respect to drugs, i would say two things. john, who is at the table in a lot of the bargaining and discussions, may have a different view. with the device tax, it was clear that that was done, not with the fees on the pharmaceutical industry was part of a negotiated settlement, so to speak. so that might be less likely to be undone, and the industry might be less likely to go to congress. remember, we will still have a democratic senate and democratic president. those were the two parties that drove the agreement. i think that is probably less likely. what i would say is that there are a number of provisions from the past, and one of the things the pharmaceutical industry was

able to do very skillfully was to keep out of health reform a laundry list of things that could have hurt the industry more. at the one open question is whether some of those things, particularly given republican control, are now may be back on the table, the sense that there might be democrats in congress who might want to do it. there might be new republicans that have different positions than republicans in the past have had or others are in the name of deficit reduction that might be open to ideas that they might have for" the past. for example, use of the deficit commission's proposal earlier this week that proposed to extend the medicaid rebates to the low-income population in the medicare program. some may be in the name of budget-savings and others, there might be more recent activity to those ideas, even in a congress that is not divided. >> this is john rother.

it is significant that the ceo of glaxo came up calling for health reform to go further. i agree that this was a negotiation in which the industry won quite a few concessions. if this issue is reopened, i believe they may end up doing worse, particularly in light of recent price increases that will look unappetizing to anyone concerned about the deficit and the cost of health care. if they reopen this, i think there will be more pressure on the industry rather than less. >> this is norm ornstein. always keep in mind that we're in a time of populist anger, which always happens with a bad economy. it is the search for scapegoats. it is a delicate time for almost everybody in the various

industries. the danger that you will be labeled the next scapegoat, that you or the greedy bastards sticking it to the american people. it is not necessarily happen because you or the greedy bastards. sometimes it is because you're the first ones i of fire. to some degree, that is what happened in the health insurance industry. -- sometimes it is because you're the first ones in the line of fire. they push them off, and sometimes it is deserved. but you can lose allies in this process that helped to get through this if you're not careful. the pharmaceutical industry, i think any objective observer would say, quite well on this. they were smart to get in early. they got a lot out of it. flack was taken from many in the industry because they thought he did not understand what he was

doing. i have a hard time imagining that they would be foolish enough to reopen this. >> i am with the fiscal times. you raised the possibility that there could be some tweaks from the president, and he said that they may look at the 990 issue in terms of small businesses and filing forms. are there some other things, and i am thinking about the mandates that democrats might decide might be worth taking a look at -- this is, after all, an economic issue in which the insurance industry is the primary beneficiary. if republicans push for repeal of the mandate as a stand-alone bill, is there a possibility that some democrats would actually do that? i do not forget, president obama as a candidate obama did not actually back the mandate. >> this actually is one of the

biggest problems to start with that republicans have. the temptation is going to be to god to the mandate. it is the least popular. americans do not like mandates of any sort. but you cannot do that and keep the other provisions that are popular without having a lot that unravels. and you may be right. some democrats might join in, partly because of reasons of mischief. the insurance industry would be the first up to the plate saying you just cannot do something like this. but looking at the mandate and making some adjustments, including looking at whether the penalties for not getting insurance are adequate to the task, maybe in light of the massachusetts experience and others, that is something that you may want to start to look at now, even before you actually implement it and to oversight. >> i have a different political take. i think that the mandate is a

bigger problem for the democrats in the sense that if republicans, in a general, do not want the legislation to work, i am not sure why they would care. one of the provisions that is unpopular unravels the entire ball of yarn. i am not sure that there is as much risk. it may give them an opening to come in and do something more to their liking in the future. i am not sure there is the huge political risk, except to the extent that it may raise costs to the current structure. but they do not buy into the current structure. i think there are some other things in there -- we talk about the individual mandates. that is essentially a tax- enforced. but there's also a series of corporate taxes in here, which are not quite a mandate but they pay or play kind of requirement, even for those employers offering coverage. i think those are going to be at the heart of some of these

oversight hearings. what are employers doing in response to taxes in the future? or maybe a penalty that is less than keeping their coverage. you have seen as a wit retiree coverage and limited benefit plans. then might be another area that might be vulnerable. again, the president may veto it. but where you can see in the name of corporate tax relief and overall cost of doing business where there might be attempts to go after those or to loosen restrictions on things that are constrained to an extent in the law. >> john rother. i do not think the insurance industry is the major beneficiary with the mandate. it will get tighter over time. i think the people who really win because of the mandate our older people, sick people who are excluded today, people who are suffering because of the

failure to bring everybody into the same pool. if we eliminate the mechanism to do that, we are going to have a difficult time protecting the people we most want to protect. >> this is norm ornstein. i think what i would be afraid about if i were a republican is if you go on after that provision and it unravels, that means that you take away the popular parts of the bill that people are looking for, and you're the ones who did it. there's a little bit of a danger there. it could unravel in a way that causes some level of chaos, and it will be pretty clear what caused that chaos. >> would it unraveled quickly enough to happen before the 2012 election? >> well, some parts of it could. this bill was designed for a variety of reasons of course, to try to provide some goodies before the disruption occurs. you can imagine that just as we

saw with the shutdown at the end of 1995, you can make sure that it is causing pain to people in a way that there's a direct connection with the actions that immediately preceded it. >> there is one thing we have not touched on either, which is the state lawsuits that are going forward. i think initially, there were a lot of smart legal scholars and others who discounted them. but a couple of those cases are still alive. the one thing we did on no -- the courts are in an unpredictable place. you may well see the results of those lawsuits having some impact on how these are written. i think that would be a nightmare kind of scenario for the president, too, to have to use the outcome of a court case to be thrust back and have them

have to defend it. i am sure we will probably see the larger repeal after the first, and it may be that republicans wait for the outcome. i am not sure that will, but they might wait for the outcome or at least more clarity. i think we cannot discount the potential impact of that those might have, too. >> this is norm ornstein. i agree. i think we should all be looking ahead. here's one substantial possibility. whatever happens at the district court level, this issue is going to the supreme court. we know that. and the part of the bill were the constitutionality is most endangered is the mandate. that is the core of the constitutional case. that is an overreach of the commerce clause to force people to do things that they do not want to do. there is a strong case to be made, especially given the burden for those who do not have

insurance falls on the rest of us because that adds to the cost of health care that the rest of us have to pay. but i can imagine this scenario where a 5-4 vote in the supreme court with the predictable 5 overturns a major act of congress, an initiative to the president, that takes us right back to the court of 1933, 1934, 1935. and a constitutional confrontation, in a way, that hasn't predictable outcomes. not just in terms of the policies, but the politics. the idea that a slender majority reflects this in the court will be portrayed in a political arena in a way that goes beyond what happens to the health care bill. >> this question is from sarah with politico. it gets back to something norm and dean have mentione

and that is the notion of the potential shutdown of a government agency, like hhs for example. mitch mcconnell has said that it would not come to that. but she is curious if you think the influx of new members who want to repeal aggressively could lead to this kind of the situation? how likely is it? >> well, this is dean rosen. my view is that i do not think it is likely. but like everything else in a divided government, in my possible. one difference i would permit -- i would remind everyone in the last shutdown is that republicans controlled the house and the senate. this time, there may be more attempts to work things out out

of necessity. before it gets to the president enforces a shutdown, you'll have some agreement between the house and the senate with what they're sending on pennsylvania avenue. i might answer and use a broader view. i think one called not for the whole discussion today is that almost all of us in the room are focused on the health-care issue. and going back to the less than that i think democrats have not quite got it out of this election, which is it was about jobs and it was about economy. norm said this earlier. so health care is a very clear example of thwhat voters were reacting to. it is not the only thing, and it is probably not job one. we have to remember that. as a result of that, i think leader mitch mcconnell and others had one of was a great

deal of humility coming in and saying that we have to remember this election was a referendum on the president and not necessarily a vote for the republicans. so in the same way, i think republicans, while they need to raise this, keep it alive, and do what they said they are going to do, are going to have to balance the need to not focusing on the entire next congress on health care and having to vote every single day on that issue because they're also a lot of things that are not directly connected. >> this is norm ornstein. there are a few potential scenarios. mr. with what it was an extraordinary comment from the likely incoming speaker john boehner on election-eve. he said to members of the president sets the agenda of the nation. either he has read his constitution -- either he is not read his constitution in a while or did not get a great civics

education in ohio or he has a different point in mind. because the constitution says congress sets the agenda and the president disposes. but we're going to get into kind of an elaborate blame-shifting game over who is actually in charge and who is responsible for some of these problems. and we know that republican leaders are trying to downplay those expectations, not just for the public at large but for these new members coming in. they want to manage the new members rather than have the new members manage them. they do not want government shutdowns because usually the president has the advantage under those circumstances. but this fiscal year that began in october, not a single appropriations bill has gone into law. we have one that expires on december 3. it is not clear we will even get through the lame-duck session. the move that into january or february, and you are going to have a lot of con nations, determined that new members who want to immediately take a meat

axe to spending. that you keep these levels going for a substantial amount of time is not something they're looking for. that is one place to look for potential shutdown or destruction. and the debt limit, this ceiling will get reached sometime around march or april. we already have a stand -- a substantial number of new members who say they will not vote to increase the debt limit. and others have said the only way they will vote to increase the debt limit is if we have already radically cut the size of government. that is what precipitated the shutdown at the end of 2005 -- excuse me, 1995, and it might come much earlier. and then we get the issue of health care, which is not the dominant issue. dean is absolutely right. but as an attempt to use the appropriations process to limit the funding, limit the spending for implementation of different elements of the plan. you'll get a labor hhs

appropriations bill that might move through the house on that basis. it will not move through the senate. so you move to a conference committee. the democrats in the conference are not going to yield on that one. they will not let the plant stopped dead in its tracks because no money can be spent to implement it. more than likely, the democrats in the senate will then put through a continuing resolution for the labor hhs bill, we will keep it going until we can resolve it. i can imagine republicans in the house saying we're not going to cave on this one. this just means that we will be able to keep going at the same level. well, you could get a shutdown of hhs and a number of other agencies. and if it was managed as cleverly as clinton managed to the shutdown, the people who really wants are the ones that get disrupted. we could have some very interesting politics at play. a lot of people who do not want a shutdown may be forced to

singspiel on their own individual control or because they cannot control their own members and to actually having one. >> good observations. the gentlemen here would like to ask a question -- she has the microphone. i am sorry. >> i am with the huffington post. some of you mentioned that the proposal that was released on wednesday, which calls for capping growth in federal health spending. can you speak to how this proposal might affect the future of health care? >> overwhelming response. >> this is norm ornstein. it is hard to say. keep in mind, it is not the commission's proposal. it is the chairman's mark right now, which in part may reflect the fact that they do not have 14 votes at this point for anything. it would be minor or maybe even

a major miracle if they ever did get 14 votes out of the 18 members of this commission who really do spanned the entire political spectrum. but there are a few things about it that are striking. one is an attempt to put a cap, a percentage of gdp, on a spending. the other is that it basically excepts the health care plan and moves to make adjustments from within that. that is one of the main reasons that some of the republican and conservative members of the commission and people outside have been critical of it. within that, it also tries to take some of the provisions that are in the bill, designed to bend the cost curve, and tighten them up and make them more firm. from that perspective, i would view it as a very constructive approach. it takes some things that perhaps were not as tough in the bill as they could have been and made them tougher. but there will be a lot of people who do not like the approach to health care, who do

not like the idea that you start by accepting the status quo. >> didn't i see some more in their a public option? >> that is a part of it as well, yeah. >> that should say it. >> i think norm is right about the fact that it probably will not make it out of the commission but i think the one thing to watch is that just because it does not get a supermajority vote does not mean that these ideas are dead forever. you look at the medicare commission that came out of the 1997 balanced budget act, and some of the proposals there, including the drug benefit and some of the competitive elements of medicare, raising the premium, and other things were things that lived on. and a number of legislators w participated in that became invested in those ideas. for this, it is hard for me to see this all hang together. one of the fundamental flaws,

probably from a number of republican standpoint, is that it does not deal with some of these other things like speeding up things but does not deal with things like should we be expanding medicaid to 133% of poverty and tacking on a $1 trillion of subsidies for health care spending at a time of fiscal concern. i think that will be an issue but on the democratic side, you saw some people come out in opposition already. it will be interesting to see whether some of these ideas of caps and other things on a macro level do continue to be a part of the debate. >> i would like to add on to that. one is you cannot deal with the deficit without dealing with health care long term. health care is the problem long term. and the sooner we get serious about it, the better. the affordable care act made

some important steps. but it is by no means the whole answer. so i do give the two cochairs some credit for at least not in decking on the issue. but i do object to the specific proposals, particularly the ones with cost shift more on to the beneficiaries. it does not do anything to lower the burden of health care. coupes fromfts from pay taxpayers to those that are sick. -- it just shifts from toupees from the taxpayers to those that are sick. i think credit should be given for being willing to take on health care, but i really think they made a misstep in how the recommended doing it. >> we have this gentleman.

>> hello. i am david from tax analysts. i wanted to follow up on something you quickly discussed earlier, and that is the 1099 filing requirement. the president has indicated a willingness to revisit it. do you anticipate anything being done about this in the lame duck or in the 112th? >> that is a goner. the interesting question that remains is how to place the revenue. it is not clear how much they will be able to do in the lame duck. they're already talking about narrowing the focus. there's some big issues that will have to come up because harry reid promised it did during the campaign, to bring up the dream act, for example. there are some other things that are very close to the finish line or there has been broad support. the safety act, for example, and

maybe the disclose act. they would like to do this one now. the witches' like to get something that is widely viewed as not just off the table, but they have to find some other funding source for it. i have not heard much on that front. >> ok. yes? >> hello. i am with the american medical news. this might be a good closing question. the republicans played the role of the minority much of the last congress. can they still do that leading up to the next elections or do they actually have to produce some results to justify having more numbers in 2012? >> actually, we have a couple of models here that are going to be interesting ones to see which one actually prevails. one is the 1995-1996 model. that is a model where republicans started, having been

swept back into power for the first time in the house in 40 years. newt gingrich viewed himself at the beginning as a parallel or even replacement president. we saw a year of confrontations, of acrimony culminated in the shutdown and the blow back. and then basically a year of harmony and cooperation. newt persuaded his colleagues that their primary goal was to get a second consecutive term in the majority -- and the majority of the house. of the men working with the president and making things better for him, so be it, and they won. -- if that meant working with the president and making things better for him, so be it, and they want. the other model is basically 2008. democrats to back the majority in congress in 2006. we had a couple of years were not much happened. it was the democrats who pushed proposals out there. they were either filibustered in the senate by republicans or vetoed by the president.

but the unhappiness over a lack of significant action continued to focus on the president, and it was the president's party, despite the fact that the other party had congress, that suffered massively in the election. i do not know how this works out. my guess is that we may find a third model developing, and it may be one where voters say, for the fourth time in a row, take all the ins and bring them all out and take all the outs in. it could be were the president praised the republican party in a split congress like the model from 1948. harry truman, after republicans won massively, 55 seats in the house, taking the majority in 1946, bridge rhythm as the do- nothing congress. he won the election -- portrayed

them as the do-nothing congress. he won the election. and then they lost so many seats. it depends on what happens with the economy. a. it depends on the leadership. whether obama can fend off his own left is because they're challenged from their base in the primaries. they have weekend in that sense -- ty have weakened in that sense. it is an open question as to republican leaders and whether they can fend off the rottweilers on their right. that will be another challenge. dd -- i willjust a just add that there will be a number of proposals from the house, and this is one of the reasons that i began with the importance of how you read the election mandate, messages, whatever you want to call them,

and i think one of the clear lessons that came through is limited spending, limited government. one of the advantages for republicans of the two-party being so aggressive and animated and the candidates are running within the republican party wasn't helped to sharpen the focus of the message -- was that it helped to sharpen the focus of the message. they will vote disorder once a week to trim the size of government. i agree that there will be this balancing act, as there is with any leadership. just like the democratic leadership. when you have the majority, it just means you have a more diverse caucus. they will have to deal with that. i think it will be interesting to see whether some of the proposals get blocked by a democratic senator or get vetoed by the president. i would say that much of that has to do with how the president either forces the issue or

reacts. at least from what i have seen the last couple of years, i think that this president is a very different president then either president clinton -- and i was not around during the truman administration, but it will be interesting to see how he reacts to this lesson as well. i think republicans will try to force legislation using the house or the do have a majority to try to put forward with a view as responsive to the electorate. >> just one footnote. every elected official is going to be judged on one thing in two years, and that is whether they helped get the economy back and help people get jobs back. if that does not go well, i do not think any of the rest of this really matters. so let's get real here. health care is not going to be the main reason people are elected or not the next time around. that is going to be about the

economy, and it is going to matter a lot who looks like that they have been constructive and who has not. >> and i will say that i think it is worth remembering that the two parties have a very, very different definition, even on the jobs, on what the response is. i do not think what we will see this time around is republicans agreeing that the way to "get the country moving again or creating jobs" is by spending a lot more government money to do that in the form of stimulus or other things. i think there will be proposals, but it will look very different from what the democratic congress has done and will have to do with things like lower taxes. whether there's any room to meet in the middle of those will be an open question. >> i have one rosy scenario. i can actually see an agreement on the stimulus package that uld cut across the lines. the agreement that i would imagine is one where we set up

an infrastructure bank, a public-private partnership. it already has brought bipartisan support. it is the only way you'll get an infrastructure that the business community really wants to invest in. and couple that with the payroll tax holiday. you could get broad support for something that might or might not work but that would not just have dramatically contrasting views on how you deal with the economy. whether any of that works in an economy that i suspect will continue to move slowly, just because that is what happens in a financial crisis, it does not create the kind of recovery and job growth that you have and if this is a traditional recession is anybody's guess. >> one more quick question. >> yes, america city business journals. i have a question on the 2012 election as well. going back to what you said in

the beginning -- let's assume the president obama loses the reelection and there is a republican president. let's assume that republicans control both the house and senate. but also assume that in the meantime, health care reform has proceeded according to plan. what would that happen in 2013? would there be a full-scale repeal? would they roll back what has already been done? how would that play out? >> how is your vision around the corner? >> let me rephrase it, what would president romney do? i think we will have a president romney. but under that rosy scenario with republicans in control of everything, i think that, you know, two years is a long time. but the depth of concern and

opposition to the current health reform law is hard to overstate within the party. you can just look it at what all the candidates ran on. i think there will be attempts to scale back major portions. again, i will remind folks that that does not necessarily mean for republicans that there is no health reform, that there's no subsidies. i think that would be the case of the president will try to make. but if you look at the proposals, they have been for insurance reform and medical liability in some of the other things. you can debate those ideas and whether they work and whether they're popular or not, but they do have a set of ideas. my sense is that they would try to replace those ideas for the ones that are now on the table. i think that the challenge that

they will have politically is if they are in the majority. i do not know how the issue makes will change over that time. but at least right now you have this resounding message about spending. therefore, i think it makes it easier to portray a significant medicaid expansion, for example, at a time when states are already under enormous fiscal pressure as something that if you were to repeal that expansion or scale it back, as something that could be done in the name of fiscal relief for the states or something to address the deficit. but that will be a message challenge, and there will still be a great need. obviously, people who do not have coverage and need subsidies have lower income. so what the alternative is becomes important. the repeal part, in some ways, is easy. it is the replace parts that

becomes the challenge. i would take the republicans at least at their word. while two years is a long time, i suspect that they would look to continue the effort to repeal it and replace it with something else. >> let me take a crack at that. we already see that issue playing out on the republican side with a number of punitive candidates ripping into mitt romney for the massachusetts plan. and we have an overly. i would view the great irony. i viewed that act as an amalgam of romney care and the moderate republican alternative to the clinton plan in 1993-1994. this is a moderate republican plan, or what used to be, with a group of people who are now under the endangered species act, i suspect. but it will play out through the primaries. what we also know is that in the

process of going after the democrats' plan or obama's plan and what we're seeing now is we have had republicans move into the position of not only defending every dime diplomatic care spitting into perpetuity but also defending employers in the carriage the they're not providing it to people. the plan and john mccain put on the table has been the core conservative republican plan -- the plan that john mccain and on the table has been the core conservative republican plan. it turns the tax deduction into a voucher and then let people go out and buy insurance. it is moving away from the employer-provided system. there are a lot of good reasons to want to do that. but i think what you're going to find is that repubcans, the process of trying to block or discredit the obama plan, have boxed themselves into a corner in terms of what alternatives

they can pursue without creating a very significant blow back. probably the most efficient way you can do things -- and if you notice the simpson plan, it deals with taxes by broadening the base a dramatically and removing that tax break and dramatically lowering rates. that is out on the table. it is probably good thing to do. a lot of people said that if you step back objectively and create a new health-care system, you would not run it through employers that have no expertise. but when you' out there saying that with the obama plan is going to do is remove that precious, wonderful employer- protection, how do you move back into that? i think you find some struggles of the beginning of a republican-run government to figure out what approach they would take. do they go with what they really want to do? which contradicts what they have

been saying the last couple years. or do they go with some incremental changes, the kinds of things we're seeing out there now? allow insurance across state lines, provide subsidies and vouchers here and there. it is not an easy place to be. >> and we're going to convene these three gentlemen two and a half years from now to follow-up on this conversation and find out which direction that this rosy scenario in either direction might take. let me thank you all for being here. thank you to those watching and listening around the country. a special thanks to our colleagues at the robert wood johnson foundation for making it all possible. i ask you to join me in thanking our panelists for a really insightful and mind-stretching with the future of the health care reform plan in the 112th congress. [applause]

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>> there are 24 new state governors after the midterm

elections. 16 republicans, seven democrats, and one independent. alabama is replacing a republican with a republican. robert bailey takes over to the term-limited governor. he was formerly in the state house of representatives. in california, a former. -- jerry brown takes over for arnold schwarzenegger. mr. brown was governor from 1975 to 1983 and is currently the estate -- the state's attorney general. "book tv" swiss weekend. the 43rd president, george w. bush, on his memoir. as the former president discusses the critical decisions of his administration and his personal life, live from miami- dade college, sunday at 4:00 p.m. eastern on c-span2. this weekend, c-span3's american history tv visits the eleanor roosevelt papers project to learn how she is the media to

communicate her ideas. in michigan, we will see how very different thing american and british leadership worked together to defeat the nazis. in a conference for the one of our 50th anniversary on the civil war. and like saturday, november 20, a daylong symposium on the civil war from the national archives. prominent historians discuss the domestic and international and packs of the war. american history tv, all weekend, every weekend, on c- span3. the national transportation safety board has been meeting in the nation's capital to talk about car safety and whether anything different needs to be done for aging drivers' speed up on this morning, "washington journal" talk with the chair of the board. will show you a portion of this week's ntsb said the discussion. -- safety discussion. host: on your screen is deborah hersman, the chairman of the

national transportation safety board. we will be looking at the safety of older drivers. we actually divided our phone lines for people under 70, and 70 or older. it is a very common dividing line when you start talking about older drivers. if you are under 70, you might have parents or other relatives that you face this issue with. the numbers are on the screen. for those 70 and older, those having questions about driving safety, they have a line as well. let's start with some statistics. first of all, the number of drivers that is the baby boomers age sadistically will go up exponentially over the next 20 years -- statistically will go up exponentially over the next 20 years. by 2013, the no. 6 -- by 2030,

the number is expected to be 57 million. and the other no. i wanted to show is how they crashes that people are involved in. if there crash numbers are coming down, why are you concerned about this population group? guest: that is a great question. the good news is that we know that older drivers are the most experienced drivers we have. they tend to be saved and where their seat belts. they do not drive after they have been drinking. they tend not to speak. one of the concerns that we have is that the experts do not really know why the numbers have come down the way they have. they have outpaced gains that we have seen in other age groups, but when you look at the numbers

of older drivers have in an accident, it is a u-shaped curved. you see a lot of young drivers involved in accidents, but that tends to go down as you age. but then as you get on the older side, especially around age 80, 85, the numbers go back up. we are very concerned with the number of fatalities that involve older drivers. one of the key point is that they tend to be more frail or more fragile, so if they're involved in an accident where you or i might walk away, and those injuries might be very serious for them or involved hospitalization. host: we're learning that now 25 states have older driver provisions of some sort. those can include having vision tests for older drivers, shorter renewal of the time frames for their licenses, not allowing them to renew by mail and behind the wheel testing for some drivers.

are you looking for federal standards for drivers? guest: what the board is focusing on is trying to understand what is happening out there. i think we found that there is a patchwork system across the country with respect to screening or assessment of older drivers. states, as you mentioned are doing in person renewals after a certain age. others are doing vision test. we want to understand what the ability is of doing these tests and we want to reduce the number of fatal accidents that those drivers might be involved in. and are there other lessons that we can learn from those systems that could be propagated throughout the country? host: could you explain how your agency has a mandate in this area? guest: the national transportation safety board has to investigate accidents in all modes of transportation. we're looking to in -- to reduce injury and fatality in transportation. just as we look at things for

younger drivers -- passenger restrictions, nighttime restrictions, and also limiting cell phone use or things like that for young drivers -- we wanted to look on the other end of the spectrum to see what we can do for older drivers. how do we make crashes.net may be minor crashes and -- how do we make crashes that may be minor crashes not so serious for older drivers? host: take note of how we are doing the phone lines, under 70 or older than 70. we are taking a look at whether your state has provisions for older drivers and whether or not you think that is appropriate. but we would like to know what you think. one interesting point, italy is

looking at taking drivers licenses away from all drivers over 80. any reaction to that? guest: i do not think we heard any data or science from the medical community, the licensing community, or the aging experts to support something like that. just as no two 17-year-old or two 42-year-old to have the same driving skill set, we do not want to make a blanket statement on the most experienced drivers on the road. but there are medical conditions, such as dementia and other things, that do not begin to degrade -- that do begin to degrade and we want to be sure to assess those things properly. host: first up is from new york. you are on the air. caller: i want to thank you for

what you have been doing. i have been watching your hearings on c-span this week. they are very informative. this is somewhat of a separate issue, but it is nice to see women discussing and negotiating and taking a look at something in a very rarified way. i am in my early 60's. my mom is in her late 80's. she just took up residency in florida. voluntarily, and i might add, very painfully, she got her license and her car. it took all her independence away, but two things that are very important. her comment when she moved down was if you could read the big "e"they were going to give people licenses. her doctor said she should not be driving, but as long as she was familiar with where she was

going, that would be ok. that a doctor could be able to take her license, i think that is not a bad place. and a couple of places, aventura specifically, they have put a huge amount of buses to cycle through the neighborhoods. it is very expensive. -- it is very inexpensive. i find that this enabling my mother to do things independently. host: this was something your mother did voluntarily or did you have to have a family conversation? caller: a little bit of both. and ultimately, we talked to my mom about it. we protested about her doctors and responses to her eye exams. my dad is now passed away from alzheimer's and that was also tricky.

ultimately, she did it herself. we did have conversations. she would push back and when we finally gave our opinions, gave the data that we understood and backed off, she responded well and truly and on her own. host: thank you, then. the role of city planners and providing alternatives for older drivers in particular? guest: something that is a huge problem nationwide, particularly in rural areas. if you are incredibly dependent on being able to drive and you give up the keys, you give up your mobility in many cases. this is a real problem that society has to address. you have got to have options for older drivers you cannot just -- options for older drivers.

you cannot just say you cannot drive anymore. one of our panel members said that it is like an them under house arrest. older americans and baby boomers, they our planners. they plan for what is coming next. if anything, this debate should foster people thinking about what are their options as they age. for his mother in her community, that there is still a lot of mobility and a provision for that, that is what people need. the calr raised some great point. at one of the things that i thought was really important was, i do not know if he is still on the line -- host: he is not. guest: the issue with alzheimer's and dementia, that is very important. i was curious how that might have felt about giving up mobility. his mom actually volunteered to

give up her license. one very interesting thing we heard from our panel is that women are much more likely to prematurely cease driving than men. it was really hard to get the men to voluntarily give up their license. but we found that many women were giving up their licenses sooner than they needed to. they still had some writing years left, but they might have been told they are not a good driver -- they still had some good writing years left, but they might have been told they are not a good driver. host: melrose, mass., jim is 70 +. you are on. caller: good morning. thank you for c-span. you provide a terrific forum. host: thank you, sir. caller: my comments are based on my experience as a volunteer

driver. not long ago, c-span had a panel on this subject and the ntsb did a beautiful job of and lightning me on these aspects. they touched on volunteerism, but perhaps i can have my own experience. i am a volunteer driver. i think a lot of people should know that many of these tasks are not compensated. the social security is an important part of my income. i might save a parking received at a hospital, typically, and i might put it in at the end of the month if needed. it is a great job, so does become law because i need fascinating people. -- so to speak, because i need fascinating people. -- i meet fascinating people. receptionist are the key.

there the first people you need. they are very kind to the patients and they are very helpful to me when i say, can you give me an estimate as to how long the visit will take, and always they give me good information. st: let me ask you a question so we can stay with the subject of driving. what organization do you volunteer with? is it a hospital? caller: it is "friendship works ," and interdenominational group. all someone has to do is call and they have a driver. and let me thank jacqueline, the coordinator. she makes it easy for me. host: thanks for sharing your experience. what did you learn about volunteer groups in communities and the role they play? guest: 1 tremendous aspect is groups like this that provide these services because whether

it is due to a medical condition or a lack of an ability to drive, they are providing a service for people to get around. we know that there are a lot of senior organizations, senior centers, aaa, aarp, and they are helping people drive longer. they're doing assessment, making sure the car fixed them well, making for the seats are adjusted properly and the mirrors are working well, making sure the seat belt is comfortable. it is small things, but sometimes it makes it easier for people to continue driving longer. certainly, volunteerism and the that driversrifices lik like the caller is making, they are helping the community. we are concerned with helping more drivers to our meeting these services, as a society, we have to figure out how to handle them. host: right now there are 32 million drivers over 70 and by

2030, 57 million. that might strike some as a business opportunity. i'm wondering about perovo of private business and developing products that can be retrofitted -- i'm wondering about private business and developing products that can be retrofitted to make driving safer. guest: as people have challenges with mobility, whether it is getting in and out of the car comfortably, being able to adjust the seat as well, there will be cars that help people to do that. making sure that you fit in your car well or that if it's you. but the good news is that we have had great advances with respect to survivability in regards to air bags, crash cages with more for give ability. one of the things we have not seen is being transferred to all drivers. the car is designed for the

average male. when we look at the design mechanisms for older drivers, we see the younger drivers have largely fatal head injuries. but for older drivers is a drastic injuries, injuries in the chest area -- thoracic injuries, injuries in the chest area. those injuries are not always fatal, but they can sometimes be. we saw an inflatable seat belt but actually spread the crash forced over more services of the body. but they can also help all drivers. host: we are talking with deborah hersman, the chairman of the national transportation safety board. robin, go ahead. caller: i have to make this quick because i have to drive to work. this really bothers me -- host: robin, are you still there?

oh, it just disconnected. i apologize, robyn. here is a tweet. i'm wondering with all the reading we are doing on fiscal stress over states and counties and localities, what is being cut back? guest: of the things that the panelists have been able to share with us during our forms is that the majority of the drivers, only about 1% take advantage of the services offered. and the cost of the services is very high for the minister of these providing them. in one case in a florida municipality, it was about 12% of their entire budget. it can be a very expensive. we want to be sure that these services are provided and they are provided effectively and that people who need them, get

them. host: john, you are on the air. caller: there is a divide between us and who have cars and those who do not. they have these caged airport vance that come and take two or three people here or there. i commend the volunteer driver, but that was contributed by a religious group. the other option is cabs. i think having a local shared vehicle, having a small, accessible the electric vehicle, there are plenty of drivers that would be willing to volunteer drivedriving people here or the.

one problem with senior drivers is that they do not realize other people may be in a hurry and they may stay in the left lane and caused traffic tieups because they do not dry fast enough. thank you. host: thank you very much. guest: that is one of the issues that we talked about, the way older drivers drive compared to younger drivers. guest: going back to your comment about a business opportunity, i think there are actually things called as a cars and there are bicycles around washington where people can buy access to them. i think your caller is right, there are people that will still

want access to a car and are still good drivers, but they do not need one all the time. and it can be a financial challenge for them. there is an opera -- a business opportunity as far as that goes. host: here is pamela, under 70. caller: my mother has been driving a car for a long time. she is 91 years old and she has had no wrecks in her life. she still drives every day. and she still drives to see me every day in lexington, ky. i happen to know some statistics and i have watched a lot of the c-span coverage. in my experience, has been 30 to 35 to 40 year-old women who have not been paying attention when they are driving. because of the wrecks that i have been involved in setting is still -- sitting still at a red

light, and i get rear ended by a woman multitasking on her cellphone. i think older drivers do not have a problem with multitasking and they are much more courteous people. i think people are wanting to get them off the road and hide them in a cave somewhere. i think public transportation is not dependable. either you have to give a week's notice to go somewhere and then you have to pay for it and give all your private information or for them to establish how much it costs. and when i watched the ntsb on c-span, i was shocked that there were so many people. and after watching several hours of it i thought, gosh, and my busy body like that, too? -- m i a busy body like that, too? this is not very professional.

you get to an age where people should be this is -- should be respecting you, do not let them take your wheels on from under you. ... it had a very creepy aspect to it -- i thought it had a very creepy aspect to it. i am not supposed to use a sea of oil because of my highest because it'll probably kill me. -- a seat belt because of my height because it'll probably kill me. host: let me ask you about your mother. derouchie drive -- we are not willing to learn because she hung up -- does she drive -- we are not going to learn because she hung up. would you like to comment about older drivers? guest: i think it is a concern for all of us because we're all going to be older drivers if we

are looking to learn -- to live long enough. -- if we are lucky to live long enough. the really important thing is for you to know your limits and for you to work with your doctor, your family, and the licensing community to be sure that you know when the best time to start writing is. it is an individual decision. her mom may be a fine driver and 90, but there may be other drivers, as you mentioned. it is really not a dependent. they may not be doing -- it is really not caged-dependent. they may not be doing a good job. people may be focusing on other things while they have the task of driving right in front of them. we lost 33,000 people on our highways last year. we had these centers for disease control at our hearing this week

because this is almost like an epidemic. we lose more people on our roadways then we do almost anything else. and we need to figure out how to do better in this area. host: and with the statistic that accidents are declining, help me understand. guest: the good news is that accidents are declining, but the bad news is that the numbers are so high that even when they declined they are still very high. last year we lost over 33,000 people on the highways. if we lost the number of people in the airplane accidents, we would be losing an airplane every day. the american public would simply not tolerate that. but somehow we accept these deaths on the highway because they occur 1 and 2 at a time. host: this of you were on twitter is looking to the future. you have probably seen the

things on google where they're working on a self driving cars. guest: one of the things that we do know in all modes of transportation is that technology can help us. it many years ago we thought that by the year 2000 we would be idriver-less cars like the jets in or something. but that has not happened. ons ore the jets something. but that has not happened. but the ability for a car to sense that you are in an accident and deploy the air bag, that has saved thousands of lives. when we look at intelligent transportation systems, we actually have systems available right now that can detect stop traffic at view, collision avoidance systems that can give the driver a warning. this is the kind of technology

that can give older drive more time to make a decision, react, and then give all drivers a better chance of surviving an accident. host: the next telephone call from georgia. this is jeff. jeff is under 70? caller: yes, i am. host: you are on the air. caller: i am concerned -- i'm calling considering age drivers. my mother happens to be one. we lived south of the atlanta in a suburb that does not have much public transportation availability. the solutions that might could be considered in the area that the lady is speaking about, as we have lain for multiple people to drive on the highway as opposed to a single driver in an automobile. there is another issue. they do not look at the concept that many older drivers, some

are on heavy narcotics medications and some are not. those are the ones we see writing down the road for 30 miles with their left hand and koran. -- with their left hand blinker on. we may need to look at the idea in the public as far as heavy community traffic in atlanta of creating lanes that can help the elderly manipulate themselves without being hazard. host: thanks very much. have you had a talk about older drivers and prescription medicine? guest: polley pharma has had multiple -- multiple prescriptions has a heavy impact on drivers. we need the medical community and promises to be able to help people understand what affects

their medication might have on them, not just for older drivers. this is for all drivers. but we do have people with age- related conditions and that increases the likelihood thathey beyond additional medication. but with respect to navigating a contestant -- congested area, the ntsb invested in an accident of a baseball team that was traveling down to a tournament in atlanta and they have an accident. at one of the reasons i had the accident is that these on edge on the road where was not good. the driver of the bus thought he was putting off on a left-hand thru lane and it turns out to be an exit lane. as he approached the intersection he was not able to stop. he went over the overpass onto the highway below. one of the things that we looked at in the investigation was the signage on the roadway.

i know all must live in the washington area, sometimes there can be real challenges on the beltway and with signage. i think every community is like this. if you are familiar with the area, then you know which way to go, but if you are not then you need good signage. as a society, we've got to do better. host: california, are you 70 +? caller: low 70, thank you very much. -- below 70, thank you very much. debora said that the crash rate for seniors has gone down and they did not quite know why. in my case, i do not get on the major highways anymore. i have lost my nerve. i asked one of my family members to take me. and i say of the road at night.

i go to the store and buy, to the post office and back. i'm not doing as much driving. before i recorded -- before i had a tour bus company and about 25% of my clientele were seniors. some of these people had nice new cars, but they went on the bus. i knew there was some stigma, especially among the men that were getting on the bus. i took that stigma out of them. i told them, look how much money you are saving. i made it a lot of fun on the bus for them to go on. i think, probably, that is one reason the crash rate has gone down. they are finding other ways to travel, especially to distant places.

the volunteer driver, that worked for the church, i believe, or something, he has to be a little bit cautious because if he would tell his insurance that he is picking up people and taking them to and fro, his insurance rates could most likely go up. thank you for taking my call. guest: the caller raised some great point. these are a lot of things that came out in our discussions. older drivers are the most experienced drivers. they tend to be safer drivers. but what the caller talked about is something not unfamiliar. the self select. they determine where they feel comfortable driving and they actually do to limit their own driving. but there are some things that can improve their ability to drive. for example, when the driver talked about not driving at night because she had difficulty

seeing, or limiting the driving that she did, we know that older drivers may have cataracts. you can get cataract surgery that can greatly improve your vision and visibility. i speak a little bit from personal experience because my mother just had cataract surgery and she said it was a tremendous change. she can actually see the leaves on the trees once again. rhaps an important thing for drivers is to get medical assistance in what they're challenges are. -- in what their challenges are. when we see those numbers going down, it may be because beforthe making other decisions or they have other options available to them. but the good news is that it is going down. the one statistic that they shared with us that i thought was particularly interesting is that people who tend to drive more have fewer accidents.

do not like you're driving skills get rusty is the thing to take away from this -- do not let your driving skills get rusty, is the thing to take away from this. this is kind of a message to our older female drivers. be careful about always being the passenger in any car that you are writing in. -- riding in. if you have good writing skills, you need to keep those up. they are not sure why 3,000 miles is the right number, but they did see the accident rate go down when you drove at least 3,000 miles per year. be sure you do not let yourself too much and keep those driving skills up. -- be sure you do not limit yourself too much and keep the writing skills up. host: where are the best driving

standards based on best practices and some of these different provisions? guest: safety board is not have any regulatory authority. we just make recommendations. the potential outcome of our form is that we can make recommendations. host: and that goes to the department of transportation? guest: we can make them to anyone that we think might actually benefit. when we look at an accident, whether it is an airplane or a train or involving a personal vehicle, we look at the human, the machine and the environment. there could be changes made to the assessments on medical issues. there could be changes made to the design of vehicles to make those crashes more survivable. how it could be changes to the environment, the roadways, signage. we know that older drivers have

challenges making left turns, estimating how quickly the oncoming cars approaching, etc. if there could be design issues, may be putting at some roundabouts in communities so that people are always moving to the right and traffic is slowing down. there are a lot of possibilities. and i think an important thing is the rising tide with all of those. what is good for older drivers is probably going to help all of us. host: they raise the issue of how -- using gps always making returns? guest: there is the issue of how technology can affect things. someone suggested a safest route to help people stay off roadways that might be more challenging for them. host: john, you're on the air. good morning. caller: thank you for taking my call. host: certainly.

caller: i wanted to relate an experience that happened to me. i'm only 58. the gentleman that call from georgia brought up the idea of people on medication who drive and how that is handled. but what happened to me -- i spent 20 years in the army and i was diagnosed with ptsd, still on active duty. and they treated me with medication. i could still drive. it did not affect my riding. -- my driving. two years ago i moved back here to maryland to take care of my father. once he went into assisted living. i did not drive that much, but one day i was driving and i

blacked out. and i ran into the back of a parked car, luckily. both my psychiatrist and a regular doctor that prescribed me medication did not say anything before that, that i should not drive. but i knew enough because i was on pain medication. when i took the pain medication i would not drive. host: john, what is the lesson of the story? caller: did they have any type of -- when you go to renew a license or whatever, are there questions or a form that asks you if your on a particular medication, and how does it affect you? host: klutzy -- klutzy.

guest: that is a good question and it raises the question of how the licensing agencies handle medical conditions regardless of age. and have the veterans day belatedly to you. -- how deep veterans day belatedly to you. hawes i think it goes to how the medical industry -- i think it goes to how the medical industry reports this. i suspect that when you clocked out it cross your caregivers some concerned and that may cause these of a licensing agency to be involved because they will know about that accident. but in many cases it is not about locking out, but making sure that doctors -- blacking

out. but it is making sure that doctors and patients have the conversation about medications. one thing that has been brought up is whether there should be a list the so that people know that they could be impaired while driving, just as people can be impaired on illegal drugs oor on alcohol. host: here is a tweet. call.take our last manchester, new hampshire. and this is donald on the under 70 line. caller: just a couple of comments. about five years ago i had an aunt and a couple of

years ago everyone made it about how he could not see driving. he was writing off to the grocery store and he crossed the median and he killed someone. obviously, he did not see any direct -- any jail time, but they took his license. i try to be patient because i know they are elderly, but how many times do you have impatient drivers who try to pass and that causes of accidents, too? in my opinion, it is just as bad as a dui for some of these people. guest: i think the caller raises a very tragic point. we do not want anyone to be in a situation when they are driving where they should not be and when they are not comfortable. just as we do not want anyone driving while they are drawn or texting or on their cell phone

while driving. -- drunks or texting or on their cell phone while driving. people should be driving safely on the road. but also, we need to address if there are conditions that are unsafe, how to work through those. they have to be individual decisions made by the individual drivers, their physicians, and families. and the state licensing agencies working together. there is no silver bullet to resolve this issue. it is going to be on a case by case basis and it will probably be very difficult in some situations, decisions that drivers have to make with their families and doctors. host: you have heard a number of callers make reference to the ntsb forum on older drivers. if your interested, you can find it at the c-span library at c- span.org. i want to say thank you to deborah hersman, the chairman of the ntsb.

guest: happy to be here. >> we are going to show you now and portion of the meeting that the national transportation safety board chair talked about. on the final day, the focus has been on how to screen and assess the physical and mental abilities of the gene drivers. this is just over two hours. >> good morning, and welcome back. today, our panel's discussed the safety risks of eating drivers, and we decided that with the

exception of the very old, there was not really a disproportionate crash risk, but when the elderly are involved in a crash, they are more likely to be fatally injured because of their frailty and low tolerance for injuries. we look at what vehicle occupancy protection systems could do to improve outcomes, and we look at what technology and highway design could do to improve the performance of each in drivers -- aging drivers and drivers in general. our first panel looks at enhancing driver performance. the panel will be discussing the ways that we assess driver capability, both in terms of a mental and physical abilities. the initial question will be -- how do we assess performance? an assortment of tests and evaluation approaches will be covered in the panel today. road tests, occupational therapy abilities for driving testing, medical assessment,

medical review board, and self evaluation. a great deal of public interest has been focused on driver screening methods, and the panel will open with a survey of that work. once a performance detriment is identified, the focus should shift to a second important question -- what can be done to free meet the driver? dr. deborah bruce and dr.van cheung have prepared questions. >> lisa molnar is primarily interested in traffic safety and driver behavior. she holds a b.a. in sociology from michigan state university and a master's in health services administration, public health policy, and she is co-

author of a recent book, on call -- of a recent book. dr. richard marottoli is executive director of the geriatric assessment center at yale new haven hospital, and he has a staff physician at the veterans administration connecticut health care system. he received his undergraduate degrees from yale university. he is the former chair of the committee on state mobility of all the persons and member of the connecticut motor vehicle medical advisory board. dr. arthur kramer is director of the institute of technology and professor of psychology and neuroscience at the university of illinois. prof. kramer's served as associate editor of perception and psychophysics and is currently a member of 7 editorial boards. he is the recipient of the nih

tenure merit award. elin schold davis is a registered licensed occupational therapist and certified driving rehabilitation specialist. she holds a b.s. in occupational therapy from the university of minnesota and has been in occupational therapy for 30 years. thank you all for coming. i'd like to start with lisa. i often see screening and assessment as paired in the same sentence. would you give us a general description of drivers screening and may be distinguished it from assessment? >> madame chair. just by way of background, as we

heard during many of the sessions yesterday, driving is a complex task that requires visual, a cognitive, and motor abilities, and as we age, most people experience some loss in these abilities, due to medical conditions that become more prevalent with aging and also the conditions used to treat them. we know that this process has a lot of variability from individual to individual. people are very unique, and the older driver population is very heterogeneous, so making informed decisions really requires meaningful information about drivers' functional ability, and the issue of -- okay. the issue of evaluating driver fitness, which is what we really want to talk about today, is really complex, and it is often

controversial for a number of reasons. one that you just mentioned is that often, there is a lack of clarity about the difference between screening and assessment, and i will be talking about that. in the work that we have done at the university of michigan, and i think that among many other researchers, policymakers, and practitioners, this is becoming also the case, there needs to be a clear distinction between what we mean when we talk about screening and what we mean when we talk about assessment. screening and assessment represent different and distinct domains of driver valuation, and screening is really the first step in a multi-tiered process. it is not something that in and of itself should be used for making licensing decisions. on the other hand, assessment provides a basis for identifying reasons for functional deficits,

determining the extent of driver impairment, and making recommendations about licensing actions. also, identifying options for driving compensation or remediation, which i know we will be talking about later on in the panel. when we think about driver screening, we are talking again about the first step in a multi- tiered process. screening is something we used to intif very obvious impairments in functional abilities and vision, cognition, motor skills. it is intended to lead to more in-depth evaluation of gross impairment are identified, but it should not be used to make final licensing decisions. again, driver assessment provides the basis for identifying the reasons for the functional deficits that might be observed and the extent of driving impairment. it is used to identify options

for driving compensation or remediation recommendations and licensing actions. and so, as we conceptualize driver screening, we think about it really as part of a more multifaceted, multi-disciplinary approach to driver evaluation. it is something that can occur in a variety of settings and at various levels of complexity. yesterday, we heard dr. dobbs talk about a process of identification of drivers, assessment, and then options at the end for maintaining mobility. screening is really that part of the identification process that involves a number of players from the community. it is done in licensing agencies, in offices and other clinical settings by occupational therapists. it is something that can be done by law enforcement who are

making traffic stops or older drivers. it is something that is also done in the community by friends and family members of older drivers who might be experiencing problems, and it is done by older drivers themselves, so it is part of a comprehensive, multifaceted, multidisciplinary approach to drivers who may be at risk. that said, i think it is important -- as was said many times yesterday -- that when we talk about identifying drivers who may be at risk, we are focusing on safety aspects of transportation. we cannot lose sight of the fact that although it is important as researchers, policymakers, and practitioners, to find effective ways to identify drivers who may be at risk, we need to also think about how we can provide community support to drivers who are not able to drive or reduce

not to continue driving -- or who choose not to continue driving so they can maintain their independence and well- being and quality of life. >> thank you. i hear you saying we need to do screening by medical providers, law enforcement, licensing, older drivers, care givers. those are a lot of different players, and i would assume that the screening tool differs, so would you give us some discussion about the types of tools and the value of each of those. >> yes, i would be happy to. as i mentioned, screening can be done in a variety of settings. in the licensing agency, for example, there are a number of forms that screening can take. observations can be made of people as they come into the counr to renew their license or take care of licensing issues.

there's also review of medical history that can occur in the licensing agency, and there are a variety of tasks that can be done -- test that can be done in a licensing setting to screen four deficits in vision, cognition, and psychomotor skills. within the physician's office, there are also a number of tools available for physicians. physicians have a unique opportunity to screen as part of regular medical care and treatment. one of the challenges has been that many physicians feel that they do not have the tools to really make fitness to drive decisions. there are also the problems with

not wanting to disrupt the patient/physician relationship. screening offers the opportunity to identify early, to identify red flags, and if necessary, refer patients for more in-depth assessment. some of the work that has been down has included developing guides for physicians like the guide for assessing and counseling older drivers that offers information about the kinds of red flags that might alert a physician to something that might be problematic with driving. the physicians guide also contains a screening battery called the address, which has a series of tests that can be administered. similarly in the licensing area, there has been a lot of work on developing some protocol for doing observations at the counter as well as developing batteries that look at the kinds

of limitations in physical functioning that we know are associated with problems with driving. having said all of that -- and if now you could go to the state of the research. having said that, i think that in general, although there has been a lot of research to develop screening tools that are valid, reliable, low-cost, and easily administered, these are particular constraints faced by physicians and licensing agencies. to date, there are really no tools that have been developed as satisfy all of these components. we have been doing the research for a long time. that research continues, on ways to improve the sensitivity, which is maximizing the correct decisions and the specificity,

which is minimizing the incorrect decisions of an individual with a high crash risk. that research continues, and hopefully, we will have an opportunity to talk more about that, but in the meantime, i think there is widespread consensus that screening tools need to focus on looking at these functional declines in addition, cognition, and psychomotor, as opposed to focusing on age or always looking at the complex array of medical conditions peopl might be experiencing. then, in addition to the licensing agencies and physicians and clinical settings, law enforcement has an opportunity to do screening at the roadside, and there have been a number of efforts over the last several years to develop curriculums and training materials for law enforcement so that they had a standardized way of using cues to look at drivers who they may have

stopped during a traffic stop, and make a determination of whether there seems to be some impairment. a lot of these have to do with cognitive functioning. they might include something like assessing whether the person is oriented in time and space, if they are getting aloft and do not know where they are or where they are going. that can then lead to referrals for more in-depth assessment. >> thank you. i recently went to my dmv to turn in my motor scooter license, so i have some questions about the practicality, but i am going to in the interest of time proceed through the panel and go through the questions by party, and at the end, i will reserve my time for then, so with that, i turn it over to in -- ivan cheung and dr. marittoli.

>> good morning. dr. marittoli has been an associate professor at yale university school of medicine. we are going to ask him and talk about some of the cognitive assessments. please give us your introduction. >> thank you. i would like to start by giving you an overview from the medical perspective more broadly, and then i think we can get into some of the original aspects. i also did not bring any slides, but if there are specific things people want, -- >> if you have any you would like to submit, i will put them in the document. >> speaking from the clinician den of the process, i want to cover what is realistic to expect and why people need to get involved. why should we evaluate?

what do we evaluate? howe, who does it, and what do we do wh the information? from there, a lot of the other questions will come. wase's the issue that raised earlier about the clinicians role in concern about the safety and health and quality of life. in terms of what to assess, i would argue that there is a benefit to looking at conditions in addition to looking at functional abilities and impairment, in part because we are also looking for things that we can improve. in this population and age group, oftentimes, our ability to intervene is limited in terms of the effect to which we can make a big difference. if we take several different avenues and make smaller improvements, cumulatively, hopefully, there will be additional benefit. the process in terms of manifestation and severity and

functional manifestations that result are both avenues for intervention. the third avenue to look at and intervene upon our medications, and this was touched on briefly yesterday, but there are many different categories of medication that could have both beneficial and potentially negative effects on either the condition they are being used to treat but also abilities relative to the driving task. in terms of how we assess that, there are a variety of ranges, and it was covered a bit in terms of the specific aspects of visual acuity, vision fields, and kind of abilities, there are a variety of different measures that can be used looking at individual cognitive domains. the ones that come up most often are things like information processing speeds, attention, and a variety of forms. space mobility and executive function.

lastly, physical ability. particularly range of motion and speed of movement. one area that has not yet looked at a lot but that comes back and is relative to everything is the issue of awareness, and we were trying to think about interventions to having people change and modify their behavior. their awareness and insight into their deficits is critical in recognizing their need for change. we also would like to have some measure of driving performance. we like to have these assessments of different capabilities but in terms of convincing people it is helpful to relate those to how people actually drive, and we have the advantage of often having families in the clinics, so we recommend the families ride with them and address that. it is helpful to have them on board with that.

there are also formal assessments that can be done. let me get to the question of who does the actual screening assessments, etc., and that is just touched on briefly, but the issue is the self assessment. the clinician, office staff, or licensing agency, and there are pros and cons of each of those. the last segment is what to do with that information. ultimately, the goal is gathering that information to convince the clinician of the need for change and ultimately convince the patient or driver and the family that change is necessary and what that change should be. also to identify interventions or adapte strategies and help ameliorate some of these problems and help people continue driving for a longer time more safely. and the issue of reporting to licensing agencies and how that

process goes on. there have been two major areas of development over the course of the last 10 or 15 years, and one that has been touched on by a number of speakers, and that is the appreciation of a more holistic approach to this, rather than dealing specifically with the issue driving or not driving, but really looking at the broader perspective of a person's mobility and how they get to where they need to go and their ability to fill in that void if they choose not to drive. the second is increasing effectiveness for a number of interventions, particularly relating to those functional abilities i outlined, which hopefully over time will allow us to change the tenor of a lot of that discussion from one that is very negative into something slightly more positive in the process. there are also a variety of education interventions that can work more broadly rather than focusing on specific functional abilities but take the driving past and look at that in more

detail. >> thank you, doctor. thank you for giving us a very good, st. distinction between various medical conditions and functional abilities. i wonder if you can comment on some of these disdainfully different professional training that our medical care professions need in order to deal with those very different aspects among hiring performances. >> that is a difficult question because there are many different levels at which one could answer that. the first is getting clinicians to recognize that it is something they should do in the first place, and i think that is an initial barrier that needs to be overcome. in part, that is because there is the negative perception of the issue any negative effect it has on the clinicians/patient relationship. secondly, the broader issue of not knowing what to actually do, and the third is what happens to

the information after the clinicians gathers it. potentially, each of those are areas to look into. from the first perspective, is convincing them of the need that it is really the safety and mobility of their patients that is of interest, and this is part of that, as well as their obligations to society in terms of public health and public safety. most people will recognize that and weigh that against potential negative effects on their patient. the second is the issue of one specifically to address, and that again depends on what we realistically what people to do as well as what they will do or can do. i think focusing on the medical aspects, both of conditions and functional impairment related to that is realistic. a lot of people have difficulty making the next step of linking that to driving safety implications, so to the extent that one can focus the physician

task, the clinician task to something more limited specifically on the nature and presence of condition or functional impairment, i think there is a greater likelihood of getting people to do it. then, there are also specific tools or think they can do fairly readily, and there are a lot of different tools out there, a lot of things that have been looked at, many of which are impractical in that setting, and it is becoming increasingly difficult because time is of the essence. there is a limited number of things people can do in that setting, and i think everything we look at has to be considered in terms of its potential burden in displacing something else from that potential action. those are trade-offs we need to think about. lastly is the issue of what happens to the information afterwards. partly dealing in discussions with families about change, and separately and perhaps deserving a much longer this course is

providing the information to a licensing agency. i will not go into detail on that because we can deal with that in specific questions, but again, keeping the process as transparent as possible, making sure everyone understands their responsibilities, the driver as well as the clinician knows what their obligations and responsibilities are in that jurisdiction, and having a process that is as straightforward and simple as possible and that also provides some communication back and forth. tend not to be a two-way street in most areas, so we are asking clinicians to provide the information, but very often, there is information that then comes back, but the clinicians often seem clueless as to what has actually happened or transpired, so some way of beating that information back into the more difficult medical consultation when you ask someone to provide input, they sent a letter back saying, "this is what happened," and i think

that would facilitate some of that interaction as well. >> thank you. one more question before we move on to dr. kramer. dr. dobbs yesterday talked about premature driving perceptions, particularly for older women. do you think these drivers are really underestimating their own competency, or perhaps our current assessment or screening tools or processes are not picking up some of the problems they are feeling? >> that is a very good question. obviously premature is a relative term, and we tend to typically hear about this when it is on the other end of the spectrum and people go on too long, as the video yesterday demonstrated. those are the ones that come to our attention and really create a media flurry.

we tend to hear very little or no very little about premature cessation -- know very little about premature cessation. there is evidence to say that by the time they have reached the geriatric assessment center, most people have stopped driving, so they are regulating in some way on their own with their family or primary physician's template -- input. there is a relatively small proportion that goes past that and unfortunately, an infinitesimal proportion that goes beyond even that. it contributes to people stopping, and the question of prematurely stopping is that outside influences that force them to do that. other people's impressions of their driving capability, or do they have some innate sense that they're just uncomfortable with that, and they are better at figuring that out than we are, and therefore, it is not

premature, but it is appropriate for that person, and we do not have a good way of measuring that precisely and really identifying that. >> thank you very much. dr. kramer, would you please give us your remarks? >> sure, thank you for inviting me. i appreciate being here. my task was to talk about driver enhancement through cognitive training, so i will be a bit more focused than the last two presenters. i wanted to start by saying that most cognitive training programs are still in experimental stage. think of it as a phase ii drug trial. there are an increasing number of commercial products that purport to improve driver training. some of them even advertised that if you go through the training program, you can reduce accident rates by 50%, and i think it is worth evaluating them with the same level of scrutiny that we evaluate drugs and drug trials because i think

they can have the same benefit and/oregon harm, depending upon what the assessment is. my bottom line is that there is some interesting and potentially promising results from these cognitive training programs, but if i was to evaluate them by virtue of the same information that is used in national institutes of health consensus statements to evaluate research in a particular field, and i did for dissipate in one of these within the last year on alzheimer's and aging, i would say that given the present state, the evidence is weak at best, and let me tell you why i say that. even the gold standard, by which i mean the randomized controlled trials that have randomly put people into one training group or another training group and perhaps the control group, and those are always tough because they have their disadvantages, ere the control group often

gets used but perhaps is not the optimal one. when we look at these control groups, they tend to be under power quite substantially. the effect sizes also tend to be rather small. what i mean by that is small in a statistical sense in terms of effect size, but also in terms of the number of variables relative to driving the show changes, that have beneficial effects, some various cognitive training programs. i will not mention any particular studies unless you decide you want me to do that, t perhaps one of the gold standard studies compared one cog in the training program that looks promising, by the way, in terms of on the road driving and driving simulation. those were the variables prior to and subsequent to the training, and found a benefit for one out o19 variables. simulator training, which has been around for a long time both in aviation as well as driving,

in many fields showed two beneficial effects for two different variables. i'm not suggesting tha then the training programs are not efficacious. i' suggesting that we need to collect the kind of data that we collect for other kinds of trials that have sethe same high bar and standard for these trials. i tnk it is also the case that we might, as scientists -- and i am a scientist as well as research administrator -- have not been creative enough in terms of the programs we have pursued. as we have already heard from our speakers, this is really a multivariate problem. it is not just one aspect of cognition or perception of physical function or disease but truly a multivariate problem. in terms of cognitive training, we do not focus on the richness of the problem. we tend to focus on particular areas, and i think this is even

true with respect to cognition. some programs focus on what is called speed up processing, which is probably much more than that when you look at the specifics of the training programs, but there are many other aspects of sensory function, whether it is vision or hearing, motor function, and cognition in terms of memory, control,erceion d speed and procesng. weeallneedo lo at e breadth of cotton the changes that takes place and how they relate to driving performance to use them in a theoretically principled way to targ in terms of our training interventions. in addition to the randomized controlled trials, which really are the gold standard, we need more observational studies. think of it as epidemiology for driving, in which we track different populations based on the choice they make in life, at least to give us hints as to what randomized controlled

trials we might perform in the future. again, there are precious few of the observational studies that would provide information and answers as to what kinds of training interventions we might pursue. just like drug trials, we need broader replication of the promising results we have seen. we need independent validation. the studies need to be done in a small set of laboratories, for us to have some assurance that they really are broadly applicable. we need to go beyond single laboratories or groups of researchers. we need to understand mechanism. for many of the training approaches pursued today, normal black box engineering approaches, and i do not say that pejoratively because i taught engineering for 15 years at the university of illinois. but they work in some cases. they give small positive benefits. of course, we need replication, but why they worked tends to be

very important to understanding the process and more specifically and more effectively targeting the intervention, so we need much more detail mechanism and studies that focus on mechanisms so we understand what igoing on. i think stratifying sampling is very important, and many of the studies that have been done have focused on individuals that are older and individuals that have very specific problems, whether in vision or visual attention or what have you. we really do not know if we look at these studies, how these training interventions and successes, even with small facts, apply to the broader community of older and middle- aged -- in fact, middle-aged people are pretty much ignored in many of these studies. we need to move on with that. accidents are certainly the bottom line, the gold standard in terms of the outcome variables, but it takes a large study to get enough accidents to make much sense of the data, and i think there are enough studies in the literature now that if

you look at them, the data does not make a lot of sense, perhaps because the sample size is so small. second, we need to come up with better proxy measures, just as we do in terms of drug targets effects that we can have some faith in that are both valid and reliable in terms of accidents so we can use them in on the road studies with randomized controlled trials. that is my statement. >> thank you, dr. kramer. i guess the take-home message is that there are some positive signs, but at the same time, we need to be concerned and cautionary in continuing the process. i'm wondering if you can give us a high-level observation. can we say that some of these positive evidence of the cognitive training -- perhaps

maybe they were -- some of the people that take these cognitive trading's are actually the safest subset of the older drivers? we really do not know a lot about the driving history of them >> this is a problem we have in any study. certain people volunteer force studies. we always have to worry about those not volunteering who might need it the most. there has been a case with a number of these training studies that the researchers are specifically selecting individuals who did poorly on some tests. it is often of visual attention or processing speed. i think population is very important. volunteers tend not to be representative of the whole population.

they have targeted people who had deficiencies in certain functions related to driving. >> thank you. one more question before we move onto the next panelist. yesterday we heard a lot about the newer technology, but newer vehicles collecting a lot of data about driving. do you think the advancement of that technology may help us out with what you have just described about a lack of observation of data that perhaps can be a better case for cognitive training? >> that is certainly the case. it seems similar to the research of gene0wide screens. we can collect genetic and health data. the question is what do we do about it?

there are many modeling techniques we can use to look at the relationship of that data to outcomes, or we can take a more principled approach. a more theoretical approach based on some of the information we heard from the first two speakers about the problems older adults have. and how those problems with cognition, motor function relate to driving. there are a number of ways to use the data with the sensors that now exist might be used to build models for large populations, and stratus by the populations. there is always the issue of confidentiality. thank you. we are actually marching down this multi-tiered process we first introduced. we started with the screening

and identifying candidates who need to be evaluated. we look at cognitive testing as one aspect. we presented the question to dr. kramer, what do we think about cognitive training? we have gotten to the end of the table. elin schold davis is the occupational therapist to is called in to take what we have decided is a driver problem and see what can be done to further assess it or abbreviate it. my first -- or alleviate it. occupational therapy is a broad field. i would like for you to describe what you actually do. more specifically, there is a driver rehabilitation specialist component i want some description of. >> thank you for inviting me and including made in this esteemed panel.

lippy shaikh the opportunity to speak. occupational therapy -- i appreciate the opportunity to speak. we address activities of daily living which are court to people's functioning. their ability to do the things they want to do. when we look at driving, occupational therapists look at driving as an instrumental activity of daily living. being the last in the panel is handy because a lot of these things have been said. we look at driving concerns as an issue of function, not an issue of age. we have issues across all age spans, but when we are looking at older drivers we want to look at the minimum skills sets. all occupational therapists for a person that finds themselves in the rehabilitation setting

will look at this still said in the domains of cognition. then we want to think about what those an apparent challenge the role as a driver, at their critical role of transporting other people? we find a senior is equally as concerned making sure they are safe to participate in these roles they are responsible for. we want to be able to provide an evaluation that looks at that driver as an individual. as we have gone down the table we were talking about screening. we were looking at more cut points that help us recognize flags. the driver rehabed specialist is there to look at the individual. not everybody needs a comprehensive driving evaluation, but if it were you being told by a screening tool

you needed to stop driving would you want the opportunity to have your situation looked at? so that you have that opportunity to see if there is anything that can be done. when i think of a catastrophic diagnosis as cancer, the first question is there -- is there anything i can do? that is where the driver rehabilitation comes in. it dates back to the beginning of the vehicle. franklin roosevelt drove with hand controls. it is important to keep in mind when we see some of the programs around the country, part of its is related to the fact that the issue of older drivers, the issue of deciding when a person sits -- should stop is new. it is requiring a different

skill said. helping anyone to be able to drive is a different skill set than deciding when they need to stop. thinking about intervention, the it is to see if we can read the somebody to drive. this could be the medical setting. then looking at what are the key things when somebody is in a declining condition when they should stop. new administers the driving a valuations? we have had some discussions. there are different domains of where people enter this system. different places -- we have a language problem we're driving evaluation is one name. days are very good services but they have different training and different outcomes. at the driver licensing level you have a performance-based testing that is a pass fail.

looking at the medical conditions at a driving school. a comprehensive driving evaluation is looking at a mixture of the assessments, pulling them together to a comprehensive evaluation. we look at their history, physical assessments, arthritis, getting in and out of a vehicle. we look at visual perception, cognition. we also ad for a comprehensive driving evaluation the assessments we can see how these compare men's play out on the road. in many models you need to qualify to go on the road. sometimes you don't need that if there is enough impairment to not need that specific piece, but it is part of the package. there are several possible

interventions. if we do an evaluation it is followed by treatment. our mission is to figure out what we can do about a problem. our goal is to mediate. when we think about driving evaluations and the high-profile media cases might be represented by a group that may have fallen into dementia and a group that is declining and is not a candidate for restoring their skills, but there are a bunch of people that are. we need to make sure we have the service -- have these services so we can develop interventions to assist them. whether it is extending their pedals for driving, making sure they have a scooter and making sure it can go in their car, so

they can do the things they want to do. there are several possible interventions, but we also as occupational therapists have an intervention if a person needs to stop. we have to assist people. if you have an apparent that leads you to not being able to drive it puts you at risk to take public transportation. hopping on a bus probably puts you at risk. the mission is a spectrum. trying to help get people to continue the driving or helping them to safely transition from driving. thank you. >> we are delightfully on time and i thank you for your remarks. i do have one last question for you. that is who is a driving rehab specialist?

i am going to wait and see if the party questions don't cover any other aspects i would have had for you. describe how that varies the state by state, a specialist -- ve state-by-state. >> it is difficult to answer. part of it has been the evolution of the field. driver rehabilitation is a professional that has been trained in how to treat driving. there is the association for driver rehabilitation specialists. the field addressing driving involves occupational therapists. and also involves driving school educators and includes rehabed engineers and the occult modifiers. there is a constellation of

professionals involved in this area. >> are they tested and certified? >> the association for driving specialists as a test that gives credentials. this make sure that person has a basic understanding of driver rehabilitation, but it is not specific to any other field. they have a certification in driving and community mobility. it make sure the occupational therapists understands the evaluation and the mobility counseling to transition somebody from driving to a non- driving. being able to address getting people off the road as well as keeping them on the road. >> thank you.

>> we will move to the panel and we will begin with the first table. if you could just identify yourself by name and organization. >> i am with the national transportation safety administration. a question for dr. richard marottoli. are there protocol's available for physicians screening of patients driving ability -- the analogy is screening intervention for alcohol abuse problems. a number of validated tools are available for physicians. the availability of these tools has fostered the growth of the screening and options for

treatment. are there similar tools available for clinician use for evaluating driving ability? >> yes and no. there are many tools available to many of which have been validated, but usually those are four individual components or a relatively small sample. there are a number of composite measure is. the ama composite measure mentioned before is based on individual alamance, some of which have been validated for their driving relevance. the entire group and has not necessarily been looked at but some of the individual components have. that is the limitation that comes up. there are individual elements that have been done but not a

multi dimensional process. >> thank you. >> are there other questions from your table? question. could you say something about the incentives and disincentives for physician reporting to licensing authorities? >> the incentives are easy, there are none. we did a study where we specifically asked and there were 200 respondents and ask them about this issue. the one positive for was that this sense of obligation to

safety and public health. that is a very real one. people who do participate do that and they truly feel they are at increased risk and feel they need to intervene to protect that person. there are some positives to that. those are often outweighed by the many negatives of that. one is the opaque process in place. two is the negative affect on the doctor patient relationship. this is something that most physicians hold very dear. the nature of reporting typically changes that from being an advocate to more of an adversary. many clinicians are ness -- reluctant to make that transition. third is the practical aspects of what they assess and how they gather that information and

the timing of that and the costs. that does not necessarily reflect the reporting aspect. >> are there screening tools available for family use? have these been validated? >> there are a number of them -- there are a number of materials available for families to help them think about changes an older driver might be undergoing and how to initiate conversations about driving concerns. there are also several self screening tools that have been developed over the last few years. although it has not been tested about the affects on a family members. one idea is that these tools can be used by older drivers to

initiate these conversations. what the research has shown with regard to screening tools is that they represent a special case of screening in that their best strength is for increasing self awareness among older drivers and generating a general knowledge about declines people might be experiencing. the impact of these declines on driving and recommendations for further evaluation. unlike other more rigorous screening tools, self screening really focuses more on increasing self awareness. some of the studies that have been done looking at how well the outcomes of various screening tools predict real problems on the road, and find a

statistically significant and modest correlations between the tools and driving. some screening tools have not been evaluated at all come up but i think there is a enough that is positive that shows these kinds of screening tools to have promised for increasing self awareness. >> another question for ms. davis. it seems changes in driving ability might be better assess over a period of time rather than a single point. would it be feasible to requirement to serve as a baseline for drivers to assess against over a period of time. >> that is an excellent

question. if we had our wish many of us wish we could get these discussions to happen earlier. then ade gives us time to plan, to think about transitioning from driving. certainly what we are working on in the occupational therapy is increasing the role at the clinical level or the practice level to identify driving it as a concern. having read flags that show concern -- and starting the discussion that we do for financial planning, housing planning. we should be thinking about driving planning. at the medical level we can start helping people understand how changes might be heading in that way. people are living longer with medical conditions they did not drive witte so long. if we can intervene earlier and

help people have strategies we believe they could be on the rope walker and enhance their ability to be self aware and be the leader in helping decide when the time is right to make that change. >> thank you. one more question about evaluation. it seems that aging-relating driving deficits may appear under stress rather than in less stressful driving. do the driving evaluations conducted by therapists typically involved stressful situations such as heavier traffic, faster decision times, but darkness? >> that is an excellent question and is something debated right now.

as many areas are working towards having a more evidence- based criteria for how decisions are made come at the same is true for driving. i think that as they practice stands right now the experienced driving a rehabilitation specialist would like to take people on the road to give them real life experience with traffic conditions and try to challenge them in planning and find where you last worked. there is some look at simulators and be able to give more challenge, but we are not sure if people are reacting in those simulated situations in a realistic enough way to make a decision about their driving competence. we try to at the appropriate challenge we think is safe for the driver and tester. >> thank you.

the question for dr. kramer. the cognitive training is interesting. could you give a specific example of the theory of the relevance of cognitive training? what is an example of a driving deficit that could be addressed by a type of cognitive training? what would be the desired outcome? >> there could be a number of examples. as we get older we are slower to respond, slower to restrict them permission from the visual environment -- slower to get information from the visual environment. these programs have often tried to force it further out in the

periphery. there is some evidence you can train days aspects of visual perception that we know decline as you age. there are many other aspects that decline, not just visual sensory function, but decision making ability. these other aspects of cognition that show cognitive decline have been addressed less frequently with the driving-related training. >> that concludes our questions. we thank the panel for their interesting presentations and answers to the questions. >> we will move to the second tabl >> good morning, with me is -- thank you very much for all the information you have shared.

we have a couple questions for you. you talked about assessment and cognitive training. for the panel, i would like to know what your opinion is on the benefit of older drivers taking a refresh her driver safety course. >> i will take a shot at that. i think they are very useful. they have all lot of validity in terms of the content. if you look at these studies of the actual benefit they are variable from slightly worse do better. there have been a couple of studies that have added training to that sent on road training. those have shown consistently positive benefits. i don't think the mixed data on

the classroom alone is a detriment. there is useful information that can be provided. it raises the awareness of getting back to the issue of making people aware of what they need to attend to. there is a lot of information provided there. there is also an insurance discounts that goes with that. i think there are many potential benefits for that. i think they can be tweaked to make them more beneficial. >> i would like to respond. yesterday we heard a great deal about self regulation of driving as a way to compensate for declining abilities. to self regulate appropriately, people need information to become more self aware. i also see the driver training

courses as a forum for generating discussions among people. >> i think richard marottoli was being humble because one of the excellent studies was his in which he combined class room training with on the road training. in looking across the literature to prepare for this panel i did notice the studies that combined the instructional training tend to fare better in terms of the outcome of variables. if we are looking for programs that might be useful knowledge might be useful but so is feedback with someone useful to provide that feedback. >> if i at -- may add one more comment, strategies and

intervention are not a one size fits all. in site-based programs are excellent for the majority of senior drivers. we need to help families and persons with certain conditions where they are not a good match that is probably the group with dementia or cognitive impairment. we cannot expect families to be using an insight-driven approach to expect that change. it is important families understand what can be good for many might not be the right thing for their situation. >> since vision screening does not insure treatment what do you recommend for a vision assessment and improved vision function for the aging driver? >> we are missing our edition person today.

-- missing our vision person. it is a bit tricky because the associations were the most common measures are relatively weak, but in terms of face validity it has a relevance to the driving task. people are also very familiar with it. it is reasonable to have a general standard on that. the question is what to supplement that with? the visual fields would seem to be the two most likely candidates with familiarity to the general audience. it depends on where you do those because not everywhere can do them accurately. the visual cue can be done anywhere and everybody knows how to interpret it. it is difficult when you

quantitatively measure visual fields. you typically need a specialized chart, but you could make those more readily available. a combination of those have shown to be beneficial in terms of identifying people at risk and terms of full risk as well. >> just to respond to the questions about over restricting, vision screening is a help screen for the health of the eye and getting them to get a new classes prescription is oftentimes -- for some people that is where they get the trigger they need to get that assistance. there is a specialized field

called low vision driving. in some states the guidelines allow for an exception when people have training in lopez and -- training in low vision driving. sometimes people with low vision want to know what states they can go to said they can meet the criteria to be able to drive. >> thank you. a couple more questions. doctors are reluctant to tell patients they should no longer drive but occupational therapists are trained to do so. how can we get more doctors to work with occupational therapists? >> one is to make people aware, like the first question on what is a drs?

many physicians are not necessarily aware of the different therapy and what the distinctions are, so many people cannot distinguish what a physical therapist does from an occupational therapist. the niche of driving rehab specialists is not recognized. one is making people aware of what they do and what the benefit is too dark patients -- benefit is to their patients. there are many reasons for that. the main one is being economic. even in our area many programs have closed and have transitioned to occupational therapists to doing more traditional occupational therapy because of the costs of the program.

it is easier for them to get paid and make more money. their access to those people is much more limited. it is recognition-enhancing the way those are compensated. >> it is not based on no need, they have been closed despite having the need. one of the things we have been doing for the american occupational therapy is educating all therapist about driving. we cannot always expect physicians to understand the difference between our specialties, but we need to identify driving by all practitioners. i forgot to mention this when i asked you to put this up before. it is just the idea that we are working very hard that all

occupational therapists are addressing driving as an instrumental activity. if there are concerns flag they will be referring to a specialist. we have a chicken and egg problem of getting more programs because we need people requesting them so that we can get more programs to grow. using deede beginning with the medical model, the screening for driving is part of our typical evaluation. that is educated into the sub specialty area that we have variability for reimbursement. this is just describing all of these are different things occupational therapists can do. not unlike ontology where other things are handled by a number of people and you send people to

the specialist when we have identified that is the right place for them to go. as we get more efficient at getting the right people and it also helps make it more financially inappropriate. >> do insurance companies pay for the evaluation? if so, how do we get more insurance companies to buy into this? >> reimbursement is variable. it is an answer that does not please people but it is true. it varies by state and interpretation of these statutes. some areas have a reimbursement for occupational therapists performing the complete evaluation, particularly when they describe it by its functional components. and in other areas titis sometimes for convenience they have -- it is sometimes for

convenience they have asked people to pay for it privately. what can help is demand of trying to make sure we are getting reimbursement for the areas that fit well within our practice. >> thank you very much. >> we will go to the third table. >> i am joined by kelly. first question is three parts. the panel stated there is no one accepted screening tool. what does the panel recommend as elements of a model system? what elements are known to be ineffective? will the public you a screen as profiling, specially in minority

communities? how can this be mitigated? >> i'm thinking in terms of what would be the optimal screening tool. i think the challenge is the science right now lags behind the need by practitioners for tools and procedures they can use right away. we have talked about the various functional abilities that are important in driving. i think i have a slide on the study which is some of the early work that came out with a screening tools for licensing agencies. that study identified a number of functional abilities that are

associated with crash risk. it also identified a battery that had a number of tests for those abilities. that is one starting point that we know we have to look at the kinds of abilities that relate to driving. part of the challenge in implementing the licensing agency has been -- there are a lot of other considerations with the restraints on time, constraints on the resources available. but we do need to think about which abilities are related to safe driving and start there. similar to what dr. kramer spoke about in terms of evaluating cognitive training programs, in thinking about coming up with a good screen we need to think about the kinds of research that

is necessary. unfortunately that research is usually very expensive. we need more longitudinal studies that have sufficient samples so we can reach meaningful conclusions about the impact on the crash risk. we have not been able to do those kinds of studies, although it is very promising there has been a lot more collaboration in recent years. there are some research efforts under way to try to get at what would be the best screening tool that could be done in physicians' offices. that research is carried out by a consortium of canadian resources. they have funding for five years. they are using a sample recruited from seven sites across canada and australia and new zealand.

they will have sufficient numbers of drivers they can test a screen they are identifying and look at crash risks. i think that is really exciting. hopefully in the next few years we might have some more definitive results on that. >> i think one of the best protections is making sure screening is screening and it does not become an evaluation. we have to recognize the context where the different screens occur and the scope of them. if we develop scanning tools they should be referring someone for the next level of expertise. it is karie important. i don't support screening everybody for things. i think that is too costly and

probably not warranted, but we need some kind of different entry points. obviously you will have a different tool at the dmv than at the physician's office. these all might be entry points. they might be places where screening tools might be used, but we need to ensure we are getting people to the right service so their needs will be met. they won't be over restricted. >> just follow up very quickly. i wanted to add i think these issues of sensitivity are key. we have a lot of screening tools. the research can inform about what are the effects of different points? ultimately policymakers have to decide what is acceptable in

terms of sensitivity and specificity. is the screening tool identifying all drivers who would have failed a road test? they also identify a number of people who passed the road test and passed those people on as well. those are considerations policymakers need to think about and what is the trade-off between the potential for losing mobility or forcing people to incur considerable costs for evaluation that may not be necessary? >> one of the difficulties is a multi-factorial issue. it is hard to come up with tests that will cover the full range of that.

getting to your last point which is the trickiest, the issue of profiling. i don't think from the perspective we usually think of that in terms of racial or ethnic, but age is the equivalent in terms of a visually identifiable or other things in terms of selling out individuals who would undergo screening. that becomes a trickier aspect. the question is, how do you identify who is at increased risk and move that person through the system into more detailed assessment? >> ok, when drivers are presented with information suggesting they may not be safe

to drive what resources are available to transition them from drivers to non-drivers? >> >> i will go. it varies from location to location. in some places there are none or very few. part of the difficulty is it is hard to generalize. one need to think about what those resources are and what the possibilities are based on that person's own social network. the question is who does bad? does anybody do that? that is part of the problem. there is no readily identified individual for home that responsibility falls. that is the biggest gap. can you muster those resources?

in many places you cannot. it would help to have a standardized way of dealing with it. >> from a research perspective, but it is been gratifying to see there is more emphasis research to help facilitate the transition from driving to a non-driving. the doctor talked about the work she has done on putting together a support groups for drivers with dementia towards helping them with driver retirement. we need to have more evidence- based practices about what are effective ways to help drivers transition. we need to have something for drivers to transition to when they are no longer able to. there was a lot of talk about focusing on providing alternative transportation.

in new ways that are acceptable to people in it available in areas they live. also making that information available to people. i think there is a lot of discussion about who should be responsible for doing that? we had a licensing workshop a couple years ago sponsored by aaa. we brought together 40 experts from around the country. the consensus was licensing agencies do need to think about how they can also participate in making the resources available. it is a community-based approach. >> speaking for the occupational therapists and the rehab setting come out we are capturing a lot of people facing medical difficulties. we are working with a therapist

to move from identifying a person should stop driving to how else they will get around. there are a number of tools we have been distributing. the beverley foundation has come up with a dimension-friendly calculator to assist what public transit options would be appropriate and what safeguards would need to be in place. there is a field that has been gaining strength called mobility management trying to help match people with support services they need. travel training has been gaining. there is an interest in gaining support. easter seal has a program to try to bridge if a person should be using alternative transportation they might need to learn how. i think the issue is where we

find ourselves saying it takes a village. we need a number of professionals in different areas. if each community works on trying to have a network of services, we hope that will be a way towards a solution. >> we will go to the last table. >> i am with the american association of motor vehicle administrators. barbara is from the governor's highway safety association. our first question is why haven't we made progress in developing screening tools that have been generally accepted and widely used? can there be anything done to expedite this? >> i guess i will start.

i think we are making some progress. some of the more comprehensive studies under way. but some of the challenges are that the research that is needed to come up with reliable tools is often expensive and time- consuming. we are not always able to do the kind of randomized trials that are the basis of work in other areas. we cannot necessarily randomly select older drivers. older driver research often depends on recruiting volunteers. then we get io a self selection bias. there has also been some disagreement on the best way to

validate measures. what is the gold standard for looking at outcomes? should it be crash risk? should we differentiate scores by crash involvement? then we need large samples. what is the river required? there is still -- what is the rigor required? also, it goes beyond just having reliable screening tools. we have all of these other constraints. we have talked about licensing agencies facing constraints. physicians have a small amount of time with patients. driving evaluations are expensive and we don't have enough specialists. there a a lot of these

different issues that make it messier than in other areas. >> a lot of the same methodological issues describing before applied to a screening as well. unique individual and parents of sufficient prevalence and depended on the outcome uni a large enough study. if you are dealing with an uncommon condition and uncommon event such as a crash, linking those together requires a large sample to do that. part of the problem is gathering that. some of the best efforts have been a state-based. they have a large number of drivers coming through and having the records available to monitor that. the downside is gathering that information sufficiently,

particularly if you have a limited amount of time you have less detailed information on them. gathering that information, putting it together and considering larger scale studies is the way to try to narrow that. >> is there a danger in using screening tools that are not evaluated? are these better than no screening at all? >> i think that is a tough one, because i think there can beat negative consequences when screening tools are not valid. they can either cause someone to worry when they should not or worry when they should. i think it is a dilemma. people need resources to use.

if the science is not there -- i think with screening, that is one reason it is so important to confine the outcome of screening to being best first step and not to use it as a licensing decision. that would be extremely dangerous. >> just hesitating as we push. there is a danger to labelling. it does have a tendency to stigmatize people. we have not really delved deeply into the issue of dementia, but it is something that is fraught with a lot of banks. if you label someone as being in. -- somewhat as being impaired,

that can adversely affect them. not to use those terms loosely. there is a wide range of ability within any capability. even when we get to dementia there is a wide range of manifestations, many of which may have no affect on driving capability until later stages. the difficulty is not labeling based on the presence but using that to work but not necessarily stopping at that level but figuring out in more detail what the meaning of that deficit may be. >> i wholeheartedly agree and say cell screening tools run the same risk. just to be cautious about over interpreting, they could be very valid and we have no control for

people who are using them and we need to be careful for the language we are using people about what the results mean. >> i want to echo what was just said. self screening tools are intended for people who are cognitively intact. they are not an appropriate instrument for people with dementia who lacked insight into their abilities. they can be detrimental if they are reinforcing -- the driver is safe to drive when he is not. in using itself screening their needs to be communication within the community of professionals about who to recommend that self screening to and to make sure both lee it is done by people who can appropriately use it. -- make sure people can appropriately use it.

>> when we are talking about screening assessments, are there any markers that identify those that may not be qualified to drive or those that could continue to drive? >> >> can you repeat the question? >> when we are talking about the screening tools, are there any indicators that would identify those as disqualified or those that would continue to drive? >> i think some of the word is trying to -- lapping of the ends of the curve. people that don't have any impairment in these areas of vision and cognition at the time

of the screening. that might be enough to make that determination. the clearing severe and mild to none decisions could be made. that does not push them to the next level. making sure that people fall within a gray area with that have the next level of access to looking more specifically at their needs. i'm not sure if that answers the question. >> could i restate that question? are there some tasks more predictive of driving than others? is that what that is all about? it could just be a yes. >> yes, there are different

aspects and different domains. there are different ways of going about that that have been demonstrated to be linked to driving performance in the crash risks. there are a range of different measures that we have talked about that are linked to those. the difficulty is narrowing that down to a simple measure. >> in one of the previous slides' looking at the battery that came out of the maryland work, there were six abilities with ratios ranging from 2.6- 4.9. all lot of those had to do with visual search. they're at least is some empirical evidence that is relatively strong.

>> these are the abilities that have ratios of 2.6 a to 4.9. >> the rehab specialist -- areas in the domain of cognition are probably looking more toward the severity towards stopping. you can have a very severe physical and parents and compensate them through equipment and vehicle modifications. >> here is my last question. we use age as a marker all the time with medical screening. i turned 50 years old and my physician assistant -- i am at

risk for certain kinds of diseases. and yet we always hear function and not age because there is a concern about age discrimination. is there any reason we cannot determine age as a factor when we begin screening? .

i think in the general category of old age, there is tremendous -- in anything that we measure. >> there has been some research done on looking at age based mandatory screening in licensing agencies. some of this has come out of australia. the only safety benefit was a study that found in the renewal. there is widespread consensus

that this should not be based on age. at the recent scene -- licensing workshop, one of the things that emerged was that there might be some room for age-based screening. having in person renewal at a certain age said that people would have to come into the licensing agency and be observed. >> thank you. >> a couple of quick questions, and number of these individuals who might be at risk will come to the attention of their physicians.

what formal training to physicians receive either through school or state requirements for residency programs on how to address drivers? >> no formal training her. this is whether they have training in a geriatric field. that is where the bomb blew out reach that is happening -- that is where the outreach is happening to try to reach practicing clinicians and more recently physicians in training. if you raise the issue with people and i encountered this all of the time, the issue comes up a lot but there is not any

background information that has been provided. >> to what extent is this getting out to the physicians? >> i think that there has been an effort to do about reach with this both on a local level and more broadly. i think that it would encourage continued effort to get that information out there. as more of the information becomes available, that makes it people -- easier for people to gather information. there is an awareness of the fact that that information is there. the original of state of that in 2003 the availability.

>> it was mentioned that one of the problems really is dementia and associated neurologic impairment said. many people are aware when their vision starts to fail or when they become uncomfortable behind the wheel. to what extent is that really the major problem. their impairment prevents them from identifying their own impairment. >> awareness deficit is common to many changes.

this affects their consciousness to some level. this is true of their physical ability and cognition parent of the major difference is that with physical changes and visual changes, one can be made aware of those. if things are pointed out, you can affect changes in people who have dementia and drive if you don't want to explain what this is. it is a matter of the identification. you will have the identification of the deficiencies and then you will have the discussion. this is an area of focus because of the inherent lack of awareness.

>> can i have this slide? one of the things i have been worried about is that i have been thinking about stopping driving. the panel talk about self awareness, self-limiting behavior, and people making good choices for themselves. screening efforts should be for the majority except for the subgroup dimension. this is an education program. people are afraid it to make sure that their seat belts are right.

they're trying -- they think that "if off people -- our goal is to help people live stronger. they are afraid that if they expose themselves, they are putting themselves into the possibility of getting their license taken away. we think that we are all of lifeless and testing that we want people to drive safer longer. we want to make sure that we are doing the right and just thing. >> you have been talking about remediation for of sense that

occurs in people's lives. one of those that you mentioned early on is franklin roosevelt. there is a fairly easy solution to that. yesterday, we also talked about technological solutions to a number of these problems. we are not quite as far as having the car drive you completely where you could sleep on your way to work but there are potential solutions in the near future that might compensate some of the things you have been talking about. the cognition issues are pretty difficult. there are other solutions. to what extent do you consider in looking at screening or assessment tools the availability of the

technological solutions that would take that issue off of the table? conversely, if you know the extent to which engineering companies are looking at your materials to try to find the solutions to your problems. >> at the technological advances hold promises for people who are charged with various medical conditions. off the top of my head, early on with dementia or a cognitive loss, there is a high risk of getting lost. how we can have a system where people can use technology. maybe that will assist with how far we can wait for a person to

drive some diminishing abilities. they might be able to assist them with the fear of getting lost and not knowing the directions. there is promise for these technological aids for us and i know that i have had some conversations with local manufacturers. they're trying to consider the needs of the agency here and their vehicles. >> i worry and little bit about pushing too hard in technological solutions. the reason i am saying this is

that there's something to the old adage of "the use it for to sit -- "use it or lose it." >> we need to tread cautiously. we don't want to do over engineering all will lead to rapid declines and a decline in cognition. we don't know if this is a possibility. >> i do think that there is an opportunity now that we have advances in technology that allow us to get objective tracking data on people to possibly use that technology to provide implementation to people about their driving. we have been involved in a couple of studies at the

university of michigan using vehicles with people with early stage dementia and having them drive as they normally would for a couple of months and collecting their data on their trip-taking, their exposure, their self-regulating behavior is. then we have been come back in and show them a summary of the driving and talk about the problems that they may experience. this is just some pilot work that we have done and i don't know where it will go in terms of actually being useful as a way to provide feedback. i would add that rather than thinking about using technology to replace screening, i think that what we need to move towards is much more of a systems approach similar to what is used in many other countries. for example, in australia they have a safe system approach and this is based on the assumption that drivers are always going to make an honest mistake and therefore they need to make the roads and the vehicles as

forgiving as possible. the hallmarks of those systems are safe roads, safe vehicles, safe speeds, strong efforts to reduce impaired driving so that it is more for life -- and we will be able to get more into the screening effort. >> we are not very good at doing individualized assessments. even though you might be subjected to some testing, i think that everyone likes that when you turn 50, these are the kinds of tests that you need. it is very difficult. we have established ages, this is when you go to school.

this does not matter you're development. this is when you start school. this is when you can drive, this is when you can drink. you might be ready to work for a lot longer but that is when these things happen. in this society, we are not well equipped and this is a colossal responsibility true tie -- this is a colossal responsibility to try. there are different parts of this that have to come to get there. we are not so good bringing all those different pieces together. when we look at transportation, we see a little bit of a patchwork system. we have a mandatory retirement age for pilots. maybe it is misguided listening to this conversation but it was recently aged from age 60 to age

65 but you have very qualified individuals who can perform the same tasks. they have medical exams on a regular basis. they're not so good in doing things in other areas because this will allow you to be screenedut early if it allows you to identify problems. what can we do that is feasible because that is a very small set comparatively of people when you look at 30 million drivers and it is not even clear what the right age is. what is an older driver? i'm not even sure when that starts. what can we realistically expect society to do as far as

screening and assessment? what i heard screaming, you are cutting off the ends of the curve. then you have to connect all of those things. once you do that, then they need to get a vision test or to an additional assessment. how do we make sure that those components are talking to each other. we have not done a very good job of talking about it and this has been going on since the 1930's. what will it take to get as to the point where it actually does work? do we need legislation? we do have fitting stations for child seats. all 50 states have them and have made recommendations about them to make sure they fit for kids. what do they need to do for older drivers. what will be the catalyst?

>> i think this is partly a scientific and partly a policy decision. scientific side, do they have high specificity? finding those that have problems in deciding that don't watch those that don' actually don't have problems. policy-makers will set those thresholds. it will probably not be the scientists but it often is and we can provide the information and data and it will be reliable. i am not an expert in screening but from what i've heard and read recently, we might not have those tests that we have this degree of confidence in with respect to validity and reliability. first, we need those tests and we need your help as government experts to get the funding to do the right studies.

we don't have sample sizes that are sufficient to look at the gold standard where this is crash probability or other standards. we don't have the studies over a sufficient number of years to do the longitudinal monitoring. meany different issues to be about to predict the outcome variables. i think the policy makers have to get involved and decide what cut off our corporate. until we have the scientific and the policy, i think we well as we have through chronological age to set various of vent times for vision screening or different type of screening that different states due at different ages. before we can get to use functional measures, we need functional measures that have signed to the credibility that we have confidence in and then work with the policy makers to decide what the costs are to send people in different

directions either for remediation or perhaps public transportation training. >> do you have any confidence that those longitudinal studies in the scientific community could agree on a measure by 2025? >> i think if the fighting is there to start the studies, we have heard about several studies, mostly in other countries, that are pursuing some of these issues. clearly, the funding has to be there. the national institutes of health has a number of consensus groups have assigned -- that have designed studies. this is for her normal aging. it is possible to put together groups of experts and this should not be won loud, this should be a fifth and fourth

life as to whether free-fall posted this stuff on the faces of -- >> if not all be on one group whether it is the clinical groups or individuals. i think having everyone to be aware of potential things that they can look for and moving forward and then setting the threshold at a very high level. the most impaired individuals

will focus on this and whether or not that should be move farther down and tel. and a lot of other countries that have systems approaches, the issues of older drivers are encompassed within a broader strategic vision. i have been reading the efforts towards zero deaf which involves trying to come up with the strategic vision for transportation safety. -- i have been reading the efforts toward floafter, the fih

of life from the flight first team and the fifth issue for a -- flex this makes it of shelf with a value if. --

>> i would like to give the example from the remediation side. there are some that would require a number of medication and there are some driver rehabilitation programs that help people understand the impact of those medications on their driving. if they are thinking about driving when they're highly medicated, to assist with self awareness and helping people that must take a number of medications be able to self- regulate and make wise choices because they're able to offer them that assistance. >> one of the challenges that you all identified is the role that physicians think they play. our concern is that we see in a

number of investigations, physicians for commercial drivers who feel that they don't have an obligation to report and they believe that their primary obligation is to take care of their patient and to help with their patient and trying to understand how you impart to them the societal obligation if someone has significant medical conditions whether they are a school bus driver or a passenger car driver. maybe i will close with a good news, bad news on the vision side. i think that this is kind of an example about how separated the system is and how many different moving parts. i went in to get my commercial driver's license renewed and i don't have any physical issues that would prohibit me from getting a license but i ended up having to go to an audiologist which is separate from an optometrist to get the vision

exam. obviously the lab, the screening, and all of these things and it is clear that all of these individuals are not talking to each other. it is clear to me for the primary person responsible for aggregating that information had not done what needed to to be done and as my top amateur sting one of the test that i needed to sign off on the form, i was a bit of a guinea pig. when i went into the optometrists, i asked him about a vision tests for older drivers. he gets referrals from the dmz. one of the comments that he made it is that it is hard for him is that he felt like all he asked to do was to read the chart and he said that many times he can read the charge but he cannot navigate around the

office and they cannot comply with directions when i'm trying to explain what they are doing. i don't have a role in saying anything. i think that this is an example of how difficult this issue is where you have lots of input. maybe people have good observations but it is really not a mechanism for that to perform that way. the different story on this is that my mother is one of those drivers that chooses not to drive at night, not to drive in bad weather, she is very comfortable having her friends take her up. she always has the keys to me whenever i come and visit her. so she says she does not see well at night. guess what, she had cataract surgery not too long ago and she called me on the phone and said, mrs. mccue can see.

i can see the leaves on the trees, i can see everything grade. -- great. i bet she will not go back and say, now i can drive at night and in these other conditions. she has 30 pulled herself down or she is not comfortable doing these things. -- she has already pulled herself down. i don't know the decisions that she makes after that. i would love to be able to see a screening program work for people like you said so that this can go in reverse, not only to take the people who need to be out but also those that need performance to get back in. you have made me think. this has been another great panel. trying to comprehend all of these pieces and put them together is the real difficulty that we have. i know that we have a number of other questions and we are a

little bit late on our schedule. i hope that maybe would be available for those questions that did not get asked to share with our researchers and a our team. thank you for being here and thank you for your questions. we will have the movie again. for those who missed it yesterday, i know you will want to see this. this will show at 12:00. we have a lunch break until 12:30. we will adjourn and come back for the last panel at 12:30." [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

>> congress returns this coming monday. members are expected to do some legislative work. they need to work and federal spending and there is likely to be debate on bush administration tax cuts that expire on january 1st. live coverage on c-span. off of the floor, members will let leaders. democrats and republicans will meet separately on tuesday. house republicans are meeting on wednesday and democrats on thursday. on on monday, the house ethics committee begins a hearing on

whether charles rangel violated ethics rules. the former ways and means committee chair faces a number of charges. live coverage begins at 9 eastern on c-span-3. >> there were people shorting the mortgage market, that sends a signal, they should be smart investors to think that this thing will crash and burn. you cannot see that the way that you can see it in the stock market. because the way these estimates were, you are not betting on real mortgages but you were working on a casino version of a mortgage. >> in 2003, bethany mcqueelean e about enron, now she will discuss her new book with us,

"all the devils are here." >> there's nothing in the u.s. constitution concerning birth, contraception, or abortion. >> argued in 1971 and ruled on on 1973, roe vs. wade is considered one of the most controversial decisions. listen to the argument at 6:00 p.m. eastern on c-span radio. >> earlier this month, the nation's highest court argued whether a state tuition tax credits by lace the constitution by going to a private religious school. we will play the oral argument in that case. this is about an hour. this is about an hour.

>> for 13 years, arizona has allowed private citizens to contribute money to private organization set up by private organizations and they use that money towards scholarships when individuals apply for them. if you placed an electronic tag to track and monitor that the plaintiffs to pay in tax, not a fraction of a cent would go into any religious schools coffers.

>> their point is that this does belong to the state and the private individuals are using because this is money that even by the new amendment says that either you pay this to the state or you use it for this purpose but it is the state's money and it is giving you bias by its right to redirect it. that is their argument. they're claiming that this is spent on religion. >> one has to do with injury. with respect to injury, our point is that as you track the taxpayers' dollars, it does not fund any religious program unlike other cases in which this court has considered taxpayers standing for religion.

their argument is that how the money is not being spent enough. this is "his tax money must be extracted and spent." in terms of the other argument as far as causation, it is specialty of whether or not that chain of events that you spelled out is that this court said that when a tax credit is given, sometimes it actually reduces the amount of money. that is the difference than the direct outlay that was a dead issue. >> we have a new system. here is what the system will be. the taxpayers who are religious will be able to check a box and the check that they send to the irs, this is cash to buy an

official and the cash is given to the local priest to say prayers for the individual the contributed the money. in your view, there is no henican chalice that. >> first, that is not that different. >> the difference is in the one case this is adduction and in this case you are paying at hundred% that otherwise would go into the coffers. does the government thinks that there's no one that could challenge that? >> i don't think any taxpayer could chalice that. i'm not sure if the government is specified which religious organizations might be eligible. -- i don't think that any taxpayer could challenge that. this is in texas monthly -- >> if you go back into history,

it would have been the case that as long as every religion, the first congress could have funded prayers throughout the nation in churches for anyone to go and pray and that would not have violated the establishment clause or if it had, no one could have challenged it. >> two things. we are talking about the standing and not the merits and with respect to standing, if the government funded only religious organizations or religious prayer, i think that other organizations would have standing not as a taxpayer because this court has been very careful to say that there is an extremely narrow exception for the taxpayers standing. but other organizations would have texas monthly's standing. >> what is the standing in your

view to challenge this scheme? >> i would think that this accords with the general elections to convert texthere standing in this area. >> if we leave out the points that you were discussing, isn't the underlying premise of that that the establishment clause will be unenforceable unless we recognize and taxpayer standings? >> i don't see that. i think that this is a very narrow exception for when someone's dollars are being taken out of their pocket and spent by the government on religion and i don't think that that is happening. >> there is nothing more because it just happens that no one has bought of this system at the time. >> i don't think that this is

gone at all when there is direct outlays to spend on religion. >> all you have to do to get around it is to create what we have here. >> i think that it can get around it in some circumstances. those who are under included in a government program might have standing by to at the end of the day, it is the results for every other clause in the constitution. taxpayers standing is the most narrow of exceptions. >> we have a bill of rights and most provisions have plaintiffs who are hurting as beecher's being suppressed. this one does not have this. this is within the constitution like many others. i thought that that was the problem was to last we saw. >> i don't see that but i think

that this court was very clear to say that if at the end of the day you cannot find the plaintiff was standing, that is not an excuse to relax the general requirements in the standing and if you granted the plaintiff standing, what you would be granting is a tax credit which is a complaint about someone else's money not being spent. >> they were not allowed to decide kinds, mueller, this very case just a few years ago. somehow, no one on the court recognized that fact nor did d s g participate. -- nor did the solicitor general participate. >> we will have to deal with this exact problem. they have conferred standing

case after case and then and when it was presented to the court and the question about article 3 county, the court said we should not have granted taxpayers standing. my answer is yes. i think that this reiterated some of the fundamental principles and the limits on flask and it it is clear that it would go no further. he would have to go tremendously apart from what this is about, a direct outlay of funds and taking money someone out of -- out of someone's pocket to find religion. >> you said the answer is yes. you agree with the criticisms of those cases and yes, they were wrongly decided. >> the results may have been the same but it would have been on the standings instead of being

mayor its parent of a bottom- line decision would have been the same but the way the court got their -- that would have been no standing. >> no taxpayer standing. texas monthly standing could have been issued -- >> i don't remember that the government participated when this came up under the tax incentives. >> we did this. >> there was no word from the government about the lack of standing and ignore list of the fact that standing has not been pushed but i acknowledge that they will be brief as they are here. >> our point is not simply that

the cost of the program is speculative, this is also the relief that the plaintiffs are seeking will not reach us their problems. if you gave them everything they are asking for, the very same religious school and they would continue to be funded, they would continue to be funded because they would leave in place the tax deduction and so there would still be government revenues being spent in favor of these religious programs. this would be 1/3 instead of 100%. i don't think that that satisfies the problem. i don't think that james madison would agree. the principal is what matters. >> thank you, general.

>> mr. chief justice and made this please the court, there is a tuition tax credit and this does not violate the establishment clause because this is a lot that results in scholarship programs of private choice. like the tax deduction. a5and there are tax credits available on a neutral basis. >> can you tell me why arizona adopted this sort of scheme rather than the more typical tuition voucher to for this gives them the voucher or what

have you at this is so much more complex and unusual and i am wondering why this was chosen or what the state thinks the advantages are. >> one of the things is true in arizona that was not true in ohio is that under the arizona constitution, any direct aid to private schools is prohibited. the other thing about the tax credit program is that it does encourage contributions not only from parents bought from the community at large and this provides money for low income students, students with -- >> does this show their nations with people who cannot have students?

>> there are some reports that have been done that show that there has been some children that have switched from public schools to private schools as a result of the program. many of the scholarship programs, in fact most of the scholarship programs provide scholarships based on financial need. >> i don't think you answered his question. the question is, is anything in the record that shows whether any of the money that is involved comes not from parents but rather from others who can contribute to the program? >> what the record shows is that there is a large amount of contributions.

there's $55 million. the department of revenue report says that this is the number of contributors and to contributes are not the individuals to contribute. this does not specifically line out to the contributors are, whether their parents or not parents. >> i suppose if some of the contributions are considerable like a billion dollars, that cannot just be a parent, right? >> you are right. >> are their contributions of that size? >> again, the record does not show what the size of the contributions are, it shows the number of contributions and the total amount. >> if you give a million dollars, you only get a five and a dollar tax credit, right? >> that is collected. if >> the programs are programs

of private choice because any assistance that reaches religious schools, that is after four levels of a private decision making. arizona sets up the rules for the tax credit and after that, private individuals and organizations takeover. anyone can perform their position and the increase in the number and diversity of school tuition organizations over the 13 years at the crest -- the tax credit has been in existence demonstrates the fact that this is -- >> arizona probably spends millions of dollars on public schools.

let's take 40% of that and spend it on religious schools. it on religious schools. people might get into considerable discussion about whether this qualifies or are they just teaching religion and what the rules and regulations are, how is arizona dealing with this problem? is there a system for dealing with the legitimacy and circumstances under which schools qualify for this program? >> under the tax credit program, the schools have to be qualified schools and order to participate and that must be a set of regulations and rules. primarily what it is is that private schools in arizona satisfy the compulsory education laws as well as they meet the

requirements that this public schools have and terms of providing qualitatively the subject matter. >> those standards have nothing to do with this program? they are standards of any private school must satisfy to satisfy the educational requirements of the arizona? >> that is correct. >> what you have to do to be a school is a very complex thing. you have all kinds of requirements that eat up quite a bit of the day. i wonder how the religion part fits in as it turns out to be. when do they do this? did they teach religion at 6 in the morning? does it matter if a person is qualified? i once had a case on this and it

got to be surprisingly complex and i just wondered how the turned out to be any problem at all in this area. >> the record does not reflect that and i am not aware of any problems with private schools in arizona and certainly have not arizona and certainly have not participated in this tax credit program. >> suppose that they discriminated on the basis of race. suppose there is no federal statute on this. would there be a constitutional violation? >> if it was a private institution -- >> this is an s.t.o. --

>> this is a private institution. >> with this there is no state statute and no federal statute. >> unless the discrimination could be attributed to the state and the stage direction. >> don't you think that it can be attributed to the state? they have rules about what -- has to be and the state provides the mechanism through the credits and the funding. >> limits for funding -- >> i assume there is a tax deduction for contributions to churches. >> yes, your honor. >> many discriminate on the basis of religion, don't they. does that pose a constitutional

problem? >> know. >> what about the answer to my question. >> well, your honor, you have said that they are sufficiently private. -- well, your honor -- >> you have said that they are sufficiently private. >> this is a private school and they are discriminating on the basis of race. the question is whether they could have tax-exempt status so they could have donations to them. >> yes, your honor. the department of revenue could preclude the university from having tax-exempt status because that violated public policy and therefore they were not entitled to tax-exempt

status. to hear all of these organizations are tax-exempt, they would not be able to discriminate based on race. >> i will ask justice kennedy's question in a slightly different way. if this was just a straight program, the state could not give tuition doctors on the basis of religion. if you are a catholic, you don't get these factors. what the state has done here, apparently, is to set up a scheme that uses intermediaries that make exactly that distinction. they can say, sorry, if you are a catholic, you don't get the scholarships. why should the state be able to do that? if the state cannot do it itself in providing tuition parent out of shelters, on why should they be able to set up a system using intermediaries that

exists for no other reason than to it minister this program that can make those distinctions? >> -- for no other reasons than to administer this program. >> anyone can set up a school tuition organization. these organizations that support purely secular schools are in existence and there has been no problem sending those up. the top tend to provide scholarships to any school of the parents choosing. >> the plan discontent and this is a motion to dismiss, there are some that make these distinctions that clearly would be impermissible if the state administered the program. these are not existing charitable proses -- programs or schools, they're set up solely

for the purpose of the minister in this program and yet the state has said that they can make distinctions that the state itself cannot. >> there was one school tuition organization that administered the test credit and certainly the private schools that participated in did exist before the school tuition organization. what this program allows private organizations to do, it allows parents to get together with private schools. >> you said that there was a school tuition organization before this program. the money went to arizona, not before the school tuition

organization and before the scheme was traded. >> before the scheme was traded they would have gotten a tax deduction instead of a tax credit. there is not a significant difference between a tax credit and a tax deduction in terms of constitutionality. the only difference between a tax deduction is that for purposes of a tax deduction, it depends on the tax bracket of the taxpayer where as the tax credit, the value is equal for all taxpayers that 0 the taxes. a court has never made a distinction between tax credits on the one hand or tax exemption and tax deduction. under the respondents theory, any money that the government does not take in would then be the equivalent of state money.

that would then undermined charitable organizations. what you need to look at when arizona decided to give a tax credit for this is if they were thinking if this is a worthy public purpose to not take in certain money. . .

>> thank you, counsel. >> thank you, mr. chief justice. may it please the court, i voted to start with the statement that if we win this case, we do not get any relief because as much money would go into religious education as those now. that shows you do not understand our claim. our claim is not that state money is going to religious schools. our claim is that state money is being given to the beneficiaries of a state spending program on the basis of religion.

it is a claim about discrimination in the distribution of these state funds. >> i get it, but the school this seems to get the most money on the list does not appear to be a religious school at all. it is not even discrimination between religion and non- religion. it does not favor religion at all. >> i did not say it favored or disfavored religion. >> what is your problem of the establishment? >> the problem is that government benefits and government benefit programs cannot constitutionally be given to a program on the basis of their religion. if a parent comes to one of these -- >> we have a government program that gives out money indiscriminately to organizations that provide hospital services, it would be unconstitutional if that

included organizations that were religious organizations as well as religious organizations that were not. that would be unconstitutional? >> let me clarify. you must give the money to the beneficiaries without taking the beneficiary pose a religion into account. >> how does this take the beneficiaries religion into account when the program works perfectly and exactly the same way if it is a non-religious school? they do not care whether it is a religious school or not. >> because the sco's are giving government funds. they are on the government's behalf distributing tax revenues. >> i did not think that was my question. how is it discriminating on the basis of religion if the government money does not care whether it goes to a religious school or not? the most money is given out our

organizations that do care. >> the state does not care whether it goes to a religious sto or secular. >> that does not matter. if the grand he cares, that is unconstitutional. >> when you have the decision made by a private entity whether to use the money to go to a religious school or nonreligious school, that does not violate the constitution because the decision is not made by the state. it is made by the private organization. >> i believe the court said the decision was made by the grantee, not the government. the government program -- grantees were given funds to educate adolescents in sexuality. the court held that although the program was constitutional on its face because -- it was not unconstitutional because religious organizations could participate, it would be

unconstitutional with those organizations distributed the benefits of the program on the basis of religion. think about a headstart program. suppose the government sets up that the head start programs in a particular community. they are all run by private organizations, some religious, some not -- >> just to get back for a moment, the entities that were distributing the funds could be private or religious? >> same as here, yes. >> the entities were not identified. the recipients of state funds were not identified as religious or not? >> i do not understand. i think the court held that if the grantees were to give out their services on the basis of religion, that would violate the establishment clause. >> do we know that the schools

here do that? do we know that these religious schools do not admit people accept of a certain religion? >> i think we do not -- we do know that, and the complaint alleges that. the board is not what the religious schools do but what the sto's do. they are government grantees to string government funds. the constitution prohibits organizations that distribute government funds as part of a government spending program -- >> it is a great leap to say that it is government funds. any money the government does not take from me because it gives me a deduction is government money. >> this is money that the government takes from people. this money has never been in the government's coffers. the government declined to take this money. >> it is money raised by the state income tax. every tax credit dollar is a dollar that has to be paid either to the government as income taxes or to an sto.

>> i give you credit. you say in your brief that there is no standing and no violation, but i must say i have some difficulty that any money that the government does not take the government does not take from me is still the government's money. let me ask you -- if you reach a certain age, you can get a card and go to certain restaurants, and they give you a 10% credit. i think it would be rather offensive for the cashier to say, "be careful how you spend my money." [laughter] >> no, it does not. with respect, the money involved in this case is money that is generated by imposition of the state income tax, not by non-and position. if there were no state income

tax -- >> would you say the same thing about a tax reduction? -- tax deduction? that is the government's money? >> we are kind enough to give the taxpayer a deduction for certain contributions. >> when a taxpayer makes a charitable deduction, that is made from the taxpayer's money. at the time the taxpayer makes that deduction, the taxpayer can do whatever they want with that money. that is not true of this tax credit. at the time the tax credit is taken, the taxpayer owes the government $5,000 in state income taxes, and you have to pay that. you cannot keep it. it is not your money. it is not that all of your money is the government's money. it is that this $5,000 a year or the government in income taxes -- >> why is that not true of the tax deduction also?

this is a modest credit, the tax deduction a wealthy person would get by making a donation to a college or university with a religious affiliation is much more valuable than this $500 credit. >> when the taxpayer makes a payment, the taxpayer is paying their own money. when you make a charitable contribution, you are using your own money. you not know how much money goes to the government until you figure out your taxes. this credit does not come into play until you figure out your taxes. >> back up. it is december 31. people know exactly, they can know exactly what their taxes will be, and if they make a deduction, then it will be x minus y.

what is the difference? >> to me, the broad differences that the tax deduction is given for charitable contribution, and i think the court will decide -- i do not think it has ever had to -- that it is constitutional for the government to support ivate charity, and if the government is going to support private charity by letting you deduct charitable contributions, you cannot leave religious charities out of that program. that is a violation of the establishment clause. so if you believe a charitable deduction in income tax is a constitutional thing to do by supporting private charity by picking up part of the tab, then you have to give the deduction to people who contribute to religion. yes, there is government support for that private charitable contribution, but it is a charitable contribution. the money in this case is not a charitable contribution.

it is not the government's money, then whose money is it? the taxpayers' money? no, and if you do not take my word for it, look at what they say on the web sites about this program. one says quite frankly that you can give charity with someone else's money. another one says that it will not cost anything. you can give shared with other people's money. >> what difference does it make what they say on their web sites? >> there's a very important philosophical point. you think that all the money belongs to the government except to the extent that it deigns to allow private people to keep some of the. that is what your whole argument is based on. >> no, it is not. my argument is that if the government imposes an income tax and people know the government a certain amount of money and income tax is due and the government says you do not have

to pay into them, that you can pay to an sto, that is a payment of government funds -- >> they do not owe it to the government if they have made the contribution. they did not owe the tax to the extent that they have given money to one of these institutions. you posit at the very beginning that you owe a full amount of taxes. that is just not true. you doot owe the tax if you made the contribution. >> i disagree with that. if you look at the arrows on the income tax form, it says, "here is your income. apply the tax rate to the income. here are your taxes too. $5,000. you may pay that in part by paying an sto." you are paying your taxes. >> that is the problem. they have to revise their form so it is a deduction -- a

deduction before the line. that is a lawsuit? >> money in this program is not private charitable -- i see your argument. the holding, i would think, which i was not in agreement with, is that the government can have a spending program, and what they did was the government spent money in the form of vouchers to be given to private individuals to use for such education as they wish that met certain standards, including religious schools, so what is the difference between the program here and the one that was held constitutional? >> the difference is that in zelman, the money went to the parents without any religious

determination. the parents got funds based on their financial need and the fact that their children went to school in cleveland. the program was to give them, based on their financial need, a voucher. in giving the parents a voucher, nobody asked them what their religion was. nobody asked if they were going to send their children to a religious school. the court said as clearly as it could that that would be unconstitutional. >> so they say to the parents going to the school, what is your religion -- in other words, they give the scholarship only to catholics? >> exactly. >> what you claim as an issue is the money that contributed to the sto has failed to give to the government when it is the government's money. that decision of whether to give the money an sto or not, whether

to give it to a religious affiliated one or non-affiliated want, there is no religious discrimination in the choice. >> let me put it to you this way -- suppose the government in this case gave the money directly, and they then gave out the scholarships -- would it be constitutional for them to say to a parent who comes asking for a scholarship, "are you catholic? if you are not, we will not give you a scholarship." >> but you have an intervening parent or contributor, and it is that person making the decision of whether to give it to a religious or non-religious organization. it is not the government making the decision. >> parents under this program are not allowed to give contributions for scholarships

for their own children. the people who can claim the tax credit, the person that gets the scholarship cannot be independent of the person -- >> i suppose they change one rule. they said they would give you tuition if your otherwise qualify if you are a child to go to the school that you wish to go to, and if you are jewish or protestant and you want to go to st. joseph's catholic school, that is absolutely fine. they will not keep you out, and vice versa. in your opinion, that would be constitutional? >> yes. >> the only thing you are challenging is the rule that they will not give the scholarship to a protestant to go to a catholic school? how do we know? >> we allege that the sto's they give up the majority of the funds, i think now it is about 70%, that they only give the

funds to parents who will send their child to a religious school. that is designated by the sto. >> that is different. what you were complaining about is i'm jewish, i want my child, let's say, to go to st. joseph's. do i qualify or not? >> that depends on the sto you go to. >> your complaint is only with the ones that would not let you send the child? >> exactly. >> and we know that they exist? >> we alleged that they exist. >> i want to make sure i understand your complaint. you just said that your areplaint was that the sto's giving scholarships based on the students religion. i thought another part of your complaint was that they were giving just to religious schools. >> they did not give scholarships to religious

schools. they give them to parents. >> but to attend that school. the essence of your complaint is aret some of the sto's requiring that the recipient child be of a particular religion? > that and some of the sto's also require that in order to get a scholarship, the parents agree to send the child to a particular religious school. >> but that does not get you there. >> you are saying both of those? is that right? >> yes. >> do you understand the beneficiaries of this program? has the state said who the beneficiaries of this program are? are the beneficiaries of this program the parents, or are they the general taxpayers? >> the beneficiaries of this program are the parents and the

children. that is what the program is for. the state set up a program to help parents send their children to non-public schools, and to do that, they are going to give them scholarships. scholarship money is going to be available. >> i would assume then that it is the parents that have to be treated equally. >> exactly. the scholarships have to be available to parents on a religiously neutral basis. the scholarships are not allowed to be made available to parents according to their religion or according to whether they will send the child to a religious school. both of those kinds of discrimination are going on here. >> i go back to your point. you were making the distinction between the taxpayer charitable donation where the taxpayer has

the whole universe. he could spend it on fine clothes, on gambling, on this charity, that charity, but your point here, this contributor does not have the universe to pick. this one has either give it to the government, or you give it to the sto? >> exactly. it is not the taxpayers' money. it is confusing because we're talking about two kinds of tax payers. my clients are general taxpayers whose money is being used to fund this program. and we are talking about the taxpayers who take the tax credit. >> if arizona had a statue that gave an income tax deduction only to individuals who make charitable contributions to educational institutions, there would be a problem there because it was not a general tax exemption for generable

contributions -- general contributions? >> when you get a deduction to making contributions to an educational organization, that could include a religious education organization. you cannot set up a program that gives you a deduction for giving to educational institutions but not to a religious institution. that would be unconstitutional. if you are going to support private charity, you have to support religious charity in the same way your support non- religious charity. >> i'm not sure that justice ginsburg was the difference between this and the federal tax contribution. federal tax deduction is available for a broad range of charities, whereas this is available only for a very narrow range. >> i may have misunderstood the question. i think the question was at the time the taxpayer makes the charitable contribution that he is going to take his deduction for, the taxpayer could do

anything he wants with that money. take a vacation, give it to the charity, buy clothes with it, buy food with it. it is a completely open system. nobody tells the taxpayer what he has to do. in this case, when the taxpayer rights that check to the sto, the taxpayer cannot keep that money, cannot use it on a vacation, cannot use it to buy food. has to either pay it to the state or paid to an sto. >> the same thing is true of charitable deductions. when you take a charitable deduction, you do not have the money anymore. you have given it to a charitable organization. you are allowed to give it to a particular religion, particular church, and there seems to be nothing unconstitutional about that, right? so what is unconstitutional here about the private decision to

give a benefit to an organization that only supports particular schools and indeed only supports people of a particular religion that go to that school? >> there is nothing unconstitutional about taxpayers sending the money to an sto. if they did not discriminate on the basis of religion when giving the money out, there would be nothing -- >> but churches discriminate on the basis of religion. when i take my deduction to give to reticulate church, that church discriminates on the basis of religion, but that is ok. >> the government says do not pay your taxes to us, pay it to a church, and the church gave its benefits only to people of a certain religion, i believe that would be -- >> it really is just that line in the tax form that you are concerned about?

the only relief you really need is the change in the tax form? >> it is the difference between charity and paying your taxes. when you make a charitable contribution, you are making a charitable contribution. it costs you money. in arizona, if you make a contribution of $1,000, it costs you $950 at the maximum tax rate because the maximum tax rate is 5%. in arizona, if you take this tax credit, it costs you nothing. it is not charity. >> just a follow-up on the question, if this system were set up exactly as it is now but arizona said contributions to sto's are deductible, you would have no problem? >> no, we would not have a problem with that. >> the only difference is that

arizona set up this system where you get a tax credit instead of a tax deduction. >> of course. >> that would be true even at the top marginal rate was 90%? >> yes, it would be true even if the top marginal rate were 9%, which is never going to happen in arizona. [laughter] >> but the federal rate has been up that high. >> that is what the establishment clause turns on? >> yes, because that is still charity. the top rate is 90%, when you give that money, it is your money and can be used for anything. even if you are in the 90% bracket, you are giving some of your own money, engaging in charity, and the constitution permits the government to subsidize private charity. the government is going to subsidize private charity, it cannot lead religious charities out. that is the dividing line. is the government subsidizing private charity? in this case, they are not.

because it is not private charity. >> if this is government money, why would it be constitutional, in your view, for this scheme to exist if the sto's did not discriminate at all? >> because it is perfectly ok to use government money for non- religious discriminatory uses. for solar water heaters, and you get something for the money, and that is totally different. this tax credit is very strange. this is a tax credit only used to pay your taxes. that is the only function it has. that willou have sto's only give scholarships for religious affiliated schools, but they will not discriminate on the basis of the students religion. if this is the government's money, you think that would not

be an establishment clause? >> if an sto discriminates either by saying they only give to people of a certain religion or not giving to people of another religion or by saying you only get the scholarship if you send your kid to a religious school that they designate? >> but he said the opposite earlier. suppose you did. suppose the government gives its money to put cat scans in hospitals. one group of beneficiaries is the association of catholic hospitals. another is the association of jewish hospitals. another is a set of totally secular hospitals. the catholic group is going to give it to catholic hospitals and so forth. what is wrong with that? >> i do not get your hypothetical. >> they have government money,

just like you claim this is, and they say that we give the money to those organizations, and we expect them to distribute it, and they will distribute it to their members, and in some cases, their members are religious organizations, and in some cases, they are not. what is the difference between that and what happened here? >> it depends on with the beneficiaries of the government -- >> the beneficiaries of the government cat scan program will be catholic hospitals because they are the ones who belong to the catholic hospital association. money will also go to the secular hospital association, as it goes with the secular sto here. >> on not clear on your program. as a government program to

benefit hospitals, the benefits have to go to hospitals on a religiously neutral basis. >> the government says -- it does give the money away on a religiously neutral basis. it gives it to hospital associations. it turns out that some of those, naturally, are supposed to give it to their members, all of whom will be religiously affiliated. >> but the hospitals are the beneficiaries. that is the difference. the beneficiaries here are not .he sto's the beneficiaries are the parents. the constitution requires that the benefits of a government spending program go to the beneficiaries on a religiously neutral basis. the beneficiaries were the parents, and the vouchers had to go to them -- >> i do not understand the answer. his question was you give it to

the hospital equivalent, and that gives it to hospitals on a religiously discriminatory basis. why are the hospitals not the >> if the hospitals are the beneficiaries, they have to give it on a neutral basis. the analogy would be that the patients are the beneficiaries of the program. the government wants to help cancer patients and so it will give money to hospitals to help cancer patients. it gives money to various hospitals on the program. if one of those hospitals say that the only true catholic cancer patients, that is unconstitutional. to separate, in your argument, the issue that some of these organizations are religiously affiliated from the arguments that moreover, they will only give money to individuals of a particular

religion. i understand your argument for the latter. but i must say i do not understand your argument for the former. >> if i go to get a scholarship from an organization and is asked where i'm going to send my child, and i say that i did not make that decision yet, they say they will only give us the scholarship we send our child to a jewish school which teaches people how to pray in the way that jewish people pray. it's education is jewish religious education. that is religious discrimination. >> thank you, counsel. >> you have four minutes remaining. >> thank you. i think i have this right. we are talking about my clients whose money is being used to fund this program. that is not a description of what is going on here. it is recognized that a special

solicitude for taxpayers when money is taken out of their pocket and used to fund religion against their conscience. if you accept all of this public money discussion that has been happening, not a center of their money is the one to fund this. >> this seems to use the wonderfully precise word, "next." white -- given that it is a nexus, what is it not also in texas were you have this complicated system that -- taxes were you have this complicated system. -- have directly subject attracted $5,000 cash to a purely forbidden religious program. >> and this is not the next

test that is the definition of what the actual tax payer plan is. it requires that tax money -- >> was that in that instance, -- >> if there is any doubt, it is very clear because exactly what you said is looking at economic affects and that will be enough and just property clause and that does not matter. >> they could not have meant that this is your particular dollar. there is no way to know that it is your particular daughter and -- dollar and that would be a silly thing to say . toflask said was that taxpayer dollars are going to this activity.

>> i disagree. i think it is about the microstructure of a sense that is coming from your pocket and being used. it may be very small, but it is a special column of conscious when it is your hard earned money being used to fund a program directly to something that you do not like. >> here, a taxpayer is challenging a provision of the tax code and has pursued to the taxing and spending power that grants a tax benefit. that is as close to an axis that you are going to get. >> i do not think that deals directly with the taxpayer. even if you disagree with me, you have to have a tax credit that will not cost the government money or save it.

if you have to know that the government will not cut spending to make up the shortfall in revenues. you will have to do all of those things, none of which that you have to do in a flask situation. have to do in a flask situation. regarding state action, i think it is this court's precedents that the fact that the government funds something does not transform it into a state actor. that would be an enormously damaging precedent for this court to follow. what blanc says is that the performance of a traditional prerogative, and here, all the sto is doing is handing out money and it is doing so on a neutral basis and anyone can

form an and anyone can -- a guy >> thank you, general. the case is submitted. >> this weekend, c-span3's american history tv looks at how the longest serving firstly use the media to committee her ideas. we will see how very different thinking american and british leadership worked together against the nazis. live, saturday, november 20, a daylong symposium on the civil war from the national archives as historians discuss the domestic and international impact of the war. american history tv, all weekend, every weekend on c- span3. >> coming up tonight, a

discussion on the u.s. strategy in afghanistan and pakistan. the council on foreign relations has released in this event. >> after acknowledging that president obama got a bad live, we to salute his attempt to rectify the situation. we support him conditionally. we feel that the president and his administration should take the time right up to july of 2011 to have a very deep, clear is it review of the situation. if real progress is not being made, we suggest that we change the mission to a much different mission, one of strict continued training of the security forces. i would know that our report has

significant dissent in it. we have to debate among ourselves that what the congress should have, the american government should have. it involves the lives of our men and women and civilian organizations. >> let me begin with the pakistan sections of the report. you talk about the need to health pakistan, who has been devastated by the flood all of this humanitarian assistance and you talk about great economic development in pakistan. you talk about a shift in pakistan's own strategic calculations. the question that i was left with, these are things that

we're trying to do today. there are elements of american policy as it currently stands. what leverage do we have to achieve more? how would you get more out of the policy machine? >> this is what we are doing now. the question is how effective we are. the bill is good if we follow through on its and develop a big infrastructure it will help a lot of people. we are suggested a shift in our approach to pakistan. rather than focusing on appropriated monies, the u.s. government should give them greater access in the textile industry which is the largest single industry. frankly, there would be no harm to our own textile producers second, i do not believe that it

is possible unless they have a good understanding of what our state is treate. >> go ahead, band 3 >> i think that he has it exactly right. we want to a censure with a positive. that includes the opening of greater trade opportunities. at the same time, the report makes it clear that we need to take a hard line on the negative side. we made some comments about the use of our intelligence apparatus and sending a very clear message about pakistan's continued relationships with some groups that do not get enough attention. that would be a groups are extremely dangerous. unless pakistan understands of they are out of bounds with the

united states, we are unlikely to see a shift there. it is not enough to have- leverage, but we could do better on both ends of that spectrum. >> let me ask you, what would be the evidence that pakistan, on these security issues, was on side? you say they are now off side. what would it take for them to be on the right side by your calculations? what could they be doing differently? >> i would hope that they would see the network in the same way that they see the pakistani taliban. they have to see this as something that causes of war between india and pakistan. if we cannot be successful doing

this, we would be dealing with a very dangerous situation. >> so, if that effort to encourage broad antitrust -- to encourage pakistan along the way, if it should fail, you said that we should move away from long-term bilateral cooperation and maintain aggressive unilateral u.s. military strikes against that list of adversaries. that sounds almost like going to war against pakistan. i wanted to explain to us what it would be and what the rest would be. >> first of all, we do not want to go to war with pakistan, but there is little difference between the drone of tax and what we are suggesting. -- drone of tax -- attacks and

what we are suggesting. >> i would simply add that the report does not advocate a shift in this direction. i think that what it does is recognizes the fundamental potential for instability in the u.s.-pakistan relationship. there is a question as to how sustainable such a relationship could be if the united states either sees over a period of time that it is not getting progress with pakistan war if we were to suffer an attack from pakistan, we would be forced to take a very different line. the recognition of the reality leads us to look at what the alternatives would have to be. it is not a desire to go there. it is not an inherent threat.

it is a recognition of the strategic reality that we both face and how uncomfortable that is to both sides. >> you can see this entire of cent tonight at 10:35 p.m. eastern here on c-span. >> in an ideal world, the fact that there were people shorting the market showed a signal that they were smart investors that think that this thing is for to crash and burn. in the market was opaque enough that you could not see that the way you can see it in the stock market. because of how these instruments were, but are not boating on real mortgages, but inventing a casino version of the mortgage. >> bethany mcclain wrote about and wrong and the smartest guys in the room. she will focus on the american economy. q &a."s on c-span "to en

>> the house will meet on whether representative charles rangel violated ethics rules to the live coverage of that hearing gets underway at 9:00 a.m. eastern and you can see it on c-span3. the u.s. senate will have 16 new senators next year. 13 republicans and three democrats. in delaware, c delawareoons serve the remaining four years in the siege vacated by president -- vice president joe biden. markhor rubio formerly served in the florida house for he was speaker. >> as the country observes veterans day, visit the c-span

video library. oral history, offers on the nation's wars and veterans day commemorations through the years, all searchable, all free on your computer any time. >> and now, bob schieffer, christiane, poor and others reviewed the results of the 2010 elections. this was at the newseum here in washington. this is about one hour. >> good morning and welcome. to our post-oming election analysis. welcome to our c-span audience who is carrying this live. they are screening this live on politico. we will keep up for the weekend.

in the editor in chief of politico. also as we get started want to thank very much our sponsors for this event, the national cable and telecommunications association with "politico," we've done a number of great things with them. they're great partners. thank you very much. [applause] i do think it is the time of year when we should be willing to take a minute and reflect on and thank the people who take risks in the name of american democracy who are willing to put themselves and their reputations out on the line for all the rest of us. i'm talking, of course, about washington political pundits. [laughter] it's analyze events, make predictions, make sense of the chaos of politics. i know this personally. in 2006 i wrote a book with a

friend of mine and a colleague, mark hall person, he's now with time magazine, probably a lot of people in the room know mark. mark and i tried to do a book, it was going to forecast what was going to happen in the 2008 elections from a vantage point of two years out, sort of the insider's guide about politics. the book was called "the way to win. "you can still buy it. [laughter] you've got to look on ebay. anyway, it was a good book. there was one problem: in its 400 pages there was one name that did not appear, and that was barack obama. [laughter] so it wasn't, it wasn't 100% rock solid guide to the -- i still think there was a lot of wisdom in that book. [laughter] definitely some things, some things we missed. my, i've got a favorite quote about the hazards of predictions. it comes from the his story, arthur -- historian, arthur

schlessinger jr., obviously, one of the giants of american history. he said the, you know, our record of bogus predictions should, quote, lead us all to acknowledge our profound and chastening frailty and to realize that the possibilities of the future are more various, more diverse than the human mind is is designed to conceive. the future outwits all our certitudes. and there was another quote on the same theme. it was by yogi berra. he said, prediction is hard, especially about the future. [laughter] i look back, so every week on "politico" we do a q&a, a video q&a with these guys, chris wallace or fox also joins us, could not be here, in this which i press these guys, tell me what's happening. i look back and, you know what? these guys had a much better

track record than halpern and i did. everybody makes fun of political pundits and all the rest, but we did pretty damn well this year. i think anybody watching these shows would have had a good sense of what happened, what is happening. and i like to think that's true of our "politico" coverage. so we don't always blow it, and these guys hardly ever blow it. i want to go and introduce them, and we'll get this conversation going. christiane amanpour, of course, the anchor of this week with christiane amanpour on abc news. she started this not too long ago. when did you start? >> august 1st. >> of course, news junkies like us and probably most of the people in this room know her from her career at cnn, just recently joined abc. bob schieffer is cbs' news chief washington correspondent and, of

course, the anchor and moderator of "face the nation." bob has covered washington for more than 30 years, but i know that's not true -- >> 0. >> more than 40 years, right? you need more than 30 years to pick up laird stories. [laughter] both bob and i know mel laird, the former defense secretary. he's covered virtually every important beat in washington in that, in those years. candy crowley is cnn's chief political corps responsibility and anchor -- correspondent and anchor. she runs "state of the union" every sunday. she took the reins of that show in february, and in her role as chief political correspondent she covers a broad range of stories including presidential, congressional and gubernatorial races. i think we know candy is one of the real workhorses, you are going to see her on airplanes, out on the scene, the authority she brings to the summit. she's -- subject. she's earned that the hard way. i'd say that's true of all the

people up here. david gregory is moderator of "meet the press," of course. he's been doing that since december of 2008, obviously, taking over one of the really esteemed chairs in this business from the late tim russert, somebody we all knew and respected and has very much lived up to tim's legacy with that show. in addition to his "meet the press" respondents, he's a regular on the today show and see him often on msnbc. been with nbc since 1995. i thought you were a youngerfy than that,day. >> not anymore. >> time marchs on. okay. i just figured we would open it up with everybody talking a little bit about their shows and reflecting back. tell me, what was your biggest kind of get of the cycle, the really illuminating moment that you said, ah, this is really telling me something i didn't know about politics. david, we'll go on down the line. >> i think in the political context there were two that

stand out, when robert gibbs said the house could fall was a moment because it was a bit of truth telling that he wanted to dial back -- >> why was that such a storm, right? this. >> well, because -- >> ray charles could have seen it coming. [laughter] and he said it and got in a lot of trouble. >> and i think we all like a real moment like that, a real moment of candor. by the way, he didn't say it was going to fall. he said, certainly, it is possible given how competitive these house races are going to be. i think that was interpreted by the likes of nancy pelosi as somehow, you know, tamping down the potential for democratic candidates to rally. so that became a bit of an issue. i think on the other side we had all the campaign chair, and i think it was striking and certainly something that the president picked up on when you had pete sessions and john cornyn, the republicans, who weren't really in much of a position to talk about, you know, what areas they would actually cut, what new ground they would break policy wise if

they got control again in congress. and i think that was an area that certainly democrats picked up and made people stand up and take notice. >> right. candy, give us a -- >> i mean, i have to give you one that i disliked only because it has a slight story behind it, and it was early on the most visible man around but jim demint, but he was also quiet. and it was hard to get at him and hard -- and so, he one day sort of surprising us said, sure, i'll come on. so we had him scheduled for the show, and i came in -- i usually come in around 5. >> right. >> yeah. which you don't even want to know what time i get up. i'm one of those people who should just stay up. [laughter] so i got there, and somebody said lisa murkowski wants to come on. this was just after she said she was going to run as a write-in. and i said, well, what do you mean? it turned out that one of her aides showed up at the guard station at cnn at literally 3 in

the morning saying can i talk to candy crowley because lisa murkowski is looking for her, would like to come on the air. she's also someone that doesn't go on on sunday all that much. >> or probably not asked that much until recently. >> exactly. exactly. and, you know, what we figured was, look, she knows we're having jim demint who had just excoriated her. she was an appropriator which was a bad thing to be now. and so we had the two of them and just the tension between these two people who allegedly worked together, i thought, told us a lot about the tea party and how that is, how that was fitting into the mainstream where lisa murkowski -- >> will how often do you see that -- how often do you see that on the show, i'd be curious whoo others think, the behind the scenes moment, hi, good to see you, sort of congeniality behind the scenes with people who have different political

perspectives, how often is it obvious they can't stand one another? >> that's hard to hide. [laughter] >> uh-huh. >> it really is. i mean, i think we've all had the experience when you get on and you think, whoa. the tension in this room is a bit much. but they can't hide that generally. >> right. great. bob, what are some of the moments -- >> you know, i wouldn't pick out any particular program. we had a really good, i thought, fall going into the elections. and, you know, one week it would be somebody from one party, and another week it'd be someone from the other party. but i felt we made a decision early on in the summer that we were going to concentrate on nothing but the elections until the election. and i felt like, i felt like we did really well on that. you're talking about they don't like one another. one of the kind of low points in the year for me that kind of underlined just the partisan divide that we have in this country is at one point when

someone one -- from one party, one of his aides called up, and we were having his opposite number on with us and asked if we could have a separate waiting room for his boss because he didn't want to sit in the same room with the person from the other party. [laughter] and we told him, sorry, you're just going to have to suck it up. [laughter] we can't put up a tent out in the parking lot, you know? [laughter] but i thought that just sort of summed up where we were in this campaign year. and so while i wouldn't call that a highlight -- >> right. >> -- it is one of -- >> that wouldn't have happened 30, 40 years ago. >> oh, no. to me, that's what made it such a telling anecdote. >> i had an example from the other extreme which is we did a debate with alexei giannoulias, the illinois senate debate, and right before commercial break i had asked giannoulias a number

of questions about his tie toss a bank that had loaned money to mobsters, it had been a tough exchange, and then kirk breaking in. and we go to break, and kirk turned togiannoulias and said, don't worry, now it's my turn, you know? many that was surprisingly nice, i thought. >> well, john, it's really nice to be here. i would just gently say that i have not yet presumed to be a pundit in washington, i'm new to this, and it has been a really enjoyable learning curve. >> right. >> and i'm, obviously,coming to it in a much more reportorial world and with a great deal of curious and curiosity rather than instant expertise and delivering my prognostications which i'm studiously avoiding sensibly. i would say that my highlight probably was my first program when i interviewed nancy pelosi, and i thought that was a really good get and, obviously, i had met her in a different context, but i'd never interviewed her. and i was, obviously, struck as many of you know by her fighting

spirit. and that, i wasn't too surprised when it turned out that she decided to fight for the leadership position right now because i think that's what she is, a fighter and be a true believer. one of the other interesting sort of combinations because i'm also doing a little bit more international and trying to put an international layer on policy and politics here, connect america to the world and the world to america. i had a program in which we had both secretary of state hillary clinton and the iranian president ahmadinejad. not that they were sitting together, but the fact was that they were talking about the same things from their separate worlds. incredibly interesting to me. hillary clinton was very determined, very hard line, trying also to straddle the line of the administration which is engagement while, while staying very strong against iran. and ahmadinejad was as provocative and controversial as he always is. but he did tell me that they were going to go back to the

nuclear negotiating talks which they'd planned to go back to. so i thought that was interesting. i know george will thought it was interesting because he sort of commented as i was on my conversation with him about stoning. if you remember the big controversy over this woman who was going to be stoned in iran. i was asking ahmadinejad about it and pushing him about it, and george will, i could hear him say, well, that's a fist for sunday morn -- first for sunday morning television, stoning. i thought that was good. >> to me, some of the most interesting answers are the ones that are the nonanswers that you keep sort of going back on and back on, and i loved at one point we had steny hoyer on, and i said, so when are you going to start throwing overboard the democrats that aren't going to win. and he looked at me and said, you don't expect me to answer that, right? this. [laughter] okay. he gets the game, i get the game, and so this is just sort of the fun parts when you keep going and going and think, okay, we kind of got an answer in a

nonanswer. >> right. >> john cornyn was interesting when he basically said on our show they weren't going to win the senate this cycle. so that was interesting. >> interesting. truth breaks out. [laughter] >> and as candy says, trying to get the details and trying to get the answers. you know, the election was a lot about the debt, obviously, that was what the tea party was, deficit reduction, eradicated debt, and it's very, very hard to get a real answer about where the cuts are going to be before this commission which is advisory, but it was very hard. so i spent practically a whole program last week trying to press them on that. >> i talked to somebody who's been in a previous white house, the clinton white house where the circumstances in 1994, there are some similarities, some differences between the circumstances that barack obama and his team face now in 2010. and president obama called the election results a shelacking,

but this person said it's more like a death. and people in politics have to go through the stranges of grief, you know, first you have denial, then you have rage, and only over time do you have acceptance, and in politics, unlike death, you do get a second chance. there's the sort of clarity about what action needs to be taken going forward for a recovery. where do you guys think of obama white house is in the stages of grief? are they still in denial? rage? acceptance? what do you think, dave? >> i think -- [inaudible] is where they are, and it's only getting worse. you know, this was not the most successful overseas trip that any president has taken. m. >> right. >> i mean, they went and thought at the very least they were going to get some sort of agreement with trade on south korea, and that apparently has gone by the by. they're in a huge fight with germany -- >> just a historical note, november's always a pretty big travel month for white houses

because they have various summits and often a peck is scheduled right around this time -- apec. i can remember the first president bush taking an awful trip after a bad election in '91, remember dick thornburg, clinton took this terrible death march after '94. >> well, and nixon, going back to nixon, you know, went off on those trips because he couldn't go anywhere. [laughter] >> right. >> but you're right, it is a tradition. but i think, i think the white house and i think the republicans to some extent are both in this just kind of holding patterns right now would be the kindest way to discover it. because republican leadership has got to figure out what to do and how to deal with the new people who have come to their party. and the democrats, obviously, in totality array in the house -- total disarray in the house where they have this unexpected fight over the leadership.

so i think until the two sides work out their internal problems, i don't think you can make any kind of prediction about what's going to come after it. but i think the fact of the matter the democratic party in washington is now going to be more liberal, and the republican party is going to be more conservative. so i think the partisan divide -- >> and you have a disappointed left, a disaffected middle and a resurgent right. and if you put all that together, it's a very difficult place for the president to be. you talk about bill clinton, i mean, what his calling card was and the reason why he's so well thought of now as a political figure is pause he was the guy -- because he was the guy, the head of the democratic party, who balanced the budget. president obama is the guy who has, you know, returned or restored the era of big government at a time when a lot of people think the government is out of control. and is not responsive to what the economy actually needs. he's failed to win that argument that government is actually vital and part of the solution,

not part of the problem. so that's where he's lost that middle of the country. and then, you know, whether it's the economy or whether it's the don't ask, don't tell policy, you've got the left that still wants a lot more from him. >> somewhere, i mean, as far as the republican party is concerned, it seems to me that the leadership on capitol hill is is right now in their post election co-oping. i think, you know, they see they want to have this freshman position, they would really like christy nome from south dakota to go in that because she had someea party backing. i think all of this talk about health care reform, yes, i think they're trying to bring the aboves into it, kind of stop the funding. but the fact of the matter is they know very well they can't repeal health care reform. they don't have the votes for it to override the veto, they don't have the votes in the senate, and they know they can't spend two years trying to repeal health care reform, so i think they're trying to play to that tea party side. i think as far as the president's concerned, one of the reasons -- and i think the

main reason nancy pelosi who was, at first, a little bit reluctant to take on this minority position was, in fact, urged by a lot of people to do it. and one of them said, you know, it's not that we're afraid of john boehner, we're worried about the president. >> right. >> you know, we're worried he's going to, you know, saw off the branch here, and she's the one that can, that can go at him and kind of hold the line. so i think, you know, the president's stuck in the middle -- >> so interest ising. in other words, don't try to pull a dick morris from the '90s. don't try to leave us out there. >> right. >> while you worry about your re-election. >> exactly. >> if so, you'll have her to answer to. interesting. >> somewhat counterintuitively, obviously, the narrative is that the republicans have won, and it's a complete shift in the balance of power, and that possibly is what it is, but i was just reading this one article, and the quote by the alabama republican spencer bachus who said you think republicans are in charge in washington, you can wipe that thought from your mind.

democrats are in control of the presidency and the senate, it would take 67 votes to override any veto. to what you're saying, i think that's interesting in terms of, really, what is going to happen in the future and whether it is just a rout by one party of another. and having covered some of the campaigns on the road, i was struck by how people, american voters were really turned off by the extreme partisanship and wanted more than anything their politicians to get together and solve these big solutions. because talking about compromise is not just a sweet little thing that we would like to happen. on the huge issues that face this country and the world, for instance, the deficit, they cannot do it with one party alone. >> right. >> and it's really -- >> tap into some of your foreign expertise,christiane. a lot of americans like divided

government, they don't want just one party to have the wheel. they like some tension in washington. from the perspective of capitals abroad, what do people think? do they worry about divided government, or do they see it as potentially a good thing? >> i'm not sure that they look so much, you know, into the anytimety createty of the divided government, but they're certainly watching these results very, very closely. because capitals and people around the world want to know whether this means the united states is going to turn inwards, is there going to be more isolationism than engagement, is there going to be battles over free trade, over protectionism? this what's going to happen with certain treaties that are there in the, you know, ready to be ratified? many people hope the starr treaty, will he get that through? if his senate doesn't ratify it, how is that going to make him look overseas? and then, of course, the afghan war. that's the highlight. and i think, paradoxically,

stronger republican representation may make it easier for him to get -- and certainly for david petraeus -- to get the troops to get the sort of war machine going. although the president is, obviously, wanting to pull that back. it looks like it's going to go on for many more years than 2011. and i think that's going to be something that's very interesting. and you've heard the tea party candidates talk -- well, the most prominent ones, certainly, sarah palin and christine o'donnell who failed, talk about afghanistan in if very broad terms. i think people abroad are looking at the big unknown which is the insurgency in the tea party and how that is going to effect not just domestic policy but foreign policy as well. >> some of my favorite imimagines from the campaign -- images from the campaign involve

candidates almost like they're olympic runners making a mad dash for their car while the hapless reporters are chasing after them. and, bob, christine o'donnell, i believe, canceled an appearance on "face the nation" at the last moment. david, i believe that rand paul canceled on "meet the press "in may. virtually every local reporter in many of the states with contested races has stories of candidates just kind of shutting down. what do you guys make of this effort to try to escape press scrutiny? i mean, gosh, canceling on face the nation or meet the press is unpatriotic. this is about unity and coming together. [laughter] >> look, they've obviously got a strategy about avoiding, you know, certain platforms where they're going to be held

accountable in a certain way. and they know that. i think in the case of, you know, sharron angle, i think a candidate who says i'm not going to answer questions until i'm elected is a joke, and they should be treated that way by the voters. i mean, if you can't take tough questions and you want to be a united states senator? you've got a problem. now, you don't have to love the press, by the way. you don't have to love our programs or us or all the rest. you should be able to take questions and be held account and not try to narrow cast your way to high office. and i think that sort of works itself out if you look at some of the results. you know, rand paul, i think, made an unfortunate decision, but he's, you know, he put himself out there elsewhere in the campaign and will continue to, i assume. >> well, i hope that doesn't become a habit with rand paul because he's going to be on "face the nation" sunday. [laughter] >> bob, i'm willing -- if he

cancels, i'm willing -- >> i'll call you. [laughter] i mean, christine o'donnell, i think that the people, what adviser she had appeared she would simply make a fool of herself, and so they canceled her, or she canceled, and i don't think it's any more complicated than that. >> i think you're both absolutely right, but i think it's, it's -- it was, you know, they brought these untested candidates because they knew that, you know, they wanted some energy and that they wanted to put these candidates out. but it was, obviously, a deliberate strategy of not talking to the press. it was partly because they didn't want to, you know, expose themselves as you say. but also because they were not able to answer, you know, all of the big questions that were out there. and as dade says, you know, in the -- david says, you know, the voters spoke, and that cost the republicans the senate. basically cost them the senate. >> christine o'donnell was a

fluke. i mean, nobody expected her to win that. after she won there were not very many people glad that she had won. and had she not won, it would have been much better for the republicans because mike cassel would have won that seat. >> it wasn't a fluke because we had tom ross on, the chairman of the republican party in delaware. he said mike castle was meant to win until external tea party support and forces came in and put her money wise and publicity wise and support wise over the top. >> are well, christine, a very small number of people turned out to vote, and no one expected, i mean, no one -- >> in the primary? >> yes, in the primary. >> she won it. >> so i would just stick with it, it was a fluke. [laughter] >> candy. >> there's no legal requirement that they show up on national tv to do anything. that's certainly their right. and i think that for all those

reasons that these guys have stated, they don't. they do have local press, and they have sort of talked to the local press which are much more important, as we know, in state races. it's much more important to talk to your big state newspaper or your big state tv station which they doesn't always do -- didn't always do. i think, actually, what's more troubling is, first of all, there are outlets these people can go to that are friendlier, and they can get their message out there in so many ways. they can just have a web site and pump stuff out, and they can go around and over the heads -- >> do you think that's sarah palin's strategy? >> sure, yeah. >> what strategy? >> you know, i think the other thing that's more troubling is a lot of them didn't do town hall meetings, a lot of them wouldn't tell you what their schedule was. and why? because they're a little bit afraid of the public because every time you turn on the tv particularly last summer, summer before were all these angry

people, and politicians never look good when they're around angry people. and i think they sort of backed up. it's not just that they're not accessible to us sometimes, it's that they're not accessible to their voters. >> i think, in this my view and you guys feel free to object to it, that one reason we see our politics being so unstable with the republicans taking control and democrats taking control, and now we have a reverse of that is that the middle of american politics, the broad middle is frustrated in what they -- and what they most want out of washington is people to not throw away principles, but not approach everything through the perspective of ideology. they want people to be mature, sensible and focused on solving problems. and yet the incentives of our political system, bunch of different incentives, push people to the extremes of right or left. and so the middle is chronically

dissatisfied. and there's a paradox. what they want most, they get least out of washington. i'd be curious anybody's thinking on that, but answer it, please, in the context of are people going to get anything like governance over the next couple of years? and to put some historical context on it, newt gingrich and bill clinton fought, but ultimately they did pass welfare reform, they did pass a balanced budget. it's not clear to me what the dynamics are over the next couple of years. is it all conflict? is there room for compromise? >> i just think the calendars compress so that room for consensus is, perhaps, a little smaller. you also have the principles involved and whether they can restore some trust where there's been virtually none to get some things done. they're the political -- do they have a grasp of the political theater in the way that the gingrich and clinton did, but i think the ground is there and i think the momentum is there for

something on the budget and cutting spending and trying to restore some trust in washington. but i'd make two other points which is i think the disaffection of the middle is aggravated by the fact that people just lost faith in big institutions whether it's wall street or government or media. so that, that compounds the problem. the second thing is that the american people are not always consistent on these points. they say they want certain things, and a candidate stands up and says, you know, we've got to raise the retirement age on social security. whoa, whoa, whoa, we weren't talking about that adult of a conversation. [laughter] so that's kind of a mixed message. you can still be punished yearly as a politician for going into some of these areas. >> you know, the budget commission thatter skin bowles, the -- erskine bowles, the clinton chief of staff just came out, they made the recommendation to raise social security and also raise the gas tax. my wife was traveling yesterday, and she saw al simpson at the airport, they were standing next to each other in line.

they don't know each other but making small talk. she said, well, are you going back to wyoming? he said, no, i'm going into the witness protection program. [laughter] >> i'm curious to ask just from a perspective abroad, you saw who was going on in france, obviously, battles on the street over raiding the retirement -- raising the retirement age just by two years. do you think, gentlemen and ladi, that they will succeed in raising the retirement age here? >> in the next two years? not a chance. i mean, that's just not going to happen. >> [inaudible] >> no. i think that what happens is they can do stuff around the edges, but i think if you're looking for major reform, change the nation kind of stuff, it's not going to happen in the next two years. i think there's some ground for debt as dade talked about in the budget -- david talked about in the budget. i think there's ground on trade. i think they have some smolally there. seems to me they'll come, obviously, to some position somewhere on tax cuts. the president seems eager, i think, i mean, we've gotten

conflicting signals, but he does seem as though he wants to be seen as compromising with republicans. but in big sort of move it immigration reform, that kind of thing, i think it's going to be smaller piece things. >> i would agree with candy. i think they're going to come to some understanding on extending the bush tax cuts with the upper levels extended temporarily or some sort of an arrangement there but, quite frankly, i don't see much else coming together. >> are right. and, bob went on face the face the nation, but here on the c-span audience can see it, please, explain your socks. [laughter] >> well, you know, my football team, tcu, is having a pretty good year, and i thought i would just go ahead and wear purple socks until we find out how this season turns out. also pulling for alabama to beat auburn. >> some athletes do not change their socks for the entire

season, but i assume you've got more than one pair of those. >> i've got several pair. [laughter] >> bob, are you going to dedicate the program if tcu doesn't get a chance to play for the championship, does this become a political question? >> it would be to do away with the hated -- >> right. >> i've already done one piece. [laughter] >> a lot of people would like to do away with that. >> i guess everyone should know, i'm not unbiased about that. [laughter] >> not on that question, no one's asking you. who, candy, are you really looking at for the republican nomination in 2012? i know, of course, we need to take a break from presidential politics, so maybe not this weekend, but, like, take a break over thanksgiving, how about, like, the first sunday in december? that's enough of a break, then we can get back to presidential politics. who are you going -- who would

you want on your show? >> passing up the obvious suspects, mitt romney, etc. -- >> right. >> look, i think you have to look a little bit at thune. i think he's -- he's just interesting in and of himself, but he's -- senator thune. i think he's interesting. i know chris christie has said he's not running, but he's so interesting, and, you know, you've had him on. he's just a great get. he's the only politician i've ever seen in my life who actually can take on an audience and actually come out looking better. and, you know, i think you've got to watch marco rubio only because the republicans are so excited about him, and, oh, this is our barack obama, and i don't think in two years they're going to do the same thing that the democrats did with rubio having two years of experience, but i think he's -- both of those guys are up and comers, and i think they will play a part in the presidential race, if not run. so i think they're interesting to watch. >> uh-huh.

>> i think that newt gingrich will announce in january in iowa that he's going to run. and i think he'll be the first one to make the announcement. but beyond that i have no idea. i think it is totally wide open. i don't think any republican has emerged and broken up -- >> do you have a hunch as to whether sarah palin would run? >> my hunch has always been that she wouldn't, but now i'm beginning to second guess myself and wonder if, in fact, she might actually do it. i guess if i were going to bet on it, i bet she wouldn't. >> i've been with bob for a long time, but i, too, am second guessing. i do think a lot of that's out the window now and that she's enough of a rock star and doing enough now to position herself. i think what bob says is very smart about newt gingrich. i'll have the speaker on on sunday as part of my round table, i'll be spew sure to saw ask him again. [laughter] but i'll credit bob.

but i think it's so important, too, which is we're in such a different climate now with the republican party that there is nobody who's off the blocks with some sort of clear advantage. there's this very unsettled feel. i think the next year will tell us in terms of how the establishment in congress deals with the tea party. >> by the way, i have a different philosophy on predictions. i think you have to, they're like stocks. you have to buy and hold, otherwise you can't -- [laughter] >> if you're going to be wrong, be consistently wrong. >> consistently wrong. otherwise, you chase it around and every day looks different. >> i mean, i'm with them on sarah palin -- >> somebody would have lost a lot of money, by the way, betting on my predictions. >> me too. but i think sarah palin, i mean, i've always thought she wouldn't run, and part of the problem is that running for president pretty much mirrors what you do to keep your speaking fees up and your books selling. so it's hard to tell what you're watching because the theater is the same and the moves are the same. >> go ahead.

>> sarah palin because, obviously, the polls say what they do, you know, not many americans think that she's qualified. nonetheless, i remember, you know, being on a program and being asked about her. it was actually a comedy program in 2008 just before the elections, and people asked me about sarah palin, and i said, don't underestimate her. and i got roundly booed by the audience and roundly told that i didn't know anything. and the thing is one shouldn't, obviously, because look where she is today. whether she runs or not may not matter, but whether she has a major influence may be, may be more to look at. and, obviously, she did in this round of midterm elections. and then i think we have to see what the tea party candidates do, as you said, in terms of influencing senate, the house and all the rest. i mean, rand paul taught us that far from the establishment republicans co-opting them as trent lott said we had to do, no, we are co-opting the republican party. maybe that's bravado and

showmanship, but i think that's going to be interesting to she how that plays out. >> david, what do you think? is the tea party going to pull the mainstream of the republican party their direction, or are they going to get subsumed by just the process and the institutional apparatus of washington? this. >> i think it does depend. marco ruin quos' a good example of a candidate who isn't beholden to the tea party. he's got a lot more crossover appeal, and he's not going to have to listen to jim demint, you know, in the senate. i think there's probably a lot of house members who do have to sort of come in under the fold a little bit, won't have enough of a power base on their own, but i do think they've made the caucus certainly more conservative, and i think independent voters are moving in a more conservative direction. i think it's less about social issues, more about government war issues. so, yeah, i think they do pull them a little farther to the right, and one thing about palin, just take a look at, you know, working class whites, the

ones who voted for hillary clinton and whether a candidate palin would have a shot at those voters. you'd have to say that she might have a good shot. that's part of how she'll look at that landscape. you've got to look at it in a narrower lane and think about her prospects. >> just an observation, if what candy says is true, that her incentives whether she really just wants to make money and sort of be a power broker or whether she wants to actually run for president, if it's true her incentives are the same, that is going to freeze up the republican field for a while because she's got every reason to leave this question open and tantalizing for as long as possible. now, i want to say something to the audience. we do not have provisions like we did at the last one of these events for you to write down questions. i'm going to exercise the moderator's prerogative, though, and if people do want to ask questions, they should raise their hand. we'll go back and forth. would like to make sure that it is, in fact, a question rather than -- and crisply made rather than a statement.

we should do that and have a little fun with that. do we have something? yes, sir. >> hank -- are we on -- what do you think, what are the prospects for the start treaty in the lame duck session? anybody want to take a stab at that? >> i don't think it'll, i don't think it'll come up, frankly. >> yeah. i mean, you know, let's remember the pressing christmas vacation is coming -- [laughter] and the tax cuts are the big thing and the budget's the big thing. there's just not room for it between now -- >> not to mention if they can move on don't ask, don't tell which gateses and the president wants him to do. it's only going to get harder if they put that off until later. >> [inaudible] ..

>> but i think he's taking a rather serious look at it. >> david, don't you agree, i don't think any entity besides to do it, he won't do it unless he thinks he can win. >> absolutely. absolutely. it's not a vanity. >> i'm going to go back and forth with the audience, along -- would like to ask each of you if you can think of it, and what it would be, you've got the ultimate booking, i guess probably the ultimate booking would be god or something like

that -- [laughter] >> unavailable. >> unavailable. but i presume y'all have requests in and i presume at some point, one of you are all of you will have to -- president obama on the show. what's the question you most want to ask. >> perhaps just off the top of my head, i would ask, you know, where does he want to go and how does he think he's going to recoup? it's the obvious question that everyone wants to know. is he going to triangulate, whatever it is that bill clinton did -- >> it illegal, triangulate? >> it sounds like strange elation. it's hard, but, you know, what, people are not sure what exactly he stands for. and i think that's a very interesting question. what is it that really motivates him in terms of what he's going to