the issue of a great deal of dialogue. we sent diplomatic notes to the government of argentina. we reviewed within the coordination boat before the arrival of the aircraft and cents. we do not know why this has not been resolved. >> the explanations you give in this note were not enough? >> i do not know what more we can tell you. >> is there anything new on the davis case in pakistan? >> there is a court hearing tomorrow. >> what about the arrest in lubbock, texas? >> making bombs? >> i am aware, but beyond that, i would defer to the law enforcement. >> the date in peace accords

that ended the war in bosnia. health care providers and administrators discuss the future of health care. a group of mayors hold a press conference about federal budget cuts in major cities. >> former president clinton and others look back at the 1995 dayton peace accord that ended the war in bosnia. they will also discuss global diplomacy and resolving other world conflicts. former secretary of state madeleine albright and retired general wesley clark, former national security adviser stanley berger introduces president clinton. this event was held at new york university and hosted by the clinton foundation. it is one hour and 10 minutes.

>> skeletal prisoners behind barbed wire. horse in europe we thought had been banished forever. yet at home, there was not much appetite. abroad, our european allies state fast and resisted tougher measures that might but the humanitarian mission at risk. by mid-1995, bosnian serbs shelled innocent families in sarajevo. it took u.n. peacekeepers hostage. president clinton concluded that american leadership was the only hope for peace. that august wheat began an all- out diplomatic initiative. backed by the use of nato force, it shifted the balance of power. the early weeks were scarred by

tragedy. first the death of three american diplomats and then a mortar attack on sarajevo. nato's relentless air strikes together with bosnian and croatian gains on the ground lead the party to a cease-fire and to dayton where for 21 days of our negotiating team led by our extraordinary ambassador, richard holbrooke, pushed, prodded, pressed, persuaded, and finally prevail. -- prevailed. more than 2 million more displaced. the leaders of croatia, bosnia, and serbia it turned the page. for president clinton, another battle was just beginning.

the president wanted to send 20,000 troops to help nato implement the agreement. most americans opposed the idea. many within the military were skeptical. much of congress was dubious at best. dick armey claimed that winning support of the house would be like pulling teeth from the back of your head. in fact the house refused to take action in support of the mission. yet the president move forward because he knew it was right. it helped end the terrible war. it has been said that courage is not simply a virtue, but the form of every virtue. to be sure, president clinton showed political courage in seizing the initiative to stop

the bloodshed and doing what needed to be done to enforce the peace that was so hard to secure. bosnia was also a reflection of his values. a belief that prosperity and progress must be rooted in unity, not division. he had a vision for europe and a transatlantic alliance at a time of historic transformation. it was a vision of a peaceful, undivided europe. it has seen some of humankind's worst brutality taking place on that continent. the new a new europe will never be born with a fire raging in its heart. it is easy to forget how bullbat statement released was. nothing was preordained, especially not the peace

agreement we live with today. the president also had a vision for u.s. leadership in the world. it was a belief in our power -- it in the power of our common humanity. it drove the administration's efforts from the balkans to the middle east, to northern ireland, to ethiopia, to peru and ecuador, to south asia and south america. now in his post presidency, he continues to champion a world where defense works to everyone's advantage. as he says, the success of our work is measured by a single question -- are we better off now than when we started? 15 years after dayton we knew

the answer to that question is "yes." i am proud to introduce president william jefferson clinton. [applause] >> thank you very much. please be seated. thank you. thank you, ladies and gentlemen. thank you and thank you for the introduction. i would like to thank a number of people. i would like to thank the leaders from the region who have come here and will be represented on the second panel. i will introduce them later. i want to thank all those preserved in the administration during those early, turbulent days. some of them will be on the panel shortly. i would like to thank warren christopher to played a pivotal

role in the revolution of the bosnian crisis and could not be here today. i want to acknowledge those who are not here. first, richard holbrooke to look forward to dominating this whole proceeding today. [laughter] the three brave public service we lost on august 19, 1995. ron brown and all of the people at the commerce department and the business community who were lost on the plane in croatia. their families are here. i hope that what we do today is a reminder of what could not have been done and without their loved ones. there are a lot of people for

all of the fits and starts of that policy who are alive today because of their service. i am internally grateful. i would like to thank john sexton, the president of nyu, and all the people here for hosting us again. i would like to thank the students who are here. many may be too young to remember what happened after the breakup of the former soviet union. the conflicts between the serbs and the bosnian muslims, the serbs and the croatians, the conflicts in bosnia and croatia. the killing in bosnia was as bad as the demonstrations in cairo and around the world today. i would like to put into some

context what all this means before i introduced the panel. i will give just a little beyond what the film did. many people seem to think that the 1990's after the cold war and before 9/11 were peaceful, uneventful interludes between the cold war and the dawn of the struggle against terrorism. i think those of us who were there would beg to differ. first, in bosnia alone, it understates the sheer scale of the destruction and the killing. in a small nation of two modern 50,000 people -- in a small nation, 250,000 people were killed and others became

refugees. , the dayton accords, the military action was really the first test of what the world would do to order itself in the aftermath of the cold war. the cold war dominated the organization of american foreign policy until about two years before i was inaugurated. the struggle between the united states and the soviet union created a architecture of diplomacy, military support, intervention or let their of around the world. during both republican and democratic in ministrations, our policy was driven by what was

generally called containment. containment to meet met two things -- first of all that we would try to contain the spread of communism to the confine which existed at the time any given president took office and, secondly, we would try to contain the dimensions of the conflict so that the nuclear superpowers did not ever use nuclear weapons. it was a useful and often productive construct and we did not have another nuclear war. i have often said only half in jest that on the nuclear issue, it may be that each country's spies were the other's best public servants. they did their jobs well enough

that we knew enough to avoid the war. on the ground, when it came to geographical containment, it often lead to contortions of our values. when everything got pushed to a narrow funnel in terms of whether this, that, or the other conflict would or would not advance the interests of the soviet union. it led the united states into supporting extremely repressive regimes in central america and ran-contra problem. it caused us to see the vietnam war to the eyes of the cold war struggle. there were all kinds of other issues which we are not here to discuss today. after it was over, there was a

big issue of how the world would organize itself now that it was no longer bipolar and what role with the united states play? how would we manage the outbreak of ethnic, racial, and religious conflict represented by bosnia? what about russia? how would we relate to russia? the russians had political, cultural, and historic ties to the serbs. is there any way they could be involved in the resolution of the problems in bosnia and later in kosovo? what did it mean for the dream of a europe united whole and free for the first time in history that the worst killing since world war ii was taking place on the european continent? what about nato? could nato had made nine cold war mission and should it have more members?

how could the united states view its interest here? secretary jim baker, who i admire very much, once famously said that the europeans should handle the balkans. "it is their problem and we do not have a dog in that hut." how should we view africa? how should we view latin america now that we no longer were conflicted and contorted by the cold war? having problems like what happened in the condo. all of these things had to be worked out and worked through. you could have all the theories in the world, but there had to be a specific example that informed us about what we could and could not do.

in the balkans, and in bosnia- herzegovina particularly, there was a enormous humanitarian issue at stake. it was order to escape. now you know when we see twitter and facebook and youtube and 24-hour cnn coverage, it is hard to remember that the balkans may be the first conflict that was a long way away in a small place where we actually knew what the heck was going on all the time. we did not have anything like the level of interactive communication, instantaneous information that we have now. when i took the oath of office, there were only 58 sites on the entire internet and the average cell phone weighed 5 pounds. [laughter] that is embarrassing.

every time i say that it makes me feel ancient. [laughter] the things we take for granted now about how the world got swept up in what is happening in egypt, it was a new thing in the balkans. it meant that deniability was not an option. it is important to keep that in mind. i thought we did have a dog in the hunt. i thought in the aftermath of the cold war, the united states had to redefine its relationship with europe and with nato and that all of our pretensions that the crumbling of communism would lead to a great start of the enlightenment, democracy, and freedom, it would look like a

fraud it the rest of the world did nothing to help them. i thought, on its own merits, because we knew, we had an obligation to try to reduce the slaughter and reduced the flow of people from out of their homelands, restore decent conditions. and we create the possibility that europe could find its way to a prosperous, secure, democratic unity. as you saw from the film, there were a lot of people that disagree with me on both sides of the aisle. there were a lot of people that thought that by doing this, getting involved, the united states was blowing a chance to claim the so-called long awaited peace dividend. if we just could get past this conflict with the russians, we could dramatically reduce our

expenditures, invest in long- delayed infrastructure and other needs at home, deal with the problems in our cities and minorities, improve the performance of our schools. getting involved here was the beginning of a slippery slope that was, in the words of president eisenhower, "giving in to the imperative of the military industrial complex." there were people who thought it would be another vietnam. there were a lot of people who believe that this whole thing was foolish. use all the film said 70% of the people were against sending troops there. it even after the whole peace accord was complete, the opposition was 58%. the first thing i did as president was try to put together an aid package for russia because they could not afford to bring their soldiers

home from the balkan states. 74% of the american people were against that. three-quarters of the house of representatives voted against our aggressive early involvement in cuts above after we had gone through the agony of bosnia. -- involvement in kosovo after we had gone through the agony of bosnia. in foreign policy you have to put your boat in the water towards what you believe is in the best interest of the country and the best interest in our values and the world and if you are right, it will come out right. if you are not, it does not matter what you did on day one. i will never forget when people thought i had lost my mind by helping mexico.

81% of the people were against it. we had just lost the congress. two years from now we have more illegal immigrants and everybody in latin america hates our guest and people ask me why i did that, i said that there was a poll that said 81% of the people did not want me to do that. that is a reminder for the young people here. we were dealing with a lot of complex situations where we had limited control of some instruments and a lot of variables. the president has to do what he thinks is right. the people fundamentally expect us to do that. i am not saying you should ignore popular opinion, but if you know something that most people do not and you can see around a corner or two, if you have to do what is right for the nation and the world.

that is the context in which this occurred. i should say one other thing, i was rally criticized for not doing this sooner than i did. warren christopher went to europe early in 1993 and try to build support from the europeans for being more aggressive when there were a lot of diplomatic efforts going on. i kept working at this because the objective was both to stop the killing in bosnia and give them a chance to make it, and to maximize the chances of a united, democratic europe. i did not believe we could do that if america acted unilaterally. just so you understand, and i am

not criticizing other people in putting this thing in a totally rosy scenario, there was a lot of people who hit me day in and day out because they said, "the longer you take to act, the more people are dying." i thought the only way peace could endure is if we did it with europe, with our nato allies, with the support of the united nations. what i think is it important to put out is that we were getting it from both sides. i asked you to think about that as i bring on the first panel. the panelists are secretary of state madeleine albright, who was ambassador to the united nations and was always an aggressive supporter of american intervention in the balkans.

general wesley clark wore many hats and became the supreme allied commander at nato. at this time he was our principal military negotiator in all of the peace talks with richard holbrooke when we lost those fine people and was indispensable in this work. ambassador peter galbraith was ambassador to croatia in 1993. he mediated the agreement in 1995 that ended the conflict in croatia and helped to end the muslim-croatian conflict within bosnia herzegovina. he also oversaw all iraq. i encourage peer to say this --

he was also at the center of a big controversy about what would happen while the conflict was still raging before we could get the international community involved in terms of whether the croatians and the bosnians would be what al because there was an international arms embargo. it seemed to make sense that an arms embargo would minimize conflict. the problem is, it was a fraud because the arms embargo operated only in effect for one side. the europeans were unwilling to lift the arms embargo because it would look like we were supporting an arms race. we did not want people -- we did

not want the battlefield to predetermine the outcome of negotiations. as you'll hear today, some reversals on the battlefield led to a balancing of interests which made the peace agreement possible. peter galbraith was at the center of all of that. it concluded a congressional investigation as to whether we did the right thing by not vigorously enforcing the arms embargo. that is a euphemistic description of what we did. [laughter] i thank them all. i would like to thank ron brown's team. he is a columnist for the "los angeles times" and other outlets involved in this from the beginning. we began to raise all these issues in public debate.

he is here to moderate the panel. let's welcome the panel and get on with it this evening. [applause] >> mr. president, good morning everybody. i am ron brown. the president has introduced our distinguished panel. let me start with an issue that president clinton raised. the title of our panel is "the dayton accords and 21st century diplomacy." during the first two years of president clinton's administration, there was a great deal of uncertainty about how this was perceived.

richard holbrooke wrote, " between 1991 and 1995, the actor national response to this tragedy was at best uncertain and it worse appalling." what it takes so long for the u.s. and europe to intervene? >> first of all, i i i think listening to president clinton, you all know -- first of all, i think listening to president clinton, you all know how fascinating it was to work for him. it was an honor and a pleasure to work with you, mr. president. i think the hard part has to do with the fact that, as he says, we were so focused on the cold war and with the fighting in the soviet union. the other part is the gulf war. there had been a war. we had won it, apparently at the time, in a way that tired the

people out. at the same time, there were a lot of things going on. one of the hard parts when you look back at history is that you forget a lot of the conflicts. we had a humanitarian operation in somalia. there had already begun to be the refugees coming out of haiti. something was happening all the time. as the president said, the people were ready for a peace dividend. they did not want to get involved. we had spent six years looking at the world to the soviet prison. i was not born in the united states. i was born in czechoslovakia. people used to say, "why should we do something about a country which cannot pronounced in a faraway place?" all of a sudden, the same thing was going on in the balkans. people did not know why they should do this. i think the president had talked

about the economy and other issues. one part he said to motivate people is that you have to understand the context of so many things going on at the same time. >> peter galbraith, your perspective on things on the ground. >> it strikes me. president clinton discussed the criticism on the ground i heard every day. "why are you not doing more?" at the beginning, there was disappointment with president clinton who said he would do something during the campaign. the situation became more complex. that is because a war had broken out in bosnia between the croatians and the muslim forces

-- the government. as long as that war continued, there was no practical way for assistance to get through to the bosnian government. when i arrived -- i was one of president clinton bawdry first appointee to arrive on the scene -- my job was to try to minimize the violence, stop the atrocities that were being committed, the humanitarian supplies. i said the first week, i included a joke that was going around sarajevo. what -- the serbs had cut all the gas to sarajevo which meant there was no water and the way to boil the water. there is a cholera epidemic. "what is the difference between

sarajevo and auschwitz?" in auschwitz they had gas. it was tasteless. that humanitarian crisis was defused. the next step to end the war between muslims and croats -- we succeeded in doing that. there is a law of pressure on big relations. the president of croatia was -- changed course. then came a critical decision, which president clinton discussed. i would like to say a word about that. the president of croatia came to me and said, "the bosnian government has asked what would be the u.s. attitude if we

permit arms to transit our territory and get to the bosnian government and some of them are coming from iran." most of them were coming from the black market. president clinton took the decision, which i thought was the right one, to tell the president that we did not object. the ashley hope for the opposite decision. he still had territorial ambitions there. the arms began to flip. when i saw the president just before he died, he said it was the single most important thing the united states did that lead to peace. it reversed a situation in which the serbs had all the arms and work in danger of being exterminated. i think it was a very significant step that led to dayton.

it is not something that happened all the sudden i in 1995. >> was the military primarily skeptical of greater involvement or were there key decision making processes that could play a role in bringing this to a close? >> it is a pleasure for me to be here with madeleine albright, peter galbraith, and president clinton. when i think back on these years, there was unified leadership in the united states government. there is a man in charge of that vision. he took us where we needed to go. the military was not part of that vision. colin powell explained it that when he was the chairman of the joint chiefs of staff. he said he would go to the meetings and say tell us what

you want us to do and i will tell you what it takes. the military was sort of in a reactive mode. in the spring of 1994, every weekend there was a crisis. it was north korea, it was haiti, it was a shootdown of aircraft in bosnia. from the outside you cannot see any of this. i had no idea. we were still recovering from the war in iraq. we were doing precision strikes, high-technology -- if you could see the ground, you could control it. we were also wrestling with the bad memories of vietnam. there were two bad memories in particular. one was the so-called weinberger doctrine, which general powell could up in the early 1980's which said you had to emphasize your force. we call it overwhelming force at first. that was too much.

we had a tendency to worst case with the opposition would do. there were some people saying it would take a couple hundred thousand of troops to solve this problem and that we should stay out of it. there was also a sense that there was an idealistic strain in the american political scene. but when the going got tough and you started to take casualties, the ideas would not be with you. we had to be very cautious. that was the military posture. they were by standing. >> it was not so much reactive as resistant. >> i have to say that colin powell and i are very close. what happened was, and i think peter was saying he was on the ground and people kept asking him what was going on -- i was known as multi-lateral

madeleine. basically everyday people would say, "why are you not doing something?" i sold more diplomats than any other american diplomat. i would come to meetings and talk about this. it was at the end of the gulf war. colin powell came into our meeting -- metals from here to here. i was a mere mortal female civilian arguing with them. i kept saying we had to do something. we would have these arguments. he had his little red a pointer. it would take a zillion troops and a zillion dollars. what would i say to the sergeant's mother when he stepped on a land mine? i asked him what he was saving all the soldiers for? he got furious with me. he said i practically gave him

an aneurism from this. his book came out. i call them up. i said, "patiently?" the sec, "i had to do it patiently." >> let me ask you about one factor you did not mention. i think it goes from a comment the president made. the europeans should take the lead on the problem. that was the idea. warren christopher went over to europe in 1992 with a very unsatisfactory series of meetings. he left without a sense of direction. in the first months, the

administration was struggling with what was the right balance in this first cold war period between consulting allies? >> that was something the first president bush had been working on. the europeans were ready to take some responsibility. but were doing pretty well economically. nato was functioning. i think we had a sense this was in the heart of europe and why could they not do something about it. it was very frustrating. at the united nations it was very frustrating because the europeans fear -- i would go to a european ambassador and tell them i needed their help on a boat and they would say they could not help me. i would go to the same person a couple of days later and they would say they could not help because the eu did have a common position. the comment the president made about jim baker saying they

could handle it, it was not our fight. it was very hard. i think we did learn that we needed to know what we wanted to do before we went to consult -- that we needed to figure out how the system worked. what i think is so interesting about all of this is the president says this was a period of institution building. i loved being ambassador of the un. we thought the u.n. could function in a way it could not during the cold war because it was paralyzed. peacekeeping operations could, in fact, supplement or makeover at the beginning military activities. it was a very exciting time in terms of looking at institution building that we thought was the beginning of the 21st century. i think we all heard more than anybody about building bridges to the 21st century.

this is what the aspects we were looking at. it was very deliberate. it was delivered to use alliance structure and the un to be able to deal with the post cold war problem. >> peter, from your perspectives and the europeans taking the role on this? were you dubious of that from early on? how did you come to assess that? >> there was a huge failure of institutions. richard holbrooke, he describes this as the greatest failure of collective security since the second world war. in the sense that the idea of the un was a security treaty. if there was a country that was the aggressor, we all ganged up on the aggressor until the

aggression is deterred. it worked against iraq. it was failing here. the europeans had said initially in '91 when the war broke and out in croatia, let's not forget the president of croatia is here -- that was our second gelinas war since the second -- its second deadliest war since the second world war. the europeans said they could handle it. luxembourg, portugal, and the netherlands -- in an environment of eastern europe, that was not a very impressive representation of europe. i do not mean to fault the individuals. it is just tell the european system worked at that time. certainly by 93, people in the region had given up.

what gave the u.s. so much power was, first, the impression left from our spectacular military success in gulf war role in one. one of the things about having all this military technology is it is great when you actually use it. when you get bogged down in iraq or afghanistan, it is not that impressive. second, we were the last resort. when i went to carry out my diplomatic assignment, i felt like the voice of god. people would never say, "no, we will not do it." they would say, "yes. you are exactly right. we would try to do better." when i came back a couple of days later, nothing had happened. we could not get done. we had enormous insolence in this particular situation which

may well be unique. >> in 1995, we take a more assertive role and more of a leadership role. what is the reaction of the europeans and particularly the russians as we move from a confrontation to saying, "this is what we what." >> first of all, the president had a good relationship with president yeltsin. we needed that. but there were different strains in the russian government that we came across. we had a russian ambassador to is the foreign minister. igor was a wonderful guy. i used to swim with them every morning. he spoke a little bit of english and i spoke a little bit of russian. he was wealthy.

he would pass richard holbrooke memos and say, "take a look at this." he would quickly scanned at and, we think he understood it, but he would not be able to object. the russian military was very cynical about what we were doing. i was on a trip. my western counterpart came up and said, "you americans -- we know what you are doing." "you are going into bosnia. that is our part of europe. you say you'll be gone in a year. we are russians. do not worry. we would do the same thing in

your position." they saw it as part of the geostrategic chest that was going on. they did not like it, but they tolerated it because there were some who tried to make the relationship work. me -- it goest in need to what you're saying before. you discussed the confrontation with direction versus confrontation while casting around for ideas. the old road to dayton -- was there a change in the administration's view about how america it would pursue its role in the world? >> he is the first one that said

"indispensable nation." the bottom line here is that i believe that it is and evolution. i remember when i got interviewed for my job at the un. president clinton made very clear to me that he sell american leadership where we work with other countries. that was the multiplier that the u.s. in conjunction with our allies could do much more than unilaterally telling everyone what we were supposed to do. it was an evolution. there was a way of figuring out that if the europeans and the others were kind of being -- dilly-dallying is the best word -- we would have to take the role.

the first president bush did a good job on building the coalition in iraq. what president clinton did was take it to the next level. we did know when we wanted to do something how to do it. i enclose a vote -- i teach a course on this -- we use every tool in the national security toolbox. bilateral diplomacy, multilateral compliancy -- multilateral diplomacy. we used 82 countries if they decided to help with sanctions. we used both the threat of military force and we used military force and we used richard holbrooke. [laughter] it was an amazing way of using a set of tools that one has. mainly we had a president that

directed it and believe in it and understood the role the united states had to take. >> peter, from where you stood, did the way the administration approached this show a change or an evolution? >> it is important that we have a broad appreciation. it is a lot to talk about the bombing as a turning point. not at all. what it was was actually a croatian military offensive that took place in august. it involved some pretty tough moral choices. the croatians -- there was an enclave in bosnia which won an 60,000 people. in november of '94, the serbs surrounded it completely. the serbs or squeezing it. at that time, the croatians

indicated by might want to be liberated. the instructions i got were very strong. tell them never. we do not want a wider war. then in july 95, there were the murder of 7000 men and boys. the danger that the same thing would happen -- the same question from the croatians. our concern was that instead of 7000, we might see 40,000 men and boys murdered somewhere else. we also knew that given the nationalist behavior that there would be consequences for the population in the serb held areas. it was a tough choice. we made the choices. we gave the croatians a no- flight, which they interpreted as a green light. it changed the military balance. the peace plan at dayton was

based on a 521% for the federation and 49% for the serbs. when they all the sudden had 45%, by all the sudden had 49% interest. the nato bombing helped. there were a series of steps that led to that. >> obviously bosnia is a turning point in the evolution of nato. we see it move in other directions after that. talk about bosnia and the impact on nato's vision on its role in the way it operates. >> nato had already done some missions in the bosnia area. we had two exercises. we had air exercise and a seaborne exercise. we were just not on the ground as nato in the '94, '95 period. britain and france had their troops under u.n. control.

the counter attack by the serbs had an impact. the new french president decided he would reinforce and the british went along with this. they put out some military. the british and french rule became very muscular all the sudden. these are not really military forces. they are there to provide assurance. the presence of artillery sadly made a more muscular. this was the beginning of talking about a real nato role. if you're going to talk about real forces, will command and control, will logistics', and reconnaissance and intelligence. in the summer of 1995 after the massacre, everyone got very serious.

when negotiations started, we began also to deal with nato as the alliance and talk about a prospective nato role in the occupation. >> you talk about the time after the agreement -- there was some skepticism about whether it could hold. richard holbrooke described it as "rocky." endured longer than anyone expected at the time. what allowed this to ultimately take root? >> first of all, i'd think the people wanted to have peace. the killing there was a dreadful. president clinton and i think that they were ready. there was also international support for it. it was rocky, but the europeans took part. the un took part. we obviously did an awful lot. it was not simple. i have to tell one story that exemplifies it. in 97, we tried to work out a

way that out of bosnia and there could be a way out to a bridge. i ask permission to get this bridge open so that bosnia would not be totally landlocked. there was a big ceremony. there were three prime ministers at the dayton accords. one of my press assistants won a picture of us on the bridge. there were a lot of suits around. nobody had on name tags. she asked anyone who was a prime minister to raise their hand. [laughter] 3 people raise their hands and another one left. it is an example of the problem. how is it that you could get this complicated system to work at it was still an issue? i hope in the next panel i can talk about it. it shows me that you cannot always check of the problem as done. it has to be managed.

in many ways, the international community continues to be a part of this, but what we learned in bosnia and what we are trying to do it now is to bring serbia and this whole region into europe and go back to the original idea of a europe that is whole and free. that came out at dayton and all the various evolutions. >> of like to say something about what it was that was accomplished. first, it is something very much in human terms. i saw this almost every day. there were refugees living in mind and houses on the frontline with babies dying from absence of medical care. never mind the massacres that occurred from time to time period that end.

that ended. it was not a short think this was going to end. it was not a sure thing that dayton would be successful. richard holbrooke had a huge amount of accomplishment. let's consider what the alternative might be. we might be discussing in 2011 year 20 of the bosnian-croatian wars. serbs occupy a part of cyprus. there is permanent hostility. bosnia as a source of ongoing conflict. it is a hotbed for terrorism. the impact that that might have had on europe -- it would be

profoundly demoralizing to europe. what would it have said about the un and the u.s. mission? it would have been a failure in its broader purposes. while the constitution of bosnia-herzegovina as a unified state is far from perfect, and from the stage year a lot of criticisms about dayton -- we were not seeking to create a perfect country. we were seeking to end the war. we did. nobody has died in hostile action since 1995. 16 years. that is a remarkable achievement. >> our time is beginning to run down. i want to ask two questions. let me start with you, madam secretary.

this is a case where we used all the tools in our toolbox. military force, diplomatic pressure, consensus building -- is there anything that model can tell us that apply to the challenges we face now in afghanistan, pakistan, and the unrest in the arab world? is there a lesson in that integrated approach? >> i do think that, first of all, i have said that there are not a lot of tools in that tool box. what i think we have learned is to try to use them together. i was asked to help on developing be made a strategic concept. what is interesting is that they took the lesson of the balkans to some extent and to afghanistan to talk about a "comprehensive approach." that is to use the military to

bring activities together and where you learn lessons we cannot solve all the problems militarily. you have to have the civilian component in terms of reconstruction and political work, in terms of getting the population to understand what is going on, and also to have all lances work. i think that is one of the ways that the lessons could be learned about how you use which institution, but you need to mix and match on these tools. i think that is finally what is going on. but it is not easy. i think sandy berger can speak to this better than anybody. systemgot to keep the together in terms of getting the bureaucracy to move the process afford. it is internal to the

sometimes you actually call up an ally and say "would it to suggest that instead of me?" >> you have to have the right conditions on the ground. that is one of the most important lessons. not only do we consult with allies and friends and others in the region, but we set the conditions. i want to go back to richard holbrooke. when the croatian offensive was really grinding forward, richard and we were marched en on a sunday morning. the minister of defence said "wait a minute. we are in complete disarray. they are shooting disorders in the street. they sent a new general to take

charge. if this is the opportunity. we will be there in a week. you want us to stop?" they stopped. after that, it never got going again. that was the 51-49 boundary. the serbs did not know it got going again. richard is all that and got the conditions set. the other thing about this, if you have to have the right personality and ability to put the pieces together. richard holbrooke was right. he did it at the dayton and with a lot of help from a lot of people. it was his responsibility. he did it. we saw pieces and bit of it. i cannot tell you all of the pieces. he cajoled and flattered and it did everything to bring those

groups together. even when you use all of the tools and set the conditions on the ground, there is a certain amount of chemistry to bring the agreement to a close. >> he had been close to the current challenge and have been involved in the bosnian challenge. your thoughts about what they can tell us about afghanistan and pakistan? >> let me turn to that. i want to add something. i listened to the tape of the meeting that dick and i had. we met along. -- alone. one of four trials that i testified at -- it was not quite as unambiguous as that. what was extraordinary was the

fact that at the outcome where these trials. every journalist said this was a cynical exercise because you are not prepared to do something. all but two of the people who have been indicted have gone and are dead or died in the process and have gone through it. i have to tell you. there is nothing that gave me more pleasure than testifying. normally, you take abuse from terrible people. some of these were terrible people. all you can do is write your memoirs that no one will read. they are probably already dead. i got to people in jail, real justice. the second point i would make, because i have been involved and served. what are the lessons? one is do not try to apply to

many lessons. what came out of bosnia was a sense that the elections were held too soon in bosnia. that lesson was then applied to iraq. it was a disastrous course of action. we would have been better off to have quick elections. from my experience in afghanistan, i cannot see anything that is applicable to bosnia except this. in croatia and bosnia we have partners. that is the key to excess -- that is the key to success. we have a strategy that requires a partner and that is why it is not working. >> we are down to our last few minutes. it was not -- the president talked about where it internet and cell phones were. it was not a long time ago in a galaxy far away. it was different in the sense that people talk about the 1990's and the early part of the

21st century as a moment when the u.s. was unchallenged for world supremacy. it is the model of how we pursue our goals in the world then still applicable today when we are talking about a much greater diffusion of power? is the vision of the u.s. as the indispensable nation the way we should be leading the world today? >> there is nothing about the definition of "indispensable close code that says "alone." -- indispensable" that says "alone." the things that happened in some far away place actually affected us at home. our engagement was very important. i believe that continues today. it needs to be done within a structure that respects other countries.

americans do not like the word "multi literalism -- multilateralism." it has to many syllables and in an end ism. we are the most powerful country in the world. we are in a screw the situation, but we are the most powerful country. that model comes in at the end. >> we need to know where we are going. we have to have a clear direction to drive that. >> when the issues in bosnia is "what is the national interest?" the question is whether it is geostrategic or whether it has a moral component. i believe american values and terms and not letting people be massacred and ethnic the cleansed is part of our interest. everybody defines it

differently. it takes that kind of leadership to explain it. why we do want to pick people in harm's way because something is happening somewhere else? he can explain it because it does affect us physically or affect our morals. >> is the way we exert leadership in the world today -- should it be different than it was at the point of bosnia? >> it is going to be different. it the power relationships are different. i want to reinforce the idea of the indispensable nation. america is still the greatest power with the great his values and credibility. we deliver. we are still indispensable. others have more capacity to contribute. one of the things we have to do is find ways to engage them with us and get their contributions. >> you have been up close at some of our greatest setbacks

and successes. what is your thought about the nature of our leadership today? >> i think the day 10 period -- dayton period and leadership of president clinton was unique. america's relative position was going to decline. the previous administration accelerated that decline with some very poor choices in terms of the places it pursued. one of the other lessons of bosnia and the war's in the balkans is just how interconnected we are as people on this planet. there was a hope on the part of policy makers -- the clinton administration wanted to focus

on many -- that we could set this aside. he was in egypt. i thought she end richard holbrooke my shared the nobel peace prize. she exemplifies that put what was happening in bosnia and our faces. we saw the people who are being shot at by snipers were not faceless people. they were women in high heels, children. people who looked a lot like us. that is very important. we have this kind of immediacy with egypt right now on the square. i think that is another of the big lessons of bosnia. >> it is a milestone in recognizing our share. blacks this has just been an incredible -- >> this has just been an incredible tour. if you'll join me in thanking

this terrific panel. [applause] >> coming up next, health care providers and administrators discuss the future of health care. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2011] it your been mayors -- a group of mayors talk about their cities. on tomorrows "washington journal" a look at the standoff in wisconsin's state house with the executive director of wisconsin and now. analysis of rising oil prices would john felmy, chief

economist with the petroleum institute. a new poll showing fewer of voters identifying as democrats. we will talk with charlie cook of the political report. "washington journal" begins at 7:00 a.m. eastern on c-span. >> this week and onbooktv, the former chief of the cia's osama bin laden unit on the war against the u.s. they think the liberal has tarnished the reputation as a trusted news source. later, susan jacoby discusses culture and "never say die." >> executives recently discussed health care policy at the university of miami.

panelists include hospital administrators and government officials in charge of medicare and medicaid. they focus unaccountable care organizations which are new models for providing health care that can buy insurance companies, physicians and hospitals. this is 1.5 hours. >> this session will focus on accountable care organizations which many are touting as a model for health-care reform. although the legislation passed last year encourages the establishment of these bigalke -- aco's it does not gotten a lot of attention.

i want to thank them for sponsoring this panel and extend a warm welcome to john kirsner he will leave the discussion. he is an advocate for insurance companies, plans, hospitals, and government organizations. we are delighted they will monitor this. with that, i turn it over to john. [applause] >> thank you very much. i would like to say thank you to the university of miami for giving us the opportunity to be here today. be a sponsor.re happy to we are a large law firm. we have 37 offices in 17 countries. when we heard about the forum

to be presented, it was a natural for the reach of our firm to match up the strengths. two of our strongest offices are located in south florida. our healthcare finance practice is among the strong this and our firm, providing innovative solutions. with that little commercial, let me get to the meat of the introductions. the objective of our panel is to talk about a patient centered care and accountable care. the perspective of the leaders who have agreed to be here to talk with us on this panel included viewpoint of physicians, hospitals, medical centers, payers, and denied

state government as well. they are a great panel of people. dr. toby cosgrove will speak first. steve jones is the president of the university hospital. john bigalke bigalke is head of the practice area. tony rodgers is deputy administrator for strategic planner. with that said, i am going to introduce our panelist in reverse order. after i got done introducing them, toby is last and he will speak first. that seemed to make the most sense. rodgers money has over 30 years of experience. -- tony rodgers has 30 years of experience.

he has worked in lansing, michigan. he was a past director of the arizona medicaid program providing health care coverage for over 1.3 million people from arizona. john bigalke has acted as vice chair and industry leader for health sciences at deloitte. he had 20 years of public accounting practice. he is the partner. he provides service to many key players including health net, cigna, universal american and others. he also provides advisory services to many leading providers. the perspective that he will

bring today will focus unaccountable care. steve jones as president and ceo of robert wood johnson hospitals. he is work in a variety of roles. the hospitals and health systems is a for hospital system, an academic medical center that includes a children's hospital. he is a board member of the hospital association and a veteran of the united states air force were specialized in russian linguistics. hopefully, he will be able to help us weave through the acronyms of accountable care with that background. if [laughter] dr. cosgrove is president and ceo of the cleveland foundation. it is a $4.6 billion health-care system and is one of the most

well-known health care systems in the world. he emphasizes patient care and experience. he has reorganized the model into a patient's centered institute model, a perfect person to talk about getting it across. he joined in 1975. he led the clinic's heart program on a 10-year run. he was an air force surgeon. he served in vietnam. he earned a bronze star. yes performed over 22,000 surgery's, which is at numbers i have a hard time getting -- she has performed -- he has performed over 22,000 which is a number i

have a hard time getting my head around. i would like to introduce you to mr. costs grow. >> i want to thank you for including me. this is an opportunity for a great discussion. art institution is unique in how it is a forms and organized. we are in not-for-profit organization. we are the second-largest group practice in the united states. we have a physician leadership. we are all salaried. there are no financial incentives. we have an review which we take very seriously. lester, we spent 8000 man hours. there is no tenure. we have one-share -- one-year

contracts. i hope for numbers 35. [laughter] we have had to the beginning growth. physicians have become interested in being part of the group practice. a number of employees has reached 40,000. we are scattered across the large area. the organization of our group is quite different than most. most hospitals or organized -- are organized around professional groups like radiologist, etc. we took a different view. rather than organizing our hospital around doctors, we decided to organize it around patients, an awful -- a novel idea. we put them together, medical and surgical.

we do them around as these systems. they had a single leadership and, and location for these physicians. take the vascular institute. it has cardiologists and vascular medicine. the neurological institute would have urologist and psychiatrists. the location this is coming -- this is a health care delivery system. you need to have the patients in the right facility at the right time for the right care. they go for the entire range of care. we have partnered with minute clinic and have outpatient

facilities where you can get strep throat swabs. we have family health centers, there are currently 17 of them scattered around cleveland. these are associated with community hospitals. there are nine that surround the main campus. the commonfter ailments of individuals. the main campus has become a high-tech facility, 1200. we no longer feared do psychiatrists. it has heart operations in complicated orthopedics. in florida, we have 170 doctors.

it is growing rapidly. they are building it on the same plan. in las vegas, we have the center for brain help looking after neurologic disease. this is not the crash of a 747, it is a new building. in cleveland or canada, we have -- cleveland clinic's welna wellness center. we are building one in of gadaffi -- in abu dhabi. we will have over 1100 beds in abu dhabi in the next few years. this enterprise is held together by electronic medical records that looks over 6 million

patients. they are all tied together with medical records. we got a nice shot out from the president. -- shout out from the president. what holds us together is the transportation system. it includes land transportation, three helicopters, and aircraft which can pick up patients from anywhere in the world and transfer them to our facility. this is part getting the right patients in the right place at the right time. it has gone progressively up as we have at the capabilities to the patient. we do not think that all hospitals can be all things to all people. it is important that we began to

centralize our activities of patients have an adequate volume to develop quality which comes from having volume and from having the efficiency that goes with it. if you look at our health care system, we have of obstetrics previously in a number of places. we have concentrated it. this will be reduced further. some hospitals only do 800 deliveries a year. we plan on continuing to consolidate. with the dead inpatient rehabilitation -- we've looked at inpatient rehabilitation. there are four cornerstones, quality, innovation, a team mark, and a service.

the u.s. news. we are numbers 4 in that. we do not know that is a measure of quality. it is more important that you measure outcomes. these are our books that we published every year. it is good, bad, and different. i did not know what we can measure. it is pretty easy in cardiac surgery to measure outcomes. to either walk out or get carried out. [laughter] i asked dermatologist to come up with their on metrics. we have asked of the dermatologist to not to say they are great determined colleges -- grated terminology a great to the metricsbut th

to this. we believe in transparency around these outcomes is important. as far as innovation is concerned, we think it is baked into our legacy from our care delivery in and continue to increase with over 2000 projects. the number of publications coming out is over 1200 a year. the patent are shown here. there are 36 spin-off companies. teamwork is another one of our corners torrance. madison is no longer an individual sport. -- madison is no longer an individual sport. -- medicine is in no longer an

individual sport. no longer will one individual be able to surround the amounts of knowledge that you need. it has grown enormously from the individuals who formed the teams back in the early 50's. they've also become more sophisticated. each one of these represented a different country. the 13 to plastic surgery. the teams have become more sophisticated. this is a cornerstone for us. it is what we are all about. we recently said that patients should be seen when they want to

see. they are given a in appointment. it is more than a clinical outcome. we pointed to individuals to be the chief experienced officers. one is a surgeon. one is a head nurse. if we start by treating patients at the door. we help them find their way through our organization. we have art on the walls that acts as a locator and allows you to break up the monotony of the facility. we designed our rooms with large amounts of glass. families can spend the night there.

we think dignity is important. they design a gown that no longer believes your cheek flapping in the breeze. [laughter] [applause] thank god i have a wife that directs me in the right direction. you cannot tell the playj heirs without a scorecard. we have color-coded all the people who work in the hospital. the patient is given this card so when someone is green comes in and it is a clinical technician. a resident is a white coat with black lettering. patients know who is coming into the room and why they are there. patients visiting hours are now a thing of the past. he can come in anytime you want and stay as long as you want. it is no longer about taking care of a patient but a family.

we have all the medical records. it is no longer the doctor's record. this is your record. you should have access one ever you want either electronically or in paper form. massage therapy is available on the floors of. there is that there be that comes into the hospital. nothing is better than a leak from a lab -- lick from a lab. there are prayer rooms. it is important for our patients and for our employees that we began to discuss the major cause of premature death. obesity, sedentary lifestyle, and smoking. we started out by making the campus smoke-free. we decided not to hire smokers. we test them coming in. if they test positive for nicotine, we allowed them to

have a smoking sensation opportunity and they can reapply. this applies to doctors and all caregivers. resulted in the county. but these are the incidence in ohio. it was 28%. it is now gone down to 15%. you can make a difference of public health. we took trans that out of our food. we tip soda out of vending machines. we have a major wheat reduction program including free weight watchers, yoga, etc. we have lost 180,000 pounds so far. [applause]

i would like to say that it is a start. we probably have 2 million more to go. a journey of 1,000 miles starts with a single step. we are in the service business. it is about putting patients first. we had done everything we can to putsnize our system so it co patients at the center of the activity. thank you very much. >> thank you. i appreciate the chance to participate in this discussion about the development of aco's or that transformation, particulates from the academic medical center. let me see if i can advance this.

there we are. we are the principal teaching hospital for the medical school. it is one of our state medical schools. we are the principal teaching facility. we are the flagship of a four hospital system. there is a pediatric system. the center of excellence have a credit basilar institute. we are proud of what they do for our country. in cancer care, it is new

jersey's only comprehensive cancer center. we have a cancer hospital connected by a sky bridge. we have the children's hospital. one of our system members is the children specialized hospital. it is the leading provider of children's specialty services. we are also a level one thomas center in new jersey. -- level one trauma center in new jersey. we are co owners of a provider sponsored managed care organization. i believe that will pay an accountable care organizations. the role of an academic medical center is you need with patient

care, education and discovery. the challenge is balancing that academic mission in a low-cost environment. that is clearly where we are going. two months ago, at the annual meeting they talked about the leadership role of academic medical centers in said that it was very important that using the strings of the medical center that they need to become engaged in the transportation needed to improve the help of all. there are challenges to the developments while we await regulations so we understand what the requirements are. we know there are challenges they need. we also have four hospitals on the same information platform. there is a lot more to do to be

fully integrated and to have the integration move among the ambulatory care facilities. access to the large enough supply, you read about the experience in massachusetts. they went their transformation. -- true transformation. we are uniquely situated. they have been doing research for more than 20 years. we think that gives us a leg up. comprehensive case management is lacking. to most medical centers have not assumed responsibility. there are fundamental change in

the revenue stream. position alignments will be more critical. they are challenging. they have the roles and irresponsibility of the chairs and the need for us to align with physicians and our community. physician leadership is critical. physician alignment will be critical. how we mix those with the academic medical center with the changes we know are needed to engage in the physicians and our community. in new jersey's experience, five systems have a major teaching hospitals as their flag ship. this is the only one with a medical school on the campus.

if each of the health systems are working to be ready. it happens that we are all co owners of the managed-care organization. we are working individually and as a group for what they can do with us. physician groups are mainly fragmented. there are lots of them. there are very few large multi specialty groups. our practice is among the largest. they are positioning themselves .o develop, -- to develop aco's they will block hospitals out of the leadership. hospital services are a

commodity they plan to buy. the strategy for development, we want to leverage the existing strong relationships with our medical school. the positions are broadly in our community. we give patients from all 21 counties. we are enhancing position alignment strategies. we are developing accountable care organizations that we call robert wood johnson partners. it includes standard best performance measures. the department of health is releasing help. we received an embargoed one.

we believe n. transparency. it is interesting, the development of partners. we find many organizations that are looking for staffs to provide the leadership. in our county, they provide this. new jersey is a very highly unionized state. there are labeled -- there are labor unions. if they are looking to manage the cost and quality of their employees. they are interested in the developments of the care organization. there are other large employers.

we just started those. it does come to lot of the pharmaceutical companies. there are opportunities there. in our state, medicaid want to transform its population which is just under a million. we are talking about new brunswick. there are one of five systems that managed to do it. there is a strong business case for health care reform. there is a strong business case for transformation. i believe there is for academic medical centers to be involved in this development.

the first is value. there is the economic engine. more important that, the economic engine is our responsibility to the small and midsize businesses. in order to build all of our state's economy is common the more we can do to help manage health-care costs, the better. there is leisure about reduction from those organizations like the clinic. they have managed these populations. they are incorporating the next generation of professionals in what the best practices are.

the need for transformation is clear. we are waiting the political change that might come in washington. the pressure to increase value will not change. in 1993, remember the clinton health plan? president clinton came to the robert wood johnson university hospital. be ready for receive visited to talk about health care reform. what happens when they did not advance? employers stroke change. it is very clear and that we need health care reform. there is a need for this. they must help that change. thank you very much. i look forward to questions from the panel. [applause]

>> i am glad to be here this afternoon. it is very rare that you have an opportunity to speak at the podium. there are a couple of points i live like to make. in my job, i work with a lot of providers and health plans. i hear what each of you have to say about the redeeming qualities of the other. that will have to change. we are talking about today are the tip of the iceberg. it is a first step in trying to do some of the things that are described. when you look at the population, you talk about

medicaid. medicaid follows medicare. what about large employer sells bonds? what about geography? what about things like workmen's comp? you have to realize it is a much bigger than a set of regulations on payments a defines medicare population. at some point in the future, this is how we will have to manage the cost. i start with that to ask you to step back. think of this differently. i'm not talking about rationing. i'm talking about caring for a population before they become a patient. never have to see the inside of a patient room. creasing the incentive for them to be paid in a way that creates

that kind of environment. that will require a different business model. i put out some of the attributes that you can argue. i would suggest that you think about their view of the consumer of the future purses may be what we might start off today. i should probably use the word "consumer." you think about them not just in the middle of postoperative care or other things like that, but may be early on. i would love to see some the things they are talking about. there are so many stories. i was at a meeting in chicago. newt gingrich was there.

that was fascinating. newt gingrich told a story of trying to manage down the cost of health care and a county in rural southern states and talking about the social conflict between recognition of a young adolescent headed for its severe obesity and the consequences of that, of being unwilling to intervene. and then complaining about having to pay for the cost of the reno -- the renal care. how do we create technology and support systems that cross over all of the aspects of care? had we figure out how to measure risk and reward the right

behavior to the right people? the incentives are not here today. i believe we will go to more of a risk model. that is when you start getting the best behavior out of the system. all of them are rewarded for this kind of behavior. you have to understand how to evaluate that risk. ending care management support. the upper end of the spectrum is treating this. there is a past majority that are night there -- that are not there. they can be helpful. if you look up what it is going to take to do the things i am describing, you are going to

have to have a different leadership and governance model. providers have a real challenge. the incentives for doctors, if you look at them by age, a specialty, the incentives are very difficult to influence behavior. it'll take a different governance model. you are glad to have to have the kind of information that helps you cross your population. being able to save data as of

april population there are real time decisions with real-boards on how to care for patients and how to do clinical re- engineering. network and physician alignment. he mentioned the challenges of physician alignment. if you talk to people who are doing very big things today in the provider world, i think you'll get lots of different definition. there is access to capital. it is hard for not for profits. there are a whole host of skills and risk-management.

i a take this down to competencies'. i think most i talked till are open-minded about collaboration. it could be a fool -- full arrangement. i think you'll find they are interested in having discussions on how to collaborate with the providers. they see the future. dana the bottle hasted shift. my suggestion of the that you do an honest inventory. we can see what good it can be.

look at where your gaps are. think of innovative ways of obtaining the resources. this is an overview. we can get into a lot more detail that i will leave that for now. with that, i will turn it over. [applause] >> thank you for inviting me here. it is about 38 degrees. i thought it could be helpful as the administrator for planning to give you a strategic you cm whites -- a cm whats -- of what cms will be driving the system

to do. we have three games. one is better care for individuals their health care to reducing costs through improvement. many of the speakers have already talked about their success in achieving many of these goals. we know the system can achieve the goals. we see a significant variants. what is causing it? the way we have reimbursed the system has created a culture in the delivery system that is that counter opposition to what we are trying to accomplish. we take this responsibility and we realign how they will operate in the future. we cannot as the system to

reform if we cannot do it ourselves. we realize the excellence and operations is how we relate to the system in the future and how we ensure our organizational alignment with organizations that are organically a line to helping us achieve it. it should go to the organizations. the patient delivery system and our community halt efforts have to be integrated with agencies that are focused on these particular areas. within the business environment, one of my roles is to reorient the business environment toward this new delivery system. we do not want to do

prescriptive policy. we would rather be -- we would rather do descriptive policy. we want to be able to expose the performance of the delivery system and look for opportunities. then of course public information. more and permission about how the delivery system works. they are investing in the future. if you want to boil it down, we see it produces a cigna began amounts of unjustified variants and patient safety. we the get these lies. he can see where it is. we are beginning to see into the

system where it is. over time, we are going to be tracking it and driving it into a delivery system. these are on the top levels of where we see significant cost versus the national average versus the best practices. we can get the difference by areas or whether it is miami or louisiana or texas. there is a relationship between the cost and quality that we see. if you look at all of the red, it begins to break down where we are seeing the best practices. our goal is to work with the delivery system and not regulate its to move it from being red to

green. we can move it and its use best practices more quickly. it is our goal to have measurable improvement in ^ that is felt by our beneficiaries. it will reduce cost because the system will continually improve. community health will become part of what the delivery system is concerned about. we believe there will be a longitudinal relationship. the system will allow a smooth flow of transition between commercial health coverage to medicaid and eventually into medicare. our goal is to create incentives that make the system organically aligned. it with a look at this as an evolutionary process, -- if we

look at this as an evolutionary process, it is episodic and non- integrated. the system doug -- does what it is paid to do. there is no consequences for not coordinating care. we want to move it to accountable care. out there is this integrated health system of vision that we have. it is patient centered and uses the technology is to create a greater engagement between patients and physicians and their health care team. it sees a patient longitude elite. it rewards the risk for innovation. that is the basic molecule of a patient centered system and informed and activated patient,

a prepared exchange with a team. we have to provide tools that help them raise their health literacy ends more accuracy engaged in their management. we have to have clinical teams that have the electronic put records and the ability to exchange that information. there has to be a common place by the patient and physician have a common set of information that they are both acting on. to do this, we believe we have to bring the pressure several parks -- several strategies. one is the electronic health records and what we are doing in investing. service delivery redesigned investment to our innovation center, which will be investing in helping the delivery system

five redesign itself. quality and cost reporting transparency. of the patients -- the payment reform. payment reform going from 8 feet per service transactional based system to more shared savings, bundled payments, value-pace payments to allow the system to invest in what it knows will work. to create a delivery system that has accountable care and medical integrated with a comment organically alliant goal -- allied goal to achieve the highest value result for that patient. the expiration of -- that patient will be engaged in the system over time. this is our management focus.

we will be coming out with regulations in the near future. the diffusion of medical homes as a foundational organizational delivery system model that we will build an ovation on. we cannot do it on a fragmented system carry we have to have accountable care organizations. ar specific focus in to douse 11 will be to reduce readmission rate -- our specific focus into dell's 11 will be to reduce readmission rates. as well as to begin to purchase services based on value, which means quality and cost will be to factors and which we purchase services. we're already starting that. we will be moving back into the delivery system. if there is a way to describe what's an organization -- beneficiary, patient focus.

when the person is not a patient, they are still part of the thinking of the delivery system. they're thinking about the family, the social environment, the about the public health environment. moving to address those upstream issues. when the beneficiary becomes a patient, the system is very patient centered. it is focused on how to improve the care and innovate around the patient experience and the care management. organized to manage care processes across the continuum of care, using the effective use of technology. unless we do something in the delivery system to great accountable organizations, which will fail in most cases to move physicians and hospitals to adopt electronic help records.

the aco is a strategy to create a market and the reason why physicians will want to accommodate electric help records. they will realize to be a part of an accountable care organization, they will need to know how to meaningful the use that tool. if we are good at this, i results will be improved care coordination. we will be sharing and learning from each other. patient activation, raising literacy of our consumers, and efficient delivery and elimination of waste and reduction in cost to continuous improvement. if we are successful, less of a regulatory environment and health care. a free cup of these organically alliance systems to do what is best for the patient. it is going to be our goal to not dictate with the structure

should be. we know there will be hospitals, organize it -- organizations, and physician that will have staff models and provider networks. they will have a number of providers coming together in a loosely affiliated organization, all centered a round but we expect the aco to do -- govern and lead. if we look at the medical home, but we see a maturing process that is necessary. it is an important part of this strategy. we know we have to move it from being just a primary care or a specialist provider. it has basic electronic help information technology. or the ability to manage the individual patient episode to a

medical home 2.0 which has patient registry information, the greatest patient access and communication to electronic exchange, is connected into the public health and bio surveillance system that has enhanced ability to report on a two weight basis. there is a two-way quality of reporting so that we can provide information on opportunities to improve quality. the medical home 3.0, which is fully capable, has advanced care management. has agreed to participate in the community transitional research as part of a broader are virtual community. is connected to to meditate resources. can make referrals that have patience learning centers that patients be, and learn for

themselves. it has a resource for they can go online to get materials that helps them raise their health literacy. helps to be part of the community. finally, integrated into optical systems. is able to do biometric monitoring of individuals so that we can keep them from being institutionalized this is our vision and where you will see our innovation investment. our free particles and the means to achieve this -- are 3- particles is the transformation -- that includes our payment models, the service delivery contacting, our performance management, etc., the delivery system transformation that is going to to this common goal. finally, not because it is low

priority, of bringing the patient into the center of this effort to, this is what we're going to be focused on a. -- focused on. i hope we will have a good dialogue. thank you. [applause] >> thank you. those were wonderful presentations and i know we all thank the speakers. we wanted to give ourselves a sufficient amount of time so that we could take questions from the audience. i hope there are a number of questions that you folks will have. i think you should be able to come to the microphone and asked your questions. i will ask a question of the

panelists first. one thing that i do want to emphasize is i am going to ask that they keep their responses short. if we can do it, and answer a minutes each, i think there is going to be a real interest in a lot of questions. let's try it and be will be quick on the answers. here is the first question. a recent leak came across a " in a book -- this is what it is. we have a hard time savings as they are. because we can never get what they were out of our heads. we do not see the problems that exist, of the shadow of the last one. many commentators and many people that i talk with, my partners, my clients, they're talking about and comparing this reform effort to reform efforts

of the 1990's. to the efforts of managed-care event i believe it -- it was very fair to say that the managed care organizations did not managed care. what is different this time? why is it going to work this time? that is the question. i am going to ask tony rogers to respond first. on behalf of the government. maybe we can run down very quickly. >> i was lucky enough to be part of that managed care backlash in the 1990's. i can only tell you a conversation i had with a ceo of a very large health management and i have said -- i was saying that we have become adversaries to physicians and the people that provide the service. we were focused on reducing cost

and not looking at the bigger picture. he said, it is not our problem. it is the physicians problem. what is different this time? we know we need to bring the physicians, hospitals, at the delivery system into the process. the solutions do not come from washington. they come from you. we're trying to create an environment in which you can provide solutions to your community. this is the problem. we know that you know what the problem is. we have to provide you with an environment where you can work out these problems and a delivery system that is in line in doing that. that is what i think is different. >> the global economy today is not what it was back then. we are trying to compete globally and there is pressure there on the business environment. ceos in america are very engaged

in this dialogue today. that is part of it. levels of sophistication of information that is available is starting to plant evidence out there that is irrefutable. >> i would agree with that. in 1983, it was just hospitals. what is different now is that we do have a vision for where the health delivery system needs to go. the physicians being engaged is a critical parts and the decision support -- we have different tools and techniques available to us that we did not have in 1993 or 1983. it is clear that transformation is coming. >> i would say that i would

agree with all the things that have been said. there is one similarity that i'm very concerned about. we have not talked about the recipients of health care. the thing that is probably going to bankrupt the health care system and the united states right now is the epidemic of obesity. it now accounts for 10% of the health care costs in the united states and is projected to go to 20%. until then began -- both of the plans have neglected the recipient of health care trade until we bring the men with incentives that lead them in the same direction -- until we bring them and with incentives. >> i would ask that you identify yourself. >> i am a physician in new orleans. a couple of questions. patient accountability was not included any of those diagrams.

that somehow has to be built into the equation. as a practicing physician, noncompliance is -- can throw away all of your accountability out the window. what is the government's opinion about that issue? the other issue is when i see your medical home model, i can tell you that our group is at 1.5. we already do a lot of i.t. and tracking for the largest geriatric population. however, we only come to see those patients in one isolated and countertrade -- isolated. in their interest in promoting

this new way of doing business, are they keeping up with upgrading their method of paying physicians for services? this is what we are talking about. shifting away from patient and counter to this management process. interacting through the internet's and where we in code for that. >> gobs tony, i think you should take that one. >> i think your first question was about how you get compliance. there are two ways to get compliance. >> you have to create a different relationship. we have to then honor that

choice by helping to that position become the medical home for the patient. that means pain care management fees. we have already begun rolling out some initiatives in that. between the visits, the physician has the responsibility -- the medical home as the responsibility to provide the care management. when the position is not involved in the care management, care management is not optimized. position, a nurse practitioner, a medical team in need to be part of the care manager process great the need to be engaged with the patient. they need the financing to be able to do so. in terms of the patients compliance, this is always a struggle. we are looking at beneficiary

incentive programs. our hope is that the medical home environment will engage the patient around the patient's issues, and around their barriers, not around a standardized of view. but every patient has the story, has a journey. we want to give the providers less ability to manage that journey to the benefit of a patient. that requires electronic health information. for the position to be able to -- for the physician to be able to see whether the patient is getting care or not, we will be providing those organizations with the information. this is the first time that we will lead locked -- electronically share information with organizations that come together and said, i will help manage care for this patient.

>> i am a professor of health care management. with the growth of acos, to lawless lag behind? -- do the laws lags behind? of a pullback on that, i trust that laws are rescinded in terms of their utilization, does that cause the potential for additional market power in the system? >> good question. i cannot talk about the specifics. we have been working with the department of justice and with the ftc about anticompetitive safe harbors that will be necessary. under what conditions and what parameters that needs to be set. the goal is that as much as

possible, there should be competition. there should not be a single source of accountable care in the community. to do that, the department of justice and the ftc are looking for how they form and will be evaluating them as they submit their applications based on the potential for anti-competitive behavior. we are working with them. the good part is that there will be opportunities for the community to comments. because we are working with the department of justice and the ftc in a very collaborative way and with the irs, it is going to make it easier for us to communicate when there is issues that we need to reconcile. the interesting saying is the commitment of those organizations to making this work. the recognition that this is necessary and they are not

fighting it. they just want to make it work for everybody. >> in other words, an organization does not have to lead to a the kind of centralization that some are worried about. i think if it does lead that way, i cannot imagine what the department of justice and the federal trade commission would prosecute those cases vigorously. i am from ohio. up in toledo, the ftc and the ohio attorney general are looking very closely at a hospital right now. these folks are going to look at these issues. we have to be very aware of these issues. the vertical integration that we

are looking at here should not necessarily raise that specter. i also would make the point that at the open door 4 m -- forum that was held in october, there was quite a bit of discussion about whether there would be an anti trust safe harbor. there was a lot of discussion by folks from the government and others that the principles of clinical integration that the ftc has put forth the number of business advisory letters probably make a pretty good starting point for antitrust compliance with the accountable care organizations. if you look at what the ftc has put out since to dozen to, predicted as a tomb -- 2002, there is a lot about it. remember that at least for the

demonstration, the secretary of health and human services has the ability to waive some of the applications of those laws and regulations if she deems it appropriate to do so. that is going to be something that we will find out how that all works out. i'm a pediatrician at the university of miami medical campus. thank you. i can believe and excited about the transformation that we will see improvements in medical care. what i do not see happening necessarily is that we are going to transform population health. if we do not change help, we will not rein in costs. i am grateful that the third bullet is population health. it is still the third bullet.

in your list about comes, it does not really less any think that would be considered a population health outcome. when everybody else outside of government starts thinking about population health, it will be very important to know how we define that. if the population, what my insurance plan covers, the folks that are able to walk through my practice door. will it be a geographic population? huckabee compensate for the -- how do we compensate? i am very interested in your comments about how we change the dynamic. the incentives right now -- i do not see them lined up to tackle that. >> would you to like to take a shot at that? >> i should to some of the

examples in terms of population health. i think we have shown the same sort of thing around both obesity and smoking. those of the two big issues, i think. acting as an employer and a provider, we have a big stake in that. it is also going to take both carrots and sticks to begin to have some impetus, some impact on population in terms of improving health. i do not think we will do one without the other. >> i did not think any one health care delivery system can tackle the entire state population. that first up is critical. we anticipate multiple markets.

if they promote wellness, and they stop smoking, i think you take the steps. we will start in those populations. >> have a responsibility. >> if i could just add a comment. to do population health, you need ingredients. one is the flow of information. until recently, there was not good flow of information across the different aspects of the system. you have to have that in place. if you look in the various pieces, the ingredients are being developed. there is a lot of pieces and place. as they mature, they will make it much easier.

>> to tell you what our strategy is, if you look at the communities, -- canada is formed around a grant that was given -- how to use the information technology to have a broader impact on population. organizing beyond around -- organizing around communities. because there was a market to -- we ask them, what do you need from us? they said, we need information. that is what we are providing. we need to coordinate with our federal agencies. the problem has been, you cannot do this with a four-person practice. you cannot do it with a clinic. been it is a model.

if you look at that and you see that model, we are using that as a starting point. it will be our goal to reduce the number of heart attacks and heart disease in the population. we are formulating a strategy to do that. how we will use these developing organizations to be part of this. >> go-ahead. >> the american health-care recipients undoubtedly is the beneficiary of the world's finest technological infrastructure. all too often, that infrastructure is not used to create equality by the practitioner.

behind behavior interventions, destructive technologies, chemicals -- county schools succeed without structural changes -- town of the goals succeed without structural changes? for example, by medical malpractice. >> why don't we start with you, doctor? >> towards reform clearly was -- tort reform was the third rail. it was not touched. you had a group of legislators that you had to deal with. it was a non starter from the get go. the rationale for that is that this is a relatively small percentage of the health care cost across the country,

probably accounting for less than 3%. but the legislation was trying to do is go after bigger fish and get something that legislatively was going to get through congress. eventually, that is going to have to be one more incremental step. it is not an essential step for the things that we talked about. >> back when the legislation was being written, there was a lot of dialogue to the constituencies and when you get to the subject of evidence based medicine, clinical guidelines, there was a discussion about a quid pro quo of there. there is some agreement to move toward that direction, would there be some kind of the reform?

that did not get there. i do not think he will have as much success with the latter i must you fix the former. there has been discussion. >> you know, this is such a hot- button issue. you can argue it from both sides. physicians to practice -- the practice and a delivery system seem to have less liabilities. electronic health records reduce its liability if it is coordinated. it will help to reduce liability. we know that best practice

drives those things down. at some point, accountable care organizations and medical homes will be organized in a way that we can then have an organized discussion about how we address any additional liabilities that need to be addressed. either through the aco or through other means. to the patient, to the consumer, the reason this is a hot-button issue is that they think they will lose something. until that changes, until there is a trust, it will be hard to address this as legislation. >> thank you. >> i am a family physician. my question has to do with primary care. i think we are engaging to go into battle and we forgot to

trained marines. what i mean by this is it takes a good 12-13 years to get a primary care physician that is fully trained. we are going to get a 36 million people into the system. if you do the math, it means you will mean an emmy -- need 12,000-15,000 primary-care physicians courage where are they going to come from? if you go to any family medicine conference, he will see that most of them look like me and older. [laughter] already -- i have retired because i was driven out of business by medicare. what are you going to do about this shortage of physicians that would be critically worse in the next few months or years?

>> i will make the first comet, ok? there is a lot of things that dr. do today that they do not need to do. that will not solve the problem, but it will help. able allow you to do more. the cause >> there is some capacity to was worth a lot of this. you can change the incentives. the medical home model, the position is awarded for the health of his population as opposed to having to do something that fits a coach. he will create -- a code. you will see some physicians willing to shift into that. >> i agree.

it has to find the need for more primary care. they will have different incentives in family medicine. primary care will be recognized. it uses a team approach, not his physician. that team is critical. that is the way we will cover more americans. >> i would just add to that. we are also looking at a huge shortage of nurses. that is something around a million a shortage of nurses. as we change the care model, we will change to the providers are. right now, for example, in cardiac surgery, we have a physician assistants to help 13 car? surgeons. -- help card debt surgeons.

-- cardiac surgeons. i think we will see the jobs migrates to the person who is able to do them and not to the most qualified or over qualified individual. >> what i would like to do, if we could, we are in our last seven minutes or so. i'm apologetic that i did not think we will have any more time for any more questions. first, i want to thank the university of miami so much for allowing us the opportunity here today. to really have a good discussion. as the close, i am going to ask each of our panelists to give some final thoughts. what are the takeaways that each of them would like to provide to us? what i would ask is that we go

in reverse order of presenters. tony, if you would start. >> i sense people are ready for a change. but there are a lot of questions. a lot of still unanswered issues that will have to be addressed. what i tried to provide is a framework to date of where we see its drive the system. i do understand that we need to come out and work with communities, who work with organizations. one of the takeaways that will help me articulate this to our new center for innovation, their role in helping to prepare communities, organizations, to be successful in this new world of accountable care.

in advance of moving the systems to regulation, in this direction. the other thing i will give you is that we are focused and aligned to transform the delivery system for america. that is where cms is putting the efforts. we're bringing in people that will help us with that. we want to make it part of a think tank, if you well. -- if you will. >> i think i will get this quotation right. the definition of insanity is doing the same thing over and over again and excepting -- expecting the same result. that is what's we have done in health care. i do not know how many of you watched the president's address last night. enough is enough with the rhetoric.

the system is broken. you cannot deny that. no matter what perspective you have, it is broken. competitively, we are leak -- losing ground despite the wonderful things that we do. each of you who is in a position to influence, try to start the next conversation giving the other party the benefit of the doubt. >> the take away is that a solution is a partnership. we have talked about providers, insurers, the employers, are pension. it will take that partnership to transform the system. >> i would like to thank the university and john for convening a us and giving us the opportunity. i want to thank tawny for the work that he does. this is difficult controversial work.

consider this an attaboy. that is sucking up, is dead? -- isn't it? at the end of the day, but or partnership is correct. we have to get the incentives right for all parties involved. we have to get the incentives right for patients, for the physicians, providers, and as soon as we all lined the incentives, i think people of goodwill will provide the right solution. i think we are in a period of transition. i fully believe that we can and must come out with a better system than we have now that will address all of those peoples and individual groups. the key to that is getting the incentives correct.

>> thank you very much. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2011] >> coming up next, a group of mayors talk about federal budget cuts in cities. congressional budget office director is an update on the economy. later, president clinton and madeleine albright talked about the 1995 peace accord that ended the war in bosnia.

tomorrow, the democratic governors' association holds its annual meeting. governors will hear from a labor and industry leaders about improving the economy and creating jobs. live coverage begins at 2:00 eastern. >> it is critically important that the house avoid a government shutdown. >> we have a responsibility to make sure that there is no government shut down. >> the c-span video library. every program since 1987. any time, it is washington, your way. >> and the u.s. conference of mayors is holding its winter leadership meeting this week here in washington.

several mayors held a news conference today to talk about cuts to their community development block grant program. as part of the to dell's 11 federal spending bill. -- 2011 federal spending bill. this is half an hour. >> i am president of the u.s. conference of mayors. >> i am mayor of the city of philadelphia. >> we will go down this way. >> i am the mayor of oklahoma city. >> i am the mayor of west sacramento, california. >> mayor of schenectady, new

york. >> and i am the mayor of des moines, iowa. >> i am the mayor of macon, georgia. >> i am this mayor of the city of atlanta. >> i am the mayor of the city of davenport, iowa. >> mayor of jackson, mississippi. >> mayor of little rock, arkansas. >> city of trenton. >> mayor of the city of north miami, florida. >> mayor of the city of tallahassee, florida. >> thank you for being here this morning.

we are here as mayor is representing our cities. we are nonpartisan. we are here because we are disappointed about programs that are critical to cities like the community development block grants that is being cut. there are other programs that are critical for cities that are also on the cut list. we take great exception to the community development block grant. this program was promulgated under president richard nixon. this program and comes directly to cities for us to have control of the funds and to insure that the funds are used for those folks who most need them and to help with projects for the people who are in need of housing.

whether that is affordable housing, section 8 housing, and so forth. it creates jobs. not just for people within city hall, but for the private sector and for nonprofits. this program is important to our citizens. if the members of congress have not thought about the impact, these kinds of cuts have of the members of our community, they need to know about them. therefore, it is going to be our responsibility to educate them and to make them aware of what the impacts are. not only on the cost side, but also on the side of the people there are affected. the impacts are devastating.

therefore, as we stand here today, knowing what happens in the house, we see that our only hope is in the senate. this morning, we hazmat to talk about to what we're -- the house met to talk about what we're going to do and how we will affect the kind of discussion. we are on a local level and we balance our budgets every year. we also are very transparent. what happened in the house was not transparent. and so we are here to raise voices for the people who are affected by these cuts. it is going to affect not only of those who are beneficiaries of our community development block grants, but to the rest of the people of our communities.

the costs now shift. ladies and gentlemen, every year, the people of our community, who worked in our communities, spend -- send money to washington. nothing comes back to us. the community block grants brings back some of these funds into our city that we can help with some of the social issues that we deal with on a day-to- day basis. these drastic cuts are unacceptable to the mayors of america. today, as nonpartisan mayors', we have raise our voices and with that, i am going to call on our second vice-president from the great city of philadelphia. mr. vice president.

>> thank you very much. i believe think of one words to describe what the house has done with h r one. outrageous. calibrate is an unacceptable. -- outrageous and the unacceptable. it stops jobs and economic development. i have no idea what has gone on in the minds of some would now got elected on rhetoric and are trying to govern with the same rhetoric. you cannot run the country while attacking its own people. certainly, that should not be going on in the united states of america. it attacks programs for seniors, programs for children. it takes and cakes and takes. -- it takes and takes and takes

great this is literally on american. -- unamerican. we will attend for this kind of activity. we need to do a better job of educated -- educating members of the united states it is clear to us that many members have no idea what these programs do, how they affect people, how they rebuild our cities and put americans back to work. in addition to running our cities, to educate members of congress about what they are doing, that is what we will do. we will not stand for this kind of attack on our own citizens. thank you, madame president. >> mayor warren? >> ladies and gentlemen, the greatest generation of americans helped to build this

country. we are now facing a crisis in our cities and towns. we have to take a stand. this generation has to take a stand. i am not just talking about mayor. you just listen to a lot of different mayors in a meeting. one of the khmer said spoke up was the mayor of charlotte. he spoke of 3000 children that go to bed at night without food and the bed. people who are unemployed. we are in the worst economic recession this country has seen in decades. over 9% unemployment. at a time when our most vulnerable in our society cannot seem to find a job, cannot heat their homes, we have this continuing resolution that cuts funding, the lifeblood of cities and towns, 66%. that is devastating.

to the people that we are talking about this morning. to the young people the we talk about wanting to have an education. to the citizens that need accessibility. ladies and gentlemen, can we have to engage our members of the house, senate, governors, a private sector, public sector. this is irresponsible and cannot stand. we have to turn it around. we are at a critical juncture right now. i want to say one other thing. i know there has been a lot of talk about the deficit. the deficit reduction. we have to prioritize in our country today. we have to make some difficult decisions. we have to ensure that we do not balance our budget on the backs of those who are most a vulnerable. that is what this hr1 does.

we cannot stand for it. we have to engage everyone in our community. one of the best things about funding is that it leverages other farms and jobs, private sector and public sector, small businesses, nonprofits. we have to make sure we are engaging every element of our community. so that we do not see the devastation that has been proposed by the house. that is why i am here. that is why we have to get activated as mayors. thank you so much, president. >> thank you, mayor. to me, this is about hypocrisy. it is hypocritical for elected officials in washington to city value city's, they valued the economy and jobs, and to create a stimulus package and send it to the states where it never reaches the cities. it is hypocritical to say that

you value the economy and then make drastic cuts to great programs bit as great discretionary opportunities to go exactly where they're needed. we understand have tweezers. there is not a single mayor up here that is not making some good choices right now. we are out there waving the -- it is also about priority. the priorities in washington need to be about cities and jobs in the economy. these proposals go through, those are not the priorities. >> thank you. who are we today that are before you? we are the united states conference of mayors. you've described us as the city fathers and city mothers of this great nation.

what do we do? they tried to look out for what is in the best interest of their family and the members of their communities. as mayors, we are on the forefront, where the rubber hits the road, what do we know better than the needs of our communities? as city fathers and mothers, we are going to get our families together, the folks in our communities that represent all of these organizations that work day in and day out. whether it be day care providers or housing or other individuals. we'll get them together. we are going to take the leadership as the united states conference of mayors because who else can and should, but us? we will bring them to washington and we will have a major march or meeting in the halls of congress with the leadership of congress. we are going to take this fight

to save and protect community development block grant to the white house and to the halls of the congress and we are not going to let them destroyed this basic program that has served this country for over 30 years. you can take that to the bank. this will not be allowed to stand. that is coming from the city fathers and city mothers of this country really know what is best for their local communities. thank you. [applause] >> our last mayor and then we will go to questions. where is he? >> we are trying to get him to come at officially dead. as you can tell, it -- to come out of his shell a bit.

i am proud to be a part of this group because behind me are ladies and gentlemen make tough choices. we balance our budgets. we take care of our citizens. the one big problem with cutting the funding is that the belief that if you cut a budget in washington, the problem disappears. it does not. those 3000 children will still be there. it is going to pick up the slack? this is a cost shift. this is a shift in responsibility. from the federal government to handle the societal problems of the cities. this will have direct impact on our citizens. cities have been the most responsible level of government in dealing with the crisis. we have continued to balance our budgets. but continued to make the tough decisions. -- we have continued to make the tough decisions.

this is an atrocity. you cannot simply wish we problems. we will stand together and we will fight this. it also does affect our citizens on a daily basis. it will affect their daily lives and it will affect the level of services. >> we will open up for questions. >> are you willing to seek aid federal government shut down to prevent these cuts? >> we are not here to talk about the federal shut down. that is their business. >> i know you are not partisan, could you address john boehner and mitch mcconnell backs of what would you say to their

face? >> we are nonpartisan. that is the beauty of standing together here as the u.s. conference of mayors is that we are nonpartisan. this issue is an issue that has been debated and -- in congress many times and has had bipartisan support. as mayors serving our citizens, we serve both democrats and republicans. but i will open it up to any marist here to see if they are willing -- any of the mayor is here to see if they are willing to speak. as we stand together, we do not know who is a republican or democrat. and we do not care. >> i am the mayor of oklahoma city. what specifically is your question? >> whether any of you would identify yourself at a

republican or a democrat. >> you were from three republicans during that last series of tirades. i do not know if we need to address anyone specifically. they represent communities all across the country. they got to hear from us. it is a little bit late for us to hear that they have tough choices to make. -- lame for us to your that they have tough choices to make. you'd be a mayor for the day and i will tell you about tough choices. the priorities need to be about the economy. they have lost their sense of priority. >> i am brindled lawrence. i and the chair of the democratic mayors. we stand side-by-side -- steig -- side by side on these issues. we can walk the halls of congress together on that. congress together on that.