letter written by fdr to hitler. and also to the lbj presidential library, some of the home middle east made by lady bird johnson -- some of the home movies made by lady bird johnson. >> the first one i want to show you is an extraordinary letter that fdr wrote to adolf hitler in 1939. roosevelt was feeling impotent with regard to what he could do because of the isolationism in the country as well as the neutrality laws. as you can see on the second page of the letter, roosevelt is right thing to adolf hitler. -- writing to adolf hitler. it seems inevitable that much of the world must become involved

in common ruan. -- ruin. hillel fdr to facilitate .iscussions ridiculed roosevelt for such a proposal. >> what other documents do you want to show us? >> one of the most important document in our collection is the extraordinary letter that albert einstein sent to fdr in august of 1939. because of the outbreak of the war, the letter was not delivered until october. it warned franklin roosevelt of the danger.

i want to read a couple of sentences. some recent work leads me to expect that the element uranium may be turned into a new and important source of energy in the immediate future. certain aspects of the situation which has arisen it seemed to call for watchfulness. he goes on to describe the possibilities of a massive weapon of destructive power. work leads me to expect that the element uranium may be turned into a new and important source of energyit the manhattan project. >> the next one will catch people's attention. >> this is an incredible moment in history. fdr received a letter by telephone in the invasion of poland by hitler. he was awakened in bed by one of his ambassadors. the sheetent pulled

of paper and wrote this amazing note. referring to himself as the president. the president received word at 2:50 a.m. by telephone from the ambassador that germany has invaded poland and that four cities are being bombed. the president directed that all navy ships and army command been notified by radio at what spirit he has written in bed, september 1, 1939, fdr. >> how did such letters get passed between leaders? >> through diplomatic channels. there was the issue of ambassadors at the time. that would have passed the diplomatic channels. >> how long did it take to deliver such a letter? >> it would have been transmitted by cable and delivered to the chancellor. >> the last item is a photo from churchill?

that is what you guys have. the next thing i want to show you relates to fdr's relationship with churchill. church of roads a very lengthy letter to roosevelt in 1940 -- churchill wrote a very lengthy letter to roosevelt in 1940. went on a fishing crews after the election, labored over this labor -- this letter, and came up in the -- with the unique concept of land lease. this text document -- this next document is a document in russian written by joseph stalin. fdrr it was initiated, reached out to stall and asking -- fdr sent his aid to meet

directly with joseph stalin. this is the actual shopping list. aluminum, 50 caliber machine guns come up 30 caliber rifles. the weekend of memorial day. we are back. linden at the wheel. always in the bankers close. -- clothes. county was in the back seat without a shirt on. was in the back seat without a shirt on. the most delightful cable car goes up to that house.

many of our weekends are spent on the lake lyndon b. johnson. , there is jack. he is usually driving. footage from movie 1955. it would shot and narrated by lady bird johnson. we're beginning our second part of the program, all look back at the lbj's early political career. these are from the johnson library in austin, texas. see lyndoning to johnson that maybe the public did not see very often. through the eyes

of his wife and others as well. isy bird johnson's role almost done as much for lbj as the tapes. >> when did she narrates these? >> most of them were inherited when she was in the white house. that is where she got that great background music. some of them are much earlier than that. he can see her commenting on some of that. he was so slim. is having a good time with these. >> a sampling of the video from our series six years ago on presidential libraries. the opening of the george w. bush presidential center last week, we are taking a look back at some of the other 12 presidential libraries for the next half an hour or so. a reminder that that video is

available on-line. you can see it in our video library. one more tip, the presidential library series is available. all of that is their, an extra video online as well. the presidential libraries are all filled with private funds, built with private funds to begin with. foundation's gift donations, but they are maintained and operated by the national archives and records administration as. a mix of public and private money to operate. peraverage cost per year library is at $75 million. member of congress has introduced a bill calling for more transparency in those donations to the foundations that creates presidential libraries is john dunton, a republican of tennessee.

he introduced his legislation calling for transparency for all those donors to be listed. we caught up with him yesterday while congress was on break and asked him about the legislation. representative john duncan of tennessee has been pursuing transparency in the funding of presidential libraries. what would you like to see happen? >> i would like to see the contributions to the --sidential libraries to be my bill does not limit contribution, but it calls for disclosure, more transparency about the process. i became interested in the several years ago when i read that president clinton had pardoned a man who had fled the

country to avoid $40 million in income taxes. then he got a full pardon on president clinton's last day in office. a short time later, it was had givenhis ex-wife $400,000 contribution to president clinton's library. there was a sizable contribution from saudi arabia and others. i thought it was something that was open to abuse and i thought something should be done about it. that bill in the house three times. >> the bill that you have introduced, what is the level at which you have to report a contribution. you mentioned foreign countries. winter bill contribute -- prohibits foreign countries? >> it would not prohibit any

contribution of any time. it would be required -- it would be to require disclosure. people could see were contributions are coming from. these committees are formed while presidents are still in .ffice to raise funds is a real potential for abuse. i think it is something that needs to be more open. all contributions of $200 or above to be reported on. >> what is the federal law now? >> there is no federal law. there is no law at all. unlimitedittees are and unrestricted. they can get huge contributions and it seems to me and to

everybody who has looked into people can make big contributions to these libraries while a person is still in office. getting special treatment from that president or from his administration. this is something i am pleased to say has received total bipartisan support. ill, but it hasuil been passed to a very few dissenting votes in the house. i sponsored the original version. when the democrats took control of the congress, the original

sponsor became chairman waxman. it was co-sponsored by the ranking democrat on the committee. >> the think he will have an attraction this time around? they did do you think you will have any attraction this time around? think you'll have any attraction this time around? >> there was a favorable to my article about it in "usa today. was three weeks ago, it brought up -- two or three weeks ago, it was brought up by someone at a presidential press

conference. the press secretary did not know the details, but mentioned it in a favorable way. juan williams writes a favorable article about it on his block. -- blog. a bite my staff member. >> you mentioned the clinton .ibrary >> senator stevens from alaska has some resistance to it. this is not aimed at any particular president. this is a bill that would apply to both republican and democratic presidents. >> he represents the second district of tennessee.

thank you for the update. >> thank you very much. i am a big fan of c-span. it is a privilege to be on. >> our conversation with congressman duncan from earlier this week. he mentioned some support from williams. presidentbout clinton's library in arkansas built with donations from several foreign governments and corporations, including the government of saudi arabia. some of those donations arrived while he was still in office. was prompted by the pardon to propose legislation acquiring in the donation of more than $200 to be a presidential -- to a presidential library to be reported. he is not doing it to a prayer -- embarrass president clinton. hinckley list -- the complete list of donors was -- the complete list of donors was made

voluntarily. use --rge w. bush president start raising money for their library several years before leaving office. the practice has resulted in several scandals. as long as presidential library --ations remained secretive, we are taking a look back at some of the presidential libraries we have covered. 12 in 2007. of all with the george w. bush center in dallas, there are 13. we looked back then at the george h. w. bush library. we take a look at the berlin wall at the museum, which came the during the tenure of

first president bush. >> the library and museum has on display very large section of the berlin wall. you are looking at it now in a live picture. we talk to the former president about his library and his career and asked a question about his response to the wall coming down. berlindidn't you go to and really after? >> it would have been a stupid thing to go -- to do. cannot express emotion of the american people? go dance on the wall. this is going very well with the russians. for me to stick my finger gloating, it would have been a crazy thing to do.

it would have been terrible. we did not know how the russian allegiance was going to react. the had trips -- we did not know whether the military would say, enough is enough. we will show these americans. the cold war ended without a shot being fired and some of that is because we showed restraint. that was not even a close call. in this emotional climate, i could just hear the voices saying this stuff to me. through the media. why don't you go do this? sometimes you have to do what you think is right. it was right not to go put my finger in gorbachev's i. >> you see a big section of the

berlin wall, which is on display. these pictures from inside the library are being taken by our colleague, part of the c-span crew helping to put together tonight's program. >> the situation is on the ground floor of the west wing of the white house. the oval office, but down below the chief of staff's office. --when you were president >> bob gates. secretary of defense. put in the coalition together. >> i am not sure what we were doing, but that is a secure telephone. must be some foreign leader. this your chair?

this looks very much like the situation room. it was very crowded. it will be great for people coming to see it. very much like it. we would have national security council meetings here. i would come down here for certain special briefings during the war. i would come down and ask them what the latest is. you can always call them up on the phone. they had a wonderful group of people management -- manning it. they would have the latest news for the president. >> one of the interesting things, we put a dossier together. seven of the members of the famous gain of eight. -- gang of 8.

>> the thing that was good about it, that there were harmonious. they have big differences. mr. president, you've got to make a decision. i would make the decision and they would in there, go forth and supports the decision. we were very lucky to have the teams that did not go call behind-the-scenes to the washington post to get their side of it out. a lot easier to make decisions when you have confidence in your top national security people. bright, he was the honest broker between strong secretary. secretary of defense and secretary of state, the vice president, the chairman of the joint chiefs. he would make the decision, he

would try to get them to look at the decision, and when it did not work, he would go down to the oval office. you musthe problem, make a decision. these people were disciplined and mature and stayed the course. that is the way it ought to work. >> our 2007 much at the george in college station, texas. the george w. bush opened last week. the presidential library system, admission isnsive in california, at the reagan

presidential library. the ticket to that is $21. -- most popular library 300,000 visitors in little rock to see the clinton presidential center. we're taking a look that some comments on facebook. have you been to a presidential library? what did you learn? what did you want to see? here is what from mary lou. she has been to nine of the presidential libraries. we would like to read some more comments from you while we have time. after our series not long

the presidential library bill clinton opened up in little rock. we will show you some video in just a moment. looking at the way that president clinton crafted his speech. from the carter center in atlanta at, all look at the camp david. >> even his adversaries could see that bill clinton has extraordinary political talents. his skills as a communicator. theld reagan was known as great communicator with a text. bill clinton was a great improviser. this club was in november of 1993 before a group of african- american ministers. deacon stopped what you hear because -- deconstructs what you hear because it is how clinton tried to move beyond the conventional stereotypes. he ticks cultural conservative

themes -- he takes control conservative themes and wraps it and martin luther king. that is a skillful -- take a look for yourself. >> marta mr. king said, like moses, i am on the mountain top and i can see the promised land, but i will not be able to get there with you. but we'll get there. if he were to reappear by my side today, and give us a report card on the last 25 years, what would he say? you did a good job, he would people.ing, electing you have more political power and that is good. you did a good job, he would say, letting people who have the ability to do so live for ever

they want to live, go wherever they want to go in this great country. you did a good job, he would colorlevating people of into the ranks of the united states armed forces to the very top. or into the very top of our government. you did a very good job, he would say. he would say the debate that job creating a black middle-class -- he would say, you did a good job creating a black middle-class. you did a good job. you did a good job in the opening opportunity. but he would say, i did not live and die to see the american family destroyed. [applause]

i did not live and die to see a 13-year-old boy is to get automatic weapons and gun down nine-year-olds. i did not live and die to see young people destroy their own lives with drugs. that is not what i came here to do. [applause] freedom, he would say. to for the freedom of people kill each other come up with reckless abandon. not for the freedom of children to love children and for the fathers of the children to walk away and abandon them as if they do not amount to anything. people to have the right to work, but not to of communities for people to abandon. my fellow americans, he would

say, i fought to stop white people from being so filled with hate that they would wreak violence on black people. their rightsht for for black people to murder other black people with reckless abandon. [applause] archivist at the william j. clinton presidential library. he has something to show us. just are opening up -- you saw the video of that speech. we're opening up the note cards that he used for that speech. this is the first note card that he used. the white house speechwriter did not provide text for this speech. there was not a teleprompter. this was done by note cards. this is a great example of president clinton speaking off the cuff and taking the speech

into a different direction. this next no card, a shabby example of the making some major edits in this. the final note card is from part of the clip we just saw. aboutent clinton spoke martin luther king and he talked about if he were alive today what he would be proud of. this is difficult for us to read. we can make up the word proud. the political process that african-americans have made -- proud of the political process that american -- african americans have made.

>> what do you think they would think if there were still alive today with what has happened since 1979? >> i suspect he would be disappointed. the next chapter in the story is the backsliding that took place as soon as both men left camp david. it is no secret that president carter found him the more difficult to negotiate with. perhaps less chemistry there. the might both be disappointed with what began so promising seems to a ground to a halt. >> the director of the library in atlanta at has been joining us all evening long. you have a carter camp david briefing book of there. cammisa see it? >> this is one of my favorite --

time we see it? >> this is one of my favorites documents. it wascan see, classified and only in the last two years has it been declassified. .y favorite part of it is here and the state department, it says, best from our viewpoint would be both sides ready to signed a document like the joint statement at tabs three, but that seems an unlikely outcome. he writes his own view in the margin. he says, at this will be our firm gold. he was pushing much harder than his advisers to try to get a big agreement. i have another document, and this is president carter's handwriting on the sinai agreement. the reason i think it is important is that we have 100

pages of yellow pad of carter's personal journals and write-ins from the time at camp david. he kept a very detailed notes because he wanted to hold all the parties accountable. the most important page was the framework for the sinai agreement, which shows carter's detailed knowledge of the area. what it was was swapping land for peace. the israelis returned the sinai peninsula to the egyptians. and the egyptians agreed to recognize israel and have trade with israel. from 2007f our series on c-span. with the opening of the george w. bush presidential library presidential center in dallas, texas. we are looking back to that serious. looking ahead to the barack

obama presidential library, at the mentioned earlier and their support of legislation for transparency. ase is a report on what -- president obama faces choosing between hawaii and chicago, a house committee reminded a bill that would make donors to the institution public. the bill would require future presidential library foundation to report donors to the national archives on a quarterly basis. it would post them on online into database. they're trying to prevent donors from asking for favor in exchange for writing a large check. the obama library could cost $500 million. thesee the number of exhibits at libraries that we have shown this evening and a number of deaths that presidents have received.

this is a 20-pack -- the number of deaths that presidents have received. this is a 20-page document. gifts received. this one is from the president of the republic of panama. this is the gift lifsting. in a bluepresented jury box with a value of $705,000. it was presented again by the president of republic of panama. on the far right, the reason they accepted the gift. not acceptance would cause embarrassment to donor and u.s. government. that becomes property of the government and kept in a presidential center, perhaps in the archives.

it is under the control of the national archives, as are all of the 13 presidential libraries. one last look at facebook. we have been asking folks about their visits to presidential libraries. have you been, would you like to go? here is one from christine. i have been to the fdr, truman, kennedy libraries. that is an ohio. i do not believe the makemie library is part of the 13 presidential libraries under the jurisdiction of the national archives. let's get some last video. we will go to the lbj library. a letter from a today -- a tv news angechor.

some film from the first presidential news conference. me are you see behind boxes containing correspondence during the johnson years. many of these boxes contained letters from the general public. what i have here to show you is an example of them. it is a letter from the very young brian williams. on lined notebook paper. it is pretty typical of some of the letters we have from schoolchildren. hope thatresident, i the men in vietnam are doing well. did they do this each day? he included a newspaper clipping. how are you feeling? i hope you are feeling good.

i am 7.5 years old and die like you. i live in new york state. i want to meet you. he decorated with a nice little american flag. >> how old was brian williams when he wrote that? >> he said he was 7.5 years old. >> we have been listening to these tapes, the telephone conversations. >> yes. it is very similar to the one that was used in the white house. we do not know what happened to the machines in the white house. this is the wind we used. this contains the richard russell conversation that we saw earlier.

it is flexible material, a plastic-like. a needle created groups -- grooves. ofheld about 15 minutes sound. if the conversation lasted more than that, it would be picked on the second. after it was recorded, the secretary would prepare a slip to go along with the recording. it would list the conversations on that belt. sometimes it included three or

four conversations. the conversation is the second conversation on this belt. the secretary would file -- they came with a restriction, they were to be restricted for 50 years. our director consulted with mrs. johnson and she agreed that we should process the conversations and make them available to the public. there are about six under 43 hours of conversation. we have processed about -- >> this is from the first ever press conference. >> he was a former "the new york times" reporter. he is regarded as the finest press secretary in the history of the job. eisenhower was not the political innocent that he portrayed himself to be.

he is trying to walk him this to make sure he does not make any slips. eisenhower was very self assured. that is exactly what he did. people debated, how much of it was scrambled syntax. >> if they can find a copy to read, they cannot understand it. they cannot find how the money is to be spent. [indiscernible] is there anything you can do to tell these people where the money is to be spent?

>>-understanding is that is what the committees of congress are for. the national defense officials from the secretary on down will appear before them and they will explain every single item. i forget the number of pages. [indiscernible] >> would you comment -- [indiscernible] >> i do not think i will comment on it. commenting would make it appear that my convictions -- it is

one of the possibilities. both sides might be very reluctant to have that proposal seriously considered. >> the rise of the television age in america. eisenhowert the library, you will see an exhibit about television. >> with the opening of the george w. bush presidential center last week, we have been bringing you a small sample of some of the presidential programs we did back in 2007, our series presidential libraries. you can see all of them, 24 hours of presidential libraries, on our website in the video library. earlier this evening, laura bush showed us around the george bush presidential center.

a number of years ago, nancy reagan did the same thing for us. this is about 40 minutes. >> for somebody who has not been to this library, how do you get here? >> it sets a high on 100 acres. it is not too far from los angeles. we can leave our house and the year in 45 minutes. it is beautiful. everybody should come to see it.

>> one of the things that struck me after being at the ranch was the winding roads, the hills. did you think about that? >> ronnie always liked to be high. shining city on the hill. our house in bellaire is high. the ranch is high. this is high. that always appealed to him. >> when you thought about this library, what was your objective? >> our objective was to have his legacy here. he wanted very much to have everything here so that people could see and read all of his papers and see the history of him and me, but mostly him. it is here for everybody. >> when you see the early what comes to mind?

>> this is where ronnie was born. he was born above the store. a small little room. he and his brother, there were very close in age, two years apart. and his mother and father. >> have you been there? >> yes. >> and over here? the eureka sweater. >> his mother and father, his brother.

that is at school. >> grade school? >> yes. there is ronnie putting his hand up to his chin. het little girl down there, had a crush on that little girl. which girl do you think i had a crush on? he could not remember her name. >> when he was growing up in illinois, you grew up how far from the dictionary of? >> you grew up how far from the dixon area? >> i grew up in chicago. he loved those summers when he life guarded.

he always said that he did not have to worry about money because he could not spend the money. he would go into the early- morning and work until late at night. he never had a chance to spend the money. >> did you know his parents? >> i knew his mother. his father died very young, 58. it was before i knew ronnie. fromything you see here these early years, just holler. we're going over to the hollywood years. >> there has been so much talk about this movie. i thought the movie was funny. i thought it was cute. "bedtime for bonzo." >> what year was it? >> i do not know. >> what was his first year for

acting? what was your first year? >> to ask me years is fatal. my first year was, had to be 49. i had been in theater before in new york. >> what was it that got you interested in movies and acting? >> my mother was an actress. i had gone to college and graduated and had not found the man i wanted to marry. i did not want to sit in chicago and do nothing. i became an actress. >> any picture your favorite? tothis is our first visit

new york after we were married. i was so excited. >> did he change from that day as he got older? >> never. ronnie stayed the same all the time. he never changed. >> how many movies? >> 11. did you act together? >> once. it was fun except there was a scene, he played a man in service and i played a navy nurse. there was a scene where he was

supposed to be telling me goodbye. we had not been married too long. i took it all very seriously. i started to cry. they had to keep reshooting it. >> there is a picture want to ask you about. you've got to president reagan here, jack benny, george burns -- did you know all these folks? >> i did not know al jolson. i knew jack benny, george burns, and ronald reagan. i did not know what this was. >> right over here -- >> this was a favorite picture of mine.

clover cleveland. i love that picture. >> i want to ask you about this picture with president truman. >> he was a big fan of truman. >> are people surprised when they find out? >> yes. >> what did he like about him? >> he thought he was strong and direct. he just liked him. >> were you interested in politics? >> i was not. i knew nothing about politics. >> or your mother and father political? >> not really. >> do you remember the>> he thot time you got interested? >> after i married ronnie. he was always involved in politics. he would always go out and campaigned for whoever. in those days, he would get in a car and drive to wherever the

event was. never occurred to him to ask for gasoline money. >> right behind you, pictures of your husband with a lot of leading ladies. is it hard to watch your spouse in some of these scenes? >> no. yes and no. no. he always talked about the actress who would get leading lady-itis. this is taking out our marriage license. >> how many years ago?

>> 47. it will be 48 in march. >> let's move over to the inauguration years. before we get there, let's go to the governor's time. the years you're in sacramento, what were they? >> eight years. they were wonderful years. they were wonderful and they were difficult because that was during the 1960's and berkeley and there were difficult years. pat brown wanted ronnie to win the primary because he thought he would be easiest to defeat. it turned out to not be so. >> these are the p.o.w.

bracelets. that is lieutenant commander john mccain. >> when they first came back, we had dinners for the first to arrive back. i had some wonderful presence they would give me. some brought me the tin cups they ate from or a package of cigarettes. to hear their stories, you cannot believe what they went through. unbelievable. he thought to yourself, you

wondered if you would be in the same spot, if you could withstand that. i do not know. >> let's go on to the inauguration. 1981, you remember what you felt like standing there? >> an emotional moment for me. it was like we got married. i remember very little. i did not even remember when the man said i pronounced him man and wife. i wish we could run it all over again. can we do it all over again? theo you feel the sense of reins being passed on when you are standing there? >> i do not think it hits you until after the parade and you walked into the white house for

the first time and then it hits you. >> what kind of things would he talk about? at the beginning of all of this. was he excited about it? ofhe was excited, yes, course. the parade and seeing people, the groups that were in the parade. our friends all being there. had're only 39 people who never done that. >> there is a button right over here that has to do with the hostages that day.

>> yes. the hostages were released. he did not announce it until we went in for lunch because he wanted them to get out of the iranian airspace. >> when did you know that was going to happen? >> we did not know until -- it was after the swearing-in. he could not announce it, did not want to announce it until they were out of iranian airspace. >> when people come to the library, is there one or two things they find to be their favorite? >> you would have to ask them. i think they are always curious about the berlin wall. the whole thing is so -- it is all here. everything in his life is here.

it would be hard for me to say which one they would choose. >> right over here is march 30, 1981. where were you when you heard the president was shot? >> i was at a luncheon, at an art gallery luncheon. hassome reason, this never happened to me before, and god willing will not happen to me again, i suddenly had the feeling i had to go. i do not know what it was. i had the feeling i had to get

back to the white house. and i did. i went up to the solarium. theread of my detail -- was a ramp up to the solarium and he came to me and he beckoned to me to come down. he said there has been a shooting. tothat time, i am on my way the elevator. beennt down, he has not hurt. we got downstairs. i am going to the hospital and he said, it is not necessary. he has not been hurt. i said, george, either get the car or i'm going to walk. we got to the hospital. there were police all around a lot of noise and they put

in a small room. there was one desk and one chair. they kept saying, he is all right, but you cannot see him. if he is all right, why can't i see him? finally, they let me see him. he was lying there with a thing on his face to help him breathe.

he said, honey, i forgot to duck. >> did you talk about the danger that you face? >> we never thought about it. you do not think about that. maybe your husband might get sick, but you never think he will be shot. ever. >> you have the actual x-ray. what was the decision? >> the bullet ended up an inch or two from his heart. they could not find it.

they would think they had it and it would slip away from them. by that time, they moved me up to a room of the above. they kept telling me what was happening and the progress. we cannot seem to get it we might have to leave it in there. finally, this wonderful doctor who had been up all night found it and got it out. we almost lost him. >> we were at the ranch yesterday. one of the things that hit me

comment talking to the secret service, any time you are at a little house, there were 54 secret service members. it seems to me you would feel very funny. >> you were not aware of it at all. the house did not seem so little to us. it seemed wonderful to us. we did not want a great big house. we wanted to vacation, ronnie always liked to be outdoors. we made a lot of changes in the house.

we replaced the porch. it was heaven for us. >> it can be very cold in that house and hot. how did you deal with it? >> i love it. i miss it. i cannot go there without ronnie. i do not know why it was taken. when did you first notice the president was having a memory problem?

>> i forget, you forget. don't you? he might not be able to remember somebody's name, but i cannot remember people's names. i did not notice anything. we went for a checkup in august of that year that he was diagnosed. >> this letter was written. is that the actual letter? november 5, 1994. how did you decide to do that? >> we had always gone public. i had cancer, he had operations. thinking it would help people. in each case, it did.

he felt a very strongly about it. people were very embarrassed and self-conscious about alzheimer's. they did not know that it was a disease, like any other disease. there was an embarrassment about it. and there should not have been. now it is amazing how many people come up and say to me their mother or father, someone in their family has alzheimer's. now they feel free to talk about it. he did a great thing. >> what have you learned? >> it is probably the worst

disease you can never have. you lose contact and you are not able to share all those wonderful memories. we had a wonderful life. >> can you have a conversation? >> not now. >> the letter itself, what were the circumstances in which he wrote the letter? >> we were in a library, sitting at the table. he sat down and read it. that was it. first draft. he crossed out one word. i do not know what that was. only ronnie could write a letter

like that. the way he expressed himself. i do not know of anybody else. >> one of the stories that came out of all of this was george shultz. november 7, 1994. >> he had not seen george in a long time. the letter is a very sweet letter. how devastated he was to hear.

it is a very nice letter. >> as you go through this disease and you begin to lose contact, how have you dealt with when people come to visit? >> we do not have visitors. >> when it did happen? >> we never let that happen. >> the other thing we learned about is you have been the care giver. what do you tell people who are watching you as an example? how do you do it from day to day? they say it is tougher on the care giver. >> it is. it is tougher. he would do the same thing for me. i know that. i am not the only person.

many people out there are who are caregivers. it is very difficult to watch somebody you love. >> what kind of shape is the president in now? >> he was referring more to another year. he does not swim anymore. john did come to see him last august, i think. he was going to the baseball game. i think ronnie recognized him, but he does not do the other things john was talking about.

>> the assassination attempt and the cancer. what have you learned about dealing with illness? >> you just do it. you take each day as it comes and you put 1 foot in front of the other, i do not know. >> next stop on our trip is the oval office. >> ok. before we go there, why did you build an oval office? >> the exact size of his office. everything that was in his office -- they have done it. they can get to washington and if they're lucky, they can get on a tour.

this is the exact replica, everything that he had. the history of the western saddles, everything is exactly as it was. the rug that we had in the oval office, everything is the same. >> exact rug. this desk? anything special? >> john kennedy -- >> is this the desk? >> no, this is a copy. >> how many times did you come to oval office? >> only when i was asked.

>> did you sit in the oval office very often talk? >> no, never. that was his -- when he was through in the oval office, he would come home. >> what time of day? >> every day it was a little different. probably around 6:00. >> when he was president, we used to do programs with him and students. he used to do it when he was governor and then one time, he came back and called. did you ever see that? i wonder how often -- it seems

like he was saying, i'm going to call that call-in show. did you watch much information television? >> of course. when we had an evening free, we would sit on trays and a library and watch television. >> did you follow the news? >> yes. >> what does it do to you when you see yourself on television? is it a good idea to watch yourself? >> i thought so. ronnie is curious about something is covered. >> it is better not to get mad. in this office and on the desk is a tiny plaque that we hear a lot about.

>> there is no limit to what a man can do -- >> or where he can go -- >> if he does not mind who gets the credit. that was in sacramento. he firmly believes that. it did not matter to him. ever. >> did you feel the same? looking back on the drug program, did it work? >> i thought so. yes, it did. i'm sorry it did not continue. just say no, the expression, i'm sure a lot of people think that was handed to me by an agency or something.

it happened by accident. i was that a school in oakland talking to sixth graders in one little progress is to hand and said, mrs. reagan, what do i do if somebody offers you drugs? i said, just say no. it became a rallying point. obviously, that was not the whole attitude, but it got the attention. even today, the expression is used. >> one of the things that a library like this does is provide history. how do you think president reagan is doing in history? >> i think he is doing very well.

a lot of people are taking another look at him. they're seeing things they did not see before, perhaps. i think he is doing very well. [inaudible] i am disappointed. i will not get into that. >> would you advise anybody in the future to have somebody come into the middle of a demonstration like that as a biographer? >> i am sure it can be useful. it depends. >> what is there to be written from what you know is available?

>> a lot of books are being written about ronnie. everybody held that until this book came out. a lot in the process of being written. ronnie's book, which is a very good book, is being re-issued. i know two or three other people who are writing about him. >> what do you want your own history to say? >> i would like them to talk about the drug program. i think that was probably my finest hour.

the fact that i tried to make the white house more livable and attractive. >> if you take for granted that you spend a lot of your life protecting your husband from others, you agree that that is something you do a lot of, how hard is that to do? how did you do it? >> i think i had little antennas that went up and told me somebody had their own agenda.

i would tell him. he did not always agree with me, but i would tell him. >> what was the first thing you would notice if somebody had their own agenda? >> you just know. you just know. you have those antennas. >> thank you. >> you are welcome. and, discussion the military use of drones. then former u.s. diplomat nicholas burns on syria's syria -- civil war.

>> tomorrow, the woodrow wilson center host william raven speaking about the future of special operations fortune -- forces. at 2:00, a pentagon briefing with chuck hagel and philip hammond. live coverage here on c-span and sees when.org. >> ronald reagan made mistakes on defense. the defense budget was not just a waste of money in those eight years. it is what created the war machine we have used to create so much havoc in the world and anger andmuch problems throughout the world

that were totally unnecessary and that made us and them to real power. that was a real negative. on the other hand, he did for the first time since eisenhower stand up for limiting the state. big government is not a solution to every problem. it can way down the private economy. therefore the idea of entrepreneurs, the idea of technological change and the idea that people should make their own decisions without some big nanny and washington, he stood for all those things. i agree with those things. that puts the plus and his column. fiscally, he lost it. he really needed to stand up for closing more that deficit. ronald reagan spent a lot of of the greatest proponent

of deficit spending. he left a legacy was permitted his followers to say reagan proved deficits don't matter. oft was a historical error enormous proportion. more with david stockman sunday at 8:00 on c-span's q&a. --a bipartisan policy to center discussion about the military use of drones. the panel included two attorneys who worked the george w. bush administration and the cochair of the 9/11 commission, thomas payne. this is just over an hour. >> to call this an all-star panel is an understatement. our panelists are a constellation of national security experts who have reflected deeply on the issues at hand today. among them, i feel like a guy

who splashes paint on house is about to talk about subtle aspects of portraiture painting s.th a group or rembrandt next to me is john bellinger, a partner at a law firm and former to the national security council. he speaks and writes regularly on public international law issues. he testified before the house committee on drones in the war on terror. happy to have you here. to his left is the director of the aclu's national security project, dedicated to ensuring the national you're sicecurity practice are consistent with human rights peerage is litigating cases and work

include the focus on the intersection of national security and terrorism. she is a lecturer in law at columbia law school. is the associate dean of the university of virginia's graduate school of arts and sciences, former secretary of state u.s. department date. the executive director of the 9/11 commission. he served on national commission and task forces and is written books to read he is a member of the president's intelligence advisory board where the word drone has been mentioned once or twice. welcome. , and national security correspondent for the new york times and cowinner of the pulitzer prize for reporting on the intensifying violence in pakistan and that anna stand in washington -- and afghanistan's and washington's response.

here is the book. i recently read it and i commend it to you all. the subject at hand. john, you have been in the arena on so many of these issues. if you could begin by fighting -- framing some of them for us. >> sure, thanks. and thank you to the center for putting this together. when i testified before the house judiciary committee a couple weeks ago, i started and ended my testimony with a plea for more bipartisanship. one of the saddest byproducts of 9/11 has been the national security issues that have become so divisive when we should be pulling together. jones is yet another one of those.

i was present at the creation of the legal basis for the use of drones. we were thinking about using it against al qaeda leaders. i was responsible for developing the legal framework. i do think as a general matter, it is permissible under both domestic law, under the authorization to use military force act, for the united states to use drones to kill al qaeda leaders were planning attacks against us. the main legality of the program are correct. the devil is in the details. the problem is we do not know a lot of the details. the obama administration when never have guessed that four years later, they would be accused of war crimes, have the aclu suing them, having the human rights counsel conducting

investigations on whether the obama administration is of violating national law. a british law has sued the british government for sharing intelligence with the obama administration, resulting in the death of a man in pakistan. four years later, the administration is finding some of the same charges that were leveled against the bush administration. a couple of years ago, at the time, i was being provocative and i was trying to nudge this administration to do a better job of explaining the legal basis of what they were doing, the policy basis and to be more transparent. i did not really think that drone strikes could become obama's guantanamo.

i do now think that is seriously at risk. this has become a real problem for them. the problem is, and this is my point, no other country in the world has publicly agreed with the legality of our program. right now, the united states is isolated as the obama administration has launched more than 300 drone strikes killing more than 3000 people. the rest of the world this finding this controversial. the challenge for the

administration is to try to convince the rest of the world that what they're doing is lawful. they are rapidly on the back foot, the administration, i know they are working at this inside the white house to do a better job of explaining the legality of the program, who they are targeting, white it is lawful, and why the rest of the world should agree with what they're doing. in the a moment, i would be happy to get into the legal details. >> thank you. thank you very much to the bipartisan policy center for

having this event and for inviting me. let me start out in the spirit of the center, agreeing with a lot john has said. the targeted killing program -- right now, the public debate with respect to those questions is crippled because we do not have a lot of the information that we need in order to determine the full extent of where the program is being carried out, with what investigation and with what measures to prevent harm to civilians. let me also start out with another point of agreement. the idea that people are against drones, and some people may very well be. as a legal matter, i do not

think they are unlawful. as a policy matter, they raised important questions because they are easier to use without risk to forces, and able to be used in places where we are not otherwise at war as has been explained to the american public. there becomes a legal issue when you talk about who is using the drones. it has been widely reported that the cia is using drones. the idea that the program is secret is one of the worst kept secrets in the world. it takes us to the question of how are we using this weapon, or any other weapon, to carry out the program of targeted killing.

that is the heart of this debate. what we know is troubling. there is general agreement amongst international law scholars that the use of lethal force is permissible under international law, human rights law, in response to a specific concrete and imminent threat. it would be permissible against civilians who are directly participating in hostilities those terms defined under the laws of war. i do appreciate and respect the speeches have been made, as well as the paper that was leaked, those are not the standards that are being applied.

this is the white paper that was a summary of all legal memo used to justify the killing of a u.s. citizen who is now qaeda leader, or alleged to be one. the restrictions the paper recognized on what constitutes an imminent threat, when you read it, you realize that what appears to be limitations are, in fact, permissions. it turns out that senior high level official making the determination about lethal force may be used -- actual evidence that a plot is going to take place. all of a sudden, it is expansive, and something similar

happens with respect to the requirement and capture. where we are now is recognizing that the requirements raise significant concerns about whether the legal requirements are being abided by. if we have that concern with u.s. citizens, we should have that concerns with non-citizens. one u.s. citizen has reportedly been publicly targeted, three others have been otherwise killed. there are reports that approximately 4700 non-citizens have been killed. there are fewer things that are more likely to undermine the legitimacy of our country as

well as our national security than even the perception that we are not abiding by the rule of law with respect to non-citizens as well as our own citizens and that we are indifferent to civilian casualty. what do i think needs to happen? at a minimum, disclosure on the legal standards with respect to who can be targeted. what is the process by which those decisions are made? who is the senior high level official who would use the decisions of high-level officials? who are the militants or the civilians who have been killed? those numbers should be disclosed. to the extent the identity is known, that should be disclosed as well. with the kind of debate that we

expect of ourselves as any liberal democratic society, one based on checks and balances, without that fundamental transparency which is necessary to accountability. >> thank you. >> i have to first explain that because i am a member of the president's intelligence advisory board, i am constrained about what i can say about this program publicly. i am not here as a representative of the administration. nothing i say should be construed as representing anyone in the obama administration. let me try to navigate a path. i want to take a moment and explain to you an argument about how to conduct warfare in this strange way.

the united states has been involved in a global arms conflict with al qaeda and its affiliate organizations for approximately 15 years. al qaeda knew it was engaged in the global armed conflict before the united states agreed it was it. al qaeda was able to forcefully impressed on the united states government that it was in such a conflict, beginning august of 1998. every our 15 years later and we are talking about whether that constant can be conducted with remotely piloted vehicles in many countries around the world. let me offer you two different paradigms for how to think about it.

i will try to make this very clear. you need to do three rings three things first. what's the doorway that allows me to kill these people? passing through the doorway, i have to define which people i can legally kill as the government. third, having defined that, i must set some sort of standards of evidence and circumstances under which people can be targeted. there are two contrasting approaches for answering these questions. one approach calls an armed conflict approach which i support. the second is a constitutional

self-defense approach which worries me. for the doorway, if you're in an ised conflict, the doorway and must be a public doorway. the country knows and discusses that it is entered into this armed conflict. the congress debates it. authorizing the government to wage war against its enemies around the world. this is a healthy attribute of a democracy. under the constitutional approach, the doorway is some entity or person who poses an imminent threat to the united

states that allows us to defend ourselves. that doorway need not be public. that determination can be concluded in secret whether or not the government has d it is in conflict with some larger entity. you can see the significance of these paradigms. if you parse the administration 's public statements on these issues, you will see references to both these paradigms. what you're hearing from me as a strong argument about the significance of one and the dangers of the other. the second circumstances i mentioned. what about the definition of the

people whom you can kill. badlysh administration mangled the definition. and it quite a lot to discredit it. the definition of the term enemy combatant to anyone who had been given some material support to a terrorist organization, equating it with .ou as the rest of law that's very pernicious. the enemy combatant standard is very important. combatant is someone our military can lawfully kill or capture without a lot of advanced notice. that is the determination that should be approached with care.

, an enemyefined isbatant is someone who directly participating in hostilities. dph is sometimes called the standard. the obama administration has dphicly endorsed the standard to defining enemy combatants. but ability that was tethered when the obama administration entered office. in the constitutional paradigm, the definition of who can be does not judge whether that person is a member of the larger entity with whom you are engaged in the armed conflict. instead it simply parses

information about that individual. at the same time it begins assuming an extraordinary high standard of intelligence and evidence about particular individuals that is really a .enable -- rarely a tenable at the third level, we have a great deal of experience and a lot of people who are well trained on the application of the dph standard. if otherow a standard people understand and know how to fight. -- we have hado a lot of trial and error with this. and howsome seasoning

to make judgments about this. in the constitutional standard, because it will turn them on evidence and circumstances so related to this individual determination. assuming that the government involved is one of good will and does not want to abuse its privileges. the irony is i look back for the years around 9/11. there was a level where we were a little spoiled about the intelligence we might have about certain people in ariely at the watching closely now for a long time. know better than people living in fairfax county know the street map of arlington. i'm serious. so don't assume that evidentiary standard is going to

in other situations. that may look more like the pre-9/11 story. if you read the commission report, you will see all kinds .f uncertainties judgment had to be made. repeated questions came up during should we shoot? so now step back. that isring a paradigm very public about how you get in. apply well understood standards about how you work but then take into account the inherent uncertainties of warfare and making judgments about what you -- you can make these

constitutional determinations. and go in a way that might be less visible to the public and yet to debate simultaneously partly because of that, imposed standards of evidence on you that make it harder to deal with the sorts of enemies we may encounter in the what we have more assets on the same. . so let me start their -- let me stop there. >> you thought deeply about these issues investigated them. give us the benefit of your thinking.

>> thank you. it's terrific to be here. i come at this subjecter of th differently than everyone appear. i am the only person who is not a lawyer. even the former cia guy is a lawyer. nationalorter and security reporter but fundamentally we try to get what'suestions about happening now and what is happened in the past. what they do in the book is try describe the history of this

secret war that has been waged. it really has been a war and the .olice has been the secret what is happening and what is happened in pakistan? places like somalia. those stories need to be told that is what i've been trying to do. i agree with -- i do agree that the idea of drones as a weapon. this idea of killer robots carrying outt his wart.

-- carrying out this war. the deeper question is how .hey're used i have written about how this way of war has become a default way the united states does its business. over time if we were looking at targeted killing, the bush administration went from primarily a capture strategy and interrogation strategy to detention and interrogation .rogram the obama administration came in

in 2009 and expanded it in many ways. as a reporter, it is been very -- the most important story is to understand how the obama administration sees this way of war. and what it has meant for american policy in the prussian of willdan group repercussions -- john said he thought using drones to kill al qaeda leaders is lawful and he supported it. shat we see these days id drones being used in targets far from senior al qaeda leaders.

the real questions we have to ask her things like what if the bar for targeted tilling? who is being targeted? , are theyaffiliates enemies of the state of pakistan or yemen. these are questions that i think are being answered but obviously when you just go no more about it. if we don't expect to see another afghanistan soon but to see a lot more yemens, pakistans and somalias, then i think there needs to be greater .ransparency on these issues

i still find it striking that as a reporter, when recently i was covering the john brennan confirmation hearings and he tiod speak -- i was struck members. many do not have the legal the targetednning killing program. , it is striking to me that members of the intelligence committee formed after the church committee investigations of the 1970's to provide oversight, don't have

these memos. not having those memos does significantly limit their ability to conduct oversight. that's the position they are in, it is tougher for citizens not government to really make more discussion in the future. >> i invite you to react to respond to the two paradigms he laid out. and the reaction to that and how it could advance his analysis? rocks -- >> i was going to take a slightly different angle. we talked a lot about films. palm palm is not the use of drones. -- the problem is not the use of drones.

inwe are in a real war germany or japan in world war ii and we have developed a weapon in which one could only sing -- kill a single person, everybody would say that is wonderful, that is legal, that is good. targeted killings when lawful and legitimate, can be good. there is a fundamental asagreement around the world to whether the united states really is in a war at all. we are about the only country in the world that really thinks we are in an armed conflict without fighting. i spent four years as legal advisor in the bush administration engaged in a dialogue. -- one of the 9/11

recommendations was to work with their allies to develop common withards for detentions not going on around the world is a different debate. administration has decided they don't want to do detention anymore. so they're not going to kill people. the issue is not the targeted killings. the issue around the world -- is an armedd states in conflict. can you be in an armed conflict -- the administrations have been .nable to persuade our allies

to use force against about cut against the world -- around the world. it is not the law of war versus he was constitutional law. they apply a paradigm of human rights law. to the extent that the united ,tates may use force lawfully meaning one can only target someone who poses an imminent threat under human rights law paradigm. other countries and international lawyers would say yes. bebin laden can be shown to

sitting in pakistan about to then yes theack, united states mac in self- defense. the rest of world perspectives which is that the united states is not in the war and they were very surprised to find the obama administration adopt this armed conflict paradigm that european countries thought would be dropped like a hot potato as soon as the obama administration came into office. continue the war paradigm and ramp up the use of drones. i agree with philip from a u.s. versus international perspective, there are two paradigms. a law of war paradigm versus not the constitutional paradigm.

>> one way to think about it is the constitutional standards and human rights standards are very similar. both the u.s. constitution allows, there's no question to invoke those rights in court. from our perspective, we have to be concerned about the precedent we're setting for for the rest the world to follow. not just with respect to the use of drones with the legal to which we can conduct targeted tilling. in a little sense when you're talking about what i think you or have read -- going back , thereprecedent-setting

is no question that multiple other countries will have access to drones and other technology. whatever standard we are claiming to use today, we have to accept other countries are going to fight back to us tomorrow. the idean't accept -- that we are engaged in the global war on terror would allow the executive branch to declare people unilaterally enemies of the state and order their killing without judicial review before or after the fact is one andust debate at least consider whether that's the kind of world in which we want to live.

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>> or if you are not eligible for either, then it will offer you what plans are available in your area. >> and this is the incentive, the discussion from the form. >> i heard a lot about the form. but we want paper, more people to use the online application. ws how many pages anything is online? >> you do not have to complete them if they do not apply to. >> this is exciting and very technical. work in administering it the

start of this program. are you in much conversation with people who have overseen the creation of similar, gigantic health systems in the past? >> we are very fortunate in that regard. i was not around for a part d, there is a lot of senior manager inside cms that worked in medicare advantage and part d, where we have experienced individuals to work with private plans. so that is very helpful. second major area of focus has been in the cost curve. do you want to talk about that? >> for those of you that all the cost of health care in the united states, what we are seeing are very high expenditures. and our quality is not where we want it to be. we are the most expensive health care system in the world.

and yet quality, longevity and all the different parameters that you want to follow. some areas we may be in the top 10. in many areas such as infant mortality we could be as low as 30 or 32 in the world. so what we are trying to do when we look at this is how we go for -- if we know our current path is not sustainable and our current system is not where we want to be -- what we want the future system to look like? i think we hear from a lot of individuals and the secretary mentioned this in a speech he gave this morning. we have been talking to people over the last several days and depending on who you talk to, some folks say, pick a date. tell us what the system is going to look like so we can plan for our future. if we are a business or industry. others say, please do not change it. this is a model we have developed. so what we are doing, and we are logicalo do it in a

step fashion, so when you see linking payments to quality, that is the first step in the direction we want to go. so instead of paying for per peredure or per surgery or therapy visit, we are saying, what type of outcomes are you getting and how can we tie payment to that? that is why we want to work with the wicomico care organizations. we have done the work to bundle payments. we're looking at multi payer delivery systems. to continue to play for it -- pay for volume, whether there is quality or not, it is not where we want to be long term. so that is what you will see us moving towards. the second area that i think you will see us trying to move is how we look at paying for a group of services. and that is some of the work the acl and others.

while we may not have the perfect model predicted, one thing i have tried to tell people is you know we are moving from a fee-for-service model to more of a payment for quality and more of a bundle payment. so if you are an industry, that is how you should start to look for. and we welcome the ideas from the public. when we did the innovation awards last year we got a lot of good feedback and knowledge. we are going to continue to look at things like that in 2013 and 2014. and you will see some of our early evaluations. there is a lot going on there. >> and how would that change how the consumers are paying for health care? does that mean that you no longer pay for just the test? >> that is part of the discussion that is ongoing. that is a great question. if i am a consumer, why do i care how you are paying my provider? i care what i am getting and the

quality of care. and i care what i owe in terms of my personal responsibility. i think one of the biggest points is how important coordinated care is in this process. and that is part of what you get when you tie payment to quality and tie payment to procedures. you start to manage the care for individuals. and while not all of our -- work but a hugemedicare, amount is done there. i have a mother who is 88. and she does benefit from coordinated care. right now i tend to be her model, because i can be but not everyone has that. so we are trying to get at how we coordinate care and make sure that outcomes are good? and that is what the beneficiary starts to care about. i do not have to go five places to understand what my next week

is going to look like in terms of the status of my health care. i am going to be at the highest quality i can beat, preferably a single person handling that. and i will understand what my out-of-pocket expenses are. and i think that is a model we all would want, whether personally or for family members as well. see as the downstream effects on private health care? >> what we have seen thus far in the last three years is that we have depended and partnered on the private industry to help us. i think we have seen tremendous growth in the medicare advantage plans. and the coordinated model. we're seeing it in medicaid and managed care. so i think that will be active. obviously, as this comes online and we see major changes

in the broader health care market, people who are in the private and service market and expect to be staying there for what -- private insurance market wonder how it will impact us. there are reports about premiums expected to rise in the private insurance market. "the wall street journal" was writing about that this week. >> when i try to explain what is going to happen with premiums, i think there has been so much information out there that people get confused about premiums. i think what we will see, if you look at midsize and large employers and employer provided health care, we will not seek a big change. in fact, i would argue in the last three years we have seen a premium. everyone still hates an increase in premiums regardless of. but you have seen your meter reitz -- premiums come down. we have seen the cost of health care come down. that is the bulk of the private

industry. the area we are trying to address through the marketplace or through some of the changes we have made a round health- insurance are really individual and small markets. so it is a very small number. and we will see stabilization there, because what has happened before there has been on predictability and pre-existing conditions where people were excluded. there have been policies that did not include all of the essential health benefits. so we have not have insurance and you are getting insurance now, you will see a cost increase because you have not had that before, but there are lots of ways that i think that this will moderate and slow the increase in premiums once more people are covered and you get out of these high-cost, unexpected fluctuations. but it will take a little while for the premiums and costs to get in line. >> -- political tolerance for that kind of fluctuation? >> i could not answer to pull

literal and into a political i could not answer to political tolerance. >> um... in the um... sorry. asthe private sector then, we go for itward, there are -- concerns people have about changes to their insurance, also. i just wonder to what extent that's going to be part of the conversation? there is a huge conversation of reaching out to people and

informing them about the new programs that will be coming on line, the exchange, the conversation that is directed towards people who are not presently it insured. do you for see any kind of similar conversation directed towards people who are insured? who are not part of needing a new program? >> i think that is a great conversation. i think we need to do a lot more of that. and i think you are asking is a very fair request. we have tended to focus, we obviously focus on medicare beneficiaries, because by law that is a responsibility we have. under the affordable care at, we have done more work around prevention and coordinated care and work around part d, and medicare advantage. there has been a lot of activity around medicare and medicaid beneficiaries and we are sending out reports and updates about how many people have got a part d coverage, how their out-of-pocket expenses

have gone down, how preventive services are up. we have done a pretty good job of educating the public on what medicare beneficiaries have and what they are receiving under the affordable care act. when it comes to those who have not have insurance, we have made a big effort to say, you will now have insurance. you now have an opportunity, if you are in the medicaid expansion state, if you are in poverty of the federal income levels, he will have access. you'll get a subsidy to help. insurance is important. we have not said a lot about the 60% or 50%, depending on which statistic that is out there saying, i have insurance now. what's in it for me? and so part of what you'll see us do over the summer to start to talk to mid and large employers about how some of the actions we are taking in our

world will be impacting your world as well. i would say that i have a very good working relationship with insurers. and i spent a lot of time with the blues or the private plans talking about how we partner? how do we have the same quality indicators? how do we have the same type of cost? how did we look at procedures, whether it is coordinated care or bundling? we are talking a lot with insurance and medicaid directors inside states and advocates for medicaid. i think the peace we have to focus on over the summer is business. what is in it for those who already have health insurance? what is in it for the medium and large employer? and you will start to see us do some work there. i would encourage you to reach out to us. and there is a lot of information we can provide in that area. >> i think we will open the

conversation up to questions, if anyone would like to ask a question. yes, a woman right there? if you could let us know who you are. a i'm dr. caroline poplar, primary-care physician. it is easy to talk about outcomes when you talk about blood pressure. hemoglobin. more complicated situations, like rheumatoid arthritis or multiple sclerosis or cancer? do they tend to trend down over time? different people trended down slower or faster. medications we think are effective, we have clinical studies that say that you get a 20% improvement in rheumatoid ofhritis, there is a scale 20 different indicators. and not everyone is going to do well. most people are not going to do

well. how are you going to measure outcomes in a situation like that? or psychiatrist? the person may be a little less depressed. how are you going to tell? >> that is a great question. i think obviously the examples you gave, control of blood pressure. those are little easier to measure and i think we know that if the blood pressure is controlled then chances are better the individual is doing better. when it comes to chronic disease, that is one of our biggest challenges. part of the work we have done and some of our pilots have been trying to get at that. if you look at some of the independents at home models, some of the medical help haul models. we are looking at how we get care to those individuals and have someone coordinate their care? because it is complicated. as you know, they are synch 45 physicians. who is going to be the person in charge and can help -- they are

seeing four or five physicians. -- or episode that leads them to a different situation. i think we have more work to do and we are going to have to work with you and other experts. we are testing some of it in innovation, but we are just now getting to the peace of complicated, complex care which is a big part of the cost of our health care system. and it is also part of what interferes with quality of life. i think we will have to work with you more in that area. and i think that a lot can be done, but it is complicated. the measure will have to be here are for your improvements, perhaps. not the take someone from a for b because there may not be a cure or a level of improvement that is the same for blood pressure control. thank you. it is a great question. >> in the gray jacket. >> hi.

i work at the association of maternal and child health programs, public health. you mentioned prevention. that onlyerstand here a small percentage of the outcomes are based in a clinical setting. withoes cms for c working public health and the future, especially in these tight budget times which people think it can sometimes confuse the affordable care act of public health and how they are intertwined? thank you. >> i think what we talked about the innovation center and some of the work going on, the innovation center will give us an opportunity. i am really proud of the project that we did recently that was just sent out where we awarded grants to, this was obviously in maternal and child and it was the strong start program. our work with infants, prematurity. so i think those are ways.

that is where we teamed up with not tolth departments, duplicate the work that was done but hopefully to complement. so i think we will see more community-based work like that, where it will give us a chance to partner with public health. so i look forward to doing that. i think it is a great area where we can make a difference. >> yes. lots of questions. that side of the room. >> i am with the american speech and language hearing association. what recommendations do you have for providers and health care or reno, specifically their peak for the exchanges and for medicaid expansion, trying to work with the essential health benefits, specifically the category of rehabilitative devices, since the definitions are not quite set? what recommendations would you have for us to help you or the

exchanges or those states where they are federally debilitated exchange? >> in the case of medicaid expansion, i would first of all suggest that you reach out to me tand to our team, because i think there is information we can give you that would be helpful in that area, because out medicaidheads o heads program. they are working with plans on these definitions. otherwise, i would also recommend that based on your area that you go directly to the come online and how you fit in. i think there is a lot of interest in these plans and understanding how to make that work. for some of us, it is new benefits.

a lot of it is education and being out there. and we will certainly help you with that any way we can. >> if it could go to the table and the center. providerental-health and a medicare recipient, my question to you -- i think this is most important -- is the reimbursement rates for medicare patients and medicaid patients. and how many docs are dropping or, whether they be doctors psychiatrists or social workers. what do you foresee in the future with regards to the reimbursement to doctors and/or other primary health care alsoessionals in medicaid, in medicare? because of medicare and medicare advantage are two different plans and the reimbursement rates are different for those two groups. so i have concerned with the affordable care act and by the time it gets itself string doubt

i will be dead. -- straightened out, i will de dead. out like are dropping flies from medicare and i suspect you'll find many docs that will not participate in medicaid. where are you looking in five years for the affordable care act? thank you. >> great question. let me start by, i think although there are many -- let me start with medicare first and then i will talk about medicaid. in medicare, while there are certainly concerned about reimbursement, i feel like i need to say one thing -- about 97% of all physicians, when we monitor physicians' to participate in medicare, it is very high. while there may be some folks who drop out, it is a very low dropout percentage. so we still have a robust

participation in medicare. i feel like i have to say that. that does not mean that we cannot make improvements. in fact, over the last two or three years, we have tried to make more torts -- we are working within the budget constraint. but we have tried to move more payments towards primary care and i consider primary-care a little broader than some. but we have tried to do that more towards coordination of care, primary care, and obviously some of that has come at the expense of specialist, which my colleagues reminds me does not make them happy. but we feel like a primary care and core mission of care is a place we want to move and that is very important. and we want to balance that more. in the case of medicaid, obviously, that is a state-by- state decision. but one of the things that we did do as part of the affordable care act is to up the

reimbursement to primary care, at least for a time. and that is going into states and the first quarter of this year. some states are giving it out but it took effect in january, 2013. the issue of physician payment is something that we are grappling with. we feel like there has to be a long-term solution. i hear you on the payment concerns. but the payment concerns are there with her without the affordable care act. so we should be careful what you -- >> do you foresee an expansion to accept medicaid patients over time? >> so we certainly are doing everything we can to encouraging e that. we are doing that from a reimbursement model to primary care. medicaid tends to be more primary care oriented and sometimes pediatrics and obstetrics. the second way we are doing it

as we are working through funding made available and affordable care at to expand the work force. physicians, nurse practitioners and others. we feel like we have to have a bigger supply of work force as well. >> interesting. right there. i am with the march of dimes. if we could turn to out -- and enrollment. the march of dimes is interested in child health and we see a tremendous opportunity to extend care and improve pre conception care for women of child-bearing age under medicare expansion. 1/3 of the population that will be eligible will be women of childbearing age. can you talk about how you are planning to reach out to different populations, demographics to bring those newly eligible people into programs? >> yes. over the summer months, and let

me define them differently -- i will get of little technical but i think it will help. i talked about the fact that we had 16 state based exchanges and some partnerships. in those states that are pursuing a state based exchange, or partnership, they have dedicated funding to work inside the states. because we believe that the old saying of all health care is local -- that is true about all recruitment into health care programs. that will be hard for us to do for washington, d.c. let's take california, for example. they initiated some of their contracts. exchanges that are federal based, then we will be working inside those communities with advocates such as yourself and others. nding hrough fu

and programs and more traditional routes that we have done with medicaid and chip expansion and other avenues of working with some of the hard to reach communities. maybe churches or schools. i think it will be all of the above. we have a federal working group that expands way beyond hhs, because there are many federal agencies that touch of the population in our country. and so we are recruiting them to help as well. inside each community and state, we will be working with state and local leaders to help develop plans specifics -- to them. one thing that is not said to everyone is that cms has 10 regions across the united states. the first thing we are going to do is put them to work inside the 10 regions. and then we go inside states and communities. we have regions all over the country and we have over 1000 staff that work in those

regions. they will have state designated contacts for you. so you will see all of this. part of our research has shown that if we start to talk to individuals about buying or applying for insurance in march sustain thee can a interest. they want to sign up then. so part of this is an intentional wait until the summer because they cannot sign up until october 1. >> thank you so much for your time. very interesting insights into this huge project. >> they give very much. -- thank you very much. . [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> our next conversation is

and will health i.t., be a one-on-one conversation between dr. farzad mostashari, the national coordinator for health information technologies at the department of health and human services and rebecca rosen. during his tenure, dr. farzad mostashari developed a series of programs to develop electronic held the record adoption and developed a health i.t. exchange. previous to that, he served at the new york city department of health and mental hygiene as the assistant commissioner for the primary care information project. where he facilitated the adoption of prevention oriented health technology with more than 1500 providers. please join me in welcoming dr. farzad mostasharian and rebecca. >> thank you so much. thank you for the entire

"atlantic live team." there is no better place to spend a beautiful spring day that ronald reagan building. let me start by getting a leg of the land when the obama administration came to power 4.5 years ago. what did things look like with healthcare technology at the time? >> sure. well, let me make it personal. when the week that i was supposed to join the administration in july, 2009, i actually had to call david bloom and fall off. i was going to join and say i'm sorry i am going to be late because my mom is in the hospital. tooher experience was all typical in 2009. and it is becoming, i hope, a little less typical. here are some of the ways in

which her experience was typical. for herhe shows up elective knee replacement. she was on no medication. he was healthy except for taking an aspirin a day. when she showed up for the surgery, they said to her, the team is there. the anesthesiologist is going to the list. did you stop the aspirin seven days ago? no.nd she said, and they had a huddle. do we go ahead? we'll be fine. right? so they did not have a system. systems are what make ordinary people do extraordinary things. they did not have a system for making sure that people seven days before get a call or text or something to say, make sure

you stop your aspirin. so then she has, of course, that's the other complications and cardiac -and- and vascula complications. i remember at 2:00 a.m. and the hospital, and she -- her heart's going through runs of ventricular tachycardia. i knew that no blood was being pumped when it was doing that. i said, cna i see the ch-- can i see the chart? when you're in the hospital and you want to see what is happening with the patient, you need to see the chart because that is the only place care get s coordinated. where is that chart? for patients and their families to peruse? no. it is behind the nurse's desk.

and the message that is being sent is back off. this is our chart, not your chart. why do want to see the chart? so i screw up my courage at 2:00 a.m. i am concerned that my mom is going to have a really bad problem. can i please see the chart? and i cannot read the name of the cardiologists and neither can the nurse. of hospitals10% have electronic health records in 2009. probably less than 2% gave patients access. since, andhappened we are at a halfway through the technology part of it, we are just scratching the surface on changing culture and all of that. but just on some measures of this, we are not from less than

10% of hospitals up to 47% in 2012. on the wqay up. records.tronic health that they do not just have, they used to make sure that medications are entered electronically. where patients have access to their own records. where they can actually measure whether they have done the standard of care quality while the patients are in the hospital instead of waiting until they have been discharged and doing some reviews to seek, did we do the right thing? so there is a lot that has changed. but it is not just about the technology. it is how the technology is actually used in conjunction with all of the other stuff that we were just talking about. >> so when you see that jump from 10% to just under half now,

that is a remarkable job. so did that roll out quickly, and what were the challenges that hospitals face? and i am wondering if you can characterize which hospitals are on the leading edge of that change, which have been slower to take to that transition? what are the reasons behind that? of our problems in health care, there was a market failure. feedback]e we learned about how healthcare is not a market. here, the hospitals were expected to bear the costs up front of adopting these technologies. but a lot of the benefits, in a fee-for-service environment where you get paid for how many procedures you do and how quickly, there is not that much of a financial benefit to

hospitals. there may be public health benefits and benefit to the patients with fewer complications, but that is income. there was a market failure. one of the things the affordable care act came after the recovery act the year before. what the recovery act did is it said if hospitals adopted these technologies and uses them in meaningful ways, like riding medication orders and a way that they can be checked against allergies and drug interactions, then the hospital can earn $2 million-plus. removingrst part was the financial barrier that is preventing people from moving ahead. >> it was profitable for them to be more inefficient. >> i do not want to be that cynical. but there are disincentives to do the right thing. been, andbarrier has this is may be turned on the

volume a bit. thank you. the other barrier had been theknow how, particularly for the smaller hospitals, critical excess hospitals that i was meeting with some today where they said, our average bed census is four. our i.t. person is also in charge of maintenance. in those hospitals, where they have low rates of adoption of this, we said, you need to give people a helping hand. so we established the health i.t. extensions. you heard about the agricultural extension programs that sparked the transformation in the agriculture sector? we said, we will need to have a health i.t. expansion program. we have 62 regional expansion programs that go in to critical excess hospitals, health clinics and community health centers and small doctors' offices, the

stuff i did in new york city, and doing it all over the country, and they helped 140,000 primary care providers in this country move to electronic health records. incrediblejust an statistic. >> hard work. of theooks like so much barrier is the implementation. it has been a lot of hard work. where do see this going? what are some of the pay of some of these electronic health records? where are the benefits coming from? >> so we think about a road map, this is a long journey, folks. it is not like you buy any technology and you get instant outcomes. the first step is to have to put the system in and a thoughtful way and began to collect data and share data. then you got to make sure that

you modify and a redesign your workflow to take that as of the technology. in interesting analogy is towards switching from wind mills to electricity. how many years do think it took before electricity, before factories gained productivity from that? 20 years. it took 20 years after we -- >> to make back the capital being invested? >> to increase the productivity of every individual. because what they're doing, they were turning some big shaft somewhere that used to be turned by water. they had the same police and systems, and it took that long for them to figure out how to redesign the factory so that the power goes to a small motor on the desktop. it is not going to take us 20 years, but we have to fundamentally shift. so that example i gave in the

beginning of my mom not getting the reminder. doctors' offices, your mechanic does and your dentist does and your vet does, but doctors' offices until recently had not been in the business of giving you reminders. they will wait until you walk on the door. door, never walk in the they would probably never reach out to you. think about someone that kills people every day. a huge portion of that is preventable by -- things we know how to do, put someone on aspirin. 32% of the time we do that. control blood pressure. half the time we did that. control of bits. it is a coin toss with you do that or not. because we do not have systems. to get systems means not just wait until the door opens and someone says, can i help you? the way we sell shoes. can i help you? it is fundamentally saying, we

are going to do something different. if you do not walk in the door, we reach out to you. how many doctors' offices and hospitals have the ability to make a list of patients who did not show up? who had high blood pressure and the blood pressure was not controlled and reach out to them and say, i am worried about you. i need you to come in. that is a fundamental transformation we need. >> how is that transformation related to the kind of health monitoring and other daily blood pressure and other things they will be able to monitor with smart phones and other technologies -- where did those two systems connect? >> we heard from an amazing woman, the administrator,cms which pays out $1 trillion and health care, and she said that we are going to have to shift payments so that we think about the total cost and total value that's delivered.

when you want to get more help for lower-cost, more health, lower cost? does it work that way? less money is less whatever. so how'd you get more and better outcomes with less money? you have to tap into resources you have not tapped into before. and the biggest resources we have not tapped into is the patient and the people will love them. so i would -- i wanted to help my mom. but the system was saying, stay out, stay back. a good patient is a quiet patient. that is changing. and i think there is a much greater realization because, honestly, i think because of deep trends in society but also because of the payment system that now there is a huge interest in doctors and health care providers to help people with behavior change. keepellp people

themselves healthy, be more empowered with in their healthcare. and that is where i see this stuff being amazing. this is amazing. yes, it is just technology. but the idea that we have -- i will give you an example. i was at my doctors and they said, take your medication, cholesterol control. i love burgers. take it every night. and i said, can i take it in the morning because sometimes i fall asleep on the couch and i forget. and the pharmacist said, please take at night. and i said, what's the half life? i'm annoying like that. standing therem

and he has got the screen -- between you and the patient. the screen is turned away from me. seconds, maybe five seconds into it, i rrealealize and he realizes that i could google it. right? pharmacists system that they paid millions of dollars for is not as quick, convenient or accurate as would anyone of us could find out in the second. this is going to be a big enablers, along with how we pay for care and this cultural shift in helping us manage our health, healthcare finances, our health care relationships in a much better way. >> it seems similar to way --

the way your mom's patient records were behind the nurse's desk, that there is a different relationship to a patient and their help information. it empowers people as well to play a more active role. >> it is the responsibility, too. this is the part that i think is the tough one, the conundrum. we have more opportunities and more obligations. in some cases it will not be my mom, it will be me. she is hundreds of miles away. i tried to talk to her most days. and a lot of our conversations are about her doctor's visits. right? what did you do today? i went to the doctor. i went to the eye doctor today. what did the doctor say? something about the cancer drug in my eyes. and i like, what? the ability to download, the blue button. do you know about the blue

button? online get your own data medicarere a beneficiary, you can download three years of every claim medicare has paid on your behalf. and there are apps that will turn those three years of history into useful information. these are a medications. these are the doctors you have seen. these are the labs and procedures to have had done. so it is an amazingly simple concept that is powerful that says under hipaa, you have a right -- if any doctor's office says he cannot have your records because of hipaa. there is a web site and there is a letter that says, actually hipaa says the patient has a right to get their own records. so it is a big in a blur. blue button -- it is a big

enabler. >> i wonder if you could speculate. for example, you are so involved in caring about your health care but you are a doctor. in terms of equity and people who do not have access to the same resources, who did not know what dr. socially? . how can we address those concerns? >> so some people who hold patient data say to me, we cannot put the patients, to give the patient their data because they do not know what to do with it. it is going to confuse them. it could be harmful to them. we need to protect them from their own information. and when we can put it in language they can understand, then we will share with them. how long is that going to take? how long do we wait? or do we say, you know what? if someone could come up withr a

i have someone- on my iphone that translates chinese to english. that translates medical latin into plain english, they will make a lot of money. i will bet on the market coming up with solutions to translate and have abilities for people to engage with their care, more than i am betting on every hospital and doctor's office to be able to have the time to craft the right understandable language. o and let thegoa n market create useful information. >> so a real role for private industry to innovate. >> huge opportunities here. go ahead. >> i was going to ask you more about private capital. >> so i find it fascinating -- any v's in the room -- vc's in the room?

venture capital, investment in biotech is down and devices is down. and information technology -- way up. and a lot of that is because the data is oxygen for innovation. through our innovations and standards and there is a lot more data out there available. so there is a lot more innovation. there is also something else going on which is fascinating. i was talking to this beautiful boardroom, the most beautiful view of the bay in san francisco i have seen. and i was talking to the venture capital fund that has done very well. and they said, our first three funds, we put money into anything that might possibly work. no matter how expensive, because it is actually expensive, it is better. if it works, even a little bit, someone will pay for it.

do you know who pays for it? we all do. right? we all pay for that, because the incentives were do more, bill maher, more scans. whether the medication is better or not. if we can charge $50,000 and someone will pay. they said our fourth fund is reduceart ups that can health care costs. we think there is huge amounts of money to be made saving money. >> right. amazing. we are going to open this up to the room for questions now. so i'm turning it over to you. one in the back who youou can just say are. >> i'm a primary-care physician. i know all about meaningful use. it seems to me that the process used -- you describe is backwards.

you get the i.t. and many figure out how you can use it. the meaningful use requirements seem to be all about management and counting. blood pressure. project. instead of figuring out oil what does that this is in need to take better care of the patient? what clinical information? standardizedf terms. i do not care if he has c.a.d. i want to know the had a heart attack or bypass or just a scan? high calcium. this.e not consulted in and it seems to me it should be about what is clinically useful, not what the technology can do. you match the technology to the clinic. not the clinic to the technology. >> thank you. ongoing, really

important issue in terms of the purpose of the technology. and to work backwards from what we are trying to accomplish. you are exactly right. it's -- this is, we have public meetings of our federal advisory committee, people who helped craft these roles. we had them on average for the past three years every other day. every other day. we have had groups coming together, experts like yourself, people in the community, whether it is academic, whatever, health plans, consumer advocates to say, what is it we are trying to accomplish and let's work backwards from that to say what do we need to do? and this gets a little tricky, because you are right. viewpf you take the oint of just delivering

excellent care, you probably do not need electronic health record. right? you can probably say wait until the person comes in the door and say, how can i help you? and take good care of them. >> [inaudible] information about the patient can communicate -- >> let me give you an example. i went to, i have 230 small practices. i do not know if you are in a small practice. in new york city over an 18 month period. implement electronic health records. and i went to visit one of them, a storefront in harlem. excellent condition who shares, is passionate about her patients. and i said, of all your patience to our elderly, do you actively

tried to vaccinate them for flu. she said, yes. i said, how many? she said, what do we say, i did 80% of them. but if we do not have the information collected to be able to run that question, run that query, to be able to look at all of our patients, we are not able to see that she had done 22%. she'd -- thought she did 80%. she'd done 22%. she said, can i send them a letter to bring them back in? het is what you cannot do if can -- cannot collect the information. nless you have a wand to say all of those with diabetes come out. you need the information to be structured to be able to do things like tell me the list of

a1-c is too high insulin.ot on -- and a big part of our business model will be, the decontrol? it did to help the patient get a underot and get their a1c control? with the u.s.n government accountability office. there is no shortage of technology and health care. most of health care, the technology is, we are in the 22nd century. it is amazing. we started out the day talking about robots. ut yet in wiring offices and hospitals, we are not even in the 19th century. what is the discrepancy? >> it has been amazing that the

green grocer recognizes they cannot continue to run a business on paper and pen and yet healthcare somehow we think we can manage the explosion of medical knowledge and do it on paper and keep it in our heads. the key has been the business case. that is changing. medicine is complex. but we have tripled and quadrupled in terms of the adoption of electronic healthcare records in the past few years. we're at the tipping point where were we will have gone from using computers not to build but to actually take care of patients, being something that was rare to something that will be rare if you don't do it. >> in the back. >> i was wondering if he wondering if-- for hospitals to

be able to meet meaningful -- next year. and the vendors ability to encourage -- >> we do this in stages where get the was to largest number of people to feel like this is doable. to do this, you set the requirements of a level that is ambitious but achievable. after you have been doing that for three years, then you can go to the next step. stage two is ambitious. but we think achievable. and the vendors are working really hard on the main push of stage two, which is the inter upper ability. the ability to share information between systems and break out of their proprietary ways of holding on to the data. and that is the big thing they are working on. it will leave a lot of help for

us to get to that stage, but i am very optimistic that the vendors realize that it is now in their business interests because it is in the hospital's interest because the pavement has changed. so you see this cascade -- you have we had a tick -- readmission adjustment that changes -- erw the venders wants int opera ability instead of hiding. i think the dominoes are lining up in a favorable way. >> we will take one more question in the front. the lobby firm in town. and i'd like to ask you a variation of a question i ask the person doing quantitative analysis this morning. he was a very excited about how he's able to do very sophisticated levels of research today it would not have been

possible few years ago because he has so much more data. is only accessing the data, the rich date of their patient base. that is typically the way it is done. so i am involved with it -- in discussions with people around the country who are interested in taking that to the next level and encourage a data donation program. without changing any laws or tinkering with hipaa, at least that the legal avenues exist into full use. you identify data that can be used without consent. and for data that does require consent, protective health information, have new avenues to make that consent easy. love your reaction. >> that was part of the affordable care act. the patient center of comes

institute. we are going to pay $30 towing for health care over the next decade. 99.99% of that health care, we will learn nothing from -- we are going to pay $30 trillion for health care over the next decade. how can we democratize clinical research so that we learn from what we are doing in the health care provided? institute just announced two announcement -- one is for networks of practices of hospitals who will accept questions from other people and answer questions, not just questions their researchers have and accept an answer questions from other people. the second thing -- they are patient-power 20 research networks. that says, you can now get your own data. and you can get your genetic and

device data in claims data and go to your hospital and doctor and get your lab data in clinical data and you can share for the purpose of research. and what we see is that there is a huge amount of pent-up all tourism on the part of people who are suffering from sometimes severe and rare diseases who want their information not to be wasted. they wanted to be used to generate knowledge that can help them or the next person. patient-k the idea of controlled over their health information and realize the ability to donate is a powerful idea. >> thank you so much. this has been fascinating >> it is my pleasure to introduce our next panel. the title is mental health, how policy coverage and policy -- a. not know of you who do james he serves as an editor at "the atlantic >

he is a doctor by trade. formal training at northwestern, harvard and ucla health systems. -- douggieard -- comparison is very apt. [applause] to everyoneo much for coming out. we of three distinguished panelists with us today to talk about mental health care. it is a tremendous issue that is still misunderstood, poorly addressed, can this part of everyone's lives. still stigmatized and talk about a lot of different issues. right dr. barbara van halen.