host: the senior fellow, lead report on students and if they're being challenged on the website. guest: and we have a great way to rank your state if you want to see how your state stacks up. see how your state does on these key indicators. host: if you go to our website you'll see this that the green party has nominated their presidential candidate. jill stine. they are meeting in baltimore. we are following that. she is going to be a guest on this program tomorrow starting at 8:30 talking about the nomination of what she hopes to do with her candidacy. starts at 7:00 tomorrow morning. don't forget at 10:30 on c-span you can see the national governors association. have a great day. we'll see you tomorrow. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2012]

>> good afternoon and welcome to the center for american progress. i am the president of the center. it is my distinct pleasure to welcome democratic whip steny hoyer here to the center. congressman hoyer has been a tremendous friend of the center over the last several years and we are honored to have him here talking about manufacturing and economic growth. since the founding we have been focused on how to ensure a strong and stable middle class because we understand that a strong and stable middle class is central to a strong economy. and it sounds like that is a basic fact, one that should not be in dispute. but as we see now in our national debate and discussion of how to foster growth, that

actly, that issue, whether building a middle class is the central pillar of growth, is really a question. we have seen over the last year and we will see continually tover next several months that this question about how to build growth is central. and there are really two visions of that. on one side there's a debate about lowering taxes and ensuring that what i would call trickle down economics that is how we foster growth. and on the other side is a broader agenda, one based on ensuring that middle class folks have the income and wages they need to build demand. and as we look at an economy that isn't growing as fast as we would all like we see that challenges are central to challenges in the economy. so we are excited to have congressman hoyer here. he has been leading an everett on manufacturing for several years.

and has really focused on how we rebuild manufacturing because manufacturing in the past has been central to our ability to create strong stable middle class jobs. and it is that issue, that engine of growth where we have middle class jobs that create demand, that create demand for more products that american companies create that is really a big challenge in our economy right now. so we are particularly excited to have congressman hoyer here today. he will be laying out some new ideas in this front and we look forward to working with him in the months and years to come on these ideas. congressman hoyer. [applause] >> thank you very much. i am always pleased to be here at the center for american progress which is doing such a wonderful job i think of giving us good information. researching those issues which are critical to the american people.

and the important to the american people in making decisions on where they want to go. so neara, congratulations to you on your leadership as well. give my best to john poddesta who is out there in the netsdzer world doing something that we know is wonderful. i know tom is here my former colleague who is working with you. and your vice president who does such a wonderful job and such a good friend. good morning. good afternoon i guess i should say. as he prepared to take office president kennedy spoke to a nation troubled by anxiety over america's leadership in the world and uncertainty over whether future americans will inherit a strong and secure commay. he offered not -- economy. he offered not soothing words but a rousing appeal and to action. he spoke to his generation of

americans and urged them not to shrink. to advance. today i would suggest we confront a similar anxiety but much greater global competition. it is i think therefore essential for us to seize the initiative in education and innovation and technology and alternative energy and in advanced manufacturing. once again, our leaders must ensure that america's role in the world is secure. that our economy will remain the strongest on earth, and that americans will continue to find good jobs and have confidence that they will make it in america. the key to success i believe is a renewed dedication to the kind of individual effort and personal responsibility and commitment that made this country the great country that it is. america's history has been one of inventing innovating and

developing better products, processes, and services. it has been a history in which manufacturing goods has played a major role. and americans overwhelmingly believe that making things in america must be an important part of our future. if we are going to be successful. manufacturing has been a bright star in our current recovery. over the last 3 years we have seen strong gains by manufacturers. we have witnessed 28 consecutive months of private sector job growth. and manufacturing has added half a million jobs since january 2000. productivity increased almost 6% in the first quarter of 2012. industrial production as measured by federal reserves index for manufacturing has surged 20% from its lowest point in june 2009. factory orders were up 7/10 of

a percent in may signaling new investment. manufacturing is also driving a rise in u.s. exports. in the first four months of this year, total u.s. goods and services exports were up 6% or 41.4 billion dollars from the same period last year. in that same time, manufacturing exports were up 9.1%. after having watched for years as america manufacturing jobs were shipped overseas, we are now bearing witness to some -- to some -- of those jobs returning. companies are recognizing the rising cost of production in other countries and are looking once again to the talent and experience of american workers. last month google announced a new device that is being manufactured only a few miles from its headquarters in california. asked why the company chose to make it here in america, google

representatives cited among several reasons the benefits of its engineers being able to travel easily between the design lab and the production line. the synergy of colocation. air bus has just announced that it will begin construction on its first u.s. manufacturing plant next year in alabama. that $600 million facility will support 1,000 new jobs. over the past 2 years other businesses have chosen american workers to manufacture their products including catter pillar ncr and ford. however, despite these recent gains americans are still worried about our economy, unsure whether our recovery will continue. uncertainty over consumer demand of which anywherea spoke hangs over a dark cloud. americans are also looking with great concern to the financial crisis that continues to plague

europend hope that it does not spread here. now is not the time to hunker down. it is most definitely a time to go on offense. as president obama declared in his state of the union address in january, we have a huge opportunity at this moment to bring manufacturing back. but we have to seize it. it is time to stop rewarding businesses that ship jobs overseas and start rewarding companies that create jobs right here in america. he is right. this is our moment. so companies can hire for jobs that will stay here. in the meantime, our overseas

competitors are doubling down on investments in their own workforces and innovation and in providing the tools that nurture manufacturing growth. not only are other countries surging ahead in the number of engineers and scientists they graduate but they are pouring money into basic research and technology departments. the national science board reported earlier this year that china and nine other countries have increased their research and development spending to match our own. and the wealthiest country in the world we will lose only if we fail to invest in the priorities of success. we have seen the manufacturing sector help our recovery gain momentum. but we know that's not enough. congress must pass a comprehensive jobs plan that invests in the advanced manufacturing and innovation that is critical to our future. two years ago, democrats introduced such a plan.

it is called make it in america. the premise is simple. if we can help manufacturers make it manufacture it grow it here in america, then it will help all of our people make it in america. succeed. seize opportunity. get jobs. make it in america combines business tax reforms that encourage business manufacturers to bring jobs back which increase investments in education, job training, innovation, green energy technology, and infrastructure. under make it in america businesses would be enabled to base decisions not on the best tax outcome but more importantly on the best economic outcome. quite simply, business judgments not tax judgments are plan is also recognized that our current system of taxation is too complex and there's a growing consensus that we should lower rates, broaden the base, close loopholes and

maintain at minimum revenue levels. businesses will make things in america in my opinion only if it is profitable to make things in america. he said, most new jobs are created in startups and small businesses. so let's pass an agenda that helps them succeed, tear down regulations that prevent aspiring entrepreneurs from getting the financing to grow. and i would add simply needed regulations to ensure protection of consumers and competitors without impeding growth and investment. that can and must be done. but addressing taxes and regulations alone won't do it. again and again we have heard from manufacturers looking to invest here that they simply

cannot find enough workers with the skills and training they need in engineering and advanced machine operations. we need to ensure that americans have the skills and knowledge to perform the jobs created by advanced manufacturing enterprises. further more, our economy will benefit from the enactment of a comprehensive immigration reform that helps us attract and retain talent here and invest in the strength of our immigrant entrepreneurs seeking , as so many of the previous generations have done, to make it in america. rejecting the most skilled is neither consistent of our tradition of wrking those who wish to help make america great nor rational in our efforts to compete in a global markplace. make it in america is the comprehensive jobs plan our country needs. it draws on the best ideas from both parties. and as one praise from both

business and labor. and we have already had some success with ten make it in america bills signed into law. including the america competes act to strengthen science and math education, the america invepts act that achieved long overdue patent reform, and the reauthorization of the small business innovation research and small business technology transfer programs. the two parties also worked together to pass the jump start our business startups act a bipartisan legislative package that included a number of proposals from our make it in america agenda support bid the administration and by the congress. but jest last week the institute of supply management reported that june was the first month that the manufacturing sector contracted since july 2009. and today, u.s. manufacturers are expected to announce that growth in first quarter earnings this year were the slowest since 2009.

it is not time to hunker down. it is time to go on offense. we cannot let this become a trend. members of congress must set aside their political differences and take action. in his book make it in america, the title of his book, dow chemical c.e.o. writes, if we make a national commitment to building things again it is going to require a new approach to governing. we will not succeed without a comprehensive national economic strategy. one that extends across policy areas, across cabinet departments and congressional committees. government at its best creates a climate in which companies can fulfill their potential. that's what american business needs. ack -- action, not inaction. dedicated attention, not indifference. this same sentiment was expressed in our meeting with the national association of

manufacturing which has been a strong advocate for bringing government and the private sector into agreement when it comes to boosting competitiveness. that's what our competitors are doing and we should not shrink from that. two months ago we saw a glimpse of how things ought to be when 147 house republicans and every member of the democratic caucus joined together to reauthorize the export-import bank. this was a major component of our make it in america plan and it will help us fulfill president obama's objective of doubling exports by 2015. however, the fact that a piece of legislation that used to have nearly unanimous support took so much effort ought to concern us all. i hope those who came together in a spirit of bipartisanship that day will continue doing so to pass more make it in america bills in the days to come.

that is why i'm suggesting today a series of additional steps congress can take right away. democrats are putting forward several new proposals as part of our make it in america plan and our calling on the house leadership to work with us this summer to act on them. first is the bring jobs home act. sponsored by representative bill pass cell that would eliminate the tax deduction for moving expenses for companies shipping jobs overseas but keep it for those bringing jobs on shore. it would further provide a new credit for company moving jobs back home. congress should pass a mislanium tariff bill to eliminate duties on certain products not produce t in the united states particularly raw materials and gsbrmeetsd inputs that are used by manufacturing to make it in america. this will reduce their production costs and help make these manufacturers more

competitive. the third and fourth new items being added to our make it in america plan will help us close the skills gap and connect more out of work americans with secure and well-paying manufacture rg jobs. one of them is a reauthorization and modernization of the workforce investment act sponsored by john too manyie. the other is representative kathy hokele's bill that grants $1,000 per student tax credit to employers that part never with colleges and trade schools in order to provide the skills training necessary. in march president obama proposed a national network for manufacturing innovation that will bring manufacturers, academia and government together to create an innovation infrastructure that will accelerate the development of manufacturing technologies. in the coming weeks we will be introducing legislation to implement this proposal. as much as we ought to be investing in the innovation network we must also invest in

prove comb proving the physical network of roads bridges rails and ports that enable our manufacturers to obtain raw materials and get their products to market. we passed an infrastructure bill as you know before the july 4th break. twass the last day at last minute for too short a time. it was the right thing to do but it will not create the kind of confidence of long term planning that america needs to make so that we can in fact make it in america. the freight act will lead to the development of a national freight strategic plan to assess the needs of our aging freight networks and create a national freight infrastructure grant program. major shipping canals are being widend and as ships are built larger as the panama canal has widend we need ports and rail facility that is can accommodate them and we must

make sure that other countries are playing fair and abiding by the rules. the enfoors act, a bipartisan bill sponsored by representatives linda sanchez and congressman billy long will establish new procedures for investigating claims against foreign manufacturers for evading anti-dumping and counter vailing duty orders. it will help us better enforce trade rules and prevent illegal imports. in addition to these measures, the house energy and commerce committee came together in a bipartisan vote last month to send to the house floor a make it in america bill sponsored by bill lip ski of illinois. it is called the american manufacturing competitiveness act. it calls for the development of a national manufacturing strategy. you can't win the game if you don't have a playbook. you can't win the game if you don't have a strategy to do so. the national manufacturing

strategy will bring together public and private sectors together to create a comprehensive plan of action. and require that be updated at least every four years. any business executive will tell you that you ought to have a carefully crafted strategy before undertaking a large projects. so i hope the full house will pass the bill and do so quickly. it passed out of committee overwhelmingly on a bipartisan vote. taken together, along with the other make it in america legislation we have already introduced, these measures will help us invest in outeducating, innovating and building our competitors. all indicators agree that manufacturing is ready to take off and carry other sectors of our economy with it. it just needs a good push and a partnership. make it in america is just the push our manufactureering sector needs. and it is a strategy all

americans can agree on. in fact, when polling data is done and people are asked what you think is a good strategy and made in america or make it in america offers an alternative, over 85% of americans say yes that is what we need to do if we are going to remain competitive in this century ahead. of course as i have said many times before, congress must work concurrently on achieving a big solution to the deficits and debt that confront us. if we are going to afford the investments contained in our make it in america plan our continued competitiveness is dependent on congress and our country acting with courage and determination to address our fiscal challenges. namely, the fiscal cliff looming at the end of the year. that is why i've continued to call on congress to go big with a balanced solution before the year is over.

we will have to address deficits due to the approaching onset of sec stration and a nurl of items are scheduled to expire such as the 2001 and 2003 tax cuts which include capital gains and dividends as well as the estate tax. the unemployment insurance. the sgr. dock reimbursement for medicare. all of these we will confront. we need to confront them with courage and with will. greece does not have the resources to solve its problems. america does have the resources. all we need is the political will and the courage to do so. we will have to put everything on the table and make strategic choices about our fiscal future. if we do not address this challenge, the confidence essential to economic growth will not be present. we in america have always been a solution-driven people.

pragmatism, entrepreneurship, and common sense carried us across this vast continent. they drove us forward to achieve in science and medicine. they carried us to the moon and safely back to earth. we must embrace them once more. we must strive for solutions tot challenges of our time. we must spstute which frontation with cooperation. if we can achieve them their effects will be not only felt in our time, it is now up to us to surmount the challenges we face and to do so we must recommit ourselves in pursuit of solution driven politics, one that will enable us to achieve what americans deserve. solution that is will help more of our businesses and our people make it in america. only working together not as democrats or republicans but as americans can we rise to meet

our challenges. i know we can do it. i hope you know we can do it because we've done it in the past and we must do so again. thank you very much. [applause] >> thank so much. the congressman has some time for some questions. if you will identify yourself and ask your question, a brief question that would be great. >> now, what you mentioned about having a solution for america made in america is very good but you need something very concrete. you need a future for america. the program represent as future for america with 6 million jobs

immediately. now, the route to taking that to establishing that is very simple. sf >> if you could get to a question that would be great. >> we need a grass spiegel legislation. we need a national banking system and we need this manufacturing process. will you commit yourself to signing on as a sponsor of glass spiegel legislation this week? >> it will not shock you that i won't commit to that today. let me say this that we passed a major reform of banking regulation in the last congress as you know. that was i think absolutely essential to put in effect a referee back on the field. we have had some major events happen since that passage which i think jp morgan chase in

particular which i think is going to refocus the congress and the american people on the necessity to ensure that the regulatory part of the banking world works and it works tot protection of the american people and the creation of solid competition. i think in that process you're going to see a lot of review of what was done previously with respect to glass spiegel, what is being done now with respect to the pposals that were included in the financial reform act to see whether or not in fact they are going to work to accomplish the objectives i think all of us share. >> additional question in the front row here. just identify yourself again and ask the question. >> thank you. as the president reet rates his support for extending the bush

era tax cuts for those making $250,000 or lower do you support the level the president is supporting or as some other democrats have indicated for those making $1 million or more? >> what i believe is that whatever figure you choose -- and the answer is i do support the president's level -- but and the $1 million will i think be a metaphor for republicans colleagues will not support increasing revenues on any persons in america no matter how much they make. but i think the president is correct, $250,000. clearly we want to make sure that the working americans, middle income americans continue to have the ability to purchase goods. we're in many respect as consumer driven economy. we need to grow good-paying jobs through a make it in america. jobs pay on average 22% more than other jobs in our economy.

but i think the president initially has it just about right at the $250,000. i want to say that i would be prepared to that i would be prepared to go lower at some time in the future. our economy is still struggling. going lower than that would have an adverse effect. i do nothing going higher than that we have an adverse effect on the economy. >> thank you very much. i represent a magazine associated with mr. with the larouche. i do not know if you are aware that a leading circles in britain connected to the investment banks have publicly called for a full glass- steagall. this was in the financial times. their argument was a volcker will not work because the

system is so bankrupt that they cannot bail it out. these are guys involved. they say just a strict original fdr glass-steagall so that credit can be made available for the kind of fdr recovery program -- there will be a national mandate you have to have the credit. >> ok. we have a question about glass- steagall. >> without repeating too much of my answer before, we passed significant legislation. the argument that it did not go far enough, i understand. i think that will be subject to further discussion. it is a legitimate discussion.

>> over here." >> i'm wondering -- i am wondering if you think the health care what's requirement that small businesses with over 50 employees purchase health insurance for their employees or face a penalty could affect their incentive to grow. >> i think the health care law, as mr. romney thought, requires personal and corporate responsibility to provide health insurance either for themselves or for those who work for them. i think that historically that has not been an impediment to growth. in fact, our health care system has largely been employer-based insurance. both for medium, small, and the

larger businesses. we have seen that he wrote it because of the escalation of health-care costs. obviously the health care bill is an effort to stanch the rapid escalation of cost, stabilize them, and give people help who need help in getting insurance and spreading the risks so that everybody has insurance. i think that is an appropriate step for us to take and i think we will have to would lolook tow that operates. we have to look at how that impacts everyone to make sure it works. doing nothing is not an option. i think that the cbo has certainly indicated we will save substantial sums through the legislation that has been posed.

i think that we will have to see whether or not it has adverse impacts and if it does, we will have to address those. >> there are a number of ways of -- that bill wallowers' healthcare -- that the law lowers health care costs. lowering cost would actually help to start hires. >> let me add to what was said. obviously, you can have a race to the bottom where every employer no longer has health insurance because it is not cost-effective for them to do so. then, you will have to pass that cost along to somebody. it will be the taxpayers. the taxpayer now pays about

$1,000 per family for uncompensated care. we are trying to broaden the base, bring cost down, make it more affordable, and more accessible. i think that was it worth the effort to end the effort republicans are undertaking on wednesday -- the 31st vote to repeal health care. after every vote over the last 31, not one alternative has been proposed. yes? >> hello. i am with reuters. you are announcing new democratic initiatives on jobs legislation. the republicans are going to stage a vote to repeal obamacare. now that we have the highway bill done and the student loan deal done, what are the prospects for congress to actually pass the extension of

this legislation before the election or do you see all of the initiatives here as being aimed at 32nd campaign ads? >> unfortunately, i think that my old job --has mile jo he said a few weeks ago that nothing will be done between now and the election. i think that is unfortunate. america is challenged. people are out of jobs. people are anxious. we need to build confidence. in the long run, as i said in my speech, i think that doing a big, bold, balanced fiscal -- >> we will find arrest of this online at c-span.org. let us go to williamsburg for

the second day of the national governors' association meeting taking a look at lower medicaid costs. >> mine ministration has been working to improve health outcomes for iowans and i know my fellow governors are trying to do the same for their citizens in their states. at the last meeting of this committee, we heard about iowa's help the state in an age initiative which is a privately led initiative to improve the health of all iowans. we also heard from the federal wellness' initiative. today, we are going to focus on the ways to better leverage the data for focusing on bringing down the cost of care for high- cost medicaid beneficiaries. this is something governors have identified to be a problem in just about every state. as you may have heard, health care and medicaid have received

quite a bit of news as of late. regardless of party, i believe that every governor is interested in improving the service delivery which is providing ways to control the costs within the medicaid program. a program that has been demanding an increasing share of our overall state budgets over the last dozen years or so. following four speakers will present today. dr. jeffrey brenner, a founder and executive director of that came in coalition for health care provider. mr. david vellinga, president and ceo of mercy medical center in des moines, iowa. also a health director for minnesota. and our executive director for the national governors association. we will hold questions until the

end of the presentations. before we get down to our speakers, i would like to yield two our committee vice chair, governor pat quinn of illinois. >> thank you very much. i think this is a very timely discussion. the concept of innovations cost reductions, improvements in our health-care system -- all of us understand this is one of the challenges of our time. both in our state and country. our own state of eleanor -- we have to make tough choices. we had to restructure our medicaid system. we had to reduce liabilities by $2.7 billion out of $15 billion systems. we did that through efficiencies and reductions, as well as new revenues. we reduced the medicaid spending through reductions by $1.6 billion. then, we raise our cigarette tax by $1 a pack.

that will allow us also to match our cigarette money with more money from washington for medicaid. a part of our reform or restructuring in illinois involves a modernizing of our systems to electronic medical record and innovative court needed care models. we want to focus on traditional medical care and integrating our mental health and human services, as well. in the coming time, we are committed to enrolling 50% of our medicaid clients into some sort of coordinated care. the medical innovations project goal is to redesign our health care delivery system to be more patient-centered with a focus on improving health outcomes. we want to develop a well the system that enhances patient safety. we plan to achieve this goal by testing community interest and capacity to provide alternative

models of delivering care that we may not have today, but we would like to see for tomorrow. we had an interesting discussion in washington on the importance of a statewide effort for wellness. iowa is showing as a good model by leading health insurer. we are interested in doing some similar things in illinois. 11 years ago, on the centennial bridge at the border of davenport, iowa and rylan, illinois i walked across the bridge to the mississippi river. on behalf of decent health care for everybody. i am very happy to say that since then, we have had some great reforms of the federal level. the affordable care act. that allows our state to carry at the mission of getting more people health coverage.

we intend to work hard on that. it is important that we hear from some experts that can help us reach that very important policy goal for everybody. i will yield back to you. we will take it from there. >> thank you, governor clinton. i am pleased to introduce our first speaker, dr. jeffrey brenner. he is a family physician who has worked in camden, new jersey for the past 12 years before establishing the camden coalition for health care providers. he owned and operated a solo practice urban family medicine office and provided a full spectrum of the family health services to a largely hispanic medicaid population including delivering babies, caring for children and adults, and doing home visits. recognizing the need for a new way for hospital providers and residents to collaborate, dr. brenner founded and has run the camden coalition for health care

provider since 2003. it is a non-profit organization committed to providing quality capacity and accessibility to health care delivery within the city. stakeholders are looking to better provide care for camden city residents. >> thank you very much. i am a family doctor. i am here today because i spent my career taking care of medicaid recipients. i do not think we are getting our money's worth. i want to show you some evidence of that and talk about ways we can do it better. about 10 years ago, as a medical student project, i have had a young person work with me to collect patient-level data from

hospitals. this is hard to get. this is the data that they used to build a state or insurance companies. we got raw patient data. the name, address, date of birth, david mission, charges, insurance status for every city resident in camden. people like me never get a hold of data like this. this is often locked behind walls within hospitals or at a state level or federal level. or with an insurance company. what i learned was really stunning about how our health care system works. half the population goes to an er hospital in one year. somebody when 324 times in five years. somebody went 113 times in one year. in the city of trenton, they found somebody who went 450 times in one year. the total amount of money for camden residence per year is

$100 million just for hospital and emergency room care. we spent $2.8 trillion as a country and i cannot get my head around that number. i know what $100 million purchases. it can buy a lot more than what we are doing now. we spend twice as much at all -- on all health care services. this is just for emergency room care for a small city. we are a poor city. $100 million buys a lot diabetic education, primary care -- 30% of the cost suspending in health 80% of the costco to 13% of the patient. i looked employee data sets. i have looked at multiple

states. that basic rule holds up everywhere you look in health care. pay small sliver of people are driving the cost. the problem is that we as a health care system ignore those patients for the most part and the system is not set up to deal with their needs. we are good with the average patient. we are not good with the very sick patient. we can transplant their hearts and their lungs and we can put them in the icu and rescue them. beyond that, we deliver very disorganized care that is very expensive here 27% of medicare recipients are seniors and are readmitted within 30 days to a hospital. that would be like spending $20,000 for that service where it was essentially a detective service because they had to come back within 30 days and get another unit of service. it speaks volumes about the disorganization of the system we have created. the number-one reason to go to an emergency room over five and

a half years as head colds. 12,000 visitors for head colds. 7000 visits for your infections. for 7000 visits for viral infections. 64 sore throats. 54 as mature 54 stomach virus. these are problems. my primary care office is boarded up right now, as are many in camden because my payment rate kept dropping. i can tell you that the hospitals bill and receive 153 -- lots of money for these visits. in the time i have been in camden, we have built new hospital wings and triple the size of emergency rooms. office like mine continue to be closed and have no value. the problem in health care is that we pay a whole lot of money if you cut or hospital i someone. we pay a little money if you talk to them. ironically in my office, i make

our money when i treat head colds than i do treating a really sick patient. i can build more for a complex patient, but if i run from room to room treating head colds, i can see a lot of patients in an hour. i am stopped talking to a complex patient with out of control diabetes, that can take me half an hour or 45 minutes. i may as well send them out of the door with a $50 bill because i have wasted a lot of time and money. that is wrong and does not make any sense. the other side of the system if they can and you take that person's foot and keep them in the hospital, that is an enormous amount of money here we have a distortion in the marketplace in how we have set prices and how we pay for services. one of the segmentation's we have seen uses geographic segmentation's. this is camden. this is five and a half years of data. three hospitals. the home address of the patient

is mapping out the payments to all three hospitals for their hospital and e.r. care. this is a small city. nine square miles. small geography. they're ready areas on the map are 6% of the census blocks. 10% of the land mass. 18% of the patience. 27% of the visits to the hospital. 37% of the payments to the hospitals. the way we house people in america as you get older and more disabled, you cannot live in the middle of nowhere. you have to live it in -- you have to live and specific housing patterns. the two most expensive buildings in the city are beautiful buildings with great management. the building at the top has senior older and disabled people. 600 patients the building had $12 million just for the hospital and e.r. care over five years. that does not count all the other costs. the building at the bottom is a nursing home.

300 patients had $50 million over five and a half years. the stories we have collected are tragic. i am deeply ashamed of the health care providers. how difficult our health care system is to use. these are patients in wheel chairs. they may be illiterate. they may be blind. deaf ear disabled. -- death. disabled. we have begun to explore data sets from other communities. we have a nonprofit that has been formed in trenton that the similar work. they have outreach teams in the committee that a primary care redesign and will stickle this together to try to get them to collaborate. -- and pulls in stakeholders together to try to get them to collaborate. we found similar patterns looking at hospital data of specific geographies and buildings that are collecting high-cost patients. you don't need the data to find these buildings. go as ems. asked the emergency room doctors here they will tell you these

buildings. this is new work. similar geographic patterns were high cost patience are being collected. we get data from the state of maine from governor lapage. we wanted to find out the basic premise held up in the rules state. -- in a rural state. these ares medicaid. -- these are medicaid patients. it is hard to live in a little of know where as you get more disabled. you live close to the town center. this makes the problem easier to deal with. and outreach team working with these patients would not need to drive 50 miles. they are collected in two towns. all the state analysis -- we have had little funding to do this. i have 15 hospital data, three counties, two employers sitting encryption.ord the data has been done in

microsoft access. i have a 23-year-old kid getting a master's degree doing all of this. this is a thousand dollar piece of software. this is not that difficult to do. the problem is actually getting the data. our organization is a non- profit. my board members of our local primary care providers. hospitals. peter health providers. community residents. our broad goal is to make the city of camden diversity in the country to dramatically been the cost curve and improve quality. there is no city or state in the country that has reduced the line in health care. this makes a powerful statement to all of you that this is not a technical problem, waiting for a vendor. this is a complex political,

spiritual, and moral problem and we are wasting public dollars. we need to spend them in different ways. we have misaligned incentives in the health-care system where people are paid more for sickness than they are for taking good care of patients. our organization is trying to do basic ideas from business. the last 100 years, our country has become very wealthy because we have become very productive. we are innovative. health care does not innovate in the same with other parts of our economy have innovated. we have invented new devices and pills. the basic process of how to deliver care has not changed in 100 years. that is what needs to change. we have a gap in health care where we are spending more and more money, but not getting value for it. our organization tries to spend a lot of time in primary care offices. between hospitals and doctors,

trying to get them to share data. deeply involved with patients, helping them manage illnesses. quickly through some slides. i want to make it point and our model. all of our care starts with data. we get real time data every day from the local hospitals and we sit down and look at u.s. been admitted and we go up to the bedside within 24 hours. this is not a case management. there are no gizmos and gadgets. we are not hooking people of to devices. we are going to visit them in the hospital. we are going to their house within 24 hours and looking up every medicine cabinet to pull out the old medicines they have to sort them out answer them away. then, we are going with them to their primary care office, sitting in the exam rooms and helping them learn how to talk to their doctor and how to

advocate for themselves. this is very hard work. this is not something you can solve with telephonic case management, which is the model being used all over the country to deal with complex patients. we pull up data from three cities and look at the top 1% of high utilize years. in camden, 386 with 5000 visits. 13 visits per patient. 80% of them visit more than one hospital. same thing in trenton and north. the poinsettia is that one hospital cannot solve this problem. -- the point is that one hospital cannot solve this problem. the community has to get engaged. stakeholders have to work together. we embody the basic idea in a piece of legislation that had bipartisan the board rejects the board. that was signed by governor christie to create a project.

the premise is that if we save money in camden, we get our act together and learn how to play nice and actually reduce costs for medicaid. the state will share savings back with us to create a virtuous cycle instead of costs going up all the time. this bill is better care at lower cost, with no up-front funding. an aco is an integrated delivery model. in camden, i would end up with fighting over's poor people, trying to align with the homeless shelter. that would be bewildering. our model is one in which working under the roof of one nonprofit in a clever way, three local hospitals, local church groups, the primary care providers can work together to

improve care. we have been working for the last 10 years to figure that out. we are slowly making progress. thank you for the chance to speak with you. next, i am pleased to introduce david vellinga, president of the mercy medical center, and 800 to bed acute-care not-for-profit catholic hospital is situated in three campuses in the des moines, iowa metropolitan area. i have known him for many years. i have been a patient in a hospital. that is another story. with more than 7000 employees and a medical staff of more than 1000 physicians and health providers including 380 employed positions and 130 allied health professionals, mercy provide

services and support to a network of critical access hospitals and health-care facilities in 18 central iowa communities and has 10 wholly owned subsidiaries. he serves as senior vice president for catholic health networks and the ceo of mercy health network. a joint operating venture between catholic health initiative is headquartered in colorado and trinity health headquartered in michigan. the floor is yours. >> governor, thank you. whenever, i am reminded of doing these public talks, is engaging. i'm reminded of my daughter who went to the university of iowa. she went to the university of southern california for master's degree in medical social work. my mother -- can never

understand why we don't live here. last thanksgiving my mother told me to come back. orange city need social workers. she said leave santa monica. come back to orange city. my daughter would say grandma, i have this great little condominium that is close to the ocean, which i am paying for -- i have a nice car that i can get around in very well, which i am paying for. i have a graduate program that i am in at usc that i am paying for. she says grandma, i love being on my own. [laughter] it is that idea that doctors and

hospitals and systems and government comes to this issue of health care. my message to you is that it is time to engage all of us. we are receptive to is it is tio engage all of us. we are tired of the fee-for- service system that has diminished our health care system and ready for a new system. i will talk about mercy des moines. it is a big place. we are responsible for about 11 other hospitals. we have about 13,000 employees. 650 employed positions across the state of iowa. there are multiple good systems in iowa, but integration is occurring. the market is driving this. our point is patients, providers, payers, and

government need to be engaged together to achieve the aaa name of better care, lower-cost health care communities. -- to retrieve -- to achieve the triple aim of better care, lower-cost health care committees. our engagement -- providers must demonstrate quality and efficiency. they need to use data. dr. brenner's comments are so pertinent. hospitals, providers, and government have not had data to make good decisions. we have been driven by a fee- for-service system. it is time to get rid of that. we must make sure we pay for value and not volume. that is the pertinent issue. how do we change our payment systems to incent us to do the

right thing? we need to have the right incentives. patients must assume greater responsibility. they cannot do that on their own. they have to have the doctor brenner's of the world working with them. it is a patient, a physician, a pair, and government responsibility. government must be sure to pay for value rather than volume. the market is driving us to value-based payment. it is happening. physicians and hospitals are ready for this. they are tired of feeling we need to crank out more volume to meet the population's needs. we need payment systems that allow us to be rewarded economically for the value we create. there is huge value to be created with the money we have.

mercy it is all in. we have made this commitment. we have said this is our strategy going forward. we believe it is relentless regardless of what happens legislatively. the market is driving us. we are all in. the tool uses clinical integration. one is primary medical homes. we have been using this for 15 years. the second is patient-centered systems. this is not the brazilian-dollar i.t. systems -- gazillion- dollar i.t. systems we hear about. these can be very simple things. dave came home and said it would be great if i had a disease registry. his teenage son developed in a weekend. it is not expensive and

sophisticated. it is simple. it can provide enormous amounts of data to do great work. we have invested in help coaches. each of our primary care clinics have multiple help coaches helphealth -- health coaches. we have transition coaches in the hospital to make sure the transition goes quickly and easily. we have ambulatory care clinics. with a sick patient, they go to the ambulatory clinic to make sure they get the intensive care they need and maybe avoid hospitalization. the standard care processes. we have agreements between specialists and primary care doctors. we do this, you do that. we avoid redundancy between primary and specialist physicians. data management -- we do not

need to do everything. we need to do everything or a small segment of patients and focus on them. we will have dramatically reduced costs. the drivers of cost reductions are simple. they are intuitive to you. counter to how we have worked for 35 years where we have been paid on a fee-for-service business. the more we do, the more we get paid. we want to reverse the incentives so we can provide value instead of just volume. the second is the decrease in the episodic cost we will give increase primary-care offices. we will improve primary care. the decrease in the administrative cost structure with improved service capabilities. this is actual data we have.

everything must change. we need to change the system. we do not have to change it for every patient. we need to focus on the highest cost chronic patients. you look at the triple multiple chronic diagnoses. there are only 399 patients, but it is over $2,000 per member per month. the multiple dominant is 14% at $955. you start to say, where can we make the most impact in the work we do? we now have the state. is the first time ever where insurance companies are providing data. otherwise, this would be very isolated. i know my hospital data.

jeff knows his physician data. this is not expensive stuff. we need to find a way to bring the data together to analyze it. the ripostes to do the results are remarkable. -- the results are remarkable. patients with diabetic test, 24% compared to 30%. patients on coumadin, 65% from 75%. significant improvement. what we have before was patients with congestive heart failure were coming into the hospital. it would be big, expensive bill. they would go back, get sick. doctors would say to do this and this. the reality is that would go home and nobody would follow up

with them. they would get sick and come back. they would come back into our hospital. economically, they came back to the emergency room and hospital. we improved ourselves economically but worsened care of the patient and increased the cost. this is not high tech stuff. using case managers and telephones, we would call the patient and asked about their weight. if it was changing, the case manager would say to do this. what happened was an 85% reduction in emissions. -- admissions. in a fee-for-service world, that hampered our economic performance. but look at what the cost savings did. this was done through no additional payment or steps other than it was the right thing to do. this shows you mercy in

scenting -- incenting positions resulting in increased performance. the benefits are real. think of the one test. look at the results. 50% decrease in heart failure. a 12. decrease in blood pressure over 10 years will prevent one death for every 11 patients treated. those tests results in health ce delivery system. i think it will be tremendously successful. then the healthy state initiative. we're proud of what we have done. we know we're 10% of the way. we have a long way to go. we're on track. sa to you is engaged positions in your state, fashion to say let's go in that direction. >> mr. vellinga, for

your fine presentation. in my previous position as president of the wind - moines university, we worked closely with mercy and other providers in the chronic care coalition working on congestive heart and diabetes patients. you have been working on this a long time. we appreciate your leadership. we will come back for questions. i will turn it over to governor quinn to introduce our next speaker. >> i am pleased to introduce jennifer decubellis with the -- she is the director for hennepin county in minnesota. she is the area director in human services and public help with the responsibility for health care reform. before joining hennepin county in february of last year, she worked in houston, texas, as

the assistant deputy director for the mental health and mental retardation office. she improved efficiencies between multiple agencies as a move -- as a means to improve patient care and reduce costs. in hennepin county, she has taken on a similar role. the county operated help plan, the county federally qualified health care center, and the social service arm of hennepin county. the idea is to make a streamlined model for health care reform. jennifer, the floor is yours. we look forward to your comments. >> i appreciate the opportunity to be here. hennepin has embarked on health care initiatives trying to look at things differently.

imagine not knowing where you will sleep or where your next meal is coming from. often we find patients not taking medications or managing blood pressure. the biggest failure of health care is we are not paying attention to bringing together health care services with social services and basic needs. that is the opportunity hennepin county is working to resolve. we identified we were in crisis. about two years back as the economy to turn for the worse, as a counter provider, we saw more people accessing services because of unemployment or under-employment. more people were coming to safety net providers. revenues were down. demands were up. the system was in crisis around health care. with every crisis is opportunity. that is what we're looking to maximize. we looked at where we were spending our greatest dollars.

you have heard others mention the top 5% in hennepin county are utilizing 64% of our dollars. it was an approach to see what they were utilizing. we found was crisis-driven care. it is our most expensive venue. most of the dollars are going to crisis services, not preventative care. we noticed system fragmentation. systems that were not working well together. systems provide specific services but do not look across the span of holistic needs the individual's need and ensure folks do not fall between the gaps. as a safety net provider, we were looking at cost shifting. we have an opportunity to look at what happens in the jails and shelters and other downstream costs where we were funneling a

lot of dollars into deep and services instead of ensuring health and wellness up front. hennepin health is one initiative in the state of minnesota of many. the state of minnesota is working on integrating and coordinating across continuance of care. they're working directly with providers and counties on initiatives where they best know the needs of the populations they serve. they are encouraging multiple models. it is not a one-size-fits-all approach. i am sharing the hennepin help model -- health model that is one of many in the state of minnesota. we have our hospitals, federally qualified community clinics, social services arm, and our health plan working together to try and find a service system that works together well. we are talking to partners and providers in the committee to say we have got to stop competing and start collaborating. when we compete and do not share

our successes and failures, we do not maximize the opportunity to improve the system across the span of care. the premise is if we do not meet basic needs, we will not get their attention on health care. what we found looking at the top 5% is individuals labeled non-compliant. the health care system felt they had done all they could to work with the population. in looking at the details of the individuals lives, we found there were reasons for that. it was transportation, lack of resources, talking to patients about why they're going to emergency rooms in large volume. it is not because that is where they prefer to get care. we found transportation was a challenge. if they had a neighbor that could drive them, they needed to go today. they did not have funding for

preventive service or did not know how to access them. they knew to call 911 and have an ambulance take them to the hospital. those are huge opportunities to reduce costs and change delivery. we're working with the medicaid expansion population. that is where we found in the bulk of our dollars going to come of population typically not connected to care and services. we started january of 2012. we have great learnings i will share with you. we have only build about 30% of what we know needs to change to provide better outcomes. population statistics are telling. 68% of our population are a minority status. mental health needs make up 60% of the population having one or both conditions. chronic pain at 30%. and stable housing at 30%. 30% of these folks are very

transient in shelters, corrections, the emergency department because they do not have another place to go. 30% have one or more chronic diseases. we have taken the opportunity to work with tier 3 members. it is the highest cost individuals the system is working the least four. it is not just a costard in model. the system is not working. that is why they are in the deep end services. for every one individual we can turn care around for, we free up amazing dollars to get to the next tier and continue to recycle dollars through the service system. objectives are to improve the outcomes for pients. we have added in improving the experience or providers. if we do this on the backs of providers by reducing rates and opportunities, we're not going to have more providers coming into the system. that is what we need.

we're watching for provider satisfaction. we have heard providers want this as much as the system and payers want it. providers got into the business to provide good it outcomes and health care. they need the tools to do so. core elements of hennepin health, we have patients helping us design the system. we're utilizing the health care home approach to get as many people involved in preventive services as possible. integration across systems is critical. we have a unique opportunity because we operate several pieces of the system. this is replicable in any system where providers need to be incentivized to work together. the cost and duplication of services are incredible. i met with one individual in a shelter who was confused about what was happening.

he said i have got a lot of people working hard to get me where i need to be, but i do not understand where i should be going. what i found looking into it was he had a case worker from the health plan assigned to him because he was a high utilize it. he had a case worker at the clinic in the shelter where he was working -- living. he had a social worker assigned from the hospital. they were trying to reduce admissions. he had a social services social worker trying to meet his needs. none of these social workers or caseworker's new the others existed. a huge failure in the system. folks were off and running in separate directions and sometimes in the same direction. a waste of resources in an individual who could not get the care he needed. he just knew he needed help. we have tried to solve that. we're looking at a 1 per patient -- at a one core patient

record. there are a lot of different systems. the one core patient record is the way to bring those together. we have created a dashboard. if i am a provider, the last thing i want to do is wave through -- wade through a lot of notes. i need a dashboard that tells me the key things i need to know. it bubbles up from the record to give them key indicators. the-board for a committee. the-board the da-- the dash board for a social worker is different from the nurses. it is the ability to be able to flag that another worker has

been assigned. we're pulling those folks into virtual teams. we do not all need to work for the same place. we do need to coordinate care and understand who is on point to get to the outcomes we want to have for individuals. it is reducing emissions -- admissions. it is reducing prices -- crisis services. it is working to increase getting people into preventive care. spending more dollars upstream to prevent higher cost downstream services. we're working to reduce churn. every eight months, individuals are falling off of medicaid benefits because of the renewal process and paperwork. it is not that they suddenly got a wonderful job and no longer

need care. they are transient and moving from place to place. they do not always know they have a renewal date coming up or how to complete the paperwork. it is a system so your to meet their needs. hennepin is 100% at risk. they have given us a per member, per month amount goes to the insurance company. we do have an insurance company in the project that gives that. the difference is the gear shifting. we have the dollars. we have to provide medicaid benefits. we have the opportunities to spend dollars in other ways. an example is somebody who has diabetes and is in the hospital greater than six times a year for insulin issues. we are finding it is simple things like my refrigerator is not working. i do not have a place to keep my medicine. an $800 refrigerator being purchased by hennepin health can

reduce hospitalization. huge cost savings and easy answers. we found the model for everyone we take care, we're able to fund social services for others. it is constantly releasing more of the funding back into the system to take care of a larger population. the other interesting part about the approach is in the past when funds are not shared across systems, folks do not take care of each other. we have individuals who are stuck in a hospital bed, medically stable but high needs. traumatic brain injury, behavior issues. high needs and nobody wants to take them. at the point the system does not work together, a hospital is on the hook for that. they are medically stable. there is no reason to get payment at that point. in the past, some were not motivated. now we wave a red flag and

social service is at the table. we have nursing homes saying we are willing to partner with you. nursing homes said now we are all in it together, the hospital is motivated to support the nursing homes. the nursing homes said we will take the difficult patients. when the patient is difficult, we need your behavioral health team helping to manage them. if you are not there in the traditional model providing support, the tendency is to call 911. send an ambulance, send them to the hospital. as soon as they are hospitalized, the placement does not want them back. it is the opportunity to incentivized working together in the wellness of individuals. it has had great successes. early learning, dental, and emergency. on day three it was identified a high population were going to

the e.d.. dental care. you get a visit and charge. they prescribed pain medications and refer you to a dentist. that population does not have a way to get to the dentist or the dentist is not available. they came back in for pain medication. we have high chemical dependency in this population. we probably made that worse. we identified that through data. we made same day dental access. stop giving them the band-aid and making it worse. let's get them into dental care the same day, provide the care they need, and solve the problem. those are the constant opportunities we keep finding of we are systems can work together to make huge improvements. pharmacy consoles have been deployed. we found in the top tier it was

not uncommon to have 11 different providers and 7 different provider -- pharmacies in 12 months. providers or duplicating services and tests that had been run somewhere else because the payments system does not motivate them to go find out what happened. or the data and technology does not allow them to know the provider existed. we are looking to change that. our pharmacy consoles have been able to do outreach and medication management to bring costs down by 50%. medication delivery is another initiative. folks were not taking a medication with the low income population, the privacy was also -- often not going to the pharmacy. we make sure they get the medication and understand how to take them so we can successfully

deploy the resources. we're gradually working our way through the list to say where is the system failing, how do we change it for this individual, how do we expand across the entire population where we find issues not working well together? those are some of the care initiatives we have. it is a small initiative of things moving as we learn more about what is broken in the system. typically health care plan and providers do not share information. we are taking our health plan and merging with providers. we're saying we do not want two nurslings. -- two nurse lines. duplication of costs. the health plan does not necessarily need the information. the providers are the ones that need to act on it.

bringing those together is huge. the same with disease management and outreach calls. there is a volume of information that often does not get to the provider. the provider is the one that can impact care. we're looking at continual of care lenghts, pedro health care -- behavioral health care programs. they have improved lives and outcomes. the patient gets referred to another level of care, but there is not the linkage of having a system that works well between transitions. challenges to resolve. we have several challenges we're looking for solutions for. members lose benefits if we do not develop a system that let them state on benefits. what happens is they go to fill

the prescription and are told they no longer have benefits and need to pay out a pocket. they cannot pay out of pocket. this is a population of less than $700 a month. if they cannot pay for it, they stop medication and in the back in the emergency department. we have cycled back through the system again. we have got to find a way to keep folks engaged. you have heard all this talk about the power of having data. as we talk about bringing health care with public health and social services, one of the big fragmentations is our statutes do not support it. we have health care statutes that define what data can be shared. we have welfare statutes. we do not have statutes that clearly define how those worlds work together. that has been a real challenge for getting information into the

right hands of the right time. informed consent is the ideal way to share information. there are folks jumping between crisis situations in dire situations where we need to be able to quickly deploy resources to get them better care. we need to figure out how to do that in a cost-effective way. thank you. >> thank you, miss decubellis. we appreciate your presentation and the presentation and perspective of each of the speakers. now we would open it for questions. yes. >> thank you to everyone for their presentations. it was very informative. it gives us pause for thought on what we can do at the state level. dr. brenner, i was fascinated a the, you made that health care has not innovated.

i was thinking about that in my own lifetime. in the last 50 years, it seems like we have seen a lot of innovation with newt surgeries and procedures, transplanted organs, knee replacements. it has been remarkable. the advancement of drugs has given us a better quality of life and improve life in the surgery room with better outcomes and quicker recovery. it seems we have had significant innovation. in the united states, our health care is expensive. it looks like the quality is very good, particularly for problems that would be life threatening light cancer, heart problems. america is probably the best

place in the world to have better outcomes for those diseases and problems. what do you mean by lack of innovation in health care? if there is a lack of innovation, why? >> that is a wonderful question. thank you for picking up on a comment. >> we have seen incredible innovation. surgeries', medications. it would be as though we were apple and had invented an amazing iphone, but every time we did a redesign, it took 10 years to come out of the laboratory. what makes i.t. so innovative is just-in-time manufacturing. at the plant where they make the iphone, raw materials come into the plant almost the same day the product comes out the other end. there is very little product on

the shelves. every time they cycled through new version of the iphone, the just-in-time manufacturing system is finely attuned to make the product come out. that is a process for engineering. the cars that come off of assembly lines, anyone on the assembly line can hit the button and stop it if there is a flaw or error. as a result, it is not just the we have a new and different kind of car, but that the way we make the car has been reengineered. in health care, we do incredible things every day. but the some part -- but the sum total of all parts is often a failure. a 70-year-old patient was fired because he was frequently going to emergency rooms and hospitals. our team went to see him. he drew up error and went to injected into his arm. he was site and.

-- he was sight-impaired and could not see what he was doing. he said -- it was a process failure. the medication in the bottle is brilliant. we should be proud we are able to produce that. but there are so many failures built into what happened to the patient. many of us do not realize how broken is until we are sick or have a relative sick in a hospital bed and 20 different doctors come into the room every day. you slowly start to realize none of them are talking to one another and you know more about the care delivery process. we have incredible quality in certain areas and abysmal quality and others. we think probably 100,000 people died a year in hospital from preventable errors. we do amazing things.

we transplant their hearts and then throw them into the community. they are bewildered at home. they are lost. they called primary care offices. they get put on hold. they come in. i agree with what you are saying. the product is innovative. how the pieces of the system data is often a failure. >> why is that? what is causing the stifling a better process. they find ways to do it or they do not survive. someone else comes along with a better product. what is it about medical processes that we are not finding innovative ways to streamline process commensurate with the products we are making? >> there is no financial incentive. if we get all parts to work together, you will close

hospitals. there is a wonderful example of this in a close health care system in which the insured owns the hospital and employs the doctors. they did a complete redesign of all the processes of care. for the average primary care office, they lower the number of patients. the average doctor has 2500 patients. that is why there are too many people in the waiting room. that is why when you call, it is busy. when you get in the room, you are waiting for an hour for the doctor to spend 10 minutes with you. they cut down a number of patients the average doctor has. they put nurses back in the office. they gave the doctor time to answer the phone. you could make a telephone appointment or e-mail the doctor to get things done. the reengineered care so every patient hospitalized got some tlc and special attention. they dropped emergency room and

hospitals use by 30%. if we dropped the bad days for hospitals by 5%, you close the mall. hospitals are in the same business as hotels. it is about occupancy rates. every hotel looks at the operation -- occupancy rates per day. they are good at building service lines and marketing those because of how we pay for health care in private insurance models and medicare and medicaid. it is by and large a volume- based model. you will put yourself out of business. there are wonderful examples of innovation being shut down because it reduced volume of service. >> from a hospital person, the issue is -- the reason we see

tremendous innovation in the area doctor permission. we do not see -- we see tremendous innovation in the area doctor brenner mentioned. the more volume you do, the more you get paid. on the primary care side, it does not mean hiring mid-level practitioners to do other work to keep patients out of your hospital or clinic. your state has done a great job. it is one of the states with lower costs than ireland. we are second or third. your systems in the state have taken is to integrate care and financing so they assume risk. now they have an economic

advantage to say we're going to try to keep our population healthy. that is a fundamental shift going on in health care. we're moving from fee-for- service or volume to value. where are what is going has led many in those directions working together across the continuing. >> i would echo that. you have heard me talk about provider groups where we are duplicating. fee-for-service incentivizes a practitioner to do more. it does not pay me if i go look at what david did three weeks ago for the same patient. we have got to turn the incentives around. we are saying we are in this together. if we can bring costs down and improve outcomes, we all gain. providers are starting to look at it differently.

it is not about me doing more. it is about doing less but better with what i am doing. if not giving extra radiation to a patient is better for them and i can look at the radiology he did, we can turn the system around. it is merging the payment system to match it. >> i would like to follow-up and ask a big picture issue. i understand what all of your saying and the manner in which you think we can reduce costs. are you suggesting the current system has more than sufficient funding, we just do not use the money efficiently? >> re- spend twice as much as any of the industrialized country in cover far fewer people. i do not think the french are a

dying industry. i do not think the germans, swiss, canadians. i realize each system has good and bad points. ours does as well. we are a country that does not like to look around the world and take best practices from other places. i think that is a shame. there is enough money in the system now. the problem is any business that has done change management, sometimes you have to spend money up front to reengineer things to make money on the back end. we're going to make investments in people, resources, human capital. states have an incredible role to play. states at the leading edge are places where the government. governor -- states at the leading edge are places where the governor or others have bank in their hand on the table -- banged their hands on the table

and brought people together. >> we think there is enough money in the system if incentives are restructured. we're getting data and starting to realize how we are in effectively using the resources we have. i think the answer is yes. we are close to being able to say, i am close to being able to say yes we are. >> it is not pulling the rug out from under providers. it is the diagram we shared where you need to gradually improve systems and release funding that can be used. if the gradual process happens, that is what will keep providers whole and not shut them out of business. if someone says tomorrow there's been a reform happening and we are changing it, systems will not be ready to switch. we will lose quality providers. i would take a cautious

approach. agreed -- i would take a cautious approach but agree. >> thank you for an outstanding panel. each of you is so insightful and have proven your theory. you are doing it every day and it works. i was reminded as i was listening to this great panel. about 20 years ago, many big city mayors thought we would never get a handle on violent crime. it was going to go up. the costs were going to continue to go up. the arrests were going to continue to go up. then they applied comstat measuring performance where you have the opportunity to rest

your most violent offenders. i have been following your work for many years. as my second health secretary will tell you, i bang my fists on the table often. my wrist is near broken over this issue. i see you are doing it. we need a common platform that takes a system that is this coordinated -- uncoordinated and disconnected. it makes it better coordinated and connected. the third thing you have to go through quickly was the notion of the patient-word -- patient dashboard, the ability for the patient to see that they are ordinance on the cost grid. i wondered if he might elaborate on that and the role a better-

informed patient plays in helping us to reduce costs. i agree. i think there's plenty of money in the system. it is not being deployed properly. >> you caught on to an opportunity we have with public health. we cannot solve health care issues. take the obesity issue. we cannot solve that in 10 or 20 minutes with a physician visit. in these to be getting word out to the general public -- it needs to be getting worked out to the general public with individuals owning their own health care. we can employ folks to do behavior changes that will help. it is using all parts of the system. right now, public health often operate separate from social services and health care communities. we're pulling together a strategy to say we need front and education. we need food resources available

for them to make health the terraces. it is taking a system approached saying we have to bring all resources to the table to give patients the tools they need to make healthy choices. >> what is the dashboard? is that something i.t. or the internet allows you to do? is it on the iphone? what is the patient-board -- patient dashboard? >> it is a provider dashboard that bubbles up what people need to see to meet their specialization. there are models across the country where there is a patient dashboard where they can go in and see their own labs and recommendations. what is being encouraged is

charging judech -- what is being encouraged is charting. there are a lot of tools individuals with computer access can be brought into. working with the low income population, we're finding we need to get them into public libraries to have some of those tools. using cell phones, and deploying cell phones the remind people to take medications and remind them they have not sent in their health or blood pressure. because of the payment mechanisms, physicians are bringing individuals in to check blood pressure. that is a huge waste in the system. there are a lot of patience tools that can be deployed at low cost. >> we are running out of time. i want to give governor markell the chance to pass the last question. >> i agree.

this is a terrific presentation. i want to drill into the issue you were talking about. you said if we reduced by 5% the admission rates to hospitals, all the hospitals would go out of business. i think this is probably the most complicated public policy challenge we have. it is a total of reorientation of an entire industry. it is easier for me to understand how we can start to make providers whole by rewarding quality as opposed to paying on the fee per service model -- fee-for-service model. can you explain how it works? i can sort of see how you do it with doctors and health care

providers. given your analogy to hotels, how do we get there with institutions? >> states have an important role to play. we have inflated the largest economic level in the history of mankind. health care is 18% of our economy. hospitals are a significant portion of that as are the high- tech specialty portion as well. we have done that through bonds. we have a mountain of debt underlined -- underlying. the states have guaranteed a lot of that. the big short is to sell short hospital bonds because if you look at the cost of what is in this, half of the costs are hospitals and doctors. the bulk of the federal debt going forward is health care.

it will be larger than the entire rest of spending in government. it will be drawing a lot of money out of medicare and cutting payments and rearranging payments to doctors and hospitals. hospitals being the biggest chunk of that. we're looking at a cataclysmic change in an industry. it is just like other industries. the underpinnings of what was going on in the economic system changed rapidly. the other analogy is psychiatric hospitals. at one point, they were 1/3 of your state budgets. -n the 1970's, we de das institutionalized that care. the question is whether we're going to build a system on the other side. health care is 18% of the economy. housing is about 11%.

finance is about 7%. think about what it will do to the model of urban redevelopment, the major employment gains we've had in health. it is being built on a mountain of debt. we have a problem. all over the country, hospitals are closing down. private equity is buying them up. that will be propped up by unnecessary occupancy through paying for medicare. when you have a capacity problem, states have an important role of the during out the transition model so we do not have massive unemployment and other problems. sequestration could be going off the cliff for a lot of hospitals. >> hospitals are rapidly becoming not just hospitals. doctors are rapidly becoming not

just doctors. you see the rapid development of the integrated system. doctors, hospitals, appears coming together to provide a better product. it is rapidly changing. i support that. i think it makes sense. right now, we have a foot in two boats. it is a delicate dance. lense says they are ready for this conversation. the market is driving this conversation. government needs to educate and support for the development of that and reward those for doing the right thing. the reality is we have the system we designed. we pay on a fee-for-service

basis. we get more volume. that is what we have. now we have to pay for and reword those that create value, not just micromanage everything, but create a system that values the value created. >> i would like to provide an update on the activities and opportunities in the health division of the nga. it provides governors and staff with information, technical assistance, policy analysis, and periodic meetings facilitating. strange. the health division will focus on medicaid cost containment, help system transformation, prescription drug abuse prevention, workforce planning. i would like to turn it over to the executive director to highlight some of the planned

activities and new initiatives thethese center -- from center for best practices. >> we are in the process of launching a presentation -- launching an initiative that ties to the presentations today. we want to invite you to tell us what else we can be doing to help you with costs in general. most of you have met christa. she is driving much of this agenda. she lets me speak for her occasionally. we currently have an initiative to get states together to compare notes and best practices on the abuse of prescription drugs. it is something important to virtually every state. it is worse in some places than others. we will have six or seven states funded to do meetings for

a year. it will run about $50,000 per state for your expenses. we will be putting on leadership retreats for systems transformations. we will have technical assistance teams going to states as well to work on child health care and how we limit preterm births. a very important piece for medicaid. it is directly applicable to medicaid but all kids as well. we will be having a meeting next week with 41 states registered with representatives to talk about the implications of the supreme court decision last week and what options you have. we will launch a new web site about labor day. i think it will be the first of

several virtual centers of best practices. it will be aimed at health. it will have case studies from virtually every state. it will have listings of your scope of practice laws state-by- state. we are doing some things with the state of maryland on expanding dental services. many of the medicaid kids are not getting sufficient and services. more to the point for today's presentation, steve lieberman taught me the bank robbers rule of health care. you may recall willie sutton said he robbed banks because that is where the money is. the rule here is why do you look at the expense of patients? that is where the money is.

that is where the need is. the other side of that is 80% of the population does not need much health care in any given year. focusing on expensive patients is an important piece of this. we sometimes bifurcate in ways that do not make sense. we worry about unusual use of resources. excessive use of hospitalization, nursing homes, or emergency rooms. we have only begun talking about how to give these people better help. it will require less health care services. it is how we take care of these people. increasingly, we are understanding that behavior help is a very important part in order to reduce physical health

costs. this is when the fee it states that integrates the physical and behavioral -- few stats that integrates physical and behavioral health. we have begun to solicit other foundations for health care analysis that will be available for all governors. one of the first things we do is software that we can give you that can replicate what jeff has done. most of you have the data said to do it at least for medicaid patients. some of you already do it so it is not new. we will have the identification as part of this initiative. separately and equally as important, it is one thing to identify the patients and

characterized them in different ways reject most of these to have chronic disease. -- them in different ways, most of these do have chronic diseases. they're very much alive. you can do something about their health. just by identifying the high- cost patients, how do you treat them? there is no simple straight answer. we have some sense of holistic treatments. one of the things we will be doing is putting in place some of these facts are already out there. they have not been tested across states. we can begin to look. we do to directly affect its? and at one solution fits every state.

a lot of health care is still lynn local in nature. we're going to try to set up tests that will allow us to evaluate what would work. we understand that health care is a dominant issue for all of us. medicaid is not only driving par but state retirees and employees are costly. it is important that we address that say you can get back to the transportation as well as health care. we understand that. we are soliciting foundation funding and other things to help broaden and share what is going on. a gives you software and technical support to do analysis if you need it. we are available for all of that. i really encourage you to tell

us what we can do more in ways that can be useful to you, whether it is some aspect in your state or whether it is these more systemic kinds of activities. thank you for letting me tell you a little bit about what we're trying to do. tell us what else you do to be helpful. to correct our time has expired. i want to thank the audience and our panelists for your presentation. this is a huge issue that affects us all greatly. i think you gave us some really great insights. thank you. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2012]

>> we are live in syria. it'll be continuing. we will show you the roundtable and a discussion on the center for disease control and prevention. we will have that it 2:30 here on c-span. tomorrow the governors will talk about entrepreneurship in their states and the impact on the economy.

you can join us at sunday at 11:00 a.m. eastern. we just saw terry branstad sharing. we will hear more from him tomorrow. he will discuss the economy and the expansion to the health care law. jill stein will talk about the presidential ticket and the platform. the finances of the post office. it proposes changes to the system. this is live at 7:00 a.m. eastern here on c-span. >> you realize that these are not coming to the aid.

that is when he collapsed. it was a question of suicide. >> a new look at the second world war. >> his main objective was simply not to be captured alive by the russians. he is afraid to be ridiculed and all the rest of it. a the brown was determined to die with him. >> sunday at 8:00 on c-span. >> >> where arina live coverage of the national governors' associatiowe are bringing you le coverage. he joined us on washington journal telling us what he expects out of the president's health-care law and the economy and delaware. >> joining us.

thank you for joining us. guest: good morning. how are you? host: fine, thank you. if you had to highlight one major agenda that takes place during this meeting what would that be? guest: these meetings are generally about us talking with each other and talking with outside people about strategies that we can employ in our states to put more people to work or improve schools or to be good stewards of taxpayer money. the great thing about being governor is not the rhetoric or speeches but if we are effective in our state on those issues. host: some of the paper stories coming out of the governor meeting as of yesterday one major topic not only among you and other governors but overall is concerning what will happen with medicare expansion. can you talk about that? medicaid. . that is an issue.

particularly in the of the math of of of-after math of the supreme court ruling affordable care act. we have been spending a lot of time in delaware looking at it. my clause is pretty simple. math is math. it is not democratic or republican. we recognize there is a human cost of doing nothing and that huge cost is we would -- if we don't do anything we would continue to have so many in our case like 30,000 more sick people who get sicker and don't have coverage and go to the emergency room which is the most expensive place and the rest of us who have insurance pay for it. so, as we are looking at this we think the affordable care act and expansion of medicaid is good. host: your state will expand that? guest: there are a couple of caveats.

one to the extent the federal government would reduce its reimbursements later we don't want to be left holding the bag. we would have to have the flexibility at that time to reduce eligibility or benefits. then the other thing is even regardless of this act there's a lot of work to be done in the country and a lot of work to be done in my state to manufacture away from what has become a sick care system where providers and facilities are reimbursed based on how many procedures they do. we have to move more toward a health care system where providers are rewarded for quality of keeping people healthy at the lowest cost. we are going to have to continue to have flexibility to make some of those things happen with medicaid specifically. but as we look at it, assuming our assumptions are correct which are proving out this looks to be good deal for our state. host: when it comes to your state how much of your economy is based on medically related

issues or manufacturers or insurance? guest: well, the biggest industry in our state agriculture is huge. very big in the poultry industry and soybeans, other crops. financial services has become a bigger employer the last 30 years. tens of thousands of jobs and within the last few minutes jpmorgan chase, capital one, bank of america, have announced yield jobs in delaware financial services. dupont. w.l. gore in our state. and important smaller companies. we love small business and the best economic development is to help the companies that are already in your state to grow. so, we are pleased to see progress there but we've lots of

work to do. host: our guest is with us until 8:20 and joins us to talk about not only the work of the national gives association but take your calls on the economy and especially the effect of governors who maintain the states. you can call on one of three lines. they are listed on the screen. governor, how does your state compare when it comes to employment to the national figure? i think what we've here is showing the national figure is 8.2%. your state in may was 6.8%. guest: that's right. so, 6.8 versus 8.2. it is obviously better to be lower. that being said, we don't consider 6.8 anything to celebrate. the way we look at it and particularly because we are a small state and we know each other and probably about everybody in the state knows somebody who is not working and would like to be working. as long as there are people in

our state who are not working and want to be we have to wake up each day focused on how we can create the nurturing environment where these people can be put to work by the private sector. that is what we focus on. there is plenty to do. host: how many people out of work in your state specifically? guest: about 30,000. so, the way we think about this, away take our lead from the businesses who are putting people to work. since i became give i probably have visited 750 businesses across the state. when i visit, i go in and ask one question, which is what can we do to facilitate your success? the appearances they give tend to be fairly consistent. they want to be in communities with great schools and work for purposes and reasonable taxes with an excellent quality of life. that is important.

the c.e.o. of gallup wrote book called "the coming jobs war" and talked about there are three billion people looking for jobs and only 1.2 billion jobs available. so, we are in this global war for jobs which maps we are in a global war for talent because the jobs will go where the talent is. the kinds of talented workers that companies want to recruit, want to work in places where they want to live. quality of live is important. businesses are looking for misses with good infrastructure, with strong linkage it higher end and really responsive government because we know as long as businesses are filling out forms and waiting in line they are not putting people to work. host: governor romney as he makes his case legged to november cites business experience and what do you make of what he proposes jobs-wise and how does that translate to perhaps what might happen in your state should he become president?

guest: i think that one of the interesting things about the election is the two candidates just offer different choices. it is one thing to head up a private equity firm but the question is whether do you learn from it. what the president is focused on is building a strong middle class. and as i talk to businesses, what they focus on is the investments in education and workforce. these are things that the president has been absolutely clear on from day one. so, having experience making money for shareholders is one thing but having experience and having the focus and plan to build a strong middle class is another. host: in 2008, 68 supported president obama. the call for our guest falls church, virginia. frank, end line. caller: good morning, gentlemen. thank you for the chance to speak to the governor. in my opinion, the medicaid escalation of cost is largely due to poor financial management. it has nothing to do with the people.

the area of concern there is no analytical difficulties or problems in creating securities that can be traded in a market to finance medicaid such as e.p.f.'s. we could design e.t.f.'sed that could be sold in the market it help pay for medicaid. what we have is people are not being very creative and i feel that this can be sold for medicaid, medicare using new classes of profits. host: governor?

guest: well, first of all, i have never heard the suggestion specifically before to create a connection 2010 e.t.f.'s and medicaid. i'm all ears for good ideas. i would say though one reason that medicaid has increased significantly particularly the last few years is in a difficult economy more people qualify for medicaid. that is just the fact. it is an unfortunate effect of the difficult economy but more people have qualified that can make it more expensive. the other side does have to do with the fact that as i said before. as a country, this is not just medicaid but overall. we have become more a sick care society where the way the

reimbursements work you do more procedures and you do more tests, you get paid more. that really has very little to do with keeping people healthy. that is something we have to focus on. i'm not pretending that is easy. is probably the most complicated policy challenge we've. but i'm keeping a careful eye on some of the great working done by governor patrick in massachusetts who has some legislation trying to accomplish this move away from what we call the fee for service model. i think there will be a lot of bumps on the road but my concern is unless we do something like that it is difficult to see how the increase in rates for healthcare would be sustainable. host: we have set aside a line for those that live in delaware to call. that is the line you will call this morning. .

i talk to people everywhere i can talk politics. we are tired of the republicans making the president look bad. i had in hand that had dialysis. there would not let her be on the machine for longer than 13 days. she was deceased. we do need obamacare. we need something to help people. it is just going crazy. i am really upset about it. guest: on the first point the

caller made in terms of republicans just trying to hurt the president, i have to say there's a lot of frustration amongst governors about the dysfunction in washington and i unfortunately believe that the tongue was very tone was very much set almost three years ago when senator mcconnell of kentucky, the head of the republicans in the senate, at the time, and this is well before this election, said that his number one objective was to make president obama a oneterm president. that does not at all sound to me like a leader of our country saying how can we work together for the good of the country. and so i am it's very frustrating and i'm certainly hopeful that after the election, you know, the republicans in washington will work with the president to try to deal with all of the huge issues that our country faces. host: when it comes to health care how do you look at it as you sit as governor when it

comes to cost containment, when it's being proposed by the obama administration? guest: so this is the point i was making earlier about the move from the sick care to the health care. i think the bill, the affordable care act, there's a number of tools within it to focus on cost containment, accountable care organizations and the like. but the caution that i would give people is to say we can't expect that all of the solutions will be found simply within this bill, and there's a lot that we as governors and working within our states and state legislators and others and constituents in our states have to do, so i don't think there's going to be one size fits all on many of these cost containment

strategies. clearly there's not going to be one size fits all with respect to the expansion of medicaid. that's one of the things we've been hearing over the last couple of days. and so i really i think we all look forward to working on more and more of these strategies. i do feel fortunate that in my state both our doctors through the medical society of delaware and hospitals through the health care association have pilots underway on this cost issue and one of them, for example, some of the hospitals in our state, had a strategy specifically focused on very heavy users of emergency departments. there are a lot of people throughout the country who use the emergency room for nonemergencies and that's extraordinarily expensive and the rest of usand this is the part that people have to remember, the rest of us end of paying that bill, our health care premiums are higher than they would otherwise be because we're essentially paying for the care for people who are not covered and who are using the emergency room. so as i say, some of our hospitals have a strategy to

help those people before they actually get into the emergency room and essentially to divert them to a less costly, more appropriate place for them to get care. that's just one of a number of strategies that i think we're going to have to pursue across the country. host: governor jack markell of delaware is the incoming chair of the governors association. joining us, robert, republican, good morning. caller: hello governor. i've got two questions. guest: good morning. caller: first 11 first, one concern, there's nowhere to help the workers unless the governor gives his approval and number two, gas is at an alltime low [inaudible] what i want to think about you think what you think about natural gas prices. guest: i didn't hear the first part of the question about a strike? which strike?

host: i didn't hear it either. if you would address the second part, particularly on the larger part of energy and if that's going to be a topic at this year's meeting. guest: the energy, obviously incredibly important, as a factor in all of our states. one of the things that we're seeing is that as a result of the drop in natural gas prices i think we've got a better and better chance to bring more and more manufacturing back to this country which is very exciting, because the more that we can actually make things in our country the better off we'll be. and i also think as you see some wages across the world increase from rock bottom, when you put it together, between higher wages, elsewhere, not that they're necessarily higher than ours but higher than they were and the lower energy prices here, we have an opportunity to bring more manufacturing home and i think that's a positive, it's something that all of us as against are interested in. host: you can see coverage of

the national governors association meeting later today. governor, this from twitter, asking you about k12 education. you were asked if it's high on the agenda and do you subscribe to the math and reading national standards curriculum. and then the viewer asked why or why not. guest: okay. so first of all, very high on the agenda. yesterday, we had secretary arnie duncan, as well as a former secretary, margaret spellings here, for a great almost couple hour conversation with governors, and it's high on the agenda because it needs to be. we're the only the only way we can have a strong economy going forward is with great schools, and i'm more excited about what's going on in public education in my state today than i have ever been, and i'm a graduate of the public schools in my state. and i'm excited about it for a number of reasons. i mean, first of all, one of the things that we're saying in my seeing in my state is a lot of cooperation amongst

teachers, principals, parents, superintendents, the business community, other schoolbased personnel, folks in government, to really focus on student achievement which is what it has to be all about. the other thing is we have better data than we've ever had before about how our students are doing. there's not a single business in the world that can be successful without having a really clear sense of how the business is doing and in education for the most part that good data has never really existed and that's changed in my state over the last couple of years because we introduced a new assessment last year which has offered fall, winter, spring, and what this allows us to do is to see in real time what kind of progress our kids are making so we made actually very good progress this year and what is almost as exciting as the actual progress we made are the kinds of conversations that this is creating amongst teachers and between superintendents and principals and teachers. every teacher in our state, several times a month, sits down with five of their peers and to drill into what the data is telling them about student performance. i sat in on a couple of these recently. one was with teachers who were

teaching kids to add fractions with different denominators and they were saying the kids weren't making as much progress as they thought they were, so the teachers took it upon themselves to reach out to nearby schools to get different work sheets and the like and to see these teachers and to feel the energy as they're really digging into this data to see what it's telling them is really valuable. on the common core question, i am a supporter of the common core. and in fact, i cochaired this effort with the former governor of georgia, sunny per cue and perdue and i'm a supporter for a couple of reasons. one, very easy to explain, it has to do with the fact that military families across the country, if you're a child in a military family and you change bases, change locations every 18 months, there's a very good chance when you move from one state to the next you're studying when you studied the previous year, you're studying what might have been studied the next year in a different state, and to have a common core evident, this has been driven by the states, this is not a federally driven program but

states got together, governors, chief school officers and others, got together and said what is it that we really want our kids to know and the expectations, these standards are higher, they're clearer and fewer than they used to be, and that's exactly where we should be. they're also more and more, they're internationally benchmarked. for too long we've had what garrison keeler talked in lake wobagon, everybody is above average, and that's not fair. when you tell a kid they're proficient based on standards and tests in their state and it's different elsewhere, you're not being very honest with them and i think a dose of honesty is very much in order. so we are really excited about all the work that's being done. it's hard, certainly the implementation of the common core standards is very difficult, but it's important and i'm excited about the progress we're making. >> host: georgia on the democrats' line, good morning. caller: good morning governor markell, and congratulations on your appointment to head of the national governors association. guest: good morning. caller: you have two questions for you. the first is regarding the

medicare or medicaid issue and the funding thereof. do you think that funding through, say, a fair tax would be appropriate or would be an alternative that maybe congress should consider? and the other thing is do you think will your state be implementing a sales tax any time soon? guest: we have no plans to implement a sales tax whatsoever. we're one of five states in the country without a sales tax. that means we invite all of you to come to the hub of taxfree shopping in delaware. we've got great retail opportunities throughout our state and we hope that you will

come visit, so no plans to do a sales tax, and i've not looked specifically at the suggestion you're making in terms of medicaid funding. obviously, congress and the administration have a lot of work to do together in terms of the budget and the likes. i've really not spent a lot of time focused on the federal portion of it. what we're really trying to do is understand what makes sense for our state. and as i said at the beginning, our view based on the math is that we think this expansion is likely to be a very good deal for the people of delaware. host: medicaid costs, the topic at 10:30 today at the national governors association, what you can see live as part of the a.m. meeting, cspan radio 2, as well as veterans issues being tackled at 2:30. tomorrow at 11:00, entrepreneurship is the topic. next from the virgin islands, herbert, hi.

you're on sir, go ahead. caller: hi, i'm a physician, and i've been interested in the health care issues, as well as the job issues that the governor has been talking about, and they are really related. for example, i believe that general motors has to pay out over $1000 in health care costs for every car it produces. it may be more, i don't recall. but this makes manufacturers and other businesses much less competitive in the united states. if there was a single payor where you separate insurance from your employer, the business business would be much more competitive. host: we'll let our guest respond. governor. guest: first of all, i think the issue of the cost is really important, and i'm glad the caller brought that up, and for the following reason. there's been so much vitriol about the affordable care agent

that people have forgotten how unacceptable the status quo is, and i can tell you when i was running for governor in 8, health care was the number one issue i was asked about, and that came from people who were concerned about rising costs and it came from people who were concerned about having access. and importantly the affordable care act addresses both of them. i'm not convinced that a single payor approach is a good one. it's not something that i would support in delaware. i think we've got now what the affordable care act, the outlines of a good first step, but as i said earlier, there is plenty for us to do in each of our states to focus on improving and sort of moving from this sick care system to a health care system and we'll certainly be doing that in delaware. host: the affordable care act has specific taxes assigned for those that manufacturer medical

devices, are any of those in your state and are they affected by this new tax? guest: they are. we've got astrazeneca and other pharmaceutical firms, we have a biotechical institute near the university of delaware with a lot of emerging companies, exciting emerging companies, so they are very much affected and obviously one of the things they're looking for is certainty, and i think that's one of the things that businesses across the whole range of industries is looking for are looking for is certainty, and so i think the sooner we move on, we recognize whether you like it or didn't like it the supreme court has made their decision, it's the

law of the land so, let's move on, let's implement, let's continue to improve, let's figure out how we as states can make things better in our own states. there are going to be lots of different ways of implementing. that's one of the flexibilities that the bill creates. and so let's get on with it. host: this is fayetteville, north carolina, frank is on a republican line. caller: good morning to both of you. briefly i've been involved in health care for 30 years, a health care provider, my wife is an elementary school teacher, i have a teaching degree and school board member, a veteran, so i've touched on the areas the governor has spoke about and let me make it clear, if anybody supports the health care bill passed and ratified by the supreme court, it has absolutely no interest in controlling health care costs when you expand health care access, no tort reform has driven costs through the roof, assessibility, uncontrolled assessility has driven the health care costs through the roof, and when you expand access, it will go nowhere but higher, and to say that we test too much, well that's true, we do test too much too often, but it's because we are forced to test too much because we always are under the guise of lawsuits and patients being uncomfortable.

one quick comment, since the passing of health care legislation, premiums have skyrocketed and copays have skyrocketed and to say we're going to increase it to the 30 million people, there's no wy to have health care costs without responsibility. i can treat all day long but the minute the patient leaves my office and don't take care of their own health, the diet their children are exposed to and cigarettes and alcohol and so on and so forth, there's no way we'll control health care costs. host: thank you. governor, go ahead. lott: well, there's a there. first of all, everybody is certainly entitled to their own opinion but not their own facts and i don't have them with me but in terms of what the caller said about the huge hike huge spike in rates, i have different facts and i can get them to to you so you can share them with your viewers, secretary of defensely, in terms of cost, the more people get covered there is a cost to it but there's a huge cost right now to people who are not covered because they're going to the

emergency room and that's extraordinarily expensive, and it's a bad way of delivering health care, and we've got to change that. and i do agree with the caller with respect to the importance of people learning to take control of their own health and taking responsibility for their own health, whether it's what we feed our kids or whether it's how much exercise we get, there's no question about it, which is one reason i said at the very beginning of the show, one of the things that we'd be looking for is flexibility, because we want to make sure the incentives are aligned properly. so there may be things we want to do in terms of giving incentives with respect to what people to people taking better cares of themselves, it's certainly something we've done as a state government, wellness programs and the like and it's important. it's been an ongoing focus, health promotion in the state of delaware to make people healthier and healthier and make them less expensive to care for.

host: this is from newark, delaware, mike, go ahead. caller: thank you governor and thank you for cspan. i wanted to let the governor know what's going on in my life. i'm in my late as, so is 50s, so is my wife, we're both unemployed. i'm a history teacher. now, i've been looking for a job for two years, and i can't find one, and people won't even call me back. that's what it's like for an older man or woman, trying to find a job in this economy. what's the governor got to say about that? thank you. guest: no question this is really what we've talked about earlier. although our unemployment rate is better than the national average the fact is we've got 30,000 people, including two in your household who are looking

for work and this is why we've got to continue to be as focused as we can possibly be. first of all we've got to be focused on making sure we've got a nurturing environment where private sector companies employ more people and the side benefit of that important benefit is that it generates the tax revenues we need to make sure we continue to have teachers in the classroom. one thing i feel very good about in delaware, over the last several years we've put more than 100 additional teachers each year in our classrooms to keep our class size ratios where they ought to be, unlike a lot of states where teachers have been laid off by the thousands or tens of thousands, we've actually not laid off any state employees over the last few years. years. we're way down in terms of employment because we've been carefully managing the attrition, but we've not laid anybody off.

so i think importantly, we recognize the job one for us is to do everything we can so we're putting more people back to work. host: as part of your job as incoming chairman, what's your agenda and what's on the top of that list? >> well, i actually get to choose a specific initiative but i won't actually be able to talk about it until tomorrow because in the meantime this is had not heinman of nebraska is the chair and we certainly look forward to building on the great work he's done. his focus has been on growing state economies. he had a number of forums across the country, and really focused on creating more of an entrepreneurial environment and he's given us a number of helpful suggestions not just specifically for our states but more broadly about how we can continue to grow state economies, and i would think for the overwhelming majority of states over the next several years, jobs will continue to be job one, also recognizing that the only way we'll have a great jobs picture for years to come is by having excellent schools as well. these two things are really very tightly linked.

host: governor jack markell, democrat from delaware, the incoming chairman of the national governors association, governor, thank you for your time this morning. >> martin o'malley and matthew hold a roundtable discussion about veterans welfare and received a briefing on surveillance. that is live at 2:30 pm on c- span. >> we look at the effect on the environment and the people today at 7:00 p.m. eastern and sunday on afterwards, peter collier on the life of jean kirkpatrick. >> she saw the dominoes start to fall during this time. by 1979 she was in full-fledged opposition to karcarter and ca rter-ism. fall, a couple of

lacerated experiences. >> the political woman behind the reagan cold war doctrine. at 10:00, author of "jarhead the military. this is this weekend on c-span2. >> they spoke about the week she spent on the ground in syria where 17,000 people have now died in the 17 month-long conflict. she said she was in the country without the approval of the syrian government. she talked about the killings, their response to the opposition, and have the international community has responded. this is about an hour.

>> i've recently spent several weeks in syria investigating human rights abuses, many of which have crossed the threshold of crimes against humanity. approval of the syrian government because the syrian authorities have not allowed human-rights organizations to access syria. i crossed the border i think the term ms. "illegally." i worked in 23 different towns and villages and in three areas of the country in the north, the area just north of the city of hamas. i would like to start talking about the biggest city, the

wealthiest, the economic capital of syria. the last place in syria i am aware there is --where there is no armed confrontation between the citizens and the government forces. this city has been late in joining the protest movement. it did not start as early as 17 months ago as in other parts of the country. the protests have been exactly like other parts in the country. every day i saw small demonstrations varying from a few hundred or maybe a few

thousand people. within 15 minutes, the security forces would intervene. they're working alongside security forces and would fire live rounds assault, weapons but also hunting rifles. in a single day on may 25, 10 people were killed, 10 demonstrators and bystanders. not only they fire on the crowds of administrations where there is no use of violence. people were sort of clapping with their hands raised above their heads to show they have nothing in their hands. then they go after those who

haveeen injured. this has been very much throughout the country from the beginning. cannot go to hospitals because they will be arrested. you have mostly young medical students, doctors, nurses, people who perform very important task which is providing life-saving emergency treatments. those people have been targeted by the regime. three weeks ago, three young man, medical students and an english students, were a part of a medical team who were providing treatment to injured demonstrators on the floor of apartments where they were at risk and the owners of the apartments were at risk.

the three were arrested and after a week their bodies were found with clear marks of torture. they had been shot in the heads and their bodies had been set on fire to give a clear message that it is not a good idea engage in this type of humanitarian tasks. elsewhere in the other towns and villages, it was a different story. i was there in april and may and through the beginning of june, it was an open armed conflict with the armed opposition, which is present throughout the country in different strengths and government forces fighting it out and in rural areas. but more importantly i went to the specific area to investigate a string of very brutal military incursions that

have been carried out by syrian government forces and militia from late february through to early april. in all of the areas i found similar patterns. i will give you a couple of examples. security forces in one city into a house where three brothers were sleeping with their mother and their sister. they took the boys out. there were 822, 24, and 26. they were construction workers -- they were 22, 24, and 26. they had participated in demonstrations. they did not flee their village because they figured they had

not done anything and they were not worried about the army. the army went into town the day before. they knew the army was coming to town. they were asleep when they were dragged off from their beds. there were shot in their heads outside their home and their bodies were set on fire. the mother and sister were not allowed to collect the bodies until 7:00 p.m. that night. in another place, the army swept in. a young man who was with the opposition ran up the hill to get his little cousins who were aged 8, 11, and 13, to get them back home. the army caught up with them,

made the four of them kneel on the ground and shot them dead. the little one was shot in the head and in the palm of the hand. other people were up in the hills looking after the sheep. other children in the area told me that he was kneeling on the ground with his hands up when he was shot. these are really individual examples of cases that i found by the dozens and for a period of five weeks that i spent in syria. in every single town and village that i visited, big or small, houses had been burned down to the ground. in some villages, half of the

houses, hundreds of homes as well as other property, medical facilities, pharmacists, field hospitals and also ordinary clinics were burned down. it wasn't just a question of some soldiers lighting amuck because the burning was a thorough from wall-to-wall. some it incendiary devices were used which indicates a level of premeditation. does it do not carry hundreds of incendiary devices with them. that is not what patrols carry. they would have to carry those with a specific intent. we cannot talk about possibly the actions of some rogue elements or acting on personal initiative -- that cannot be the case because the patterns

are too similar. brutal execution, burning down of large numbers of home and property by different units who were operating in different parts of the country at different times. this is a state policy quite clearly. they also in every village took away mostly young men. those who were killed or mostly young men and also elderly people and children. it was the same for those who were arrested.

the ones i could speak to were the lucky few who have been released. they bore horrendous marks of torture and open wounds. those released were people the security forces no longer had any interest in or whose families paid a lot of money to get them out. a small number of cases. there are hundreds that we know about but many more who have disappeared and have been detained, some up to a year ago and they have never come back and the families have had no way of knowing where they are detained. when they contact the different intelligence agencies that are responsible for the detention, they are told that they are not

there. sometimes families manage to get some news because they hear from people who have been released and tell them, "i was detained with your son." in most cases they had no idea that their relatives have disappeared. we have to be mindful of the behavior of the armed opposition. the armed opposition was formed after several months of peaceful demonstrations being shot at and demonstrators being killed and injured and anybody suspected of being involved with protests or demonstrations being rounded up and tortured and in some cases disappeared and in some cases killed. an armed opposition was formed and it is becoming stronger and more organized. it is engaging in a more efficient way in recent weeks with government forces and

gaining more ground in recent weeks. they, too, have begun to commit human-rights abuses. it is for now at the level of individual cases. we all know that in the situation of armed conflicts things can escalate very quickly. i would like to have a small digression on the issue of the term "civil war," which is being used in the media quite a bit when talking about the issue in syria. i do not think we are in the situation of civil war. as a kind of private initiative. the monopoly of violence has been firmly in the hands of government forces.

syria has a certain ethnic composition. sick. issue has not started with the uprising and goes back many decades. there's a danger because some of the development that we have seen since the first large- scale massacre that was reported on the 25th of may and in which has not completely been clarified until this day right up to the massacre that was reported last night. the reports in these cases which remain to be very -- they are all militias from villages going into sunni alleges with the support of the armed forces that shell the area with artillery and then the militias going in and finishing the jobs, so to

speak, killing people. government forces targeting their opponents because they are at their opponents and because they protest. the danger as the conflict continues is that it could acquire a greater sort of sectarian element, which would be very dangerous. i would like to end with a few words of the role of the international community. everybody i met, if there was one question that everybody was asking was, why is the world doing nothing?

why is the world watching? the syrian uprising took place during the arab spring and people in syria saw that in tunisia and egypt. people brought about change without it becoming armed conflict. in libya, it was a different story. there was intervention by the international community. in syria, the world has watched and has done nothing. the international community is paralyzed in a way that it was not in libya. looking at this from the perspective of a human rights

organization whose interest is first and foremost the protection of the civilian population. it is striking first of all if one goes back and looks at the kind of debate that was being had in the spring of 2011 at the syrian uprising. very quickly, the only option that was being discussed by the international committee. should there be a military intervention or not? but there was no discussion of any other initiative and there could have been a number of initiatives. the situation in libya was referred to the international criminal court within two weeks of the first demonstration taking place. we are 17 months into what has

been a brutal assaults on civilians. the leaders of the free world are still discussing whether it would be suitable to refer the case to the international criminal court. we have seen the international community agreed last april to the setting up of the united nations mission in syria. it was a case of too littlte and too late. the un supervision mission in syria was there with the wrong mandate. it went in to observe the cease- fire. there was no cease-fire, not even for a single day. it was clear there was not going to be a cease-fire. things had moved too far for a cease-fire to be a realistic option.

two useful things that should have been done that would still be useful now would be for the situation in syria to be referred to the international court and for the mandate of the u.n. mission to be renewed notthe use of that would be that it would be sending a signal to the perpetrators of these abuses. the time for inpunity is over. it is regrettable that that message was not delivered to the concerned parties right at

the beginning. it is not too late to do so now and i'll stop there and be available for questions. >> thank you very much, donatella rovera. thank you for your comments. the challenge in syria from the operational ground level all the way up to the strategic picture, you have levels of complexity and a kind of challenge that the region has not seen in decades. my comments will focus on taking us from the internal to mention -- dimension and the obstacles therein. the roots of the crisis are tied to social economic disparity. the mismanaged distribution of

natural resources. social mobility challenges in places that were the wellspring for protest. the crisis has evolved at a pace and scale that has metastasized the internal politics of the opposition and the responses of the assad regime. one thing can be said about the assad response. the grievance at depopulation level is that while every lesson about libya, yemen,every authoritarian system about what to do to maintain power does very little to translate into a path forward for a future for syrians and for a way out for the assad regime. it can only prolong the crisis. it has made things that more

intractable. you have by far more polarized environment, no communication between assad and the opposition. this has now ballooned into a struggle for power in syria. that is shown in both sides from the nebulous opposition in the country to the opposition in foreign capitals like paris. you have on both sides an effort to shape a message in what is happening in syria. you have a battle for what the course is in terms of the right steps that the assad regime thinks they can take. nurses the steps the opposition is taking -- versus the steps the opposition is taking.

it doesn't change the fact the both sides have been battling to craft a message. this has been happening in the context where you have an environment that is far more polarized and divisive than at any point in the last few decades. syria now sits on a broader regional fault line, not necessarily by design but by default. the level and skill ofthe competition and the -- competition in the gulf states and the polarization along the rhetoric of -- the struggle is between the regime and a predominately sunni opposition. this fault line impacts the future. kind of longevity in the access to lebanon and supports the has

a lot and try to shape some of the outcomes in syria first is the gulf states that are trying to reshape the balance. you do have a difficulty in reaching any kind of consensus at the regional level over what to do about syria. everybody wants to negotiate as long as they get exactly what they want which is not exactly the definition for negotiation. beyond all this, the gulf states find themselves at a crucial crossroads in politics. this is the first time that they can shape regional outcomes at a time when the three traditional pillars of the arab

state system, namely egypt, iraq and syria, are either silent or unable to change events and that is shaped the tactical choices, this idea that whatever emerges locally will most likely be predominately sunni to be supported. all these things complicate the struggle that 16 months ago was essentially a grassroots efforts to shift the debate about what syria's future to look like, what government should look like, what economics should look like. there is no international community on syria.

if there is not likely to be one in the near future. you have actors like the united states that are struggling from the lessons of past experiences and places like 11 non-and iraq, countries with deep divisions that the u.s. -- like lebanon and iraq, countries with deep divisions that the u.s. cannot fix. syria is very critical to the stability of neighboring states like jordan, lebanon and turkey, as well as the stability of israel. the reality is the view in washington is that there must be a strategic view on syria, at a time when egypt remains unstable, jordan will change

leadership over time. none of these paint positive images for syria pose a future. -- serious future. you have continued support for -- from external factors which will make the kind of scenario as and on the ground experiences that the syrian people are suffering all the more intractable overtime. this is going to be a long-term crisis.

and even have assad were removed or left, it would not change the reality that whoever runs syria will have to face the socio-economic, political and economic ramifications for the next decade if not longer. we can talk about the other points during the question and answer period. >> ladies and gentlemen, let me throw things open for questions but before i do so, let me ask a favor of you. if you look around, you can see how many people are in the audience. a lot of them are going to want to ask questions. i'm going to ask you the favor of actually asking a question, not making a statement or a speech, having the question of simple enough so the panel has a chance of actually answering it, and before you actually ask that question, could you please indicate to you are and the organization you are a member of if it is an organization you're speaking for. with that, let me ask you as the first question? forgive me if i don't identify those of you i know by name. i will just point but the lady and the front row -- please,

>> barbara slavin from the atlantic council. the question is -- we read that the opposition forces within the country are getting stronger and they have a defect of control over large swaths of the countryside. is that the case and, if so, what are you so pessimistic route -- about their ability to defeat the assad forces? >> in the whole of the north which is where is i was and is no different in other parts of the country, it is kind of a shared management of the land, if you will. the government forces are

present. have checkpoints on the main roads and sometimes they put up flying checkpoints at intersections with smaller roads and the smaller roads you can move if you are careful and always check ahead that there is not a sudden flying checkpoint. it's that kind of division of labor -- also on the main roads at night, the government forces tend to kind of lock themselves up in the tanks and not stay very visible. i would not say there is total control that the opposition has anywhere but they certainly have operational ability to move around. >> thanks for your question. you have to understand a static snapshot of what is happening along the frontier with turkey

is something that is not going to capture the scale of what is happening between the regime forces and these units that are operating as part of the opposition. there have been reports, none of them completely accurate, about command and control by opposition forces in places. the mapping we have seen suggests over a significant portion of the promise, they are reporting and i am suspect about that. there are indicators that there are strong pockets of control along the turkish frontier. there is a reluctance now by the syrian military to send the kind of messages that could aggravate further an already

difficult dynamic with turkey. that being said, the assad regime still has enormous repressive capability. they have always expected as far back as the early 1980's that the next battle the security apparatus would have to face is not unlike what they saw in the 1970's and 1980's. you have an ideological military and far too many desertions as opposed to defections and you still have a fair amount of command control but the challenge this patrician battle really poses to the regime is that they are engaged in a struggle that always shifts, it is like a game of whack-a-mole and does not -- has learned not to stay and fight to the and it will drag things out further. that is partly why i am a pessimist. neither side is able or willing to make the kinds of decisions that slow the pace of violence.

i would not be surprised if we're talking about this kind of cycle well into the end of the year if not into next year. >> i'm going to try to spread things around the room. the gentleman next to the gentleman with the microphone. >> thank you. i have been listening for months on this thing and have been waiting for someone to give a percentage of population of syria. >> to ask a question please? >> i would like to find out what is the percentage of opposition as opposed to assad forces. >> why we take a couple of other questions at the same time? the gentlemen and the second row there. -- in the second row there. >> i appreciate and things are more horrific than they thought. i was surprised that the role of sectarianism is not bigger. could you draw more of the sectarian roles and how they play in this? >> one more question? the gentlemen in the front row. >> thank you.

my question is for the entire parent. when you look from lebant to the bay of bengal, what does the panel think the chances for all this violence in syria to spill over to jordan, turkey, and elsewhere and become a catalyst for a larger regional conflict? >> i think we would all love to know the percentage but the situation in syria just does not make it possible to conduct that kind of research. there is either people and journalists in syria with government approval and their movements and their actions are

tightly controlled and observe and monitor. then there is others who go in illegally and have other challenges in terms of how much they can move about and what they can do and so on. it is very difficult to know with any degree of certainty either what is the percentage of support amongst the population for one side or the other on the one hand as well as a exactly -- the numbers in terms of what is in the syrian army, that is reasonably well known. what is less well known is how many people have actually defected. the figure is very -- the figures vary greatly. i have not seen a figure of the exact number of members of the armed forces that have deserted that i consider to be reliable.

i think there are various figures. it is still a small percentage. spill over potential -- i would like to rewind back to libya. that was one place where the international community acted or reacted with lightning speed. everybody was united pretty much on what to do. there was a small group of people who named them sells the national transitional council that essentially represented themselves, not anybody else but they had good contacts mostly in the western capitals in america and europe. all whole world fell in love with them, completely forgot any of the people. i was in ban gauzy and -- benghazi and everybody thought libya was going to be so easy because there are not the sectarian issues you have in

syria with different communities. it is very homogeneous. and they forgot about tribal differences. the regime in libya fell and now you have 100 nations in a single city and many hundreds more and when there are disagreements, people don't sell that and more by punching it out but they fire rockets at each other from across the street. the situation is very messy, indeed. in terms of when you talk about spill over, the parameters of analysis that have existed for a long time in the middle east have been sort of thrown up in the air in the last year. it is because those who brought about change have not been the

traditional oppositions. in any of these countries, they are trying to play a role now to a larger or smaller degree of success but certainly, the opposition played no role from tunisia to syria. it has been young people who have just come out and got us to where we are in the different countries. i see too many of the parameters of the old analysis that have been used for decades to predict what may or may not happen and i don't see not taking into account analyzing the situation today of a new reality that the actors have changed, at least the change that is deeply chicken the

country. -- shaken the country. you still have the older guys trying to find a place in the new egypt or the new tunisia when they were really not very present during the uprising and they did not play a decisive role, if any at all, in bringing about the downfall of the regimes. i think that is something to really bear in mind. the second thing i would say is that after the french revolutions, they got napoleon. it took many decades before democracy. what has happened in the middle east is the beginning of a process. it does not matter -- in each country there are challenges. in none of the countries, it is going to be great. even in the best case scenario, there will be internal conflict, internal strife at different levels because people who have been denied the

possibility to have a free press or free expression or free assembly for decades are going to need to find their own way to create spaces for debate, for resolving their differences. while applying the old parameters of analysis is worth bearing in mind, there are rather new elements. >> on the question if you can reliable man about the percentage that supports the opposition or supports the regime, it is hard enough to map out the players involved in politics as it stands. you will not get a reliable

picture in terms of accurate numbers. what is clear is that you do have a large cross-section of the syrian population that has to deal with the reality, the myth of a unified syria under some language of arab nationalism which has been pulled out of the equation. you now have communalism. you have communities like christian minorities and some heterodocs. they can be critical of assad but they don't know what the alternative is in terms of social economics and politics and security "is still a sizable popular support and even with the in the sunni community. have a significant portion within the armed forces that are hanging in there because of the real threat that they face should there be some kind of

debasqification. you have these kinds of defections are people being sidelined. on the question of sectarianism, the assad regime has widened the communal told -- the communal to mention the of largely -- largely lost control of that message. it has polarized society and you have the lot of mob politics that impacts this. the communal dimension and the potential divorce between communities could be a source of instability and require true leadership in that something as increasingly scarce in syria. in terms of the chances of spillover effects, with libya as a country that imploded and

syria will exploit of things continue, we already have instability in the northern provinces. they are launch platts -- bear launch pads for opposition activities and in syria, you have a sunni community in lebanon bettis in the same politics of the shiites before the and the 1970's. they feel they have no leaders and they have, because with their brethren in syria. lebanon has become increasingly unstable and subject to the effects of a potential tsunami of instability from syria. jordan has already seen a number of prime ministers come and go and it is not a good sign for stability in jordan and there are pressures there in a country that has fewer sources of revenue and is relying on external support for stability. even turkey has to face the reality that it has an 800 + kilometre with syria and its own source of instability and

iraq tested deal with its own sunni-shiite problems. in none of the countries where we have seen regime change or changes in the distribution of power do we have any sense of certainty that the players who are shaping events today will either be relevant or able to shape outcomes in the future. this is not the kind of cycle that one can assess in 2013 or 2012 alone. we will have to assess this overtime and who ultimately in harris the centers of power is deeply uncertain. -- inherits the centers of powers is deeply uncertain. >> i think that both panelists race an issue which needs far more attention. these are changes taking place in the region which, for

decades, as seen economic and demographic pressures build on a largely national level. there is varied little regional integration or regional economics accept for a local security arrangements. the pressures that are outlined will be extraordinarily difficult for any government to solve. that report to the conclusion that many of them could not be adjusted by a company and government on -- in less than a decade simply because of the u.s. pressure, economic pressure, the disparities in income on the problems of governance. there's a warning that i think needs to be drawn particularly by americans, a confusion that there is an easy route to

elections and elections produce legitimate governments. historically, elections do not produce legitimate governments. virtually every election held in the post-colonial period did not produce a legitimate government or one that could survive for half a decade. the president historical even in europe is one that we might bear in mind. i remember a senior arab official making this point -- it was in st. for westerners to -- insane for westerners to talk about an hour of spring -- arab spring when westerners have their own experience. they had a spring in 1848. last it arguably until 1914 and did not end well. i think this is prospectively what we want to keep in mind over time. the gentlemen in the second row

over there and we will take another series of questions. >> good morning. while it is clear to me who is supporting the regime, i would like to know in your opinion if it's true that in the opposition there are also minorities or is it just the sunni uprising? >> the gentle man in the far back over there. >> thank you. i'm a former prisoner from syria. you mentioned the icc. when need a resolution. on not sure if i understood this but you describe the

mission of the un observers as useless because there is nothing to see there. what you expected from expanding a useless group? there is lots of weapons and nobody will collect those and how you deal with those steps anybody picking up arms is in a position. >> thank you. the gentle man in the front row here. please -- theood morning, i'm from leadership academy in from the building. what is the position of the international community on syria and today have any plans or actions to take on stabilizing the community and stopping the violence of syria?

>> who supports the armed opposition was the first question. that is a good question and i think it is one where the answer is likely to possibly keep changing as the situation develops further. some of the armed groups that i saw operating in syria had one kalashnikov between four people. they were poorly armed. that has changed a little bit in recent weeks. the last week that i was there at the end of may, i saw some more and they have light weapons and a arms -- in the hands of armed groups. they have been able to capture more weapons from a temporary military camps that they have been able to overrun. obviously, there are different

players outside mostly who seem to be offering help. none of it is done very much in the open. i don't like to work with speculation but with facts. for now, i think there will not say anymore because i have no certainty and i don't like to speculate but certainly what i think is clear to all is that there are different players as in any other conflict who might have an interest and influence in things and may choose to do so by providing support of different kinds. to the question over there, icc

russia - it has not been tried. we have seen that russia and china agreed to the un mission to the kofi annan plan. it is regrettable that the international community did not think outside the box and did not try to address and look at options which were options outside the military intervention. that is what i think it's regrettable that from the very beginning, the debate that was had was should there be military intervention and not look at other options. there has been no serious attempt. it is quite clear that russia has been playing an obstructive

role but it is too easy to just blame russia because even the government's were talking tough today, only four weeks ago, there was an initiative by the swiss government precisely to rally support for going to the security council and tabling a resolution on referring syria to the icc and countries in the northern hemisphere were still saying that maybe we should give the kofi and non plan a chance. they have not tried and that is regrettable. with regard to the role and mandate of the u.n. mission, i did not say they were useless i said by the time they got there, the mandate that they were given was inadequate. there were there to observe a ceasefire and that was the mandate and there wasn't a ceasefire to observe and there will not be one to observe any

time soon. but what we would like to see is the mandate to be renewed but expanded -- for them to be given a mandate to investigate human rights abuses, crimes against humanity, war crime and if they're given the mandate, they will also be given the human resources necessary. in terms of the question on the role of the international community, as i said earlier, the international community has very much focused only on looking at the possibility for military information and -- intervention and decided that was not a good route to go down and it has not done very much else until now. >> in terms of the question on minority representation within the opposition, the reality is that by a factor as opposed to by design, it has been difficult to build an opposition that has minorities and meaningful -- in meaningful leadership positions. there has certainly been

syrians who belong to minority groups who have distanced themselves from assad but that does not change the fact that the opposition groups remain largely dominated by sunni demographics. you have to be careful about pigeonholing anyone group. many minority groups are cautious. on the question of the u.n. mission, and whether it should be renewed, you have to look at the alternate scenarios. includes a protracted civil war not unlike what you saw in algeria or lebanon which would go on unabated and with metastasize further and no one will have a sense of what the outcome will be. beyond that, you have the prospects of deepening

instability and communal division. the annan plan was the right idea at the wrong time and not supported by a mob of the players that mattered locally to say anything of international. is only now the people are starting to come around to the reality that this will become a very messy and long-term crisis. in any form, there needs to be some prospect of diplomatic effort. a lot of what we are seeing is deeply depressing and-on syria. that does not mean one has to completely close of the diplomatic channels. on the question of whether or not, what is the position of the international community -- again, there is no international community on syria. you have a very divided political sphere. have disunity in the security council. you have russia that is deeply

suspicious of any western efforts in syria. it is based on what they view as the erosion of their interests in the region to say nothing of their own internal pressures tied to the expansion of nato and all of these things make it very difficult to chart and a meaningful course when it comes to syria. it is not very good answer but it is as close to the truth as i can find and it is not clear what any player at the international level can do in the short term to stymie the violence. >> ladies and gentlemen, i've been instructed to end this discussion formally at 11:30. i would like to thank dontatella very much of giving us a human rights picture. i would like to thank aram for providing perspective encourage you think and in the usual manner? [applause]

[captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2012] >> this afternoon, maryland governor martin o'malley and the wyoming governor hold a roundtable discussion about veterans welfare and receive a briefing on by a surveillance, live at:3c- >> throughout july on c-an radio, historic supreme court arguments focusing on election issues. >> throughout the briefs, they refer to us as being anomaly, independent, professionally run, that the candidate knows who is helping them and why. we think these are all code words for saying we are

effective and that because we are effective our speech ought to be choked off. >> today, campaign spending and free speech on c-span radio. >> hitler by then had absolutely no plan. when he realized that these armies or remnants of armies were not coming to his aid but were trying to escape to the west, that is when he collapsed. he realized finally that things had come to an end and he coted sui. >> a new look at the second wod wafrom adolf hitler pose a rise to power to his dark -- rise to power to his dark final days. >> he was afraid of being paraded through town in the cage

and being spat at. he was determined to die and if lebron was determined to die with him. >> last week, health and human services secretary kathleen sebelius outlined the next steps for implementing the health care law. she made reference to house republican efforts to repeal the law, saying it is important to remember what is at stake when we talk about repealing. she also said she will hold meetings with governors to answer their questions, starting at the end of july. this is about 20 minutes. >> please join me in welcoming secretary sibelius. [applause] >> good afternoon, everyby. i am delighted to be back in george washington. i was telling people that i have had theleasure of being here

at the school of public health and number of times and announcing a number of important new initiatives here in this auditorium. i think it is a perfect venue to discuss the affordable care act and the importance of the supreme court decision. the want to thank everyone for the hospitality. you are going to have of great treat.

you will have a great treat. some colleagues i have worked with for a long time are members of the panel that you will hear from. certainly, the other keynote speakers. i will tell you a little something about them that may not be immediately obvious. we all have kansas connections. i am a former governor, former insurance commissioner. in kansas, my husband is a federal judge. tom married a kansan. sheila burke, longtime aide and assistant to senator bob dole, the senate majority leader from kansas. you may have thought we were here for our health care expertise, but it is really our kansas connections. over the last couple of weeks, there has been a lot of commentary about the supreme court decision and what it means for politicians in

washington. we have heard speculation about who is a winner and who is a loser, what it means for november. with congressional republicans, today holding their 31st vote to repeal the affordable care act, it is clear that some want that political discussion and political battle to keep going. i am really glad to have a chance to be with you today to talk about what the healthcare law means for those outside of washington, the hard-working families that the law was really designed to help. to do that, we need to set the stage and remember where this country was when this law was passed two years ago. back in 2010, the urgency around health care challenges was growing. this was related both to the health care of our nation and also the economy of the country. despite spending more than any

nation on earth, we were moving toward 50 million uninsured citizens and really mediocre health results. our health expenditures were consuming an increasingly greater share of our gdp, threatening our global competitiveness. families, businesses, and governments were all struggling under the burden of rising costs. between 2000 and 2009, insurance premiums doubled. the share of small-business owners offering employee coverage dropped from 70% in 2002 to under 60%. medicare costs continue to rise, putting the trust fund on pace to be insolvent by 2016.

one business owner who wrote to me early in my term summed up the frustration many americans were feeling. he wrote, "i am near the breaking point. with guaranteed annual increases at 10 to 15 times the rate of inflation, eventually, we will go out of business or be forced to cancel our employees' insurance. either way it is a lousy set of options." at the same time, the private health market was becoming more consolidated and less competitive. some americans had dependable access to coverage in public plans -- more children, the seniors, disabled, veterans, even the poorest adults and pregnant women -- through medicaid. employees of largest companies usually fared pretty well.

that left a lot of hard-working families in a broken market where insurance companies made a lot of the rules. totally legally, insurers could cap your coverage, raise your rates, or cancel the coverage with a very little accountability. if you were one of the 129 million americans with a pre- existing condition like cancer or even asthma, you could be locked out or priced out of the market altogether. that was a fairly successful business model for many insurance companies. in fact, in 2009, the five largest insurers made $12 billion in profit. but that did not work very well for a lot of the people who were left on the sidelines. the healthcare law was passed in large part to address the twin issues of cost and coverage. that is exactly what has begun to happen over the last two years. the law's first principle is pretty simple.

if you have coverage, you can keep it. for the 260 million americans with insurance today, the main change is that they will get more security. the law puts in place new insurance rules, and many of those are already in place, prohibiting insurers from capping the coverage or canceling it without cause if someone gets sick. preventive care is now free for 54 million americans with private plans. there are new limits on how much of your premium insurance companies can spend on overhead costs like ceo bonuses. as a result, starting this summer, about 13 million americans will get rebates from their insurance companies. you heard me correctly. insurance companies are actually sending money back to their customers thanks to the 80/20 rule.

the affordable care act does not cut medicare benefits. in fact, the program is more robust than ever. new benefits have been added for seniors. the law has begun to close the insurance gap in medicare prescription drug plans, saving over 5 million beneficiaries with the highest medication costs, about $600 apiece. we have brand new efforts and new surveillance tools in fraud and abuse areas. we have already returned in the last two years about $5.4 billion to the trust fund, and that does not include the new $3 billion settlement just announced last week. yesterday, our department announced that so far in 2012, more than 16 million seniors and persons with disability on medicare have already taken advantage this year of at least

one free preventive service like a wellness visit or a cancer screening. we also know small business owners were at a very difficult place in the market. they are beginning to see relief thanks to the new tax credit which covers up to about one-third of their insurance bills for employees. all americans with insurance will benefit from no longer having to pay the extra $1,000 per family that is estimated to cover the cost of uncompensated care for americans with no coverage. the law is beginning to provide some better coverage choices for middle-class families. we have about 3.1 million young adults, and some of them might be here, who were previously uninsured prior to 2010 and now are covered under their parent's plans. we have 70,000 americans around the country taking part in new high-risk pools that were previously locked totally out of the insurance market because of their pre-existing health conditions. at the same time, the affordable care act has begun breaking the stalemate in washington on addressing health- care costs. there was a lot of agreement for decades that our health care costs were too high and they were continuing to rise. while there was a lot of agreement that we had to do something about high costs,

there was not a lot of action in congress. the ideas put forward by those who favor repeal would limit government health spending, lower government health costs, simply by shifting costs to seniors and patients. but there is an alternative vision that is part of the construct of affordable care act. it really captures doing on a national scale what some of the best health systems have begun to do around the country. that is bringing down costs by actually improving care. prior to the passage of the affordable care act, many of the financial incentives in our two large public programs and medicaid and medicare right now include about one-third of the country. almost 100,000,000 people are participants in one of those two programs or sometimes in both. the financial incentives actually many times penalized care improvements the way we pay providers in hospitals. over the last two years, we have begun to change the incentives in the health-care system to reward providers for improving care. we've had an enormously enthusiastic response from

doctors and hospitals across the country. just on monday, we announced that a total of 154 health organizations serving 2.5 million americans have already signed up under the law to form the so-called accountable care organizations. these are structures where providers share the savings when their patients stay healthy. there are many more of those strategies underway -- lowering hospital-based infections, medical health homes, bundling care -- all designed to keep people healthy in the first place, out of the hospital, and lower the opportunities for return. all of that progress has been going on in the last two years. when we have, as we have again today, people talking about repealing the law, i think it is important to remember what is really at stake.

this has nothing to do with the fortunes of elected politicians around washington, all of whom already have excellent health care. it is the health and economic security of middle-class families around america that are really at stake. repeal actually could subject those families once again to some of the worst insurance abuses. we know it would automatically raise the price of seniors' medications and add financial barriers to their preventative care. it would end the tax credits

that are currently helping small businesses cover their employees and force millions of young adults to once again begin their careers without the security of health coverage. it would mean that, too often, the best quality of care would continue to be out of reach for most americans. what we know is that the supreme court decision, there were four justices who actually voted to strike down the law that would accomplish those goals. but the majority of justices have allowed us to move ahead on full implementation of the act. with a slight change in medicaid, which now makes the program a voluntary program and removes the penalty phase of medicaid so that the department of health and human services could not take all of the underlying medicaid funding away from a state that chose not to participate, medicaid

expansion will operate very much like other expansion has operated over the past number of years, where states voluntarily come into the program and we have given a very generous framework of state federal participation and the opportunity to ensure the largest number of low-income adults in that program that states will indeed decide to insure their populations. most of you know that two major parts of the program do not take effect until 2014. the new marketplaces will be set up in every state where families and small business owners actually get to make, for the first time, a comparison of health plans and choose the one

that is right for them. there will be new rules for insurance companies. no one can be discriminated against because of a pre- existing health condition, and you cannot be charged more because of your gender in an insurance plan. others who cannot afford coverage can qualify for a tax credit, averaging about $4,000 per family. members of congress and their families will get coverage through the same exchanges, alongside their constituents. over the past two years, we have been working on implementation because setting up these new markets cannot happen overnight. we have partnered closely with states to set up the new consumer-friendly market places. far from what is reported as a federal takeover, the law really gives states maximum flexibility in shaping their own market. states can decide, for instance, to fully operate their marketplace, to partner to run pieces of the exchange, or

to have us do it all. the law contains a provision that if states come up with their own way of covering the same number of people with the same kind of quality and no cost increase, they can present a plan and take over the whole system. the president has asked congress to move up that provision from 2017 to 2014 so states can have the flexibility in year one. yesterday, i received letters from 12 governors saying there are already fully engaged in planning to establish their own marketplaces. we anticipate more to be fully ready as we move through 2012. in the months to come, we will keep working with states to meet them where they think it is appropriate and have all of the exchanges running in every state by 2014.

another key change that is coming in 2014 is that states will begin receiving a very generous federal match to expand medicaid coverage to uninsured adults can at 133% of poverty. those of you who do not walk around with poverty tables in your heads, that means for an individual who makes less and $15,000 a year and for a family of four, the income is less than $31,000 a year. we are talking about some of the poorest working families in this country. here is what states are being offered. for the first three years, the federal government pays 100% of the newly insured enrollees. after 2017, the federal government share is reduced, but never less than 90%. the lowest it gets at the end of 10 years is a 90/10 share. the states also have flexibility in setting the

benefits for the newly covered folks. their expenditures will be offset by reduced spending on uncompensated care for the uninsured. this has unprecedented federal support, access to affordable coverage for low-income residents and steep reductions in costs for the state, the citizens, and the health care provider. we think at the end of the day, this is a deal that states will not want to turn down. as i said, we have been through this before. when congress expanded coverage for kids in 1997 and offered to pay 70% of the costs, not 100% of the costs, states were initially skeptical. only eight states began covering eligible children in the first year. but within 2.5 years, all 50

states decided the benefits far outweighed the costs and committed to participating. the 2014 medicaid expansion offers states a better deal. we are hopeful states will take advantage of it to cover the needs of their families to ensure their doctors actually get paid. earlier today, i sent a letter to all governors, many of them my former colleagues, laying out this information. we will keep working closely with states to make sure the hard-working families who are looking forwd to this new day

have access to affordable coverage. now that the supreme court has issued their decision, i am hopeful we can stop refighting the old political battles and trying to take away benefits millions of americans are already enjoying and instead move forward in implementing and improving the law to provide more security to americans who have insurance, more choices for those who do not, and lower costs for everyone. thank you all very much and i