to susan b anthony. she told her i want you to say this is for me as a gift to all of you. later on, she corresponded with susan b anthony. a friend of hers later confirmed that she strongly believed in a friend of hers later confirmed that she very strongly believed in women's suffrage. that is the first incumbent first lady to publicly support suffrage. >> on this trip, she has a massive seizure. is this when her health really begins to to deteriorate? >> yes. what also happens, mckinley has purchased an original house that they had the first three and a half years of their married life together. so, they had rented it, i should clarify, they rented it for a year during the 1896 campaign. the house, which still stands, and he lived there longer than anywhere else, that is not where the campaign was.

the campaign was at the other house, they rented, and then it came up for sale. she is very depressed because of the onset of the seizures now, but there are these blueprints. i will expand it. he gets her into this idea that they will finally retire. she had a very strong record here of his assassination. it was very rational. it was because of the movement of the anarchists killing leaders around the world. she did not want him to run for a second term, and he refused to say whether he was or not, and

as that summer unfolded, she began to become -- it became very clear to her that they were getting the house not for the retirement use, but to house his campaign and campaign staff. there are letters that says this is the most depressed and the lowest she has ever been. >> one of the things ida could do is this, counsel those who had a political benefit. we will learn more about that in our next video. >> we have this billfold. this has never been on exhibit. this was recently donated. what is wonderful about this is inside, it has a picture of william mckinley, and this is something that we see in a lot of her personal belongings. this was her sewing bag, and she would keep her crochet items in here.

this is one of her crochet needles. it is her favorite color, blue, and inside, we have a picture of william mckinley. even when he was away from her, she would have something to remind her of him. ida mckinley was known for her crocheted slippers and she would spend hours crocheting the slippers. we think she made approximately 4000 pairs in her lifetime. these are unique for the soles they have. she would make them in various sizes. we have a pair from, obviously, a child's size. they were usually made in a variation of blue, grey, or an ivory color. these represent the basic colors

that she would use. since she was not well and was not able to do other types of work as a first lady, this is one of the things she could contribute, one of the ways she could contribute. she would donate these to a charity, to needy children, war veterans, or she would donate them to the auctions to raise money for a charity. >> sheldon cooper wants to know, did william ever give knitted slippers to his political friends and adversaries? >> yes. there was actually, it was pretty brilliant. i understand she was a very witty woman. if she did not like someone, and the one area where we do see her really having an influence is in judging the character of people that he is considering for higher positions, to be around him. if she didn't like someone or if she didn't trust someone, it wasn't like she threw a fit. she gave him a very rational explanation. anyway, she also indicated how

she felt about them by the color of the slippers she gave. she would give purple as a way of saying this guy is worried loyal, and yellow if she thought he was a yes-man, and a bit of a coward in expressing himself. >> well, the so-called friend was watching this relationship between the two more closely than the public could. she said the fact that her husband had been a shield between her and reality had made her a pathetically spoiled it difficult woman. mrs. mckinley knew what she liked and got it royally. >> i would say that is partially true. it was more true and held up when she found out that he was going to run for reelection, and he had not told her. at this point, she is more physically disabled, which is now going into the year 1900, his reelection campaign. she was very frustrated. as a widow, she was really

remarkable. she was basically saying, the longer i live without him, the more i realize how completely dependent i was. you know, the story has always been painted like, you know, he was a great hero and protector, but he was also controlling the situation. he controlled her medicine, he controlled a lot of things. you know, from her point of view, she was willing to accept her limitations and adapt herself, and there were times he didn't want that. >> i will come back to you in a second. joe from kankakee, illinois. >> i have been enjoying the program a lot. i am looking forward to the second season, especially since

i am a history geek. i meant to call with this question last week and didn't. i have been to the harrison home in indianapolis and the weekend i was there, there were actors. do any of the other homes do reenactors where they reenact the presidents and their families? >> at the mckinley home, you have a docent. i have not been there recently, but i know there were those in the past who did volunteer there. it serves a dual purpose of being a center of study for all the first ladies as well as -- there have been docents at the saxon mckinley house who have done that. >> jonathan from chicago. >> i grew up a few miles away

from camden, ohio, and i visited the mckinley monument where william and ida are married. my question, down the freeway in chicago, there is a southside area called the item mckinley home. i was wondering, is it just a memorial named after her? i don't know if you would know that. >> specifically that, i don't know. i will say this. there was, you know, again, the story never gets fully written and people get miscast and caricatured. she was involved with two organizations. one was the crittenden house and the other was the red cross. the crittenden house was interesting because it

specifically helped women who had been battered, who were homeless, and it provided them with shelters, and with shelter, education, and really helps them reestablish their lives. she didn't, you know, willy- nilly support every group and everything. she did do the slippers. they fetched a lot of money at auction, but she was very careful about where she allowed her name to be used. it might well be that there was a connection either with the jane addams and hull house, the crittenden organization, but i am not sure entirely. >> we heard that the president didn't really consult ida on his decision to run for reelection. we have a quotation where she said of him, i will be glad when he is out of public life. i do not want him to run a second time. i thought he had done enough for the country, and when his term expires, he will come home, and we will settle down quietly, and he will belong to me. what was the 1900 election all about?

>> the 1900 election was a rematch of 1896. mckinley ran against william jennings bryant. it is a testament to how much mckinley had succeeded. prosperity, he was, by 1900, seen as the man who was out of the great depression of the 1890's. he knew america's place in the world. it was new to most americans -- imperialism. bryant and the democrats and good government republicans, liberal republicans, basically opposed to the idea of american empire. mckinley, on the other hand, for a number of reasons, he was a reluctant convert. the question i have, we have been told, i believe by the white house military aid, the most important decision he had to make as president, after going to war, was deciding

whether to keep the philippines. hugely important question. very controversial. the white house military aid said that, in fact, it was ida's constant hopping on all the good work done by methodist missionaries that heavily influenced her husband's ultimate decision, which he always said had religious connotations. to take the philippines, and "educate and civilize and christianize" them. >> i actually found that evidence not just by benjamin montgomery, the military agent who was there in the middle of the night tom of the guy transmitting all of the messages to and from the front with president mckinley in that little telegraph room upstairs at the white house, but also julia foraker, also a political operative, and there were several people.

what is interesting is mrs. mckinley is not what you consider a traditionally religious person. she never went to church. she went to the theater a lot on sunday, but she sure didn't go to church. she was a very devout methodist. >> his mother thought he was going to be a minister. that never quite took, but he literally, all of his life, was a significant influence in his decision. >> he went alone. she did not go with him. the suggestion is, though, that she really believed that, from the sub -- from the reports they were getting, they were intrigued because the whole population was summarized as if

they were, you know, living in a primitive way, that their lives were less about christianity, more that their lives needed to be improved in a way that, you know, only the americans -- >> people believe that is why he was annexing the philippines. >> with ida's concerned about reelection, one of the stories was about potential assassination. she had good reason. here are stories of the assassinations happening all around the globe at that time. the president of france. the prime minister of bulgaria. 1897, the prime minister of spain. 1900, the king of italy. those were all attributed to anarchists. >> anarchism was a worldwide -- it is terrorism today. >> and their choice for the leaders of the country. >> you cut off the head of the system, and the system will die. >> it was not always cooked up by a large -- these were people acting on their own. >> can you speak to his decision

to put theodore roosevelt on the ticket? >> it wasn't exactly his decision. they had managed to alienate political bosses in new york who had, in desperation, turned to him as the great hero of the war, the only one who could win election as governor of new york in 1898. he was a reformer. most of his reforms seem pretty mild to us today, but they were at the heart of the political bosses and the status quo that they wanted to preserve. the united states senator from new york, the easy boss, as he was known, basically hatched the idea of getting rid of t.r. mckinley seems to have ambivalence about this. people might ask, why did you

have him? he already had a vice president. hobart had died in 1899. so, there was an opening. the convention went wild for t.r., who had tried to indicate he didn't want to be vice president. he knew his own temperament. it was not his style. >> there is a very important factor in this about ida mckinley. she was crucial in at least two instances, at very important points in the rise of theodore roosevelt, perhaps the most dramatic one, i will just tell you that one, is when roosevelt was with the cavalry and was trying to get on a train to get to the transport ships in florida so they could go to cuba, nobody would give him permission.

he was saying, why are to their telegraphs to the secretary of war? it was mrs. mckinley. she took it and she brought it to the president. she had met roosevelt and trusted him. that is what got roosevelt to the transports in florida. roosevelt responded to the president, please tell mrs. mckinley to think of the rough riders as her very own and we will make her proud. from that point on, roosevelt earned a favor with ida mckinley. there was an event in 1899 where she came in, big dinner, thousands of people, roosevelt is speaking, and he thought she was coming and right at the right moment, three cheers for mrs. mckinley. she sort of gave favor to him. >> 13 minutes left. a lot more story to tell. you are on the air. go ahead, please. >> i love your show. i love, love it. is it true that robert lincoln, abraham lincoln's son, who was

at his bedside when he died, was also at mckinley's assassination? >> he was at garfield's. he was at the train station at the time when garfield was shot. he was in buffalo. [indiscernible] >> before we get to the assassination, the question is asked, if she was frail, how did she function as first lady in the white house? we have talked so much about politics and bringing people together to perform politics. did the mckinley white house do that? >> she was not interested -- this is interesting. apart from her illness, because even before she had gotten the seizures, she was not interested in housekeeping. she was not really interested in the menu or entertaining. they have basically lived in

hotels in washington and in columbus. she was interested in him. again, that is a good question, but from the idea that she was always this invalid, and she was not. mckinley took control. mckinley was the one who actually planned a lot of the dinners. she was at them. she was at the receptions. she did a lot of the traditional stuff, but she was not particularly interested in making those decisions. >> presidents are being sworn in in march. it was six months later, in september, that they went to the exhibition. we have more footage about the exposition. it is a new american century. is america beginning to change its place in the world? >> absolutely. the pan-american exposition was a celebration of the western hemisphere, but in a larger

sense, it was a coming out party. america now owned most of the western hemisphere through the spanish-american war, cuba, puerto rico, and the pacific guam, of course, hawaii, and the philippines, all in one presidency. again, you have this remarkable explosion of activity, and the american people are having this debate, which in some ways goes on to this day, what is our role in the world? >> at that space and time, he was shot by this anarchist. how long did he linger before he died? >> was it six days? eight days. >> what happened to ida mckinley after his death? >> well, you know, it is very

interesting. she wanted to be with him. she wanted privacy. she wanted to have a moment with him. on the day before he died, the night before -- in the late hours, she was brought in to be with him. they did have some private words together, and, you know, mckinley said something that i found that has never been quoted widely before, but after she was brought out, he said to the doctor,"what will become of her?" it is almost a little bit cold. it wasn't. he knew he was dying. the doctor was really a good guy. he was the one who really got her on a regimen. they would not allow her to attend any of the public ceremonies. she was in the white house.

she had time upstairs with a closed coffin in the east room, and then she was just brought to the train, brought back to canton. the coffin was an open coffin for the public to pay their respects to. she was not permitted. she said one thing. she said, i want him one last night in this house alone with me so i could look at him one more time. they brought the coffin and they sealed it. she was very bitter, frankly. she was very angry. i have found instances of her saying things that were really sharp and frustrated. she did it after they did that. >> our final video is returning

to ida mckinley -- the museum, learning more about mrs. mckinley in mourning. >> now we want to take a look at some of the things that happened to ida after the white house. her white house years were cut short by mckinley's assassination and she spent the next six years in mourning. there are not a lot of things that represent this time for her. she mostly was a recluse. she stayed at home almost all the time. when she left, it was usually only to visit her husband's grave. when mckinley first was assassinated, condolences poured in from all around the world, and she couldn't take care of each one of them personally. she sent out this card, which would acknowledge that she appreciated what people had sent to her, and she often didn't sign these. this would've been something you would have received after you sent her a condolence. now, we also have a bound book.

this is family and intimate friends. we have lots of professional and public condolences. this one is extremely special because these would have been closer friends of hers. they would have been family members, cousins, things like that. these would've been the types of things she would have wanted to keep close, and it would have been bound for her to have and look through. some of them are acknowledged on the corner. they will have a date on them. the secretary can keep track of which ones she had acknowledged. not all of them have that. these are also, this is a good one because it shows some of the mckinley family members. these would have been the most nearest and dearest friends and family. >> as we close out here, john richardson asks a very interesting question to both of you on facebook. if ida mckinley had written a description of herself in the third person, what do you think she might have said about herself? >> a devoted wife by her own

choice. >> i will leave it at that. [laughter] >> dave wants to know, were ida's daily trips to her husband's grave seen as a mentally therapeutic process for her? >> they began right after the services. he wasn't buried. they would bill that monument. -- build that monument. it looks like a church of stone. in it were large floral displays, then eventually banners of groups that came. everyday she went. at first it was therapeutic and a way that was helping her to get out. but over time, it became rather ghoulish and grim for her because she was focused on death. she was even focused on the flowers that were dying and

trying to keep them alive and trying to get new flowers that she would put and. -- put in. it was sort of grim. she wanted it done. there was a really incredible little moments that happened. i thought that was the rest of her story, and it is not. the nieces old have a daughter each. suddenly, at the end of her life, there are these two little girls in her life and she starts going to the tomb every day. they start walking again in the middle of winter. they were talking about the flowers in the new buildings and she really returns to life. you have something here? >> queen victoria for 40 years grieves the death of prince albert. some of this is the victorian obsession with death.

to me, this is the earliest chapter in this whole story. it is, allegedly, she would have another seizure. i won't get into it here, but seizures, you know, people still have seizures. there are many different types of seizures. i had material reviewed by members of the board of the national epilepsy foundation. it has to be handled well in describing it. we only know so much. the fact is that she had regulated her life to this point in terms of dress and diet, and then expected the nurses to take care of her later on, kind of became secretaries, may account for that, but also the stress, the paradox of this. part of the reason they would get stressed

out his she was worried about him being shot. by him now being gone, that stress was removed. >> he died in may of 19 oh seven, just shy of her 60th birthday. 59 years old. i wonder how the country reacted when she died. >> it reacted with, you know, as often happens in the context of this young family, the roosevelts in the white house, there was some sort of nasty little thing that, the roosevelts were aristocrats. the mckinley's were village people from ohio. there was almost nothing said about her as a person. everything that was said about her was a symbol. it was all through the lens of him. the truth is, in their lifetime, she didn't really care what

people thought about her. the public loves her. she cared about what they thought about him. >> t it is.rt. -- it is t.r. >> they want to know about the fact that you have written a whole book about her without a picture. they want to know why you were so interested in this first lady to tackle a biography. >> it was inspired by the founder and president of the national first ladies library. the great intuition, she sensed there was a real story to tell here. that really began it. it was quite an undertaking. it was a lot of work. there is not one repository of the papers. the effort was far and wide.

it was like taking a magnet, one letter from here, one from here. it was pretty arduous, but like i said, even toward the end, you know, at the 11th hour, there is hope. at the end of her story, it was true. so, i hope what it will do is eventually wear away at that caricature and give history a little bit more of a fully developed human being. >> we will give the people the last word on this. we are running out of time here. where do you think she should sit in the pantheon of first ladies? >> the book is exactly what this series is all about. taking a fresh look, beyond the caricature, making the re- acquaintance of women, who we may know very little about, or we may know broadly about. it is a wonderful note on which to end this first series and a wonderful springboard for part two. >> thanks to both of you for helping us learn more about mckinley's presidency and about the side effects on the first lady during that first term. we appreciate you helping us

learn more. as we close here tonight, you have heard several times, this is the final installment of our first part. we will be back on september 9 to pick it up again, all the way through president's day of 2013 with a look at the modern first ladies. during the summer months, we will continue to have historical things on the first ladies during this time slot. we will continue to try to feed that interest. thanks for being with us. [captions copyright national

cable satellite corp. 2013] [captioning performed by national captioning institute] collect our website has more about the first ladies, including a special section, welcome to the white house. thehronicles life in executive mansion during the 10 year -- 10 year of each of the first ladies. we are offering a special of the book "first ladies of the united states of america."

now available for the discounted price of $12.95. >> c-span, created by american cable companies in 1979. >> in a few moments, a form on internet security hosted by the council on foreign relations. in an hour, the america foundation discussion on immigration bill working its way to the senate. chief of staffy on preventing sexual assaults in the military. , we will continue looking at immigration efforts in congress with former cbo director.

followed by a discussion on u.s. electronic surveillance programs authorized by congress. he is director of their project on government secrecy. how theter talks about three branches of government investigate the legality of my breaches of public trust, and national crisis. washington journal is live at 7:00 eastern on c-span. >>@council on foreign relations form on internet security. recently revealed data collection programs are not new and those who leaked information about the programs should be punished. he is cochair of the councils tasked on internet security. this is an hour.

>> good afternoon. i am the director of the task force program. it is my pleasure to welcome you to this special event to release the reports on u.s. policy in the digital age. i hope you have all picked up a copy. let me take care of a few housekeeping items first. the question and answer period all on the record. refrain from leaving early, if you can. turn off all devices and anything that makes sound and if you would like to use another eletronic device you can do so outside of the room. when you are called upon to ask a question, following the usual procedures, please, stand up and identify yourself. i want to say a few quick words about the task force program.

it is chaired by john negroponte and sam palmisano and directed by senior fellow adam segal. cyber issues have dominated the news headlines recently, and this task force has met over the course of the year to consider the broad ranges of challenges and opportunities. task forces, as we all know, are bipartisan and independent. cfr takes no institutional position. task force members are responsible for the content of their reports and each member participates to his or own capacity. they are consensus documents, meaning the members endorsed the general policy thrust of the judgments reached by the group, but not necessarily every finding a recommendation. task force members are listed on the back of the report, and we thank them for contributions. a number of them have joined us today. we have bob, eugene, thank you for being with us today. many others, of course, were instrumental and i thank all of those who contributed, and especially our hard-working

staff. i am pleased to turn things over to tom from npr who will guide our discussion today. >> i am a national security correspondent at npr, and i do a lot of reporting on issues in the cyber domain. so it is a privilege for me to be able to moderate this discussion today and to help introduce this important report. you know, i have been to a lot of these cfr meetings and i usually get stuck way in the back. one of the special privileges of being moderator is you get really a front-end seat. it has become a cliche to say how revolutionary the development of the internet has been, how it has transformed communications, political organizations, crime, intelligence gathering, and even war fighting. the development has occurred so

fast that governments, lawmaking, our institutions have not had time to adapt to it. this lag, this developmental lag has been exaggerated by the very decentralized nature of the internet. it hasn't needed any superstructure to evolve. but a technology this powerful attracts the attention of legislators, government, especially those who are authoritarian, and it makes it urgent we think carefully about how to defend the internet. we are at this critical moment, and the council on foreign relations should be commended for focusing on this issue at this time. speaking of this time, i mention for the benefit of my fellow journalists and for people watching on c-span and for those in the room, i am going to make

sure we at least touch on some of the current news, ranging from edward snowden's revelations, to the u.s.-china summit that just concluded in california, both of which raise issues relevant to the material we are discussing today. you are familiar with the co- chairs -- john negroponte, one of the most distinguished records of public service in america today, i think in ambassador to the united nations, director of national intelligence and deputy secretary of state, and sam palmisano know something about the technology world, having served as chairman of ibm, and i just found out today sam has been over the course of his career to china 35 times. so, he can lend a lot of expertise when the issue of china comes up. we have adam siegel, director of this task force. he is one of my own go to sources for all things related to china and cyber issues

generally. welcome to all of you. i would like to begin with each of you sharing your favorite point that you have taken away from your deliberations on this task force. one point that you would like to especially drive home to this audience with respect to this task force. >> i think the most important thing i took away from the task force is the origin -- what the origins of the history of the internet are and how it in many ways applies to the future. the internet itself is open and collaborative as the technology. most technologies, if you look at their origins, got created by an individual company and the government got involved. ibm, the mainframe, microsoft, the server model, etc. it happens a lot in technology. the importance of the internet is it is open, collaborative. academia, agencies, industry work together. there are informal groups on standards and compliance and the

like, and everyone complies with it. i do mention that because, as the task force recommends, to try to defend the model, the key to defend the model is open dialogue and collaboration. if you shut down the dialogue and collaboration, you are running the risk of balkanizing this wonderful technology. there is tradeoff. but the task force came to the conclusion that we need bodies to steer but not necessarily overcontrol. >> ambassador negroponte? >> i guess one of my takeaways this exercise is i reflected on the different challenges we face in defending the internet. i think this is a great title, by the way. we got that kind of feedback from others we visited around

town. is that however technical and scientific the internet may be, that in the end, geopolitics also has quite a bit to do with all of this, and that some of the problems -- in fact, all of these topics -- open, global, secure, and resilient -- have a political and international dimension to them, not the least of which the subject you promise to come back to later on. i guess that would be my main observation. there is a significant international and geopolitical dimension to this. >> a very powerful technology. >> after struggling over all the recommendations, i will take the view of the parents, which is that i love all equally. [laughter] but i will say, what i think is

most interesting for the report and for the task force and the council more broadly is that there are lots of players that came up in the writing of the report that the council normally doesn't think about. private companies, we talk about. individual users, users and other countries. think tanks and other countries helping shape the internet there think tanks in other countries. an age -- we were underrepresented in the taskforce, but anyone between the ages of 20-30. the main shapers of the task force, of the internet and moving forward. how do we rethink what traditionally for the council has been a simple problem of who we talk to? the ministry of foreign relations? the ministry of defense? how do we think about how we address these new constituencies

and how do we think about how most of the users coming on will be in developing countries, how do we reach out to them? >> i would like to unite some of the points you all made. one of the promises it seems of your report is that we can defend the internet. sam, as you said, this was a technology that originated in an open system. it originated in the united states. u.s. agencies had a tremendous amount to do with it. now given its power and its reach, is it presumptuous for you to think that we here in the united states can devise policies that are going to defend the internet? we are now talking about something a tremendous geopolitical ramifications, as ambassador negroponte says. >> you need a role in the defense of the internet. who can lead? one thing we recommend -- because you will be one of many

members participating, just as we do on the engineering side -- so, if you are going to be credible -- drawing analogies with engineering -- if you are not capable of engineering it is hard for you to have a role in this band or two of the -- the participation of standards or the evolution of standards. so, if you are a government, if you are not credible, it will be hard for you to lead or to convene people who think your way to have influence. therefore -- and we recommend this -- if the united states wants to assume a role of leadership, it has to lead itself first before it worries about leading the rest of the world. there were lots of recommendations in the task force about what we should be doing here domestically to take care of our own role and then hopefully convince, cajole, persuade, countries and

leadership that think the way we think, that align with our interests, to come along with us. i think it would be very, very difficult in today's environment, given the nature of just the technology itself, for anyone to control it. it is just pervasive now. it really touches everyone, everywhere. even in the government to tend be more authoritarian and restrictive. they have great challenges. it has gotten to the point where it has been part of the world's ecosystem, how the world functions. but there are lessons of history. you have lots of immature technologies that, when they become pervasive and touch society, governments have a role. when you go back to the origination of computer science and computing, mainframes. at some point in time, when it became such a large participant in the economy, they decided ibm had as much of a role -- it happens all the time. it happens all the time.

i know this is broader in many ways because there are billions of users and the internet, 450 or 500 million uses a pc's, so in many ways it is much more pervasive, but it has followed a similar pattern. so, if you are going to be a nation who wants to have a constructive role in persuading others, you need to leave yourself first. we recommend that in the task force. >> that keep this in practical terms as much as possible. ambassador negroponte, i don't know if you have been following the debate at the united nations going back almost 20 years, right, over the international role of governance over the internet. it has been quite a tussle. >> right, and there has been pressure from parts of the

international community to make the internet -- to try to bring it into some kind of a top-down governance approach. we, i think until now, have successfully resisted that. there is still acceptance of the existing mechanisms of governance of the internet. but i think we are definitely under pressure, and that is one of the points the report refers to. we are under pressure to broaden participation. i do not think that is hard to accommodate. as we speak, there are steps taken daily to do that, bring in more third world participants,

to enhance the capability of other countries to benefit. the idea of a multi-stakeholder basically bottom-up kind of approach to the internet is still intact, although under some threat from this very phenomenon you talk about. >> how do you empower the stakeholders to assert their stake? >> one of them is to increase their capabilities so they can use and understand the internet better. i think that is probably as important as any. the other is, i think you will see around the world, as our societies move forward, a growing middle-class everywhere around the world, including a place like china, which is, at the moment, pressuring for greater control of the internet. but i think -- and centralized control -- but i think they have elements in their own society that get it with respect to the

internet and its freedom and its importance to the realization of the potential of human beings and business enterprises, who will be a force more aligned with us, shall we say, than they are with their own government in the future. and one can hope reasonably, i think, that eventually that point of view will prevail. >> in august of 2009, the six member states of the shanghai cooperation organization -- russia, can't expand, kyrgyzstan, tajikistan, uzbekistan, and china, kazakhstan -- information war, they defined as a confrontation between two or more states and the information space aimed at undermining political, economic, and social systems, brainwashing to destabilize society and states. i think that is a good indication some authoritarian governments see some of the exchange of information. they really see this -- the soviets used to talk about ideological aggression, but isn't this, adam, the background

of what advocates of free and open internet are up against? these governments that see free and open communication as potentially subversive to the interests. >> one of the reasons we have had such difficulty finding common ground with the chinese and the russians because, as you point out, a talk about information security, which is the protection of information spaces. we focus on cyber security, networks and routers, all of those things. there does seem to be some slow progress on that front, though. if you look at the current summit, there is agreement that we need some rules of the road. the chinese have agreed to consider that the law of armed conflict will apply to cyberspace. it has been a subject of 14 of 15 last meetings. the fact that we are getting some agreement there suggests we can temporarily put cybersecurity things to the side.

it is clearly a main motivator for china and other totalitarian states. >> do you know ways that china has been willing to talk about internet security? >> i was there with the state department this morning. we kind of exchange notes. we have seen something similar with the new government being formed. it is very logical. when you look at the challenges of the new government that is being formed, and their necessity to expand beyond their regional economy, seven point five percent gdp growth -- it is not enough to maintain appointment -- employment at a level that is good by our standards, but by theirs, not acceptable. they have to engage the world economy, not just as a manufacturing hub. as they think about engaging the world economy -- i had these conversations three weeks ago -- that means they need to be more innovative. they need to be more creative. it means intellectual property. it means self through internet technologies. it means, you do not like being hacked either.

who do we hack? the guys with the money, or the guys with the ip? why would you hack somebody other than for national interests? you could have other purposes. >> which you are speaking about very freely. >> i am the economic side of the equation. we met with a lot of the folks, and you saw this change, very, very quickly. therefore, i would think of it as, having been there many, many times in the past 35 years -- i would think this is an opportunity to engage. it is not now the opportunity to

hold back or be cautious. now is the time to engage in these dialogues and these discussions, and put things on the table that are mutual self- interest to both countries, not just one party. any negotiation that is one- sided will not go anywhere. if it is mutually beneficial, i really think there is a chance for progress. when i came back, i was stunned. i was there in june, when the old government was still in power, last june. the difference is rather dramatic, and you can see it not only in meetings with the government.

you see it in meetings with the leading academic organizations. you see it with state-owned enterprises. there has been a very spirited, enthusiastic discussion of why they need to engage the world economically. i think it lends to a forum to have a discussion to address some of the concerns. >> i am curious how much leverage that gives the united states and some other countries. china appears to be very anxious to invest in the united states. i look at the example of smithfield foods. chinese investment in the united states is now something like five times what it was five years ago. >> from a very small base. >> still, each of those chinese investments, or most of them, have to be approved before they can go forward. does that give us some leverage to incorporate some demand that china respect intellectual property, and the condition of particular investments? >> why don't we make the point that this has to do, in a way, with what kind of world, and what kind of relationship, the

united states and china are going to have overall. do we want it to be a zero-sum game, like the shanghai communiqu? you referred to? or do we want to look for the summation of what we can contribute to each other's economies on a collaborative basis? it is kind of a fundamental question, whether you are talking internet, environmental issues, the world economy -- which ever. henry kissinger raises this point very often. what kind of world are we going to have? if we have a divided world order of some kind, you can see it is going to lead to no end of complications, and neither side is going to be able to fully realize its potential. i think the encouragement i take

for the meeting between the president's this past weekend is that it seems to me there is a search to find a way we can work together collaboratively, so that we can, each of us, most fully realize our potential. >> let us talk a little bit about some security issues which are really tough ones. all of you who are familiar with the history of internet policy are familiar with the attribution problem, the problem when you are trying to defend against cyber attacks, the difficulty of identifying the source of attacks. it is called the attribution problem. former director of national intelligence mike mcconnell said he a bird reengineering the internet in order to make it possible to attribute attacks more carefully. but if we talk about other governments, china, russia, or any other government, do we want them to be able to attribute activity on the internet? or is that going to jeopardize the anonymity of internet users?

isn't this kind of a two edged sword? >> it is. i think the report is fully cognizant of that trade-off. you could identify everyone, and you would reduce anonymity, and the possibility that something like the egyptian spring or those types of event would occur. >> because those guys would not be anonymous anymore. >> they would not be. >> it does seem that attribution is perhaps less of a problem than it is always pushed out there to be, in the sense that general alexander said that for a major attack, at the level that was widely disruptive, that was going to take out the power grid, there are only a few actors that could do that. nation states, china, russia, a couple others. we would have a pretty good

sense of who would do those attacks. the challenge becomes everything below that threshold, which is what we are seeing. clearly, the defense department wanted to send a signal that we are getting better at attribution. secretary panetta made his speech last fall, where he said we were getting better at it. that was clearly probably targeted to the iranians. these denial of service attacks. but you are definitely right, we don't want to live in a world where everyone is completely known in cyberspace, and the task force is certainly not taking that position, that we are promoting that. we think the u.s. has a lot to gain from an open internet that is secure, but where people have the freedom to communicate their ideas and to organize what they need to. >> we also focus on the fact that without having to share from a traditional perspective, there are ways to better manage threats or issues as they occur. there are much better ways to do it than we do today here. there is a term called information sharing.

if you look at the major participants in the internet -- and the technology, communication companies -- they see these patterns well in advance. perhaps becoming a problem. if they were allowed to share the information with the appropriate authorities, by the way, whomever it happens to be, defined by government, and do it in a way where they were not exposing themselves to any kind of legal action -- kind of in a constructive way to solve a problem -- not, by the way, this problem occurred, and they take your credit card and now we have a class action suit against you because you told that you saw the pattern, so now you are liable -- right? that is why people tend to hold back because they are worried about the trial lawyers. but if there was a way to shared information -- because there are people who are seeing the patterns before the problem

occurs. one of the things we recommended called information sharing some if you allow the information authorities who obviously have the authorization to participate in this, we could at least anticipate and get ahead of some of the problems. back to the emerging countries. we also argue that one way to get them to see it from our point of view is to make the argument on economic development. i believe the study -- internet, 4% of the worldwide gdp, on its way to 5%. if they could see it as economic development, then they would be open to ideas about information data sharing so they can participate in this global economy. it just wouldn't be the cloud services of an internet borne companies selling to them. they could become, the internet

born company selling to others. so, there are ways -- some refer to it as economic diplomacy. there are ways to get them to have an interest in defending and making sure they are secure and resilient in dealing with some of the bad apples. >> i think everyone agrees that our online presence right now with respect to critical infrastructure is undefended, and isn't it true that private industry has not stepped up? is it just a matter of fear of liability? but isn't it true right industry has not stepped up to responsibility? >> that is completely incorrect. private industry has stepped up and they act in their own self interest. that is what private industry does. that is what we do. my company is heavily defended. we spent a lot of money doing it. the question is then how do you share all that and participate? people argue that some elements in the technology industry are

more advanced than others, telecommunications, banking financial services. people do complain about the utilities. utilities are not as heavily invested. the answer then becomes you need put mechanisms in place that is in everyone's economic interests. that mandate with a heavy hand, you must do certain things. the problem with the mandates is they will not work. truly from an engineering technology perspective, not from a policy perspective the pure engineering, it will not work. and all you're doing is telling the bad guys out again. -- how to get in. it is like giving them the combination to the vault. that is what you're doing. the reaction to this has been more about if you're going to do something top-down at least do it in a way that will work.

i think people will be open to that. it is very hard to do. why don't we collaborate with a heavy-handed approach? the industry argument has been let us cooperate with a heavy- handed approach and policymakers feel like if you put somebody in charge to mandate through legislation or executive order than the question that we ask is what to the mandate and will it work? or are you exposing us to greater risk because you're telling people the combination to the vaults? >> i guess we will have some responses from the audience. i have to sneak in a couple of sexy questions or i lose my arguments here. the report advocates -- directors of national

intelligence do not like transparency all that much. i think that's fair to say. nevertheless your task force advocates the transparency of a possible offensive use of cyber weapons. are you comfortable with that? >> i am because i think what we say here is that just like in other types of warfare, using other types of weaponry, it is important that there be an understanding of what they can do, how they are used. one of the things we ask in our relationships with other countries is for more transparency and how to prepare the military budget. i think the greater openness you have less chance there is of some kind of miscalculation. particularly, there is no doubt about it that the internet and cyber is an element of warfare. it is a tool of warfare.

just like with other tools of warfare, nuclear, you need to have a dialogue between nations about how to use -- why they are used, even if you want some rules of the road and what is off-limits and what is on limits. i think that dialog needs to begin. it doesn't mean you are revealing secrets about latino about security or anything else. >> it just seems to me as a reporter u.s. government hasn't been very anxious to talk openly about its possible use. >> there is probably transparency in transparency. one of them is to have this discussion amongst the potential users and maybe start small and then expand further. initially you have to talk at least among the cyber powers, china, russia. we recommend a cyber alliance. i think we need to work closely with our nato allies. talk about what circumstance we

use this kind of weaponry, if at all. i think that requires a certain degree of transparency. >> as former director of national intelligence how you assess this cascade of leaks we have had in the past week about intelligence community's use of surveillance tools to track what is happening on the internet? >> the use of warranted surveillance, completely legal, not very new. i try to figure out exactly what is new. it is certainly not conceptually new compared to what we have been doing a number of years earlier. how to assess it? i find it shocking that somebody with clearances and who signs a confidentiality agreement to then turn right around and reveal publicly that kind of information. i think it is utterly reprehensible and i hope that

the individual or individuals concerned get punished for it. >> what are the population of people that have cancers that -- have clearances that put them in a position to disclose information like this? >> there is a trap in your question there. [laughter] however many thousands of people or even hundreds of thousands who have top-secret clearances in our government, there aren't necessarily thousands that have access to that particular kind of information. my sense of it, without having inside information anymore, is that is a pretty darn restricted program and access to it was probably very restricted. >> i think it as to the point sam was making, information sharing is going to be much

harder legislative push. mistrust of the nsa was high and now it will be higher. bills will be harder to push through. the second is what we see in china, already and in build assumption that u.s. technologies were in bed with u.s. government. when you read writing from the chinese website, we are 80% dependent on u.s. a. companies for this. all companies have back doors for the nsa. no matter what happens with these findings, that perception is going to be widely reinforced in china. their efforts to keep companies out an increase procurement standards from u.s. companies require u.s. companies -- all that is going to happen. for u.s. companies abroad, the operating environment is going to be much more supportive. -- is going to be much, much worse.

>> we ran all over the place in this half hour and now i think it is necessary to at least get a little bit of sense of the sweep of this report, which is very impressive. it is your chance now to focus in on issues that interest you. in particular we are going to invite you to join in the discussion. we have microphones. please raise your hand and once your call on please wait for the microphone to come to you. speak directly into it and give your name, and your affiliation, and please make it a question and not a speech. i am sure there are a lot of people that want to take part. yes, sir? >> thank you. bill from the university of maryland public school of policy. i am intrigued by the title of your report. do you see the adjectives as really being linked to each other in the way that success

depends heavily on achieving the others or dc them operating -- or do you see them operating independently? >> i would say they are linked. inextricably linked? i would not go that far. the main objective of the internet is freedom. three years, free expression, free access, unhindered use and access to the internet. to achieve that, you need some of these things. >> i would agree. it has to be resilient and secure for it to be global. there is an interdependency. if it was not secure, it wouldn't be global. it would be controlled by some entity. i think they are, in many ways, connected. that is how we thought about it throughout the task force. >>: the program up, that is a -- holding the program up, that is

a smart move. but i thought there would be attracted to the report. >> alan, i was intrigued by your comments that to lead the world toward the objective in the report which should lead ourselves here at home. i wonder what you think about the implications of that for an embodying our own internet policy, a privacy policy, cyber security policy, and legislation. you did speak about not wanting to mandate from the top-down. do you think that the fact that we have not had a comprehensive privacy statutes in the united states the inability to access sap security legislation and our to enact cybersecurity legislation and our hands-off approach to the internet, which has led the world for many years, do you think that creates a bit of a policy void that does not allow u.s. interests to a dance as they should be? -- to advance as they should be? >> i would hate to say that, it sounds so monday. -- so mundane. what is our strategy from the perspective of u.s. national

interest? i have been involved in multiple committees. i may not be knowledgeable of it. what is the strategy? in many ways we go to the dark side of the internet. clearly privacy is the dark side of the internet, that needs to be addressed. no one in this part of the world would disagree with the fact that there are many issues about privacy, not just national security, protection of children and the like, that we need to have policies around. i would do it in a strategic context of that. it is not so simple to say you cannot use the internet until you are a legal age. that is not going to happen the could be rules of the road,

there are all sorts of things you can do beyond legislation. as we have in drug awareness and so on. kids do understand the implications. i think we need a strategy. this is a personal opinion and we discussed this in the task force, it gets overwhelmed by national security and underwhelmed by personal economic interest. we try to accomplish a balance between national security and personal and economic interests so it tried to maintain that balance in the recommendations. i do believe that if you err on the side of national-security and become restrictive on the open architecture of the internet -- and start with a strategy. having been involved in some of the legislative debates, i am

more comfortable with the internet model forces open cooperation and people solving the problems in their own ways. versus the mandatory top-down. the technology moves so fast. by the time it to the legislative process, assuming it was really good -- let us assume it is the best you can have in the world. it would still be too late. you really cannot. it moves too fast. i understand why you could make the argument for political reasons and why you need to do these things. the technology is not going to wait to stop. it is done over the world. there are really smart people over the world working on these kinds of issues. my point being is i recommend in a way this collaborative

structural center -- i find that if there is the set of strategic guidelines that set the rules of the road, which is i think something that could be done through policy so we know when minor theft happens in the bank i hate to say that is minor, but compared to an act of war, it is certainly different. there are some guidelines we conform as collaborative approach. i think there is hope. i do not think it can be solved legislatively. i only make the argument as looking from an engineering technology point of view. it goes too fast. and skills are global. there is almost nothing you can do to stop at elsewhere in the world. it will come here because it is an open internet. >> yes, sir?

>> thank you. david robinson, former legal adviser to the department of state. has the internet made the ancient craft of espionage and counter-espionage -- has it made it harder or easier or both? >> i think it has made everything faster. i think that is probably the one thing that has happened, the rate at which information moves around. the other thing i would say in terms of analysis, which is the end product of an intelligence process, you have to look at a lot more information. how you sort the weed out from the tap? -- from the chaff, and distill things down to what you want the decisionmakers to know?

on balance, i think the internet and modern technology have made intelligence far better and i think particularly with respect to the integration of information on the one hand and using it in a real-time basis on the other, two key elements of intelligence and operational activity have been improved dramatically by the absence of information technology. -- the advent of information technology, and its progress. >> it isre in front.

your turn. >> i cannot help but remember -- i am going to do part of this to john. we know from a past experiences that so much is political, not just technological. i wondered a couple of things. you already reference the fact they did not have young people on your task force. in your report it to make any recommendations relating to getting at the culture and getting young people to realize that this is another form of stealing? the second question is the degree to which you review the many treaties and laws that are on the books related to intellectual property, trade, copyright, and other things. i would make a third comment, the united states, canada, and europe, and just a few countries in asia, walked away from the

agreement in the itu in dubai. we have a lot of homework. that is a really serious demonstration of both our arrogance and naive to take. -- naivete. >> the model did not exactly conform to the multi-state coalition that you all have advocated. >> that is correct. >> the itu agreed we would continue with the current governance of the internet while we debate these other issues. that is why the system is still enforced. that would be one point. one of the recommendations the commission makes also is that we better prepare for the itu meetings and do it more before

hand. -- beforehand. the last big session in dubai, we only appointed our delegation at the very last minute. i gather at the next meeting in 2014 will not be one of these large scale meetings. we already have the head of the delegation in place at the department of state. more attention to the itu and preparation for those negotiations. >> to answer the point about the cultural mission, 55 countries refused. it was not just us and a handful. 55 countries refused to sign. and take your point, we have more work to do. the task force suggests a three- prong strategy. as john suggest, be engaging the itu earlier. mechanisms exist to bring

countries into it, like the internet governance forum, which are not really being used in the way they could be because often countries did not know about them, they do not have the resources to go there. the third is to search for an alternative forum. there are lots of people that we think should have discussions outside of the itu on separate security where we need have more development capacity built in. on the young people think, if it is a problem for the council probably. but i do think we are talking -- no offense to anyone in the audience. [laughter] we do identify a hacker ethos but not in a negative way that everything is free. in a positive way of let us have the system and make it better or

build something ourselves. how'd you get those types of people to get to government service? how you involve them on the defensive side and the offensive side? it is about the guys who created tumbler and facebook and things like that. they think of themselves as hackers. how'd you get them to contribute? part of that is having the idea of the cyber service. people think of themselves as an elite group. how can the council engage smaller startups in california, in the washington area? it would traditionally be outside the scope of the council. >> i'm curious, speaking of agriculture. -- of hacker culture. the taskforce is critical, for example, of the development of people that developed a zero-day

exploits and back doors. those happen to be really important tools in offensive war. i know that the nsa is looking for people that have the skills. i am curious about that disconnect. are these people who are serving the american interest? >> we have a hacker on the task force. jeff moss was a hacker. he started defcon, one of the biggest conferences for hackers. i do not want anyone to think that he is playing a negative role. he serves on the advisory committee for the department of homeland security for these exact issues. i think on the proliferation of malware, this is an interesting place for government discussion. this is one of the areas where the chinese and russians, at least for malware focus on critical infrastructure and

security centers, we do not want to see these things in hand of al qaeda or non-state actors. these are difficult conversations, but how can we bring this in? >> the nypd would say, we flipped it. >> in the blue shirt. >> thanks very much. peter evans with general electric. how did the task force grapple with the metrics it? -- metrics around that? how do you measure this and what is the goal for achieving our knowing that to have achieved any one of those points, even if they are independent or connected? >> that sounds like a question for you. >> jump in and maybe you could elaborate. i would say that one of the -- it is a great question. one of the thoughts the council

has is to find ways of continuing some of the work that has been launched here. right now adam is the cyber force of the cfr. the cfr needs to do more work on this. there is obvious need for followup. we found very enthusiastic response everywhere. we had meetings, including out in silicon valley. i think you are raising the kind of issue that could be an important element of our work. >> i think that is a great point. there are places you can go to, freedom house, and other places that measure internet freedom. to secure resilience, probably less so. that is an interesting point. >> thank you. i am with the georgia institute of technology. former australian department of

defense. i was wondering if you think there is any hope for china and the united states to collaborate on global internet security and what sorts of mechanisms could get that going. >> i will talk with the hope that my colleagues can -- i'll give you a few seconds to think about it. the reason there is hope for collaboration is because we're both countries are at this time, because of where both countries are at this time, there should be some constructive dialogue that can be viewed as leaders of the world. it is in their interest to come together. this is something that they can collaborate around. it is a very difficult thing to

say you do not want it. they can make progress. as i mentioned earlier, i will give a point, countries have had industrial policies. this is new. industrial policy in the economic sense. -- this is not new. it is industrial policy in the economic sense. if you look at the people that try to steal ibm's trade secrets over time, they moved around the world. i can give you examples of japan, korea, russia, and even the western european countries. what happens? all of a sudden those countries emerge and develop economically and create their property and therefore there is not the same goal of trying to take others in that process. you look at where we are and

this is my sense that if china is going to be more of an innovation economy -- somebody putting tops on bottoms is not unique. if they create international intellectual property owners and process their coined have the same goal as all of the people that innovators have. therefore there is going to be this natural collaboration. i was there before i even retired. if you look at the history of these things that is normally what happens. we get to this point and then you began with of the mechanisms. >> you ask about mechanisms, obviously the bilateral one -- perhaps on the particular issue that is before us.

for example, one of the recommendations we make in the port is the stealing of intellectual property over the internet becoming a rate of -- a regular feature in future trade agreements. it already is. maybe you can ship them in a little bit more detail. i think it somewhat depends on the specific issue. in the back there. >> this question is for -- the leaked story, mr. snowden is now in hong kong under chinese security. -- chinese soverignty. are you afraid that china would, like the nypd, flip him, to get him into helping them?

america has the capability of checking where he is and sending the nsa folks to hong kong instead of turning himself to the red china. >> with regard to your first question we are going to have to wait and see what happens. i have been reminded that hong kong does have an extradition treaty. one of the things that -- when hong kong became the re- integrated to china was to maintain many features of your local rule. one government, two systems. we will have to wait and see how

that plays out. obviously in the united states i would just assume that you have a strong interest in him being brought back to the united states so he can be brought to justice. i am sure we will do whatever we can accomplish that. >> we are almost out of time. you have to make it brief. >> my name is pat from the state department. i am looking ahead with the upcoming transatlantic treaty that the investment partnership that we are going to be interesting and negotiating with the eu, to what extent can do expect separate security to be involved in these issues? >> the question is should they be front and center? the free flow of data should be part of all of our trade agreements? we do see emerging security standards being possibly a trade barrier or at least eight -- or at least different trade restriction in different

constituencies that may cause problems for u.s. companies moving forward. depending on how this nsa thing goes, i did see some stuff about eu parliament saying we need to consider it. i think those are issues we are going to have to look for to as a move toward. >> i think we ought to wrap it up. we did promise you would be out here by 1:30 and that time has now come. i would like to thank the speaker for this project task force. thank you all very much. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013]

>> in a few moments, the new america foundation discussion on the immigration bill making its way through the senate. it is a little bit more than our. subcommittee on

defense tomorrow morning will hear from chuck hagel and general martin dempsey. relive coverage of this hearing of the 2014 budget is at 10:00 a.m. eastern. >> the name of this place still resonates with the shuddering of the american people. more than any other name connected to the civil war, gettysburg reverberates. it was the crux of our terrible national trial and even americans who are not here know that all the glory and all of the tragedy we associate with the civil war most indelibly here. wonder 50 anniversary of the battle of gettysburg live all day on sunday. american history tv on c-span

three. beginshe u.s. senate debate on immigration bill, the new american foundation hosted a forum. this is a little more that an hour. >> welcome, everybody. my name is andres martinez. thank you for joining us for what turns out to be an even timelier discussion than we had anticipated when we scheduled it, given the week ahead here in washington on immigration reform. to my left is simon rosenberg and to my right is tamar jacoby, who is a fellow here and is the president of immigrationworks.

thanks. as you know, both these individuals have storied biographies, but to keep things rolling i will leave it at that other to say that would be hard- pressed to find two other people in town who have had as active and engaged experience with immigration reform and who have been more influential, both in this round of immigration reform, but also previous rounds, so we have battle-tested experts. our premise today is immigration reform has shown a great deal of traction this year. we hear a lot about how washington is broken. there is excessive polarization, nothing gets done, and that has

been the working narrative for quite some time about our political process, and yet we have seen this year great progress on one of the more intractable difficult issues of recent years, immigration. in fact, a lot of the conversations i have been around on the political climate in washington generally always point to immigration as the one kind of sunny exception to the gridlock that has occurred in d.c., and one thing i worry about is that might be too optimistic and maybe to prematurely optimistic because, as these two individuals know, it is not quite done yet. we have seen a very ambitious bill put together by this gang of eight in the senate, voted out of committee, so we have an ambitious comprehensive immigration reform under way,

and this week it is going to the floor of the senate and then the house will weigh in at some point. some of us have seen this movie before, 2006, 2007, so i am a little skittish to predict victory. we have seen improbable success so far, or progress, i should say. one thing i would like to start us off with and maybe you could get us started is to step back and talk about what we have seen in the senate, how comfortable are you with the parameters of what this immigration looks like now? is this something you are ecstatic about? and then since you are playing the role of democratic advocate for immigration and you are playing the role of republican advocate for immigration, i want each of you to talk about the

potential pitfalls and obstacles that the other side might throw out and play with and have at the end of the day another instance of gridlock and disruption in washington. then we will reverse roles and each of you can see what each of your sides can compromise on to get us to the promised land. simon, in terms of what the legislation looks like now, how are you feeling about it? >> thanks. it is great to be here. it is always good to be up here with tamar, who i have learned a lot from, and i think she has had a harder job than i have over the last eight years, which is keeping the fire burning on the republican side. i have incredible admiration for the new american foundation, so it is great to be here.

i have to say if we go back to when these gang of eight negotiations began, there was not a lot of reason to be optimistic. this is an issue that has been brought up, we passed it through a republican senate in 2006, mccain and kennedy leading the way. then the house would not take it up in 2007. the democrats had won the senate. for reasons we could spend the rest of the program talking about it did not pass. there was caution, cautious optimistism. we were cautiously optimistic, and the gang is a new group. i think it has worked. even though there are things and that are in the immigration bill that i do not like, i feel all the compromises that we saw were understandable. i could explain them.

i did not feel democrats accepted things they did not get something in return for. this is in some ways -- it goes back to the origins of the bill, mccain and kennedy, when they built the bill in 2005, did so in an old-fashioned way, or everybody got something and everybody gave something, and there was a powerful force was going to see the bill through. that spirit prevailed in these negotiations. as a democrat, we would like that path to citizenship be less arduous, and there is the main complaint that you will hear from democrats. this is at a time when partisanship has diminished the legislative ambition of a lot of legislators in washington. this is an anecdote to that. it deals with border security, significant infrastructure

investment along the border that will create jobs on both sides of the u.s.-mexico border. it deals with illegal immigration system so it is more skills-based undocumented in a way that the undocumented immigrants that at the end of the day i will take it. it may not have been how i would have done it, but i will take it. those are the major components of it. optimism, happiness can't explain the compromises, and that is why you see democrats fighting for this. >> thank you for being here. it is great to be on the stage with simon. i also am very astonished at how much progress they made and how in the big view how good a product it is. we can get into the weeds about the concerns come up, but it is remarkable, the work they have

done, and a year ago, to say that republicans would be for partners in a comprehensive reform bill, people would have laughed at that on a panel like this. they were at the table and they were full partners and the sides worked together effectively to find the sweet spot. i think all of us in washington think that they had lost those muscles, that people do not know how to do bipartisan compromise anymore. what is astonishing is you put eight guys in a room and they have the will, they still know how to negotiate and get to a deal. they did that not just on the big things, because on some level, the grand bargain for those who want an answer to the 11 million unauthorized, more enforcement, they made the bargain, but this comes down to every little detail has to be worked out so it works for democrats and republicans and works on the ground.

they did quite an amazing job of getting those things right. they looked for the sweet spot and found that. the biggest one is a humane and practical answer to the 11 million unauthorized, combined with a pretty serious determination to get enforcement on the border and in the workplace. they are going to spend up to $5 billion on the border, and every company in america is going to have to use e-verify to make sure that the people that hire them will work. those are big enforcement pieces. the other big deal here, the big compromise, they rebalanced our immigration system. right now 66% of the green cards of the permanent visas go to families, and 7% go to the employment space, 7%. way out of sync with other countries.

and in canada, 25%. the idea is there is a rebalancing. you talked about skilled people, but workers we need for the u.s. economy and what is in our interests and a rebalancing with their interests. it will be hard to predict and it will depend on the economy and how many people apply, that we could get up to 60% to 40%. that was bipartisan agreement on that. republicans might have been after that for a long time, or maybe some democrats. the answer for the unauthorized immigrants is there is an answer, it is tough, not automatic, but there is a path.

we try to find the sweet spot. concerns on my side -- obviously we are going to see it playing out in the senate in the weeks ahead over are the border triggers tough enough, that it has these provisions that say people cannot it be citizens until the border is secure, and e-verify, every company is using it. there are many republicans who say it is not a meaningful trigger. we will see a lot of debate around that. >> and there are amendments. unless you harass the 101% of people trying to cross -- >> the key point there is that for republicans to have meetable

requests -- >> you both are appreciative of the compromises that have been made, and i should say you both played a role in making that so. let's interrupt the kumbaya vibe. tamar, tell us what are your concerns of what his team might do in the next few weeks, months, both in the senate, but when we get to the house that could get us off track and we will be here in the fall bemoaning the fact that immigration is another in a long list of things that congress cannot handle the partisanship. >> if i was imagining -- if i was a democrat, i would say we won the election with 71% to 27%

of latino votes. that is a good score. why would you want to change that? parties work hard to get numbers like that. why would you want to change that? why would you have to share credit with the other party and go back to latinos and say you do not have to eight republicans anymore? without knowing anything that anyone said -- it is not hard to imagine that there are people thinking like that. will they prevail? there will be opportunities where things will be going badly, going rough, where it will be easy to say let's not compromise on that and let's make it look like it was the republicans and it will fail and they will say we tried.

there is a lot of talk about should the house vote on the senate bill, and there is hope among democrats and you hear advocates on immigration reform groups saying the senate bill is a good compromise and the house should vote on it. the house will not and cannot in a million years vote on the senate bill. the house will want to come up with its own product. if it was forced to to vote on the senate bill, the answer would be no. people who continue to say that, that is in my view a nonstarter. to a lot of republican members, this is liberal democrat-driven with afl fingerprints all over it. that is not what they want. even if it was good, they would not want to take it up to the senate, the democratic senate. that is one the issue, and there has been a lot of talk and

recent weeks there is a bipartisan group in the house working to craft their own bipartisan answer that they hope will be parallel to the senate the law, and there is a lot of talk that the democrats have made it difficult for that group to get to a solution, that they have not been as forthright in compromising as some in the house. i have not been in the room, and there has been talk that it is hard to get to a compromise there because there are folks who want the house to have to take up the senate bill. that is all procedural stuff. >> what to you think are the unreasonable things on the part of democrats that would derail this and would be beyond the pale that you would consider the parameters of what is doable? is it health care subsidies? the pathway to citizenship?

>> there will be people who want the borders to be tougher. when you get to the house, there will be movement to the right, and the house will try for something shaved back, and the issue, where there will be issues is there will be a path to the legalization for the unauthorized. the question is, can the democrats accept that? there will be huge debate on health care, and the issue that has kept this secret group in the house, that is where they have been hung up for the last month. health care, but not only health care. also the low skilled worker program will be an issue. i and many republicans think the low skilled worker program in the senate bill is a good

design, but it is too small to diverge and rechannel illegal immigration. republicans in the house who are concerned about we do not want to be here again in 10 years facing another unauthorized 11 million, that program needs to be more responsive. the afl is adamant about that, and can't it be more market sensitive and can democrats give them all of that? >> i am sure tamar was not talking about you when people were looking at the scoreboard and say why don't we preserve this lead and not endanger it by allowing republicans to seem constructive on the immigration issue. you weren't, right?

>> no. >> talk a little bit from your perspective, what are the stumbling blocks of republicans? >> just listening to both of you, i thought about this in a new way, which is democrats have basically signed on to the senate bill, not in the house yet, and we will see what comes out of the house this week, but in the senate there is no effort to drag this to the left. we have accepted we are happy with the bill, we picked up republican support in the committee process, a 13-5 vote, pretty extraordinary. even though as we gain this out there is this other body that is about to weigh in that is in all likelihood going to attempt to move the bill to the right. there is no parallel effort to move the bill to the left. democrats are accepting what we

have, which in itself creates a little bit of a curious situation in the way washington works, because in theory if in any negotiation one side gets more, the other side has to get something, and structurally this is not being set up that way this now. the house republicans have a decision to make because it will pass a series of smaller things that will not be the senate bill, and the question, is how far do they go? do they try to make something that will be reconciled in a normal conference committee, or will they stake out such difficult ground that it will be difficult for their members come back and accept compromise? we may need only 20 or 30 republicans, so we could have a situation or there is a bill that passes with 100 republicans in a house, goes to conference, and only 20 or 25 can accept it

and the bills still passes. how much of an obstacle that is we do not know. the bill goodlatte and gowdy introduced last week is something that goes so far that is hard to understand how the republicans go back from it, because it includes things like providing weapons for ice agents and mandatory body armor, and it sounds like they are going to commit extraordinary acts of violence against undocumented immigrants. it is the wackiest moment we have had in this immigration debate. stumbling blocks is the border triggers are a real issue. republicans have a legitimate concern about the border. the idea that 700,000 people can walk across any order of any entry when they want is not anything any country can accept. we have to do a better job policing our porous mexican border. it makes sense, and there is a

lot of effort that to toughen up on the triggers, democrats have said no. the senate gang of eight have said no on any re-altering of the trigger mechanism that was negotiated. the third thing that make it complicated down the line is the house republicans have said no new spending, no new net spending. the cornyn amendment, right now the senate immigration bill, it's $100 billion over five years. it will be $10 billion, $15 billion, $20 billion a year to achieve the ambitious enforcement goals. i do not know how we will reconcile, and the cornyn bill called for 10,000 new guards. that bill alone was $70 billion over a certain time period.

the issue of whether or not the house republicans are ever going to accept a bill that has new net spending in it, it will be a bigger issue in the fall, but they have been aggressive about that and the senate bill will be expensive because it is ambitious. what is interesting is a guy like cornyn, the amendment he is floating around is an affirmation of the role of government, giving government a lot more money to achieve goals. can house republicans accept that? that worries me in the fall and not in the next couple of months. >> the asymmetry that you describe, where a few facts on the gay and lesbian amendment, it did not get voted on, but it was discussed, would have taken

away from the left that republicans could not before. there were people in the committee, democrats, who when somebody's point of labor business balance came up, said they would vote for it, but with an asterisk, where they would fight it for another day on the floor, so it is not as if -- i am not praising it either. >> has simon described them correctly, where we started the conversation, where there is this compromise that has been achieved in the senate, but now we have to have compromise between this bipartisan compromise here and a republican majority that is not symmetrical? >> i would argue the original proposal was not entirely

symmetric. >> do you think it is fair to think of the senate bill not as a bipartisan bill? >> but leaning toward one side. that was because, let's look at the low skilled worker visa program. the afl was always saying if we are not happy we will walk, and if they walk, we will not get enough democrats to vote, and that was always a sword hanging over the negotiations. the afl had a veto on how market sensitive it would be. it is a good compromise, that leans and little bit toward some of the people on that side of the table, on the border triggers as well.

>> describe for those of us who are not as steeped in the detail, i think i know what we mean when we talk about a trigger.

..

in my notes somewhere a perfect addition to this panel. our final speaker is carl mcdonald. he is a director and senior analyst for citi investment research and analysis. he has followed the managed care industry for a decade or more. we have asked him to take a clear look at the future of medicare advantage from a business standpoint. was tasked with the question of whether not figure advantage is a viable over the long term. we take payment policies, some funding challenges and is the

program going to be around five or 10 years? the answer is yes. the key factor to think about here is that medicare advantage plans are competing against a completely inefficient fee for service program. these companies have the .bility to save costs examples -- medicare advantage can try to make sure seniors have a primary care physician. somebody they can go to for opposedextensively as to showing up in the emergency room. a second example would be what they tried to do in terms of fraud and abuse, something the federal government attempts to do but with limited success. a final example i will give you is medicare advantage plans are constantly reviewing provider

networks. if there is a specific doctor utilizing more than everybody noe in that region, with explained reason, they can eliminate that doctor from the network. these are different ways the company can be more efficient. when i say it is a viable in the long term, i should be more specific. the way things are set up, medicare advantage can we viable in urban areas. think miami and los angeles. question of whether it can survive in a role markets -- rural markets. as you look at the last couple of years, the few for for -- service medicare program shows increases in the 3%-five percent range. there has been a significant district -- difference in the

last couple of years. as we think about where medicare advantage is going, i think it is helpful to understand where they are today. this gives you a summary of the medicare advantage program today. over 14 million people in risk plans. the average payment the plan gets is around $900 a month. medicare advantage private billion inin $155 revenue. 85% medical loss ratio. sg&aor service, the ratio. some is executive salaries. the rest is the care management

program i was talking about, keeping people out of emergency rooms, fraud and abuse, all that stuff costs money. that is what the and a is -- sg&a is. what is interesting to me, if you look at the payment rates to medicare advantage plans, in the last five years, they have not gone up a single year. the base reimbursement has fallen, including 4-5% cuts in a couple of those years. that aregg about cuts coming in 2014, this is not a totally new environment for these plans. what is interesting, if you look at the. frame, medicare advantage plan enrollments have accelerated and margins have been stable. the benefits offered to seniors

have been consistent. another indication that the plants have been able to mitigate rate cuts through some of the cost savings mechanisms we talked about earlier. this is a chart from humana. it breaks enrollments into quartiles. the peoplear is that have benefits that are 15% or better than fee for service. you can see over that three- year. , -- time frame, the benefits of increased. the benefits have been stable and that has been consistent across all the payment quartiles. the ability that plants have to

save money versus fee for service, it varies a bit. these are humana statistics. it breaks down memberships in terms of provider reimbursements. --they turnal money over to the hospital and doctor and it is up to the provider to manage care. in those situations, humana can save almost 30% versus fee for service. that goes to the point of why i think medicare advantage can be viable in this payment system in those urban areas. if you scroll down to the bottom, providers that have no incentives or very little incentives, the savings is only 9%. in those areas, it will be difficult to offer extra benefits that attracts seniors into the program.

explain whyo companies like humana are doing everything they can to try to into productsle where providers are taking risk even to the point that humana has gone and started buying up doctor practices. you have seen a couple of those acquisitions across the industry over the last couple of years. this runs through publicly traded companies and gives you a sense of where membership is today among different products. there are some significant differences. spectrum, youthe have a large medicare company, united, where almost 70% of their membership is in hmo products. a littleike humana, more than 40% of their products is in hmo products.

as you think over the next couple of years, much easier for companies like united was a lot of hmo, with a lot of risk sharing with hospitals and doctors to be him to work through those cuts that it would be for a company like humana or universal american to have a significant amount of areas within rural providers with no incentives. a thing i think will become more , these star bonus payments. the higher-quality medicare plans. starting in 2015, you have to get to four stars to get a four percent bonus payment. are three if you stars or better, you get a bonus payment. if you don't get to four stars, no bonus payment.

three point five star plan, not only do not get that 44% bonus payment, as mark ,- four percent bonus payment inh that will translate to the specific example i have, you could have a $50 a month differential between one plan that is four-star rated and one that is not. that is a significant amount of extra benefits. these payments due become significantly more important. is where they stand for my star ratings perspective. it is almost four stars, just under. they are in a relatively good position versus somebody like well care, who is under three stars at this point. well care operates specifically in the hmo markets.

florida is a big market. it will be extremely difficult for them to compete if they're not getting bonus payments and everybody else around them continues to. i will stop there and we can start questions. >> thanks very much. you have the opportunity to join the conversation. if you're going to a microphone, or you ask you to identify yourself and to the question as brief as possible. if you have a question, hold it up and someone will bring it forward and we will spring it on our panelists. >> stuart gordon from wellpoint. alyssa did a great job of , butighting the successes

one of the things that happened is that they changed the risk adjustment in such a way that it will impact particularly the low income and chronic needs people that are in wellpoint special needs plans. it looks to our actuaries as aough the impact will be reduction in reimbursement almost equal to the growth factor increase. , has a staff had a chance to look at the impact of that risk adjustment calculations? >> what we have done their is when cms put out its call

letter, we have a comment on that change. we were concerned about it. we felt that they had kind of mixed coding with risk adjustment. we feel it should be accurate but there felt there was some mixing of the coding change. we suggested they step back and not of lament that right away. right implement that away. what we have done -- this is talked about in our june the 12 report -- we think there does need to be some improvements to the risk adjustment system for these types of populations. we made a center for conditions in which we think would tighten the risk adjustment system. we think there is some adjustments but can be made to the risk adjustment system that would take the distribution.

for those people that are taking the chronic condition -- the risk adjustment would work better for them. this is already out in june 2012. i was opposed to say that a lot of the things i i was saying are in our march 2013 report. i forgot to tell you that. .> yes, ma'am >> i am a primary care physician. of the medicare population is responsible for 80% of the cost. of medicare days advantage, there was concern that waspopulation attracted to medicare advantage

was healthier than the population of fee for service costsn so that their would be lower. i was wondering if anyone has look at that recently? nobody has mentioned it. >> i think there has been some examinations of that issue and has found overall, the differences in the risk scores, which i think is what you are referring to, has never had over over time.rowed it differs across the country, so that is something to consider. i think more research as well. >> i would add that initially when the program began, there

was not a risk adjuster. that has been added to the program, and made a significant difference as well to make sure that appropriate payment is made for those with chronic illnesses. what you see in the advantage plans are a huge emphasis on coordination and emphasis on primary care to make sure those individuals are getting the right care. >> is there a discount for people who don't require care at all? >> yes, you get a lower payment because of risk adjustment. lex i think i would have said the same thing gretchen said. there has been narrowing of differences but there were three recent studies in the last year or so -- they are still finding mae lower risk profiles for beneficiaries, but it is not as high as it has been in the past. >> i am jim of medicare advantage news. i would like to ask paul mcdonald the question gretchen

brought up. in thesee any change most recent annual election. -- timeframe? to what extent do you think it will likely to increase in the coming years? >> i will exaggerate and say basically zero, directly. seniors don't care. the examples i would give you is if you are and what is considered a low performing plan or under three stars for certain timeframe of years, seniors get mailed a letter giving them the opportunity for aspecial election to move to higher rated plan. few seniors choose to make that move. generally, the feedback from senior shopping experience has been they care about premiums, first and foremost. it is much easier to sell a zero premium plan than the $50 premium plan. it will be things like drug

coverage, primary care credit -- co-pays, etc.. the point i made indirectly, if you're a higher plan, you can offer extra benefits. with that, you are able to offer lower premium plans and extra benefits. there is an indirect but generally seniors don't care about star ratings. do you see that changing? >> probably not. >> i will follow up to gretchen and that is what kind of measures of provider quality are included in that and is that a good system for beneficiaries to know about the providers in the network beyond satisfaction? >> part of what is included in the star rating system are what are known as measures which are quality measures that measure things such as did someone get the appropriate test that they

should have received, are they getting the appropriate preventative care they should receive and measures such as that which should be correlated to the quality of the physician. measuressures are such as the patient's satisfaction. also, some administrative measures that are included as well. there are measures in there in terms of whether are not the physicians are doing what they should be doing. >> not directly about the physician? >> no. >> hi, i am with the heritage foundation and i have a question about enrollment in the future. in 2010, the actuary said the aca would reduce enrollment by 50%. >> could he stand closer to the microphone? the cbo said012,

11 million people would be enrolled and they now say it will be 21 million in 2023. that includes reductions. i know that none of you are cbo, but do you have an idea of why they drastically changed their enrollment projection? >> they have not given in an formation of what drove the change. i'm speculating here. historically, they have not assumed any cost savings for managed-care companies. all they have done is look at the projected payment ratings for the plans over the future. and madeame assumptions about enrollment. to have that kind of a swing, they have to be assuming some level of efficiency that managed-care companies are able to realize.

my perspective is these new numbers are directionally better, although they seem a little bit optimistic given the payment challenges that we will face over the next couple of years. the opportunity not to answer your question. i don't know why they changed their estimate. i want to pick up on some things karl said and what might be implied by why people like karl and others are looking out. i am often asked these things. what i want to say is that actually i think there is really good news here. again, i think carl's comments get to it. under the old payment system, where the benchmarks are set well above fee for service and people are bidding above fee for service, we are getting average goods out of managed-care. basically, the private plans or

saying, i can't provide this benefit as efficiently as the traditional fee for service. as a country, we were paying 10% above fee for service for that privilege. now what is happening is under the pressure of the benchmark and the fact that certain plans have been moved out of managed- care environment, you now have much more focus on the plans that actually can deliver the benefit more efficiently. of feerage bid is 96% for service. managed-care plans can provide services less expensively. the question is, whether it is a program would take a vantage of. , their average bid is 92%.

maybe that has something to do with people looking forward and thinking lands may be viable in the environment. that is not official from cbo. membersyou get together, do you hear optimistic or pessimistic views of the future enrollment? >> when you look at the numbers that are out there in years to come, in terms of the cost, the new tax, it is hard to see how you can keep the level of service, the level of cost sharing and the level of benefits stable because they are such huge costs ahead. it is a big concern. it is a very big concern, how people are going to want to work hard to keep stability for their beneficiaries. it is critical for older people to make sure -- they get scared.

i know my appearance were in medicare plus choice in the 1990's when plans left. they called me every day and it is a huge problem for people when their plan premiums go up or they have to leave the program because of funding cuts. when you look at numbers ahead and other concerned with a sizable cuts and you look at the -- are people going to say we will hit medicare advantage again? it is a huge concern in looking at the costs. a lot of worry but a lot of work. we will continue to work on new innovations using what we're doing on the private sector but is very effective in translating that to medicare advantage plans. >> one interesting side note, it is helpful to think about

existing programs versus new seniors that could come into the program. the distinction i would make, seniors already in the program, plans can do basically whatever they want to go seniors and they will not leave. you can raise premiums as much as you want, cut benefits as much as you want and time and time again, seniors as shown they will not leave and go back to fee for service. they could switch to another to early going back programs, seniors left and went back to fee for service when their lamps went out of the market. as you think about the growth of the program, we think about the cuts, it is going to be about how attractive is medicare advantage to seniors that are not in the program now. >> george? go ahead. the healthrge with plan of new york.

we have been contracting with medicare's unfunded 55. -- since 1965. i have to say, i have never heard so much i can disagree with. in particular, the tone of the optimistic enrollment forecast. if you forgive me, on page or team of your excellent report, the optimistic sentence that the fact enrollment continues to grow. . am shortening that sentence in your report, you point out that 44% of medicare advantage members are in high fee for service areas. a high percentage of those are in what we called zero premium plans. most of these are in urban areas, serving people. use of the data before -- who

cannot afford supplemental medical coverage. that is a big part of the constituency. the other part that you have not talked about are the employer members who age in. in, as projected, the rates those urban areas are going to go down to 95%. if you add to that the data that alyssa gave you on the impact of ,he cuts, several of the cuts we have gone through the pleasure of presenting our bid to cms for next year. how can you make these enrollment forecasts? what am i missing? the comment people would not leave, i am sorry -- 40% of the

membership is employer-based and a price sensitive. they will leave depending on price. those low income people who cannot afford it, they will leave depending on price. maybe somebody on the panel can tell me what i am missing, but when we come back to the title of this presentation, the future of medicare advantage, i have been doing this since 1971. i am very pessimistic, so please tell me what am i missing here? i think no question, it is a difficult environment. 2014 is going to be a challenging year. the way i see next year playing out, to start there, enrollment in the program is going to continue to grow. not nearly as much as what we have seen in the last couple of years, but i think things to

keep in mind is there are many more seniors turning 65 now than was the case five for 10 years ago. there is a demographic aspect to it. overall, most plants are looking at something in the vicinity of the five percent reimbursement cut in 2014. ,f you assume costs will rise there will be a headwind. plans are going to be able to adjust to the benefits in most regions to be able to absorb the bulk of that. there may be margin pressure as well, but i think that type of toobursement cut not dissimilar woman sought in 2010 when rate fell 5% -- of what we saw in 2010. it could be a comparable example where plans were beat

able to cut benefits and you saw the enrollment increase in 2010. there is some historical precedent for some seemingly big reimbursement cuts to be mitigated by the cost efficiencies. >> the thing i was going to say is once again, i think the change in the benchmark has put the plan under pressure to find efficiencies that in theory they should have been pursuing all along. i do think -- i don't mean this -- you ask what you are missing. what i see is a big change over the bids i4 years, have come down and creating the under fee-for-service to finance the benefit. each year, we keep looking at thee bids and you tell me,

plans themselves are projecting nine percent and 10% increases in enrollment. they think they will be increasing enrollment. we are in an environment where everybody is pressurized. the same sequester that hits the ma plans, they can bid themselves away from some of that to some extent, although they risk losing beneficiaries. the congress set up a system to have higher benchmarks in those parts of the country where managed care can't do as well. that is an important policy question we ought to discuss and the reason why google might be optimistic is there are subsidizing plans in the country and something else other people said -- i'm sorry i did not mean to say all of this -- the quality rankings.

that will drive money to certain plans. plans can leverage that, they won't be able to get additional resources to offer benefits. i don't think you're missing anything but that is what i look at. at least in the near term, that is what i see. the projections spanning 10-15 years out, i have no idea. i am with the national committee for quality assurance. thanks for a great panel. we are seeing plans in the past that were not serious about quality scores. what are examples that you are seeing from the palace perspective, things that are helping to get the scores up? how can we make this measurement more relative -- relevant so they do care about them when they go to pick it plan? when you go to the plan finder, they're listed by cheapest plans. maybe if they had high-quality

plants first, would that help drive more enrollment to the high-quality plans? i would say from the plan perspective, what companies have done, they have started to care about them now that there are dollars attached. if you go to any one of these companies, they will have a whole team of people that will be able to tell you down to a contract where are we on each specific metric. companies go after the low hanging fruit. if there is a contract where they are currently at 3.8 stars and if they can get 50 more people to see a primary care physician, that will push them up to four, that is where first dollars are going to. it has been targeted at this point.

as star ratings soared to get better, it will be more difficult for plans to see that kind of improvement. that is what they have done up until this point. in terms of how you get seniors to care about it, your idea of sorting is worth a try but it seems like every single selling season, number one, what is the premium? maybe right below that, is my doctor in the network and everything else is down the list in terms of co-pays, the but the ratings. -- star ratings. >> i would add that plans are working hard to try to get better data because a lot has to or you getting the data can see results with greater focus.

i agree with you that people are not paying attention to the ratings -- i do not agree with you. using similar at ratings for exchange products. i think you will see attention to these kinds of rating systems across the board. >> go ahead. brian and i amis with the national health association. i am wondering, what if xp you see these payment reductions have a on medicare advantage rural safety net providers, critical access hospitals? are huge uphe cuts ahead. there is going to be -- it will put a lot of pressure on payment rate supervisors, keeping benefits at the levels

that you will see cutbacks in benefits. increased cost sharing and it will be difficult to maintain the kinds of levels we have seen. we are worried about all of that. the cuts ahead are huge. go ahead. >> i am mike miller, a health policy consultant and the blogger. one thing i have heard about people talking about is shared savings programs are like a training ground or minor leagues for medicare advantage. can anyone talk about those kinds of plans organizations evolving and growing into medicare advantage plans and how that might affect the future band with for a number of plans

and enrollees? may be people at the other end of the table would be speak positioned to about this, being closer to the industry. the people that are coming into .y office -- i lost him again where are you, mike? there you go. for some reason, i contact helps me. i feel like i am actually talking to the person who asked the question. the people coming into our office and talking to us about this seemed to mostly break out on the side of know, the supervisor driven organization. it is driven -- different than an insurance organization and there are certain advantages to that. even though we might want to drive toward application -- capitation, we are not thinking insurance.

i don't know how to characterize this but there are people who show up and say we are thinking down the road that we might jump the fence. the sense is, most of the people coming in and talking to us, it is a different model. at least for the near-term, that is the way they are thinking about it. just a quick brush. we consider patient centered medical homes the foundation and we have patient centered medical homes and almost all states. we are partnering with those ourician practices in private business as well as our medicare advantage business and we are also partnering with the as well.driven aco's we will be incorporating those types of arrangements going forward. concept isthe

interesting but it is a challenge for provider groups to become a managed care company. you basically need to transfer the actuarial underwriting capability of the managed care plan down to the provider level to make that his success. hospitalonprofit conference every year in new york. andsay we will take risks we don't need them anymore. this past year, we did it and the direction is still the same, but the pace and tone is very different. it is collocated. these companies have been doing it for decades. -- it is complicated. the idea would can come in and price it appropriately is -- they realize it is a very significant challenge. they just don't have that infrastructure. the one thing that the plans are doing better this time around

relative to the physician practice management issues of a couple decades ago -- rather plans giving risk to provider groups that are willing or dumb enough to take it -- as mark said, they are starting baby steps. is your coste threshold. if you go above it, that is ok and try better next year. year two is double-sided risk. at some point, you can have providers taking on full risk. as opposed to jumping in from day one. >> bipartisan letters from congress more than 160 i see in one of the handouts, the centers for medicaid services, how effective for these -- were these? >> the subject was? the cut that turned into an

increase earlier this year. i think you are talking with the update on what consumption was with respect to the physician payment update. we felt that it was -- that they should always assume that congress would fix the payment rate in the medicare advantage update for several years. cms three years ago with a legal opinion saying that did notake sense -- make sense that there would be a big payment cut to physicians that will be included in the medicare advantage update which cut it significantly. and then you pay it back year after. that is not the the way we set our contracts of hospitals and doctors. we think it was very important that this year in particular were medicare advantage plans were facing such a significant

cut to make sure that the payment rate reflected the correct assessment -- assumption with respect to physicians schedules. for the last 10 years, there's been an assumption that dr. fees will be cut. congress has acted every year to make sure that not happen. we were very supportive of the final decision on that. >> i may have my timing off, but the button -- the bipartisan support, boy did not matter -- probably did not matter. the initial rates came out in february, fairly shortly after that, they made the decision they were going to fix the payment rate to the advantage plans.

biotime the bulk of the decisions came out, the decision had already been made. -- by the time the decisions came out, the decision had already been made. i think part of it is who is sending the letters. it matters a little bit more of who the people are and whether it is nontraditional. >> we like to think letters matter. it is how much do they matter is an unanswerable question. next. i wonder if you can talk a little bit about my merry care physician recruitment -- primary care. isn't normally a problem with fee-for-service?

are you seeing that as a big situation that you have to deal with? >> yes. we have been focusing a lot of our efforts on trying to to placeprimary care a better emphasis on primary care. we think the patient centered medical homes are so critical and a major foundation. onave not seen the numbers graduation rates and how many people are going into primary care recently, but i know that our plans are working closely. some of our plans have actually ordered with medical schools to try to get more graduation rates and more people going into primary care residencies. that is a major focus of planned efforts across the country. a little bit off the

subject, but i think your question is broader. in our work, we survey every year for access. we have seen stability but to is people -- it looking for new primary care. the commission has made a series of recommendations to try to rebalance the physician fee schedule in order to move resources towards primary care and away from procedural services. i won't take you through the gory details that is something something we are worried about. back to you. >> ok. you have talked a lot but the impact of the cuts and that they will be devastating. this question is what tools do you have, such as blue quashed -- blue cross blue shield has

to try to mitigate the increased cost of those imposed by the health insurance plan? >> we are urging congress to repeal that tax for everybody. it is very expensive. it will add not only to medicare advantage premiums but to premiums, individuals and small businesses. it adds for a small business a family of four, $400 a year. we are working to try to repeal that tax. it is difficult because it .aves -- it costs $100 billion you have to find an offset, which is challenging. plans are working to constantly try to work with their providers. we are working on patient centered medical homes.

carefirst has shown again for the second year in a row, 2.5% savings. plans across the country are working closely in partnership with hospitals and doctors to better costs, to employ management techniques. when you look ahead, the health insurance tax is a clear attacks and will increase the costs to beneficiaries both in terms of medicare, medicaid. federal employees and to others. it is a big problem. >> what are some of the actions that plans can take to reduce costs at the beneficiary end of the day and how would you change what services are provided or what reviews are being done to beneficiaries? >> each plan will look at their own situation.

people may be increasing cost sharing and may look at reduced , doing more coordination and management. you don't want to increase cost sharing or reduced benefits. their ownill look at plan and try to be as efficient as possible, try to get the prices down if they are paying the hospitals and doctors, employee more coordination and management of services before cutting back benefits. my guess is, it will be accommodation of all of those. >> -- a combination. >> you will see in a couple of markets, plans exit. make a point than anything else. if a company like you -- united or humana, they pick rural members and leave.

they could say there will be consequences. we exited these counties and we will do it again if we have to. it will not be widespread but i think you will see that in response. .> that is a major concern we know what beneficiaries want, security and through the best stability of their benefits. older people are very concerned about their health care expenses because they are so significant. is an articlere about the financial stability. it is a great worry for people. we are very concerned about the impact. >> stuart gordon from wellpoint again. let me run an idea by you. star ratings that don't have a huge impact on

beneficiary choice of plans. assess starcould or bias of thety commencement to the plans of the state and put a rating for fee- for-service enrollees on the report card with ratings for the plans. would that make ratings anymore relevant? dr. miller, you may know how difficult that would be or gretchen, you might know. >> we have a question asking mark to comment on how you would compare quality and fee-for- service if you are trying to achieve neutrality between the two. i should try to get off the stage. we actually did an extensive report on this. the report is now -- i'm going to say -- this is what i am

struggling with the answer. the report is about three years old. there are several issues. some of this goes to -- one of the big issues that rises is we have a different risk structure. anything you put out there, you have to be able to contract through the differences in risk. that is not a simple thing. not necessarily impossible. is the issue that arises geography. sometimes you say here is the plan, but the plan has reached .cross many different markets to truly make comparisons fair, what you probably end up needing to do is comparing the plan in that market to fee for service was is the plan as an entity across many markets in the

country. those are at least a couple of the challenges. then the report goes through in much more detail some of the differences in measures and what would have to change in order to do this. this is a tall order and would be very expensive. win-win for the report out, it was a request for report to congress. we said these are the types of steps you have to take and i only touched a few that i care member of the top of my head. also, they would need to be given the resources to pull this off. it would be a big undertaking. you're absolutely right. in terms of payment neutrality, which i did not have time to say this -- where you ultimately managed care that as an entity, i don't think this proposition is there yet, notwithstanding research that was cited. if managed care is a better

quality product, then payment should reflect that relative to fee-for-service. the signal to the beneficiary should be there as higher quality over here, so we agree that there's metric should be established. and comparisons should be made. it is a tall order and it was written up a few years back. maybe that will give you some the to work with. >> good answer. >> alyssa, this question is -- if you are a beneficiary, why ?hould you choose an ma plan >> we are lucky and we offer both. we think people should have a choice of plans. andblue plans offer medigap most offer medicare advantage. --y get lower benefits

higher benefits. i think a lot of people make the decision for those reasons. in yourthe cap apply medicare -- medigap plans the same? it does, but you pay a lot of money for it. there are additional requirements that are above what people in traditional fee-for- service get. >> for gretchen, our quality measures in the star system good enough or how can it be improved? we have done a fair amount of work looking at the quality start ratings. ratings. they are comprised of different measures and most of the measures that are currently out

there that could be -- they are measures of whether or not physicians are doing appropriate tests. they include the cap measures, which assess whether patients are satisfied with their plan will stop they also include administrative measures. do they have the right translators to their customer service. include all of these measures, i think some have raised questions as to whether or not there needs to be a different balance to the measure or some measures should be weighted more than others. i think that it is still being debated and it is still up in the air. they include many quality measures in them. >> do you want to add to that?

mark, we have a question that came in advance directed to you but it is not fair to direct it completely to you. it quotes the medicare trustees report saying that the medicare advantage plan bid assumptions were lowered to reflect recent data suggesting that certain provisions will reduce growth by more than was previously projected. what is or are the recent data that was referred to? holdsay, i don't want to marquis response will for the trustee said. -- mark responsible for what the trustee said. i would not want to speak on their behalf. >> ok. you stumped the panel. [laughter]

we have exhausted the people at the microphone. almost. you should take the time while diane is reading this question out loud to fill out the blue evaluation forms that are in .our packets after you are done >> i think the system has generated a lot of interest. that weast question will take today, some plans have complained they have been scored on criteria before they knew what the criteria were. is this a problem and is hhs working to improve this? >> i would say our concerns about it.

we want you to know what the criteria are and there will be an opportunity to comment. we would like to see a more formalized process underway. >> is there any indication the department is moving to a more formalized process? >> not that we are aware of. >> if there is anyone in the audience that will like to chime in on this, they should feel free or not. >> obviously, there is a lot of interest in being able to assess how well the beneficiaries make out when they are choosing one managed care plan over another over fee for service. i think we have seen a lot of issues raised today, but i think we also are hearing very clearly that we need better ways to measure what we're getting for what we are paying and also for how to pay. medpak and everyone

in town is going to continue to work on these challenging issues. next time, we will put mark on the spot. , we will add to that continue our examination of different aspects of medicare. another briefing we are bringing to you with the partnership of the foundation next month on the fee for service cost sharing floatingosals that are around on capitol hill and elsewhere. we look to deepen our knowledge about a different part of the medicare program at that point. i would say thank you for keeping the conversation going in a very lively and useful direction. family foundation for their contribution to making this a success and ask you to help me think the panel for a very useful conversation. [applause]

thank you. it was very nice meeting you. >> thank you. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> in a few moments, an interview with michigan rep john dingell, the longest serving

member of congress. "washington journal" live at 7:00 eastern with segments on data collection programs and how washington investigates itself. the house of representatives is back in session for general speeches at noon, eastern, with legislative business at 2:00 p.m. on the next "washington journal," we will focus on immigration and tax policy, our guest is the former head of the congressional budget office. the federation of american scientists will take your question about data collection programs that use electronic surveillance of phone calls and the internet and will be joined by a reporter with the associated press to discuss the recent article about how washington investigates itself. she will look at the relative power of the executive, legislative, and judicial branches of government. "washington journal" is live on