when we get to ask why level? -- to fy level? that would result in success rates. the opportunity that, for the challenge grants, which we put forward as a major new component of what the stimulus money might fond, expecting to get applications and be able to fund like three or 400, they'll have to be reviewed. it has been reviewed.

the funds need to be awarded. there is fabulous science there. this tells you what a pent-up demand and opportunity exists out there. obviously, the success rate is born to be really low, maybe 3% will actually get bonded when the dust settles. the rest will presumably come back as applications next year and a year after. so, we're going to see both a potential falling off of the cliff if the fiscal year 2011 is stimulated by this economic opportunity. a perfect storm, if you will. i think you can make the case with great compelling logic that the support of biomedical research is of value.

it is almost unmatched in terms of its peak -- in terms of its economic returns and longevity increasing by one year every six years. it can be traced to our research and every dollar that goes into a grant returns about $2 and a quarter within a year. this is a very good place to put funds. obviously, there are going to be many other concerns that the appropriators will be wrestling with in terms of the future of where the discretionary budget goes. many of those other needs will also be quite serious. this cannot be considered an easy conversation with an easy outcome. again, if there is one area for myself, i feel it will occupy

the most intense energy to make that case for the success of our nation's leadership in biomedicine. to achieve that kind of predictable funding so that a young investigator that is starting a career in biomedicine has the confidence that there is a career for them. that has to be our number one priority in the coming years. i will try whenever i can, and maybe with your help to try and make those points to those i hope will be interested in hearing it. i am going to stop here other than to say that i hope to lead a phase of nih when is an important feature of everything that we do. that includes being open with the press in the case of what questions you have. thank you. >> the thank you very much dr.

collins. >> i will open it up to questions. gestation name in your affiliation and then we will go to the phones. >> donna young from a bio world. i would like you to expand a little bit when you said fiscal year 2011 is what is keeping you awake at night. i am assuming that you are already trying to come up with how your want to present this to congress and the american people. what are some of those stains that you are working on to be able to make that jump from the fact that you need the dollars to do the research into the importance of wine. >> it is my first day, so i have not completely formulated and will the prolonged plan that is more to be necessary to make this case but i think i can mention a number of directions. clearly, to simply make this case on the basis of a success

rate is not want to be sufficient. we have often pointed to that as something that matters a lot. it will be a reflection of the enterprise console that will be on a list. but the skeptics will say that maybe you just have too many investigators and to many grants and you have overfilled the pipeline and to the shortfall. i did not agree with that. i believe our pipeline is under filled in terms of the promise, but we have to go beyond success rates to make the case about the way and which scientific opportunities are truly unique. those five teams will be part of what i will try to talk about. i think i will also need to make the case about the economic returns for this kind of investment of public money which

is extremely impressive when you compare the degree to which a dollar of nih money feeds back into the economy. one of the things that i would like to spend a little more time looking at, and we already have a plan for a quick brainstorming session, is to make a case that has not been generally heard. this is actually a way of identifying pathway is towards health care options that are not expensive. if you look at our cost per person, is out of line. there is an assumption out there that many of the commentators talk about this and talk about [unintelligible] whenever nih does another study, health care gets more expensive. and there are counter answers to that and i think that we need to be putting forward

information of that sort. people are looking at the scary trajectory of our cost. that is 16% of gdp. we have to been that curves. it puts it forward. it will put together optimal therapy is and comparative effectiveness research in new innovations to do a better job of treating diseases with compounds that will be less likely to cause toxicity. all those things have to be part of the case to be made. the bottom line, it has to be put forward and it has all of these potential benefits. furthermore, if you do not figure out a way to do that, you really are not at risk.

they can only stand so many of these ups and downs before they decide to go to law school or do something else that is not going to meet this vision that we all have for what nih can become. >> previously, he voiced a vision for a very broad cross sectional, long-term study in which everything from kitchen gnomic information to nutrition to environmental exposure is included. tell me how that vision looks now coming into an agency that has a very robust budget and especially with current focus on research that can produce a direct economic benefit in a short time scale. >> that is a great question. >> i have been enthusiastic for five years. i published a paper about this.

enrolling individuals numbering up to half a million and a million. hi selected them across the country through social economic and agent population background to be a snapshot of our country and then collecting information on all those individuals as far as their medical experiences and their genetics. this was studied intensively by an expert group of about 60 people. it got all the way to the point of getting pretty specific in terms of saying exactly how study could be run, down to what clinical items could be determined every four years. the cost of this at that point can out to be $400 million a year for half a million people. that was a draft of that

particular protocol. i think that attracted a lot of interest. the price tag never really got off the ground various proposals were made about cobbling together the existing prospective studies that are being run by some of the institute's. and they create a virtual study. it would not work nearly as ideally as you would like. it would turn out to be very heavily loaded with older individuals that were turned out not to have the geographic racial representation that you would like to see for a study of this sort. it would do very much a second choice. i think that perhaps we could look at the opportunity of doing something along those lines.

but i will be bold and say that if we do not start a study of this sort, present, we will be kicking ourselves when we wish we had the data. in many ways, a study of this sort might preclude that. it is not an easy case to make for a high price tag of this sort. now that i am here, i would really like to initiate some more conversation about this. we have a study that is somewhat similar to this in terms of its national snapshot. it has been under a pilot phase already and it has many similar goals. it will not tell us much about

middle-age or delayed onset disorders for very long time. if we are interested in knowing more about diseases that afflict people in mid to late live, we would probably need another way to get there. i would like to see the conversation explored a bit further. maybe there is a way. a lot of this will depend on what is done with the resources. >> just a follow-up, is this something that could be funded with the common fund? >> certainly, the common fund, as most of you know, is a component of the budget that is legislated as part of the authorization act. it has the intention of supporting projects that are not appropriate for a single institution to john benon.

in terms of the science, it would be a fit. it is about $500 million. this would be 80 percent of it. i would tell you that the common fund is supporting a lot of exciting science. there is not going to be a large amount of money coming available for new initiatives. there is a provision in the authorization act for to grow and that is only if the budget as a whole grows. it is coming back to where we were in several of these iterations. it will be very much dependent. in an ideal world, the common fund might be a sensible place for resources to come from.

i was wondering, you mentioned taking on some of the risk. i wondered if taxpayers expect the should have that? >> there is a sensitive topic. those of you who have been around awhile will remember the debates about reasonable pricing clauses 3 it that made it very clear to me, watching it, that this was a third rail for the pharmaceutical and biotech companies and the idea of there being some kind of government intervention in setting pricing. that would make them very uninterested.

the idea, here is a trend. this started with two to $4 million. the idea is that there may be an investigator who understands something about the disease. it sets off a light bulb about a new possibility of an approach to therapy. that could be approached with what we now fund. each one of them is a midsize pharmaceutical company to begin to screen for compounds that might have potential benefit. trend then allows the next step for the products to go forward were you have a promising compound, but it has to get

across the valley of death and the ability to [unintelligible] that is where many things get lost. trend will unable them to go to that process. and of the other end of that should come as attractive factor. one would hope that it would be of interest to a biotech or pharmaceutical company. that compound will have the intellectual property attached to it. so the model that people are talking about will be through a licensing opportunity in this would be competitive so many companies could ask to be given a crack addict. an arrangement where the compound as license, the ticket for clinical trials and a

license involves royalties that would then return to the government to support research if the product makes money. your not regulating the cost of the compound. that seems to be the deal breaker. your engineering as system that allows some payback to the public. what we will go to the phones, too. >> with regards to translation, you mentioned increased collaboration. will there be any increase cooperation with other federal agencies? >> absolutely. i am glad to ask the question period is really important. certainly, for me personally, what to build a very strong relationships with other agencies.

the fda would be at the top of that list. i know peggy hamburge from the clinton administration and i know that by speaking to her, she is strengthening those relationships. i think there are needs there. in particular, when it comes to rare diseases, there are issues were the standard fda approach may not be very friendly. likewise when it comes to final approval. sheik pete -- she seems very amenable to how we can do that. i think relationships with cdc should be prayer or caused.

-- should be prioritized. nih is often the producer of the clinical study is an art is often in the position of trying to look at an analysis across multiple studies and draw conclusions. d>> we will take one question from the phone and then we will go back and forth. >> dr columns, one of the questions that came to mind for me when you talk about the need to continue the funding beyond 2011 when the other funding runs out is the need to continue with

your researchers in the pipeline. all throughout the federal government, there is concern about the retired way that will move through as more and more baby boomers reach retirement age and decide to move onto another phase of their life. how do you understand the challenge in that regard? how might that enter into the discussion about trying to keep the funding levels to keep the younger researchers working? >> the demographics are complex. they are somewhat different i need to know more about this. it is certainly true that the administrative staff has serious concerns.

that is about the likelihood of retirements and sharing -- and sitting our work force with a lot of people who labored so effectively and are approaching retirement age. we will have a less vigorous pipeline. in terms of the workforce of scientific investigators out there in universities and institutes, it is a little less of a problem because science has been growing at an exciting rate. there has been a lot of interest. not enough, i would say, but a lot. the graying of the research enterprise is not quite as much of a concern in laboratories, doing bench research. but even with that said, i think

the most major concern we would have would be in the young scientists that are just starting their careers. they're in a fragile state. you go through many years of graduate school and you often spend it many more years as a post doctorate fellow because it is so hard to get supported, a young person is not funded until they are after 40. if you lose that person at that point, that is a tragedy. you have lost their future scientific contributions and has spent all this money on training that person to be cutting edge scientist and now their own to go off and do something else. of all the issues in terms of generational ones, that has to be number one. >> we are going to go to the phones.

the first caller, please identify yourself and your affiliation. thanks. bucs it always takes a minute. >> no questions. >> thanks, following on that last one, you were talking about encouraging more young investigators. what are you suggesting? is it tied to the budget being larger? is there a strategic way to make that happen? >> nih has been very creative about this and it is good that

there is some diversity. many of the institutes have programs were young investigators are coming in with their first application and get a special leg up in the review process where their priorities scores or improved slightly above the fact that they are coming for the first time and councils take that into consideration when they try to figure out how the to the funding. that is not the ultimate solution. if you have a budget that is not too limited, and then they come back after they have had their first successful grant and they can i get a second one, then you have not really solve the problem. i think we need to do something about the aging of the investigators before they come to the first application where the average age has crept up to 42. that is before you get your

first independent grant funded. one thing i have wondered about, and this is purely blue sky, and that is whether we can pilot, on a small scale, a program that is famous at the white hit institute. you take a promising student that has finished their ph.d. and instead of requiring them to go through six-seven years of post doctoral fellowship, you give them a small amount of resources, a laboratory, a technician and a mentor who can guide them as far as not making missteps, but it is up to them to decide what the project is that they will work on. that is not for everybody. postdoctoral fellowships are good as part of training for a lot of people, but for an exceptional person, such as a joke receiv[unintelligible]

this might be a way to get that person going while they're still young and full of spit and ginger and ready to set the world on fire. i think that kind of thing might not be a big contribution. >> bucs could you talk a little bit about your priorities combating aids ward in one and administering the vaccine? >> bond due one there is a remarkable arrival of this on the scene of the swine flu virus. i am not want to tell you anything that you cannot derive by looking at the extensive information that you can find on the web at the flu.gov website.

there were no less than three cabinet members that appeared and i was very impressed but level of knowledge and detail that was presented at that meeting and how much that clearly involved people at the highest level d. when i have questions about the swine flu, i know who i can go to to get the latest plan. as you know, there has been a decision made about particular groups that are high risk. this includes pregnant women. this is a strong effort to try to move at a prodigious pace

obviously, everybody is holding their breath. this has a very high in the activity. the virus will behave very much like it did in the spring. there are fears that it might acquire increased virulence, but that has not materialized. at the moment, i am melding information that i heard from others. if you want the real scoop, dr. tony. dr. collins, congratulations. i will not ask if you have composed a song. >> that was considered and rejected by those who have better judgment than i. i was considering it and i

thought it would be undignified. >> we will wait for that. >> two quick questions. some research advocacy groups are calling it a goal to work for. i was wondering if you resonate with a particular number. you mentioned peer review and innovation in the same sentence. there are many in the research field the believe that there are finding -- fundings. the takeoff path of least resistance proving the most innovative science because there -- there is just simply not enough money to go around. two great questions. thank you, susan.

i can promise you that if that were to come to pass, it would be a wonderful idea. if you simply look at what has been lost as far as buying power since 2003, setting aside this two years of the stimulus package, the lost about 17% and simply to try to recover that would bring the backup into the range of $36 billion. i guess one has to balance the opportunity with the reality. if you want to do the math and ask what it would take to stay on a stable trajectory that would mean there was an extra 5 billion in the budget for 2009 and 2010. if you wanted to stay flat with that, it would carry you to 35 and if you wanted to see some growth potential, you need to go

a bit higher. those are just numbers. obviously, there are many reasons why the nih director has to be realistic in dealing with this. when you ask for a professional judgment budget, 40 billion would certainly fit in that envelope. in terms of innovation, this is a chronic issue. the question about how to stimulate innovation has come up repeatedly. half a there is a great concern about spending even $1 on a project that might fail when you have in front of you very credible people. that might be the wrong decision.

it is interesting that we have met the energy in terms of the opposition to innovation and it is ourselves. if you're the scientist that said it was highly innovative and it got dean, you were offended by the process. that same scientist babysitting on that later and joined in with a chorus. maybe we should let them come back for another application because we have all these others. if we're serious about innovation, we have to mean that. we have to see grant's supported that ultimately failed to produce because they were too high risk. they are trying a lot of things. things like the new innovator of grant. a like a pioneer grants were you

ask people to come up with a nearly ground baking -- groundbreaking report. those are a whole new category of support the requires innovation if you're bored to get on the on ramp. when it comes to the rank-and- file what goes on in study sections, this is an issue we have to pay close attention to their was reviewed of a process that was ably led by jeromy berg and reported about a year ago on a number of recommendations to try and do a better job. the steps that were recommended by that group are being implemented now. some have been some are almost there. it will be interesting to see

how much of a reinvention be achieved and how much do we need to go back and looked at again. i will tell you that this will be a very high priority to make sure that our system encourages people to do things that are not obvious. that is what we should be all about. >> there is time for one more question. >> is it fair to say that you're holding out for some comparative effectiveness research in return for a more steady funding source? >> i would not say it quite like that, but i am saying that it should not be a reluctant partner in trying to understand how we could best modify health care.

that is part of our mission. it seems that that mission is getting particularly high priority for reasons that i resonate with. i do not know that i would say that it is a carrot. it is a circumstance where we are raising our hand. it is going to cost money to do these research efforts. we need to have a conversation about that. this is being driven by the scientific opportunity. >> what we all appreciate this debate, i enjoy the musical reference. that makes you relatable.

the american public wants to be engaged in what is happening. explain to the american public why this agency is important and deserving of the funding. >> that is a big charge in something that i agree. most of the american public does not recognize this as meaning anything. i think that we have an opportunity in. maybe i should start treatiweet. this is the next generation of young people excited about playing a role.

i would like to see this as a serious opportunity to be more visible and to be more proactive and not simply wait for one of you all to call us up and ask if we have a comment on the following. not a way that we would try to be still promoting, we have a lot -- still promoted. we have a lot going on. i have a list of the exhibit like to accomplish. i have that list of my pocket. i might be embarrassed that i only get three of them done, but one that i have is to try to come up with a communications strategy that has a broader

impact of let's the public know what we are doing. you all can help with that. >> do you think that congress recognizes the importance of nih funding to the small business community which is america? >> congress are a bunch of citizens of the u.s.. certainly those that are in the position to have the largest influence in the appropriating to get themselves informed. every member of congress brings their own personal experience to the table and if they happen to have had a personal experience, that are likely to be much more jazzed about what we can do. one thing i think we should do more of is to have our grantees invite someone so that this is

not so hypothetical. i hope we can see more of that happening. >> this does not preclude individual interviews. i just wanted to know that you know that. i will give you the floor and then we will wrap up. come to us if you would like to have some follow-up interviews. >> just too quick questions about here on campus. i was wondering if there is any immediate plans for infrastructure plans or any changes to the heads of the institute and a second, unrelated question is if we can expect the stem cell registry any time soon? >> good questions. as far as the upper structure, you may know that there were funds put in. that was wonderful to see because that was a number of

years that they have very little financial support and a lot of buildings and infrastructure have suffered as a result of a lack of basic maintenance to be able to carry out, but with this influx of funds, we're in a better position to be able to catch up on some of those things that have been delayed. in terms of a stem cell registry, you have seen the final guidelines about stem cell research. it involves the convening of a working group that will be empowered to look over the evidence of various stem cell lines that have linked up to the standards put forward by the administration in terms of informed consent and so on. of that working group will be assembled quite soon and will begin their work. the way that this works out, as

you probably noticed, an investigator needs to come forward with a proposal. they do not go out to try to do goes out of people. we hope that the lines of greater scientific interest will come forward first. i cannot tell you what the timetable for that is going to be in terms of how long it will take once the working group is impaneled and the applications begin to come in, i do not think that is quite clear, yet, but i can tell you that this has got to be a high priority to get this done to turn loose of the incredibly creative ideas. we will see or we can go with the field that has been moving more slowly in the past and that is something we will have a chance to do. . .

>and for that reason, they thought that would not be a great idea to go out and recruit an institute director until it was clear whether there might be a merger in the works. we will have to see how that plays out. i do not know the current status of those deliberations. >> thank you. dr. collins, if you had closing remarks, if any, then we will wrap it up. thanks. >> well, i will say that i am surprised that one question did not come up, and that is my involvement in discussions about science and faith, which has certainly been something that has graced many pages of the blogosphere and in the last three or four weeks since the nomination was announced, and they're even a couple of op- ed's.

i have completely stepped aside from any involvement in those activities, although i was involved prior to today. i resigned from the foundation that focused on science/faith conversations, an area that i found previously, and that will go on under the direction of others. i want to assure everyone that i am here to lead the nih as best as i can as a scientist and that my personal interests, which will continue in a personal way, about the interaction of science and faith will not interfere with the decisions i will have to make as the director of nih. >> thank you very much, everyone, for joining the session. >> all right. [captions copyright national cable satellite corp. 2009] [captioning performed by national captioning institute]

>> white house adviser valerie jarrett was asked over the weekend about the ongoing contracts that the blackwater security firm has. that is next on c-span.

after that, president obama speaks at the veterans of foreign wars convention in phoenix. then, maryland congressman elijah cummings hold a town hall meeting on veterans' issues. on tomorrow morning "washington journal," a conversation on the detainees at guantanamo bay. a former judge advocate general for the air force joins us. after that, the citizens against government waste. then, an author and former nra lobbyist. he has a book called "ricochet -- confessions of a gun lobbyist." "washington journal" begins at 7:00 a.m. eastern. and later, kathleen sebelius on medicare fraud. over the weekend, the secretary said a government-run health- insurance option is not vital as

long as the measure increases competition. live coverage begins at 10:00 a.m. eastern. now, white house senior adviser valerie jarrett. she spoke at last week's convention of on-line activists hosted by the group netroiots nation -- netroots nation. one of the subject is being gay in the military and they do not ask, do not tell policy. >> the questions roughly break out into three stages. first, a lot of people are not quite familiar with her work, how she got this job, what her relationship with the obama administration is. we will start there, establishing who she is and what she does. she is inside the white house,

and this white house is all about transparency, so we will combine those things and get her to be transparent about some of the things behind-the-scenes at the white house. transparent from our public aspect perspective and bulk of questions lend on healthcare. equal rights, housing so we'll do a big round of those. for those of you in the room, at home on c-span, what's up c-span? that's my network. that's hot. anyone can throw up your question paced on what we're talking about or not talking about. face book.com/net roots nation. click on the live tab and you'll be able to throw your question up there if you didn't get a chance and think i'm being a terrible irresponsible moderator. you have that option. on twitter.

/tag, nn 09. are we clear how this will work? two people are clear. are we clear about how this will work? all right. then let us begin. wikipedia describes your office in the white house as the front door through which everyone can participate and inform the president. we want to understand your job and how you came to know the obama's and i'll take a line from the movie office space. you'll recognize this. what was a would you say you do here valerie? >> i don't have a stapler. so what do i do? fair question. a variety of different things. my title describe as few things. i head the office of public

engagement. that is really the front door of the white house where every possible constituency group can interface with the white house. president obama's entire campaign was based on inclusion and working with the american people and giving them a venue to have an on-going dialogue to serve that purpose. it's headed by tina chen. i have to find out if she's twittering. i was probably one of the people that sent an e-mail. exactly. trying stack the deck he. office of public engagement. we've had over 3300 different groups come through the white house since we've been there and whole purpose is to be available and transparent and accessible. and inclusive. that's one office.

secondly, i succeed in the government affairs office. we work with elected officials not in congress. the mayor's, governors. county board. state legislators. everyone outside of washington and i'm particularly comfortable because i'm not from washington and don't know congress. my area is the city of chicago and local politics and i understand what it's like, in fact i'll tell you this to digress for a second my biggy frustration working for the city of chicago was the federal government therefore i'm uniquely qualified to give the people at the local level a voice inside the white house and all of the other federal agencies as well and that leads me to two other responsibilities. one is office of urban affairs. president obama created that and we coordinate all the federal

agencies that have an impact to be urban centers around the country. so part of our frustration and the president shared this is you have all these different federal programs that are confusing and there's no way of looking at neighborhoods in a come prohen save way from the federal perspective so our office of affairs is to do just that. in addition, thank you. >> applause is cool. >> so in a ticks to that the president asked me to share the white house council on women and girls. tina chen, shout out to that office. saw men clapping out there too. obviously, um... women are still earning less than men and we have inequities but we did pass lynny ledbetr.

shout out for that. laying around dormant for a while but we got it done and that's one step. part of the what the council on women is girls is doing is a task force made up of prep tenthives from off the agencies and we're looking at all the programs and we have a report due this month to describe every program that touches women and girls and looking for ways to improve their qualities of life and house on the house and sete side to see if there's further legislation we can do. in addition, we have a business council made up of various federal agencies that touch business from the small business to commerce and federal, energy department, u.s. trade representative and we meet often to see whether or not we're creating the kind of environment and this is important, where business can expand and grow and create jobs to get the economy

going again and i probably, what e else can i tell you about? >> i think that's all the jobs in the white house. >> and then seniored a voi sore mean i serve whatever the president asks me to do in addition to that. >> thank you. first question from daily coast. this is from when is it enough. if she's now in the office previously used by karl rose, has it been swept for bugs and more importantly, did you de contaminate it? good question. i tweaked it a little. >> well, funny you say that, we actually did get mild amusement but it was counter balanced. it was also officed by secretary clinton before that so i'm hoping between secretary clinton she balanceed the office of

karl. we did play calming music to level the playing field and give it that zen like quality. >> yeah, okay. now you first met the obama's when you hired michelle in 1991. how did that turn into you being their most trusted friend and professional advisor? that's unique path. give insight to briefly, i had been a lawyer for the city. i was mayor daley's chief of staff. i never really loved practicing law, so i left the law firm to go work for mayor washington, who was the mayor at that time, because -- [applause] that makes me feel so good, because -- i tell you why that makes me feel good, because i was speaking to our interests in

the white house a few weeks ago, may be about one week ago, and i was telling my story, and when i told my story about working for major washington, there were blank faces, and none of them were born when he was mayor, but i've -- >> how dare they not know that. >> how dare they not know their history? whether they had been born or not, how dare they not know their history? anyway, to be honest with you, i had my daughter. i got divorced, and i was leaving her home every day, and i was going down to the sears tower with this beautiful view of lake michigan, and i would feel bad. i would sit there, and i was saying, i am doing everything that everyone said i should do. fortunately, my parents sent me to a good school, and i got a good job, and i hated it, and a good friend of mine worked for mayor washington, and he said, "take a leap of faith.

if you do not like it, you can always go back. just come for six months." 8 years later i left city government but michelle was going through a similar experience at her law firm and felt she had so much more to give back and was interested in public service. the chief-of-staff today, worked in the corporation counsel's office and sent me michelle's rest may. terrific. i asked her to come in and we hit it off and through that, i was introduced to her fiance and they got married and our past's have been together every since and we've grown to be dear friends. i love them both dearly and i hope you do too. >> president obama is calm. keeps his cool, somewhat disturbingly calm sometimes and

you've known him well for a long time. have you seen him lost it. scream at people. does he lose his cool? >> i will tell you the truth. since 1991 i've actually never heard him raise his voice. doesn't mean i haven't seen him angry but never heard him raise his voice. i would say when he's his quietest he's probably a little unsettled, but he has this very calming tempura meant. his highs are not high and his lows aren't low. and we encountered this in the campaign, when you needed it most you saw someone that managed to keep that calmness in the midst of chaos and we're in a chaotic time in our country and we want a leader that will stay calm and not fly off the handle. [applause] >> the president said the

following about you. quote, she's family. she combines the closeness of a family member with the savvy and objectivity of the a professional public policy expert. how difficult is it for you to play both roles the friend and expert advisor in the height house now? >> i don't find it difficult at all. i get this question all the time and he's surrounded himself with a team of people he trusts and respects and encourages to tell him what they think. his view is if you just agree with me, why are you here? i want somebody to push me and be honest with me and we have such challenges and i want to make sure i'm making smartest possible decision. so i think the team all has that philosophy. i have a unique rerakes ship

because of the length but if we're watching a movie or something and i'm with their family i'm not asking about healthcare because he needs down time too and needs to know that when he's just trying relax and catch his breath i'm not trying to get him to focus on the pressing issues we have but on the other hand, in the oval office i treat him with due respect and call him mr. president as he deserves as the president of the united states. but the point is his whole team has that philosophy of being trusted and people he respects and people he wants to push him hard to make the right decisions. that goes for you guys too. >> they don't need any pressing on that. i was promised a cage match between you and romin manual. when can we see that? >> we had members to the white

house for a picnic on the lawn. in the morning i said ron, your actually the number one person they want to see in the cage where you throw the ball and they fall down and get dunked, but i have known ron for a very long-time and we've always had a good relationship and i think what happens is the press, particularly the press in d.c. tries to stir up a little mess. i've never had a team of people whom i've worked with that i've had so much respect for and part of what president obama, that calm face. we all hear this all the time in the campaign. no drama obama. he believes if you start having chaos in your administration you can't focus on the american people and i give rom a lot of credit for bringing everybody together and addressing everyone's voice to be heard so when we go to the president

we're giving him our best so there will be no fighting match between us. i strongly need him. >> talking strong smack about rom. then the final question kind of about what your role is during the campaign, week saw you play an and with raise. encouraging philadelphia speech. president obama is black but most advisors are white. what is your presence doing for black americans, for women or anyone else tradition not represented. >> ly say that the president has surrounded himself with a diverse and inclusive team. he said doing in and this was important if the transition to reflect the diversity of the country so we we're hearing all perspectives. he's fortunate to have several tough women advisors and african-american advisors.

my chief-of-staff is here. raise your hand. don't be shy. and so i think we have a good team of people and that's again how to make the best decisions possible and i think he takes great pride and having that diversity in the white house and in administration throughout. >> okay. on to phase two, all right. president obama said he could rely on you to monitor the dynamics in the white house. given this description and transparency mandate, describe both of those. we see things so often through the filter of the a media that could have other motives. what was the transition from campaign mode from wanting power to wielding it and what broadly speaking, more specifically what was most surprising about the transition? >> interesting question. we talk about this a lot.

it is very different campaigning to governing and the president wanted to make sure that we harness that energy you guys saw on the streets in all of the folks so involved in the campaign and wanted to make sure when they came into dpovpt they kept that sense of urgency and change, and that chance of willing to get in there and shake things up, but you have to have an order in government and you can't have everybody going off doing their own thing in the campaign, we encouraged people on the ground to go off and really develop relationships on the ground and we deferred enormously the people on the ground. i think when you're in the white house now the president has to really make sure the voices are still being heard and he's so good about bringing the very junior most staff person into a meeting and giving them an audience and letting them participate by working in a structure. that's been a bit of a

challenge. the other dynamic where i've tried help is we've recruited a lot of terrific people who were not apart of the campaign or with other candidates and we want to make them feel they're on a level playing field and make them feel like family too so i spend a lot of time working with the people who aren't as well-known to everybody else, and give them a voice and a sense of belonging and this from time-to-time. it's worked so well, and we're not going to be able to keep all the energy and terrific part of the campaign unless we change government. that's the real challenge. this is all government. local level in chicago, i know this is the case throughout the country. you find so many people there that have been doing things the same way for a very long-time and you'll come in with a fresh

idea, and they'll say, well we tried that in 1932 and it didn't work and your like what about this way? well, no i'm not sure. and you also find and i want to be really clear about this. people in government that have been hungering for change and all they wanted was fresh leadership because they didn't have a voice for their great ideas. harnessing that kind of energy is really important. let them clap for a while. >> what is - this is a question from jack and jill policy. how has being in the white house fundamentally changed you, the first lady or president? >> i don't think at this age, face it i'm 52 i don't find you change much and certainly they're not that much younger than i, but i think we all have this - just extraordinary awe of the opportunity. there's not a single day i come

to work, that i don't stop and just pinch myself for this extraordinary opportunity to see our country change and to be right up there and have a front seat and an opportunity to participate in the process and so i think we're humbled by it in my wildest dreams it never occurred to me i would work in the white house or know the president of the united states as well as i knowur president. so it's a very humbling feeling and you wake up and - i'm scared all the time. i'll tell you this. there isn't a day that goes by that we're not scared, we have to make the absolute best of this opportunity and we have to work really hard but you know you can't do what you did in the campaign working 18 hours a day and i'm going to tell you a bad story. we worked so hard the first couple of months we had this terrific event in the white house. poetry slam.

we were all looking forward it to so i would go to the poetry slam and i couldn't find mike and i said what happened to him. he had gone in someone's office and put his head down and went sound asleep. so we were just exhausted. you can't do that because you're not making best decisions that exhausted so trying get people to take a breather for a moment and balance their lives but you know four and 8 years goes by quickly and so many people are counting on this president to change not just our country but the world, a lot of pressure. >> all right. there have been some dramatic public moments, administration has gone through some wonderful, painful - can you talk about what the mood and process is like with tom dashle is? >> it's very sad. the president is very close to

tom and worked with him in the senate and thought he was uniquely qualified to head this healthcare initiative to it was on a personal note for the president a very sad day, and i think the good news is we've bounced back between nancy and secretary and the rest of the team working on health care, i think we're well represented and i think that's part of the president's strength is that even in the face of adversity he's extremely resilient and you want a president that bounces back. he's not going to say, now what do you do for about more than 30 seconds. he'll come up with another plan and team in place now i think is just terrific. >> when the stimulus started hitting the country we saw the eruption of tea parties. lots of protests, how seriously does the president take what a lot of people in this room know to be somewhat manipulated

situation? what's his reaction when they first started coming out? >> look, you guys the reason he ran for president was because we wanted to move away from that kind of tone and the reason i think so many people got on board and were supportive of this unlikely candidate. if y and i think if you asked the vast majority of the american people, they were tired of that business as usual. they were tired of that manipulation. we are seeing it in the health- care debate whether it's a small group of people trying to scare people, and what makes me sick is that they are trying to scare elderly people. i have elderly parents. why are they trying to scare the elderly people? [applause] so i think it is an example of what we are fighting against, but it is there, and i think, to tell you the truth, i think they

underestimate the american people. i think they are a lot smarter than that. i think the media has been focusing on many of these channels these town hall meetings where voices are being drowned out. what they have not covered anywhere near enough of the thousands of meetings around the country where people, such as you, are coming in, and they want to be informed, and they want to express their ideas, and that is not where the media tends to focus. the media like the sensationalism, and i think it is incumbent on us, and we were talking about making the pitches to the audience, and you will do yours, and i will do my, but make sure you get accurate information out on the ground, because a lot of people are depending on that sound bite on the evening news or the morning shows or the table for their news, -- i will do mind. this is back to kind of a regional effort, block by block, person by person, and that is

where you guys can be extraordinarily productive. >> ok. a final question on phase two. issue. do all the black advisors and staffers in the white house eat lunch at the same table? >> [laughs] >> is there a black table in the white house cafeteria. transparency. >> there's not a black table because most people don't even eat lunch. a few of us went out to dinner and normally i have serial for dinner. my mother would be so pleased. we rarely. if i can grab lunch by four in the afternoon. that's good. so there's no black table in the cafeteria. >> good job. you ready for phase three? i see the twitter feed. i know your chomping at the bit. according to the president, you are trusted quote, to speak for

me. particularly, when we're dealing delicate issues. so i ask you president obama, on this transitional tro sees in government. this we got on twitter. how many of the 300 resumes sent to the white house received many serious reviews? >> many, many, many. i cannot tell you the people working in the transition day and night going through the resumes and we've received some amazing resumes. there are many, many people working in administration on the campaign and many had absolutely nothing to do with the campaign but are so talented and everything from senior staff to the most junior people and we are constantly looking for new people and we take those resumes very, very seriously. we made it available to come on-line and send in your resume and we encourage people to do

it. our personnel office takes this seriously. yes, we look at all of those. >> question from face book about lobbyist influence. administration set strict rules on who could work and not. how do you feel about that decision 7 months in, for the concern your limiting the quality of candidates? >> i think there's so many talented people out there that didn't lobby that it has not been an disadvantage at all. we've made a few exceptions for those uniquely qualified but what we ran on in the campaign and in government we have to stay focused on the american people and what's important for them and we can't let special interests that have a hold on washington dictate. this gives you a flavor of the white house. lobbyist were used to be the ones bringing in clients and

i'll meet with just about anybody but what frustrates lobbyist is when i call the principal directly and i hear the lobbyist wanted to bring the person in and i'm like i don't need somebody else to do that and i don't see why they should have to pay you to have access to my office responsible for giving them service. [applause] so i'm not very popular a bong lobbyists and that's okay with me. >> probably a good thing. >> this question is from face book from martha elizabeth. is the president going to call all the blue dogs in his office and give each a piece of paper with the amount of stimulus money and say i want your vote on healthcare. if you're a democrat get in line

otherwise any time you want money in juror district you can ask jim de mint for it? wow. mary elizabeth! >> mary, elizabeth. she has a fan club. >> i was going to say. i'm jealous. i haven't got that kind of applause yet. my goodness. the fact of the matter is i know obviously that's hit a note here, and i know that there is a lot of frustration here and around the country, and i'm telling you, i am convinced this president has it right and he is going to continue to go along the way he's going. he is not one to punish or do any of the kinds of things that perhaps you might want to do in a moment of span the mayty or anger but he'll count on the

american people to put the pressure on their elected representatives because that's way the system works the best. it doesn't work for him to punish from the oval. when you guys get out there - and it's hard work but when you organize and when you, and not just form letters but when you call and - i met a person right as i came in going and having 60 meetings on the hill in the next few weeks with they're elected representatives. meet them in the district. go to the town hall meetings and make phone calls and organize your block and audiences and bloggers and put the pressure on them that way. that's how we'll get healthcare done this year. not quite as much applause, but trust me. it will work. >> this question has a flip side and because healthcare is so - the thing right now. when i ask you, from face book

from adam. the republican senate from house leadership has said they have no interest in bipartisan ship or creating a good healthcare bill. you can read they're tweets. given that they've shown such animosity in governing why attempt to placate them at all? can't you get a good plan done with democrat as loan. it worked them, why can't it work for us? >> it didn't work for them because they're not there anymore so it didn't work for them. thank you. i like you. i mean the whole reason why we're here is american people got tired of that kind of politics and i think that, when you talk about by party son and i know it has a bad name right now. it's not so much working with the elected officials on all sides of the aisle but working with the american people who might be republican or

independent or democrat. that's who we're trying reach and let's face it, i get a little worked up about the healthcare issue and it's because michelle and i worked at the healthcare facility and know how hard it is for people struggling right now and even those who aren't struggling may be struggling one day. all the people healthy and fine today may have a pre-existing condition and when they get dropped by insurance, it will have an impact on their lives so the way we look at it if we want to reach across the country, that's why the president was in montana yesterday in a community not considered typically democrat. he's reaching everywhere to engage the american people because there's not person in this country that isn't touched by healthcare or who right now is not adversely effected by the current healthcare system and it's growing worse every day. that's really the effort to reach out that we're talking

about. [applause] >> okay. this question, kind of touches on the seriousness of the debates happening. there's a feeling there's a substance and a lot of noise taking up air time. from jack and jill politics. do you believe the birthers are a, crazy b, racist or,c both. those are your options. [laughs] >> interesting options. i mean come on you guys. this is ridiculous. of course he was born in the united states. unless they don't want to think of hawaii as the united states and maybe some people don't view that. but i think that, i mean the good thing about our country is everybody crazy or not is allowed to have a voice. that's what we do and i wasn't calling them crazy, i was just

saying everybody gets to have a voice. >> she's good. >> yeah, i thought about that. seriously. of course one person is crazy and another person is sane, i get back to my point from a few minutes ago. i think in all that noise, eventually and the good news is that this week everybody was at least talking about healthcare and not other issues, so i think that, and it's hard to be patient at a time like this when every day is so important, but i do believe that people - because they're so personally vested will take the time to get informed and i also believe that all of this miss information that's going out there, where as everything from the allegation about the youth natuf nicing.

all of this becomes martianized and cast a side and i'm confident that will happen now. we have to take the time to educate people and when seniors are scared to death and they're told the president did a town hall meeting with a aarp, and people were saying, well you know, we don't like socialized medicine and in the next line they said, don't do anything to disturb our medicare so trying educate people about what really is in the various bills that are being looked at by the committees is so important and we've got to get into the details. >> okay. this is about public option. there are related questions. there's a lot of tweet action going on. oddly, fdl on twitter. will the president for regional co-op for bipartisan vote on healthcare reform and is the president prepared to veto a

bill without a public option? [applause] >> well. let me be very clear and i talked to the president yesterday about this knowing i was coming here and i said i want to make sure, this is what i'm going to say and i know this is what you believe. the president wants the public option. he has made that clear everywhere he has gone. but - let's go one step further too. he wants the public option because there needs to be some competition. we have looked where there's two or three insurance carriers compared to multiples and competition works. prices come down when you have competition. he says that from the very beginning. i don't want to fast forward to the end of the process and talk about what he will detail down

the line but he did it yesterday and every day making case as to why he believes the public option is the right thing to do and i can tell, you guys do too. >> cnn director said a majority of americans over the age of 50 appose the proposed obama healthcare plan. those under 50 support it. very widespread in aim and reflects some of the trends we saw during the campaign who was supportive of obama and not. how does the wte house handle that knowing seniors have more time and investment in the system as it is? >> that's part of why the president wanted to do the town hall meeting. he did one with a aarp where we had literally thousands of members on the phone new jersey the audience able to ask questions directly to the president. he recognizes and if you look at the miss information out there,

it's no wonder the seniors would be concerned about the plan. he wants to be sure we're talking to every possible age group so they understand what's in the plan. again, this is a place you guys could be helpful. if they understood what was in the plan, they would see how this is going to help them. the whole goal is to make healthcare more affordable and the quality of hair, this is something particularly interesting to seniors is better. we're spending so much money on subsidies of the insurance. have anyone ever gotten a medical bill you understood. i haven't. >would not be nice that our parents are traveling, and we had technology so the physician that was taking care of them where they are could look at their medical records and transport them back and forth? there is so much wrong with our

system. i went with the president to the cleveland clinic a few weeks ago. i do not know if anybody has been there, but we went there because it is a good model of what works. their physicians are paid a salary. they get a three-year contract. at the end of the three years, their contract is renewed based on what? not on the number of the tests that they order but the outcome of their patients. are there patients actually have feared -- actually held fear? is that not a good test? is no wonder that people are ordering multiple tests. oftentimes, -- let's get the incentive in the right place. let's reward physicians when the outcomes are good, when people are actually healthier. let's have a system where we are encouraging people to have primary-care physicians where they are having all kinds of preventive medicine in place. i could go on for the rest of

our time talking about what the importance of health care would do for our country, but the real challenge is educating people, and many times, seniors who are fixed income and depend on medicare are the ones that are honorable, and to scare them is outrageous, so we really need to pierce through that noise -- are the ones that are vulnerable. reform. >> want to go to equal rights, civil rights issue. we've got this question in a lot of different forms but a hot point on twitter. how will the obama administration regain it's promise to be an advocate for,lbt americans example by reenforcing the don't ask don't tell policy in the defensive marriage act. >> this is something i care about and so does the president and he's been clear and said this during the campaign and i've been with him in meeting after meeting in administration where he's so chris c crystal c.

he believes don't ask, don't tell is wrong and seeks repeal in congress. absolutely. he believes defensive marriage act discriminates and a lot of people were upset by the brief written by the department of justice and i've talked to eric holder about having to defend a law on the books. they're they have to defend their law. the only way to get out of that is to repeal the law and that takes an act of congress. we're committed to getting both laws repealed but we can't do it without the support of the american people. put pressure on congress to repeal both of those laws and partner with us. [applause] >> we got a lot of questions i

would put under the header of not enough change for candidates that ran on this massive platform of change and also could be put under category of a little too much like bush. why has president obama continues so many of jorge bush's policies. signing statements. prolonged detention policies, keeping the defense department largely in tact? what is, back to this inside assessment and dynamic, why? why is the president continuing so many of these policies, many of which he criticized as a candidate? >> well, look. it's affair question but also i think you have to look at what has he done. from the very beginning he signed an executive order saying we're not using terrorist torture anymore and give him credit for it that because he did it immediately.

it should have never have been done and put our country i think more at risk than if we'd never done it in the first place. he memos talking about the justifying of torture in the transition of transparency. everybody knows what's in the pictures. i think the - this is where he gets very delicate and i know it's touchy for this audience but what he's trying balance as president is keeping us safe, not giving ammunition to people that already had am new nix to be adverse to us. he's trying change the tone around the country. this is why he went to cairo and reached out to the people of iran and traveled to turkey and went to normandie. he's trying set a different international tone and it'll be one to lead to a more safe

country and that requires some balance. i can't - hear you. you know what you got to do is figure out how to get your question on here. we're not going to have shout-outs here. >> this is not a town hall like that. ya'll know what i mean. obviously an important question. he asked is why does he continue to give black water 150- million dollars? >> listen. well we're certainly trying get rid of the no bid contract. the defense department has actually cut the portions of their budget. secretary gates came in with suggestions on how to cut waste and he's taking his responsibility seriously. so i think, i hear the frustration and you don't have to insist, settle down over there, i hear you, but i think

the point of the matter is that you also have to say, we're six months in. i think you have to accept the fact that some things take time and that you have to follow a process where you get some buy in from the people your counting on. do not forget we have men and women who are at risk every day overseas doing the best they can to defend our country. so the president has to balance putting them at further risk with having kind of transparent and open and clear availability of information that you so desperately want. he has to balance national security with transparency and i bet with him. i bet with him and i'm asking you to trust him and i know that's hard because i know how pure you are to the cause, but he also has to keep in mind that he has to keep those folks safe. >> thank you. thank you. [applause] >> just a note on tone.

like hissing is just not cool. we're definitely getting questions and she's here answering them. you may not like the answer but y you're going to get that everywhere. thank you for your home training. immigration reform? this question came via e-mail at america's voice. during 2008, latino voters played and historic role turning four stage from red to blue. it's a defining issue for latino voters and president obama campaigned on a promise for this. how is he going to get comprehensive immigration reform done now. we've seen the dates flip a bit. what's doing on? >> what the president said throughout the campaign and in office is we have to have comprehensive immigration

reform. my top person who is head of international governmental affairs, the question she asked before joining the administration is, is the president committed this and he absolutely is and he's pulled together members of congress, those who are supported of immigration reform and those who are not, brought them together in the white house and began to dialogue. we have someone working hard on the hill to see what measures we can do in the short-term but the real solution is long-term immigration reform. you mentioned the date has slipped. obviously there's a full plate but i think the president multi-tasks and he is moving forward with the immigration reform strategy that will lead to immigration reform. the process is underway. >> thank you. from twitter. some progressives feel it's

important to challenge o a bah ma from the left. how will this president respond to that pressure from the left? >> well, i think he responds well to pressure period. when you say pressure what you mean is engaged american people who want to participate in their government and he's all for that. and so, when you say pressure om the left, what he's looking for is ideas. and i think that's what you mean when you say pressure. so if you have suggestions and you have constructive ideas how to move healthcare reform faster and ideas how to move energy reform faster than we have, ideas for better educating our children to compete in a global marketplace, we're open to that and if that's what you mean by pressure, bring the pressure on. >> you heard it. bring it on. what's the status, this is from jack and jill politics.

what's the status on the women's forum that we haven't heard much about since. when will the plans be announced to the purpose and mission. >> i don't know what your talking about. we are planning - we have an on-going of white house women and girls, an on-going engagement with women's organizations around the country and i would be interested in having a women's forum. we had some and we're hope open to more but i'm not sure what your talking about. whoever wrote, follow up with that absolutely. >> we'll get more clarification. collectively ya'll are smarter than me and that's why we're doing it this way. overseas on foreign policy. in 2004 obama said genocide is on the way and we cannot set by and let this continue. the only concrete action seems

to be special energy zoi. what steps has the president taken to end the long running genocide and war by displacement and starvation. >> president has spoken clear about what's going on in dare 4. it's atrocious. he's on the ground and whole purpose being there is to come back with concrete steps we can take and it should not be just the united states but an international effort. we need everybody focused on dar f or. and it's a top priority of the administration. >> does president have a plan to work towards passage of paycheck fairness. >> absolutely. we're committed paychecks fairness and in the process of working through, there's a lot of support for that in congress. particularly among the women

develop bears d and men as well. more easy one. >> we'll bounce around. during his campaign he repeatedly made the commitment to establish a global education fund capitalized with 2 billion dollars, the purpose of which to close a financial gap to have universal education in developing countries. will he honor his commitment for this fund and will education be recognized as an essential element with the african continent? >> let me ask or answer the second question first. absolutely. clinton came back from a very successful, she's on or was on a trip to africa and education is absolutely essential not just here but overseas as well. the president highlighted this not so long ago and obviously, we are better than a lot of countries around the world in

education but we still have a long way to go here to allow our children to be competitive on a global stage, and i'll digress for the second as i talk to business leaders around the country. they always raise the fact that we're trying so hard to compete and so hard to create jobs right here and at home and most companies would rather have people right here at home, and yet, we're seeing our education standards dropping. the secretary of education who i think i've known for his entire life is so completely committed improve the standards of excellence and it's not just something the schools can do alone. parents need to be involved as well. we need to get our act together here and we have a relationship and a responsibility as well around the world. >> segway to economy questions talking jobs and education. this is from curtis on face

book. what's the cost-benefit analysis, actually before i launch the question, i want to let folks know, you're the only closed an visor to the president that's actually run a multi-million dollar business. a lot of these questions have that knowledge built in so we're expecting some great answers. what's the cost-benefit analysis of trying control dangerous industries like health insurance, too big to fail businesses, how do we regulate the huge pieces of our economy during a bad recession? >> it's a very good question. i think it's more important than ever to regulate them during a bad recession. what we're trying do here is we're not just trying reset the clock back to where we were when the economy was booming a year or two back. that was based on a bubble, a false economy. dependent on credit