definition, very manpower intensive? >> it is. the generals implementation of the new strategy that focus is so heavily on the people, is clearly a requirement to be distributed throughout the country, of vista, where the people are -- of course, where the people are. it is very direct and very face- to-face. i think we understand that. he has made that, literally, and job number one for the forces since he has taken command. >> how would you respond to george willis's column. he writes, america should do although it can be done from offshore.

he goes on to say that we should focus on the 1,500 mile border of pakistan. is it time to get out of afghanistan giving your concerns about footprints? how do respond to that? >> i have a lot of respect for mr. will. in this respect, i do not think that it is time to get out of afghanistan. i think that the notion that you can conduct a purely counter- terrorist type of campaign and do it from a distance simply does not accord with reality. the reality is that, even if you want to focus on counterterrorism, you can do that successfully without local law enforcement, without internal security, without intelligence.

the general robling knows more about counter-terrorism than anyone in or out -- the general probably knows more about counter-terrorism than anyone in or out of uniform. the process in which we have killed or captured terrorist, we have used that for the next target. the notion that you can somehow have a campaign that focuses solely on the border, has no interaction with the local afghans along that border or elsewhere in the country, for that matter, or assumes that the status quo in afghanistan -- that there cannot be a status quo in kabul, if you just walk away, that the situation will mature. , i think that is under a -- that the situation will not

deteriorate, i think that is unrealistic. >> you cannot do it to remotely and you cannot do it from off shore. again, i certainly do not think it is time to leave. we have new leadership, new strategy, resources moving in, and i think this approach has great potential. but it is on to take some time. >> you talk about the general's concern about how the forces are perceived by the afghans. in light of the revelations of what was occurring at the u.s. embassy, photographs have come not above -- that have come out about behavior that would not be

acceptable, how do address that? >> i do not have the information to say what ought to be done. if those allegations are true, those activities are not just offensive to the afghans and muslims. they are offensive to us. they are inexcusable. >> what is your reaction to their much -- to the remarks yesterday from their russian ambassador. he suggested he wants russia to be in the planning strategy of afghanistan. what is your reaction to that, given to russia in afghanistan? >> first of all, i think the russians have a very clear interest in the success of our endeavor in afghanistan. they are very worried not only about violent extremists, but also the flow of narcotics into russia coming out of afghanistan.

the russians have been cooperative and helpful in terms of our no. distribution network. we welcome that. on a bilateral basis, in terms of the u.s. and through the nato-russia council, there are ample opportunities for dialogue and learning from one another. >> obviously, the sour note to the left in afghanistan, will that not affect their participation? >> i think their role on the ground in afghanistan is of to the afghan government. -- is up to the afghan government. >> one other reasons for falling support is casualties. there is not a strong sense among the american people as to what the missionaries.

the president has spoken about that, but i was hoping you could speak to that. could you shed some light on exactly what the military needs to achieve? >> i think that it is important to keep our perspective. the fact is that 9/11 represented the first foreign- based attack on the continental united states with significant casualties since the war of 1812. that attack emanated from afghanistan under taliban rule. the taliban did not just provide a safe haven for al qaeda. the actively cooperated and collaborated with al qaeda. they provided a world wide base of operations for al qaeda. so it seems to me that we are in

afghanistan less for nation- building then we are in giving the afghan state the capacity to oppose al qaeda, to oppose the use of their territory by other violent extremists, and for them to have the capacity to be sustained over time. the reality is that terrorists lurk in a number of countries. but the problem is manageable because the governments of most countries are opposed to their activities and have intelligence, law enforcement, and internal security capabilities to sustain that opposition and to be effective. it seems to me that, in the context of the president's goal

of disrupting, dismantling, and destroying al qaeda, we seek in afghanistan that is our partner in that endeavor and that can sustain that endeavor after we argonne. >> my only comment is that the intelligence continues to support that al qaeda and its extremist affiliate's, one of whom are the taliban, still very specifically target this country, our people, as well as other countries. that has not abated and that is not point to go away based on anything that i have seen. as the secretary has described, they thrive on the one governed states. >> during the iraq and debate, general petraeus was very effective and very public.

do you think did ministration needs to do more publicly to clarify what the messages and to keep reminding stipples -- reminding skepticals? [unintelligible] to think he should perform as a public servant? >> i think that the president's message in his speech to the vfw was crystal clear about what we're doing and what we are about. clearly, press opportunities like this and other opportunities for us to talk about this and why we are in afghanistan and why it is important are important. all you have to do is look at the front page of any newspaper or turn on the television to

know that afghanistan, right now, as far as the media and the garment are concerned, art in the forefront. there are a lot of people other talking about this they are debating the issue already in terms of the way forward. i think there is clarity in terms of their strategy. i think the president has described it. i think i just described it. and we will continue this effort as we go forward. last question. >> holbrooke said that we will no progress when we see it. will one of you address more specifically how we measure progress in dismantling al qaeda? denying a safe haven in pakistan, is that part of this mission as well or moving that to some other states? >> one of the most significant

new elements of the president's strategy that he announced at the end of march was in fact recognition that this is a regional concern, a regional problem. the chairman has spoken often about the pakistani part of this and he mentioned earlier that this is a piece that is independent -- this is not part of general mcchrystal's writ, if you will. but it is an interval part of the president's overall strategy and the military approach. i think we do take that into account. first of all, the administration -- let me answer that in two ways. the administration has developed measure of effectiveness. the seven shared with staff on the hill.

they will be shared with members when the members comeback -- they have been shared with staff on the hill. they will be shared with members when they come back next week. those that are unclassified will be made public. one of the things -- and we started this ourselves. this is not something imposed by the congress. this is something so that we can evaluate how we think we're doing and not keep rolling of the goals that we're doing, but keeping a genuine measure on whether our approach is making headway or not. i think that that is a very important thing. in this one respect, there is a comparison between iraq and afghanistan. that is that success is the afghan national security forces

assuming a greater and greater role in controlling and protecting their own territory as we recede into ended advisory capacity and it ultimately with from. >> i would only have to specifically or say specifically to the save hazen in -- safe haven in pakistan, the way we get to that is by a growing and sustain the partnerships with pakistan. one of the ways that i measure progress is that, if i look at pakistan in the last 12 months and the success of the military in terms of this operation and swat and the movement in that direction to adjust the extremists in their own country and that kind of continuing pressure, eventually they will provide security for their own people so that, in fact, their own people who now protect located turn them out.

-- who now protect al qaeda turn them out. it will take some time to do that. but i think, strategically, we know how to do that. >> thank you. >> all this week on c-span 2, at 8:00 p.m. eastern, bootv. bill harris joins us to talk about his new book. -- bill ayers joins us to talk about his new book. see him tonight at 8:00 p.m. eastern on c-span 2. >> we will continue our review on health care in congress tonight with highlights from senate committee meetings, and analysis by sheila mary, and this weekend, a comparison of health care systems around the world. that is sunday on q&a.

>> as the debate over health care continues, c-span's healthcare have is a key resource. go online, follow the latest video ads and links. share your thoughts on the issue with your own citizen video, including video from any town halls to have gone to. and there is more at c-span.org /healthcare. next, we have remarks from prime minister gordon brown on security concerns in afghanistan. he answered questions about the region's stability and his country's future role there. this news conference from london is one hour and 15 minutes. >> good afternoon.

we have been particularly engaged with a published analysis and assessing the counter terrorism and the techniques of counterinsurgency and military assistance in postwar reconstruction. [unintelligible] one of the more immediate contributions that the institute makes to international conflict resolution is to provide diplomacy for those who like the structure for this purpose. each year, since 2004, the institute has convened and the so-called manaba dialogue and bahrain.

[unintelligible] at the dull of last year, the u.s. defense secretary robert gates was asked in public about their right policy in afghanistan. he replied, in part, in this way. this is the afghans fight. it is their country, their fight, and their future that is at stake. i believe one of the highest priorities is to get the resources into the country to help train and accelerate the afghan security forces and to give more of them to fight in their own country. we are there to help then. we are not there as occupiers. i do worry. i'm prepared to go forth with the suggestions of the commander in 2009. but i also worry about the size of the footprint of forces on afghan soil. i am more mindful than most of

that, with 120,000 troops, it can be still lost. that is because we do not have the support of the afghan people. we need a serious consideration as to how many forces we should send in. as we complete in these a troop increase is, we should concentrate long and hard. he went on to say that the european emphasis on a comprehensive strategy that combines both secured and economic developments and civic development is exactly right. the obama has taken office and the security situation has remained challenging. some called for less and others for more troops. meanwhile, public opinion in the u.s., the u.k., and in many other countries has become more skeptical about this war. the mission in afghanistan and

the strategy to meet its needs needs explanation. the prime minister of the united kingdom has recently returned from another trip to afghanistan. we are delighted to have him here to speak on the important scene. prime minister, your audience in this room, your yours on the web cast, and the wider public would be hugely interested in in your strategy. this podium and the floor is yours. thank you very much. [applause] >> let me say, first of all, how grateful i am to be here,

not just for hosting a speech that i am giving to the, but for longtime interest in afghanistan and for your leadership in addressing problems of terrorism around the world. we meet here in the week that we commemorate the 17th anniversary -- the 70th anniversary of the beginning of the second world war. on the skill of achievements and the record of service in sacrifice that has defined our british forces for generations, it is a history of external occurred and dedication, often -- history of extraordinary courage and dedication, often in the face a diversity. -- face of adversity. as people gathered in battle, as they have done today, to honor to great servicemen, a local

trivet that has become a national symbol of honor and gratitude, remembers all of those who made the ultimate sacrifice for our country. nowhere have i seen more clearly that spirit of service, but also the resilience of spirit of our armed forces, then on each of my visits to afghanistan. as i traveled last weekend, our forces were the first to point at the positive signs of meeting the challenges. i visited a police station that had stories of afghans of voting for the first time. i witnessed the operation room at work, british forces now supporting the afghan army and police and bringing security and the rule of law to the provincial capital. i heard from the governor about the real progress we have made combating the heroin trade. i also saw, and others who have

visited, the skill of the challenges now and in the months ahead. to date, we have seen another series incident where taliban hijackers had to be intercepted. in the last four months, over 50 british servicemen have been killed. 64 have been seriously injured. these are not just statistics. each one is the loss of a professional, dedicated, and brave servicemen. he returns to families' lives who will never be the same again. it is right that the service will now be recognized by the new elizabeth cross, announced by her majesty the queen. there's nothing more heartbreaking in the job that i do then meeting people who have lost someone who is a loved one in their family.

there is nothing more heartbreaking than as it did this week, visited a teenager who has lost his leg. these young men, we have got to thank for their service to their country. i want to take head on, therefore, the sixth -- the argument to suggest that our strategy in afghanistan is wrong and i want to enter those who question whether we should be in afghanistan at all. there are those, of course, who feel that history of intervention in afghanistan is doomed to failure. there are those who argue that policies for development, while admirable in principle, will make no difference in a country that is one of the poorest and most corrupt in the world, no difference, at least, for many years.

[unintelligible] i want to answer those who argue that, while we may be well- intentioned, does say that our strategy is flawed. i want to remind you that what we're doing in afghanistan is part of an international strategy. it is right that we play our part and not leave the people of afghanistan to struggle with the global problems of their own. others, too, must take their share of the burden of responsibility. all must ask themselves if they're doing enough. for terrorism recognizes no borders. all of us benefit from defeating terrorism and gaining stability in this region. all of their collections must play a good part. this is part of a wider net international strategy and must be and to do -- this is part of

a wider international strategy and must be understood in that regard. we are in afghanistan as a result of a hardheaded assessment of the terrorist threat facing britain. we are part of a coalition of more than 40 countries embracing the situation. this remains above all on international mission. we have all seen the reality of the threats and valet, mumbai, and on the streets of london four years ago. the efforts of our allies, the efforts of our armed forces, a police and security services in britain, which prevented and continue to prevent further terrorist attacks. is the totality of effort that britain is better resourced and corrugated than ever before. -- resourced and prepared for

than ever before. [unintelligible] we knew that, as we route removed -- as we remove the taliban and al qaeda, so will al qaeda relocate, and they did so. the general of our security services says the links reach back into these mountains, a presence -- at present where the threat millikan's from the pakistan side. there will be able to use it once again as a sanctuary to plan and launch attacks on to

britain and other parts of the world. the sustained pressure up al qaeda in pakistan, combined with ministry actions in afghanistan, is having a suppressive effect on al qaeda 's ability to continue in the region. al qaeda retains some contacts and provide limited support to the afghan insurgents say, principally through the provision of training foreign fighters and military expertise and continues to do afghanistan -- and continues to view of tennesseandafghanistan as fundamental. a stiffer afghanistan means a safer britain. -- a safer afghanistan means a

safer bet than. preventing terrorism coming to the streets of britain, america, and other countries depends on strengthening the authorities in both pakistan and afghanistan to defeat al qaeda and also the pakistan and afghan taliban. the taliban is allowed to undermine legitimate government. that would give them greater freedom from which to launch greater attacks against the world and would have longer term implications for the credibility of nato and the international community and the stability of this crucial region and for global stability. this is why our strategy published in april would have an integrated approach across both countries. we're now seeing what has not been obvious before, joint and complementary action on both sides of the border. in pakistan, in the last few months, the army and security in services have taken on the

pakistani taliban. forces are preparing to tackle the threat. terrorism poses a serious -- as serious a threat to pakistan as it does to the rest of the world. in afghanistan, the afghan army and police are not yet ready to take on the taliban purely by themselves. that is where the international coalition must maintain its military presence. i believe that most people in britain except this, but i know that they're concerned about how long international forces and british forces, in particular, will have to stay. and they ask what success in afghanistan would look like. the answer is, we will have succeeded when our troops are coming home because the afghans are doing the job themselves. from that day on, we will be

able to focus our efforts on supporting the elected government of security and development and along human rights. the right strategy is one that completes the job, which is to enable the afghans to take over from international forces and to continue the essential work of denying the territory of afghanistan as a base for terrorists. .

it is clear that thousands boded rather than a few hundred some have claimed. turnout was not as high as many like me might have hoped. the incidence of voter irregularities intimidation being reported must be thoroughly investigated, including by the electoral complaints commission. the very fact of the first elections run by afghans themselves is an important step forward. remember the taliban voted to destroy and they failed. 6000 polling stations opened across afghanistan. as we look beyond the elections, the biggest challenge facing our forces is remaining -- defeating the taliban tactics. mines and roadside bombs.

having failed in 2006 and 2007 to defeat international forces by conventional means, the taliban have more than doubled their ied tax over the past year. international casualties are almost twice as high as this time last year as a result. three-quarters of them are due to ied's. this is a tactic which of course is inherently hard to defend against. having spoken to our commanders and experts who have been working closely with the americans and the coalition in revealing how best to respond to this evolving threats, i am confident we are fully focused on dealing with that. in doing so, our forces will have every possible support. it requires not just new equipment and new tactics, is better surveillance, specialized troops, and specialized operations. not just one single response but many. we have since 2006 spend over 1 billion pounds from the reserve

on new vehicles for afghanistan including 280 [unintelligible] which offer protection against ied's. we have increased the number of helicopters by 80% and well -- as well as sharing coalition helicopters, we least hours from other operators. let us be clear. while we are committed to giving our commanders more options, what separates successful counterinsurgency from unsuccessful counterinsurgency is that it is won in the ground and not in the air. this year we have deployed 200 specialist counter ied troops. last week our forces cleared one of the most dangerous stretches of road in the world. the notorious pharmacy road. their skill and bravery uncovered and defused 1000 ied's

in an area where 7000 -- seven british soldiers have been killed. we focus on in countering the ied to read. one of the largest explosive device making facilities have found in helmand province, hidden in buildings was seized and destroyed along with the pressure plate ied's, fuses, detonators, and quantities of tnt and ammonium nitrate. i can report this brings the numbers of explosive devices found during the current tour by 19 light brigade to over 1000. 1000 ied is designed to kill and maim and successfully dismantled by british forces. now as i mentioned we are sending another 200 specialist forces and new equipment to find

and defuse the explosive devices and identify a target. we are increasingly -- increasing our surveillance to target the bomb makers. to ensure we have the best protected vehicles we're buying on top of the ones ordered and coming into the theater, another set of vehicle so that more will be going into operation. the first helicopters i saw adapted to afghanistan will now be flying in helmand province within two months and together with enhancements to other types of helicopter by next spring compared to 2006 will have doubled the number of helicopters and increased flying hours by 130%. the equipment has to be manufactured, delivered and adapted. the personnel trained to operate it. it is wrong to doubt the speed of our response as we adopted the tactics of the taliban and the scale of the financial commitment by their both to our

soldiers into this campaign. military spending in afghanistan, the spending that comes from the treasury reserve over and above the defense budget is going up far in excess of this significant -- increase in troop numbers. it was around 180,000 pounds per year to support each soldier 4 -- fighting in 2006. in recognition of the debt and the need to equip them, we are increasing pay at a faster rate. we introduced the first flat rate bonus for all serving in afghanistan and other operational theaters paid for under the treasury reserved. fear that income tax relief and offering more money for the average soldier. medical care in afghanistan and in britain and elsewhere has

been radically improve. i will s -- will send the medical teams and support staff for their dedication and achievements. unless your we doubled the lump- sum compensation we give to the most seriously wounded while recognizing we need to improve this program and have started an urgent review. we are giving our servicemen and women the additional resources they need to keep themselves safe, to fight and succeed in operations and to bring security to afghanistan. as we do so, we will also continue to adapt and improve our counterinsurgency strategy for central helmand which we set out in april and underpin the summer operations. it is a strategy that starts with short-term security but links to medium term afghanization of what we do and longer-term development to create a state for afghans and the future of their country. it is a strategy that has to be

based on credible deliverable and time specific objectives. objectives for the advance of afghan responsibility and autonomy for their affairs. more can take responsibility in the short term, the less our coalition forces will be needed. in our case as a strategy focused on the key population areas of some -- central helmand, don'not just the townst the river valley in the fight against the insurgency must be won. this is a strategy radically different from the russian strategy in afghanistan. indeed from all previous foreign interventions in afghanistan, which lacked the support of the population, which stayed in the cities and ignore the country and did not seek to empower afghans themselves in maintaining security. ours is essentially a four-

prong strategy. first, we will partner a growing afghan army presence in central helmand. secondly, we will be strengthening the civilian military partnership including on improving policing. thirdly, we want to support the governor of helmand by strengthening district government, backed by targeted aid and more effective and cleaner government in kabul. fourthly, we want to build on the success of the initiative which i have discussed with the government and we want to extend it to thousands more who depend on the land for their livelihood. back in 2007, i said that we would shift overtime the emphasis of our strategy to what i call afghanization and greater responsibility for afghans in this area so let me take each in turn and how we plan to progress it. the afghan army, the numbers of our forces devoted to trading --

training a mentor, the afghan army has been increasing, albeit slowly. we have helped train tens of thousands of troops and thousands more afghan police. afghan forces are already running security in kabul. over time, they will take over other districts. a british battalion has been mentioning an afghan army brigade, a living, trading, and fighting alongside them. -- living, training, and fighting alongside them. we must partner with them as they take more responsibility for their country's security. when we clear an area of taliban, it is the afghan army and police who must hold that ground and prevent the taliban from returning. when i met the new nato and u.s. commander general mcchrystal in afghanistan, i made clear that to back his counterinsurgency approach, britain's ordered faster growth of the afghan national army and

police. in the spring, nato announced we would support the expansion of the afghan army from 80,000 to 134,000 by november 2011. that training is proceeding but it is at the rate of 2000 per month. britain would support a more ambitious target of 134,000 by an earlier date of november 2010, which would mean increasing the rate of training to 4000 at least per month. it is clear that to achieve the rapid increase in afghan numbers, and to increase the quality and effectiveness of new afghan forces, this will require a new approach, shifting from entering where small mom -- members of mentor's work with units to this approach apartment where our forces will be dedicated to working side by side with the afghan army. these troops would live, train, and fight together with their partners to bring security to

the population. this is an argue -- this is the best route to success and the best way to transfer responsibility, the best way to gain the trust of the population, and the most effective way to complete our task. every british combat unit could partner of larger afghan unit. by 2010 we envisage one-third of our troops partnering forces. our combat units in helmand could be ready to partner and afghan army corps of around 10,000 soldiers. to help us achieve this goal, we will press the new afghan president to assign a greater numbers of afghan army forces to helmand where the challenge to a legitimate afghan government and the security of the people is today the greatest. this is a military strategy, complemented by an even greater emphasis on civilian effort to work with local communities. the second element of our strategy is strengthening the

security of and support for the local population. by the strongest possible civilian military partnerships including support on policing. our forces were the first in afghanistan to set up a joint military civilian headquarters. we did so in 2008, a model which the americans are looking to roll out across the country. in the 12 months following, we doubled the number of civilian support experts on the ground and i saw this joint approach in action on the hjort -- joint center. the police are often on the front lines, taking heavier casualties than the afghan army which is why over 100 armed forces are dedicated to mentoring them in addition to our civilian police mentors. the chance is -- there are positive signs including the success of the focus district development program. we need to go further in

tackling problems of drug abuse and corruption and logistical problems like insuring police are paid ethically and on time. without progress all will be impossible. the third element at the heart of the future for afghanistan with its predominant village general population is the strengthening of local and district government. a vital part of any counterinsurgency strategy anywhere a vital part of countering the shadow governments of the taliban. a few months ago when i was last in afghanistan before last weekend, i attended a meeting of district officials and others. they were discussing plans for policing and -- informal justice and basic services. as our policy of afghanizations and localization advances, our experts will help more villages

and districts and across afghanistan, party must be given to the training and mentoring of the 34 provincial governments but also 400 district governments as well. our development department has over the last three years in helmand funded many kill maters, 60 kilometers of new roads. 1800 wells, irrigation for 20,000 hectares, construction has begun on a project to develop the hydropower plant and will expand the airfield. construction will begin on a new road linking the towns. i will say today that we are ready to fund and partner the first afghan district teams to be sent down to helmand for stabilization purposes. afghan officials working alongside our teams not only are we reinforcing the hard gains of our forces during this most difficult of somers, but advancing afghan responsibility

for their own affairs. to ensure this effort has support will provide an extra 20 million pounds for security and stabilization working -- work in helmand including police training and basic justice and increasing by 50% we have provided over the last year. the fourth part of our strategy is moving the economy of central helmand over time and to diversify even further. attacking the heroin trade is not of course the fundamental reason why we are in afghanistan. the fundamental reason is to ensure that this can not use -- be used as a base to plan and execute terror attacks. the drug networks are one of the most powerful forces standing against the legitimate afghan control which overtime, could take over the job of dealing with terrorism and the insurgency.

that is why we as part of nato have been part of mounting more than 80 operations across afghanistan in this year, precisely targeting the links between the drugs networks and the insurgents. we also know that the strategy will work best when we provide an alternative livelihood for the farmers. i believe that the key to reduction in heroin in helmand by 37% this year, the fact that was announced by the u.n. this week, was the governor's program. with the support of military and experts, wheat seed was delivered to farmers, combining an alternative to poppy with protection from taliban intimidation. the study carried out by a university confirms that the results in the food zone are better than outside and we will help the governor to extend this program next year. we will help set up an

agricultural training college. we want to see central helmand restored to its former position known as the breadbasket of afghanistan. as we look beyond the elections, there are changes we want to encourage with our coalition allies at a national level. the priority is for the new government of afghanistan to retain the trust and support of its people. this means action against corruption. it also means reaching out, including two other candidates in the election. as in every other conflicts, lasting peace and stability will involve all sides reaching out and engaging in dialogue. this process must be led by the afghans themselves. as president obama has said, there is an uncompromising -- the taliban must be defeated but there are those who have taken up arms because of coercion or simply for a price.

these afghans must have the option to choose a different course. our military efforts are essential to this process of reconciliation and reintegration of former fighters. it must take place from a position of strength. the insurgents must come to believe they will not win but that all those that can be reconciled, they must see an alternative way forward, founded on the wrist -- the renunciation of violence and acceptance of the democratic process and severing any links with terrorists. political progress must be backed by a stronger economy. in a country where over half of afghans live below the poverty line and 40% remain unemployed, three-quarters of which are men under the age of 35, poverty and lack of opportunity is a problem that must be addressed. that is what we're committing 36 million over the next four years to a national afghan program for employment which will create

20,000 permanent jobs and boost income for 200,000 afghans. as well as increasing our civilian assistance to helmand to back the work of our forces there, the department of international development will work at a national level on longer-term objectives, continuing to support as we have since 2002 improvements to health, access to education, sometimes forgotten at times like these. it is a truly remarkable achievement but thanks to the help of the international community, basic health care now covers more than 4/5 of the afghan people. 40,000 more afghan children will see their fifth birthdays this year compared to 2002. we should remember again that when the taliban run the country, only 1 million children were at school. all boys. today there are 6.6 million children at school, 2 million of them are girls. with the help of our development

funding, 10,000 new teachers were recruited from 2007 with more expected in 2009 and this is an investment in the future of afghanistan and its stability and its resilience against extremism and therefore in our security. our work on education in afghanistan, together with the increasing focus on education in pakistan, brings me to a final point. i have described the courageous and skillful work of our forces. rightly the focus of so much of our attention and our concern and behind that work, our counterinsurgencies strategy. aimed at building up afghan authorities to a point where they can defeat the insurgents and terrorists themselves and our forces can return home. the challenges facing us as we put the strategy into effect, the work we're doing to improve it, and the broader national

context. returning from afghanistan again, i also reflected that while our objective is to advance justice, tolerance, and opportunity underpinned by security, that of our enemies is an ideology of violence, intolerance, and resistance to monday, t-- modernity, as alien to islam as it is to the west. achieving our objectives depends on us winning hearts and minds. the task of winning hearts and minds in southern afghanistan is not primarily hours. it is for the elected government. we can and must support them in this. just as we support them in security and development. encouraging new links with muslim thinkers and young people, using all modern means of communication to engage with moderates and all espousing a

peaceful interpretation of islam, corporations between institutions of learning, showing we are not in a struggle against islam but against extremists who abuse is long for their purposes. britain will continue our proud tradition of supporting education, a free media, the exchange of ideas, and learning in afghanistan as we do in the rest of the world. this is more than soft power or smart power. this is about people power, empowering individuals and communities to stand up against extremism. this has been the most difficult of summers. the situation is serious, no more so than in helmand. there are young people who have suffered at the hands of taliban and they are in hospital. when i meet the families of those people who have been bereaved, i have to keep asking myself, are we taking the right decisions for them and for the

conduct of the action in afghanistan? are we doing what is right both by our forces and by the population of this country, and every time i asked myself, as i do with these questions, my answer is yes. we are taking the right action, the action that is necessary to safeguard both our country and promote security in the world. it is at times like this that we must strengthen, not weaken our resolve. we must stand up to those who would threaten our way of life. we must take heart from progress that has been made since 2001. we must take actions to deal with the changing and new tactics of the taliban. i know we are asking a great deal of our armed forces. i can assure them that the government will continue to give them every support. just as important, so to i know well the people and the communities of our country. in return, we are setting

credible and deliverable objectives for their work. above all for the advance of afghan responsibility and autonomy. i repeat, the more the afghans can take responsibility in the short term, the less our coalition forces will be needed in the long term. this of course must be accompanied by a credible, deliverable, and specific objectives in pakistan, especially on action against terrorist networks in the country. continuing the enhancement of security for our forces, expanding the final work that is discovered -- that discovered and dismantled explosive devices, radical step up in the training of afghan forces through partnering, ready to work with our allies to trade 10,000 new forces in helmand alone, stronger district government's in helmand and afghanistan, local communities given greater power to run their

own affairs, backed up by a civilian strategy to provide clean policing and services as well as security, through our development work securing for afghans a greater economic stake in the future of the country and pressure on the new government for an anti-corruption drive through the country, these are objectives that are clear and justified and realistic and achievable. it remains my judgment that a safer britain requires a safer afghanistan. afghanistan -- in afghanistan i was further convinced that despite the challenges we face, a nation emerging from three decades of violence can be healed and strengthened and our country and the world can be safer. together, we have the values and strategy and, i believe, the resolve to complete our vital and important task. thank you very much. [applause]

>> thank you very much for your remarks. we have gathered together a large portion of london-based membership and experts on afghanistan and pakistan and the region. we are grateful that you are able to stay a few minutes more to engage in a discussion and debate. an awful lot of strategic questions were raised by the remarks that you just made. people will be interested to judge whether that goal, to have afghanization and to train 4000 per month is a realistic goal given the situation in afghanistan. people will be interested to investigate what the true balance is between the challenge we have in afghanistan and the specific challenge in pakistan. you mentioned much above -- much of al qaeda were displaced.

some might remove themselves again to a safe haven in afghanistan. people might be interested in knowing what is the relationship between these two. if we have a large footprint in afghanistan, will be the tolerance of pakistani public opinion for the action in pakistan. a third big strategic question, and exactly how and what point does one negotiate with the taliban or deal with the reconcilables. what is that strength then how do we determine we are strong enough to flip some of the taliban to our side or in support of the elected government. those are some of the questions in my mind. the members will have more. michael howard has already caught my eye, a former professor of war. >> dr. chipman quoted the policy

statement of secretary gates about what american policy is. you frequently and properly told the alliance and what our allies are doing, not what they are not doing, that is another matter. if one is to read the press in this country, one would believe that we are the only people out there, we're the only people making in the efforts and the only people taking sacrifices. we are a vital part of a larger alliance for which the u.s. are making by far the greater contribution and suffering the greatest losses. i asked my great nephew age 18 the other day whether we should still be in afghanistan or not. his surprise astonished me.

he said we have to be there because the americans are. i never expected to have that kind of reaction from the young man of his generation. his point was that we have got obligations as allies which we cannot weasel out of. our success there is the success of the west as a whole, not simply of this country. our contribution there is -- goes very much more deeper than simply establishing stable governments in afghanistan. it is establishing this success, the self-confidence of the west under a very heavy general thread. -- threat to. t. as long as the americans are there, we have got to be there as well. >> thank you for both your

contribution to our country as a great historian and also, to the contemporary debates of our time and i should join you in thanking your nephew as well for his contribution. i am encouraged by the fact that the proposals that we have been making about greater afghan responsibility for afghan affairs is the established policy as you have heard from the remarks of mr. gates reported earlier on. we are at one on the challenges we face and how we must meet them moving forward. i am also at one with you that this is a broad coalition of forces, brought together by the americans after 2001, and these countries are countries that also owe a debt to the nato alliance. each country must look over the

next few weeks at the contribution that it is making to this project. at the level of burden sharing, they should be considering for themselves and i think it is true to say we have a right to expect other countries to make a bigger contribution in the future. the fact that we share the same basic and fundamental values of the americans, that arises from our history and our experience but also from our basic traditions and philosophical thought. the fact that we share the same objectives for how we can achieve things in afghanistan makes me confident that the alliance between britain and america is stronger than ever. but also makes me confident we can persuade the rest of that nato alliance and the group beyond nato that is involved in the coalition to recognize their responsibilities in the matter for the years to come. >> in the front row.

there is a microphone behind you. >> thank you for coming in and talking to us so clearly. can you help those of us who support the campaign over the question of measurement? in most wars, you can measure progress or lack of progress. it is errors on the map or places you take, it is enemies to kill. neither of those fit to and part of the reason for the anxiety and sometimes dismay in this country is it is very hard to know what is actually going on. is the success -- what follows from that? if we could have a system regularly produced so that we could -- so people could measure more clearly by a number of indices in a number of ways, even if we are doing badly, what progress is there or lack of

progress? this haze of anxiety that people live in, people with families, i find it is this haze of anxiety. they do not know enough about it which is baffling and in the end, dangerous. >> i am very grateful for your question and for what you have done over many years to strengthen the relationships that are part of our alliance. and the civilized way you conduct debate. the last time i talk to you, you were writing a book and i hope i was able to give you some information about what was happening. you rightly ask, the british public are saying to us, can you show us that you will bring forward results, that you will have success in the time to come? you rightly say, what other measures of that -- what are the

measures of that success? the taliban were prepared to take this head on and we defeated them and the use of the explosive devices means that they are effectively if fighting guerrilla warfare. the first thing i think we have to say is despite what has been said in newspapers all over the world this summer, the record of success of our forces in dismantling these explosive devices has been very high. when i say 1000 devices, i mean a very high proportion of those that have been laid by the taliban with the view of killing our british forces, they have not been able to see them ignited in a way that they planned. what then is our measures for the time ahead? we have to show that we are tackling this id -- ied threat.

it must be the quantity and quality of afghan forces in the field. it must be the quality and size of the afghan police force and its effectiveness, free of corruption. it must be the success of achieving local governance that is accepted by the people of afghanistan themselves in the local communities. when i visited a meeting and have people talking, you can see where they moved from a system where the taliban were enforcing their form of justice to being in the center of a justice process themselves. we must strengthen local governments. we must be able to show that the corruption is reduced. we will have to show also that we have made progress on the economic prosperity of afghanistan. people must have a stake in the future of afghanistan other than in heroin. there are measures of progress that you can examine.

this is part of the debate at the moment that we're having as a result of general mcchrystal's review. a high proportion of explosive devices are dismantled. it is essential that we show that we have in practical terms, built up the afghan ability to run affairs and there will be measures of that and the population the comes within the civic institutions within the scope of the police and afghan army that i think will be the decisive measures of the future. what i'm saying is i understand that the british people need to know that what we are doing at this part of the strategy to move things forward, they know the taliban have changed the tactics. we have to show that our response to that directly by dealing with the devices but also our response by moving forward afghan responsibility is something that could make a difference. i believe it can and i believe

and you rightly ask the question, can we amount -- increase the amount of training quickly? yes if we make that an important part of what we do. talking to general mcchrystal and the other countries, they are ready to play their part. some of their some of -- some of them more ready to play a part in training than they are on the ground. this is a deliverable objective and this is what we can discuss with the rest of our coalition, where we are involved but also for afghanistan. >> the editor of our journal which has produced a lot of analysis on afghanistan. >> thank you. this is a coda to what was already addressed. of course, what is palpable is that there is rising debate and

dismay and anxiety in the u.s. about the extent of the goals and the extent of the mission. you dress, you started your remarks addressing these very directly. forgive me if i raise it again. when you said that it would be a huge profit and boon to al qaeda -- propaganda failure for al qaeda to see a stable and peaceful afghanistan, the flip side of that that many worry about is it is a propaganda benefit for al qaeda if there is a long-term, indefinite, and very bloody commitment. the question is, -- your remarks about afghanization will be

welcome. when people talk about solidarity and the extent of the problem and when you talk about a, you get to a situation where you are describing the goals in perfect terms. is there a council of realism that should be part of the alliance deliberations as well as a council of solidarity? >> i do not want to suggest that there is an absolute position that we can get to. i talked about credible, specific, and in some cases, i think time specific objectives that we can set. it is credible to say that over the next period of time, we can build up the afghan army. i think that the afghan soldiers themselves according to my friends in the british army are good soldiers and potentially able to do well. the issue is, will the coalition

have the determination to follow that true? that is also true of police. we have had initiatives to train police. we have sent police trainers. it is also true that other countries have made promises they would do this and they have not stepped up to the mark that we expected. it will depend on the determination of the coalition to follow through this strategy. it is deliverable and credible and most would agree. you can set time horizons for training of the afghan forces and for the partnering objectives we have set, but we will need the rest of the alliance to work with us to achieve it. if the same thing goes forward, not just police and army but for the buildup of civic institutions, that is a more difficult thing to say that you have achieved results because local government can be successful under one personality or individual then that person is transferred and the whole thing falls apart.

we're going to have to work not just at a national level but everybody recognizes at a local level at working with the tribal chiefs and recognizing some of the problems that we have not recognized at the beginning about how they wish to operate themselves and working with the grain where we have attempted before not to work with the grain. are they deliverable? i believe so. does it depend on the will of the coalition? yes and that is an important element of every discussion. >> professor of international relations in the front row. >> thank you, prime minister. two questions, one about the adversary, and one about objectives. you have hardly mentioned, maybe

you have mentioned the word pashtun, and it has looked in recent months as if we have plundered without intending to do so with -- into a war intopashtuwith pashtun national. you have mentioned al qaeda. i wondered if you could say something about how you envisaged the possibility of pashtun elements. ands it can be addressed and separated. you said at the beginning you would address the objection of that an afghan state cannot be built. you have parlayed developed an answer to that.

-- partly developed in answer to that. i wish you could say more. to many, it does seem as if up to now, there has been an attempt to do the impossible. to create something that has very little meaning in most afghan mine. nothing in history suggests the loyalty to the state transcends loyalty to family group or tribe or whatever and there is no reason to suppose that nor could the afghan state developed in a situation where even now, eight years after the initial western involvement, it is -- there is little in the way of a justice system. that operates under the afghan government and many survivors of the justice system operating locally or taliban participation. the notion that we should be focusing on a state may be too ambitious a notion.

perhaps a simple question of ensuring no al qaeda revival in afghanistan. >> that is a tough question. we will. two -- we will take two more. >> i wonder if you could say a word about iran's role in assisting regional stability. immediately after 9/11, they seemed to be helpful and they saw a common interest in stopping the western flow of drugs. more recently, one hears they are being unhelpful, perhaps after tightening u.n. sanctions. they could be still less helpful. >> the third question in this triptych from robert fox. >> in the buildup to the program of afghanization, do we have

sufficiency of combat power? it seems to have been a problem since 2001 and particularly 2006. you talk early about the achievements but look at the low level of casualties. have we been too light? have we got enough in the kitty for contingency? al qaeda is not resident in waziristan. it is resurgent in yemen, somalia, where we have obligations. >> this is a fascinating group of questions. let me start with prof. roberts who raises a two -- who raises two questions that have risen. people need to feel secure and feel stability.

the second is the recognition of tribal loyalties is something we have failed to take fully into account. in our efforts. i think there is some truth in the suggestion that post-2001, we did not, all the allies, appreciate sufficiently the long history of afghanistan, the weakness of the central state, it was said in written in 1914 that the only knowledge that people would have of the state if they lived in a remote village or part of the country was the existence of a post office. in afghanistan is true to say that when you meet people in local meetings they are not talking about the role of the central government. they're talking about how they can get local justice and how they can get greater local security. they rely upon for that not a

central government. they rely on what can be created locally. i do agree with you that we cannot place all our faith in their responsibility being taken by a government. we will have to build up local government. that answers your second question. to build up local responsibility for local affairs and this is a question in relation to the pashtuns. it will have to work with the grain of the history of afghanistan. that does not mean that in cases where you have tribal chiefs who are drug overlords, that you can condone the behavior, but there must be some recognition of a local systems, the modus operandi of the tribal system in what we do. more emphasis has to be placed on local and regional government. were you have a good governor -- where you have a good governor

like the governor in helmand, but he has to be encouraged to have constant contact with local leaders and build up district government's -- governance. we cannot ignore the fact that if you are having at afghan national army, you have to have an apparatus at the center. we cannot ignore the fact that as long as afghanistan's legislators are wanting to impose laws that are quite in contradiction to the dignity and rights of women, we have to be clear that this debate has got to be held for afghanistan as a whole so we have to get the balance right between what we now know is a greater emphasis on local communities and having a state that is at least

successful. you are telling us that we have got to have a better understanding of the history of afghanistan to move forward. but also raises for me the question of pakistan. -- and that also raises for me the question of pakistan. probably the most positive development is simultaneously on both sides of the border, there was action against terrorism. i am surprised and encouraged that by the speed of which there appears to be developing a national coalition in pakistan that the terrorists have to be taken on. what happened when the pakistan army went into the swat valley, there could have been action taken that was successful and along the term, build up support for the taliban. what seems to be happening is people are returning and their managing to resume their lives but under justice that is not

taliban justice. but under a better framework. i hope what pakistan can prove is that their attention to the problem of terrorism has never been complete. it is something that is bringing results but can still command support across the political system and bring the army and security set -- and security and politicians together in one common effort. when it is raised with me the role of other powers in the region and to raise the question of iran and its tactics, i am conscious that if you are going to have a desertion from the taliban, then as the professor has said, we are dealing with people who are paid some dollars a day to do the work, enough for their mercenaries, and we're dealing with people who are intimidated and therefore, they are reluctant people and we are

dealing as you said with nationalists who might see the future of afghanistan depends on resisting an occupying force rather than supporting pashtun. you also have this group of irreconcilables and they claim islam to justify any terrorist attack on anybody who is from a western our coalition power and they attempt to exclude other rid religious views. -- other religious views. the one group can be -- renounce views and that is something pashtun nationalists say, they feel that there only alternative is to support the taliban. there are opportunities here, but as long in my view in this is where we might part company,

as long as you have a strong enough afghan government and you have local government that is in a position to make it possible to deal with this problem of reconciliation from a position of strength, i think the third question was about the number of troops necessary for the afghanization. this is what we have got to look at in the next few weeks. i always said that it would require the review that is taking place in america and here after the election. to determine for us what is the proper level of our troop numbers for the next stage of the exercise. clearly, the approach is as i have described it, the new element of that is greater attention and concentration on partnering with afghan forces. that requires us to look at what resources we need for that particular part of our exercise and what i am discussing with the chief of the defense staff, i have had a discussion with the

new chief of general staff, we are involved in discussions with americans and this will have to be a coalition decision as to whether other countries are prepared to share the burden with us and with others. we have a situation where the netherlands, canada, and potentially japan have indicated their wish to have their dates by which time their active forces will not be in the country and we have to do with that situation at the same time. this is part of the continuing process after the election of reviewing the strategy that we are outlining which is a shared strategy between us and the americans. >> we have to stop at 3 so i will take a couple more. bob edgeworth will be doing interviews on the third floor so some members of the press may be able to catch him there. could i first have -- if you

could stand up? if you give me your name, i shall remember, i promise, for a long time. if you could stand up when you ask the question, it is easier. thank you. >> i wanted -- if your program is successful, could you envisage a situation whereby our troops are [unintelligible] >> i think the issue is how fast we can move on this. what we're saying is we're going to move faster. if as i say afghan forces can take more responsibility for the functions of security in the different parts of afghanistan, and if we consider that transfers of responsibility are done district by district or province by province, it is

possible to envisage that as the number of afghans taking responsibility grows and the quality of their leadership grows, we can reduce the numbers of our forces. that is the basis of our strategy and it is the basis of the american strategy as well. i can be time specific about the buildup of afghan forces that we are trying to achieve when we see the quality of the effort and when we are assured that responsibility can be taken, that is the point at which we can say that the need for british troops is a great deal less than the need for afghanistan to take more responsibility is in fact what we have always been trying to achieve. >> the last question before we conclude. >> taking away from afghanistan but staying on the same thing, i wonder why your government and other western governments are not paying attention to al qaeda in places like soltan --

like somalia. >> the answer is we are paying attention to the role of al qaeda in different parts of the world. a considerable amount of effort is being made to examine and see what we can do and the position that somalia faces -- my worry has been that over the course of months you will see al qaeda moving into different parts of africa, undermining elected governments there, creating religious divisions that mean there is conflict within these countries, and using these countries as a base to send terrorists out of these countries into countries like britain. i think we have to except the leadership of al qaeda is based in the pakistan mountains. the crucible of terrorism that i have talked about is the concentration of al qaeda supported by the taliban of pakistan and the taliban of pakistan. this is the most serious

concentration of terrorist planning in the world and we have got to recognize our responsibilities, not just on our behalf to keep our streets safe and working with allies to do with that problem, i can assure you that a great deal of work is going into looking at the position of al qaeda. al qaeda operates in different ways in different countries. some people exploit local grievances that are in fact local grievances masquerading as al qaeda objectives for the extreme view of islam that some of them take. i think we have got to look at each individual area as well as look at the general position of al qaeda. >> thank you very much for choosing us to deliver this important speech and engaging with our membership. debating a little bit different in style than you are accustomed

to and as intellectually challenging. given that you are interested in these subjects, on the 18th of september we will be receiving the president of pakistan and a few days after that, general mcchrystal. both have been mentioned in today's address, for which we thank him. [applause] . .

bill when congress returns from its recess is shailagh murray. thanks for joining us. that committee is one of the five senate and house committees working on the health care bill. we start off by giving our audience an overall picture on

where we stand as congress gets set to return. >> four of those five committees have acted at this point. there are three committees with jurisdiction over health care and in the senate there are two. the finance committee is the only one that has not completed its portion of that particular bill. reason being that health care encompasses so many different policy areas and finance, it oversees the taxing, medicare, medicaid portions of the bill. whenever there is money involved it takes longer. it is tougher to find consensus, but the health committee bill we will talk about has most of the policy. wellness prevention, a new framework for how people can buy

health insurance and also guidelines for how to subsidize it. in the house, the three committees have acted. it was pretty ugly at the end it was pretty ugly at the end getting it through the final committee. house leaders will wait and see what happens before they moved that bill to the floor. they will have to rewrite the bill before it gets to the floor because of changes that were made. while health care reform is farther along than it has been in a generation come it is -- farther than it has been in a generation, it is just a big bill. >> we will focus on the senate health committee version. we touched on a couple of bullet points. what else is notable about this bill? >> the health committee's bill is the most straightforward, because it outlines -- a lot of

folks don't understand the scope of this legislation. the health committee bill and a series of titles out lines how employers are going to be penalized for not provi what size companies will have to provide coverage? what happens to employees if they do not? . establish an individual mandate requiring people to buy health insurance. the finance committee has to create the mechanism for doing that but the health committee sets forward the policy. there are provisions on how to encourage and create incentives to get people to do the check ups and detect diseases like diabetes, which have set such enormous public health costs -- which have such enormous public

health costs. a key to lowering health-care costs long term, which is the underlying goal, is to get a handle on these diseases and try to intervene with them before they become explosive cost issues. >> you have two different committees on the senate side working on their versions. tell us about the process. once the finance version is finalized what is the next step? >> the finance bill has to emerge from the committee mid september. at that point, senate majority leader harry reid said he will create a committee or group of individuals to combine these two bills in order to put them on the senate floor. that is a process we usually

associate with the end of the legislative process, but you cannot put both these bills on the floor and let the senate worked its will. >> that opening video was notable because senator dodd was in the chair for senator kennedy. what has senator dodd -- what are his plans? >> we expect him to become the chairman of that committee. he has not indicated his preference at this point. he could remain chairman of the banking committee if he wants, but he has the seniority to take over that committee. he was very close to senator kennedy, and this week senator reid tipped where senator dodd was leading when -- where he was leaning when he thought he would become chairman. we don't expect that to happen until after congress returns.

>> it has. i think a lot of people see that moment as an opportunity to reassess this effort in a broad sense. it was distilled down to a lot of flash points over the recess. none of them were central issues to this effort, but i think people will have an opportunity to reconsider the magnitude of this effort. also, the way senator kennedy went about things, which over the course of the career earned him the respect of many of his colleagues, including a lot of republicans. >> one of the flash points was the mention of the worst public plan. in a moment we will show some --

the mention of one of the words public option. >> it is the centerpiece of this health committee bill. it is the flash point of the debate and yet most people don't understand what it is. it is a government-backed health insurance option that would be offered in all markets in some form that would allow or at least provide a minimum option for people who don't have health coverage to purchase it so that they would not be forced to buy a more expensive private insurance plan. the idea is to introduce a

consistent form of competition across these markets. and create some consistency in the way that benefits are is administered and offered so that people know what to expect. people in montana have the same options as people in new york. that is the idea. to many people it sounds like the government moving further into the the committee passed the bill on a party-line vote. what about that particular element? does it have any republican support? >> not really. a lot of democrats are uncomfortable with the idea. one of the big holdups in the house and big challenge going forward for the house bill will be this public option. >> we will take a look at 20 minutes of debate on the public option from the senate health

committee. >> this amendment would strike the public health insurance option as established in section 142 as indonesia -- as envisioned in need bill. it would not save consumers money. that does not uphold the spirit that the president set out to do health care reform. they all but omitted that in their revised estimate wednesday said that community health insurance option -- when they said the community health insurance option was not projected to have premiums lower than those charged by private insurer plans. what is the point? martin mcclellan noted this

auction falls short even of what supporters had envisioned. -- noted this option fall short. they can get lower cost by exerting power of their plans don't have, or a can go the other way. -- lower-cost by exerting power of their plans don't have. -- other plans don't have. it does not meet the spirits of the president's objective. the reason why proponents don't want to overreach is because they know american people are opposed to a government-run health insurance option. by a 60-31 margin, americans prefer receiving health coverage by private insurers, according to national polls. some may have noted a recent poll indicating wider support of the government option,

but that poll was over sampled. i would suggest this is a confusing array of government controls for the sake of government controls. i think i agree with my colleagues. we need health care reform. it is desperately required for our system to be revamped, but we will not be affected if we think the government can do it and do it better. this is not fair competition. if a referee is also a player in the game that is not about competition. i would urge my colleagues to vote for the amendment and strike the community health insurance often.

-- straight the community health insurance option. >> i vigorously oppose the gentleman from north carolina's amendment striking the option to enroll in a public health insurance plan. it erodes an important principle we're trying to establish, giving consumers more choice for affordable insurance. the public plans that we are advocating is very much in keeping with the principles that the president stated. the health insurance markets, this is what president obama said. the health insurance markets severely lacked competition and ask them to consolidate power over decisions best left to doctors and patients and have a big impact on costs. what the public option will do

is provide stability by being in every market, provides insurers to move in and out of market changes, make sure that they have consistent providers. the public option definitely promotes efficiency. the community health choice bill can achieve growth and fair competition, and also promotes innovation. our current health care system does not deliver value in the private market in the way our system is set up. it will promote it. the public option in the committee, and ordinarily i committee, and ordinarily i don't " materials. but the editorial by the new

york times calls for a public option. it calls for it because it talks about how we provide competition, comprehensive coverage, insist on creating a new paradigm that creates a culture of wellness and prevention and at the same time promotes innovation in that area. i would hope that the gentleman's amendment would be defeated and go forward to others. >> madam chairman? i just went to call attention to this chart that we passed out. this is taken from a study of the american medical association nd what "competition and health

insurance." it goes state-by-state and tries to talk about the market share of the two largest health plans in 2006. it makes the point that in north carolina, between 7% and 79% of the market share. -- between 70% and 79% of the market share is shared between the two largest health plans. in my state is was between 50% and 69% of the market share that was controlled by two largest health plans. those state-by-state and the point which i take away public n

is a way to provide that additional competition and give people an additional choices, as the chairwoman has said. i would strongly oppose the amendment. >> thank you madame chair. i would like to have my voice in strong opposition to this amendment. i found it very interesting to see that poll which said 72% of votes nationwide would like to see a public option. recently up in oregon i have a town hall in a rural conservative part of the state. many people rose to speak about health care because of some concerns they heard. after a dozen folks had shared their opinion i took a poll of

the 120 folks gathered. a handful said they would prefer to have a single option. about 15-20 raised their hands to say they would prefer to have only private health care options. the balance of 80 people raised their hands to said they would like to have the full set of choices so that they could choose. i think this makes a lot of sense. in oregon, we have a public option in workers' compensation. two decades ago the business community was concerned about the dysfunction in the private insurance market and decided to create a public option in workers' compensation. the result has been an outstanding improvement in the insurance market for workers' compensation in the state of oregon. more efficiency, the competition has produced lower prices.

it just kept everybody on their toes. we have these sorts of arrangements for about our society. we have a public option on mail that competes with private companies that deliver mail. i really think that taking away and options from the citizens to choose a health care plan they think would be better for their family is a huge mistake. it will result in the same runway prices we have right now, the status quo is destroying our nation. we have cost increases per year of 10%. we even had a major insurer had a year over year increase of 26% followed by 14%. can you imagine the number of small businesses with this cost

increase that are saying we cannot continue to provide insurance? another piece that is attractive to the public option is there are areas where private insurance companies are not good at doing. one is prevention and also disease management. they may not have that person as a customer 10 years into the future, so as the public option is structured, there will be influenced by local boards that can provide guidance on how that would work in their particular state. i think that is a very valuable possibility as well, so that states that would like to see more done on prevention, maybe more done in terms of the structure of payments so we have more integrated health-care providers reduce the return rate to hospitals. let's not take away a

fundamental opportunity for the citizen to choose the health care plan that best suits their family. >> madame chair. >> i would yield to the ranking member. i appreciate that. thank you. what we are talking about here is you call it public option and i call it government-backed. i don't think one plan is the answer to more competition. one plan takes away choices. pretty quickly we would have one plant and not two. we see a% of the market stunned by two of the largest health plans, we would have -- we have 80% of the market owned by two of the largest health plans and then we would have just one.

we all agreed that a lack of competition is the problem, but don't eliminate lack of competition by doing one company that can have dominance over every other company and put the rest of them out of business. we have medicare partd. when we started to go into this we said there are only two people in wyoming produce pharmaceuticals. what will i do if wyoming winds up without a provider? one of these solutions was thrown out there was having a program that would be done by the government that would be a backup in case there were not two companies that provided the insurance. we provided a lot of incentives for people to do it and i never had to worry about that because 49 companies wanted the business in wyoming. we went fromtwo to 49.

it brought down the prices by 37% before it started. it has been below ever since it started. every time i went around the state and i did a bunch of town hall meetings to get people to sign up for this. if you don't sign up, then you start paying a penalty. i am pleased that my amin was one of the record states for a signing up, -- i am pleased that wyoming was one of the record states for signing up. their first question was how come i cannot get the drugs i want? how come i can i get the drugs my doctor is prescribing? the program had not started so i said i bet you are a veteran. they would say yes, how did you know? i said the veterans organization is a government-run operation that takes bids. the only way you can do bids on

different medications is to say to the producers of the heart medicine that they have to bid against each other. the doctors will say those drugs do something differently. for my patients one of those is better than the other by one of them ends up with a contract. that one medication is the one that the veterans can get. i had 1000 veterans change from the veteran program to medicare part d so they could get the prescription they wanted. kent conrad suggested a way to increase competition. he talked about co-ops. but he got the idea from the wyoming farmers union who thought that a health co-op would help them. i hope he will take a look at that. that is a way to have more

competition in every and even r. that we are able to participate in. that is nationwide but different states have different requirements, so there is a smoothing technique and the costs are kept down. it needs more fleshing out but it does remind me of a program that i brought up in the senate called small business health plans. the way that that competition worked was businesses could group -- they could group together through their association across state lines and even nationwide. they could get a big enough pool so they could effectively negotiate with their insurance company. ohio has one of the lowest

costs. they have enough population that they are able to do these plans without going across state lines. what was the effect? the effect was 37% administration costs came down to 12%. that is a pretty big saving for any business but especially for a small business. that is what they can achieve by grouping together. that bill came up with the -- it came up in the senate and it got 58 votes. we never got to mn for those, so we never got to solve the problem -- we never got to ammend for those. people were working on something similar for a long time called associated health plans. with this, those organizations

could form like a big company does and use derisive rather than other requirements. there was a lot of opposition to that, so that never went anywhere. but the small business health plans has a lot of potential everywhere, a way to bring down costs, a way to increase competition. you mentioned that in some of these states cannot 50% of the market is by the two largest health plans. i bet that a lot of times the largest part of the market share in any business is held by one or two companies. i would like to reverse that. i think small business is where it is at. i wonder with the general motors' problem what would have happened if we said back in november, we are not going to give you any money.

i think we would have had a short-term catastrophe and a long-term solution with many car companies developing out of that. each one trying to find their own niche and competitively working. it would have been another example of how competition can work. one plan is not the answer to this. we are not adding options, we are taking away our options with a government plan. >> that was debate from a senate health committee. the amendment failed 10-13. shailagh murray, that we heard the senator talk about analysis by the congressional budget office on the public plan. he said it showed implementing that public option would not result in cost savings. >> that is probably the best republican argument against the public plan, that is difficult

to illustrate under the terms congress relies on, which is the 10 year window that whoever is trying to pass a bill of this scope is always unhappy because it never takes into account the variables. the democrats' argument is that a public plan would change the behavior of the insurance industry which would lower health-care costs in the long run and create less costs were the government through medicare and medicaid, and save businesses money and leave it to this economic tipping point, but it is hard to illustrate that. so what republicans are saying is this is a huge risk. we are taking the government further into the health-care

business, yet we are not getting anything obvious back. >> just in recent days there was some talk about the cbo looking beyond 10 years and@@@@@@@ @ @ >> and getting government spending costs under control. they cannot figure out how to change the system without making it look like they're trying to change the system to benefit for their own purposes. that includes some of the policy risks involved. there is a credible argument to be made in health care that it is all encompassing and you

cannot take a traditional look at it. but they can agree on a non- traditional way of looking at the budget numbers. >> one idea reheard and a lot more about is cooperatives. what our health care cooperatives? >> those would be modeled on the way that world electricity providers are organized, or the way telephone service used to be provided where you have lack of competition in a marketplace. consumers band together and provide a not-for-profit format service to themselves. these cooperatives would function that way like the bluecross blueshield model originally. that is how that company came into being.

that is kind of what the supporters of cooperatives have in mind, but critics say the democrats who prefer the public plan say aren't cooperatives just as big of a risk? the government would be responsible for these. >> there are democrats who are supporting co-ops, correct? >> that is the finance committee bill that is likely to create a cooperative model as opposed to a public plan, because finance committee members are more conservative and don't like the public plan. >> the public plan was subject to a number of amendments. another was cer. tell us about that. >> that is one of the provisions that scares people because one of the problems with the health care world is that it is an ad

hoc. the type of service you get and how a disease is treated depends on what hospital and you end up at 81 part of the country -- and was part of the country you are in. people have come to rely on that. they have come to see that as choice, and that is a reason the u.s. health-care system is so great and offers such great service, but it is also what is costing the system so much and leading to a lot of deaths and medical mistakes, and is partly what fuels the malpractice problems. competitive -- compared it

affected this is a way to look at -- the comparative effectiveness is a way to look at procedures to see what works best and impose those procedures broadly. disease management is the big bowl -- the big goal is to find ways to manage diseases like diabetes and heart diseases. >> it is not something new. it is happening now. >> exactly, and everyone in the health-care industry wants to become more efficient and safer and make people healthier. >> is this the issue republicans are focusing on and saying this is rationing health care? >> right, and it will take options away from you. if you want to have a c-section , that ought to be your right,

even though statistically that is not the best option for you. there is a sense that -- we have a sense that we have all the options in front of us but not all of them are from us. >> which uses this cer the most? >> the idea would be it would work from the grass roots up. doctors and providers would start to make decisions based on this, and insurance companies, at their policies would reflect those decisions. >> there is 25 minutes of debate from the senate health committee on comparative effectiveness research. >> some of the conversations we have had especially during the round table was the fact that the cer section was to provide research that did not necessarily mandate standards or

deny care. if you go to section1-13 -- section 10-13 which passed with bipartisan support, there should not be any reason to oppose this amendment. what this amendment is designed to do was to not allow somebody besides you and your physician to decide what your care will be. as senator mikulski has correctly noted, i can give you 1 million examples why cer will not work. if we think it will work for any other reason other than to ultimately practice medicine at the federal government or use it as a tool to ration, one of the ways to secure that it will not do that is to adopt this amendment and embraced what

happened in 2003 in the medicare modernization act. what this amendment would require that the director for the center of comparative of effectiveness research shall not mandate any quality health standards. it does not mean they cannot study or recommend, but it means they will not mandate. the reason that is important is a question i raised when we were having a conversation, because if you mandate it and my patient should not be treated that way, you have created a liability for me that will be impossible for me to defend in a court of law because the government says this is the way you treat patients, not what my clinical experience says. it also prohibits cms from making any coverage decisions. that is the current law.

it shall include a reference to the prohibition in any recommendations resulting from projects published by the director and any communication activities performed must reflect the principle that doctors and providers should have the best available evidence upon which to make choices in healthcare. services, drugs, treatments, devices. it is the research must recognize that patient preferences may vary. all given the same outcome. if we have the assurance this is not meant to ration care and our purpose in doing this is to find out what we think is best most of the time for the average patient, and we want to put that out, then fine. but if we're going to tell

doctors what they will do and patients what they will do, it is not fine. because it is not based on the best care, it is the best based on cost as well as outcome. without this amendment i would like to know what section of the bill prohibits the government from using cer to decide what treatment the patient can and cannot have. what section prohibits the government from developing rationing methodologies like they use in england? i trust that your intent is good, but where is the protection? i will go back and remind the of that today medicare -- i will remind you that a medicare patient today cannot have a

virtual colonoscopy per orders of the dictate of cms. cms has decided that is too expensive for the benefits that we get, so no medicare patient can have it. we are already starting to see inside cms the utilization based on cost data but not necessarily outcome data because things cost too much. the data on costs compared effectiveness is clear. all you have to do is look at cancer survival rates. all you have to do is look at lifetime -- the first coronary artery and then. it is clear. i am happy to have cer in there if we have protections that says we will not have a bureaucrat telling a patient what they can and cannot have.

i am not against good practice guidelines. i think we ought to do everything we can. but a mandate is a totally different thing. when we mandate it, what we do is we say medicine has checked the box and we deny the fact that medicine is personal, that past medical history is pertinent, that a physical exam at the time of considering past medical history as well as the clinicians experienced with the patient, should have an patient, should have an

will deal with the washington bureaucrats. like every time this discussion comes up about washington bureaucrats deciding, washington bureaucrats are not going to decide anything. they are going to publish reports. let's talk about who we are talking about when we talk in washington about who does research. washington bureaucrats are called nih. those washington bureaucrats are called fda.

those washington bureaucrats are called the institute of medicine. i don't happen to think they are washington bureaucrats. i happen to believe they are very capable research people who devote their life to trying to come up with evidence that would support the initiatives that would save lives and improve lives. could we get off of this washington bureaucrat stuff? >> the question is -- >> i am beginning to find it on their behalf, offensive. i represent people who work at the national institutes of health. i represent people who work in fda. they are doing their best to come up with those ideas that either will save lives or extend lives. you have given examples of cancer and virtual colonoscopy

is. where do think that came from? that came out of a lot of government-sponsored research or government doing research so that the private sector could use it. when we talk about aren't we the latest and greatest? we are in the top five of medical expenditures in the world but we are in the bottom 37 in terms of health outcomes. the whole idea of what is coming out of comparative effectiveness is to enable more evidence in the practice to -- evidence informed practice to occur. the people who are going to be providing a lot of this research will be coming from these iconic institutions in our country. they are iconic, that they are known around the world as

incredible institutions. we are finding it convenient to turn to the institution of turn to the institution of medicine to do a study, but whe we call them washington bureaucrats. like they are people who have these implicit goals and incompetence. i would like us to get off of that. the second thing is, we continually say that in this legislation, and i have given chapter and verse that we do not mandate a clinical practice. >> there is nothing in this legislation that prohibits -- there is no clear language that prohibits the mandate of this interfering between a doctor in patients decision. please name the section where you mandate that a prohibition

that you will not have. >> go to page 323 and tell me where that says it is not construed as whether that is sufficient. then its says what you want to do in your and then it is safe not mandate national standards of clinical practice. there is nothing in here that requires a mandate. quality health care standards could be any number of things. one of which could be the development that the effectiveness of various checklists like the famous one that you know and i know has improved outcomes surgical arenas and saved lives. i think michigan told us it saved $200 million. it is not the clinical practice that i worry about, it is the quality health care standards.

>> may i ask you a question? >> i would like to finish because we could have enlisted questions. >> we need to have endless questions on this. >> what is it about quality health care standards? you have said over and over, using the same arguments. let's go to the quality health standards. >> i want to read you the text. recognition shall not be construed as mandates. that is a big difference than saying they will not be used as mandates. bay i make a suggestion? -- may i make a suggestion? let me make my point. let me make my point for a minute. we are in medicare -- where in medicare law do we have the

right to tell an 85-year-old woman that she cannot have a virtual colonoscopy? and yet that is exactly what we're doing. that is what is happening at cms today. as the pressure builds on them as we get to 2017, we will see more of that. >> could we come back to quality health standards? >> sure. >> because i don't know what you object there in establishing a

standard in quality health care. >> here is where i object. we decide that we convene people in washington from very iconic institutions. we set a standard and then we will expect to put that out and now we will have a national standard for care that is going to be [unintelligible] not because it is mandated. because the -- if you go against the quality of care he will expose every physician who does not do it exactly that way, even though their patient should not have it done that way, to liability. all of a sudden we now say there is one white where to do this -- there is one right way to do

this, and it still does regards the patient history, clinical history, experience of the physician and all those combined. >> according to the sections in this bill where we talk about national quality standards, we're talking about patient safety, the reduction of medical errors and things that happened inadvertently. i sincerely disagree with you. what you do have been here that is good is to conduct research on the proven methods of disseminating information. i think that is good because we have to know how best we communicate this in a way that people could be broadly informed, but evidence informed

and not the practice mandated. also, on the last 21 through 25 , we are back to prohibiting cms may not use data obtained in accordance with this action to withhold treatment or prescription drug. i believe we have covered that. >> can you offer me a way where we can give providers protection if the art of medicine says at this instance i should not do what the government recommends? >> let's turn to the national academy to do that, because you know more about the practice of medicine. i know more about the administration. >> i am talking about in the legislation. >> throughout this legislation i have turned to the national academies for advice to be sure

we do not interfere. i have great respect for clinicians and the responsibility they assume, and their training and dedication. if you're looking at how to do that, i would like to ask them how they think is best done rather than a back and forth here. >> there may be exposure to physicians based on what we will do. >> based on what we did in the american recovery package and what we're doing here, i think we met that need. if other national academies of clinicians, whether they are pediatricians or cardiologists say we think we have a better way, i would be open to hearing it. right now i don't want to change what we have in the law based on a back and forth.

there are also some other illegals wordings, but i think we need to look at that. >> mr. chairman? i will ask unanimous consent that on page 323 of the bill line 5 where it says these should not be construed as mandates for payment coverage, that the word on line 6 be stricken and that the bill would -- the bill should not be used as mandates for treatment. i think that would satisfy a lot of the concern raised here. >> that is exactly the suggestion by senator harkin. >> i call that the harkin rule. >> i will be sure i know the consequences because words have meaning. i don't want -- i would like to

reserve the right to object if we could -- >> could we leave this open as a possible suggestion? >> that is exactly right. >> the acting director of nih, not a washington bureaucrat, stated that cer would be used to contain costs, as did very summers and kathleen sebelius. -- as did larry summers. >> if we can leave this open, that is great. >> i appreciate -- >> i withdraw my request under the circumstances. >> this is a very important section of this bill. medicine is personal. medicine is individual. it does not fit in a box. >> but it does fit practicing

guidelines. national academies of clinicians -- >> can i finish my point? guidelines are important but they are just that, they are guidelines. if in fact you pass this bill out here with this, you will raise the cost of medicine, because now what we will do is here is the guideline that you need to follow as sorted out and implemented. the people who will implement this will be bureaucrats. the first rule of the bureaucrat is never do what is best when you can do what is safe for your own job. that will be the logo under which they operate and administer whatever comes out of cer. and when we deny the fact that medicine is personal, that it is individual and guidelines are just guidelines, and we create a

situation where physicians have another step in the process, here is the government guidelines so now i have to back up what i am doing with this other stuff because i know from my experience and what the patient is telling me that she does not fit the guidelines. i will spend a bunch of money because i am not about to expose myself to a lawyer that will say you did not fire they -- you did not follow the guidelines. if we are trying to save money, you will actually increase the costs for everyone who doesn't fit guidelines. what is wrong with us saying we will not allow this to mandate the care and get in between a patient and a doctor? >> as i have been listening to this and senator mikulski has done the bulk of the work on this section, but unless i am missing something, i don't hear much of an argument here. maybe there is some language we

will look at, but as senator roberts pointed out, if what senator mikulski has said repeatedly that it is page 323, and the word used would make it clear on that, then the debate over. we are checking that out, but i don't think you are wrong at all. the question is does the language form to that goal? once it does i think we have answered the question. i think your point is taken. senator mikulski agrees with your point. the issue is whether this language -- i am asking if he knew something about the word i did not know and we did not get the answer to that. i hope that will solve this issue. >> it solved all the issue but the liability. >> that is different than this.

>> the point is we are not going to fix the liability, so you will still increase the costs. >> the issue of guidelines exists, and i presume in every court of law were in action is brought against a provider, that guidelines would be suggesting it you did not follow a guideline. i presume that is a course of action followed by a plan in any medical -- are you mandating something? i think we are all pretty clear that we are not because of the point you have made, but i presume some lawyer will make a case that guidelines have not been followed. . .

>> what congress is trying to do is to set forth in a system of grants and entities that will help to advance the developments of quality control measures and also the best practices that will effect the practices that will effect the way all -- people are focused on this. the intent of this effort is to manage the broken arm and to the chronic and thematic --

asthmatic child to cancers and heart disease in the end of life issues that have attracted so much attention. >> as of these grants are government brown? -- government run? >> what they're calling a research and evaluation within the government umbrella -- under the government umbrella to conduct research on the effectiveness of health-care services and procedures and to provide providers and patients with the most effective treatments. basically, pulling together all this information and trying to make sense of it and give guidelines. people complain all the time about how did not understand the health care system. they do not understand the

protocols for procedures and they are now getting straight answers from their doctors. that has an effect on the economics of health care as well. people are not able to control their situations as efficiently and effectively as they could and 12. . . . impose both an individual mandate requiring people to buy health care mandate requiring people to buy have insurance.

they see this as being administered through the tax code. it is not their jurisdiction. >> would anybody be exempt? >> all kinds of people would be exempt. if you were eligible for medicaid, which would be expanded under this bill, you would be required to sign up for it. one of the big gaps in coverage right now are people who are eligible for government coverage, up 9 million or 10 million people, they're eligible and do not sign up for it. a lot of these folks are people with diseases and the sharp at emergency rooms and are costly uninsured individuals. trying to get people into the system is another goal. the individual mandate -- the goal would be to force them into

the system. >> what about families? are the penalties different? >> yes. this is one of the most difficult issues that the finance committee is wrestling with and is probably -- it will probably cloud this debate all the way down the line. what costs can you impose on people, middle class people who may be under insured or who do not have insurance and cannot qualify for government coverage but for homwhom and what have to pay more under these bills. to the health committee bill would provide a subsidy for people up to 400% of the federal poverty level. that is about $75,000 for a

family of three. the gap between what the subsidy would cover and what a family would have to purchase in health insurance could considerably. several thousand dollars a year in out of pocket costs that will be hard to find room for. that is an issue that this gang of six negotiating this and continues to go over again. >> here is what the health committee had to say about this amendment dealing with insurance. >> i would offer an amendment to 04, currently the legislation includes a requirement that all americans obtain coverage -- amendment 204, both the sec and the healthy buy

coverage, -- both the sick and the healthy buy coverage. it is a major factor in expanding coverage. individuals who do not comply are assessed a penalty, or that is what is proposed. currently, the penalty would be 50% of the cost for a family. such a penalty could be as much as $3,000 for an individual, up to perhaps $16,000 for a family each year. that penalty is too high in my view. the amendment i am offering would reduce the cost to a more reasonable level of $750 per individual or a family per year.

it is my intention the penalty would be sufficient to incentivize most americans to get coverage with up creating an on fairly large penalty and an unfairly large financial burden. creates parity between the payments that an employee would have to make if he failed to obtain coverage and is a payment made by employers, $750 per year insuring that shared responsibility and employees. it would improve the basic bill. i urge my colleagues to support the amendment. >>, i asked the senator a question? has cbo looked at this?

>> i do not believe so. >> it is an ecological, if you reduce the penalty -- isn't it logical if you reduce the penalty and more than that for families, that people are going to opt for the penalty rather than buy insurance? crest i think it is logical that some would. the number, i do not know. at least based on my interpretation of what's cbo has told us this morning, they believed that most americans would go ahead and obtain coverage. if there is a financial penalty for not doing so. the size of the penalty is a factor with some, but it is not the main factor. i think you would have some last compliance. i did not think it would be

substantial. >> wouldn't the cost to the government go up significantly, too? those folks who opted to pay the penalty would theoretically not be paying, not be insured. when they go to the hospital or one have an accident or contract a serious disease or marginal disease, those medical costs will probably end up be by the government specifically. you would wind up with more uninsured -- the $750 would not cost the medical -- it would not cover the medical costs. what their medical costs would be and their insurance costs. >> you say people who choose to pay the penalty and do not it coverage, they could then be running up the cost to the

government. is that your argument? >> it should they incur in medical costs, somebody is going to have to pick it up. >> we have talked a lot this afternoon about cost shifting. the biggest cost shift that exist is by folks who do not have any coverage. providing coverage to them and going to the private sector. the main thrust of this bill is to reduce the number of those who do not have coverage. you are right, there will be some who choose not to get coverage and instead pay the penalty. i think it would be a relatively small number. i think the advantage of reducing the financial burden on families and individuals far outweighs the downside of having some increase in the

number of folks who choose not to obtain coverage. >> wouldn't you want the penalty to track with the cost of the insurance? because obviously to the extent the penalty is less than the cost of insurance by a significant amount, you basically will be subsidizing those who opt out of insurance. >> i personally do not feel comfortable supporting a penalty that is a success -- that is as substantial as the cost of the insurance is. i think that is an undue burden on those americans and families and i would much prefer to have the penalty imposed on individuals at the same level as the penalty imposed on employers. >> i do think this type of limit has a fairly significant impact on two items.

>> as i say, the amendment has not been scored. none of the amendments have been scored. this is one of those. >> can i ask a question? i did not hear the whole thing. i am not sure i understand your amendment. what would be the penalty to a family? >> the penalty to a family would be $750 or for each individual who is required to obtain coverage. if a family is made up of a single spouse and a child, the spouse -- the adult would have to obtain coverage for that family or would pave the penalty of $750. >> my question is family and

how you're defining family. you are defining it in terms of a cult members of a household. how are you defining a family? >> i am not changing the definition of a family in this amendment. the family is defined in the bill and i am taking that definition. >> how is the family defined? are we defining family or members of a household. >> let me ask for clarification. >> there is no statutory definition for a family. the underlying text refers to family coverage. >> here is my question. in some ways, piggyback saw on the other senator's bill. two adults in some type of the

union. i think it would be $3,000. is that correct? >> it is a percentage -- >> one under $15. -- $115. >> could you clarify that? >> it would be a percentage of the applicable premiums. it is harder to define in hard and fast terms. it would depend on what the premium would big. it would be no less than 50% of that. >> what if you have an extended family and you have two adults and their adult daughters who might be living in the same household and they might be single. does everyone in that family and they might have children.

the adults are aged 40. the daughters are age 40. they are living at home. all that is going to happen for $750? >> livni clarify. any individual required to obtain coverage -- let me clarify. there would have to pay $750 penalty if they did not obtain coverage. if there is a child's that is not required to obtain individual coverage, the adults would also -- would still be obligated to obtain that coverage for the >> thank you. >> we have said for a long time

that the bill taxes too much and covers too few, but if you change this individual mandate in your bill, i think that individual mandate amounts to about $36 billion worth of revenue to cover the costs of the bill, and then of course any mandate is a new tax. we know that the majority of the uninsured are low-income are middle-class, and that is who would have to pay this tax, i assume. i think that this is a way to lower those taxes. i do not know how to fix the score or if the people that are covered, but i am curious why you did not reduce the $750 down to a lower number as well. >> why did not reduce it? it seemed to me there were some value in having parity between what the eventual -- what the individual was obligated to pay

for failing to obtain coverage and what employer elsewhere in the bill is required to pay for failing to obtain coverage for employees, if the employer has more than 25 employees. for roughly 2 million plus the federal employees, under the rules, when the dependent of a federal employee turns 22, on their 22nd birthday, they are no longer eligible to be on a federal workers' health insurance. in many cases, those kids are still in college. my question is this. for those 2 million federal workers, would their children when they are driven off the federal policy at age 22, would

they then fall under this panel today that they had to have their own insurance? they still may be a dependable not eligible for their parents' insurance. >> senator, i think the amendment clarify is this. you. not a reason why it might be simpler to go with a clear per capita assessment. the language as written would say that if there were a failure with respect to more than one individual in a household, the applicable penalty would be 50% under a basic plan, basic qualified health plan. that does raise a question of how do you find the family grouping packs there's not any federal definition of a family. this change would obviate the

need for a kind of definition. >> so the dependent of a federal employee would be uninsured, would not be assessed a penalty for not having health care coverage under that amendment. >> i do not believe so. the requirement to obtain coverage, a loss of the penalty for not obtaining coverage pedicures to every adult and to the extent that the adults is uninsured or does not have qualified coverage, then the penalty would apply to that individual subject to all of the exceptions. >> to further understand, the dependent of a federal employee

would be responsible under the plan for a maximum of $750 fine per year if in fact they did not individual insurance for themselves even though their parents had a federal health insurance and if we did not pass that plan, they would be exposed for a penalty of 50% of the premium of healthcare purchased. is there right? >> partially. under the hypothetical you described, the 22-year-old would be available -- it may not be a case for this. the 22-year-old would have available coverage if they did not have other options through the qualified health plans in

the gateway. if for some reason they chose not to come up there would have a young adult plan option. if there were not covered under the other exceptions, they would be subject to the penalty. >> i think you. if this was a pool of 2 million individuals, i would think the question would be insignificant. it covers an independent style as long as there in education up to the age 25. do you know? federal employees, opm sets the date whether they are in school or not at age 22. 25. there is a three year difference with those two million-plus federal workers who are faced with a totally different situation.

a it reduces the cost of insurance for the federal government by zero. the premiums do not go down. your now loading the pool up with older, sicker people. i do not want federal workers to get a double whammy if their children to not have access to health care and find they cannot access affordable health care. >> there is a provision that applies essentially to every other insurance products except that and there is interest in taking a look if the insurance reforms and applying them. this committee does not have jurisdiction over that. there was no way to include it. >> i think it is a great point

that richard has always. we should raise that. this should be conformity. let me also -- i want to support the amendment. but think you have raised a good point. we do not know if the amendments will be excepted or not. i think i will make the request. i would request of cbo to take that amendment and givecourt in terms of the bill. i think leaving it as is, the numbers would be high in terms of people's ability to pay. it would become tremendously costly. >> are you saying the bill is not, fair? >> it is a high number and an unrealistic number. we're talking about middle income and low income people.

you end up with an assessment that may be high. i think it is good. all those who vote -- how do you want to do it? >> do it by voice. >> all those in favor say aye. the ayes appeared to have it. i will make that request that senator gregg has raised. it is a good question. >> you have been watching some of the debate of health care legislation. shailagh murray of "the washington post" is with us. >> the senate health committee bill would impose a tax of up to $750 per individual who does

not have health insurance. there are some exemptions for indigent folks and illegal immigrants would not be covered under these provisions. the house would impose a tax on individuals as well. it would be 2.5% of modified adjusted gross income. it would allow the government to collect a lot more money from upper income people who are not insured, younger people, for instance who make a lot of money. >> we have talked about individual responsibility and family responsibility. what about the responsibility of employers? >> another difficult, a technical issue. the fundamental debate boils down to a question of, what is the best way to incentivize

employers to provide more and better health coverage? the have had enormous, plenty discussions about where to cut off, whether it should be 25 people, up 50 people. who to include in this mandate. the idea is to get as many people as possible into these employment-based insurance pools. it is the way it is organized. it would be best to maintain that system. there is a debate going on both in the house and the senate over how you do that. do you create rules that businesses must abide by otherwise they face penalties and taxes? the house would take more of that approach. the senate health bill would

provide a whole range of incentives and the taxes -- >> but no penalties. >> penalties also. it is a link the provision. >> silly penalties would be for a -- how would that work? >> yes. for businesses over a certain amount -- there are subsidies that would be provided based on the income of the employees from the government to help the employer provide the coverage. then there would be penalties if the employer did not provide the coverage. the finance committee light -- likes the carrot approach better where you incentivize employers to provide coverage. they cannot figure out how to do that. in the meantime, they are exploring this penalty where you

would not interact with the employer unless the employer refuses to provide coverage, and the employees and upon government health care. if you're a company that has a lot of low wage workers and they end up in medicaid or their children and up in a government health care coverage program, the employer would be penalized for that. it is called a free rider provision. so that is a very much of a live ball how that will be resolved. >> listed below and some of the debate on penalties for employers who do not provide health insurance. >> the amendment i am calling up which i will be calling up shortly talks about employer

responsibility payment to this bill. the bill -- employers with 25 or fewer employees are exempt from the current responsibility payments. businesses will pay the responsibility payments after you hire a 26 employer. -- a 26th employee. with this amendment, passage of this amendment, they will -- payments will begin with the 26th employ you. they will pay for the number of employees over the 26 exemption. if the company employs 27 employees, they will pay for those over 25.

a number of my colleagues have concerns about these cliff of 25 employees. so i think this is a way the weekend have the operation while insuring employers are providing coverage. i hope the committee can adopt this amendment. >> let me strongly endorse the amendment. i think it clarify this what i think we ought to be doing and that does not have a cliff or a penalty when you hired your 26th worker. you would have to pay 700th $50 per year for that 26th worker. you should not have to pay $19,500 per year when you hire the 16th worker.

the 16th worker. it is my it is my belief that this is a very good amendment, and i urge people to support it. >> i appreciate the efforts of senator murray, and on this, i think it goes closer to the intent, and i do believe that if we had left it as is, the incentive for the employer would have been very real, to never go past that 25. that is not good for the businesses. that is not a good message to be sending to small-business is across the country, so i appreciate the efforts. i think we still need to have a little more information about what we had discussed earlier, about what is the right number? is it 25, 50, or is it closer to

500? i think they describe it as a sensitivity analysis on this, but i think that this small effort is certainly very helpful. this could be used against this one. it is an improvement. i have a question. this would be for david. we're not just excluding the first 25 people. this would be 25 people in all businesses. >> correct. if i read it, it would apply to the 26th and all subsequent employees. >> i was going to raise the same question. whether you employ 26 or 2600, the first 25 would be excluded. >> that is correct. if you had 26 employees, you

would be paying the extra money with respect to one employee. >> one additional point. $52 billion. >> no, senator. >> when did the change? >> i thought it was $15 billion. >> we got a cbo scores yesterday. no, we got one yesterday. >> i think senator murray may be right. >> it is only 15. >> is still $15 billion. you are still going to have fun trying to get the taxes raised in this country to pay for this bill. it will be increasing. the way we do cbo, we do not look beyond 10 years.

>> i would respond that it did -- what did cost $52 billion was the amendment you offered. we are all offering amendments that we think the strike the right balance. the amendment i have offered the strike the right balance to make sure we do not discourage employers from hiring a 26th employee. >> the $52 billion was $52 billion a did not want to collect in additional taxes with a deficit of $1.8 trillion. >> a good, clever argument for $52 billion. >> i am struck by how on the one hand we are criticized for putting too much burden on employers. it is attacked for being too

expensive. >> i would be happy to answer that. we're coming from the viewpoint that we think it will not raise taxes on anyone. we think it can be done in a better way with greater patient satisfaction with less cost to the american public, less burden on the economy, and still cover all of the goals president obama wanted to cover. we sent a letter last night. >> i look forward to seeing what that letter produces. >> we were doing well. let's keep moving. all those in favor of the murray amendment, say aye. the murray amendment is agreed

to. >> what did they finally decide in terms of penalties cannot provide health insurance. >> they would have to pay an annual fee -- small businesses would be exempted. small employers would receive a credit to provide coverage to their lower wage employees. so what the committee finally decided to do, it springs from the individual mandate. employers would be required for coverage and contribute at least 60% of the premium cost or pay $750 for each full-time employer and three and some $5 for each uninsured parton employer.

-- for each part-time employee. there would be an incentive for employers who could not carry the burden themselves and a penalty. >> $375 for part time. this could lead employers to just take the penalty rather than provide the coverage. >> four individuals, that would be the case, too. it would cost a lot more than that per year for a lot of individuals to buy health coverage depending on their situation, their age and what not. >> is that an incentive for businesses to drop the coverage? >> again, they think the incentive side of it will make it the much more appealing and it will become more of the norm for lower-wage employers to

offer health coverage. more employers would simply offer coverage. by creating these exchanges and making an creating the health committee calls them gateways. they're more commonly called these health insurance exchanges. people would have more options in the marketplace. there are not a lot of bareboned policies to choose from that provide things other than catastrophic care. one of the goals is to create more choices and better better suited for individuals, younger people with a lot of health problems. it would also be cheaper. they would be more inclined to buy the policy. >> we will show some of the debate from the committee on the expansion and the potential

cost. we touched on medicaid briefly. cattell's what they're proposing. >> the health committee bill would expand medicaid to all individuals with incomes up to $100,000. the house bill would only expand up to 133%. this provision is very costly. it is also very complex. medicaid is administered by states and through a matching program with the federal government. a lot of states have extended their medicaid programs to offer coverage to people at 1 under 50% or even higher in some cases. -- 150% or even higher in some cases. but for states who are going above and beyond and how to

help states cannot afford to extend the coverage, the finance committee negotiators had a big conference call with a bunch of the governors before the rest -- before the recess. >> we have about 20 minutes of debate on the expansion of medicaid. >> the amendment i would like to offer, and i will try to respect time is very simple. it says that if congress decides as a result of the work of this committee in this bill to expand medicaid eligibility in -- and to require states to increase what they paid physicians and hospitals who provide medicaid services, congress will pay for it. there will be no unfunded mandates. i would like to start -- amendment. i would like to start with a story.

since my late friend said if i started with a story instead of making a speech, someone might actually listen to me. it is a good story. 1981, a long time ago, i was in my third year as governor. i made the point to see president reagan by myself. i came to washington. i said, mr. president, i have a proposal. why don't we make a grand swap. why don't we -- you take all of medicaid -- that would be the federal government. and the states will take kindergarten through 12th grade. our reason was of thought washington's interference was removing our own responsibility for making it better. arisen for medicaid is after having been governor, i could

see this but responsibility with the federal level paying 60% and the state level, 40%, was creating confusion, and elect responsibility, additional expenses, wasting money, and fraud. i thought it would be better run as a single program. i think often back 28 years to if that had happened that states would be better off. every governor in virtually any state has struggled with finding a way to deal with the medicaid program. the cost has gone up. they have been partly dictated by mandates from washington. i considered waiver requests by governors that take a year. by a one-size-fits-all approach that results with a federal

program that is being administered in the states. it is a source of enormous frustration. we just sent a letter to the national academy is asking them to look at the status of the research universities. fe and other public institutions across the country -- they and other institutions are under stress because states do not have any money left to put into public higher education because they are spending all the money to keep up with the medicaid program. tuitions are rising. students and families are complaining. congress is upset. the medicaid program has been a source of problems. i go with this amendment to say that if congress in its wisdom as a result -- i notice it is a

decision from the finance committee to begin with. it is impossible to look of this without having some understanding of where we will end up. if congress decides the best way to provide health care to low- income americans is to put another 20 million people or so into medicaid and require states pay more money to doctors and hospitals, congress will pay the bill. this is especially important to understand because of financial conditions of the states. we have the unfinished of having a printing press. states have to balance budgets. states have small amounts of money these days. it was in 1936 before the federal government spent more

than the states did as a whole. the federal government's used to be relatively small. in tennessee, the federal dollars that they spend is $19 billion. the state dollars are $11 billion. the states are becoming appendages of the government with the budget's been a large amount of federal dollars and smaller amount of state dollars. so we do something that affects state dollars, it has a dramatic affect. we will not appreciate what a big effect it is. we throw big numbers around. we throw very big numbers around here. in most states, the numbers are smaller. i have tried to give an example or two of that by asking governors what would happen if

we decided that the medicaid program should be expanded to 100 beekeepers in sign of federal poverty level. i know that has not been decided yet, but it has been talked about. it is assumed sometimes that when the cbo writes letters about what the cost of this bill might be, and it has been talked about an assumed sometimes that we might require that the states paid higher dollars to doctors and hospitals so that the medicaid program works. right now, the medicaid program reimburses physicians and hospitals at a much slower rate than the medicare program does. the medicare program reimburses at a much slower rate than the private programs do. in our state and across the country, about 40% of doctors do not see medicaid patients, for many of the things that medicaid patients want to be seen. if we add another $20 million to it, maybe it will get up to 50%.

low-income people into a medicaid program, which i object to, then we should make sure they have a doctor to see. otherwise, it is like saying here is a ticket to the bus, but there is no bus. with this cost? governor barbour of mississippi said an expansion up like that would cost mississippi $300 million a year and have at least 300,000 people in medicare. in florida, they are having a difficult time meeting their population now. there are 2.6 million people. the amount of money, if increased, it would be $5 billion a year for south carolina. -- south carolina -- i mean, for

florida. those are the state costs of the medicaid program. those are the ones i wanted to give to president reagan years ago. they are about 40% generally speaking of the total cost. what does that mean in real dollars? i have tried to compute that. if tennessee had to come up with $1 billion or $1.2 billion in new dollars as costs shifted back to the states, that would be an amount equal to a 10% state income tax. we did not have that kind of money. tennessee is a very conservative state. i doubt if pennsylvania or for months or a georgia has anything

like that kind of money -- or for monvermont or georgia has ag like that kind of money. the federal government winds up paying for it. states do not find out that the have no money for community colleges and the haft have massive tax increases. that is the point of my amendment. i think this points out why the medicaid program is the wrong way to help low-income americans. it is poorly run. it is not accessible for many of the low-income people who need it. i think a better approach and one in which the taxpayer could

well afford would be is what is represented by the burr bill or the gregg bill with the idiot that senator hatch have offered. -- or the bill that senator hatch has offered. they can choose private health care of the kind that most of the rest of us have. it was pointed out that maybe it would cost more. maybe it does. maybe it does not. if the program is properly done. it does not add a penny to the deficit. it gives everyone an opportunity to be insured. medicaid, with all of its other problems, it wastes one out of every $10. $32 billion a year. that is a separate discussion.

we have talked about this before. we have different views to some degree. i think medicare is a better alternative. congress chooses to expend its then congress should pay for it. >> mr. chairman, i would have to oppose the amendment strictly on the ground that it is not really germane to the bill before us. this is a finance committee issue. the amendment makes an effort to deal with two problems. one is mandated expansion of medicaid. the other is mandated increase in provided payment rates. we are not mandating either one of them. this is something that senator

enzi set, under hashed or any other republican -- senator hatch, it would be entirely inappropriate amendment at that time. but this amendment here, to have this committee go on record trying to dictate what happens with medicaid payments i think would be a big mistake. i would oppose it on those grounds. >> technically, my friend from new mexico has a point. we are in an unusual situation. we work for the united states senate. we're taking a big subject and splitting it up and saying, you work on some of it and you work on some of but in one committee. we each have our responsibility for the hall. i have a copy of the bill we are

working on. it is marked with collars all of the provisions of the bill -- is marked with colors all of the provisions of the bill. this is part of what we're trying to do here. we're trying to look at health care as a whole. it is the position of those who wrote the bill that the way to deal with the people who can help themselves the least in this country is to expand the medicaid program and to make it worked as we have said, you are almost obligated one way or the other to make sure that the doctors and hospitals are there for people that you put in the program. how can we finished a bill here that in visions solving the problem -- that's envisions

selling the problem without taking into account the principle that if we do that, we ought to pay for it. it is not our job to say how to pay for it. but we should have some idea of what it costs. unless we say we understand, this is our strategy and our vision. but we are not -- we do not believe this should be dumped on the states. i think we have an obligation to take a position on whether we should pay for it or states should pay for it and leave for the finance committee how to pay for. otherwise, we should go back to the bill and review all of the provisions that might have something to do with another committee.

>> i want to go back to your story the you open your remarks with. what did while reagan do? >> he liked it. there are just too many people in washington that disagree with him. the chairman or ranking member of this committee actually introduced legislation which proposed such a grand swap. the idea was that k-12 would come to the states and that medicaid would come here. i actually think it would be the right thing to do today. there is some programs, the americans with disabilities and others, which are separate. the basic medicate responsibility, which is what we do for low-income americans, i think we should legislate it, we should figure out a way to do it, and we should pay for it. it could be part of the single

payer system. or if through medicaid, we need to say that we pay for the increased doctors and hospitals so that it works. are we do it the other way and we give people money and let them go buy private insurance. we cannot ignore it. >> i will leave this open for longer. we will not ignore the issue. we're not the only act in town on this health care debate. finance committee has an important role. there is some overlap. those who serve on the finance committee are correct. this is a fundamental question. i am not arguing with you about the numbers and the impact. this is clearly an issue we will

have to address, particularly as you increased the number of people. we cannot complete this process, in my view, without addressing the issue. is it a matter for this committee to address? i am willing to accept the notion that this is a matter that needs to be addressed. i do not have any objection to that. it goes to the heart of the role of the finance committee. they are wrestling with it at this very issue. how to pay for it? it is not an enviable task. i'm not disagreeing with the points you're making. we will confront this. one way or another. it has to be a part of this debate and discussion.

i think we have these other matters that we must address if we're going to move forward. this goes beyond the pale in terms of overlap of jurisdiction. >> are we not going to agree with how to reduce the number of insured? your letter in your new proposal said we will dramatically increased the number of insured. the way we will do that is we will pumping a lot more low- income people into the medicaid program where doctors will not even see them. then you're saying we're going in the right direction. getting costs under 61 $11 billion. or whatever it is. $500 billion on the table. it is floating around there

somewhere. >> we talked about the issues. our bill combined with the work being done by our colleagues in finance -- we're not doing work of the finance committee. we used a number. >> it is not floating over there either. >> whatever it is, we have to deal with it. cbo has to score what we do. we will have a lot to do. our job here is to write our legislation, score our bill, which i am consistent we do before we actually vote on number so we have those numbers. .

the state is going to decide different ways to be involved in this. i have never brought up a matter here that has not been scored, unless someone has brought up a separate amendment on their own. you cannot score this, and so therefore, we are falling beyond something that goes not to just a question of modifying points, but a fundamental, statutory disagreement that is way beyond the jurisdiction. it is a major point that they have to grapple with. and we ultimately will as well, because the matter what they do, we will all want to be involved in that choice. i would be remiss in my responsibilities to support an amendment here that encroaches so far on the jurisdiction of another committee. >> a portion of the debate on an amendment by center lamar alexander. it failed 10 votes to 13 with democrats voting against.

at the end of that debate, senator dodd makes the point about this being out of the jurisdiction of the senate health committee. why did they even take it up? >> because they wanted to express themselves on the issue. it is such a fundamental part of the whole overall effort to expand medicaid. you expand medicaid in the range of what the hell committee has been talking about, -- the help committee, or the house, you encompass a lot of uninsured people. you can close the insurance gap significantly by expanding medicaid, and medicaid is a government program that is already in place. it is an interesting case, because this bill, putting aside the public option would vastly expand government's role in health care through the medicaid expansion, and also through all

of these different medicare changes that both the house and senate are contemplating in an effort to force some economies into the health-care system at large. . . some of these initiatives are targeted. >> so it is fair to say the health committee takes on medicaid to send a message to the senate finance committee on how they would like to see the finance committee? >> you have former gov. lamar

alexander concern about the effect on their state and wanting to express themselves on the issue. the buy-in has to be considerable to pull this off. right now you have states across the country struggling with enormous budget problems. they cannot afford medicaid roles as they stand today. some of them see this as a major imposition, essentially. >> taxes are another area of the jurisdiction of the finance committee. what is under consideration in that regard? >> the most likely source of revenue on the senate side is a tax on very knowledgeable health care -- i'm sorry, health insurance plans. most people have no idea what the value of their health insurance plan is.

many high-income workers and union workers get very generous benefits that sort of flow through the system without being taxed. but they are not taxed as income. ideally, as conservatives would like to start taxing those conservatives because it is a major loophole on the system. the largest in the tax system. but that is not going to ever happen because so many union workers, lower income people, benefit from that, sort of like the mortgage deduction. i think they seem to be finding some compromise position where very large package is worth over $25,000 a year, that the policies themselves would be taxed on the insurance companies.

so insurance companies would be discouraged from even offering policies. so the overall objective of getting people to think about how they are using health care, using it more efficient bank, ultimately, using less of it. >> the next clip we will show is a debate among -- on defensive medicine. what is that? >> that is what many people believe doctors and hospitals practice in order to avoid lawsuits. many states have capped medical malpractice awards and have started to crack down on this issue which has created a lot of doctor shortages in the country, apparently. at least that is the strong conviction of advocate for small progress -- malpractice tort reform. if, hypothetically president

obama were to concede some language on that issue, it could be received positively by republicans, but now is not the time to start giving that stuff away. >> we will be hearing from orrin hatch in an amendment that he proposes. this is something that he proposes on medical liability. >> this is designed to improve access to health care providers and increasing assets -- access by reducing the liability system that is placed on primary-care physicians and underserved communities. what this amendment does is it improves access to health care services and provides improved medical care in underserved communities, rural communities,

and especially among primary- care physicians. what this amendment does is it takes on the medical liability issue directly. let's be honest about it. as someone who used to defend cases on behalf of doctors, nurses, health care providers, i have to admit, once they change the law from the standard of practice in the community -- if that's occurred, then they would be an assault from liability. they changed that law, mainly grew personal injury lawyers, to where it became the doctrine of informed consent. from that point on, every case with the slightest evidence goes to jury. even if the evidence is faulty. in the process, we have had an

upswing in medical liability cases throughout the country that have been devastating to the health-care industry and especially to obstetricians and gynecologists, especially in rural areas. if there is a bad result, even if there was no negligence or fall on the part of the health- care provider, what ever that brodeur may be. you can have a runaway jury verdicts that basically run up costs for everyone. consequently, a lot of obstetricians and gynecologists -- i'm centering on that because we just passed an amendment try to take care of women's problems. we have had a lot of obstetricians and gynecologists quit their practice. in some areas of the country,

they are not only woefully deficient, women have to travel miles and miles to get health care treatment when they are in the process of delivering a baby or having other difficulties during pregnancy. what this amendment would do is alleviate some of those problems because this is aimed at eliminating needless litigation costs in our healthcare system. let me go into that a bit. when the doctrine of informed consent became the rule, that meant that there was no way any doctor could fully inform the patient of all the problems that could possibly happen. you have to go to medical school to learn how to do that. even then, they would say that you have not met the standard. we have a doctor in pittsburgh

where i practiced law, who would testify against any doctor, no matter what. he would make a case against the doctor and the case would go to the jury, even though they were, in my mind, frivolous, and often fraudulent. that has been rector of -- replicated throughout the country. in the process, we told doctors that they have to make sure you have to do everything you possibly can and have every possible procedure in your history of that patient, so if you are sued, however frivolous, that you can say, i went way beyond the standard of care in the community. i have done everything i possibly could. i have used every procedure, medical device, etc. and in the process, even that

would not fully protect you and the doctors, but at least you would have an argument in court that you did everything that a great doctor would do under the circumstances. hopefully, the jurors will understand there are cases where there were bad results but no negligence and there should not be a jury verdict inthis. i have to say, this is what i call unnecessary defensive medicine. having said that, all of us would like to have necessary defensive medicine. in other words, doctors doing the necessary procedures, approaches that are minimum to making sure they have ruled out certain possibilities that could hurt you. today, and they go way beyond that. secondly, we know there are

other utilization, capstans, mri's. these are important devices in the cannot do without them, but they are sometimes over utilized. one reason is because of potential medical liability. there are other reasons, too. the fact of the matter is, most of these doctors are trying to build that history, that record. if someone has a bad result, they can at least argued was not because they failed to do something that should have been done. in the process, i said 30 years ago when i believed all necessary information -- when i believe that there was all this on necessary information, if i recall, they agreed. the american medical association

acknowledged there was about $60 billion. they knew it and i knew it. today, it was far more than that. we have become so dependent on unnecessary defensive medicine that the costs have skyrocketed. when this particular amendment would do is impose limits on non-economic damages that can be awarded in suits against primary care physicians in rural and underserved areas. they would -- this amendment would limit plaintiffs' ability for the same model of occurrence. finally, there would raise the standard for the amount of punitive damages in suits against doctors and facilities particularly vulnerable to the cost associated with not practice litigation. i'm the first to say that there is negligence from time -- time to time in the medical field and

there are legitimate cases that are brought. certain cases have to be settled for a certain amount of money, but that have to be done. so there are legitimate medical liability cases, but there are about majority brought to the defense, that are somewhere around $25,000 on average, and if the attorney takes that cost, they will take 30% of that. if the cases are legitimate, i do not have a problem with that, but that would amount to a lot of cost to society. this amendment may not be everything i would do. if i had my way, i would establish health courts to establish these problems in a fair and reasonable manner. if we can do it, which would be

non-jury help courts, i do not know if we could do it, but at least we could move in the direction. secondly, there might be other pressure point ready to determine if doctors were negligent or not, without having to indoor runaway jury verdicts. it basically puts limits on non economic damages, which is very important. it would limit total non economic damages of $750,000. if he had punitive damages, it to be the greater of to enter the thousand dollars. -- greater of $250,000. no matter what the cause, you be able to recover them. plus, the non economic damages. i would prefer them to work on

something better than this. this is where we are right now. i believe it is the right thing right now we want to get health care costs under control. wherever they have done this legislation, they have had much greater success in getting it under control and limiting the explosion of litigation that occurred in our country. the state that had dennis have benefited. frankly, i think it would resuscitate the ability of communities, especially rural communities, to get sufficient data to help with the problems of women go through and the problems that children and child reabirth. i think it is something we really need to do. i would be open to even better ideas of somebody had them. i think we need to set an

example here. mple here since we have to bring costs under control. i intend that unnecessary defensive medicine is leading our country alive. frankly, i do not blame the doctors were trying to bill austin their histories, their medical histories of the patients so that they can try to detect themselves if they are ever taken to court. hand that is happening, and i do not think anyone can rebut that. compared to when i was practicing law, i have to admit there were all lot of insurance companies who would insure for medical liability purposes, but not anymore.

i know is an unpleasant subject and those who are devoted to american dollars -- i am devoted to them on the right, does not this issue. the fact of the matter is, the sooner we can get litigation control, the better. >> first, let me express from my very great respect and affection for the distinguished senator from utah who has obviously been an extremely distinguished member of this body. before that, not just a leader of legal community in utah, but a nationally recognized lawyer of great stature. so it is with some reservation

that i regretfully must disagree with him on this amendment. it concerns me that the insurance industry will so willingly turned its guns on the most severely injured victims of the catastrophic medical error. the cost of liability insurance in the medical arena is the set -- comprised of medical expenses, investment income. it is comprised of plan experience. and it is also comprised by the cost of individual claims. in dealing with all of this, the one place the insurance company chooses to turn its guns is on high claims. high claims which are experienced by the people who suffer the most devastating injuries.

a couple who have to come home with a damaged infant, which has completely changed their lives. for the rest of their life they will be carrying a burden of care. their dreams for that child are changed. their lives are turned upside down by it. it is on them. the person who comes home severely disfigured and disabled by a medical error that there damages exceed half a million dollars, that is the person that has to bear the burden under this theory of insurance reform. take a look at the investment income. many people believe that it involves process is more than claims, but look at the experience part of it. it is now admitted, established

by the institute of medicine that 100,000 americans are killed every year by avoidable medical errors. and that we will tap of the iceberg is part of a much larger iceberg of medical care that is not legal. if it is 100,000 killed by medical errors, god knows how big the number is of people who are injured, left in the hospital, coming home with one leg instead of the other one. maybe they got the wrong one taken off. for all of that injury, i think this bill and particularly the effort led by the senator from maryland, our chairman, barbara mikulski, on quality reform, will actually do a great deal to reduce the body count, to reduce

the butcher's bill from ever in american medicine. i hope we can focus on that because that is the humane and intelligent way to deal with this problem, the cost of medical error. it is to have less medical error, not take away the rights of the people who are the most injured by that medical error. i think we find some support in this from cbo, just yesterday. i believe it was just a day. it has been a blur of health care for a while. i sat next to doug elmendorf from cbo and he was asked by distinguished members of the committee where the savings would be from tort reform, an insurance reform, in an amendment like this, and he said, no, it is very small. negligible savings, and you really cannot pick up defensive medicine because there are so

many reasons for there to be. that distinction cannot be drawn for innumerable reasons, from good ones too bad ones like having a friend with an ownership interest in an imaging clinic where you want to keep sending people. there is a lot of defensive medicine practiced, and not all that is a bad thing. some of the key to america healthy and this type of legislation simply cannot be documented to save significant funds, at least according to cbo. the last point i want to make is they always try to hit at the jury system and we all know that the jury system can be disruptive and uncomfortable. but under our constitution, it is supposed to be. it is often the last refuge of

the individual when they are badly injured, when the forces of society are against them, when money for interest control of the executive. the founding fathers were keenly aware of the vulnerability of governors and legislative assemblies to both corruption and passing passion. what they trusted to remedy that was that we could get before a jury of our appears to have our problems heard. to have the insurance industry now coming forward to disabled piece by piece that fundamental constitutional prerogative of americans, implied through the 14th amendment, i think it is just wrong. it is something we need to guard against. i would urge my colleagues to vote against this amendment. >> a portion of the debate from orrin hatch on medical

liability in rural and underserved areas. it eventually failed in a party- line vote. shailagh murray is our guest as we go through the debate. they tried a number of times to pass amendments dealing with medical liability and it has been a discussion in health care for a number of years. as it stands now, are there provisions in the senate health bill or on the house side to deal with it? >> certainly not to the extent that republicans want and would become attractive to them, possibly convert them. this is an issue where it is not worth giving a little bit away because you will not get anything until you give a little away. if you are going to deal on the issue, you have to yield some significant support on the republican side because it is too much of a broader political

issue. >> any likelihood it will be taken up by the senate finance committee as the final piece of their bill? >> it has not gotten a lot of attention by the finance committee. they have focused on the medicare provisions up to this point, but certainly as this debate unfolds in the senate, it is conceivable it could go in a lot of different directions. it could go sharply partisan and democrats could try with their barely 60-vote majority to pass a bill on their own. as soon as they turn in that direction and try that, they will discover factions within their own party that raise almost the same issues they are dealing with now with these republicans they are trying to convert.

if that does not lead them across the finish line, then they are going to have to find a way to go back to republicans and bring them to the table, a few of them to the table, at least. that could force some policy compromises that liberals would not be happy with, but that could be the only way to a successful conclusion to this debate. that is probably more likely route, but it is just not clear. we will have to see what the collective frame of mind is when we return. >> the next piece we will show his with giving grants to state to set up single payer systems. >> the single payer system is the goal for many on the left

and will likely not be advanced by this bill. is an interesting issue. we were just discussing earlier, there had been little republican resistance to these medicaid expansions. there was concern about how it would flow down to state, but most people believed the need to start filling in gaps with medicaid, and insure adults with children, and what not. and these programs are already in existence and they certainly do not function perfectly. they provide care that no one in the private sector presumably would. government would have to subsidize it at the least. many people on the left believe that this bill should ultimately move the country to a single payer system, but that just

seems to be working against gravity at this point. >> we talked about a public auction, now we are hearing single payer. what is the difference? >> single payer is the government acting like a national insurance company, providing -- you know, it depends on how you would do if. but the way that it operates in other countries where there is a national health care system and people are taxed or the money is collected town hall from the government and then it flows through the system that way. there are arguments in favor of it on a cost basis, that it would be more efficient way to deliver health care, but again, look at the political difficulties they have run into with just some of the pilot programs, looking at comparative research. he would have to impose that on

a broad scale to make the system worked. >> one of those in favor of the system is bernie sanders. here is 10 minutes of the debate where he argued single payer. where he argued single payer. >> what i am intro i will do that on the floor of the senate. what is in an -- is an opportunity to allow those states who want to go forward to do so. this is what this amendment would do. it would provide a maximum for 5 state a year whose grants would be up to $4.5 million to be used for 30 months to assist in developing a statewide single system. ifwhat to do,stuart. what happened of a stake to just go forward? up to two each year would then

be awarded an implementation grand to carry out the plan. planned mets include state approvals. -- plans must include state approvals. in other words, we are not talking of putting more money into. whatever they would have received if they had not gone, that amount of federal money will go to the state to be used for a single pair. not anymore. it is not more money coming into the system could the state are implementing a single pair -- into the system. the states are in some -- are implementing a single payer. persons who moved out -- it

cetera, et cetera that is basically what this is about. i used to be a mayor. i am actually a strong believer in the concept of using state and cities as some laboratories of democracy is. seen it. a city or town comes up with a great idea, and mike wildfire, it goes around the country. i think we should allow those states that one too -- and i cannot tell you how many will want to -- but we should allow them to go forward. if it does not work, we will have learned something, if not, we will have learned something as well. from a conservative point, those who believe in local rights, this program makes sense. mr. chairman, that is the amendment. i would ask for the support of my colleagues.

>> depending on the outcome, we appreciate your knowledge and input. thank you for that. any comments that people would like to make? >> let me first commend senator standard -- sanders for his passion and focus on the issue. i agree with him and many of his criticisms on and we currently have in terms of the health delivery system in the country. i am not able to support the amendment, and let me give two reasons why. one is a general reason. i think this exercise, as i understand it, that we have been going through these days and weeks, is an effort to essentially improve the current health care delivery system we have in the country. fix the problems in the health

insurance markets, provide additional subsidies for folks who need coverage but cannot get it. some of the ways, the coverage, keep down cost and build on what we already have. this amendment goes a different way. this amendment would start us down the road of replacing the current system and had we decided that that was the right way to go, maybe it would make sense to consider this amendment since we are not proceeding to do that -- this amendment. since we are not planning to do that, i would have problems with the implementation provision on page 6. it calls for states may request

and the secretary shall grant the falling waivers of requirements. to the extent necessary to carry out state plans. when you start looking at those waivers, that the secretary would be required to grant, if requested, they would of course include a waiver of arisa as well as a waiver so that all medicare funds provided under title 18 of social security for beneficiaries residing in a state be allowed to be used for this. that all funds provided for medicaid for people living in a state be allowed to be used for this forfor chip funds to be able to be used for this.

to purchase -- not otherwise be available to purchase for federal employees and retirees in the state made available. and then the other federal funds that the state might identify and want to use. i assume that could include indian health care funding. try care, i do not know what else. there are a lot of people in my state who very much value those programs. i know we have had a lot of discussion and debate about how medicaid is a flawed program. held various of the other programs are flawed. i can tell you, there are many people in my state to appreciate those programs and i think they would be upset that often that their ability to obtain their health care coverage through those programs would be put at

risk by a state requesting an implementation grant and asking to take the fund that would otherwise be available through those programs for them and pool that for use in this kind of a single payer experiment. >> could i respond briefly? >> i think senator bingaman raises an important point. essentially what you are worried about is if someone is on medicare, medicaid, schip, they might see a deterioration in the quality of the benefits they have. in this bill, we are specific. individuals who would otherwise have received healthcare through any waived program would be guaranteed benefits at least as generous as those offered under the federal program. you raise a legitimate concern

that the bill addresses it. >> i think the concern would be that this would insert into our current system of healthcare delivery very substantial instability and ups -- and uncertainty. i am aware of that provision that you cited but i think there are people in my state, for example receiving their coverage through medicare who would not want to trust to the good offices of the secretary that all of this will be taken care of. they just assume keep the care you have through medicare and people on the federal employment health benefit program as well and various others. for those reasons, i could not support the amendment. >> further debate or discussion on this amendment?

let me say, bernie, as well, you made a lot of comments that we can agree with. the reason we are around this table are for the reason that you have identified. the system is broken. it is in desperate need of repair the way it is. so i do not have any quarrel whatsoever on your comments about that. i also have no quarrel with your comments on financing of campaigns. many of us have supported that for years and decades. it is pernicious and dangerous in my view. whether it is about this issue or others as well, they are equally as important. as jeff started out, the idea was the understanding that a substantial number of people in our country are presently lacking the coverage they have, and therefore want to know that we will not necessarily try to

undo that, which we support, but rather to fix that which is broken. a substantial part of it is broken. there is a legitimate constituency in the country that embraces exactly what you are asking. that opportunity, as things emerge and moved in time, will move in direction -- in that direction. but i would be reluctant to take this, which would to plan everything else we're trying to do, and i realize that is not what you are suggesting, but that is the danger that i would see in the adoption of the amendment, and therefore and am planning to oppose the amendment. >> thank you, mr. care. i want to applaud the senator from vermont for bringing forward a creative concept that is to utilize the state laboratory as a way to experiment with the single payer

plan. when the state of oregon was immersed in treating the oregon health plan, they apply for federal waivers that were not granted or in some cases only granted after long delay. it is difficult for the state to experiment and the senator has laid out a framework that i am sure will cultivate a very intense debate within any given state because it would take a statutory action by the state, as i understand it, in order to proceed down this path. that sort of debate about designing a different type of health care system i think would be healthy for the democracy as a whole. it would give us an example of an experiment that we could all learn from, both in the works and what does not work. we are certainly the beneficiaries of what has been taking place at the state level in oregon and elsewhere. this simply allows a far more

flexible latitude in terms of the content -- design of a state experiment. so i certainly support the amendment and thank the senator for bringing it forward. >> you are watching debate from bernie sanders of vermont giving state grants to study setting up some of their systems. it failed 4-19. it was a lopsided vote in the senate health committee. we are talking a bit about this. what does that say about the likelihood of the debate, single payer getting any attraction in the house? >> i think it speaks for itself. health care is always an interesting challenge because it is such an emotional issue. people have very deeply held

views about what would work best. some conservatives feel just as fervently that you could create these health savings account systems where people would be paying a lot of their own health care costs, that people would use health care more efficiently. so this debate, among many other things, it is an opportunity for people to express -- in the case of tom harkin, bernie sanders, it has been their life passion to try to change health care to adapt better, according to how they see it. a lot of what we saw in the town hall meetings, i guess, were the passions that are stoked by those strong positions on either side.

threading a needle on the policy front through that sea of warring factions is just extraordinarily difficult. >> we are focusing on the senate health committee who is focusing on the single payer, public option, and the discussion of health care cooperatives. do any of these ideas -- is any one of them gaining traction or scenes more favored by some as it moves through the senate? >> what people seem to be galvanizing around now -- and this is very early, but people, i think on both sides agree that there needs to be a reconstitution of the national

insurance industry. a lot of the extremely popular provisions from all of these bills out there would stop insurers from denying coverage based on pre-existing conditions, would lift lifetime caps on insurance. all kinds of barriers to coverage that people confront on a regular basis. regular folks trying to ensure their families, but they are not able to based on these barriers. able to based on these barriers. th the idea of creating some alternative, possibly only on a catastrophic level, that the government was set forth a catastrophic policy that everyone would have access to, instead of forcing the will to buy more cars than they may need at age 30.

in a release could been inserted there with a bare minimum policy. something you can water down the public plan by contacting it to a private insurance company like kaiser for instance. >> they would run the public plan? >> it will be administered by a brand-name ensure that everyone would know. >> that is not in any other country that you know of? >> no, there is not the wherwell fertilized private insurance sector. you have large insurance companies that could be capable of administering a program like that. at what time does it ceased to be a public plan and become a national policy? the good news for dealmakers is that as the comeback to

washington, very few of the ideas on the table at the beginning of august are on the -- are off the table now. of ectively eliminated, even as hyperbolic as there was. there probably will not be any final language in the bill that sets for end of life procedures. otherwise, all these issues are still there and left pretty much where they were one month ago. it is up to these dealmakers in the health committee, finance committee, and house, to navigate through this. >> we are going to look at about 10 more minutes of debate. then we will be back with shailagh murray. >> this is straight forward. it just says what is good for the goose is good for the gander. let's put the members of

congress in it. we like what we have. we are telling the american people we're trying to give them what we have, so let's demonstrate leadership by requiring every leader of congress have to get their health insurance from the government plan. >> i accept the amendment. >> well done, thank you. [laughter] >> let me object. >> in the so-called government- run plan says in the second sentence that no person is required to participate in the plan. no american, no penalty assessed against someone who does not participate. i do not know why we should not have what is cruz is good for the gander? we qualify, we did not give up our citizenship to become members of congress.

i do not see why we should be required to participate in a plan that we are specifically saying no one else need to participate in because we are in leadership positions. >> if it is not good for us, it is not good enough for the rest of america. >> we are protecting their right not to participate and we should protect -- protect the right of every american ought to participate, including ourselves. >> i would disagree. we're moving in a direction -- we are already under 60% under control of the government in this country. we are going to move to 70% and we are going to be a part of that. all we are saying is we should take the lead and say, we will sacrifice, we will give up our right to choose, and as a demonstration of our faith on how good this is going to be, we are going to put ourselves into the plan.

why should we be giving up the right to choose that which we are expense of providing for every american? to demonstrate how wonderful this will work. >> i accept the endorsement of the senator from oklahoma. >> i think he may not have caught my tinge of cerf -- sarcasm. >> if the idea is the government plan ought to be available for members of congress and staff and other federal workers to participate in, if they choose to, then i would agree with that. i would support that amendment. i think the right to choose whether you buy a private plan or you buy this community health insurance option or by your coverage through that, this bill goes to great lengths to ensure that choice is there for everyone. it ought to be there for

ourselves, our staff, every american. >> every american is some said was an insurance to the tune of $12 million a year. what we ought to demonstrate to them is we have enough confidence in the system that we are willing to expose ourselves to this system by taking the lead and giving up our right to choose. we are not asking anyone to give up their right to choose. it is just the opposite. we are giving people an additional choice that they can make or can reject. >> ultimately, you will have everyone in this plan. ultimately, everyone will be in this plan. >> you are the only one that believes that. >> cbo does not believe that. >> well, cbo has been wrong on every mandatory program quoted about the cost and outcomes. we can rely on cbo just like we can to the difference of what we

said yesterday. other forms of competition on generally declined. you will lose jobs. that is what cbo said. peoples whose wages could not fall. one program that creates work disincentives for the recipient is medicaid. that program is structured so that eligibility is eliminated as specified income for most categories. >> what does this have to do with your amendment? >> it has to do with the fact i know where we are going. you assume we are not going there but we have never seen a government program not role in health care. if, in fact, the government plan is competitive for people outside the plan, they are going to move to it. except it will never be financially viable because the

secretary will set the rates. the only way you will have a plan that is going to be viable and have enough people in it is to have a lower rate than the cost, like the main public plan. maine has a public plan right now with 10,000 people in it and they have increased the number of people uninsured. it is a failure. >> this may turn out to be a failure, too. i understand some of you do not like the idea of a public plan, but the idea that we can provide that as an option for all americans except members of congress and their staff who would be required to be in it, i think is it logical. i would oppose it. >> all those in favor of the coburn amendment, say ya. . say aye. [roll call]

>> senator reid? >> no, by proxy. >> senator sanders? >> senator brown? >> no by proxy. >> senator casey? senator kay been? senator white house? >> no by proxy. >> senator gregg? >> aye by proxy. [roll call]

[laughter] >> we are a team. a new coalition. i would love to be a little church mouse in the comforts committee when this is dropped. >> shailagh murray, you heard the senator joking about require members of congress to be on the public plan. it failed in the house, one of the few non-party boat in the committee. does this have any chance when it goes to markup?

>> it is certainly one of those provisions that makes us very uncomfortable. i think that is the way it was intended. also, like many of tom coburn's amendments, he is making a powerful point which is, do not pass anything you would not want to participate in yourself. so many of the problems in health care is because they are done in the third person without really thinking about the practical implications. >> we will presumably see this markup session in the coming weeks as congress returns to session. can you give is a snapshot of what you think will take place and how quickly they can get it done? >> the first order of business is for the finance committee to produce a bill. they are facing a september 15 deadline for these negotiations. very unclear whether that will

produce a bipartisan bill or not. it will certainly produce a bill, and the finance committee, dominated by democrats, will be able to pass it. it will probably be a smaller bill in scope. i think members coming back are going to feel probably more conservative in their ambitions based on the town halls, based on new deficit forecasts, based on the overall cost pressure that they just do not want to take a huge risk. they want to pass something they can pay for through medicare savings and through these tax incentives. after the finance committee acts, the house will try to take its bill out of the committee and onto the floor and will probably make some extensive revisions, including getting rid

of this wealth surtax that has gone over like a ton of bricks and especially with a lot of your younger democratic members. >> so this will be a markup session? >> essentially it will be a be read before it goes to the floor. -- rewrite before it goes to the floor. they do not want to make any bold moves yet because some of the tax options could be adopted by the house. the big question going forward, ultimately, is how partisan is this debate going to become and the more partisan and becomes, the more challenging it will be, especially in the senate. >> what can you tell us about the cost of the bill on the house and senate side? >> the house bill we have been discussing was scored by the cbo at $16 billion over 10

years. of course, that does not include medicaid expansion, medicare changes and other issues that the finance committee has jurisdiction over. so it is not a phone number. the house committee bill is about $1.10 trillion over 10 years. . .

that is when your mother is screening get you to get something. those kind of thing slipped through the cracks. it is the horse race coverage that has kind of overtaken the policy debate in the last month or two. hopefully, we can steady that in the of them more in the months ahead. the biggest in many the enemy to a bill passing his people not understanding what it is.