it is not adjusted for inflation. the benefits stay about the same >> in a few moments, president obama on the investigation into the recent attempt to bomb a northwest flight to detroit. after that, british leaders onç the terrorist threat in yemenç, and later, democratic leaders talk with reporters about negotiations over the health care bill, and we will look at long-term services in a journal -- in a forum hosted by the journal of health affairs. .

i called these leaders to the white house because we face a challenge of the utmost urgency. as we saw on christmas, al qaeda and its extremist allies will stop at nothing in their efforts to kill americans. and we're determined not only to thwart those plans but to disrupt, dismantle, and defeat their networks once and for all. indeed, over the past year we have taken the fight to al qaeda and their allies wherever they plot, be it in afghanistan and pakistan, in yemen and somalia, or in other countries around the world. ñihere at home, our intelligenc,

homeland security, and law enforcement agencies have worked together with considerable success, gathering intelligence, stitching it together, and making arrests from denver to texas, from illinois to new york, disrupting plots and saving american lives. these successes have not come without a price, as we saw last week in the loss of our courageous cia officers in afghanistan. but when a suspected terrorist is able to board a plane with explosives on christmas day, the system has failed in a potentially disastrous way. it is my responsibility to find out why and to correct that failure so that we can prevent such attacks in the future. and that is why shortly after the attempted bombing over detroit, i ordered two reviews. i directed homeland security secretary janet napolitano to review aviation screening technologies and procedures. she briefed me on her initial

findings to date. i am pleased that this review is drawing on the best science and technology, including the expertise of secretary of energy steven chu. çói also directed my counterterrorism and homeland security adviser john brennan to lead a review into our watchlisting system to fix what went wrong. as we discussed today, this ongoing review reveals more about the human and systemic failures that almost cost nearly 300 lives. preliminary report public within the next few days. but let me share some of what we know so far. as i described over the weekend, elements of our intelligence community knew umar farouk addulmutallab had traveled to yemen and joined up with extremists there. it now turns out that our intelligence community knew of other red flags, that al qaeda

in the arabian peninsula meant not only to hit targets in yemen but in the united states. we had information that this group was working with an individual who was known -- who we now know was in fact the individual involved in the christmas attack. the bottom line is this. the u.s. government had sufficient information to have uncovered the plot and potentially disrupt the christmas day attack. but our intelligence community failed to connect those dots which would have placed the suspect on the no-fly list. in other words, this was not a failure to collect intelligence. it was a failure to integrate and understand the intelligence that we already had. the information was there, agencies and analyst who needed it had access to it, and our professionals were trained to look for it and bring it all together. now i'll accept that intelligence by its nature is

imperfect, but it is increasingly clear that intelligence was not fully analyzed nor fully leveraged. ñithat is not acceptable and i will not tolerate it. time and again we have learned that quickly piecing together information and taking swift action is critical to staying one step ahead of a nimble adversery. so we have to do better and we will do better. we have to do it quickly, for american lives are on the line. i made it clear today to my team that i want our initial reviews completed this week. i what specific recommendations for corrective actions to fix what went wrong. i want those reforms implemented immediately so that this does not happen again and so that we can prevent future attacks, and i know that every member of my team that i met with understands the urgency of getting this right. and i appreciate that each of them took responsibility for the shortfalls within their own agencies. immediately after the attack, i ordered concrete steps to

protect the american people -- new screening and security for all flights domestic and international, more explosives detection teams at airports, more air marshals on flights, and deepening cooperation with international partners. in recent days we have taken additional steps to improve security. counterterrorism officials have reviewed our system including adding more individuals to the no-fly list. while the review has found that our watchlisting system is not broken, the failure to add umar farouk addulmutallab shows that this system needs to be strengthened. as of yesterday, the transportation security administration is requiring enhanced screening for passengers flying into the united states from or flying through nations on our list of state sponsors of terrorism or

other countries of interest. in the days ahead, i will announce further steps to disrupt attacks, including advanced passenger screening for air travel. finally, some have suggested that the events on christmas day have caused us to revisit the decision to close the prison at guantanamo bay. let me be clear -- it was always our intent to transfer prisoners to other countries only under conditions that this security is being protected. with respect to yemen in particular, there's an ongoing security situation which we have been confronting for some time along with our yemeni partners. given the unsettled situation, i've spoken to the attorney general and we have agreed that we will not be transferring additional detainees back to yemen at this time. but make no mistake -- we will close guantanamo prison, which has damaged our national security interests and become a

tremendous recruiting tool for al qaeda. in fact, that was an explicit rationale for the formation of al qaeda in the arabian peninsula. and as i've often said, we will do so and close the prison in a manner that will keep the american people safe and secure. our reviews and the steps that we have taken can and will continue to take to heart the counterintelligence and homeland security that we need in the 21st century. just as al qaeda and its allies are constantly evolving and adapting their efforts to strike us, we have to constantly adapt and evolve to defeat them. because as we saw on christmas, the margin for error is slight and the consequences of failure can be catastrophic. as these violent extremists pursue new havens, we intend to target al qaeda wherever they take root, forging new partnerships to deny them sanctuary as we are doing currently with the government

in yemen. as our adversaries seek new recruits, we will consult, review, and rapidly update our intelligence and our institutions. as they refine their tactics, we will enhance our defenses including smarter screening and security at airports and investing in the technologies that might have detected the types of explosives used on christmas. in short, we need our intelligence, homeland security, and law enforcement systems and the people in them to be accountable and to work as intended, collecting, sharing, integrating, analyzing, and acting on intelligence as quickly and effectively as possible to save innocent lives. not just most of the time, but all the time. that is what the american people deserve and as president that is exactly what i will demand. thank you very much. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

>> josh gerstein at the white house -- what is the headline from president obama's remarks? >> it is one of urgency and immediacy of this problem identified in the attempted bombing on christmas day. the president does not want any more finger-pointing by government agencies but to get to the bottom of it and fix it. the other headlines were that there were heads rolled, no agency officials being removed at this point. the white house trying to turn the temperature down on bad in the last week or so. but the biggest news to come out of this is the president's announcement that there will be no more returned of guantanamo prisoners to the country of yemen, which is where the bombing plot is thought to originate, in the foreseeable future. the white house is sent conflicting signals about that

in the last week, saying that it would halt those returns and then beat counter-terrorism adviser john brennan seemed unwilling to say that there are a b.s. suspension of those returns -- that there would be a suspension of those returned to yemen. >> how many of the detainees being held at guantanamo or from yemen? >> there are 198 guantanamo detainees at this point. 90 of them approximately are from yemen. most of them face some sort of the prosecution in the united states, either in front of the military commission or united states court. but a dozen of them had been cleared for release. the and not as states does not think it is feasible to send them back because of problems we have had in the past with escapes and people returning to the battlefield on behalf of al

qaeda. >> what does the president say about closing guantanamo? >> the president is still committed to closing guantanamo. he is saying -- closing the prison anytime soon is not really practical. they blew through lead headline at the beginning of this -- up deadline set at the end of the year, and what the president said today is that it is theoretically possible that the situation in yemen might be well enough resolve that by the end of the year, some of the prisoners could be sent back. >> the president made the remarks after meeting with 20 members of his national security team. there were reviewing the security lapses concerning the attempted bombing that you mention. the president said that we have to do better and that we will do it quickly. any indication about what the

next up will be? >> he outlined some of the changes, but the president has said that he wants to have a system in place that will ensure that not most of the time but every time they are at a vote -- able to gather the disparate information and match it up. that would make it far more likely in the future. you did not hear those from the president yet today. we heard more about putting more people on the watch list. we heard more about airport security measures, including new pat down searches that will be required on all travellers coming from 14 countries that the united states considers terror-prone. the president says that he does not think that the system is broken but that it needs to be strengthened. >> josh gerstein of the

politico, thank you for your time. >> britain's home secretary says that british airports will introduce new bomb detection equipment and body scanners. also the far end secretary david miliband told members of the house of commons about the closure of the u.k. embassy in yemen. this is a little more than an hour. >> order. urgent questions. mr. keith bass. >> will the foreign secretary make a statement about the situation in yemen, including the closure of the british embassy in yemen? >> my right honorable friend will address all the security issues are rising from the christmas incident. i will address the broader picture. as my right honorable friend knows, the government has been

increasingly concerned about the situation in yemen and the number and scale of the challenges faced by the yemeni government and people. we believe that increased security -- and security poses a risk to the region and to the u.k. our cross-whitehall discussions that ended december -- september 2009 to develop a new country strategy for yemen. it is currently being implemented across whitehall, including many agencies, and covers four areas. addressing the causes of conflict thirdly, building yemeni ability to tackle security issues. and helping the government to deliver the functions of the state onshore and offshore. to further strengthen the support for the government of yemen, the prime minister announced on january 1 that the u.k. will host a high-level

meeting later this month. the meeting will focus on galvanizing international support for devin's fight against terrorism and coordinating assistance to address the economic and social factors underlying extremism. mr. speaker, the symbol of the government's long-term commitment to yemen -- they signed a 10-year partnership arrangement with the government of yemen in august, 2007. the u.k. development fund is fully allied to our yemen strategy and to the priorities of the national reform agenda. we will spend 25 million pounds in fiscal year 2010, and depending on progress of reform of states in yemen, up to 50 million pounds in 2012. the government of yemen is embattled on four fronts. first, the troubled rebellion in the north. separatist movements in the south. economic decline across the

country, particularly important in the context of -- the population of yemen as foreseen in the near future. also, the growing threat from islamist terrorism in the form of al qaeda at, which finds safekeeping in -- safe haven ad yemen. it detracts from the government's short-term efforts to address these priorities. as a result of security concerns, the british embassy closed early this week on a precautionary basis for two days. the embassy is now open and staff is back at work. the public services section, the set and consular section, are closed. this is under regular review. i discussed it with our ambassador yesterday morning. it is not unusual for embassies to close during times of heightened tension. in 2009, the british embassy closed in the capital city on over a dozen occasions.

it would not be right to comment on the specifics of this closure, but i do assure the house is kept under regular review to ensure services are maintained. the embassy maintains regular contact with the british community, and with a british nationals who are registered with the embassy. the overall threat level in yemen has not changed. as we made clear and the travel advisory, the threat from terrorism is high and remains of concern. we continue to recommend against all non-essential travel to the country. >> i refer the house to register. my personal interests, having been born and yemen and lived there for nine years, in welcoming the london conference, will the foreign secretary state precisely what additional support has been given to yemen as a result of this recent initiative? can you also confirm that all the money pledged to yemen in november, 2006, in london, has

been paid over. can we stop referring to yemen as a failed state? çit has the capacity toç failf britain, america and the arab states do not support it. could we make sure that the foreign secretary visits this country as soon as possible? >> mr. speaker, three parts. first of all, the london meeting will not be a conference. i do not think what is -- that is what is needed. some 5 billion pounds was pledged at the london conference and 2006. a small portion of that has been ini] part,ç because of concerns about how the money would be spent. there are other issues raised. 40 percent of it has been assigned an 81% allocated -- a small percentage has actually been spent. in terms of his attempt to send me to yemen, i cannot quite

promise them that. my hon. friend, the minister of --u! will be on ça wrecky toçn çnext month. the conclusions of the london çmeeting in inappropriate way. >> mr. speaker, may we welcome on behalf of the opposition, the calling of the conference in london on january 28. agreed that yemen as a fragile state, rather than a failed state. it matters to british security. thereo7k are three setsç of questions. on the closure ofçç the embas, is the confidentç that the rigt level of consular support can be given to british citizens and officialsç in yemen? in the event of further closures of our embassy, and plans are in place to offer them protection?

for u.s.-u.k. support of the counter terrorist police force, and a yemeni coast card operation, -- ç[unintelligible] çóbut specifically, does this refer purely to financial support? or to any actual assistance on the ground in the form of trading? what is the timescale for the delivery of this support, and when is that you knew it expects to be up and running? -- the new unit expect to be up and running? on the part of other gulf nations that may be willing to work with us on this initiative. third they, at yemen cannot be viewed solely through the prism of an al qaeda problem. the foreign secretary refers to a mixture of issues. çit is an internal conflicts, fuelled by political grievances, poverty, corruption, competition

over depleted natural resources, and requires political leadership from the government as well as international assistance these issues -- can he assure us that these issues will all be addressed at the conference in january and will continue to be treated as a priority by his colleagues? will it also focus on the dam and the government's responsibility -- the yemeni's government's responsibility? >> i am confident that the right procedures areç being followedn terms of consular support for british nationals. the yemeni çdiaspora and britan as long standing -- in britain is longstanding. çthere is some need for customr support, but i am assured by the ambassador that is being taken care of and the appropriate way. çspecifically, toward network,

which operates in many countries, -- the warden network, has not been met so notified. in respect to the work goilg on with the yemeni authorities, money for training, which is the important part of the cooperation taking place -- we will be discussing with a range of the attendees at the london meeting whether or not there is a way in which they could support the u.k.-u.s. efforts. and we will look for a purported ways in which to use the skills andç expertise that come from other countries. mr. speaker, i was glad to hear what the right hon. gentleman said about the threat of the british program there and then need to maintain it. the short, medium and long-term are related. most of the grievances that exist in yemen are of local nature, not of global jihad. xd-- where al qaeda can try to

find it reads there, the vast bulk of the issues -- çwhile al qaeda can find roots there, the vast bulk of the issues are the ones that the government can address. it is the prime responsibility of debt and to do so. >> the actions of the foreign officer in closing the embassy enjoys support across the house. will the foreign secretary reassure the house that in supporting action against al qaeda in yemen, we are insuring that local people are not inadvertently alienated by our actions and those by our allies? in giving it ministry support and aid to the yemenis, and the strategy you talked about, are we impressing upon the government the importance of avoiding civilian debt and building a sustainable coalition against al qaeda across the whole country? >> the hon. gentleman makes an

extremely good and important point, and a highly relevant one. there has been a very wide welcome across the gulf, and within yemen, for the fact that the london meeting will not simply focus on counter- terrorism. that might play into the dangers that the hon. gentleman is referring to. the into this that is al qaeda of the arabian peninsula -- tghe xdhe incubus of al qaeda in the arabian peninsula should not become a rallying point. they become the victims. he is absolutely right to insist that the economic, social and political issues that are at the heart of yemen's development do need to be addressed. i think that yemen's oil wealth is likely to run out in 2015. the dangers of water scarcity are very real. these are issues that are not

amenable to counter-terrorism solutions. they require a much more deep- seeded and -- that is why the fourth priority we mentioned of the function of the state is so important to these questions. >> the foreign secretary mentioned the radicalization. we undertake a very close talks with the saudi arabian government, which makes some of the westernized countries seem unorthodox. some of these contacts seem to be working and i think we need to learn from that. >> the saudi arabian program that was featured today it was one that i visited last year in saudi arabia. there is a counter radicalization program. it is extremely innovative. i met my self a failed suicide bomber, one who had been inveigled into driving a truck

-- and failed. it is not a laughing matter, since he killed a lot of people in that truckee was driving. he did not know what the contents war. she was going to the program. there were a number of other people going to the$ogram -- he was going to the program, qincludingç religious instruct. there are larger, innovative profuqmeáqáurns -- in regards to return to normal life after the program. i congratulate the saudi arabian government in this program. >> mr. speaker, can i declare an interest -- i visited yemen a couple years ago. i found a very impressive foreign minister read things britain has a key role to play in that country. what i also found is that the electoral gains made by radical islamists have been in those

areas of the greatest party. what we need -- can we also do more to eradicate and rehabilitate their breeding grounds? >> sorry to sound like a stuck record, but the hon. gentleman makes an important point. those who in çthe newspapers today are alleging we are çwasting ourç money and spendg development money and anti- party messageñr --w3 programs. they are actually wrong. çççthe fact thatç they enjo- party support is a positive he is right, that ifç we want o w3ççkçstop yemen becoming a e çdangerous for the ground for ççterrorism, it needs to devep the sort of life chances that you and i take for granted. >> at enormous cost and a loss of british human lives, we joined america at in an invasion of iraq and afghanistan.

before we commit even more human lives to another nightmare, should we consider the possibility of having an independent, british foreign policy? >> we should certainly have a foreign policy that is decided independently by the government and people of this country. what we should not have is an isolated attempt to workq on its own. i am proud that we i am proud that we're close partners with united states and a large number of countries in the gulf. the attention that we have been paying to yemen of the last 18 months is a significant part of the growing concern in 2008 from countries in the gulf who wanted british help because of the concerns about the situation in yemen. we are not on wellcome helpmeets and yemen but we are

not trying to decolonize yemen. >> thank you, mr. speaker. i welcome the short discussion about yemen. we're having it because of al qaeda. would it not be instructed that the government to produce a document or hold a london conference and talk about the international strategy against al qaeda because for we have had other statements about other countries where al qaeda is operating? perhaps not necessarily in the news at the moment. >> the honorable gentleman makes a good point although he would be one of the first to recognize to not distinguish between senior leadership based in afghanistan and pakistan, the al qaeda of the arabian peninsula, there are distinctive issues related to the senior leadership and several franchises of al qaeda on the other hand. to debate and the more the better

as far as i'm concerned. there was our recent meeting with parliamentarians on the situation in yemen before the christmas incident. there is a thrivingç all-party parliamentary group, chaired by my hon. friend that speaks to the close links that exist between britain and yemen. long a that continue. >> is a significant proportion of terrorists turned out to be radicalized here inç britain, ratherw3 than niemen ?rd elsewh, should not t prime minister also be considering the radicalization that takes place here? -- rather than just in yemen. >> there have been a large number of meetings. -- not just within government but all around the country to address this issue. >> mr. speaker, i agree with the

foreign secretary about the importance of aid in removing what i call this courage of these spots where terrorism-- the scurge were the spots of terrorism can rise up. they described as yemen as fragile. çcould the foreign secretary indicate just how widely supported is the government of yemen of cross all the people, bearing in mind the tribal conflicts in the north and the separatist movements in the south? >>çç far be it from me it to a lawyer for the right hon. gentleman, but i thinkç he said that yemen is fragile, rather than the government is for agile. in his defense, or at least an explanation of his position -- the government is fragile. the president is currently in his second term of office. the constitution prohibits him

running for a third term. parliamentary elections are due in 2011, in yemen, and they will clearly be a massive challenge. one of the issues that will need to be addressed our democratic elections and the ability of people to express their opinions. the number of citizens committed to violence, whether through the movement in the north of the separatist movement in the south, with links to al qaeda, is a small minority. >> all over the world, our armed forces and our aid budgets are stretched, in afghanistan, in pakistan and in somalia. why has the prime minister chosen to take a lead in yemen or in our resources are stretched? is it better for the u.s. to take a lead? >> so much for an independent foreign policy, mr. speaker.

this country has longstanding history with yemen, and i think that gives us an important role. secondly, we are in a group of donors with the united states, with the germans, with the dutch as well, and with the saudi arabia into our preeminent donors. in terms of the stretch, we have been careful to make sure that in our funding and yemen we only spend what we know the government has the ability to properly spent there. he is right that there are a range of other problems. somalia is addressed best through the amazon security work, but on the political level through the un security council. the meeting that has been called an the other forms of corporation being established the fits the situation in yemen. somalia is rather different. >> international aid funding which they have promised -- it pales against what the oil-rich

countries should be providing shouldn't her majesty's government make clear -- shouldn't her majesty's government make clear how much they should spend, rather than spending millions of pounds? >> i am not sure that the government spending money on skyscrapers is what he is referring to. some of the largest pledges at the 2006 conference were from gulf countries, not from western countries. it is important that those pledges are fulfilled. which of those pledges that? the bank paid? that is a curtain in point in regard to this. -- which of these has been paid? it is not to say that we have the biggest program. it is to explain that we have the berdych program. he has a right to say that this initiative -- we have a british program. he has a right to say that they have put us on the alert about

their needs third . >> secretary allen johnson. >> with permission, i would like to take a statement on the failed attempt to destroy a passenger plane at the detroit airport and its implications for national security. on december 24, abdulmutallab, the nigerian citizen it traveled from lagos to amsterdam, where he boarded the 2 flight53 2 detroit -- flight 253 to detroit. on the way, he detonated a device on his thigh which resulted in a fire. he was subdued by flight crew and passengers. remains in custody in the u.s. -- many countries are doing

everything they can to piece together his movements shortly before this attack and are considering what urgent steps need to be taken to prevent further attacks of this nature. it is an issue of grave concern at that the explosive device was not detected by security in nigeria or in the netherlands. as has been widely reported, he attended university college london between 2005 and 2008, where he completed a degree in engineering. during this time, he was known to the security service but not as somebody engaged in violent extremism. his family and friends have stated their belief that he turned to this during his time in yemen. from the information we have currently, it is not possible to chart with absolute certainty his exact movements after he left the u.k. 14 months ago. he is known to of spent several

months studying international business at the university and dubai and in august, 2009, he traveled to yemen where he is thought to have stayed until december before returning to west africa. he came to the attention of u.k. authorities again on april 28, 2009, when he applied for a multi-entry, student visitor visa to attend a course provided by discovering life coaching, based in east london. the u.k. border agency refused to his application because discovery did not hold a valid accreditation with a u.k.- approved body and was not eligible to sponsor international students. since march, 2009, only institutions that are sponsors or hold a valid accreditation are permitted to bring in short- term foreign students from outside the eea. universities and colleges must

be able to demonstrate that they are offering a genuine courses that will benefit students seeking toq study in the uk. this new regime has reduced the number of institutions able to bring students into the u.k. from 4000 to approximately 2000. following the refusal of his application, his name was added to the u.k. watch list. mr. speaker, in light of the serious questions this incident raised, i want to set out today first lead the immediate steps we are taking to tighten aviation security. secondly, what measures were taken to prevent radicalization in our universities. thirdly, the actions we are taking to disrupt al qaeda in countries where they are known to be active and to prevent future terrorist attacks and to improve cooperation with our international partners. it is of great concern abdulmutallab was able to penetrate airport security at

amsterdam. the device used had clearly been constructed with the precise aim of making detection by existing screening methods extremely difficult. abdulmutallab underwent a security check at the airport in amsterdam, as do all passengers transferring from nigeria to another flight of the the it -- although theç airport was using some of these in trial, there were not used for that flight. he passed through the metal detector. however, certain types of explosives, without metallic parts, which can also be concealed next to the body, cannot be detected by these technologies which is the reason why airports also search passengers at random. to defeat the terrorist threat requires constant vigilance and adaptability. a great deal of progress has

been made in enhancing aviation and border security since 9/11, but terrorists are invented. the scale in nature of the threat changes and new technology needs to be harnessed to meet new threats, whilst minimizing inconvenience to passengers. last year, we issued a new public guidance to the industry on our technical requirements for screening and the detection of improvised explosive devices. . . my noble friend and hide have been intensively engaged in this review and we are setting out initial steps. mr. speaker, it is clear that no one measure will be enough to defeat invented and determine terrorists, and there is no single technology that we can guarantee will be 100% effective

against such attacks. airport security is multifaceted and needs to adapt constantly to evolving threats. we therefore intend to make changes to our aviation security regime. air passengers are already is used to being searched and having their baggage traced -- tested for traces of explosives. we will creep -- increased the proportion of passengers searched in this way. there may be some additional delays as airports attract -- at that, but i am sure that the traveling public will appreciate the reasons behind this. new restrictions will tighten up screening for transit passengers. we're reviewing the standards in airports operating direct flights to the u.k. passengers will also seek an increase prescience of sniffer dogs at airports to add to our

explosive detective capability. we also intend to increase more body scanners. the purse scanners will be deployed in around three weeks at heathrow. over time that will be introduced more widely. ll be introduced for widely. we will be reviewing all airports to introduce explosive trace detection equipment by the end of the year. the best way of doing all of this will be dealing with the operational and privacy issues involved. we've started training airport security staff and behavioral analysis techniques which will help them to spot passengers acting unusually and target them for additional search. beyond this, we examining -- we are examining whether additional passenger profiling could help security. we will be mindful of civil liberties concerns and aware

that identity-based profiling has its limitations, but conscious of our overriding obligations to protect people's lives in liberties. these build on the substantial progress we have made in recent years to strengthen our borders, including protecting people in transit against the watchless will be 95% complete by the end of the years. it makes is one of a handful of countries to have the technology that can carry out advance passenger checks against our watch list before people travel to the u.k. those who apply for rugby's the will have to provide fingerprints and their records are checked against the new watchlist which holds over 1 million records of known criminals, terrorists, people retry the into the country illegally, or those who have

been deported, and those considered to be a threat to our security. through the e-borders program, we have made 4900 arrests@@@@@@ we prevented over 65,000 can adequately documented passengers from travelling to the u.k. during 2009. mr. speaker, addulmutallab's failed attack highlights the importance of information sharing between the various agencies are about people who pose a threat to our security. threat to our security. you can watch list is managed by the u.k. border agency and incorporates intelligence from the law enforcement and the security and intelligence agencies into a single index. nevertheless, although the integrated approach works very

well, we want to see if we can further strengthen it. we will be conducting an urgent review with the robustness of our watch list. it will report to me and two week's time and i will report the findings subject to security restrictions. there is a concern that addulmutallab's radicalization may have been fuelled or started at university college, london. the tolerance promoted in higher education are one of the most effective ways of challenging views which we may find abhorrent but that remain within goal. however, we know that the small minority of people supporting violent extremism have actively sought to influence and recruit people through targeting learners and colleges and

universities, and we must offer universities guidance to help prevent extremism. as part of a measured and effective response to the threat, the department of business innovation and skills have published guidance on managing the risk of violent extremism in universities, and will work closely with universities to provide targeted support. alongside this, each university has a designated police security contact that university management can discuss concerns with. the strategy works closely with the higher and further education secretaries and has a full-time officer. his family believes that if left -- he turned to extremism after leaving the u.k. but we need to make sure that we continue our efforts to stop radicalization of young people in our

universities. finally, mr. speaker, i want to say something about our work internationally and the steps the government is taking abroad to disrupt al qaeda where ever they are. our success in tackling the international terror threat depends on strong relationships with our international partners. in our efforts to fort al qaeda, we have a longstanding productive partnership with the u.s. i am not prepared to discuss in this particular case about what we established -- what we shared and wind. we do not routinely comment on such intelligence matters. moreover, some of these issues are still current and are highly sensitive. however -- however, i would like to clarify that whilst we did provide information to the u.s. link to the wider aspects of this case, none of the

information we held or shared indicated that addulmutallab was about to attempt a terrorist attack against the u.s. i spoke to the secretary of state and the homeland security. we discussed in the light of this failed attack that we will work together with our international partners to maintain confidence in aviation security and deepen our partnership to disrupt al qaeda's activities overseas. forced out of afghanistan and under increasing pressure in the borders of pakistan, affiliate's and allies of al qaeda like al qaeda in the arabian peninsula group claiming responsibility for the detroit of -- bombing have raised their profile. then again demonstrated their intent to attack innocent people across the world. the aim of our counterterrorism strategy is not to reduce our

own vulnerability alone, but to disrupt those organizations that pose a threat to the u.k., whether at home or abroad. al qaeda will take any opportunity to exploit instability, whether the threat is in somalia or yemen, pakistan, iraq, or afghanistan. we must support governments and work with partners to address both the threat of attack as well as the underlying causes of extremism and instability. we have been working with the yemeni government, as my right honorable friend, the foreign secretary, has just said through law enforcement and security apparatus to disrupt al qaeda and denied their safe haven in yemen in the future. we are also one of the leading donors to the development of the country, standing at 100 million pounds by 2011. we recognize the need to strengthen further our partnership with countries in

the region and beyond. that when we can coordinate against al qaeda more effectively and find greater support for the many people to reject extremism. international cooperation is critical to making what is a global threat, the coming together to discuss yemen will be an important step toward security there and across the globe. mr. speaker, it is important to reiterate that this was a failed attack by a nigerian national on the u.s. by someone who was refused entry to the u.k. and who it seems was radicalized after he left this country. however there are lessons to be learned by the international community and the measures that i have outlined will provide the u.k. greater protection from terrorist attack. along with our work overseas and our international -- and with our international partners, enhanced airport security and more thorough collation of

intelligence, we will be able to strengthen our efforts to attack the root cause of violent extremists on and reduce the threat of future attack. i commend the statement to the house. >> thank you, mr. speaker. i am grateful for the home secretary providing me an advance copy of this statement. let me start by dealing with the issue of airport security. i think we all have said that we have learned lessons from their recent plot, happily unsuccessful, that additional security measures will have to be taken. the use of more sophisticates -- sophisticated scanning technologies are inevitable, though we have to make sure that sensible measures are taken to maintain privacy. but the statement is actually ambiguous about scanners. can he be clear, does he plan to make full body scanners compulsory at all u.k. airports? kenny clarify the situation also with the european union over the use of e-borders?

we also believe that it is necessary to take a more intelligence-led approached, all much security as well as pledging for suspicious behavior among passengers. the government will have our support in taking prudent measures to protect passengers. these must under be -- these must be under constant review. however, mr. speaker, the percentage planning themselves should not be the home secretary but the prime minister for it twice in three games the prime minister has been caught out making false claims about the contacts made between britain and the united states all over the security threat to our airport. he admitted to the bbc that supposed discussions between him and president obama of about the bomb plot about the situation in yemen had not actually taken

place. then yesterday he claimed that britain had supplied intelligence about the bomb suspect and his link to extremists to the united states in 2008, a claim that downing street now admits is untrue. this the government that have systematically misused intelligence over the years, most notably in the so-called dodgy dossier for the prime minister to mislead our spend intelligence information, particularly when related to a terrorist threat, does he agree that this is absolutely on acceptable behavior -- unacceptable behavior? it is to establish an acceptable principle that we did not comment on intelligence matters. why did the prime minister break that rule this week? does the home minister also agree with me that it is damaging to our most important intelligence relationships with

the united states for information to be disseminated by downing street in such an inaccurate and cavalier way? mr. speaker, this entire house will be relieved that on this occasion the bomb plot was unsuccessful. it will serve as a strong reminder to the governments across the world of the ever- present terrorist threat and we all need to remain vigilant about that threat as well as united in a determination to defeat it. it is also worth saying that the threat from a small group of islamic is remiss -- extremists in no way reflects the views of the vast majority of decent months and people around the world. people who have always been victims of terrorism of the decades, we must band together regans that thread. that task has not been helped by the actions of downing street in recent days. >> mr. secretary. >> mr. speaker, i do regret the

fact that the honorable member uses this very tense time to score cheap party political points. to use this issue -- mr. speaker, i saw lots of faces on the benches opposite appalled that this situation should be used to make personal attack on the prime minister. the honorable member on the raised three points that i believe are relevant to this issue. the first in terms of the number of all body scanners. what we need to do know is work with the airline industry to decide how many and where we can locate these scanners. as i said in my statement, we will have the first ready at heathrow within three weeks. there is a limited capacity to manufacture these and that these employees and also get the authority and the agreement of the different airline companies and their input into this.

that will become much more widely available. the honorable member also talked of the eu's situation. that was clarified before christmas and there will be no e.u. community issues about the transfer of their permission. it still needs the country's transferring that information to agree about transferring techniques, but there is no e.u. issue which the commission it was originally looking record and the third issue, which was about our use of intelligence and about our cooperation with united states. the prime minister was absolutely right, as i said in my statement, that we did share information with the u.s. none of this information or the nature of that information and the affirmation itself that we do not routinely comment on, but none of that suggested that addulmutallab was planning a terrorist plot. incidentally, i met jane lucas and mentioned that statement

today, and she did not mention this issue at all this morning. this is a productive way to deal with this issue. to deal with these issues, and there is absolutely no relationship in the world stronger than the relation between the u.s. and the u.k., particularly on counter- terrorism where we work together and we will continue to work closely together in the light of this latest threat. >> chris him. -- hume. >> i thank the secretary for statement. the announcement that scanners will be rolled out its welcome. but there are several questions to be raised, and can they -- and can confirm that all body scanners would have detected the substances carried by umar farouk addulhutallab? why is it taken so long for him to act, given that they are already in trial, and four are reported to be in storage at

heathrow? and the third question is whether he will respect those who may have a deep felt objection to be -- to the scanners to opt instead for a pat down? pat down? and can he give assurances that it means additional searches for those with suspicious travel partners, i am sure that those who would object. if he means stopping everyone who looked asian, then i fear he will alienate those communities whose cooperation we need in the fight against terrorism. which is it? then there is the information sharing, which the home secretary cannot dismiss by saying that the government does not to walk -- comment on things like that. can he confirm that brittan told

the u.s. authorities that the bomber had linked to extremist? and can he confirm that the u.s. was informed after he was placed on the u.k. watchlist? in the light of these contradictions and the open spat with our closest ally, what measures is the government taking to improve the flu season with a united states or possibly with the prime minister's press operation? giving the transit, or the dutch authorities notified of our concerns at any point? had we shared our information either through other routes and what mechanism is there for one eu country to become aware of such intelligence on the suspected radical held our collected by another you -- either country? do we routinely share information about our watchless with eu countries?

in the light of this attempted attack, did these systems need to be improved? . canners. what they had been effective in relation of the time? the indications are, given where the six bosun was place, with them o -- with the explosive was ta -- where the explosion was in place, there was a 50% chance of being detected. i think that we need to see the next wave of technology with explosive detection as well as the body imaging issue. we need to see that ahead very quickly. i do not accept that we took so long that act. this happened on christmas day this happened on christmas day and tmas period we have been discussing -- my

colleagues at the secretary of state have been talking about the availability of this equipment. there was one body scanner at manchester. there have been a number at heathrow on a trial basis, but whether they are serviceable or whether they need to be operated on to be serviceable, is still an open question. the issue of privacy, mr. speaker, is going to be an important issue, but given that all of the images are destroyed immediately, given that the person responsible for the scanning is separate in a separate room. there is a version that glass co as well. there is no immediate contact between the person doing the imaging and a person being imaged. i think we have to put these considerations -- they are important, but i think that we can actually ensure that those

concerns will be satisfied. i cannot see a situation where people can simply object to a body scan. perhaps not as the first line, but as the second line on iran the bases as part of the defense. the honorable member mentioned the important issue of profiling. i said in the statement i recognize the sensitivities here. anyone who looks at the case in 1986, a pregnant woman in faded by her syrian -- inveigled by her syrian boyfriend to carry a bomb on board, the name would not have alerted anyone, but nevertheless the issue of whether we can deal with some of the sensitivity issues must be part of l%9eñ any defense we can find to ensure that this gap in our defenses, which

thankfully was unsuccessful but which was found, and we need to recognize the concerns and the civil rights issues as well. on the issue of information sharing, we shared information all the time. we share information on a routine basis and you -- and the u.s. share information with us. we did not inform at the u.s. that addulmutallab was on our watch list because he refused a student visa, because that was an issue conducted without any concern that he was coming to commit a terrorism incident. it was about an immigration issue. we would not share that routinely with the u.s. but we share other information with u.s., and we share this information routinely with our european union partners, although if there are concerns about counter-terrorism, it would not wait for a watch list and it would not wait for the plane to be taking off. it is outside of europe where we have the problem.

within the european union, we have a very close relationship which means that we deal with the security issue straight away. we do not wait until they are trying to get on the plane and other countries. >> order. several members are seeking to catch my eye. like to accommodate everyone. the number should be perfectly manageable. level me remind the house that there are two further statements to follow. each honorable member should ask a single, short, supplementary question, and that the home secretary will reply within equally economical answer. >> the home secretary is right to consult with the airline and measure the response, and we ought to have these body scanners. the international cooperation aspect is the most important.

are there any more lessons to be learned as to how we can improve the situation? >> doubtless there are, and i recognize my right honorable friends expertise in this matter. i said in relation to the watch list, we think this integrated watch list so that there's not a separate -- in some countries there is a separate one for security and for policing in crime, and for those who lost their passports and immigration issues, and integrate the watch list and with e-borders continually coming onstream, we can deal with this that has taken off. given that addulmutallab was not tried to enter the country but blow himself up before it landed, and that does not matter if this -- and it does not matter what country was his destination. i would be the last person to

appear complacent about this. at the prime minister said, this is a wake-up call. every attempt must be picked to pieces of that we can find anything we can to strengthen our defenses and that is what we intend to do. >> mr. taylor. >> does the home secretary realize that scanners cover all white area? some require you to go through a box and others actually can do it remotely in airport lounges or railway stations. can the government institute a research program -- several british companies are involved in this -- but we need to stay ahead of the terrorist and not deploy after every incident? >> the honorable member raises a valuable point. we are dealing with smith industry shortly and talking to the document that we repeat -- that we produce last year about

our security minister in 2009, it was specifically aimed at the scientific community innovators to get this moving and to find new ways to deal with this. i think that the important part about this is that there is a big part of the british technology here said that we can actually exploit it and insurer -- which is one reason to talk to the airlines -- and that soul -- and you're absolutely right. there are a variety of these scanners and we need to use them effectively. >> john bolwheaton. >> can i welcome the emphatic way in which the home secretary emphasized that there is no single magic bullet to solve these problems? in light of recent media comments, particularly the full body scanners which require

standardized procedures, which are still in trials, and it requires a range of search procedures and technology, and above all, the last honorable gentleman who spoke said that it will require constant innovation in batted in everything that we do. can i therefore ask the home secretary it will build upon the good work been done by lord west and make sure that a partnership of the government and private industry is given more resources in order that we can stay ahead of the cut of the terrorists in introducing new ways of terror? >> mr. secretary. >> i think my right honorable friend makes the point that my right honorable friend did and i agree. this is about reasonable efforts to stay ahead of the terrorists. we will not deal with the issue of body scanners alone. sniffer dogs every day, in looking for ptpn, and the use of

behavioral detection -- all the techniques that we can use, even then we will not be 100 percent. we can never guarantee 100% safety. but there are a lot of people out there waiting to innovate and to work and to provide equipment in a technological capacity that can move us to the next level. i believe that that is really the main lesson of detroit on the 25th of december. >> mr. robert keep. >> willie acknowledged a debt that we owed to the ministry of defense personnel and other start reduce servants working at one company in my constituency about terrorism who are responsible for all of the day-by-day innovation which goes on in terms of science and technology? and willie talk to the ministry of defence to have tremendous

budget problems to ensure that there is not only no cut in the defense budget as it affects this, but that they should have all the resources that they need to counter terrorism? the boilers the home secretary. >> the honorable member is a great advocate for his constituency. i am talking to the defense secretary perry this is a cross-government initiative. we are all working to do this using all the agencies of our government. >> aviation -- what new steps are being taken to link intelligence information with the best system of security at individual airports? babblers mr. home secretary. >> my honorable member -- my honorable friend is a member of the transport secretary committee. talking to jay lucas today,

we're talking about the lessons from it and we're still talking through -- there was a view that we should go to brussels and the opportunity of the spanish presidency very interested in this matter comes up in a few weeks' time. more and more we're centering on that, the opportunity to get transport ministers, homeland security ministers, perhaps defense ministers as well together to talk about an integrated program as to how we can act internationally. my honorable friend is absolutely right. by its very definition, a nigerian coming through holland to detroit with ramifications for a much wider set of countries, we need to deal with his senate -- with this internationally. >> mr. speaker, to organize the -- who authorized the downing

street spokesman to talk about the bomber? >> i will not get into who authorized to to say what. what the prime minister said about exchanging information with united states was absolutely right. not all of that information remotely -- not that informational remotely indicated that he was planning an attack. >> with my right honorable friend considered a central reporting area for members of the public who spot lapses of security in airports in which they are traveling coming in to the uk? the boilers mr. home secretary. the >> i will consider my honorable friend's suggestions. there are plenty of opportunities for people to report these things. there was a program over christmas about the emergency service being misused. there is a problem and a security problem, that is one

cause of action and there are others. my honorable friends makes a good point and we will look away to make it easier for the traveling public to report any suspicious that they have. >> we have the only airport in the u.k. sector to terrorist attacks in scotland. can the scottish airports expected be a first line for the body scans and can he assure me that he will be working hand in glove with a scottish government to ensure that the scottish airports are safe as possible? >> i can answer the honorable member on both of those points. we need to talk about which airports for three i believe he wrote, given the huge amount of transit -- because we're talking about transit passengers as well. addulmutallab was a transit passenger in holland and was not searched possible -- properly. i believe the discussions have i believe the discussions have already started with a

can i pass on a warning ? there has been talk of competition between terminals. they enter security comes before competition. >> cannot give that insurance. i am not sure to what they are referring. in terms of providing security, the absolute priority is not competition between terminals. >> there are many who have expressed concerns about the activities of schools in northern nigeria and the roles of a pay -- play in forging ahead. can he confirm that the schools will be swept up in that? he is had discussions with his counterparts.

>> it raises an important one. i think this is an important issue we need to discretion. -- discuss. we need to make sure we are doing everything we can to prevent this radicalization taking place in the first instance. only for local security but to prevent this radicalization taking place in the first place. with a that is in this country or abroad. >> during this debate there has been some very interesting proposals about investing in research about the technology required to detect terror. i am concerned, although the home secretary acknowledge the risk of identity basis is for profiling, that there will not be sufficiently robust -- robust research into the consequences on young men who are muslim or asian who think that they are expected to be paid in a certain way and therefore say, why don't

die? can he assure the house that there will be very robust research into the potential consequences of identity-based profiling before any such process is introduced? >> i can give my right honorable friend that assurance. behavior detection is different to profiling 3 behavior detection is something used by the british transport police. they are well trained to do that, and it is observing individuals and how they act around uniformed officers that gives certain signs away about whether they should be -- that is a preliminary to them being researched. it is different on profiling. i recognize that just the sensitivities and the civil liberties issues raised from the liberal -- the liberal democrat bridges -- ages, but we were talking about the terrorists being one step ahead, and if they think there is a profile that it escapes this, and it is our main weapon against them, then they will use that, whether

it is pregnant women and or whoever else a gentleman like me. i think that is the other danger of profiling and we need to be very careful, and i am acutely aware of that, but it would be strange that if in response to detroit we did not cover all the different elements and all the different options and it thoroughly air -- and thoroughly explore them. the dollar's been wallace. >> is it rich that the government has come here, year after year after cutting the defense budget, and what had [unintelligible] we have to go to the americans to get the funding because this government cut the funding. could the hong secretary please tell us what actual concrete resources he is going to put into further developing technologies and to make sure that our borders are secure? >> i know the honorable member

has some experience in this field. i do not understand the criticism of this government in terms of what we have invested. he is no longer in this place but the opposition benches, he was continually praising the government for the science and innovation project. when i was secretary of state at the old dti, half of my budget was signed. it was frustrating at times because i could not touch it for a good thing. criticize us for a lot at this, but did not criticize us for the budget. >> helen my right honorable friend consults and communicate changes that are made and profiling? it is difficult because these changes need to be made in a way that does that actually trigger, as you suggest, the knowledge of people that we're doing this, but it is important to avoid unnecessary communications as well. >> i take my honorable friend's

point. there would be no benefit from even studying the use of profiling if we were not sorting and did groups representing different ethnic minorities in this country. we have to take a bus along with us. -- we have to take them along with this. there will be different views in different communities among different ethnic minorities. all i am saying that this dispatch box, mr. speaker, is i think it would be irresponsible not to let it weather profiling can play a part in strengthening our defenses. >> to search people more thoroughly and introducing more body scanners, we will need more space and more employees at our airports. seeing that our airports appeared to be fully cram, will he make it clear to the airports

that security matters have to come first? >> maybe the honorable gentleman is inviting me to change the use of space at airports. this is one of the important discussions we ought to have with the airport authorities and with the airlines. how we physically can do this properly with the minimum of inconvenience to the public, and ensure that people can go about their daily business, that is a very important part of these discussions. >> then we have stronger action for people who are expected of promoting extremism and those to be suspect becoming radicalize, and can we include in that list those people who go on offense of marches? >> we always keep these issues under the. it is important that we do not

take action -- we are a democracy. on our university campuses, there needs to be proper debate. because people have the views that are found of all right but not illegal, it would be applauded for us to be heavy- handed in that respect. what we do to prevent is to strengthen the institutions to help individuals, to provide the information and the facts and the advice to those who want to counsel some of these radical views. as part of this, of course, we deport and seek to deport a lot of people. there are many cuing up for deportation at the moment. they had their right to be the use of the european court, all of that is important, but provided we have done our job, those people will be deported. >> given the strong links that umar farouk addulmutallab had in

this country, will the british police be able to interrogate him about those leaks? >> all that i can say at this stage, mr. speaker, is that two metropolitan police are working in america with the fbi on this case at the moment. the police were taking immediate action in this country. we did not comment on current police operation. we will have to wait for them to come to a conclusion that may well involve the british police asking questions 3 we will have to see how the operation does. >> i have some constituents expressing concerns about health risks and dignity. is there anything on the public record about these matters? >> in terms of radiation, one is that there is less radiation from bodies can then you will

get from actually flying, from the flight itself. on the issue of privacy, we can think and do more but at the moment the fact that all the images are distorted immediately, the fact that the person operating the machine is remote from the person being scanned, and that therefore there is no face to face contact, they are anonymous when being scanned, it is difficult to get around the privacy issues, given where addulmutallab was trying to hide his explosiv [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> in a few moments, democratic leaders on negotiations of the versions of the senate bill. a book that long-term care services in a forum hosted by the journal of health affairs.

after that, president obama on the investigation into the recent attempt to bomb a northwest flight near detroit. later we will be aired the british house of commons session on the terrorist threat from yemen and airport security in great britain. >> on "washington journal" tomorrow morning, eric wilson talks about airline security since the attempted bombing of a northwest flight. we will look at anti-government protest in iraqn. -- iran. even column of questions about this. and the role in the financial system. it is live on c-span every day at 7:00 a.m. eastern.

>> we speak at the washington center for the role in the military. that is that neglect a.m. eastern. the discretion of conflicts in the developing world hosted by the wilson center and catholic relief services. president nixon pose a meeting with elvis presley. the photo of the two together is the most requested the to from the archives. -- photo from the archives. >> i am always concerned about the potential of unforeseen consequences. is it? as a tax. when you regulate something, you tend to get less of it.

is this weekend, republican commissioner robert mcdowell on efforts to create a national broadband plan. saturday at the clock 30 p.m. eastern. >> next an update on health-care negotiations on capitol hill. democratic leaders spoke with reporters for 10 minutes about their efforts to pass a bill. >> have the new year. welcome back. -- happy new year. welcome back. it is great to see you all. we just had a successful meeting with our chairs. i want to commend all of them.

we are very pleased that our conversations continued with our counterparts in the senate. we are optimistic that there is much that we have in common in both of our bills and that we will resolve or reconcile this legislation in a way that is a triple a rating. accountability, affordability, and accessibility to many more people and our country. with that i would like to yield to our distinguished majority leader. >> thank you very much, madam speaker. we have reached a very historic bill. it the senate has passed a healthcare reform bill. it is necessary for us to reconcile these two bills. there are significant differences. we will be discussing these over

the next upcoming weeks. we expect to move very forcefully on this effort to bring these together. we are very hopeful that we will pass a report in the near term and get the signature. teddy roosevelt started this effort almost a century ago and said we needed to make affordable and quality health care available to all americans. over the ensuing century, we have not accomplish that objective. we have now moved further than in any time in history on a bill that does exactly what teddy roosevelt and many presidents have said. we are here working on that effort. we are going to be successful.

thank you very much. >> i'm trying to hide behind him. i do believe that all of us have talked to our various constituents. we know that they are looking forward to us using the time between now and when we reconvene to have a legislation on the way. we are trying to reconcile two bills. there are real good things in the house and senate bill. what we need to demdo now is mee these two bills with the american people fill the time and energy has been worthwhile. >> we are particularly delighted

with the leadership of the president of the united states. without his leadership and vision and encouragement, we would not be on the verge of passing this historical legislation. it is right alongside such security and medicare. -- social security and medicare. >> in number of moderates have said [inaudible] what changes are critical? >> we want our final product to ensure affordability to the middle cows, accountability for the insurance companies, and by lowering costs for every stage. those of the standards that we have.

>> [inaudible] >> i prefer to call and the public's options. we want to increase competition. there are ways to do that. we look forward to having those discussions as to reconcile the bill. unless the whole the insurance counties -- companies accountability, we will not have affordability for the middle class. we need to end discrimination on the basis of pre-existing conditions, to cap payments and co-payments. it is about affordability. that is essential to accessibility. we will have what we need to

hold the insurance companies accountable. i contend that whatever we have coming out of this bill, we will hold them accountable. there will be crying out. -- they will be crying out. >> [inaudible] right now there has been a ping- pong. any response? >> really? there are a number of things. i have referred the letter. >> let me thank you. that may point out that the health-care debate has been subjected to unprecedented degree of public scrutiny.

you then had a summer where you had thousands of hearings around the country and town meetings where people wear showing up as well as telephone town hall meetings. you have a whole series of hearings. there were over 100 hearings held by the chairman of the three committees who are with us today but as i've heard from 181 witnesses. the list goes on. we will continue to can -- this process as we go through this phase. there will be discussions. we will continue to keep the american people informed. >> we do not even know yet if there will be a conference of the speaker. it is not clear whether or not that will happen. >> [inaudible]

he tell me it was an insult to democracy. >> i do not know who you are talking about. there has never been a more open process for any legislation. tens of thousands of people participated in our town meeting. we now have another town venue. that is the internet. our legislation has had visibility for a very long time in that place. i do not know who you are talking about. what i will say is that completely disagree. we do not know what he will take. we will take the route that does the job to help the american

people and do it in a timely fashion. we will do what is necessary to pass the bill for affordable, accessible, at the legislation that holds the insurance company accountable. >> [inaudible] >> we will see what that does. the sense that we have the fairest approach in our bill. when it comes to tax policy, it is like a mirror on the wall. we will proceed in a way that helps people. thank you. >> if i can just add to that. whatever the funding mechanism, the president and we and the senate have pledged that this

will be paid for. it will bring down costs. it will bring down the deficit. >> [inaudible] how do you know it will be posted online in 72 hours before? what kind of update mechanism do you foresee? >[inaudible] >> my experience has been you know before i know. i presume that will continue to be the process. thank you very much. >> now discussion of long-term care services hosted by the journal of health affairs and the scan foundation. it included a look of a provision in the senate will kill -- helped build that will create a long-term health insurance program for the

elderly and disabled. this is two hours. >> good morning. welcome to this health affairs briefing on our new january 2010 issue, advancing long-term services and support. this is a very special day. we are very excited about this issue, which is the first full issue of the journal that has ever been devoted to this particular topic of long-term services. the we are extremely grateful to the foundation which provided us with the funding to execute it.

key provisions in the house and senate versions pertain to this area of long-term services and support, the largest one thing the provision of the community living class act. we will be hearing later from one of the key people who make sure that the class act was part of help reform, connie garner. there are other provisions that pertain to long-term support for services. we will hear more about those today. the fact that this is the case, that health reform will also include a meaningful long-term care reform is an achievement not to be understated. there is a lot of reforming left to do. there will be even if the other provisions are an active. whether the goal is advancing

the quality of care of long- term services and support or providing the most appropriate type of care in the most appropriate setting or providing the most appropriate care for those in nearing the end of life or recruiting and paying a top class, long-term services support to work for or figuring out how to spread the burden of the cost of all this, all of these questions will remain with us and there will be a lot of work to be done. papers in this issue topple all of the sentence and lay out an agenda for those in the long term care sector as well as for those in government as to how best to proceed. as i have stated, we are very excited about all of this. today marks the debut of the new redesigned of affairs. we have this new redesign and a format for the physical

condition of the journal. we also have the early prototype of our redesigned web site, which will be unfolding in its crater cori later this year. we also converted from bimonthly to monthly publications of the hard copy. we have a new logo. we even have a new motto. we are now at the intersection of health care and health policy. we hope you will take a copy of the redesign journal with you and see for yourself, we have been able to execute. we think you'll find it much more readable, visually interesting, and much more user- friendly than ever before. it maintains the core of the old concept health affairs.

i want to introduce you and say thank you to the health affairs staff who are here today, all of whom worked hard to execute the new journal. will you all please stand up and take about? [applause] -- take a bow? [applause] some of them are actually out in the hall is still working to get this show on the road this morning. i also want to say things in particular to donna abraham who is the lead editor on this issue. thank you very much. i went to thank mary of the university of pennsylvania who be speaking later today for serving as are out urging our

outside adviser. i want to say thanks to barry wheeler who helped to engineer the publication of this issue without whom we would not be here. thank you very much. i want to thank the foundation once again for making this issue possible. i am going to introduce to you the ceo of that foundation. he will make some brief remarks. he comes to us from california. that is where the foundation is headquartered. the mission is to advance the development of a sustainable continuum of care for seniors. it is the second largest foundation in the u.s. focused entirely on improving the quality of health and lives for seniors. before hand, he served as the

director and chief medical officer for the los angeles county department of health services. that is after serving for the department's senior all medical director. in earlier he had served as the regional medical director for california health programs for the largest network models that were planned. previously, he worked as an academic internist. if he is currently adjunct professor of medical at ucla. he served as founding jury of ucla's five-year program. please took me in welcoming him. >> good morning. it is a pleasure to be here. let me first say we are thrilled to see this issue arrived today. it is great to see all of you

here. this is a very important in defining moment in how we think about health care and the care of seniors. i want to just begin by thanking susan, her entire team for bringing this issue to fruition. when we had this idea a little more than a year ago, we came to the conclusion that we had this nutty idea. we think you should do a clean issue of long-term services to support it. it does not seem to be a topic that you guys have covered in a long time. it is not one that you covered in a robust way. from the very first conversation, susan and the team said this is a great topic. it is time. it is something we should give more attention to. we are here today to really celebrate bringing together the leadership that could to give this issue. susan, thank you very much. i want to take the authors and the folks who have helped on the

editorial side. many are here today. you all have done a terrific job. many of you have worked on these topics for many years. we are just thrilled to see help of verot create a vehicle and opportunity to bring together your thinking in a comprehensive way. we are truly at a seminal moment. if you look at where the things that are contained in the house and senate versions of health care reform, and this is not just a bill about standard health care. if you think about where we started out, it to be about

coverage and access. that is one of the discussions going on today here in washington. if you look at the bill carefully, the foundation of comprehensive and longer-term service support in this bill. when you look at things like creating an office for the center of innovation. if you look at the proposals, if you did get the ideas around improving home businesses that the state level taken as a whole, long term services starts with what is in this bill. the stars of health care reform. if one really cares about things like improving quality, creating more care, creating a quality of life and not as tough agenda, and the really important

decisions like and in the cost curve -- it is for those who use the system. it is for those most in need for those opportunities. we think that today's issue and the comments that will be made by i by our officers will really be here today. thank you very much. [applause] >> as bruce mentioned, several authors are also with us today who will not be presenting. it is only because we cannot have a news briefing that was three or four days long. we did not include all the others in this issue. i do want to say a special word of thanks to don taylor of the duke, diane meyer of mount sign a, and all who contribute to the issue. they were healthy to have as with them. long-term care and health care are long-term issues. there also a deeply local and personal issues.

we also talked of a national perspective. we want to be conscious that help affairs is very much a local issue. we are very happy to have with us this morning from the d.c. city council, an independent council member of the d.c. council. he was elected in 1997. he headed the committee on health care for the council. he is also a member of various other council committees including the committee on government operations and the environment. we asked him to come today particularly because he has led dc's effort to make enormous and often ensung inroads into the insurance problem here in washington, d.c. he has begun to take on the long-term services and supports issue.

people from washington are as much a citizen of the country as anybody else and a deeply affected by these issues. let me briefly welcome to the podium to make some remarks from a local perspective, councilman catania. >> good morning, everyone. thank you, susan, for that introduction. this is an issue that is incredibly important to the district of columbia. yet 19 skilled nursing facilities. we have twice as many cmf did deficiencies at the national average. three homes are rate among the worst in the country. this is an area that has long been ignored in the city. we just sent only the quality of care.

do you measure quality? how you define efficiencies? a few components we are working on in kansas is a requirement for physician services on the premises. we found [unintelligible] we have found that the first thing that our skilled nursing facilities do is called 9-1-1. 20% if you live in the district, 20% of our pms calls in the city are to our 19 skilled nursing facilities. the average more than one a day. a few of the reforms we are seeking is a physician present at a minimum of 40 hours per week. we are looking at increasing the nurse staffing ratio per patient per day.

we are requiring expand its services on our side that include everything from a tie tree to dialysis. -- from podiatry to dialysis. we are making a huge investment in community based care. we have tripled the number of placement of our elderly persons with disabilities labor. we have invested more heavily in any jurisdiction in the country with community-based care. we have to make sure we reconnect our center with patients who are in nursing homes and has seen people checking in and not checking out without aggressive front end. we are requiring within 72 hours of its mission a conference of help analysis. there'll be discharge planning under way to make sure that if

the patient need to be there they will be there. if they do not need to be there, we will connect them with our epd waiver. we are looking at being very pro active in making sure that our nursing homes have no way out. if you are in the long term care business, we pay you a hefty wage to take care of our residents. it will no longer be standard operating procedure as a privilege. with restraint in not only our use of restrictive licenses, but strengthening our petition for receivership so we can actually assume control if we are not satisfied in the way we are operating. a few other items. we are going to be eliminating the use of restraints in the district. we are strengthening family councils and forcing a greater

care. we are increasing the standards for our nursing home administrators. we will test competency to make sure you can sit 3 class and absorbent. we are improving the way in which our community whichlbg community [unintelligible] these are just a few of our items. we have policies of every nursing home. we saw that some had no procedures. what we are undertaking in the

district is an effort to be the finest provider of long-term care. we have started this for steps. we thank you. >> as we can see, much remains to be done on why our issue is so well times. we will begin our first panel which is an overview panel on you is getting and delivering care. some of our audience are encountering these issues for the very first time. we sat -- we strive to set the context. we are going to try to do it today as well. i will introduce our three

panelists for our first panel. and then they will get up and presented their remarks. you also have copies of their slides in your packet. we will hear from stephen kay, an adjunct professor at the institute for health and aging and the department of behavioral sciences at the university california's san francisco. he served as co principal investigator at the center for personal assistance services, which is a rehabilitation training center funded by the national institute on disability. he is also co-director of the university of california at san francisco's disabilities to cystic center and a co principal investigator of the specific ada center. he is a ph.d. -- ph.d. from stanford. we will then hear from carol levine who is with the united

hospital fund in new york city. she directs the family health care project which focuses on developing partnerships between health care professionals and family caregivers. she directed the citizens commission on aids in new york city previously. she was senior staff associate of the hastings center. in 1993, she was awarded the fellowships for her work in aids policy. she edited a book called "always on call." she also co edited a book called "the cultures of caregiving." she has a personal experience with being a family caregiver, having cared for her brain injured husband for a number of years before his death. we will then hear from robyn stone, and the executive

director for the center of aging services. since she started the institute 10 years ago, she is developed a number of national programs including the center for medicare education, the better jobs better care of national program. she was a political appointee during the clinton administration, serving in the department of health and human services. she also was assistant secretary for aging in 1997. she is been a senior researcher for health services research and project hope center for health affairs previously. to begin, but welcome to the

podium. let's welcome him to the podium. >> people tend to view long-term care through a particular lands, depending on what they are interested in. some people focus on specific federal programs. they might focus on quality issues or workforce issues. they also tend to focus on specific populations of elderly. as carol levine said in her article, the whole is often eclipsed by a separate part. this article is an attempt to paint a picture of that hole, although i realize there are plenty of my own biases in it.

we include people receiving long-term care from public programs, from family members, from private paid workers, whether they live in the community or institutions, whether they are elderly or of not elderly, whether they are nearing the end of their lives or perhaps have a stable and live on disability. to do that we analyze data from five national surveys conducted by various federal agencies. for details, see the article which you have that is written -- which was funded by the national institute for research. how many people need long-term care services? that depends on how you define the long term care population. it can arrange all the way up to 11 million people if you

include people need help with any kind of routine daily activities. . . it is well known that women dominate, especially in institutions, where two-thirds are women. you may find it surprising that more than half of the long-term care population is not elderly. despite the fact that the vast majority of people living in

institutions are elderly. over half of the long term care population does not elderly, even if you define it narrowly. half of those live near or in poverty. who provide services to people who live in the community? as you would expect, a person's primary source considers -- varies with their age. parents dominate for adolescents and young adults. by age 30, the spouse becomes the dominant helper, followed by a daughter or a son. more often a daughter and then a son. that holds true until age 75 trade at age 75 spouses start to

decline and daughters and sons take their places. only by age 85 do paid helpers are really come into play. as you can see from this chart, and paid helpers' dominate for people of all ages. 9 tons of people needing help -- 9/10's people needing help get it this way. who pays for long-term care services? that depends on the setting. on the institutional side, medicaid dominates as the pair. usually with a substantial copiague by the resident or his or her family's -- copay by the

resident or his or her family's. for others, the resident pays all or most of the bill, which is typically $5,000 a month. medicaid is not a major player on the institutional side except for early in the nursing-home stage. on the non-institutional side, things are different. you may find it surprising that medicare and medicaid are nearly equal as the players. medicare pays for home health services after a hospital discharge. that sense of being a lot of the it services in the community. often it is the person and his or her family that pays primarily for services. this pays typically last, at $250 per month.

if people save money when they are hiring workers themselves by hiring an independent provider which not only saves them money, but gives them more consumer control in contrast to government agencies, nearly always use an agency providers. oops. how much does it cost. in terms of medians, there is a factor of five, the difference between the two. about $5,000 per month for non- institutional care services. the indians cannot tell the whole story. on this -- medians do not tell the whole story. this shows that base and long- term health services are almost always less expensive than nursing-home services.

nursing-home services hardly ever cost less than $3,500 per month. 87% of non-institutional long- term care services cost less than $3,500 a month. these are two very different populations. they are very different populations, but not as different as you think. the average number of daily activities that people need help with is 3.5, compared to 3.9 for people living in institutions. there are a lot of people with rather severe disabilities in both groups. 40% on the institutional side need help with five or more activities of daily living. they are different, but not as different as you think, and yet you have this factor of 5 ratio and cost. in terms of national

expenditures, we are getting an estimate of $147 billion per year and national expenditures. you can add or subtract $20 billion depending on what you want to count as long-term care verses non. more than three-quarters of that expenditure is for institutional services, even though, as you recall, institutional services are a minority of the long term care population. 80% of those expenditures go to elderly people. half of the long-term care population are elderly and half are non-elderly. before we conclude, i think this chart shows fairly clearly what we have a long-term care system that is out of balance. most are services that people do

not want. the services that people do want are often tightly rationed. i think it will be fairly hard to justify the five to one cost ratio when we find that the populations are not that different. we feel that the emphasis on institutional services for the elderly may end up the nine non- elderly people that need long term services their share of the long-term budget. we also think that there is evidence that most people do not seem to use paid help when they have an alternative. people cannot use paid help as a secondary helper. that turns out to be very rare. we wonder whether these considerations over the woodwork and fact -- effect, we feel that

these may be exaggerated. [applause] >> thank you. i am really delighted to be here. i wanted to thank susan and her staff for working so hard on this beautiful new special issue and the scan foundation as well. i also want to acknowledge david of the united hospital fund. they set the stage very well for this. nearly every discussion of long- term care and services is important.

informal care givers, family and friends are the system's back bone or bedrock. like bedrock, family caregivers, that is a term that we prefer to informal. informal sound so casual, so easy, so much fun. bedrock is underground. bedrock is invisible. when you start to see it, you may be a little bit nervous. that is what is happening in the policy world. we are starting to see these underground workers that are starting to appear and make some demands. families have always played an important role in caring for people that are sick or aging. in the past two decades, family caregiver roles have changed. in addition to funding social

support, many are now taking on demanding managerial tasks. managerial tasks are just as hard, if not harder than the actual direct provision of care. family caregivers as a large group are very diverse. some provide a little bit of care, some provide a lot of care. my colleagues are focusing on this. people with multiple chronic illnesses, multiple medications to manage, frequent hospitalizations, high-cost. at the end of the day, for these caregivers, there is no end of the day. the institute of medicine recognizes in its 2008 report, when it recommended that the definition of the work force be expanded to include family and friends, it also noted that it

was not clear how to integrate family into health care practices. one of the purposes of our paper and the campaign which i direct is to demonstrate that it can be done and give examples of how it is being done. there are models out there. let's try this. i am going back. i am sorry. do you want to get me back to where i was? sorry. next one. go back. one back. sorry. thank you. family caregivers confront fragmented systems. fragmentation exists within the system and even more between systems. providers work mainly in one silo or a sub-silo or sub-sub-

silo. caregivers move frequently between their rapid frequent transfers to acute, to sub- acute it to the family settings. we heard that this morning. home and community-based services are sometimes described as a patchwork of different programs with different eligibility rules. a patchwork suggests individual pieces sewn together to make a whole. community care is often the patches without the connecting thread. to navigate this complicated and still incomplete system come up family caregivers are to provide continuity as advocates and quality sentinels for people who cannot manage on their own. transitional care to next

healthcare and long-term services at a critical moment for quality, cost, and outcomes. there are no discharges in transitional care. the handoff is not completed until the patient is under the care of the family caregiver. there are several models like can be shown. this includes a website, www.nextstepincare.org that is designed to improve relations between hospitals. if it is also organizing an event in new york city in which 40-50 providers will work in partnership to improve the transition and care from our collaborative design group, six

months working with 14 providers. our biggest learning was getting people to prevent sending patients back and forth four years. they never talked to them about the process these. they talked about the locations, but not the process these. -- processes. the transitional care model is one of them at the university of colorado. andy care program at johns hopkins. there are others out there as well. our article concludes with some recommendations. we want to encourage and develop information about caregivers, not just in their psychosocial state and what they do, but how they interact with

the health-care system and the social services and how those things could be improved by bringing them together. we believe that working with family caregivers in this current and future environment house to be a core competency for all health care and social service professionals. this is not something that is intuitive and can be caught and -- can be taught and can be learned. we want full integration of family caregivers and medical homes and transitional care programs, and not just by name only, but by explicit attention to what the family caregivers need. we want to encourage creation of payment schemes which includes the support. policymakers are often moved by family caregivers valuable stories.

the story is supported by the practitioners must be translated into specific policy actions which are family caregivers. the health-care provider and policy-makers and join forces with their combined efforts and can be a positive force for better coordination and integration of all of the elements of long-term care services. [applause] >> good morning, everybody. but also want to thank susan at health affairs, bruce chernof, and all of us collectively for putting together a fabulous volume.

it is pretty cool to have the first long-term care services. i said that this was a bastard child and now we are in the forefront. quite only have a few minutes to talk about, what i think it's a very important issue, probably the most important issue in all of this. if i start with the caveat that the article that i did with mary, to husband around for a long time, we focus primarily on the providers providing services to older adults. that is not to say that there are not other substantial issues for the provider community for persons under the age of 65. most of our work has been done

in the area of caring for the elderly. the literature is much stronger in the caring for older adults. there is work and needs to be done caring for the younger populations. i wanted to start with one other comment. that is come up who provides long-term care in many ways it depends on your definition of long-term care. we will never reach a consensus on this. what we have recognized is that the long-term care, -- a term services and support, formal service sector is somewhat unique, but embedded in the larger health-care sector. somehow, we have to struggle and figure out how to get a enough attention in that part of the

service sector that it begins to get parity, not only with other industries, but with the larger health-care sector itself. i will talk about that in a minute. it is important to understand that medicare may not cover a lot of long-term care, but it covers a lot of post acute-care. sometimes we talk about it as long-term, sometimes we talk about it as acute. whether we want to talk about it as long-term care or not, it is the long-term care providers that frequently have to deal with these issues. next in the family, they are the folks that are embedded in this mess of service providers across the acute, primary, sub-acute, primary, and long-term care sectors. they are really key, next to the

family, and holding this fragmented system together. in the long term care sector as opposed to the acute, and primary, and ambulatory care sector, they are primarily the hands-on care system next to the family. at least 70% of all services are provided by your front line. in your personal care workers. this is different than the acute-care and the primary care world. we have a much heavier a bubble of professional staff. the professional license staff, while fewer, have substantial managerial, clinical oversight and hard-core clinical and support of work that they have to do. these are the medical directors, the lpn's your licensed social

workers, and the administrators. as you heard, where i live, the problem with the d.c. nursing- home is, it is the people, stupid. it is the people in these institutions. they have not been given the support, training, the ongoing support to do their work well. it is difficult to ask for quality when you have not supported the work force to do the job. it is a very labour-intensive field. one of the most labour intensive next to hotel industries. to not invest in our workforce and talk about a panacea of quality, comes without warp -- worrying about what people do every day is a mistake. we try to make the case that this is where much of the investment needs to be. this lays out a framework for

assessing work force reform in the context of long-term care specifically. with the caveat that long-term care blurs with acute care, chronic care, preventive care. it is difficult to pull those out. we have to look beyond traditional supply and demand theory. they do not work. we have a lot of demand for services. we are going to see a lot more that has not translated into more money, more investment, and the supply and demand. does not work in long-term care. a lot of the reason for this is that we are heavily dependent on the public sector. unlike other forces of the health sector. almost all of our pay comes from medicaid and medicare. we are dependent on the public hears. what they pay is what we get.

-- public payers. what they pay is what we get. our framework argues that we have to recognize the long-term care work force as a distinctive, but related part of the health sector. every time we work on health care reform -- health-care reform, health care work force reform, it goes towards hospital, ambulatory, and primary care work force. it has been an afterthought. we have seen this with the elder care work force alliance and the others that are happening. specific attention needs to be paid to this long term work force if we are going to develop this over the next 20 years, particularly if we are going to talk about the aging of the baby boomers. we have to be responded to new

philosophies and models of care. we cannot do better integrated care without the work force to do it. the social hmo, 25 years ago failed not because they cannot have an integrated system, if it failed because the people to not know how to integrate. it is the people in those models. it is the people that need to be taught and supported and have competencies around that type of service. it is the people in transitional care. an electronic medical record will never solve our problems in transitions. if it is about the people knowing how to communicate and share information and knowing how to hand off and take responsibility and be accountable. it is about developing that support and those models. it is about developing competencies. if we do not know what a medical director has to do or a social

worker has to do or a therapist test to do or a front line caregiver has to do in various settings, how can we expect those people to produce? competence is essential. the implications for a long- term health care work force are essential. we need to expand this. i would argue without the things i talked about before, without the investment, without the competencies, it is very difficult to expand the supply. nobody wants to go into long- term care. how do we turn that on its head? just as long term care is going to be the economic driver in the 21st century in most communities, that is the sector that is growing the fact -- and to growing the fastest. where are we going to get the work force to do that? investing in work-force development, this is a serious issue.

i want to say that we have to make these jobs more competitive. that is not just for the front line, which is an abomination in what we pay our front-line givers. if you look at nurses, if you look at physicians, if you looked at social work, if you did an analysis of the wages and pay and benefit the, there is no clarity across the sector. if you do not make these jobs more competitive, it will be difficult for us to create the work force that we need. it is the people, stupid. if we want to get the quality, if we want to support economic development in the 21st century, we need to invest in the long term care work force. thanks. [applause] >> thank you, all three of you, for framing these issues in an extraordinarily compelling way.

we are going to have some time for q&a for many of you in the audience. i am going to take him moderator's point of asking the first question. as per said it earlier, we have a major provisions of long-term services in the health care legislation assuming the enactment on at least one big piece. no money goes out the door to support caregiving for five years. we have plenty of leave time to gear up the system that will be able to execute the kind of support that the class act will extend to families. there are other provisions that will kick in sooner. the class act is a compelling goal to shoot for, or least the day in which the dollars

actually flow. i want to ask all three of you what you think the nation needs to do in addition of the legislation to get ready for this day. if we begin to think about the initial next steps the policy- makers are quick to have to begin to take so that we have the kind of community-based system in particular as well as a transitional care system that you can see the opportunity is supported by the formal legislation, where do we start? we will start with you. >> i make the case in our article and i will continue to make the case, that a least in part, it is a short and long term investment in the people that do the caregiving. that concludes if i was going to

write an article not our brown family caregiving. the family caregiver what have been included. the family is really the first caregiver. we are starting to see with some of the legislation, so i think it is just the tip of the iceberg, targeted investments in this work force to prepare them and to set a standard for attracting a pipeline. in the short term, we have to deal but -- with what is, which is incumbent staff and getting people in. in the longer-term, whether it is coming into play in five years when we see the expansion of a need on the older and younger disabilities side, we need to get that pipeline ready. our educational institutions and our investments are so ask

backwards in terms of preparing people to do this and supporting them with good wages, good salaries, and good benefits. at least creating a framework for that is important. >> i agree with rob and a lot. -- robyn a lot. too often that health-care workers can be perceived as, not enemies exactly, but working against each other. they are those absolute essential partners in this. we need to do more to make families and their health care workers work better together. i could never have survived 10 years of caring for my husband at home without the health care workers that i said.

in 17 years, i had five people. that is probably some sort of a record. it was not always easy, but we work at yet. -- at it. at all levels we need a recognition, not just in rhetoric, but in reality that the patient is not an isolating -- not isolating an individual all alone in the world. from every level of service it works as an individual and needs to involve the family to the extent that it is appropriate and possible. we already have two programs that are federally funded. why cannot we put more money into them? a family caregiver support program which is fully under

funded. one of the queries on my article, it was 2.5 million for the life span rest but. it seemed too low. it is too low. it is what it is. let's work to deal with but we have and then try to get people to understand that care coordination and integration of services is not easy. it is not something to say that we can give you more money and do that. we need to figure out how to do it on an operational basis. it is fairly complicated because everything is so fragmented. let's figure out the way that things can be done and make those accountable. this is my personal thanks. why do we not hold hospitals and

nursing homes and home care agencies accountable for the medicare regulations and the conditions of participation and that say that you must have a discharge plan in place, you must do this, you must do that. when i talk about having a providers, they looked at me and laughed. poor child, you do not understand. we do not have time to do that. that is regulations. why do we not make providers more accountable to do that? they just think it is not important. >> i can do a soap box, too. i wanted to say that i think the next policy step is the community choice act. i think the class act is good.

it will mean that middle-class people will be encouraged to be prepared to take care of their long-term care needs or at least have been subsidized at some point in the future. as i said, half of the population need long-term care services lives in or near poverty. i do not think that population is very likely to pay into the program. in any case, a lot of people need services now. as long as the states have optional and not required home and community-based services, they will do what is happening in california and many other states and the times of financial crisis. they will cut programs. they will not cut institutional services because those are

required. health care reform is the community first choice option. it is still an option. an option is not enough, at least according to my coat- authors and me. it needs to be mandatory -- co- authors and me. it needs to be mandatory. it incentivizes states to do this. good. maybe some states will actually do it. it is still optional. >> also want to commend your attention to two other articles in the journal. one is an up close and personal look into the lives of two cult care workers. a piece on the debate over the

class act that was written by a founding member. that is an entry point issue which attempts to shine a spotlight on a contemporary policy issues, one that has crept up on the agenda, long after we conceived the issue of health affairs as it is published. let's open it up to questions or comments from those of you in the audience. please introduce yourself by name and affiliation, that would be extremely helpful. let's get the microphone over to you. >> i would like to pick up on things that carol ann roberts spoke of. -- and rob spoke of. we are talking about care and

coordination when we are talking about the formal terrace side. we're calling about the need to train the staff at all levels. -- talking about the need to train staff at all levels. we need to train the staff and how to do teamwork. the only way we can do care well is through teams. the only ways they make change depending on the needs of the patient. and maybe informal care working with formal care. we know that these are formal combinations exist in the community. we do not have team work and we cannot train aides to do teamwork. if we do not train nurses to work in teams what they typically pass them in long-term care and to not do much else is the general approach unless it is an unusual place.

we need to think about teams and we need to think about training beyond clinical training and in terms of communication and prevention. we need to bring long-term care up into the 21st century and bring hit in to make all of this happen. >> are totally agree with that. at every lawful we need to understand what is needed and we need to train and support and reimbursed. everything needs to be tied together. right now, the incentives are not in line with a system that we would want. whether it is on the development of the workforce side or frankly, on the split between institutional and home-based services. we definitely need to have a

system that supports the concept of teamwork at the individual level as a microcosm for the way that we want the system to work. it is a real systems approach and the training and education that people get, if it does not move in that direction. long-term care more than other areas. it is so inter-disciplinary print -- the disciplinary. it is a model about how you could build an optimal system. >> what does that mean in terms of the individuals making the systems? >> probably the folks in the room that are from the various disciplines can speak better than high. -- than i. a licensed play nurse is what

they call me. most of our training is not in that direction. in addition to that, there is not a focus in specific places in the long-term care sector. it is the notion that somehow by osmosis, the focus on other parts of the sector will somehow translate into the long-term care sector. there are some competencies that are needed. there are some that are generic. we need to figure out what both of those are. in the under 65 population, there is almost no literature, except some work that has been done on the support worker side. we are a long way from having an educational and training and support system that provides the framework for a system that we keep arguing that we want

quality. it always seems crazy to me that if it is sold heavily human capital oriented that you would not have the investment in the human capital and ordered to make that happen. >> another comment. let's take that here. >> this is bob. you said that the institution can be non-institutionalized had roughly the same needs. that is a quantitative difference. is there a qualitative difference that might require greater services? >> i am sure there is in ways that i cannot tell from the data. i can tell from the fact that certain kinds of interments are more likely to be present in

institutional settings. i do not know what in particular that would raise the cost that much, so i have not quite worked that out in my mind. >> some of the costs are room and board costs, which you do not have a community-based setting. some of us have argued that the act gets to this. we have an entitlement in nursing home care which is an entitlement to room and board services. we do not have a similar entitlement on another side. the failure and growth and assisted living has been that there is no real investment on the room and board side. there is only an investment on the server side in this program. you are not really comparing apples with apples. that is part of the problem.

the big chunk of shelter is only addressed on the nursing home side. that is a big part of the cost. if we are going to be honest about this and talk about the community-based infrastructure, we need to talk about the shelter piece of this. we do not put into the cost of what people pay out-of-pocket. their mortgage and their property taxes and whenever. they are paying for the room and board over their head and then the services are subsidized. we need to get at what the true costs are. >> we will take one final question or comment back here, please. >> thank you so much. i am a dietitian. this is a very exciting issue. and most of the literature that

i read, and never see the word dietitian. we deal with people's basic needs. i hope the when you talk about the work force in the future, you will, registered dietitians. i hope that you have a group that focuses on health and aging and there are several hundred dietitians, thousands of dieticians working in long-term care. we are looking at non-nutrition. we can see when someone is failing to thrive and point that out to the doctors and nurses. we can be a team member. we are dealing with issues. -- term care is not sexy. they note that the agent group is, how do we get entry-level dietitians to come in the golan to something more glamorous? part of that is work-force development.

>> we will work on making long- term care sexy and the next edition of health affairs. we will give it a shot. what we have heard on the first panel is that we have a long- term care system of balance. we have heard from carol loving that we have patches in the long term care -- carol levine that we have patches in the long term care system. if they say that it is the people, stupid. the investment in the people will be the key part and what makes it better. thank you very much to our first panel and to the authors for their contribution. [applause] it is my great pleasure to introduce our next speaker. she is a policy director for disability and special

populations for the u.s. committee on health and pensions. she has been the lead democratic staff person, the lead person for the class act designed to help adults with severe functional impairment obtain the services and supports that they need to stay functional and independent. she joined ted kennedy's office in 1996. if she was the senior policy analyst in the office of the assistant secretary for special education and rehabilitation services at the u.s. department of education. while working up the department, she was the fellow of the coordination for children with disabilities and served as the liaison for the secretary of education and all areas related to help them children, including representing the secretary of health's interests.

we are fortunate that we have a new health care reform debate. we are fortunate that long-term care is a part of the debt. we are delighted as all get out to welcome you here today, connie. [applause] >> thank you very much. thank you for making this issue a priority in this debate around the health-care forum. this is a tough, uphill struggle. i want to thank everyone in the audience who has worked so hard, from a family point of view, to make sure that long-term services and support stays on the agenda for long-term health care reform. i have an article that i wrote. i am here to talk about an idea and a vision that came as a result of a lot of work with senator kennedy that began back

in 2003. i will stall a bit of this notion that we had a five-year resting. in the bill. the will give you a little bit of why senator kennedy felt so strongly that this was an important issue. we had a trip up to massachusetts at the end of 2002. we went around to the western part of the state. we did stop that in number of nursing-home said and assisted living facilities. he came away with a couple of funny things. one is a joke that he told. i am not sure if it is a joke or something that was true. she told me the story as we were dropping into the parking lot of a trip that he had made with one of the presidential candidates are around the state. he got into one of the nursing homes and visited what

everybody. when walking up the door, he stopped to talk to three older gentleman who were playing cards at a table towards the front door. i am not sure what he was staring at them for. he did not recognize them. if he said, do you know who i am? he said, no. the lady at the front desk and those who all of us are, she will tell you. he thought that was the funniest thing. there was not a time that he told that that he did not break into laughter, whether it was 2002 or later on. it was a very high-opening trip for sen. he has -- i opening trip for him. he had watched how important -- eye-opening trip for him. he had watch how important it was.

this is the cold core piece of this paradigm as they were trying to put out there as a new idea ted you either have to throw it out there and see how it works or you'll never try it. in the development of the long- term services and support system, it is for individuals over 65 as well as under 65. we look very carefully at the marketability of that. we look at the connection that we will never rest this idea of long-term care. it will always be long-term services and support. it takes me back. i have a very good personal interest in this. i have seven kids that i have. the one i do have that is disabled. i know what it is like to not be able to get here until 9:00 in the morning because she has no transportation to work. as a practicing nurse

practitioner, i know how important the staffing issue is. if she is absolutely correct. it goes back not only to the philosophy of where we are in this country, because it is not the same in european nations and terms of the value system of taking care of your arm. if the other system is the educational system. i remember the first time in nursing school when you went on rotations and you go to a nursing home trade when you get hit with is how awful that particular rotation is. you hear it before you get there. you walk in and everybody says you have the bedpans over here and this is the water sank. i had been a candy striper up in philadelphia before i went to nursing school. if it is the only job i got fired from. the reason was i did not have any brothers. i have four systems -- sisters.

i filled the water pitchers. i did not know the difference between the water pitcher and the urinal. i filled the urinal with ice. there was a tremendous greene became part of this gentleman's broome. -- a tremendous scream that came out of the 10th man's -- this gentelman's room. any experience i had in that arena, it was never positive. it was almost like what happens to p e teachers when they get stuck with the special education kids. it is always dp class that the teachers do not want to have -- the pe class that the teachers do not want to have. it was what it had with his

mother with rosemary. that was not the way that individuals with disabilities in this country were looked at. on the other hand, he saw his mother struggle and how hard she struggled with the dignity issue. it was not about nursing homes being a bad place, it was about a better trust for her. living out her final days in a place that main memories for her. everybody in the hospital still wanted to stay there. we drew straws on who wanted to cover christmas eve and christmas day. when you did it, you felt like to make a difference. nobody wants to be there. people want to be home. if it needs to be a continue one that works with what ever is important to that person. we try to develop a model that was a choice model. it was the beginning of a cash model. if people had a choice to do

what was important to them, if not was -- what was important to us. the other piece that was very difficult was that we were spending an enormous amount of time on disability and why is it in this country that the number of people that we have with functional limitations, number of people that we -- qualified with people being poor have to be significantly disable before they can get what they need. why do we have a reverse incentive that this is what we force people into. it does not matter where they are in the continuum of life. if you are poor enough, you can qualify for medicaid. if you are really poor, you can qualify for the nursing-home benefit. why are we doing this? we took it all of the way back. i ask you to think probably about what we do in this country

in terms of public policy. if we did what we really do it in terms of forces. i go back into that room and the gerber baby is not the gerber baby anymore. the entire family is turned upside down. what happens when they leave the nursery? but happens when they cannot get an education, a job, a house? what happens to the family we are speaking about? that young person becomes an older person and they have the same functional limitations. they just happen to be a different age. we set up public systems where you have to be poor, if you have to hide your assets under the mattress. we have to do something with grandma's money. that is when we put people -- what happens when we put people for a general responsibility -- responsible people. the amount of tax dollars is a

lie. what happens when the boss does not come anymore? the first day of the school year, up to get a social security flyer. there is not enough support for young people and disabilities to get the job. you are seeing the crisis of a large number of young people who are going to be living with the implications of the autism sector, more than you even know. we have medicaid and social security and watching tv. these are in addition to the kinds of services and supports that we need. it becomes much more of a medical model. it should blend together. i heard a lot today that deals with the aging population. for this particular piece of the health care, for us, it does not about that. it is about the functional limitations that anybody has. how can you merged this

population and the investment populations together so you can create a system that works together. there is not a person in this room that can guarantee what they will look like 24 hours from now. we have not internalize that as a guy you system in this country. that goes from the education that people get, the value where you put your money, and the value and a long-term system. i had learned what a tough issue this was and continues to be to get on the radar screen for a variety of reasons. it is not global warming. short of dying, this is going to be me perianth this is the heart -- this is going to be me. this is the hardest part of the negotiations.

we had to keep it a voluntary nature and try to make it as close to a 401k opt out. how could we make it simple so it was not complicated? you could do a cash model where is your money. it is not the taxpayers' money. it is different than the poverty case model. this is an insurance-based model. these are the principles, these are the policy objectives. to work with people under 65 as well as over 65. we want that allegedly -- eligibility to be about function. even if it means being in assisted living and having the extra kinds of supports that you need to function in your day there, or in the nursing-home if that happens to be where you need to be.