tax code spends a lot of money on our behalf but does not give up the ability to discipline in any sense. let me just open the floor to questions. please just wait for the microphone to come to you and then please state your name and affiliation. thank you. in the back there. please stand up, too. >> i am a member of this group. i do not understand something. when did being a doctor stop being a profession and not a business?

they wanted to have a presumably steady income. now, we have doctors who own portions of a hospital, the radiology lab, this and that. they are in business. it seems that is part of the problem. that is to say, doctors do not they are not the ones getting rich here. i think it is completely wrong. >> it is completely right. thank you. >> in small areas, in country situations, it is a problem. there is still, if there is anybody, a country doctor not making much money. in urban centers, i do not think that is true. >> i am counting on my fingers the numbers of doctors my family has been to in the last year or so. it is probably a dozen. none of them is a consultant for a drug company or at a clinic.

the vast majority of doctors, as i point out in the article, and the nurses, they are the only ones who do not live in this alternate universe of being on the gravy train the rest of the country has not enjoyed for the last decade. it is just a fact. on my list of priorities, i would care more the regional sales manager is making a half- million million dollars a year than i would the doctors are making half $1 million zero or a million dollars a year. >> that is part of the pricing system? >> that is crucial. i talked before about how medicare's choices affect the practices of medicine, not just the cost. one of the most important things medicare has done is by underpricing the services of general practitioners relative to procedures. it has caused over two generations to disappear.

this 6000 left in the country. 6000. you may have thought, medicare expansion going from 500 billion, that is serving sieges seniors. one of the reasons medicare prefers procedures and tests and major operations is because it is easier to justify spending money on them then somebody else's time. what do we have among seniors now? less than one third of appointments seniors have would doctors now of pediatric -- two thirds are now for specialists describing specific procedures. i want to be careful not to talk about excess care as a matter of money. lance published a great study a year ago looking at every

medicare patient at the year of their death. what they discovered was shocking to almost anybody in this field. one out of every three medicare beneficiaries -- one out of every 590-year-olds had surgeries. most doctors will tell you there is almost no reason for a 90- year-old to ever have surgery. when i talk about problems in medicare, it is not really about money that the type of care being driven for our seniors. test rich, diagnosis risk -- risk, and what really matters is we are subjecting our seniors to an enormous amount of care that does them harm. >> i agree completely the incentives for general practitioners and doctors are just completely reversed.

i will add in the debate over the obama care reform, there was an effort to add various measures which would allow medicare to opine over whether someone with terminal cancer should have hip replacement a month before they would die. that became part of the betsy mccoy death panel and everybody just ran for the hills rather than try to pursue that form. >> old people should depend on medicare. they like that program. he will not get rid of it realistically.

if aetna tried to do that, they would go after that, too. >> a different point there in terms of how the politics get in. it is almost impossible -- >> not quite. to take an example, there are state laws that mimic medicare. medicare says if the drug is fda approved -- congress says if the job is fda approved, they have to pay for it. various state laws mimic it, especially when it comes to cancer drugs. even if one drug cost eight times as much of another drug, to be licensed to sell insurance, private insurance, in

that state, you have to pay for drugs. i do not think you get rid of the politics of this if you get rid of medicare. >> i say we cannot get rid of congress. [laughter] >> that is right. what i am proposing is not that we get rid of government supports. the difference is, by creating more of a market in routine services, we create other incentives. we try to balance it. the reality is everything you are saying is absolutely right. my point is, we have one disease. dialysis is regarded as the most corrupt, poorest quality, highest cost, most complex, and ultimately the most dangerous part of our healthcare system. the ceo is one of the -- my point is not that we should

get rid of all of governments involvement in healthcare. my point is, let's turn the safety net into a safety net. what we have now governs the medical economy in such a way that creates perverse incentives for stuff. people are suffering. we can look at low prices and say, it is about low prices. not if care is genuinely interest. people are taking -- not if people are taking too many drugs. but if they are doing it in an environment -- i saw it happen to my father, the type of sloppiness i would not expect anywhere else in our economy. since i have joined the board, what i am aware of is that they do not have the right discipline. they do not have the right accountability. i would like them to balance that. i do not think it is either or. we are just entertainers at the end of the day.

[laughter] class keep entertaining the crowd. any other questions? >> the guy with the google glasses? >> are you sure you can interrupt yourself and talk to us? [laughter] [indiscernible] [laughter] >> one of the things [indiscernible] dealing with medicare, this results in the best doctors. just ask their patients. does this not cause us to end up having giant hospitals, the hospitals doing a lot of

medicare [indiscernible] i am trying to get this in the right spot. are doing well because [indiscernible] other hospitals do well because they can handle the insurance system well. doctors can handle the insurance. >> hospitals do well because they do especially well in places like connecticut where they are the only game in town. then they tell the insurance company what they will pay. >> there are still economies of scale in healthcare. one is leveraging in insurance. with medicare it has a single diagnosis. 65% percent of hospitals have an exemption to it -- an exception to it. another 25% are completely. >> they are really not material.

>> they are material enough to lobby heavily. the second economy scale is very important. which is administrative. if you look at i.t. and healthcare, that is the worst of any consumer facing industry. they invested very heavily in billing technology. the major economy scale and administration in a hospital is dealing with regulation, insurers, and payment. general hospital's long ago stopped being the best way to treat people. yet, their political power and enormous advantages in the administration have prevented small, specialized institutions from competing effectively. the average doctor spends 20% of his time in paperwork. you're taking the most expensive and value part of the system and turn them into insurance clerks.

>> they are happy to sell their practices to hospitals so hospitals take that over. >> next 10 in -- next able in the back? -- next table in the back? >> thank you for putting out doctors are not the one making money on drugs. i am an oncologist. >> you get a little bit of a market. >> you are actually losing money. people in private practice is a much more because hospitals are getting massive discounts and that is why they are able to buy up practices. it is much more expensive than the hospitals. people who think doctors make so much money, residents age 31 and 32 coming out with $200,000 in

debt and getting about 130 or 140. i would worry about who is taking care of us in the future. that is my big worry now. >> question, explain to me why the choir got the salary he got when he required -- retired. -- why maguire got the salary got when he retired. he still want up with about 1 million and one half dollars. that is one of the reasons we have art of our healthcare cost. everyone tangential -- >> there is no competitive healthcare market in this country right now. there is not likely to be. you will see above market salaries. hospitals are good at things they do a lot of. depending where you are, if your hospital does a lot of specific procedures, it's success is greater.

when you look at the world hospitals protected by congress, you may have seen this study in health affairs two months ago. for most conditions, they do so few procedures in a hospital, you are better off flying to a city. it is cheaper. general hospitals do not exist because they are good at everything. they exist because they are general. they are like big department stores. they not so good at things they do not do a lot of. we would be much better off having the type of competitive advertising leaves see in other things. we do not have it in hospitals. it is unfortunate because the presumption because it is big and does everything, it is the right place to have my hip replacement or my bypass or what have you is not a presumption that is met by the evidence. most consumers do not know that, just like they do not know there are massive differences between the safety records.

[indiscernible] >> sure. the political thing for me, it is something we agree on, the political influences major in these things. part of my argument for moving more dollars through individuals is to move some of it away from political decision-making. if you look at something like dialysis, you see the influence of political contribution and how medicare pays for dialysis. >> i would add if you have much more transparency, it is probably the only way you will fight the fact the healthcare industry spends something like 3.5 times what the much bear military complex lobbies in washington, which is why nothing we are talking about a peer will change. unless you get people really angry and the way to get them angry is to give them information, to tell them there is a $77 charge.

this hospital is doing a lousy job, this hospital advertises, those are the kinds of things to get people aware of this so they can counteract maybe what the forces are in washington. >> we know in new york -- one last short question. the young lady in the back? >> two really short questions. i just want to make sure i understand what the solution is. are we talking single-payer, all payer employers driving the change to high deductible plans and abandoning -- demanding more

transparency? is there any country in the world that has the model -- >> don't say [indiscernible] there is something wrong about that. [laughter] singapore -- he will say singapore. they point to finland to change the american education system. anyway, i purposely did not expound on a master solution. i do think what you need to restore or create israel leverage in the market place. part of that is the market has to intervene. you can have all the transparency you want. when you tell that cancer patient, who is waiting and sweating, to say, the transfusion costs over $13,000 and only costs the hospital less

than one fourth of that and it costs the drug company a couple hundred dollars. you can have all the transparency in the world, but he needs the drug. this government, this country, some way or another, has to intervene in that part of the marketplace the way every other country in the world does. there are all kinds of possible solutions, but they all involve the same thing, which is a lot of transparency, and some kind of intervention because you have to ignore its the fact this is not a free market -- to acknowledge the fact this is not a free-market. >> i am glad we are agreeing. we need to take advantage of what healthcare can do in this country.

our healthcare will get far more personalized, far more responsive, far more integrated. the amount of care spent on the urgent cases declines every year. healthcare will be our major consumer industry. the question is how do we organized. right now, we are organizing it the way we first thought of it in the late 19th century. your house burning down. right now, under the guise of home ownership, home insurance, we are paying for, what happens if your house burns down, all of the utility bills, and your furniture going out of style. the problem is not, that makes us that consumers. it makes the industry that providers.

consumers do not drive any consumer driven industry. providers do. the providers come out with a new phone, a new car, a new this every month and try to convince you to buy it. we found a discount m.r.i. in my family by calling around and asking. in every other industry, they find you. that is why we are in the media business. so they can find you. healthcare will look more and more like most industries in terms of what it can do but we continue to structure it in a way that is old-fashioned. y echo one of the reasons is that we look at the rest of the world and say, look what they are doing. how come the europeans can get similar, better mortality data on less spending? one of the ways to get less spending is by spending less. we are never going to do that in this country. congress has never been able to do it. everything is subsidized one way or another. another reality of america is healthcare spending has nothing to do with mortality at this point. mortality drivers are diet, drug use, smoking, alcohol, income, and education.

>> and playing too many video games. [laughter] >> which my kids argue will increase their lifespan but it is a shortening mine. [laughter] we say, they are doing so much better than that. they are not. no country is confident on their ability to handle the growth of health-care spending that comes out of the statement of, we will pay for everything you need, cause the industry response to the net -- to the statement, the amount of healthcare we need will get bigger and bigger as we get healthier and healthier. guess what. there is no way to fund or discipline that. i like symbol for -- singapore. i like it for one reason. they did a lot of things that would be hard here. it is the only country on earth that does one thing very differently. it separates out the role of under and payer.

we have forgotten they are separate. an insurer can write you a check and you can be the payer. in singapore, you are the consumer even if the government is paying 95% of the bill. you always make the purchase decisions. they found the affect to be extraordinary. they have healthcare just like everyone else in the world. perfectly good. a lot less demand and lower prices. >> you left out the fact they have price controls. >> i did not. there are tons of things singapore does we would have a hard time doing here. we will never have control with congress. it is not an option. it will never happen. what can happen here? this is a country where we are leaving things to consumers constantly. i am not going to -- for 100% of the market. let's take 1 million and one half dollars and put half of it in a catastrophic care system that is national, universal,

cradle-to-grave, and that the other half go back to healthcare. we will see in industry where the providers have different motivations. steve mentioned cosmetic surgery. anything not touched by health insurance, including carefree documented. basic, primary, documented, operates on a competitive cash market. it has nothing to do with the type of care. it has to do with the type of payer. what i am calling for his understanding. treating healthcare as one thing. recognize some of it as catastrophic. where we need intervention and insurance. if we build a whole system based

on the worst cases, we will have more of what we have now. incentives doing the wrong thing at high prices. >> i disagree to a little bit on the definition of catastrophic. women in stamford who had chest pains. they thought it was a heart attack and did not have one. you want to put her on her own. another patient who fell down on her backyard and broke her nose and had cuts on her face, you want to put her on her own. i think, again, even if it is collective knee surgery, there has to be controls because you do not have the free markets you have for lasix surgery. >> we have it in undocumented care. >> you ask the people who provide the healthcar, they will be the first to tell you those people are underserved. they are driven deeper into poverty and are not getting the equivalent healthcare other

people would get. >> i do not want to put people on the rh?ne. the average working person in this country who has a family and is fortunate enough to have health insurance, is putting about 25 to $30,000 a year into our health care system directly through taxes and their premiums. if a catastrophic care system costs $3000 a person, that means that prison is on the rh?ne on $10,000 a year. we have got to get some idea of the scope of money. the $2.7 trillion we will spend on healthcare this year did not all come from somewhere else. 350 million people are not all being paid for by somebody else. we are all paying for it. we will pay billions of dollars subsidizing medicare.

you could give 100 million people $8,500 a year for their care. that is $34,000 for a family of four. when you build a system inefficient on price and administration and you are all paying for it. >> you left out the fact the people who are the beneficiaries of medicare have medical needs because of their age, that puts them five or six times above the average. you are comparing apples to oranges. >> i am happy to talk about that. >> let's table the discussion. we cannot give you both the last word. >> saturday evening, the eighth annual conference on technology and public policy.

-- at 8:00, daughter of nancy pelosi moderates a discussion about women running for elected office while legislating. you will always -- you will also hear from barbara lee. a panel looking at candidate statements that became news stories in past elections. the annual conference on c-span this saturday. >> a forum on how recent protest in brazil are affecting the country. adebate on whether there is connection between mental illness, guns, and violence. a discussion on how mental health issues are being addressed in the affordable care

act. >> we came out of those see a seaand we could of humanity coming from union station. when you was going to be big. be leadingposed to the march, but people were already marching. there goes my people, let me catch up with them. [laughter] this sea of humanity just pushed us so we locked on and started moving toward the washington monument, on toward the lincoln memorial. inwas a wonderful period american history. >> the fourth of july on c-span. civil rights pioneer congressman john lewis shares his experience

on the march on washington 50 years later. some of the places we visited and the stories -- historians we have spoken with during the first season of first ladies. pulitzer prize winning photographer's display their work and talk about their coverage of world events. bill clinton and chris christie discuss proactive steps against natural disaster. a panel talks about what it is to be a modern-day american citizen. >> brazilians have been protesting recently. the protest began over a hike in bus fares. situation in the largest country in latin america. this portion is a little less than an hour. >> i want to make this into a conversation.

i'm asking you to keep it to about 10-12 minutes. good luck. instead of focusing on what we do not know, we try to focus on what we think we know. what are the causes. why now? why is this happening? i think there are many variables here that explain what is going on.

one is that within covering for sometimes, it has become a well- known argument. the rise of the middle class in a country like brazil. that applies only to brazil brazil, but to other emerging markets. when you had the first decade of the century of high economic growth, these natural resource rich countries, you had a time of high growth because of chinese growth, a commodities growth, and countries benefited from this. in brazil, that is clearly the case. the government was very successful in riding that wave, which led to a rise in the middle class for the first time in history. it became the largest class in the country, over 50% of the population.

what does this mean in terms of politics? a lot of people are starting to analyze how the political middle class behaves. to have the same political behavior then than they were when they were in poverty. a lot of analysts say that they think they believe differently, but the do not know how. i think we have seen signs now that there is a shift in the population led by this rising middle class. the demand more. only their agenda goes beyond employment. it goes beyond just wages. it goes to more a quality of life agenda.

for a government that for years implemented successful cash transfer programs, that is not the answer anymore. one thing is to have access to goods. to cars. you can have a car, but you can write in the streets with have no potholes. the services that surround those goods, those become the real issues. these demand long-term planning from governments. if you compare what is going on in brazil today with what happened recently in the middle east and the arab world, there are many similarities. you can point out a few distinctions.

the main one would be, with some exceptions, while most of the middle east were driven by these government oppressions, in brazil it is not about oppression. it is about incompetence. on the local levels in the federal levels, the challenge for leaders in brazil is how to deliver more to this middle class, in terms of services, with less. they are faced with favorable economic environment globally.

everyone expects the next five years will be less favorable than the last 10 years. the predicament here is to help deliver more with less. that is a government issue. why now? there is a beautiful story. he gives you broad trends of what is going on. why now? what triggered it. i think one of the things that may explain, when you look in hindsight, everything becomes easy. brazil, you had a high turnover in municipalities. you already saw glimpses of this in public services. you've had a brazil that decided it was to host a major national event, the world cup and the olympics.

a lot of people in the streets protesting were in the streets back then celebrating this is a sign of brazil's rise. now the cost of these events are becoming more visible. i do not think it is a coincidence that these protests actually gained more momentum when the cop was happening. the cost became visible with the stadiums being built. the infrastructure that surrounds the stadiums not being there. airports, roads, it said rep. the promise of the government made was that these would lead to improvements. the focus has been on the stadiums than the surrounding stadiums. and love the population do not have access to the stadiums.

i think that became visible. there was a cost to host these events. well i do expect the protest to die down and go to the fringes of the political system, there is no single issue that glues these protests together. the risk is going to be a contention prone environment. the risk of these protests rekindling israel. the world cup will happen 3-4 months before the election. we can get into more details on the discussion. what is the political impact on this? i think we will see recent polls telling a much more of a shirt term -- short-term story.

approval ratings going down. not necessarily being transferred to the opposition leaders. number of undecided voters increasing. a crease is a dark horse candidate. and not a political noise and volatility in the next 2-3 months. it is too soon to say that the chances of her elections have diminished the point where she will not be a candidate or she will not run. the era of presidential popularity that began in her second term, that was unusual for brazilian history standards. now she's back to the norm.

the end of a super cycle presidential popularity. even where she is now, she is competitive when it comes to elections. i think that it is soon to say to make long-term predictions on this. i will end here. >> i wanted to raise a quick question. you said something that made me a bit pessimistic, we talked about corruption and incompetence. such incompetence, how was brazil going to resolve this? if it is incompetence that got them there. they have the confidence to get

out of it. >> i think they do. of course, when you talk about incompetence, you are not saying that everything that they have done is wrong. when you look at the positive part of the story, every social economic indicator has improved. definitely, there is signs of hope there. there is intelligence in brazil. >> well i am happier now. >> thank you for the invitation. i agree with what he has just said. no controversy. just add two numbers. 89% live in cities. brazil is far away more urban than most european countries. even more than the u.s.. although we are agribusiness, most brazilians live in cities. there is a disconnect between the country, where the gdp has been growing so much, there are

so many recent successes, and our cities. brazilian cities are still stuck in that unmanageable country of the 80s. they are even worse now because more and more cars are on the very bad streets. our housing projects, if you've seen "the city of god," -- they are still a disaster. they are very different from the national picture. the economy is not so bad. there is been improving in the last decade.

resilient cities are still very obligated -- very cop located. most are going to college first generation. that middle class is demanding more and more services. the government is not capable to answer. when i was living in china, i was optimistic about brazil hosting the world cup and the olympics. it i are member being in beijing in 2007. they had 40 miles of subway. in 2010, they had 160 miles of subway. now they have 250 miles of subway. although i am skeptical, i thought that is a great opportunity for brazil. i do think that many brazilians now have this frustration and disappointment.

we are expending a lot of money on stadiums. it is where the corruption meets the world cup. how many brazilians, without having access to the numbers, or the background stories, these stadiums that cost almost $1 billion each are somehow too expensive. the same with construction companies, which built those stadiums. the greatest fundraisers for our political campaigns. if it is right or not nationally, the brazilian middle-class thinks that. in the legacy that is being made

in beijing, somehow we are building everywhere, i am -- most brazilians are happy about finally we are going to the streets. i think from the brazilian government, should the brazilian people, we were condescending in the last decade. now we are great. now our gdp is even higher than some european countries. i think that moment finally has ended. we are not the united kingdom. we would love to have the health system of the british. i think that condescending moment, a lot of money in public, created this bubble. it is about accountability.

the disconnection between the islands that you're seeing on tv, and the reality of our crowded buses, and our subway systems that do not grow at all, finally paid the price. trying to answer a question about if it is good or bad, somehow, every country needs politicians. every country needs political parties. we are in a very bad moment. worst of all, the success was extremely popular. she is not a politician. she is not as charismatic as lula. she does not speak quite well.

but she is an amazing manager. i think that manager image is severely damaged right now. he took 10 days to answer the protest. i think she was as scared as the governor. when she answered, for she suggested a constitutional assembly. let's organize a referendum and change the constitution. in 24 hours, she changed her mind. actually, the congress must cause a assembly. she met the leaders of the fair free bus campaign, the movement that started the protests. they demand fair free.

she hosted them in. one of the heroes, she left the meeting saying i'm happy because the president hosted us, she was totally unprepared to talk about transportation. she does not have an idea. a 23-year-old girl. it is terrible when someone leaves the presidential palace saying the president was unprepared. today's before, -- they do not have any data yet. probably the girl was right. let's not jump to early conclusions. i think there is a vacuum. there parties are not enjoying a miracle.

it is in trouble. both the governors are facing criticism because of the harsh police oppression against the protesters. when the streets are completely unsafe, and may need to hire private security to feel safe, to see oppression by the police is very real vaulting -- very revolting. i saw thousands of brazilians going to the streets to protest. i think the failure of our police is something the governors will have to pay. i political class has been cornered.

it is very much afraid of what is going on. there is always the danger when you are afraid to go to populist answers. some of them are already in place, when you need to raise the fair. you can sell that, because you are afraid of the streets. someone is going to have to pay that price. imagine if no one in brazil was to raise the fares in inflation, because i fear protesters in front of my building. what happened, and so on. it is good for society finally coming after a family of years, start demanding, and make politicians work more. it is too early to see if they're going to answer with rationale and populist answers.

>> thank you very much. very interesting. >> good morning. thank you. i was brazil -- i was in brazil when the protests were happening. i was very upbeat with what i saw. even before the pope endorsed the protest. the pub is -- the pope is visiting brazil at the end of the month. the detonator of this, there are many causes of this.

the detonator was civil rights. people in same paulo -- protesting in favor of buses. you do not need to add more protest. when they started shooting at them, people that were against the kids going out joined the protest. it was a beautiful thing. it was about civil rights. yes we have the rights. they have the right to protest. can your police protect that right, competently? this is a symbol of what is behind this. they were scenes of violence here and there. there were protests in 35 cities. by the scale of this, it was minimum violence.

in some cities, protesters took care of their own. organize security when they saw that the police could not handle it. i think that there is the issue and cliff has analyzed this, he has talked about this many times the issue of quality. what brazil society, middle- class, there are lots of people from 3-5 minimum wages. it is not that this is the belgium [indiscernible]

this is middle-class door absolutely urban. it is people saying we'd like the place will read are going, which is the more prosperous country, based on the middle class, with more equity and more access to goods. we sense that this is over, because the economic growth is based on consumption, and this is exhausting. but, we're not not going to go back. we still want to go to that place. we want to go to that place and democracy. this is highly democratic event. do not tell us that we cannot go there. it is basically a debate on

priorities in public spending. it is the first time that we have a debate on that in brazil. that is the positive part of it. impunity, corruption, some of the initial movement responses from politicians were to -- if you're why and well-to-do, you have almost a guaranteed -- [indiscernible] the ladies that were sentenced to jail terms, which involved the president and her circle, they say that those sentences should be served immediately. 75% of brazil. the people who identify themselves as sympathizers of the workers party believe with

that margin of 74%. there is a changing that is very important. it is brazilian society telling people we are going to continue that. it is our democracy. politicians pay attention. there are real issues here. they are more complex than reducing bus fares.

it is clear that the space has been opened for that debate. the challenges is the challenge of leadership. we will act accordingly. it is too confusing because of this proposal presented. my senses is that this thing is not going to go very far. most likely, the congress of brazil has all the power it needs to have in order to reform the electoral laws, reform the political system. the make and submit that to a popular referendum. that seems to be the most probable direction. there are so many things about quality. there are wonderful signs, if you go to "the new york times," there is one you can click on that relates to soccer.

the cartel of global soccer. there is one that i absolutely love. we have a very long national anthem. fifa says they will only play the first part. the players and the public sing the whole thing. just to tell fifa you don't -- but they brought something wonderful. the first world stadium, the people immediately said we need standards for education, fifa standards for health. in the image of brazil abroad,

we are so concerned about that. the sign said that i love said, "we apologize for the inconvenience while we improve the country." it is very affirmative. the challenge is what they will do with this. and how you're going to harness this positive energy. their obvious winners here. the potentially biggest winner is marina silva. she is a known politician. she is seen as a person opposite the challenge. you have other politicians, the

former governor, a probable candidate for the presidency. if the cup is sin is -- [indiscernible] both come from political dynasties in brazil. they are all talking to each other all the time. these people are in consultation all the time. the political system in that sense is starting to respond. congress has rejected some stupid proposals that were on the table. eque was something that the party saying homosexuality is an illness you have to cure. that went out last week.

was voted down and there was another one, to reduce investigative power of public prosecutors in brazil. .hat was six or seven votes there have been seven decisions. .here are dangers you have -- you could have a populist coming. benefit, the could only one was president lula. president lula was remarkably silent about this. think that is viable for political and non-political

reasons. therefore we have this challenge of capitalizing on this energy. i think that talking to people -- yesterdayple their having the stock. there is no economic -- not a major economic crisis in brazil. the economy is still growing. fiddes underperforming. our economy is not very aerodynamic. there is no political crisis as such. it is a crisis of renewal. whoever that against brazil getting out of this as a better country in the past 30 years mistake. it is a moment of great promise for the country. i think people remained

mobilized. the next big event is july 11. the unions and brazil have called for a day of protests. most people i talked to say that will be a flop. that will be too much. unions in brazil have been instrumental parties and parties have zero political prestige right now. they're part of the old political mediation that no longer works. the only comparison i would make with their protests going on in the world. the people going out to the streets is the same methods which is so funds, social media. they know when to pull back. you do not know, comes out to the streets.

very intelligently stepped back. you're not going to have i public- the next major event, a lot of those issues are coming on is one the pope visits at the end of this month, especially after he endorsed the protest yesterday. not make -- it would that.tions about she may be in a position to run. think we are in a new political landscape in brazil that we do not yet understand. -- there were all

perplexed initially. what animal is this? we have not seen this before. there were all like that. and with this phrase -- there wl perplexed initially. . he was a great fighter for democracy in brazil who was in a very difficult situation. whoever claims to understand what is going on is completely misinformed. >> thank you. and preparewe start , what i hear is a pretty good analysis of what is wrong in brazil. that infect the demonstrators themselves provide statements of what is wrong. i also hear that the first reactions by the political class have not been particularly impressive for responsive. i have not heard extent to which brazil is capable of

responding. there is a hope now out there that i can. can a corrupt, political system -- reform itself, can you really redirect money that are flowing in ways that have been determined, to the and others have the patience needed. is there some reason for optimism aside from reno know what is wrong. now is public. that is the sort of question that emerges from this. whether it is good news or bad news are simply notice.

let me turn it to pat. saw.ast the first when i maybe it was a red shirt. >> i am hearing analyses of the changes in brazil. i am hearing that this is an but an urbanclass phenomenon. i would like to ask about the city's i have not heard about. other partsening in of brazil and are there different issues in different cities? >> mine is an extension of peter's question. herer,were advising

is what you ought to lay out questio? >> thank you. just on one pretty direct question. what is the role of the u.s. or foreign powers in this. >> non-. >> thank you. >> this gentleman over here. just came back from the beach. >> i am struck by some of the parallels and divergence is between brazil and russia and this shift toward a middle class society. . i was in brazil in 1992. and there was this great expectation that this was a watershed moment.

this would be to a renewal of brazilian democracy, or rejection of corruption. what is different today, are we going back to another cycle of ?isappointment >> thank you. thank you for an excellent dialogue. when the professor spoke about the spirit of brazil i .emembered one comment when there was the election of the pope, the pope is argentinian but god is brazilian. >> that has not changed. >> i question is, you have expressed that this is the way of a dialogue of democracy.

you have also related it to other governments. how would you compare it with the occupied movement that took place here in the united states? >> what do we go in the same order? thank you. interesting questions. in terms of the cities and -- severallieve hundred cities, medium-size cities had some sort of protests. was basically an urban event. brazil is urban you can: a national event. you can began with public transportation. definitely other movements, many middle-class movements,

use, etc., they seized the opportunity to make themselves heard. we definitely have a very colorful movementsding their issues. which is a good thing. movements will dissipate a bit own agendas. it is something unseen in brazil's history. rousseff,president the good and the bad side of this movement and what is going on, on one hand it is anti- political. regardless of how the political class response, it will not be 100%. it is an anti-political movement. for president rousseff, from on there will be more

accountability and scrutiny on what they decide to do, which is good. checks and balances. brazil's political system is very brazilian. it adapts. when you look at how it evolves, it is usually two steps and one step back. when you look in the u.s. on privacy that we have today, i'm not saying that it has failed in terms of civil rights, but you do have challenges. it is the basic growing pains of being a democratic system. that is the main difference between brazil and russia. it is definitely a good story. u.s. foreign policy and the foreign powers, i fully agree with pablo.

the only role is to watch. some may be able to learn, as brazil has learned from others. the occupy movement -- there are similarities. it is against capitalism, but with no real solutions against it. too late for that. missed the boat. again, the occupy movement was important. it was a sign that something needed to be addressed. after several months, it basically died out. in brazil, that could be the case. i do expect more competitive, political environment moving forward, which is good. that way you do not have 80% president approval ratings. at the end of the day given that brazil is a democracy with challenges, it is good that

you have other candidates. >> i have seen other cities problems. since 2008, the brazilian government has offered tax breaks to carmakers in order to provide more jobs and sell more and cars. no other city has so many cars. not los angeles or tokyo. it is a gigantic number. there is that federal policy of accumulating car sales. there is a second federal policy that is the flagship housing project that basically provides big construction companies to

design 5000 or 10,000 inhabitants who have lower income. the downtown areas space is expensive. they tend to build these houses in projects far from the city. brazil somehow not only has this, but every big city has a percentage of their popular nation living in -- you force the poor to live from where the jobs are. there is no transportation

system sustainable if people are living so far from downtown areas. the federal government has reasons for these process. how do create cities that are sustainable? we are no longer in the 1950's where cars were the future of the world and it would be amazing if everyone lived in the suburbs. it would be bad if brazil followed that. we need to remember that the first democratic government in brazil that it was led by a president who was a supporter of the military dictatorship.

so after the fall of that leader, for the first time the opposition of the military dictatorship started to be in the palace. lula considered -- there was a major change. i think the corruption is in the right and the left. i think there was a renovation. i do not have any doubt that president lula and president rousseff are far better off than the previous governments. the body of lula was social movements.

if you are a union leader, the left of the catholic church, feminist, gays, you name it, you would be under this. after 10 and a half years in power, the social movement were hibernating. they got good positions in government. what happened i think is the beginning of new social movements that do not see the workers a body as their representatives in the social arena. the workers bodies no longer represent change. that is why they are against political parties. they do not see them

representing them. in occupy, i think there is a major change with what happened with brazil and occupy wall street. the brazilians are having answers somehow. they kept their anger, but no political answers. at least brazil is trying to address and not crush them like in turkey. >> it is important. i have given many interviews. sometimes there are other guests. some people try to get their issue into this. this is urban. i hope they do not put this into a vote. this is urban. this is what they were saying. 80% of all cars in brazil are supported by the economy, which is a federal program.

the cities, the cities in brazil is a product of those policies. instead of financing public transportation, networks of public transportation, we decided to offer private cars. brazil is now -- emissions are going up. there is a change. we are going to voluntarily reduce 30% of our emissions. because of public policies done in the wrong way.

there is a major dilemma. education and health are the obvious issues. the problem is, where is the money? priorities need to be set. becan do this, they have to balanced budgets and make decisions. we have probably too many public officials in certain areas and not enough in others. you have to do public policy in a competent way. she will have to deal with the pressure from congress and the counter pressure from the streets that will continue. the people are not just going to go home. they have discovered to have the capacity and this energy.

regarding the u.s., let me elaborate. this is democracy. we're not going to go back to anything. forget about it. we are a democratic country, traditional democratic country. every four years there will be a vote. the results of those elections have to be representatives, have to reflect what we believe and what we want. this is a nation that has been reenergized. out of a crisis that was devastating, the first elected leader after our tahrir sqaure when millions of brazilians went to the streets. you mentioned something about

[indiscernible] i think history will be very good to him. he was the guy after trying everything had political wisdom to call a sociologist to run economy, which was the right thing to do. really set brazil in an important direction. he was the guy who really started the opening. brazil started to go forward more open of the economy. brazil will have to become a more open economy. we do not have an alternative. well-to-do people, heart of the

middle class, including the people who used to be poor, these people have access to products at lower prices, etc. highhave to pay very costs. they don't have access to the more competitive world economy. there people formulating this. opening up the brazilian economy, which is complicated to do because it has to be done carefully, but it is part of equity. it is essential. if you do not understand that, you do not understand result. we will grow with more equity. people are telling themselves that there is no way back. we have seen the promised land.

more prosperity with equity. we will get there. that is the message coming out of the streets. i think there are politicians that we do not yet know. it is like the soccer team last sunday. when you got new coaches and we have the capacity to allow good energy, new people -- i do not know half of those kids -- and to allow them to have a plan and play, they do it. that analogy is very good for what i think is timely.

>> we will get to the next round. >> lawmakers will consider a strategy to bring immigration of legislation to the floor. republican members are scheduled to meet next wednesday to map out a plan. senators are expected to take up stallone rates which doubled on july 1. for the rest of the month, the house and senate will likely work on an annual spending bill. forspending bill is ready house floor action. the senate appropriations committee is completing work on four of the 12 bills. is monday at 2:00 p.m. in a few moments, a debate over whether there is a connection between mental illness, guns, and violence. and an hour and a half, a discussion on how mental health issues are being addressed in the administration's possible

care act. a look at how media is affecting the cable-tv industry. now discussion of gun violence and mental illness. john swansonlude from duke university. this is an hour-and-a-half. >> good afternoon. and welcome. is jose muldonado. i am a forensic psychiatrist. joe and i were trying to plan this year back in december. we decided it was difficult to without including -- one of the deadliest campus shooting.

>> there has been a tragic shooting incident today at fort hood in texas. >> several people have been shot at a grocery store in tucson, arizona. >> at least 14 dead, 50 injured after a lone gunman opened fire in a theater outside of denver, colorado. >> back to our coverage of a shooting in a temple early this morning. a frightening scene unfolding there. >> at least 27 people have been killed at an elementary school shooting in connecticut. >> at least 27 people killed,

most of them children. it was an elementary school at a small town in connecticut. >> senseless slaughter, the latest has opened the subject of gun control and the second amendment. >> there is no doubt the debate over gun control will heat up in the coming days and months. >> i believe that my role will be more to raise questions for our speakers than to try to answer any of them. thinking about where gun related violence comes from, looking at the media, the issue of mental illness. in america, we have about 3 million guns. 89 guns for every 100 people.

these numbers are equal to about three deaths every hour. all taken together, taking into consideration the vietnam war, where 58,000 people. when you think about children, in 2010, about 16,000 children and teenagers were injured with firearms. when we think about violence and we think about how people die, it is clear to see probably the leading

that.of there is some data to suggest that the availability of guns go down, the incidence of homicide would go down with it. anotherke industrialized country like japan, where all guns are banned, compared to the united states, where we have a right to bear arms, you can see there dramatic differences in gun related homicides between the two countries. those are statistics that are difficult to argue with. homicide is not the only part of the equation. two thirds of those victims are going to die from homicides. on the average, there are 49 gun suicides every day.

the majority of the children who are dying are dying from using guns they obtain from family or friends. aboutis a question whether more restrictive laws could do something about this. i want to draw the attention that we have laws. the question is whether they can be enforced and whether they are enforced in a sustainable way. it has been said that mental illness is probably one of the causes of the violence. there are many instances on tv where people have directly said that only crazy people kill. if you look at the actual numbers, rental illness only increases by a bare minimum. less than five percent of

american crimes involve people with mental illness. those numbers are difficult to sustain. i have questions for our speakers. i am sure they will address it at some point. the question is how we will define mental illness. there are questions of label anyone violence mentally ill. if we do that, it is easier to say that only mentally ill people commit these crimes. we final question, how do differentiate pure malice from mental illness? those are the questions for our speakers. i would like to introduce our

first speaker. a currently senior fellow at the center for the american and a former special advisor to mayor bloomberg and director of mayors against illegal guns. he received his bachelor degree from harvard college and a law degree from harvard law school. he is a native new yorker who lives in washington, d.c., with his family and he tells a compelling story. lasthould be looking at week's new yorker. [applause] >> thank you. i will also start with some numbers. 32 -- that is the number of people who were killed in the largest mass shooting in

american history at virginia tech. the shooter in that case was someone who had been adjudicated mentally ill by a court, but the state of virginia had failed to provide that record into the background check system and that failure meant he was able to go into a gun store gun.uy the 33 -- the average number of americans who are killed with guns every single day. 323 -- that is the number of people who have been killed in mass shootings over the last four years. 44,337 -- the amount of people who have been killed in all shootings.

that number is the number of americans who died in gun suicides and gun accidents in that four-year period. the vast majority of those were suicides. if we think about the aggregate toll over many years, if we take the year 1968, which was the year that bobby kennedy and martin luther king were assassinated, more americans have been murdered with guns or killed themselves with guns or died in accidents in that period than have died in all of the wars in our history since 1776.

with those numbers in mind, i want to talk about for things today. what i would define as scoping challenges, how do we think about guns and mental illnesses? the first question is, should we think of people who are mentally ill as perpetrators of gun violence, as victims, or potentially a scape goat? the next question i want to get people thinking about, what is the problem that we are trying to solve? mass shootings, everyday shootings, or suicides? or mental illness for that matter? the third thing i will talk about is background checks, that has been the focus of the debate in congress.

what might some other solutions be to this intersection of mental illness and gun violence? the first question, are mentally ill people significant perpetrators of gun crime? this is one measure of it. this is a graphic that describes people who are rejected from purchasing guns when they go to gun stores and what portion of the people rejected are in the various categories of people who are prohibited? the biggest category are people who have been convicted of felonies. those are most of the people rejected. a very small portion of the people who go into a gun store and are denied the ability to purchase a gun are in this category of people who are mentally ill.

part of that relates to the fact that many mental illness records are missing from the background check database. your chance of being killed by schizophrenic person is about one in 14 million. that is one type of serious mental illness. you are more likely to be struck at lightning than that. another way to think about mental illness and gun violence, this is a category of people who are victims of gun than perpetrators. mental illness is very widespread and it is a problem that affects many americans. i would focus on the last number, which shows that people who are mentally ill are more likely to be the victims of crime than everybody else. i think there is a third way

that mental illness has come into the gun debate, particularly in the period since newtown. this is a quote from the nra. year,ember 23 of last nine days after newtown, we have a completely cracked mentally ill system that has these monsters walking the streets. we have to deal with the underlying causes. the question is, is this the problem that we need to solve? is mental illness the cause of gun violence? that brings us to the second scoping challenge. what is it we are looking at? mass shootings, everyday

shootings, or suicides? when we think about mass shootings, there is probably a compelling compelling case you can make that mental illness is quite involved in mass shootings. a mother jones magazine analysis of 62 mass shootings looking at the record, some of the court documents, most mass shootings involve some degree of mental illness. if we think about some of the most prominent recent mass shootings, there was a significant record of mental illness and a number of those shootings. when we think about everyday shootings, everyday gun crimes, we see that people who have serious mental illness tend to commit crimes at a lower rate

than the overall population. they are responsible for a lower portion of crime. likewise, when you look at crimes with weapons, which most times will mean guns, again, crimes committed by people who are mentally ill is underrepresented. it is worth pausing for a moment to think about how does fit into this picture of everyday shootings? we may not have a gun crime problem where the mental illness

component is exceptional, but the gun crime problem is exceptional. we are not a uniquely criminal society. we are not a uniquely violent society. but we are a uniquely deadly society. the level of homicide in the u.s. is unusual when you compare it to similar countries. we have a level of homicide that is seven times higher than comparable countries. firearm homicide is way higher. we do have an exceptional gun crime problem. when we think about these everyday shootings, until illness does not seem to be deeply involved in it. that leaves us with suicide, which is the majority of sudden deaths every year in the u.s. we know that suicide attempts that involve guns are far more likely to be successful.

people who use guns to commit suicide are the people who are really seriously wanting to succeed. it also may be that impulse suicide, people who are in a particularly low moment, this is the mechanism that is much more effective and when people have this mechanism available, it is more likely to have a deadly result. there is this question that mental illness and suicide are related. before i talk about background checks, the bottom line is that

mass shootings, guns, and mental illness, there is a nexus. suicide, guns, and mental illness, there is a nexus. the gun crime and mental illness is, for the most part, there is not a nexus. when you think about some of the mass shootings and background check systems, that has been the subject of the congress, a number of some of the most prominent mass shootings have involved gaps in the background check system. in virginia tech, it was a shooter who had been adjudicated, but the records had not been put in the system. columbine, it was going around the background check system by buying guns from a private seller at a gun show. which allowed people to get

guns, no questions asked. that was also the case in the shooting in brookfield, wisconsin, in october, where the perpetrator got guns online from a private seller, no questions asked. tucson, he had a history of mental illness. he had a history of drug abuse, which had prevented him from entering the u.s. military. that record was not provided by the military to the background check system. that could have been a disqualifier. why is fixing background checks important? it is probably especially important not in its nexus to mass shootings and mentally ill, but to its nexus to everyday gun crimes.

there have been prisoner surveys that suggest that the vast majority of people who commit gun crimes get guns from transfers, purchases, or getting it from a friend that do not involve background checks. i put a question mark under it because it is just one data source. it is very hard to know much about this secondary market for guns. it is the guns sold after the gun stores have sold them. sometimes from somebody who says they are just a collector, but might be selling 100 guns at a gun show. sometimes that of the garage, sometimes online. the best statistic we have, which is almost 20 years old, suggests that maybe it is around

40% of gun transfers every year. are no background check transfers. the solution is to require these private sellers who go to a gun store and do a background check to provide a little context. in our country, we have 58,000 gun dealers, almost as many gun dealers as we have post offices, mcdonald's, and starbucks combined. this is something that would not be a great inconvenience. there is a good study mapping all of the gun stores. 97% of americans live within 10 miles of the gun store. another issue was this issue of

records not getting into the background check database. there have been a significant amount of improvements in virginia tech. it was just under 300,000 records before virginia tech. now there are over 2 million. 18 states, six years after virginia tech, have continued not to supply records into the system. one of the things the legislation in congress would have done had it passed was toughen the sticks. do background checks matter? it is a hard question to answer. crime overall and gun crime has gone down a lot in the u.s. in the last 20 years. but it is very hard, people do not agree what causes the drop in crime. it is very hard to think about outcomes and what causes an outcome, but there is a fair amount of studies of particular

laws and an enormous amount of circumstantial evidence to suggest that gun laws do have a substantial impact. different states have different laws. tightn california, very gun laws. other states, very weak gun laws. if you look at states that have universal background checks, you see the murders of women is basically very similar in non- firearm homicides. if you look at gun homicides, it is lower. the portion of the legally trafficked guns in states that have universal background checks are much lower.

in this study we did at the center for american progress, we looked at the 10 states in aggregate that have the strongest gun laws and the 10 states who have the weakest gun laws. we looked at 10 outcomes of gun violence, 10 measures of gun violence. you probably will not be able to read the text, but you can see the pattern. on each of these measures, the states that have stronger gun laws have substantially lower rates of gun violence. in the aggregate, it is half the level of gun violence. this is the correlation, when you see correlation over and over again, it suggests pattern. my final thought is, as we think about gun violence, gun

laws, mental illness, we should about, what is the problem we are trying to solve? areoptions vary, but there things we can do beyond background checks and things that could be quite effective. one thing, for example, what happens when somebody fails a background check? for are rarely prosecuted that. that has something that has been talked about quite a bit since newtown. the federal government does not have a process to tell state and local law enforcement when seriously mentally ill people are rejected from a background check. what would've happened at virginia tech had the shooter

failed the background check? showght've gone to a gun that weekend. and bought a gun with no background check. were the campus police and virginia tech or the state mental health authorities been alerted that a seriously mentally ill person in virginia attempted to buy a gun. they would not have been. alerting law enforcement and mental health authorities when people are rejected for background checks would be one good thing. another thing that would make a difference is effort to recover guns once people become prohibited persons. when you have been convicted of a felony or when you have been adjudicated mentally ill, you no longer have a right to buy a

gun. what about the guns that you may already have? some states, some cities have undertaken efforts to make sure becomeen people prohibited, law enforcement it's to those people and get back their guns. california just passed a law that will provide funding to do this for 30,000 people in the state of california who are prohibited, but there have not been the resources to go to their homes. and get the guns. there are cities and counties in california who was had very effective programs in recovering those guns. even red states like indiana have laws in place to do

temporary actions to recover guns from people who are mentally ill. there are a number of things we can do, but as we think about what to do, we should go back to the first set of questions. what are the problems we are trying to solve? are we trying to have a better system for taking care of people who are mentally ill? there's a lot we can do. are we trying to reduce gun crimes? there is an enormous amount we can do there. in the end, it might be of a less important problem to solve. what happened in newtown was a terrible tragedy, but if you lose a six-year-old in a single victim shooting, if you are the parent, it is just as bad. nobody is going to pay any

attention. maybe a short local news story, but it will disappear. when you take those single victim shootings in aggregate, you are talking about a newtown, virginia tech scaled massacre every single day in our country. thank you. [applause] >> we are going to leave all the questions to the end. we would like to introduce jeff swanson. he is a professor of psychiatry and behavioral science at duke university. healthertise is mental services effectiveness research. he has received numerous awards for his outstanding contributions to mental health

research and has written numerous papers. 175 comes to mind. perhaps the country's leading authority on the link between mentale and severe illness. [applause] >> i would like to speak with

you for a few minutes tonight on the link between violence and severe mental illness, gun violence and mental illness. in the context -- my slides are automatically advancing. in the context of the other causes, the other important causes of violence in our society. and what such an understanding might imply for the product of developing better laws and policies that will be both more effective and fair. in terms of reducing gun violence but also avoiding sexually reinforcing the stigma that goes with the unfortunate understanding our belief in the public mind that all people with mental illness are dangerous. which is the cause of a great deal of stigma and discrimination. social rejection. how do we think about balancing these important concerns, public

safety and the one hand, and civil rights on the other hand. the two would like to begin by kind of putting this problem in a big picture perspective. i think that all of you -- let me quickly acknowledge some of the sponsors of the research i will be presenting to you this evening. from the national science foundation, the sociology program and the robert wood johnson foundation. for grant makers to courageous they sponsor research in this area. i think all of you have been to our national mall and you have seen what a sobering sight is to contemplate. 58,000 names carved in granite wall. that is the number of american military deaths that died in

vietnam in 10 years. i would like to ask you what if we were to build a memorial, a monument to commemorate all of the americans to have died in the last 10 years as a result of the -- a gunshot. if we would build such a moral it would have to be five times larger than the vietnam memorial. i present that to you not only to show you something about the magnitude of this problem but also to take it apart a little bit. it turns out that 39 percent of those deaths are homicides. 57 percent are suicides. 4 percent are other situations such as law enforcement action or accidents. i've done some calculations and made some assumptions about the prevalence of mental illness and the untreatable risk of homicide and suicide that is associated

with mental illness. i calculate roughly that if we were to reduce all the risk associated with mental illness, we might be able to reduce number by about 100,000. we might be able to bring it down to two under and 7000. 95 percent of that would be from reducing suicides. why is that? if you think about their relationship as an epidemiologist with, someone who studies the problem of violence in populations, not just individuals, what you can learn is that there's three ways of looking at this. the server is confirming it. one is absolute risk. the percentage of people with serious mental illness diseases such as schizophrenia, bipolar disorder, depression who would engage in violent behavior, some minor or serious act of violence in a year. that is 7%. 93 percent would not.

. .

>> we now have three general clinics that include primary health care, psychiatry, and pediatrics, dentistry, access to gynecology and we have 18,000 people, adults and kids, every juror going through those -- receiving those direct services. we have been confronted by some general issues that we needed to address as a center, and a state, and that the national level. people with limited income generally do not access preventive care as often as they should. they over use the emergency and specialty care. this is complicated by illness

and significant lower rates of primary health care and routine testing. one thing that is not talked about a lot is poor dental care and that impacts over all health-care profoundly. there is little integration of primary care and psychiatry which beginning to change. in an important federal study known for the comparison of psychotropic medications, the caton study, also found that a small minority of individuals were receiving care who had high cholesterol or high blood pressure and somewhere around 1/3 who had diabetes that were receiving the treatment. this is a death sentence. that's certainly goes a long way to explain some of those outcomes we have been seeing in

terms of the mortality and morbidity of people with serious mental illness physical health care is a core service and behavioral health care systems have a basic responsibility to provide access to health care both for disease management but also for wellness and recovery. you cannot lose that was recovery focus. management and integration of medical care for people with serious bill must should be part of our basic missions. because -- i showed you a slide earlier that helped us persuade our state in missouri why we should be the first out of the block. we were able to achieve the status under the affordable care act of establishing health care homes. one was the primary care health care home, for people with chronic conditions. the community mental health

center helps their homes. i will refer to that as a behavioral health care home. the community health care's and our affiliates in missouri have all become part of the homes. we have a number of functions that i will not go through in detail. we have these slides. we take a whole person approaches. what is beautiful in missouri is that we found that we can help centers that have not been able to have primary care within their walls to be able to coordinate care and to achieve good outcomes. across the spectrum of different type of centers with different assets, i think we have been able to achieve the kind of outcomes that we need. the way we have done this is we have taken our existing services.

the behavior program is not separated. the centers as the most successful if integrated into their over all day-to-day functions as a center. the difficulty is that we get funded for a minority of the people we are serving in terms of behavioral outcome. in essence, we have to transform our entire system to impact our overall populations in terms of cordoning care. this includes the addition of additional measures care managers as may be a physician consultant to can go over treatment plants and make sure we fell in the gaps and people are getting the services they need. there is a strong need where we have to have good information technology. behavioral health has lagged in this. this is one of the critical areas in terms of what were

doing in terms of being able to achieve the status and better integrate care and compassion and the help of this population. in missouri, all the people, the 17,000 individuals across the state receiving the behavioral health care home services are having metabolic screens on a routine basis which means that we're looking at their blood pressure and their cholesterol counts. we are looking at the waist size. we are beginning to integrate that into their over all planning. data analytics is critical and can only be done successfully because we have individuals who have all their health care paid for by one source, medicaid. we can see if people are picking up their medications, if there

are other physicians for duplicating agitations. we have problems in that arena more frequently than people realize. we have nurse care matters as consultants who are on a routine basis looking at that. then we are utilizing the extensive experience we have in terms of developing and covering networks. many of the individuals are pierce specialists and community support specialist and coordinators' and clinical case managers. we're turning those individuals into community health and wellness coaches. in disease management first and moving toward wellness which includes issues of life spouse changes. we are using strength tests

based promotions and are promoting human big help be a years. this slide is actually one that was a key in missouri to be able to persuade our medicaid office and the governor's office and the legislature that we should become -- that the health care home should exist. the red line is the two years prior to individuals receiving services for our safety net service. you can see the dramatic rise. this goes back to -- we need to find a system where we can make people eligible for care back two years earlier. because people have to be eligible for disability services, many times they have to deteriorate to this point to receive services.

the blue line demonstrates that this is when treatment began and you can see a real rise, the jump in overall costs. the costs are going up rapidly. then they come down rapidly after a few months. we not only bans the cost curve, we reverse it almost back to what it was what two years prior to the beginning. this is a four-year slide. it demonstrates the cost savings we can have thurgood care management. there was some reference to the reports from missouri as to what are outcomes were. we had managed to have cost savings even let you deduct the the overall cost of a behavioral health care home. we have some real challenges. i think it has been mentioned that april health care organizations are behind the

curve, by and large, in terms of h.i.ti. we could not find a medical record that would do the whole thing in terms of primary care and behavioral health care. i think products are developing more now. the cost of those products is sky high for these marginal, not-for-profit community health centers around the country. we need some help and we were left out of the earlier hit be enhancements that the federal government provided. a number of us have taken advantage on the medical services side and we can get our psychiatrists covered but we have many other individuals we need to invest capital in, the capital for most organizations is not there. health information exchanges are

advancing rapidly. many times without behavioral health being added. we need to get said. their funding issues in terms of sustainable funding for early intervention, limits of funding sources for the uninsured we have talked about and silo funding. we made these changes in missouri because we showed that the single funding source in medicaid was saving money. when we save money for schools and when we work with drug corpsa and picked on recessive recidivism, we're not getting paid for that. that is a major problem. we have work force recruitment issues and a lot of that is within states in terms of restrictions on who can do what in terms of state statutes that protect professional organizations. we need to expend within teams

what pierce can do and made to show our outcomes by benchmarking them and agree with those outcomes are across the country and between states. we need to work on our culture changes we had tickets to work on in terms of developing a recovery model. we have to develop a wellness model within a few years. in terms on some basic principles, we have to remain close to the people we're working with even as these clinics become more important, is real important with the target populations to go where they are like in schools and homes. thomas and recovery need to be integrated. these centers are uniquely positioned. we are working toward a person- centered system of care.

it is within sight but we do need to deal with these barriers in order to make sure we don't have often as practices but rather the stage route to run the country. as organizations develop this, what is our role of community health centers and behavioral health centers -- be a hero help homes. the answer to that will be critical. thank you very much. >> that's terrific, thank you very much. i apologize for getting the panelists that other analysts pointed toward. when i was interrupted, you can now join this conversation. there are green question cards that you can fill out and hold up and someone will bring them

forward. there are microphones that you can go to to ask a question in person. if you do that, please identify yourself and your institutional affiliation and to keep your question as brief as you can. this is so we get as many -- this is so we can get to as many questions as we can. i would like my co-moderator to charge -- chime in with questions and answers. go ahead to. >> i'm at the office of the national coordinator of health technologies. thank you for a great presentation. dr. wilson just referred to it but i would like to hear perspective from other panelists about the work that still needs to be done in terms of quality measurement, the creation and validation and then the specification of quality measures for behavioral health.

>> from the cms perspective, we have a number of quality measurements, activities in place that i would like to refer to but i did not have the time. it was our adult quality measures and our children's quality measures. both of these are out there for public consumption. we are encouraging providers and system to use that. a number of them actually include mental health and substance abuse quality measures, we are hoping we can include some substance measures.

they are open each year for comment. pay attention to the notifications you get because we want to know whether the measures we have make sense or whether we should think about new measures and whether some of the measures we have should be replaced with new measures. let me see if there are other folks on the panel -- >> the quality measurement is a big issue. state mental health agencies are struggling and trying to support this and we have a quality measurement system for hospitals that we run. we're also hearing questions from states. a lot of the measures cut across boundaries of different systems. if you're trying to look at reducing use of hospitals, you are looking at medicaid and medicare and different datasets. it gets into the importance of starting to use information exchanges or ways to be able to access data from different

services. from the state's perspective, we hear that a number of states are putting in electronic health records but they are being left at the back of the queue would changed data electronically. it is an area we are hearing that consumers and found and the state and community progress all want to have more consistent say in quality measures. >> inthe aco, there is one mental health screening measure barry will work -- we were in proposal that would be indicators around psychotherapy, an area that needs attention. i think what you'll see is the iom tackling that in the next few months and that will begin

to contribute to the need for measures. just as we're behind in the use of hand-held technology and other things, i think we are behind in this but fast in terms of a desire to catch up and attention to it. >> my question is about evidence-based practice. thank you all for your great work. i'm wondering we could expect an extent where we could see differential incentives for providers offering evidence- based practices. on the medicaid side, i am wondering what your thoughts are about that. >> i would start there.

right now, states have the opportunity to be able to do that. in some places i know, whether they are doing it through their own volition or fee-for-service is or managed care, they have been implementing rate differentials based on different types of evidence-based practices. should there be more of it? probably, but there are few things that would prohibit a state medicaid agency to be able to develop that rate differential or begin to think

about moving towards payment for outcome. some of what we have been trying to do true air bulletins around quality and care for a nation is to try to get states -- and they have been -- changing individual services. >> this is a struggle not just in mental health but in health care generally. there are guidelines about what you should do. if you have chest pains, it involves aspirin but it is spotty in some places. i think this is a struggle around really taking research and then changing practice. money matters a lot of people do what you pay them to do but you have to make sure the differentials are worth that. this requires an investment. take critical number of people know the new practice can teach it, can supervise it, so when you talk about investments and differentials, you've got to make sure it supports what you want.

>> i he a question about mental-health services that are privately finance. the discussion is about serious mental illness and a population publicly financed. it seems to me the pros another population that could fall into that group if not cared for with some of these approaches you have described, combining the clinical services for mental and physical health. what are your thoughts of the importance of this group? we sometimes think of teenagers in this group. that relates to the issue of gun violence. other populations as well.

how important is this group and what the social benefits of aiming at this group and how do you emmett them? what does the aca tell private insurance -- insurers to do in the way of parity. >> after running a private not- for-profit where we worked hard to get insurance to pay for different things, we had a number of individuals in working with the schools who have fairly good coverage. in the past, there were covered by traditional services that were not the one that could make a big difference. we need to go into the home and renewed to work directly with school. it never seemed to work out.

the parit legislationy hold a lot of promise but the issue, in terms of the temple -- implication, john and others are much more expert at this. that is where we will see the difference in terms of whether or not this continues to fall into the safety net when people need more than office-based care. when the real evidence-based practices show that we need to use approaches that bring together systems of care, they have not been supported in the past in the private sector. >> with respect to private payers, it will focus of the

affordable care act is on private financing of health care including mental health. half of the coverage expansion and allies in medicaid and in the half of marketplaces and requires the provision of central health benefits for qualified help plants. that pertains to private health insurance. the other piece are reforms to our health care system. that is focusing -- its target our private health plans but now have to comply with the same rules that help plants follow in employer-sponsored insurance. private health insurance is really a chief of this of the reforms in the affordable care act. >> if i can pick up a couple of

questions from the cards -- there is one for john and probably one for linda. one question asks -- but a second witness trade and so long or read the rules for mental illness and parity. what have been the consequences of that long delay. and those of mckelway newspapers don't count of a hearing in the legislature yesterday in which the insurance commissioner was lamenting his lack of tools for trying to enforce the parityo requirementskk with some of the private insurance firms. for linda, john had mentioned that the states flexibility of was covered in the essential benefits package. i wonder if the behavioral health community is worried about that flexibility.

>> do you want to go first? >> sure, well, i am sure there are a variety of reasons why it has taken a while to get where we are at today. the good news is that we have a commitment to have those regulations finalize this year. i think there are certain places where we have seen issues with commercial plants not implementing parity as we intended to it -- to be. i've seen lots of land since 2010 have taken some significant strides to make sure it did comply with the parody. while we still have issues, you bet. working with the plans like the department of blog -- labor and hhs has been doing is to

understand the power to block an enacted on the commercial side and that has been effected. we have been working pretty closely with our state partners who are moving forward. it is important for them to understand parity and plan for what that will look like as part of their essential health benefit. and as in most cases, we're going to probably not here about one lewd good left to did to the right thing. again, is of the more and the web the said -- again, we are worried about state flexibility. we understand the need to give states flexibility at a time when there is this expectation that they implement lots of

changes including, hopefully, and i expect they will buy into the medicare expansion, but then, in turn, we are a country that feels very strongly about states' rights. it is a fine line. in terms of giving them flexibility. the good news is that stakeholders in those communities, all the groups including the managed-care companies, i think in some i have a stake in ensuring that the state does the right thing. i think there is a lot of organizing going on in states to

make sure that happens. what are the mental health -- >> what are the mental health services that can be provided? >> i was wondering if linda wanted to cover this. the national council has terrific experience around the country in carrying out the institute which is working towards helping a lot of different types of areas around the country in terms of integration. my experience with that is that there are some real challenges in lower density areas. we have some rural areas that

crider, or is, but at the same time, in some of those areas, you get more flexibility because the competition is less. you're able to accomplish an awful lot more more quickly. some of the tools that we really need and we need to address restrictions on include telemedecine and other procedures. none of the most successful homes in missouri is in northern area with nine counties. they have a part-time position consultant. they really don't work very well with primary-care providers throughout of their area. they have had real successes on the clinical basis in terms of controlling the blood sugar

levels and bringing down blood pressure and using everything they have together and they have gotten very good support across the board. in urban areas, it gets more complex and there could be more problems. >> i am a medical student. my question pertains to the third alkalizing goal of thecmcs the cmcs would integrating behavior health and i was wondering what is the model of care that has been identified or if it has not, what are the plot around the model of care that will be used to integrate primary care and mental health

care? if it is similar to that of the behavioral health home, how was the behavior of help from home different from the model of care of the patients center medical home? >> terrific question. i will defer to some of the other folks on the panel for more detail but we don't have a prescribed model. part of what we want to do with the health home and state plan opportunity as well as our innovation grants was for the states and even the providers to come back to us and say we would like to try this. some of it is based on research and some of it is yet to be research. we felt it was really important that was not just one model and we really wanted to reinforce that it was bidirectional and sometimes it was behavior health embedded in primary care and

other times it was primary-care embedded in behavioral health and other times it was our rural and frontier communities and we will have to be creative about what we do. we are fascinated to see what the next year or two of help homes will be to be able -- to be able to inform of where we might go more permanently with that program. >> when you talk about embedding mental health and primary care, channeling an imh they would save the model is a collaborative care of and if you look at the impact work of a few years ago, that is the work that has the research. i would suggest that to you. >> here is a question about young people who have an

opportunity for coverage under the aca. a big problem is the 18-25 age group. some may be covered by their parents' insurance but seeking treatment is difficult. what activities are you pursuing to help reach out to this age group? i would say this is obviously beyond the group of people eligible under their parents' insurance. there is coverage opportunities for all age groups and average and enrollment will be a critical element to the success of the affordable care act. people with mental illness and others might be -- might find it difficult to get into coverage. what can we do in the field to help reach out and the ball people into coverage?

>> anybody want to take that on? >> others probably have some ideas that i will take that on. part of what we know we need to do was to have a fairly impressive enrollment effort. what we have done today in terms of the chip programs is primarily focused on children but also an older children as well. some of those efforts that states have to do some average and a moment to get people eligible will be important. even if we get people eligible, they will not always seek services. some of the national think tanks have been looking at how to use technology to engage individuals. it is not only in the enrollment process but the treatment process. i will say this like i'm old ma

but there are some nifty smart, applications. you might want to say a few things about this. >> i think of two things when i think about that question. i'm not sure which one director man's greed can get help the young people to enroll so that our premiums can stay under control? that is a very big issue because they think they are invincible. the penalty for not and rolling is not that big. when we said earlier that people do to pay them for, they -- punishment does work and this is not much punishment. i think that is a problem around healthy people. in terms of enrollment, one thing we tell our members and we will talk more about is their capacity to enroll people on site.

and to begin to help people get to that computer and medicaid will be simple with a simplified process application and people who deliver services will have to take this bond. particularly for people who have ellis says, i think what they found in massachusetts is people will often come to the front door without coverage even though they are eligible. i think there'll be a wonderful effort using technology as well as in knocking on doors to enroll people bought providers and practitioners have to also have the capacity. >> one thing we hear from the states like states that are doing this exchange and during the medicaid expansion is the mental health agency is working with their providers to get consumers trained to be held navigators and tell people enroll in services and make sure that when anybody comes to the door that they are found to be

eligible and can get whatever services they need. you might recall that cost as a major reason people don't access services for a 18-25 is the year that is the onset for schizophrenia and a major mental illnesses. mental health first aid and recognizing, we can get people into service as much quicker and as a potential to break some of that cost curve. right now, people have to get really ill and become severely disabled before you qualify for benefits to get into the public system. if people have basic service -- coverage and don't have to wait until they are really -- in really poor health, that is what some of the studies suggest where there could be positive outcomes. >> can i ask a follow-up to that? this is one area where we have had some experience.

the law has been of an effect for two years? i'm wondering about the experience that local and state level in terms of who has the -- who has taken advantage of this change and a lot to maintain coverage under their parents' insurance. there are millions of nearly ensured young people but have we detected anything in terms of people who have mental illness? >> we have not. we have not heard from our member organizations that they have. i think this goes to your early intervention study people do not come to the attention of organizations until they have been ill for a number of years. and they are ready to go on medicaid. there is a barrier. it has developed in states in

order to control access to these highly specialized services. when that begins to change in tandem with the insurance changing, i think you will see insurance companies want to do some of these more inventive constellation of community services rather than what they do now with young people developing schizophrenia which is to pay heavily for people going in and out of the hospital, basically. i think it is the combination that we can see some action. >> if i can add to that -- i completely agree with that. one of the major problems we have had and i have seen that over the past three decades is the transition from children to adults and the barriers where they receive services and the good work that happens when kids services are being lost in this canyon before individuals become available for adults services.

we were really looking forward to, at some point, when missouri gets medicare expansion, that individuals who had to wait until they were at rock bottom because they had to be able to qualify as being disabled, that we would be able to enroll them earlier because of their income status under medicaid or in terms of having subsidies in terms of the insurance exchange. hopefully, we can then change our state rules with federal support in order to be able to mobilize these more intensive services and sports. this is an order to help them earlier. we know we get out people earlier that the outcomes will be much greater down the line in terms of their overall health.

it is also in terms of their employment status. >> we have several folks waiting to ask questions. let me dispose of one that was directed to dr. wilson. it is asking about p [ara- professional definitions. i suggest you take this offline after the briefing. it is a very good question but very narrowly drawn. feel free to approach dr. wilson . go right ahead. >> i am with the united health group. i have a more social-cultural question about health utilization. i'm interested in the correlation between utilization of children and teenagers in particular and household income.

i am wondering if you have noticed any trend where children or teenagers from families with higher incomes have high medical need rates. >> i don't have data on that but i was just reading on the plane here this morning, a piece about over-diagnosis and kids. it spoke to the issue that people who have insurance coverage, there is a higher diagnosis of adhd in that population. i don't know if that is what you're getting at but there are statistics about that. i am not an expert. >> our data recovers people who get into the public system. i can't answer that either.

>> i'm with the national real health association and i wonder about this status of dual eligibles and the efforts to integrate primary care and mental health services. >> we have an office that specifically focus is on medicare and medicaid coordination. we have gone through a series of activities that have solicited states that are interested in moving forward with developing a dual program. it has been slow, at best, and some is really helping states think through the right model. around integration and some of it is around changes the states have to make in their policies in order to be able to implement the program. but got a couple states now we have memorandums of understanding between us and the states. and medicare and they're just

beginning to move forward with implementation. it is getting there. is probably not as fast as folks would like but it is getting there. >> thank you. we have time for only a few more questions. we will get to yours. we hope we take this opportunity to fill out the evaluation form that is in your packets. >> i am with the american society of consultant pharmacists. i know what you mentioned that we don't to a good juba of dealing with the mental health issues and the elderly population. i'm wondering if anybody could comment on your thoughts about that given the large proportion of baby boomers that will be age 20 in the next few years. the utilization in the public mental health system drops off the older people get.

within the national association of state mental health directors, there has been concerned for years about the lack of geriatrics psychiatrists and psychologists who have expertise in treating their needs as well as the capacity. there is a lot of discussion about the coming beijing -- baby boom aging into that group and how will overwhelm the work force capacity that now exists. that is being talked about but i don't have a good solution. it is a group that is recognized as under-utilizing services. >> there is an iom paper that deals with this issue. the place to start which is expensive as medicare which pays quite handsomely for inpatient

psychiatric care for elderly people but as a very limited benefit, a very traditional, not evidence-based for elderly people. when paper are ready to take them on, we might see some more attention. i think that as a barrier right now. >> thank you. >> have a question for dr. wilson. what influence your organization to become a federally qualified health center? was it difficult to do and did your organization change in medicaid reimbursement when you became an fq8-c. >> yes, we did.

that was a wonderful incentive for us to take that step. the severity of the -- difficult step. cultures are different and the fqh-c work very hard so had to work quickly. when we were looking around for models in the country, we found that there are many places that had spun off fqh as opposed to becoming one but a few like cherokee in tennessee had done a wonderful job in terms of making that transition. we wanted to retain a lot of the community-based behavioral health care components and the recovery model. putting those all together was the major challenge.

we found when we look at our board as being an organization that could help us politically and could help us in terms of our legitimacy a local basis and where it was to have bush of the dollar rebounded we had to debate how to go about doing that. i think that struggle has paid off well. in terms of making that transition. we think it works well and we would recommend it where it is possible. i think it is only possible probably in areas that don't already have an existing fq8-c and we have great models of partnerships in missouri between community health centers and existing fq8-c's around the

states of their many ways to make this all work. the organizational structure depends largely on what is already there and with the overall mission is. i would recommend other organizations will meet this one of our colleges already done this. an fq8-c has merged into its so we have that model in missouri and that is expanding. >> this will be the last question that we have time for. it brings us back to what several of the speakers of reference. how will you create an

environment, the questioner asks, where people from -- suffering from mental illnesses will look for coverage woman up there. i was officer of the others i have a point of view that not be popular. i think is happening. i think is about younger people who are blogging -- and talking and chat rooms and other social media. these are vehicles that i can of not pronounce. i mention cantor and al is-- how cancer and how that is

changing. and i think in your packet is a piece for people who have mental illness or disservice is, they did not list this as a barrier. it was much more money and confusion about where to go that was more an issue for them. i think what happens is, the general public, at this point who are older and have trouble interacting with people with serious mental illness is one of the reasons that we abraded metal -- mental health, to enable people to have those conversations. generational the, there's a difference. i think some of it is coming out of the shadows just as people like me die away. [laughter] i hope brought -- i hope not right now. >> we need your leadership. a few years back in the greater st. louis area, a number of us came together and with the help of a wonderful health foundation, the was the missouri foundation for help. we started working and how we

can better integrate our services. there were a number of forms that occur at that point. the responses of many people, many times they would say i love the services i am getting and i love my provider but it was hell getting here and we had to swim shark-filled moats for to get from one spot to another and we were given the runaround and sometimes it was like having to learn a secret mock and a door in order to get in. we need to greatly address that we can certainly do that through as the development of more integrated systems. and we need to greatly address

and that is easier to say that is to do. sometimes we need to help these people through these past -- pathways to navigate them. part of the affordable care act is health navigation. we need to organize that into our communities in order to help families and individuals to end up in the right spot, because when they do, largely you hear that good things happen. but you also see that large numbers of people are not getting what they need and a lot of that is a matter of they did not survive the large moat to get there. >> i think that has to do with a couple of things. a lot of states have anti- sigma campaigns and other activities. bringing understanding and recognition of mental health helps to bring that together. when states are talking about

programs to meet the needs of returning soldiers and armed forces members, people come out of the woodwork for being at those meetings and to support them. it starts a dialogue about mental health and suicide and ptsd and trauma that can drive the discussion about everybody in society. i also agree that it seems to be getting better, but there's still some ways to go. >> this is the perfect question to end the discussion on. it's kind of where we started. i almost take it for granted that we are making progress, as linda described. and we see it every day, i think. we see evidence of that progress. and incidentally, we do not want to see discussions in these special chat rooms.

we want to see it on facebook and mainstreamed discussions. >> facebook is over. >> it is? i'm just getting used to it. it probably is over. but one of the most compelling slides that we saw was your slide release of the success of interventions for mental illnesses compared to things like heart disease. i think if we understood and remembered that slide and were less defensive -- we're almost apologetic about raising the issue of mental health in general, broader conversations. and we all see it. that in itself breaks down barriers. and yes, there is stigma among people with mental illnesses. we have to realize there is stigma that we all feel about

this issue. when i see that slide, when i see those numbers, i think that really does help move the conversation forward. >> i also want to underscore what karl said. i think for a family that has an adult child that develops schizophrenia, worse than the stigma is navigating how to get help. i think sometimes the more services we have, the more complicated it gets. that is what i'm always afraid of. how do you help people? my hope is that parity and the aca and these new delivery systems will keep families involved during that very difficult journey at the beginning of illness. >> we have come to the end of our allotted time.

several thanks are in order. first, we have done a number of briefings on mental health, substance use. we have never had a response like this. i want to thank you for signaling, i hope, a new sensitivity and openness to try to deal with some of the gaps in the system that you have heard so eloquently identified today. i want to thank the colleagues at the robert wood johnson foundation for not only cosponsoring this briefing, but helping in a very direct way to shape it in a terrific conversation that i think it was. and that brings me to the final item on this list, which is i would ask you to taking -- to join me in thanking the panel for that particularly good conversation. [applause] that does not absolve you from filling up your evaluation

forms. [laughter] thanks again. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] in saturday evening for the net roots nation eight annual conference on public policy. pelosi, daughter of nancy pelosi, moderates a discussion about women running for a lack it office. you will also hear from other california democrats. panel looking at candidates statements that became news stories, including comments from those releasing the 47% video. nation's annual

conferences on c-span this saturday. moments, a look at how digital media is affecting the cable tv industry. " washington journal" is live in u.s. inwith segments on afghanistan and the presidency of george washington. and a forum on what it means to be a citizen from the ask and ideas festival. west, theyrt coming would leave behind the racism. the sun did shine more benignly on them here, but i remember a number of them telling me that there was even more cruel find facecism, a smile on the but a dagger behind the back is how they describe california. a were not allowed to live in any of the cities, not even the small towns. the only land available for them were these patches of land.

literally when you ride up on the land and you look at it, it is so salty it as if it has snowed there. this is a land that was available to them, and they built their wooden shacks here. no water. they they had our houses. no police around this area. it was in no man's land. -- the on theoakies, black oakies. we explored the literary life of bakersfield, california. cable and tele- communications conference in washington. a discussion