we are going to move on now. --on is going to tackle megan is going to tackle three of the cases you are going to hear a lot about and will get a lot of attention, certainly in my business. one involves campaign contributions, one involves abortion protest, and the other is legislative prayer. you act surprised. i know you will have something to say. >> everyone knows there is cast to which you can contribute. -- you can contribute to individuals, committees -- this is the amount total that you can that is the question in this case. obviously, campaign finance is controversial. will this be another citizens united? what is your take on this one? a pretty esoteric area

of the campaign-finance world which many people in this town care about very intensely and other people in the country don't. other than they see headlines and president obama at the state of the union criticizing the supreme court. they got that buzz, but i don't think many people understood it. lay a candor, i will marker around this discussion. i won't try to get into the discussion. 441 b the parties debate that. >> let's talk about the court and how they look a campaign- finance and what this may mean in terms of how they approach some of these cases. >> the commentary on the case -- some of them is trying to tear it up as a citizens united. a bedrock campaign-finance decision from the 1970s may be in some danger based on the march of cases waste on the past few cycles where the court has

been first amendment protected and been willing to strike down campaign-finance or strictures. today have cases been on the expenditure side. this is a contribution limit case in what is going on is sean mccutchen challenges 120 granting aggregate contributions. they argue that the contribution limit should be subject to its tricked scrutiny -- to strict scrutiny. the things that animated the scrutiny of aggregate contribution limits in the past don't really exist anymore. >> in other words, it's a different world. >> they came in and close some of the loopholes and a the buckley court's willingness to indulge the aggregate limit. the buckley court did address

this kind of aggregate cap but in a very short piece of their opinion that the court said was not separately briefed at length. i think the real question is, on the first order of questions, do aggregate contribution limits fall? if i was a betting person, i would say that they probably do in this case. although those expenditure cases don't exactly map on this. we are a bit odd -- we are in a bit of a new world on the contribution said. i think they will have to distinguish or repudiate that portion of buckley that else with this seemingly quite narrow piece of campaign-finance. asked to rulebeen overrule oakley if they are so inclined. i think there is some appetite among many justices to do that. but that was so the test the question of how far they're willing to go. are the cheese and justice alito willing to take out buckley -- are the chief and justice alito

willing to take out buckley. >> which they were formally not willing to do. >> right. some people can argue that it is misguided and other people argue to get rid of this artificial distinction. willing to doem that at this point. but that is a bit of a gamble. >> does anyone see this being a big sweeping -- let's walk away from buckley -- kind of case or is this something that they will do narrowly, too? >> i think they will uphold these things. the rationale makes no sense. if i give 10 $25 contributions with that corrupt anybody, what difference does it make if i make 100 $20 contributions? i don't really see any opportunity here or necessarily

appetite to throughout the whole distinction between contributions and expenditures. justice kennedy has expressed some displeasure with this distinction in the past. >> they could lay the foundation for that. they can continue to express foundation. then two or three years out, they can do that. i do think it will have enormous real world impact your people get very excited about these cases in certain groups. but it does effect a very small universe of people. i am not in that group and i hope the contribution limits .ever go away >> they are giving a maximum to 19 different candidates. it is not like it is this corrupting potential where they are wanting to give $150,000 to one person. they just want to be able to spread the wealth to a bunch.

friendnt to give to 25 candidates, not 18. world saynds in that it will affect about 25 people. >> so the lesson is, when you hear all of the breathless coverage and the skies falling, our panel is saying, in this case, don't believe all the hype. let's move on. you can see a lot of people saying the abortion protest case case, whichthis involves a buffer around reproductive health clinics and whether or not people have to stay back is one that could very well overturn a case from 2000. my bet is they will overturn that case and justice kennedy will write the opinion. hill in 2000, it is -- it

treated an eight foot buffer zone among people entering health care facilities. they took care to find health care facilities broadly. the buffer zone was merely narrow. but it was not important enough to keep justice kennedy from writing a very strident dissent -- >> which he read from the bench. i was in the courtroom that day and his voice was shaking. he was so angry about the court had done. but the majority have held saying that people could even give them a little pamphlet. >> so i think hill is really in some danger here. i think a lot of people think that hill is sort of a constitutional anomaly. it seems to be in that bucket of abortion-related litigation that has its own set of jewish credential as opposed that would

not he applied if it was any other sort of context and that is something that you see a lot filed including the aclu and they i fco where this paradigm is a ride to the types of facilities. you can see it being rather pernicious because there is a 35-foot zone in multi-directions from entrances, exits and driveways. i won't bore you with the details, but there aren't three clinics at issue in massachusetts and they have slightly different circumstances. but in a couple of them, this basically means that the protesters and counselors -- they take pains in greece -- it's an 80-year-old grandma with a pamphlet, not a violent protester. but they're basically shut out from the opportunity, which the record shows that they are quite effective at their mission.

so i think those distinguish men's will be meaningful to justice kennedy. he will probably go down and return to a much more narrow approach that prior to hill the court had two cases, madden -- madsen and shank, that had approved injunctions against disruptive behavior and clinic access obstruction. sustain those. but you can see that they were moved by the actual record of violence, threat and a structure that is not really present in the massachusetts case. so there are more interesting nuggets in the record here. i think that really covers the landscape. it will get a lot of attention. i know other states and localities are looking at similar laws that maine and oregon are considering. accepting this will get a lot of attention. obviously come abortion cases, we always cover. those are huge cases for the media. it is an irresistible narrative. if hill goes down, the new

roberts core and o'connor gone come i think you'll see a lot of that kind of narrative emerge. and the court could -- i don't know if they will -- again take a different path from justice o'connor and maybe create new law. briefsalled counter ursus galloway. it really involves a case from 1983 called marsh versus chambers that sustained a legislative prayer practice in nebraska on a largely historical analysis and legislative prayer has been done for 200 years. it is part of the fabric of the constitution. it is not an establishment clause. i think people think that is an

odd analytical construct nec criticism of that as being sort of a generous approach to it that may be unsatisfying. but here, the town of greece had a practice of convening town board meetings using volunteer prayer givers that drew primarily from christian congregations in no small part because of the demographic makeup of the town of greece. so these two residents sued. one claim is not relevant anymore. but the other says that it advances the single violation -- a single face in violation of marsh that we can i use legislative prayer to proselytize one particular case. they lost in the district hurt -- district court, but the next court disagreed. prayernt to impart the language, the identity of the prayer givers. they have a map of where the congregations are. and the town appealed arguing that his is an -- that that is improper. the patient is the with marsh

and not brought in this endorsement test. now this'll sound familiar. justice kennedy was in dissent in allegheny saying that the endorsement test is a terrible idea and we should apply marsh in this case. what you will see before the court in a couple of dynamics -- one is does this prayer practice come sufficiently within marsh that they can just say marsh applies, don't bring in this endorsement stuff from this other line of cases. or, as they have been invited to do in the briefing, do they go further and really down on the current establishment clause jurisprudence endorsement test. >> then this would make it a white significant case. that peoplehe area are very dissatisfied with and have been calling for the critically not because it has the sense of being very ad hoc

and case specific and unpredictable. >> what is a reasonable observer? >>) that has been used to strike down various things. have work toito strike that down. so the appetite may be there, but it begs the question whether they are willing to reach out and go further towards allegheny and endorsement or just sort of apply marsh and take -- and say the second circuit misstep. >> anything you want to adhere? of adjusted -- the absence justice o'connor. the direction of the court? incrementalism? there are a lot of jumping points in these cases.

>> according to the petitioners, the take great issue with presence of crisis the town square, which i think would save the courts of vocation. they might be able to slip through under the historical respondents view of it. >> i think there's also a distinction in the local town meeting. they are not really encouraging other people to participate. it is really just one person at a time offering something. so it's not really encouraging others. >> one thing that i found interesting in the briefing was this pivot that i saw towards our ship in and the completion -- and the complaint was that prayer was course of two children. the allegation of the complaint, the special solicitude for children in a school setting, for example. at the supreme court state, they have a brief that reads quite heavily on adult coercion and a lot of things that have been

spun out that i don't see in the record, but they are really trying to spin this coercion is.. -- coercion theory and i don't think that the court will be very responsive to it. but that may be some we can -- some weakness on the endorsement test part of it. clause ofablishment verger's the last 30 years has hardly been a seamless web gave it has been an ungodly mess. >> ungodly mess, guys, you got that? [laughter] question think there are it to results. they will either take marsh to chambers and say will just follow the sister of a practice and i get into it or they might want to take a shot at endorsement because o'connor is no longer there. kennedy doesn't believe that the respondent's brief was a argument where they are trying to build on their leavy wiseman .rgument i don't think they were very persuasive in that. but even they recognize that the

endorsement test may not be long for this world. , it screamse area for some kind of coherent guidance. i do know for will it, but we might get some limited [indiscernible] >> anybody else want to add to this? let's move onto neil. i know you have to leisurely. i know you have already weighed in on a couple of the cases, but northwest versus kansas -- versus ginsburg. you can really get booted off your frequent flyer or ram. did you know that? -- frequent-flier program. did you know that? >> let me start by talking about a pro bono death penalty case. this is why this is interesting. criminal law is the place in at least in the war in court we saw democratic

appointed justices were siding with the defendant and nixon with thes were siding huskies should get justice scalia said i am the poster child for the first -- for the criminal defense clause and there's something very true about that. when you look at the decisions in the confrontation clause area, in the jury trial area and sensing guidelines and the like, justice scalia has really stake out an originalist position that is remarkably pro-defendant and says this case is one of those cases. a got case, you have named scott cheever who has been taking methamphetamine straight for nine days. he hadn't slept. to -- policee come come to the house and he is hiding upstairs. as the sheriff comes up the stairs, he panics while he is

very high on methamphetamine -- he had taken something like 150 units. something like 80 is enough to kill an ordinary human being. and he takes his gun out and shoots the sheriff point-blank. he is indicted for murder of the sheriff gave he is indicted for sin state court in kansas, but the kansas supreme court then declares the death penalty unconstitutional because it violated the jury trial right in kansas versus rain here in so the cane was then moved to federal court. while in federal court, cheever said here's my defense. my defenses i did it -- there's no doubt and i'm not putting up an alibi defense. but i lacked the premeditated intent for first-degree murder. i was high on methamphetamine and it undermined my ability to reason or premeditated for purposes of first-degree capital murder. underderal government, procedure 12 said, ok, you are

putting on a mental state defense and we get to have a psychiatrist evaluates you and ask you questions. so they did that for five hours. the trial was going to happen in the federal system but then due to some complicated things with the lawyers not being available or something, the case got moved back to state court. cheever put on the defense and called a -- a psychiatric expert who said, you know, he is high on fn phentermine -- on methamphetamine and it can be reasoned for premeditation. the state introduced all of that evidence from the five and a half hour evaluation against it. supreme --sas cheever objected and he was overruled. said -- and said, hey, you cannot use my words against me. but he kansas supreme court unanimously said the cheever was right. the government of kansas is wrong. he will -- cheever wasn't trying

to put on a mental state defense like insanity or something like that. he was simply putting on the defense that he lacked premeditated intent because of the methamphetamine and you couldn't use his words to the psychiatrist against them. the kansas solicitor general and it was granted. so the question in the case really is were -- is what are the meets and bounds of the something termination clause and what are the rules about rape -- about waivers? justice scalia wrote an opinion saying, hey, although this stuff about waiver and self- incrimination rights is pretty much made up. it is all for policy reasons. he says maybe this policy reasons are good, but they are policy reasons nonetheless. and the structure of that argument is the same one that has been playing out in all of his opinions about the confrontation clause and about the sentencing guidelines which is how much in a constitutional

-- how much in the guise of constitutional interpretation are we willing to take policy arguments and incorporate them? and this court has been pretty reluctant to do that, particularly in the criminal context. might be a rather surprising result in the case because of it. with respect to the business community cases, -- >> by the way, that was one of neil's cases. >> i'll talk about them, don't worry. >> is pretty remarkable to have that many. and they are old friend. -- and they are all different. >> yes. there is northwest versus ginsburg. i know people the snow room no of preemption is. but it is that federal law trumps state law. it comes from the constitution and in oracle six where it says that federal laws or cream over state law.

this is very important to the business community because there are any number of stay laws on any number of things that national businesses that operate in lots of states find difficult. and if one state has a really restrictive rule, say on labeling of cereal or something, if you are a national group like kellogg's or something like that, it is very hard to sell different cereal boxes to vermont andhen to iowa and alabama and the like. so preemption is a constant theme of the business community before the supreme court. i argued a case of couple of years ago about greenhouse gas emissions in which several states said that the nation's power plants were contributing to global greenhouse glass omissions -- greenhouse gas emissions. we actually sided with industry and said, no, the clean air act three amps all of these different state law things. it sweeps away.

and there's one federal standard, not 50 individual standards. the supreme court unanimously accepted that and come in general, i should say that the roberts court has been accepting most of the preemption cases. there have been a couple of notable cases -- notable exceptions, but there is a robust view about the national market. here is why this case is important here in it is again the question about is the roberts court more friendly to business than it is to other interests, consumer interests and the like? judge poser, one of our legendary art of appeals judges offer this study last year. he found surveying decisions from 19 a.m. on that the roberts court is remarkably pro- business, siding with this is approximately 62% of the time as opposed to 42% of the time over that time. >> those cases don't always break by four. >> absolutely.

when i say that -- when i say roberts court, don't mean that it is roberts alone. i don't think it is a left-right thing. i think he more interesting statistic from judge posen or is this. of the 10 most pro-business last 70 during the years, four of them are currently serving on the court, justice alito, justice thomas, and justice scalia. and of the most anti-business is only one, justice ginsburg goo. i think there is something to that. this case is perhaps a good illustration were the what is likely to go. so you have this guy. he is in chicago. flyerongs to a frequent program, northwest airlines. and northwest airlines evidently is complaining a lot about various things about the

program, not getting all of the benefits and so on. and there is a clause in the contract which says, if you are a persistent gripe or -- persistent griper, they can build you from the program. [laughter] question did not know that. but she brings the suit in illinois and, under illinois, -- under illinois common law. and the airline says, no, the airlines deregulatory acts weeks away all of these contrary stay laws and imposes one uniform federal standard. so the question in the cases is how do we read this federal law against the tapestry of all of these different state laws? what was commerce intending to do? were they trying to get rid of all of the state law causes of action so it options under one ?etric

every once in a while, the court does decide that commerce really did want 50. been veryhere has much in favor of preemption. before i go, let me just mention thepattern terry -- [indiscernible] system is getting close to broken. i think mike said that the grand jury will indict a ham sandwich. the patent trademark office will indict a grilled cheese sandwich with its corners cut off. are really important. they incentivize innovation and so on. but if you can read patents broadly, then they become tools to block innovation.

because people say come i oh, you're in -- say, oh, you are infringing on my patent. when google puts out a phone and have 250,000 different actors that are essentially at issue forpotentially bases infringement. so there is a huge robust about accidents and so on is moved very much and those lawyers can move very much into this space, representing nonpracticing entities. yesterday, the court took two different cases about a mechanism to rein in abusive patent litigation. thes in section 285 of patent act which says, in exceptional cases, the -- fees can be awarded against a litigant. if you're a file or any don't do your due diligence, which i think everyone acknowledges happened in the high mark case, you haven't really done all of

the work necessary before you march into court and say, hey, you are infringing. then the defendant should get their feedback and there should be some penalty for bringing forward son frivolous legation. in these cases, the federal circuit has been reducing the amount of power that section 285 has been and it is really one of the few tools that defendants have in patent cases. unfortunate, in these cases, they often go to discovery and often have losses and it's hard to kick them out of the pleading. they get very technical. so industry, i think, is really concerned that 285 needs to be restored to its original position. megan's firm was esther mental in helping us. cases --ct these megan's firm was instrumental in

helping us. i do expect these cases will come forth. the supreme court unanimously reversed the federal circuit saying that the human genome is they aretable and becoming increasingly comfortable getting into the space and very comfortable reversing the federal circuit. i give you the rates reversal of the sixth circuit. the federal circuit isn't too far behind the sixth. >> and talking about this kind of court being increasingly willing to step into these cases, i is that important? why are your cases important this term? what impact you have? why should i care about that? >> right. the great thing about america is that it is an innovation society.

you look at other countries around the world. maybe they have natural resources in the middle east or maybe they have a billion less people in various countries, but this country does innovation extremely well. and the engines of our economy. and we should care about this because if the patent system gets out of whack, a lot of those innovators though elsewhere. i am in the silicon valley every couple of weeks. i can tell you they are worried about this. they are thinking maybe this isn't the place to set up shop. americaa real cost to if our innovation starts losing -- and starts moving offshore. >> already. anyone want to weigh in here? ok, shall we move on to nick? i think we cannot give neil a round of applause. [laughter] [applause] thank you very much. and we look forward to your arguments, which of course will

not be televised, sadly. but that's a whole other topic. what theysummarize have already started talking about. you want to start with bond and then go to the recess appoint a case? >> yes. i know why you're all here and why you're all watching c-span. you're looking for predictions for how these cases turn out. >> you are not one to be a contrarian on this, are you? >> maybe you are talking with your book he now getting ready to place bets. i went one for three last year. i would urge you to take my prediction with a grain of salt, but i will take a crack at a couple.

so she gets toxic chemicals and puts it on the doormat and doorknob and/or of the neighbor and successfully avoids that. mostly, she gets a minor number and at one point. so it turns out it is not terribly harmful, but potentially could have been quite harmful. so this kind of conduct is obviously all kinds of state crime. actually tried under the chemical weapons convention implementation act. [laughter] >> it wasn't me. [laughter]

>> the chemical weapons convention implementation act probably wasn't -- they weren't thinking about this sort of set of facts when they wrote it. but it seems to fit. it seems like she might fit under the statute. choose using chemicals. she tried to harm her neighbor. so it seems like it might fit. from another country -- >> we have this treaty that chemical weapons convention implementation act. she is tried under the statute and she says where does congress get howard to enact the statute? where is the congressional power? what we normally do is flip open arc of -- flip open article one section eight which has a list of congressional powers. she says i don't see any power over that that concerns importance. and the government says something interesting, which is it doesn't matter that you don't

see it here in this list because we have entered into this treaty can the chemical weapons convention. that automatically gives us power to pass a statute that implements a treaty even if they wouldn't have had the power to enact the same statute absent the tree. by that proposition, the government cites a case by justice holmes in 1920 called missouri v holland which seemed to say that. it seems to say that, if we enter into a treaty, congress automatically gets the power to pass legislation even if they would have lacked that power otherwise. inave written an article 2005 arguing that that is wrong. that orholmes said implied that, i guess, in a five-page opinion with no reasoning whatsoever. i have argued that that's wrong

and now mrs. bond is arguing that that's wrong and that congress lacks the power to -- the treaty cannot give congress this power that congress lacked already. if missouri ve, holland is right, this is a potential and run -- potential end run up hours. but if the government is right in this case, then congress has all those powers plus any power that they can enter -- any power concerning any issue that they can enter into a treaty. >> that could be pretty much anything. >> and the conventional wisdom is that there is no subject limitations on treaties. so if you can find a foreign country, zimbabwe and make some agreement about mandating that people buy insurance or requiring that they not have

guns in the schools or whatever it is, then suddenly would get that power even though they lack the power before hand. that is really what is at issue at the case, whether the congress power is limited or actually increase the bull by byaty -- increase-able treaty. >> what is your take on where the court may come down on this? >> it is hard to reject. on the one hand, there are many ways for the court to actually dodge the fundamental question in this case. they could construe the statute narrowly or they could construe the treating -- the treaty narrowly. airways around taking this issue head-on -- there are ways around taking this issue anhead-on. that they did grant the case. it is not that interesting unless you're trying to get to this issue. >> and the fax.

are lovely tocts talk about. [laughter] moreover, i filed a motion on behalf of divided argument time. my reef is off squarely on this issue. the court is still arguing that. if they grant that, that will indicate that they want to take the big issue head-on. so our fingers are crossed on that. >> was there never any discussion of this going back to the state? it is pretty interesting that the given test proceeded this to this extent. >> this is the second run at this, too with the courts. [laughter] >> yes. this is a big mistake. odd how i came to pass. first, the government took the position in the third circuit that she didn't have standing to

make this argument in they convinced the third circuit of that hearing and then acting solicitor general confessed errors. of course, that's not right gave of her she has standing and the , of course, yeah, she has standing. thethird circuit said, in merits, we urge the court to rethink this. it seems like it might be crazy to us. so that is what is up before the strip in court. >> less talk about the recess appointments case. we talk about originalist on the supreme court. they will all kind of have to be originalists in this one. about the these is scope of the power of a branch of government, legislative, executive and judicial.

these are fundamental separation of powers cases and there are not many cases like this. so this really puts the court back to considering first principles, really digging into tax, really being into history. for scholars, these are interesting cases because they are driven by first sensible's. is driven bye first principles. so this concerns president obama appointing various members of the nlrb, the national labor relations board. nlrb takes an action and no canning says you don't have power to take that action because you don't have a quorum, because a couple of you were not not appointedy -- properly. if you're not up when did our play, you are just citizens and there are not enough hooks there to do this. so it is in implicating question over what is a proper appointment t.

in a general matter, the word amen most senior officer is appointed is that the president wayn a general matter, the a senior officers appointed is that the president nominates and congress confirms. >> you do carry that in your pocket, right? >> i do. i took it out of my pocket already. the president shall have the power to fill up all vacancies that may happen during the recess of the senate by granting commissions that shall expire at the end of their next session. it is easy to imagine what was the paradigm case that the framers were thinking about when they wrote that. of course testut is out of session and some crucial general is killed. can appoint a new general instead of waiting for the senate to come back and senate -- back and send that

back in session. those are exigency circumstances. you shouldn't have to wait for the senate. what happened here, you might recall, the senate was holding what they call pro forma was coming senator in and gaveling the place to order for a few minutes and then gaveling it closed. but 98 of the senators or whatever it was worth home in the president said that is not a real session. you are not really in session. you are really in recess during so that triggers the recess appointments clause and i can just appoint these folks, even though there is a pro forma. case raises first that sort of narrow question of what about these pro forma sessions? does it matter that the session -- that the senate itself claimed to be in session and

audit was in session but president obama says, no, that is not a real session. so one question is what we make of those pro forma sessions? recess count and the appointment clause is not indicated? is the recessn appointments clause again philip in vacancies that may happen the recess with a capital r and the d c circuit said that actually means the recess sessions, between two s sessions, like the one that is at the end of the year and when it begins at the beginning of the year. so there is no intrasession recesses. it doesn't include intrasession recesses in that is a big deal.

so the senate has many intrasessions -- recesses. that was one dramatic and major holding of the d c circuit. decidedwent ahead and that more important and theatically, again, president shall have power to fill up all vacancies that may happen during the recess. , ai suggested already straightforward understanding of that animating idea would be the recess occurs while the senate is not in session, right? the generator -- the general is killed while the senate is not around.

now the executive branch has taken the position for 180 years ,ut that actually means exist that the vacancy exists during a recess, even if it happened when the senate or occurred first when the senate was first in session. the executive branch has taken that position for 180 argue years. and the d c circuit said no. what it means is that it has to occur -- it has to first become -- the vacancy has to first begin during the recess to trigger this clause, which is quite a dramatic holding. and the court has never squarely answer this. almost -- >> as you are saying, republican administrations, democratic it administrations make use of the

power to make recess appointments. . circuit opinion is affirmed, that will curve that time-honored tool. >> on its face, it looks like a little tool. how often are they in recess anyway? but everything that happens in washington happens in the shadow of these fundamental decisions. so how a decide on how recess ointments work changes the balance of power after regular appointments. when the senate is in session. out,he president wait it wait for a recess and get the reset he wants or not? and it is broader than that. it shifts the balance of power as to everything because appointments are a bargaining chip. so this is one arrow in the quiver of the executive ranch if

he gets to do this or the senate if he doesn't. you can win concessions on other things. a.b. we should postpone wemacare unless -- maybe should postpone obamacare unless you appoint x people. every negotiation between the president and congress have been in the shadow of these fundamental rules. ok, let's talk about the less powers case, bankruptcy court. then we will open it up to questions from the audience. this was pretty significant. >> this is extremely insecure. i will do 30 seconds on it. it is called executive benefits insurance agency. this concerns bankruptcy judges. bankruptcy judges are not article three judges. they have particular constitutional protections. they have life tenure. their salary cannot be

diminished, etc. and backs of debt and bankruptcy judges don't have those things to their different. the question arises what kinds of things can you give to bankruptcy judges to do versus what kinds of things have to be in an article three court? are quieted of securing complicated on this particular kind of claim, fraudulent conveyance and rights,this private public rights distinction. it is all extremely confiscated and it's here and i will not written you all with this. dish it is externally complicated and vague and i will not burden you all with this. i will give you two possible visions. one is that it is really protecting individual rights,

you're right to a certain kind of adjudicator of your claims, really about personal rights. if you have that conception of it, then you might say, well, then it is wava bowl -- it is wavable or consent to a different kind, right? so that is one conception, which would lead you in the direction -- i should say this case implicates whether you can consent to this are not, whether consent matters. if your conception of article three was that it is really protecting individual rights, you say, yes, you should be able to waive it if you want, i suppose. on the other hand, you could have a conception that it is so structural, that it matters not only to the parties involved in this case, but to us all in a sense, the power of the judiciary article three.

after that, you would necessarily think some particular party ought to be able to waive that. that is what is at issue, how you conceptualize that. these are deep structure of government cases. everything that happens in washington happens in the shadow of these sorts of cases. that's why they matter. >> thank you. does anyone else want to add before i toss into questions? productions? -- predictions? it will be an interesting term. >> [indiscernible] [laughter] >> i agree. i think it's a pretty easy case. i think it is probably one of the clearest examples of constitutional favor by this appoint atrying to new spokesperson when the senate claim itself that it was not in

recess. to me, it is preclear. when they were appointed, they would have been able to serve for two years, right? it was right at the beginning of a new session of congress. i just wonder if they just pushed it a little too far. ok, audience. anyone? >> we have a question over here. >> if any of you had a chance to look at comments on the oklahoma case on the restrictions of abortion drugs? >> do you want to take that one? >> someone needs to at least look at it. thank you. i don't think it will get teed up for decisions this term. this is an oklahoma statute that purported to restrict the timing and theyal abortion,

require prescribers to abide by the fda approved methods for prescriptionsese and it results in the narrowing of the window. prescribers have gone to off label uses with a slightly longernt protocol and a window in the early stages of .regnancy obama said, no, we don't like to. they seem to have some record of doubt the off label use as being riskier to women. i don't know if that record is legit. if the state court did find it so and the law was struck down but therial court. a -- itn came out of moved onto to a from the validation of the law.

it simultaneously referred to statutory questions to the oklahoman supreme court. how will determine appropriate the case would be for the supreme court to hear sort of metalevel. then -- in arizona, a claim was filed on a different law. the oklahoma case may not be on a fast track because the oklahoma court doesn't have a deadline to answer these questions that seem to require more work than was required. --they have raised dairy raised a very interesting questions on how abortion fits under casey and gonzalez and how you gauge undue burden under casey and the availability of methods in carhart.

but it's been a long time since i have read those original decisions. so i won't say much more about that. but it's out there and people are worried about it. so people will be watching those. >> it doesn't sound like you think we will get this term. anyone else? >> while we are talking about cases the court may grant, we saw some high-profile petitions is anyone able to comment on those, which ones might be seen or if they will be heard this term? >> i haven't followed them closely enough to know. >> they are barreling their way. i don't know that they will get it this term. do you think? >> there's one from the first circuit involving the search of a cell phone.

addressed more by the concurrences in jones. any thoughts whether the court will wrestle with that more this term? >> mike was going to make and then we will go to your question. >> i'm not entirely sure the timing on the hobby lobby here in it is conceived the -- it is conceivable. there is also a series of challenges brought by catholic institutions and they may wait until those earthly and take the whole smorgasbord at the same .ime >> on electronics surveillance case, i don't have strong feelings and i haven't really reviewed the papers on this particular one, which seems to be the search incident to arrest doctrine and how far it will let you go in searching the contents of a cell phone pinned not such a big deal, suppose, if it is an old-fashioned flip phone. people get nervous about it when it is a smartphone when it has

every thing about your life. i won't venture a prediction on then there is a movement and i'm waiting for a case to percolate up on some of the many unresolved questions under the fourth amendment wiretap act rubric that the courts are struggling with. there have been a couple of search petitions over the years it did not get granted. you confirm for -- you can infer from that that the courts are not looking for a fight on this yet. but i think they will get involved. the case in the clapper case last term. i think he will hit the court in the next couple of years in some form or fashion. but they are usually our defendants with litigation in rather than true constitutional questions. >> i would agree with most of

that. the supreme court will have to take a crack at the fourth amendment and new technology. with lots ofe area unresolved questions. and the technology is evolving so quick way. i think the court will have to think about what its framework will be for deciding these kinds of questions. i think you actually will see -- i don't know about that case in particular, but we will see many such cases in the next decade. >> i think we have time for one more russian than we will have to call it a day. question and then we will have to call it a day. the accuracyabout judges i wonder how that would apply to magistrate judges. a magistrate and can make a decision as opposed to just a recommendation to a district judge. there is a lot of pressure on parties to agree to that otherwise there may be 10 years before you get a trial for district judge. that thee ideas

parties can't wave a because it's the right of the public, will that affect the way civil litigation is done in the federal and district courts? >> that is a great question. it is a hugely conga catered area and it implicates magistrate judges and territorial courts and military courts and there are a lot of non-article three courts in the world. what they get to do and why is a very unsettled area of law and the court has been very confusing about it. so implications for that and there are implications are out. two of the big themes of these consent.e been, one, should that matter? should that be dispositive? that is a running case -- a running theme in these cases. second, what kind of article three review is open?

they can take a crack at the question at an appellate level. what is the scope of review? these are two of the themes that run through these cases. how these factors work or how they get balanced is what unsettled now. rate it will be unsettled even after this case comes down. >> i actually have time for one more question. so this will be the last question. holly disparate impact case, can you talk about the history preceding it and how pulled.se was tol cracks i think the major significance is whether or not it affects justice scalia's view of the statue. any doubtink there is that he will incorporate. the question is whether he will defer to hud's regulation -- not

having an affects test is a cousin and is germanic late add-ons with the purpose test because it prohibits you from considering race and the effects test basically obliges you to do so. thei think that is one of reasons they have been slowing down things to get to the core because they want to get the hud reg out before the supreme court considers the case. >> we will have to and it on that note. thatve to end it on note. we'd very much appreciate you. thank you to c-span and a huge thank you to the panel. that this is evident is the panel to analyze the upcoming term. i want to thank you very much and thanks to all of you for coming. [applause]

[captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] chief justice john roberts exiting the cathedral with washington, they left the red mass that is traditionally held the day before the first monday of october, when the supreme court begins its new term. this service dates back to 1928 invokend is intended to less things on those who administer justice and is usually attended by members of the court and other washington officials. we will take a look as guests left the cathedral.

>> honolulu you. -- holly liliana -- honolulu yea [no audio]

>> this is the red mass this morning and washington, d.c., just ahead of the supreme court term. next a discussion on health care

and the impact on patients and survivors. coverage starts in january. enrollment opened on tuesday. itour next panel is what means for patients and providers. the affordable care act will expand health insurance through a combination of members, ask -- eligibility,anding rules for insurance companies, and requiring individuals to purchase health insurance and more. this conversation is going to look at that conversation from the perspective of all stakeholders examining costs, benefits, and the changes to the system. our panel was moderated by the communications director and health policy advisor for the alliance on health reform. she was previously the robin toner distinguished fellow at was alsoalth news and an award-winning health care and welfare correspondent for the

national journal magazine from 1995 to 2010. joining marilyn on stage for this discussion are kiersten vice president for worldwide public affairs at pfizer, dr. jean johnson, the chair of the board as well nurse practitioner health care and dean at the george washington university school of nursing. jennifer lee, board member at the arlington free clinic, peppermint, of the american society for clinical , and dr. johnence severin, chief executive officer of the american cancer society. quick reminder, please do tweet all of your thoughts, comments, and questions at the # . we have a great and robust

dialogue going on. i would like to keep that going. with that, maryland, i would like to turn it over to you. rate, thank you. we have a lot going on. millions of people are about to become insured in january. the phones were ringing off the hook yesterday and the day before. we saw the system actually go down. the politics, regardless of what people are believing, people are interested, people are going to sign up, there will be more insured people either through private insurance or through medicaid. at the same time, many people will be left uninsured. we have a great panel with us today. a pretty straightforward question, but with different answers for just about everyone on the panel. so, we are going to start off

with an insurance question. there are many insurance changes in this law. sense for hows a insurance is going to change? what are some of the differences in the rules in this law? we are talking about changes with pre-existing conditions. what does this mean for the country's sickest patients and for all patients? what does this mean? >> i think it is transformative. i think the choice of transformation for this conference is highly appropriate. particularly i would suggest cancer patients, meaning that for the first time in the history of the pop -- of the republic people will have access to survivorship. organization is the largest voluntary organization in the world with $1 billion in

revenue. ago there were virtually no cancer survivors, today in america two out of three cancer patients are survivors. third losest, the his or her life most often because of lack of access to .ealth care through insurance so, when the american cancer weiety started 25 years ago, had the only database in the country that could show during the debate on the affordable care act that followed. it has stated diagnosis, outcome, and whether you have insurance or not. we were able to show the american public a woman with stage two: cancer with insurance had a better five-year survival rate than a woman with stage one who got treated. very important points. it is no surprise to anyone. surprise to see

that even if you get diagnosed at stage one, you are more apt to die if you have nor -- no insurance. for the first time in history all of our citizens will have access to survivorship. >> for cancer patients, for any patients, what are the most important insurance changes in the law? >> for cancer patients in particular, think about it, my wife is a breast cancer survivor and could not get health insurance. now anyone who needs it can get it and there are no annual or lifetime caps. can sometimes exceed lifetime caps in one year of treatment. then i think what is really important to remind everyone is however we build this out, the centerpiece will be access to preventative services. we know that over half of all human cancer is preventable

during the human lifespan. people now have life -- access to colonoscopy, we can actually prevent the colon cancer from occurring. so, this is huge and transformative for all patients. >> ok, so, we know that a lot of people will have access to coverage. what about access to care? with a lot of people entering the system, the question becomes -- will there be enough providers? especially primary care providers. there is talk of a potential workforce shortage. johnson, do we have enough primary jean johnson? >> yes. [laughter] do we have enough primary

care providers, one, and in what areas? a lot of states are now talking about scope of practice that they can create new opportunities for advanced practice nurses. what the prognosis is for workforce issues and help us to understand what is going on in the states right now. >> workforce issues are certainly a challenge and there is no way to fix in terms of having an adequate primary care , but the affordable care act has included helping to expand the primary care shipsrce through training and payment programs. these have certainly been successful. there have been about eckstein hundred nurses now reported

through the national health service court because there has not been significant health service funded -- funding added to the core, you can get some very underserved areas. however, even with those kinds of capacity building efforts, and the efforts on the financial incentive side in terms of a 10% bonus payment for five years to primary care practices, paying for fee for service to medicaid ,atients, the medicaid rate there are other financial kinds greater liability for primary care practices. financial the effortses and expansion

, we still have the problem with skull practice for nurse practitioners. they are a major workforce in primary care. there are 130,000 nurse practitioners currently and the number will continue to grow. there can be more nurse at theioners produced adequate pace of physicians and i am certainly not saying that we do not need physicians or that nurse practitioners will replace physicians, because i am a firm believer in this practice , but unless nurse practitioners can practice to the full scope of their education and clinical decision-making skills, that will limit the services that patients will be receiving. right now 17 states, plus the

district of columbia allow independent practice that is basically and supervises -- unsupervised. supervisionrequire specifically for prescriptions for prescribing. thing that we do know is that there are states with limitations and a pretty great need in terms of primary care. health services at the resource administration have recently noted that there are 67,000 geographic areas in the country that are primarily shortage areas. is significant. that is current with the additional folks, the demand will become even greater. ,ust to address those needs

more providers are needed and we do not have the production capacity. 45,000e numbers up to , we do not have that capacity. restt me open this to the of the panel, who are patients going to be seeing when they get this new coverage and want to come in and see -- are they necessarily going to come in and seeing a dr.? where are they going to be getting their care? >> you will find that people are going to seek out care wherever they can find it. you may find folks coming to the and pharmacies all over the country are doing laboratory work on a contract basis. areratories in this country

already trying to figure out how they can be better at giving patients access to not only the care that they need, but the information. change, thesed a laboratories will be sharing patient results with the patients. it will enable the laboratory community to fill some of the by beingimary care able to explain or refer information because there is not going to be enough time for what coverageionally call of the landscape. >> you are saying that those folks are going to have new abilities to work with patients? >> they have the abilities, they

just have not exercised them as well as they should have in the past. but with the system the way that we believe it is going to evolve , there will not be enough folks to go around. auditoriums are going to have to step out to help patients better than they have in the past. situated inhey terms of workforce? there will be so many new people in the system. are there enough people in the lab to handle the influx? >> that is the concern that we have. is no way to know yet how many extras will be needed. in our profession we have the ability because there is a level of entry to be able to help with some of the gaps, but once you get to the level where you need

, pathologists to talk to patients, that shortage will be very limiting. or has the potential to be. >> i would like to speak for a moment about one of the things i did not say, which is that we do theknow exactly what provider workforce is that we need. if we reengineer how we work , we still have primary care doing one-on-one and we are not looking at the systems, the population, how can we best destroyed the variety of the workers that we have? looking at the physical therapy occurs, the pharmacists, everyone, i think that is a key thing and the centers for medicare and medicaid are looking forward to seeing what kinds of things come out of that.

>> go ahead. we have a free clinic and do not get federal or state funding . >> explain to us the difference between a free clinic and the community health center. >> community health centers and similar get federal funding and have gotten support through the affordable care act in particular. a lot of them are expecting to see these new patients. through private donations, the product is communities trying to fill a gap to provide care to those without access. we think that we will very much

still be needed during and , there will be millions of patients that still do not have access to care. i think that in the early going people are going to go to the places they are familiar with and in the early going people with additional coverage will go to the community clinics hospitalslinics, actively working to redirect patients in that regard, getting them into a traditional primary care kind of setting, but theever the setting, adequacy of the provider network is a real and legitimate concern . the massachusetts experience with that has indicated that the observation often times is that should be nurse practitioners or

primary care, but the reality is that to accommodate patients today in a redesigned system, we will need more of both. from the physician's standpoint there is a real problem in that regard. there are restrictions on the number of residency positions available. last year graduates were not able to get residencies and there were limitations on the training slots. that needs to be examined as well. >> from the health system perspective is this something that you were able to -- what was your role? >> major educational and research centers around the country today actively support a number of training programs above what is being paid for through the government, as well as offering advanced nurse

practitioner training, for example. on the commercial insurance side of things as well as the philanthropy that comes into those institutions through training programs. that is a medium-term, longer-term approach that should be able to help down the road. january 1, as you mentioned, this was a problem in massachusetts where we saw long waiting lists waiting for people to get into see a physician. if there are people who cannot get into see a physician, they show up in an emergency room, your clinic, you have new working relationships between the hospitals, the physicians, the clinics and your system,

what are you doing to prepare in the short term. it is already underway, the point that jean was raising earlier about raking down the silos. you see a lot of different partnerships developing between hospitals and physicians. how it plays out in every community is different. those of the local community. it is not really being throughout uniformly

the country, so that is just one example of how the exchanges are rolling out around the country being very different as well. how close are we with some of these state scope of practice laws? some of them have been passed, when patients go into a physician's office they may start to, instead of seeing their doctor, they may be seeing a nurse practitioner or when they go to see the pharmacist they may be doing more. we going to see a system starting next year where the patients may be getting more? ontead of relying as much the doctor that we may actually see a different system where we more providers? where are we in the process?

>> we are already on that way. it was a recent study done by some good colleagues, bob , a family physician. 2000, onlyo, around 30% of the practices practiced .ith nurse practitioner pa they repeated that study and just over 50% of practices now practice within np or a pa. plus in the health care landscape we are seeing the emergence of retail clinics, largely staffed by nurse practitioners. there has been a big investment in terms of, you know, establishing the clinics for convenience and for very specific types of problems, but

i did wonder when they first emerged how successful they would the. them in fors take ear infections, minor things, and they are being used. certainly i understand the expansion plans. abouthave spoken mostly bots of people getting insurance, but many others will not did insurance either because they're medicaid has not expanded in their state or because people choose to pay the penalty without purchasing insurance, or the cost is such that they will not be required to pay the penalty, so we will and what happens

providergh the various areas that we are talking about, the health system, the free , how will it affect your cancer patients? how is it going to affect your individual areas and pharmacists providing pharmaceuticals for the folks who are left uninsured. do you want to kick us off? >> patients who are uninsured are paying for cash if they need and they will continue to provide patient assistance to who have difficulty meeting their medication needed.

-- medication needs. so what is going to happen to the uninsured? where they have gone historically, to the free clinics, the community clinic, they will continue to come to hospital emergency departments where they were obligated by law that they and mission will treat them for quite some time and weeks at that to continue for quite some time. obligated to stabilize them, but they will not get extensive treatment? through the stabilization process and as they have until now they will be arranging for their continuation they areg care after

stable. >> can you tell us how hospitals are going to be able to handle this, financially? hospitals are losing some of the funding they have traditionally gotten, which is government funding helping to make up some of the losses from uncompensated care. and it differs, so medicaid is a good example of that. when the law was originally passed the concept was that there would be reductions over and that was an approach that was supported at the time

but was under the concept that medicaid was going to expand uniformly nationwide after the supreme court decision. from the american hospital , whatation's standpoint of the issues that needs to be are the adjustments consistent with new enrollment taking place. how it takes place will differ state-by-state. >> what is the chance of the federal or state government stepping in to give some of that from the state standpoint, i gave up trying to predict a long time ago, and we do not have the kind of funding to be able to expand that in a significant way, and the consequences that hospitals will be able to provide a significant amount of charity care as submission. >> to your question about what happens to the uninsured, this is why we know that free clinics

will still be very much needed in every community and why we do not expect our patient demand or workload to decrease at all with more support, because we have seen more need in recent years and we know that the situation is different in every state and community. in arlington, virginia, they have not yet decided to expand medicaid, so the majority of our patients do not have any new or good options yet. we hope they will in the future but right now those 100% of poverty are above may have access to the marketplace and we are excited about that and want to get them connected to new those who are the poorest have no new options right now without dedicated expansion. we are just as busy as ever and need as much support as ever.

>> are you concerned about continued support and the perception that free clinics will no longer be necessary? actith the affordable care and expanded coverage there is the assumption that they will not be needed anymore, and it is not true. there are those who continue to be uninsured. those with coverage and without access, they continue to provide care for the media's agents no matter the situation. >> elisa, your folks, how do you deal in the clinical labs with the uninsured population? >> in this country the laboratory community is not

homogeneous. they already have built into their business plans the absorption of uncompensated care , as do all the hospital-based laboratories. we know that a number of patients that we see are never going to be reimbursed for what we do. -- thatast that has in has extended itself to people with insurance because cancer patient tends to always overspend their caps. and we know that be able to pay.

that will continue for the population who is not documented in this country. still, we need to access the additional small neighborhood laboratories. they already do a lot of and there is an increased level in uncompensated .are >> we have not talked a lot , yet thereaceuticals are effects of this law firms who doodles are. pfizer -- >> pfizer started to

pay for the company expansion in 2012 -- 2010. all of that notwithstanding, we believe you did the right thing. and that is difficult to do, insurance helps bring you time, but in order to stay on and in him -- and have an enhanced regimen, you need the access to insurance and reforms that are in place that means that they cannot be taken away. all important through medicaid and the health insurance exchange, bringing new

people into the marketplace. the revenue question does not offset the fees, but it again goes into the right place. >> not just coverage expansion, but they are reducing cost. pharmaceuticals are effective in avoiding more expensive health interventions. would they not consider the cost of medicines? they are known to reduce other and they can really prove who -- really prove outcome and prevention. parts of it being effective are that you do not just get your

and we look at the benefits coming out in the design. or with your free cancer screening on the formula of your >> you all talked about how you would be working with patients in new ways and i wonder if others on the panel can talk to us about new ways in and they haves

been together for a while now new drugs ares released to the market, there are companion diagnostic test released to help to monitor the therapy of it. and this has helped to move diagnostics and pharmaceuticals and possiblyying experiencing downstream complications because they did and weply properly with also in the laboratory i have

started a lot of molecular i have developed response to whether the patients , andrespond to the therapy make us much more efficient and and -- that is visible continue to happen, as long as this role continues in terms of looking at the individual, that is what we are used to. >> hospitals and physicians are working between those entities, between them working together with patients on the question of and the individual

petition himself, the right care visioneight, the right and there has been active light around the country with medical creating the systems and the ability. what the patient, based on their and wass and issues related towards the end of life.

that family of issues have risen to the surface and are getting and level of attention that has various things like andital infection rates i think that a we're only at the very beginning of understanding how to use with a group of

children having the same and they ares basically looking for confirmation with additional information and are also pointing to the really engage in decision-making. that is something that the aca has record -- has recognized in so, how is that

happening? >> i wanted to pretty up on what and the first words out of his house were reviewed and and they do the healthiest

nation, which we are not. institute of business shows that we are compared to assist in assess andax will and they can get the health insurance and there is an individual mandate, they must get it. and inamic has changed

said -- you know what how we can and so, i bet that it was in addition to the standard where the episode on the page eight for the out clothes regarding non--- she pointed out that

it is giving that late, it is making sure that we reimburse and identify the right is -- and i was not a good system. the commendation of the acts created the infrastructure to do that but it is making sure that the payment is used, available, and analyzed property. this is the right different .lace >> there are two themes. we have been doing this for years, it is trying to patients

out of the hospital. we are seeing unnecessary readmission is a big theme. i know that, and i had volunteered in the free clinic, my patients with diabetes, we were adequately controlling their blood sugars and we were keeping them out of the emergency departments, we were reducing hospital admissions. we have also spent a lot of time focusing on prevention. have spokene we about, improving health are alln, these investments that will save money in the future and promote good health. >> we have heard a number of people talk about things like, as she said, putting providers in the boat together. we have heard coordination.

the word that comes to mind for me is consolidation. we have seen it in a very rapidfire way to talk about what they have seen a little bit, the effects of that consolidation. where exactly we see that happening, who is consolidating and where we are now in relation to where we were in 2010. exactly?nsolidating, how much more of it are we going to see happen? what are the ups and downs of that consolidation? >> in terms of the hospital and physician community, there have been a series of different relationships emerging between

hospitals and between hospitals and physicians. they are all oriented towards developing systems of care. if we want more integrated care to achieve what we are talking about, you really need the , and organizational that represents for many of these organizations and expenditure of hundreds of millions of dollars to deliver the kind of care we are talking about as well as the managerial capacity and capacity to manage the risk associated with the new payment models described here today that we all see as a great , but you need the organizational capacity to do that. hospitals themselves are very labor intensive and capital intensive. one of the concerns of many , we want to bring

those inefficiencies out of the system with a certain degree of harvesting that needs to occur. that is an important part of developing the system we are talking about in the future. it has raised some concerns in some corners about the providers having more influence on the system then the insurance company. if you step back to look at what we are trying to achieve, i do think we are coming up on a kind of decision point on this issue, which is that we have to decide is the creation of a more --,nized system of care like the kaiser system in california is often held out as an example, but the kaiser enormouslyn integrated system that accounts for 40% of all insurance telephone you.

what they have been able to do over time is developed the efficiencies that many of us are talking about today. , buterstand the concerns hopefully we can get the benefit of the partnerships being developed to provide the protections that people were concerned about. >> i would like to echo that, to an extent. the affordable care act and establishment of these organizations have, i inc., during thecommunity managed care days. centered for ar, different reason, providing across aare and access

large continuum of places you , not just aare hospital or academic medical center. the thought consolidation or coming together of different care sites, you are seeing in minnesota, the shenandoah valley, virginia, the haas totals are doing hospitals and clinics with physicians practices, then taking a look at how we are doing things in this that the make sure quality is still the same. in one center as opposed to another, maybe through physicianation the will always get the same

results. that will be good for patients. if no matter where they go the , it willeans the same eliminate a lot of the redundancies. our hospital and laboratory thatm can bridge information to anyone, no matter where they are. this is the kind of thing where i think that the act, the impetus is different from what it was in the 1990s. just sort ofke to jump in with the changes to the financial models, one of them

being bundled payments. they will not sit for every health care problem, but by having that payment everyone has a stake in the game. that may prove to be what a powerful consolidator. coupled with the outcome measures attend to that. >> let's open up to questions from the audience. i believe we have some else walking around with microphones up the middle here. if you could please identify yourself? particularhave a panelist you are addressing your question to, let us know. >> i volunteer at the arlington

free clinic. my question is for the gentleman from cedars-sinai. earlier this morning we heard that cedars-sinai is not going to be part of the network for any of the care plans offered on the exchange. how is that for you? are you planning to make any changes? appreciate the shout out earlier in the program. [laughter] but i think the question is a good one. one, it illustrates the point i was making earlier that this is how the law is going to be very different, state-by-state, and we need to recognize those kinds of dynamics. with regard to the california

situation, your observation is correct. the networks that have been put together for the california exchange are more limited than the commercial insurance market. we are embarked on a grand experiment here and we are also embarked on new market, which by definition come together over time. so, what has happened here in will likely play out over time. but it also plays an important regarding efficiency and cost, they are not this is and be a high-cost and so my or -- my

own organization provide some of the most advanced medical care in the united states. we have a significant teaching research mission to benefit the this is horrible largest providers in california. the question comes together to impact what the cost is. with theforward affordable care act and how it plays out, the question of understanding efficiency and cost, the question of how we will provide access for people who happen to live near these and solutions and others, my own in the example, those kinds of

questions have yet to be answered and i hope it will be as we move forward. here?, right >> joe coopersmith. recently the director of the --earch program in the v.a. one thing that everyone agrees upon is that costs have to come down and no matter how that is done, distribution, efficiencies, what not, it means money in the system for hospitals and other aspects, less people employed, with a certain amount of economic change for the institutions in the community, because hospitals are among the highest earners in many, many communities in the country. i wonder how you see that aspect of it. you are absolutely right.