making the law work into making sure that people have affordable health care, we kept working on it. we fixed the problems, we hit period lastedweour enrollment almost a full year. and yet it was only in the last total pool20% of the cut themselves and rolled. people signing up for nce had azed insura shorter time, and over 1/4 of them waited until the last month to get enrolled. i understand that the beginning -- butrollment period what we've learned in massachusetts is when it comes to enrolling in health care, any of us wait until the end to get

it done. what didator tavenner, the administration anticipates would be the pattern, of enrollment, prior, what were you thinking prior to the launch of thinkcare.gov, and do you the early problems you had are moing to affect the long-ter pattern in enrollment? >> we assumed we would be able to enroll folks throughout the six months, but that that greatest surge would come in december, because we got there were people who wanted coverage on january 1 and the second search would come late february, early march, by the individuals who were not as motivated to get insurance. figures, butment they were lower for october him and i think they will be low, and it follows the massachusetts experience, and that was part of

the reason for such a long and rome at period -- such a long enrollment period in the first year. >> and you have time to get these problems fixed? >> i think we have time. >> we agreed that the problems of the website are unacceptable, but our experience in massachusetts suggests it might be prudent for us to take a deep rest about this. -- a deep breath about this. the launch of our website was not smooth, but we kept working on it. when we had data mapping and volume problems during our launch in 2007, we kept working on it, and when we needed our tech surge to work on it, we kept working on it. we kept working on it because we stayed focused on what mattered -- our conviction that no one deserved to be bankrupted or shut out of the health care

system when they got sick. so thank you, mr. chairman. >> thank you very much, senator warren. >> thank you, chairman. i would like to talk about my home state's experience. governor chafee, a republican member of this body, decided that early on that he was going to do this and get it right. stake, but weall are a pretty smart state, and he put christy ferguson, who some of the people might remember as thischafee's staffer on committee years ago, in charge of the project, and i want to say that in rhode island it has been a success. the first time that i went to visit i walked through the front door, it was late afternoon, 5:30 or 6:00, to make sure that people could come in, and there was a family, mom, dad, three little kids, and they were at the reception desk, and they had

just come in -- he had come in they hadn the day and been served and explained, walked through the whole process, and they were so thrilled with what they heard that they had gone out, and this was their return trip, with two bagboxes of "coffee and a of donuts, because they were so happy. i walked around and talked to people who were taking the calls and dealing with people over the computer him and one woman who was just beaming, and i asked her, you look like something wonderful just happened. you have quite a smile. she had just talked to somebody who was paying i want to say , and hadnth into cobra just found a better plan for $500 a month, and $300 a month is actually a pretty big deal in

a family pot life, so she had had a really wonderful exchange with that person who had called in. we have people when they come in live, they are taken to private rooms to discuss it, and when people find out what the deal is, we have a lot of people who are getting hogs. the rize story today about a woman who burst into tears of joy's when she got coverage. i would like to have that "new york times" study put into the record. there is more than one story about this. rhode island is not a very big state. we made this work. it has worked pretty well. we had a glitch or the hull boys down and a couple hundred people could not get through. we're working through that. when i see these much bigger states who do not even try, they did not even try, and now everybody is complaining that the federal government did not do them well enough. there is a part of me that says, next time stand up and give it a

try yourself. you know? you do not have to be just a recipient, and we are up nearly 4000 people and rolled -- enro caccounts.00 of all these wonderful stories. there is an another path, and we are sorry you had this much of the health care website rollout, but it should not mask that underneath it ere is a plan that is making a lot of families really happy, really, really happy. if you go to the front lines and go to your state exchange and see what people are seeing, you will see a lot of the stories. they are happening across the board. there is more to this. if you did not want to take the trouble to bother to set one up yourselves, it is a little nervously to be complaining that the government did not do it

well enough when you could you had could do it if saddled up and done it. i would also -- there are these letters that people have been talking about the people have gotten. when we got this started, we were dealing with a health insurance industry that was so cold hearted that when is took a client who had been paying premiums for years and suddenly came in with a big claim, their first reaction was not how do we help this family, it was let's look at the records and see if we can find a way to disenroll them and get rid of this liability. they had acne. is that a pre-existing condition they did not this close to us? can we throw them off? that was the attitude. there were snazzy stuff that was happening to some of these letters. i want to use the example of rhode island who cross blue

shield. it is a terrific letter. it is very clear that lays out what your choices are. it's as if you like what you got, you can keep it, and here is how, and it's as if you do not like it, if you want to use the exchange, here is how. it is three steps to stay in blue cross shield road island. it is three steps to get on the exchange. there is another way to do this. i think rhode island has done right, and we are seeing pretty low drama. good luck getting through this mess. it is been frustrating for all of us. but i think it is safe to say that across the river there are for us to go to. thank you, mr. chairman. >> thank you, senator white house. -- whitehouse. ms. tavenner, you have a hard time that you have to be out of

here also. i want to make sure that people have five minutes and have a chance to ask another round. i would just say first of all i fork senator whitehouse mentioning rhode island. that will be put into the record. senator isakson asked for an i.t. report be made of the record. that will also be made part of the record. at theot mention that time. again, i like what senator said about this new affordable care act, or website, not not a about a website or some technical fix. it is a value system. do we like the old you system? where people could not get coverage? where somebody got sick, they

would drop your policy, cancellations? i hear so much talk from the republican side about these cancellations. i did not hear much in the past when the buddies would automatically cancel you if you got sick. posse ifnot renew your you had cancer or breast cancer or something like that. did not hear about that. you are saying that is over with. that old value system was no good for this country, because too many people, like mr. streeter that i mentioned in the beginning, who was in the column on sunday, or i could mention kathleen ferguson of des moines, where eight years ago her son died at 30 sikkim and she said he died needlessly because he had a pre-existing condition and cannot get insurance and medication he needed. i want us to take better care of each other, and i'm grateful that people with pre-existing conditions can now get coverage. that is the old value system.

a person from iowa wrote about her brother, then tried to find interest coverage for years. coverage with a $50,000 deductible, but nobody would give them a policy. when the exchange "he saved $700 a month on what he paid before. aca givestes that teh ache us a chance to avoid bankruptcy. there will be disruption when you move from an old system to a new system. certainly, we have to make sure that we fix these problems in the website and other things. i will refer again to what i param out security, ount. on, is one thing we agree that security is paramount in the system. the system itself,

in terms of the system itself, it is going to work, it is going to be better for this country. i might say in terms of these cancellations, i love the rhode island letter. it was very clear. blue cross who shield sent a letter out and said do not worry, nothing is set in and they sent another page, you can either stay with us or go on the exchange. they said, do not worry, you have plenty of time. that is the cancellation notices. in the past, you know what a cancellation notice was? you are no longer eligible for insurance, good luck. that was the old cancellation notice. you have choices and options. again, i see the people have to take a deep breath and wait to understandople

what is going on. now, i must say there was a story the other day in the paper about somebody who said now i got -- i have to take this policy that covers maternity care. my wife and i are not having any more children. why should i have to have a policy that covers maternity care? i got to thinking about that. i thought, you know what? and i doause my wife not have any more children and they are grown up, maybe i should not have to pay property taxes to pay for my local schools. huh? why should i worry about it? maybe only people who have kids going to the public school should pay for it. we are better than that in this country. we are talking about being part of our society. , my wifeour benefit and i, to support our local

schools because that is our next generation, their want -- we want them well taught. same with health care. it is a values system. i am indebted to senator warren for mentioning that. no one will be left without insurance. no one will have to wait before they get advanced: or prostate or breast cancer before they can go to the emergency room and get help. that is the new value system. we are not turning back. fix the problems, move ahead, but let's aggressively get people enrolled in the system system of new value health care in america. i've used up my time, mr. alexander. tavenner,ou , ms. for being here today. the chairman is describing the --damental district

fundamental differences we have had for the last four years. by expandingvolves this is that we already knew cost too much and the result is increasing premiums for millions, canceling insurance plans for millions, destroying relationships with doctors for millions, raising practices -- raising taxes by millions, spending money on new programs instead of investing in medicare to make it more solvent, and encouraging employers to work to have their employees work 30 hours and set of 40. that is not the values system that i support. we have a different approach, which would say let's encourage competition, let's encourage choices, and let's try to make health care cheaper so people can actually afford it. but that is our fundamental

difference. venner, you, ms. ta don't you know with the improvements with a website how many people are trying to sign up every day for obamacare, how many are succeeding, what their level of insurance that they are buying is, don't you actually know that now? information that we are putting together and we will have available next week. >> next week? >> mid november. >> you're going to release it once? why don't you release a daily? >> we have said long before the program went live that we would to its similar to how do medicaid, medicare. >> this is different, these are people making decisions, people who will lose their insurance starting january, that have to sign up by december 15 -- >> that is all the reason to do it monthly, because people can decide to go in and out and have

to decide to make payments until december. >> the people who need to know about it are the members of congress. let's say i'm a governor in a state that has not decided whether to respond medicaid. i want to know if 90% of going on medicaid or whether it is 80% or 70%. if we get a how many hamburgers and cars and records are being sold every day, why can't we know how many people are enrolling in obamacare? it is such a success, wouldn't that promote the success in the program, build confidence in the program? >> we will have that information next week. >> but that is once. why do we have it every day? you know it now, right? >> we are in the process of putting that information together. >> we are the congress and we are entitled to know answers to these questions so we can make our judgments about what to do. so our governors and consumers across america. >> i understand. as the example i used,

emily from tennessee, isn't it true that the covered tennessee canceled by obamacare, the case of washington saying that insurance is not good enough so you cannot buy it anymore? >> i do not think it was canceled by obamacare. the insurance company made a decision to cancel up halsey -- a policy and offers of somethinng else. >> this is a letter from a state -- from the state this is covered tennessee will not be available starting january 1. this affects all covered tenn members. the new federal health care law will bring many changes, including new coverage options for tennessee. the obamacare said if the law had maximum limits, if you did

not meet the standard for maximum limits, you cannot offer that insurance anymore. that is the law. it is case, for 60,000 people, obamacare said that insurance is not good enough for you and emily has to pay $6,000 more. >> we have been down this issue before. they could have been grandfathered in -- thehe law says that if state program does not meet the maximum limits, it is outlawed. does the law not state that? >> for new plans. i would have to -- >> for all plans -- >> there would be the opportunity for all plans to be grandfathere in. >> the law says if the plan does not eat the maximum limits, the plan cannot be offered -- >> you're talking about lifetime limits. >> that is correct. >> -i will be glad to- ed thatacare outlaw

plan. why don't we put the president's word into law and say if you like your plan you can keep it. my time is up. thank you, mr. chairman. >> senator baldwin. >> thank you, and i thank you for staying around for a second round of questions. opportunity, first we were talking about the situation in the state of wisconsin. we are hearing a lot of people reference this idea if you like your insurance plan, you can keep it. in the state of wisconsin, a lot of people like badger care, but because of the decision of our governor, having nothing to do with what congress did years ago, 92,000 people who may really like their health care plan are being kicked off. because of this i really think it is a shared responsibility to

figure out how to most effectively help these 92,000 people transition from badger enroll participate and in the federal exchange. i wanted to ask the companion questions, if there is a shared responsibility, what specific steps can the administration take to insure that these individuals are enrolled as soon as possible, but also that options are available to the state of wisconsin to eliminate the risk of losing this badger care medicaid coverage january 1? >> let me take that in reverse order. toconsin had the ability have expanded medicaid at no cost. about 25 states have elected to do medicaid expansion, including many republican states. but obviously wisconsin was not one of those very and so what we

are trying to do is we are we will work with the state of wisconsin, with the medicaid office to identify those individuals and make sure they are aware of what is available on the exchange. there is a cost to that, so you get into the issues of subsidy and this sort of thing, but we will try to work with the state doubt these people, at least identify what is available to them. >> what sort of means? earlier, you asked sort of questions about how do you target young people? how do you target these 92,000 people , andr what is the state's role? >> obviously, the state knows who these individuals are, so they will be able to send them information. what we are doing is asking wisconsin to give us a plan on how they can do that. it is a shared responsibility. we will try to help.

>> i would have to say as commentary before the exchange opened, a letter went out from the state, and you were mentioning that the state is aware of who these people are. it basically said someone in your household may eat on badger care and may be losing it. information in my mind is not adequate to assure have aople do not lapse in their coverage. my other question in my remaining time relates to the experiences of those states in the country in the early phases thisis articulate -- marketplace, what is their experience versus states in the federal exchange like wisconsin in enrollment people, what

comparisons can you make at this point, and can the 36 states that rely on healthcare.gov exchange expects similar results when the technical issues with the website are fully worked out? >> yes, i think we would obviously expect similar results to what the states are seeing. i think we have released the formation around applications submitted. some states have talked about that publicly, and that is part of what we will release next week. if you look at texas, for the, statesare some large peop with people who are uninsured. >> with regard to the state- based exchanges, marketplaces, can you talk about any of the successes they have had or challenges in the early phases of enrollment? >> many of you have read about

kentucky. kentucky has been a successful state. was on the medicaid side and on the exchange side. their governor has been obviously 100% behind this. he has led the effort. and so they have released numbers publicly, and i can get you those. washington was another, new york, california. of what willpart be reported next week. >> thank you, senator. >> thank you, mr. chairman. since you began a story, let me talk about mr. hood who lives close to me in north carolina. he now pays three and $24 a month for a plan with a $10,000 deductible. under the new law, the comparable plan for next year's just a paid 820 five dollars per month with an $11,000 family the peccable. their annual health payment would almost double from working thousand dollars to $24,000.

and he is unlikely to be eligible for a subsidy. let me suggest that the reason that congress has covered this so thoroughly is this could be a hell of a lot easier. i would remind the chairman that dr. coburn and i came up with an alternate bill. we were denied the ability to amend on the floor of the united states senate and to offer an alternative. and that alternative took care of pre-existing conditions. it kept children on their insurance of their parents'. encompass many of the things that republicans and democrats alike about the affordable care act, but it did not get into a large top-down government- designed program that x winners and losers. and when you can have stories that are as passionate as yours and mine, clearly the system we have designed picks the winners

and losers. it is not individuals americans who get to choose what they want, how much exposure or how much benefit. in other words, their health- care coverage matches their age, their health condition, and their pocketbook, and that is not what this does. let me ask you, what is the target enrollment for the end of november for the exchange? >> for the end of november? >> yes, ma'am. >> we were looking at between october and november, i think that number was i want to say around 800,000. insurersil 1 of 2014, urquhart to begin submitting bids for the 2015 plans. an extension was granted on enrollment to march 31. for many americans, they will not sign up until next year. considering that insurers will have no experience or very

little to go on, which is to 2015,heir quotations on what accommodations will you make to make sure that insurers make informed decisions? >> the open enrollment period, we work in cooperation with insurers, so we think they will have the information necessary. between april 1 and april 27, 2014, they will have to submit their costs for their plans for the 2015 plan year? >> they would submit that over the second quarter of 2014, yes. >> without much experience of what the plan -- >> they will have the experience that they have had for the first four or five months, he yes. >> there are many people who are not required to sign-up until march 31. that is the month rental april. in other words, a day before they start submitting. you said earlier in your testimony that all the fixes done by cgi would be required

without additional fees, and that is in a cost plus contract. can you assure the committee that there will be nothing on the plus side, that the federal government pays to cgi for their repairs on a website contract? >> the cost-plus contract is planned for or payment through march of 2014. so i am sure that that is a contract that they will operate under, yes. >> i am asking a very specific question. plus waste part of the contract. i am sure the plus aced deal with additional work done over the scope, over the stated scope of the contract clearly. fixing this exchange was not part of the contract. >> it is required, there were, in their existing contract.

they have to fix their problems. >> know that many of us will be looking at the statements made on the plus side to see if in for theire paying cgi individuals to fix a website that they were contracted to produce for the federal government. again, i thank you for the work you've done on this. i know this is not fun to come up and answer the question. i would say the moral of the story is the more we share upfront, which we have not on the affordable care act, the more informed all members are. thank you, mr. chairman. much, senator.ry thank you very much for being here and being forthright in your answers. i thought this was a good session. i think you and your staff understand some concerns that both sides have on this. i think there were legitimately good questions pertaining to that aspect of it. of course, as my friend from

tennessee points out, we still have philosophical differences on this issue. are some points to take on which both sides agree that we need to ensure, get fixed going forward, and i think we have started on those quite forthrightly. thank you very much, and as i said, the record will stay open 10 days for other statements and questions. thank you, ms. tavenner. the committee will stand adjourned. [captions copyright national cable satellite corp. 2013] [captioning performed by national captioning institute]

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>> like last week, today's testimony will be followed tomorrow by kathleen sebelius who will be before the senate finance committee to answer questions about the rollout of the health care excite and more. today's hearing will be available shortly online at www.c-span.org. ,omorrow fostering at 10:00 live on c-span. carl icahn were today continues this afternoon at 2:30 eastern, with the seller foreign license committee, holding a hearing on the disability rights and international law treaty before the united nations. tom ridge will testify along with richard thornburgh and tammy duckworth. that is this afternoon at 2:30. tonight, live coverage of election results in new jersey and virginia.

both states are electing governors today. live coverage at 9:00 on c-span. impact of the health care law on hospitals and the quality of care was the subject of an event held by u.s. news & world report monday. donna shea leyla took part in this discussion. also bill frist. [applause] and thanks for allowing me to host this panel. this is an amazing group of folks appear. ,, i doi get to the topic not want to miss the opportunity given that i'm sitting to somebody who is positioned to give us thought about how things are doing with the limitation of the affordable care act act. i wonder if you might venture to give a grade to the limitation.

>> am glad i am here with cardiologists. >> is been very tough. if we know anything in this country it is how to do software. look at the states that are doing it themselves. they are registering people and already have a platform for medicaid so they are registering hundreds of thousands of people for medicaid. the problem is we don't have enough of them. those running their own exchanges are registering people on medicaid. i think we have enough time to get it right. we must have everyone enrolled. there is no way we can continue the way we have been going on.

everybody has to have decent insurance. it has to work. the technical problems are just that. they are technical problems. i haven't heard anyone say they are design problems, fundamental design problems. we know we have large numbers of uninsured, we know we have to get them insurance. we know some of them need to be subsidized. at the end of the day, we're just going to have to get that done. i happen to think there's enough time to do it by march 1. >> i don't know if anyone else wants to give a grade. i would just turn attention away from the hot topic of the day and get us to the hospital tomorrow. dr. evans, one start with you. an interesting thing in "the post" this weekend, it was about the whole affordable care act. they cited a letter that was

sent to the administration early on after the law passed, and heard it was interesting to me that one of the things cited was that no attention was paid to the provider. you lead one of the largest provider organizations in this country and if you think about the transition. ahead and implementing this legislation and making the changes that will be needed, how do you think about those challenges? how will you manage to get from one side of the river to the other, from the volume-based worldview heard about to the value-based world in a way that allows us to continue to provide great care? >> i do think we need to be patient. we will get everyone who needs covered signed up. we live in this 24-hour-a-day news cycle and instant

gratification by everyone. we are all appear without our cell phones and our blackberries and we need instant gratification. think about when medicare was introduced. there was no iphone, and so i think we all have to be patient with that. so this is a big question about engaging the providers. i think the kind of common theme is what do doctors to, they do you pay them to do. this is going to be a change, as toby mentioned, and focusing on delivering the highest quality care at the lowest cost while at the same time providing excellent customer service. that is a different paradigm. i think it is going to be an educational process, changing of a culture. toby has a great system in that everybody at the cleveland clinic has one-year contracts and he can influence that.

think about the large hospitals that have multiple private practitioners. even inside the university system where even the universities don't take into account quality oftentimes in the promotion and appointment process. i think it is going to be a big change and there are going to be some bumps in the road, but we must change to reward people based on quality outcomes and holding cost. we have never been charged with doing that. we just want to do as many big volume cases that are high reimbursable cases like heart, lung transplants, big surgeries. that is going to change. one of the things that i'm concerned about is when you use volume as a metric for reimbursement. it is to have a level playing field to define what the quality

for parameters to use. public reporting data came out in new york, there is a lot of exporting of the difficult cases west to the cleveland clinic. i think that whether by design or just by circumstance, there may be a de facto rationing built into this because we are not going to take on the tough cases and not offer the services. >> we knew we needed to get from one side of the road to the other. i think everybody is clear that we need to say we are paying for value. what i'm here it's not the where we need to go that is a problem, it is how we build the economic model. i'm still, as we heard earlier, a lot of my business is still in fee-for-service. how do you think about managing

that transition economically? >> i'm going to escape to where think the puck is going to be, as wayne gretzky said. we think about the implications of how to decrease re-admissions as toby was saying and how to manage chronic care outside of the hospital. i think there has to be an incentive put in place that changes the behavior of providers. as we're speaking earlier, there has to be some shift also to taking away some of the things that physicians have done in moving it down to extenders, whether it be nurse practitioners, nurses, pharmacists all working together as a team. an incentive that drives behavior. there is a recent paper verifying the big surprise that pay for performance actually changes professional behavior.

>> one of the things that i hear is that we have to get out of being in the hospital business and in the care continuing business. we have to think about the whole patient across all that sides of care. you have been a leader in your private business and in the policy world and thinking about how do we build out a more robust continuum of care in different settings and get patient involved. help us think about what that means for hospital. >> we touched on the big changes. people ask me all the time with the biggest change that we are undergoing. i think the biggest change that we can be transformative -- the shift in risk. money flows, winners, losers,

also efficiency and eliminating waste. risk used to be in the purview of government, of the big payors out there, but with obamacare the risk is shifted to the providers, the hospitals, the doctors. that is what is new. hospitals don't know how to manage risk. it never had to do it. now it is in the providers. so the hospitals are what we're are talking about for the next couple of days. the consumer is the new element. the consumer is going to be -- for you stay competitive in this

new world, you're going to have to focus on consumer-based experiences that go all the way from scheduling, how easy it is to see a physician or a team, how long it takes, how you were treated. how much data is given to in your pda and your personal device, do you get laboratory tests before or after, what is that follow-up to keep you not in the hospital, but out of the hospital, which means the hospital is no longer a structure, but like bob says it is an integrated system to keep people out of a high cost to a low cost side of care. i'm optimistic about that. i think the government has made a disaster over some very good principles in obamacare so far. time to recover, but we will see. i think the leadership has been poor, it has been laid out poorly, it hasn't been done

well, but it am very optimistic and here's why it is so important what you're all talking about the next several days. technology today, ipads didn't exist three years ago. now you have a hundred million out there and we all depend on them today. 94% of people have telephones and 54% have smart telephones. the socio economic underserved -- that empowerment of data, and data is not electronic health records. information technology is not electronic health records. government pushed a set way. information technology which is going to drive the innovation which is going to be consumer driven, not driven from above, is going to be automation, decision support to make sure the right decisions are made with the resources that are available by doctors at consumers. it is going to be the connectivity which means an investment to get those tentacles out there to do the

outpatient care, the inpatient care. the big data means data mining, the sort of stuff we couldn't do before. in some ways to stay competitive you're going to have to have consumer-based experiences. the consumer is going to be technologically savvy in terms of prevention care treatment, and it will be driven to the connectivity and automation in the decision support in the data mining that is available. if we use is effectively, you can stay competitive and patients can have better outcomes. >> one of the ways that consumers get to health care is through the employer and to the pay or indirectly. what doctors i can see, what hospitals i can access, a lot of the benefit structures are determined by employers. that is changing now a lot of the way employers are purchasing healthcare is beginning to change. employers are getting impatient with cost of health care in the traditional benefit structures. from your perch, thinking about benefits for employers large and

small, where do you think the purchasing behavior driving a hospital business in the healthcare business? how is that going to change over time given where employers are going? >> employers have always been uncomfortable with the rate of inflation in health care, but they've always manage to pay. one of the outcomes of the aca is the excise tax cap that hits in 2018. you can complain as much as you want about the law, but gives you an out as an employer. i've yet to meet an employer is going to pay the 40% excise tax on the system that they already consider efficient. we have established a ceiling that employers are willing to pay. i think what the senator pointed out is that consumers are going to be exposed to more risk. it is going to come in one form or another. when people start to see how much more they're going to have to pay -- there are only two ways for an employer to stay. the unit you have to raise deductibles or out-of-pocket limits. as a general rule of thumb for every dollar you try to stay

under in premium, you have to increase maximum exposure to participants by $2. if you're talking about $50 is not a big deal, but if you talk about a thousand dollars that's a huge exposure. if you're a hospital that is a huge exposure and uncollectible debt. the second side is if an employer doesn't do it by increasing exposure to participants, they're going to have to focus on much narrower networks. right now the whole network selection criteria has been make sure my doctor is in, make sure my hospital is in and make sure all the others are in, too. most of the networks around the country are established to include everyone. i think what we're starting to see on the public exchanges and we expect to see it in the employer realm, a lot more of

these specialized narrower networks. if you try to go to a large employer occupation and sarah will give you access to 50% of the providers in the community, there is an upper. if you go to an uninsured population that is had no covers before and say i'm going to give you coverage a half of the providers in the community, that is a win for everyone. i think as those networks are to get filled, people that are in these access, of access problems of their own, you may go to a less efficient provider. so there is a lot going on in the employer community. not just about how we do it smartly because there's a plot of moving dynamics because the uninsured have access to health care. that is good to be big challenge for people. >> this change in high deductible, there are some good things about that. that does bring the consumer in. the consumers we are going to be bringing in for obamacare to work is going to be a younger population. so deductible five years ago was probably $500. now it is $2500 for most companies. so 30-year-olds are going to be forced today, mandated to get everybody in the insurance pools who will have deductibles of 2500.

plus they will be paying $1500 and they're going to be the ones going to the pocket, pulling out an app and pushing a button and saying, ok, i need an mri. my physicians as a do and push a button it is going to cost $2200 at the center over here with very well known academic health center and $1200 in green hills and $300 next-door. and the quality is the same on the same machines and this button is telling me that. all of a sudden it's going to have a huge impact in terms of the power of the consumer who is empowered with a bucket of money now, mainly their own money, to shop and the system is going to have to respond. to me that is going to eliminate waste, inefficiency. 30% of the $3 trillion being spent today that doesn't go to federal patient outcomes, to me that his rate positive. of course i am more optimistic about the future, but technology will allow and empower the

consumer to make those decisions. >> i think it is a really important trend. if you are a high-cost provider, let's say a large academic medical center or a big specialty practice, you are probably at the high end of that pricing list on the app. let's just pause -- which is positive the transparent world, the prices are going to a lower level. that is revenue that is supporting a lot of other things going on in medical centers. i wonder, from the perspective of a university of miami, how do you think about the economic pressure that this puts on the sustainability of these important centers? >> there will be tremendous pressure, particularly when the government

is reducing the amount of research money that is coming in. you have no place to cost shift to. the fact is, we're going to have to live in the real world. we are going to bring our costs down at the same time. we're going to have to eliminate overhead and do all the things that other providers have to do heard i'm closer to the employer than the provider, so i see it from both sides. i don't think academic health centers will get off the hook. if we are 20% more expensive now, we're going to have to bring it down so that we can compete. i would point out, though, that most people who come into medicare have not have a lot of choice. so they're really coming out of hmo's, out of narrower networks. so moving medicare to narrower network, moving medicare to less choice, may not be as big a jump as some people would suggest. i would, though, say a word about people that can't afford high deductibles. we have to be very careful about price sensitivity for poor people, for old people. we're bringing in a lot of young people into obamacare, but we are also bringing in low-income

workers. with that group we're going to have to be very sensitive about whether they're really going to have real access to health care system if they come in with high deductibles. it will be just as bad as the current system for them. that is what makes it so complicated. the different kinds of patients and people that we are doing with, some of them can live in a world with very high deductibles and others are going to have to careful with, or we will end up with lots of charity care for the in-betweens. >> i would echo what president shalala says. some of it is made up by the more prestigious places through philanthropy recruiting talented individual to get more grants.

you can never make up the overhead by just indirect costs coming back from grants. i am concerned are there has always been this healthy tension between the dean of a school of medicine and ceo of the hospital about funds and how you support the academic mission. that is going to be even more difficult as time goes on. i agree that in order to be competitive, the inefficiencies within academic medical centers, particularly hospitals, and a lot of it has to do with trainees' responsibility and ordering too many tests are not the right tests, we're going to have to fix that. there has to be a lot of attention. i think that the really good places will get this figured out

and it is already starting to happen. toby showed the graph about the u.s. consortium . they're focusing on that now and improving quality and holding costs. that is going to be the ratio we have to watch. >> we took 900 positions out or academic health care center. physically there were administrative positions. we're are doing that corporations are doing. we looked at our staffing and we protected the clinical side, but we took a whole layer of administrative cost, recurring $40 million or $50 million in recurring costs. we had to do that because we can see what is coming down the pike. we're going to have to be a much more efficient organization, both for employers that are sending patients, but we are employers, too. we can't afford high cost academic medicine as an institution. >> i think academic health

centers -- as both of your very involved are, for most people in the room, we all need to define our goals. our goals today are patient outcome. we have already said that, but now for the first time come over the next five years, reimbursement is going to follow outcome of the patient over a continuum of care increasingly with bundling and reimbursement for one year, post transplant. increasingly we are going to move to more macro bundled imbursement. for most people in the room, the goal for the hospital tomorrow is maximize outcome for existing resources or maybe less. your role is a little bit different because this maximizing patient outcome, but you need to train the cardiac surgeons of the future and the primary care surgeons of the futures and the nurses and the

team-based approach -- >> and research. >> and the third column is research. i am an academic, or had been. you need to justify the $60 billion of research or $20 billion or whatever it is going to be. we need to have a team-based forget the legacy way i was trained or bobby was trained. isvate a team approach, that new stuff and you need to train them because by the time they get out in the real world, it is too late. we'd put a price tag on that but you need to justify that. for most people, the hospital of tomorrow is not going to be even or evil in -- or cleveland clinic. it's going to be the other 5000 hospitals out there that have to survive. i will come back and say that patient outcome is measured

because that is where the reimbursement is going to flow and i will be driven by consumer engagement with 200 million people changing the system instead of just a hospital ceo. >> to we need 5000 hospitals in that world? >> probably not. interested -- i don't know what the percent of gdp should be, but do you need 5200 whatever hospitals out there each trying to be a comprehensive hospital with as much marketing to attract patients -- it is kind of the old way but it's not the way kayak and the airlines, not in term of delivery of services, yourow you actually get airline reservations trades off the way it's done today and that's going to be the difference.

every hospital didn't have to offer 20 different services. of course you don't see -- you don't need 5200 hospitals. >> we have seen this and all of our immunities. of one hospital gets the latest greatest mri scanner than the other has to have it and that's going to be over. if you look at the margins of inpital -- most hospitals the country, they are low single digits and a lot of these hospitals have not been able to survive, nor should they. difficult too be make that transition if you are not part of a bigger system because that's going to be where you get the critical mass. the quality of administrators to make these things happen. model.ave to change the we cannot deliver care at the

same high cost during have to figure out to -- a way to deliver the care, but hang on. where are all of these deliverers of care going to come from? enough doctors surely to deliver the primary care. we certainly don't have enough nurses today and inc. about where demand is going. how do we produce enough capacity? >> let me set up,. the numbers out there, 40,000 that use ae doctors conventional 40,000 doctors needed today. that is before if obamacare is another 30ented, million people coming into the system who don't have insurance. someone comes into the

system, their health care system goes up 50% more than when we were into the system. before you factor in coming into the system, what do we do? [laughter] just doctor and start thinking about how people are trained and allow people to practice up to their training. nurse tactician or's handle about 70% of the primary care. we should be using well-trained primary care doctors for the ambiguity. this is the point bill and everyone else has made. teams. to create that means physician assistants and pharmacists and other care .roviders we have to get over the cake on the rules

state by necessary because that is what restrains us from creating these teams in many ways. we could handle this primary care if we could deal with the and if wect is issues could overcome our let them to talk about teams as opposed to hierarchy, will he have to train people in the future, yes. but we have to train them better and use them up to the level of their training and i think they can handle it. most of them have been getting health care in one way or another. will goare costs initially. in and thesettle teams of caregivers could organize primary care, chronic

care management and life care. cane are lots of things we do to step up the barriers. >> the policy is important. doctors don't like teams. [laughter] you have a patient coming to the door, you are the surgeon, and you have to fix it. listening to a collaborative way to other people, we want to cut, fix and get them done. [laughter] in all seriousness, this is a huge transformation. our ethics is not to be team- based. butike to say that it is the practice of medicine today, you are not trained. withess school is trained six people to get an outcome

that allows collaboration, integration, leadership and distribution. that's not the way doctors are trained. it's not trained very well to be a team-based approach. done, doctors don't need to be making those decisions but the system has not yet responded. that's going to be after my risk transformation and innovation through patient engagement. the third is the team-based approach. what we are not there yet. tory hospital needs encourage it. if you have a doctor's lounge, you need to integrate social workers and the epidemiologist medicine and the yoga specialist and doctors just don't like it. >> economic incentives are driving us in that direction. patient safety and readmission

we have been forced to i happen together through team training, we are doing more of the groups together. economicrive it with incentives. i don't care people are brought up, whether there are incentives out there that can drive a change in behavior. >> doctors do what you pay them to do your 80 other thing that's going to happen is the game is going to shift from the inpatient side to the outpatient side and to the home. to getwe are going welth called -- house calls, probably won't have time to do it. we have to deploy these other assets and leverage the training of these other individuals.

the game is going to take care and there are programs now to start to begin to train family members as long-term care dividers. when patients go home with the familytentimes but i think care the game is going to shift to the outpatient home trying to prevent readmissions will be a huge thing. imagine her non-health care clients listening to this about a big line item and the people who provide that service. and we to work in teams have to figure out the customization thing and how do we standardize and liberate

polity product? useave to figure out how we data. we are making big investments but we've never been a data- driven organization and we want dafind more scanners and vinci robots. how much longer are employers going to stick around for this story versus saying i'd rather not be involved in this anymore? >> large employers are relatively committed to providing the services. them do actually help it better, but they have the excise task hanging over them. much more inclined today than they were five or 10 years ago to partner with these local communities to figure out what positions and get that out there. it's only done to bring the cost down and really starting to

educate the workforce on the fact that some of the things improve the quality of care at the same time we bring in the cost. employees have gotten smart on how to do that and it's going to make a big difference and pave in a way you could not >>e done 10 or 15 years ago. 60% of all employers 12 years ago provided health care and now it's down to 50%. that's before obamacare. people who hate obama care will care setshink obama up the potential for a lot more employers to get out of the business. in the short term, it's going to cost a lot of money. investors can make a lot of money. can stop giving

health insurance and gives an employer -- that employ a packet of money they can at the exchange, go out of by a good plan. it does not work long-term because health-care inflation goes up two percent faster over time. over time it does and is likely to return and that's where we will get hit. tos already gone from 60% 50% with obamacare and now have more flowing and with a better system to choose rum. potentially another 10% to 15% of employers can get out of the business. it's ok for the first two or three years but after that, because of high deductibles, isn't going to be able to sustain above two percent of gdp

over time. .'m a little more concerned i think consumers will drive the system and i think employers will drive the system because they do partner what you said and the cleveland clinic's are at establishing a culture of wellness and i think employers have a huge role to play. toould encourage them partner with their community employers. -- if wethink about want to be competitive for good employees, large employers are not going to get out. the smaller ones cannot read the risk. they haven't been able to get the prices down, so will obamacare do that in a way which will attract them? midsizelarge and employers will continue to provide health insurance to control costs because we've got to do it.

those of us who recruit people from their own region, it becomes increasingly important. >> it's going to shift a lot more of the burden and account ability to the patient. you are to have to resume some responsibility to health care, trying to prevent and keep evil healthy. we will probably pay more attention to it. i'm often shocked at how people put into maintaining their car as opposed to maintaining their own health. it becomes a pain for them financially and i think we will see people become more educated and go to the doctor and follow the blood pressure, eat and exercise.

>> we are going to have very good data for it. i can even price a repair because they are bundling payments. it will make up for underpayment over here. a longll have to become way for consumers to be able to compare cost. thating able to have technology will happen very quickly and people will shop, shop on ak they will cost ratio but there has been one of the scholarly work and people will go for cost for the go for quality. >> from your perspective as an the xing patients even know what quality is? is it just service quality?

>> the overriding thematic has to be improving patient outcomes. resources.g how do you maximize the use of resources? it's data, innovative technology, data mining, price transparency. even though it terrible and tough to do, on the first half of the equation, maximizing patient outcome traditionally we are measuring process measures. we are only getting to the point that true patient outcome we didn'tasurement even think of that until four or five years ago.

now the patient is going to demand it. ultimately, the success of the hospital of the future will depend on patients coming in and for patients to come in, it cannot just be a patient engagement. it has to be consumer engagement before they get sick and after they get sick with rent loyalty coming in. know we don't have a lot of time on it, but it gets to the opening remarks. our outcomes in infant mortality and how long survival is much less. 26 and 30 compared to other countries. terrible and discouraging. therefore, we need what? care am a it is what goes on at the home, it is palliative care. that is why you have to have

these integrative systems with tentacles out where you monitor the continuum of care over time. that's where everyone is going that will bring those systems then. outcome is not as good, the therefore is critical. if you look at how long somebody 30% genetic, 15% how rich you are, socioeconomic that is, it's five percent the environment around you and 40% behavior. do we wear seatbelts? do we smoke? that's not what anybody in this room has historically been responsible for. the 15% of all of that is what hospitals, doctors, nurses, obamacare.

you cannot fix the 15%, i don't care how a fish hospital, if you want to fix the debt and entitlements and the future of america and the american dream. , yes address the 15% thee the hospital fits, but changing behavior getting into communities, partnering with employers and engaging engages thehat consumer who is out there a year after hospitalization. wearing this job own thing that you have that tells you how much you sleep, that's going to have to be the purview of the hospital if you want to make people live longer and lower the burden of disease and improve the health of the nation. quality,d say about the heart surgeons have for

years have results printed in the newspapers. you can all do goal it. when i operated on patients, i would print out, and there are about 65 or 70 field that will say here, based on your data, your comorbidity, family history, here is your chance of dying from this aortic valve yourcement trade here's chance of being in the hospital for more than five days. personal results from patients like you. we have to demystify all of that data and empower consumers. many of the patients we saw would come to us with this data already. intove to push this down not as educated people through churches and social programs am a school and start early. a campaign where children need

to know what the data is. there is a very innovative program that a high school student in the bay area came up with. get immunity project hours in the school. work to your parents to say you need to get online and do this survey so you know what you're numbers are. what's your cholesterol question mark what is your bmi? it's going to be an education process and we need to inform them and push them about what quality really is. >> i want to keep us moving you lead a large, prestigious academic institution. i have four kids at home. three of them are teenagers. i'm not asking for you to let the men, but that would be great. [laughter]

with the doctors and executives and others facing really tough challenges ahead, the migration ahead is challenging. yearsrt says i'm five away from retiring any other part of the population says this is exciting and i can't wait to solve these problems. wanted to work in the hospital of tomorrow or work ifm health care in 10 years, you are thinking about a future in health care, to build an optimistic case, why should they take on this challenge? >> it is a combination of things. is where the next adventure is. it's a major driver of our economy. there are huge amounts of new money going into it and we can't keep doing it the way we have been doing it. for a young person who is

entrepreneurial and adventurous and want a real challenge, there is going to be nothing like health care. it's where the action is going to be and where the excitement is going to be. that's what i say to my students. me in thanking our panelists for a great discussion. [applause] >> i want to introduce him, dr. gregory sorensen, ceo of siemens health care north america. siemens is a company at the forefront of the intersection of medical treatment and technology. great is an esteemed neuroradiologist. before he joined siemens, he was a professor at harvard medical school, codirector of the martino center for biomedical imaging at mass to all hospital and a faculty member of the division of.i.t. technology. his own research and extensive experience continues to inform

the field today in work being done on stroke, cancer and other health issues. 80s and gentlemen, it's my pleasure to introduce reg sorensen. [applause] -- greg sorensen. >> and it was even with yellow tape. bit of a a little wrinkle to the beginning of my remarks. i am just going to share a few slides and thought synthesizing what we have heard today and perhaps painting somewhat of a direction for the future. it's a real honor to be here with so many of my friends and colleagues from such great institutions. in our new job, i have had a chance to visit with these coming toey are understand part of what the u.s. news & world report process does is help us learn from each other.

it gives us an aspiration we work towards and helps us compare best practices. just for thee case top 18. there are hundreds of other hospitals that are ranked. they try to aspire to this level of accomplishment. a lot of good has come from that and it deserves some celebration. it's interesting to see how we pattern ourselves after each other. commonalityt of among these hospitals and i've got some of the data here highlighted. 81% in cities of a million or of them are teaching hospitals. many are part of a chain. that is because success breeds success. we learn what works and we try to emulate each other and raise our level of a compliment. i think that is great and there are a lot of good things that

come from that, despite what we have heard from the challenges of infant mortality. in complex diseases, the united states is unparalleled. willng at cancer survivor rates, we are number one in the world. this is true in disease after disease and all of you know that. none of you are flying to other countries to get treatment. we see people coming to the united states for the top care, not other countries. that is in part because of this process we are talking about that has focused us in the past on the most complex illnesses, the most ethical challenges, and in many ways, intellectually is the most interesting and has attracted the brightest minds in some of the best capital. that has paid off. roomof the people in this

have developed the kinds of tools and systems that have provided this impressive result. you can see some statistics that highlight the outcome of this focus. we have a highly sophisticated workforce. but higher than the average in terms of specialization. there's a funny joke about in boston how if you are at a restaurant and you raise your hand and say i need a theatric neuroendocrinology us, you will get four hands raised, no problem. there is a level of specialization across america that is the envy of the world. we have a tremendous life science industry which is the engine for a lot of our growth. biotech research and also bio informatics, devices and lots of impressive while logical thought rossa sees and minds immigrating here to the united states not just because of the funding but the atmosphere.

a student i had was from by rain and now she has come to the ukraine and spent some time in london and called to say it just not the same where there is this level of excitement and innovation. we put our money where our mouth is and it shows. it shows on things like nobel prizes and i think that's all wonderful. what we are here to talk about is the hospital of tomorrow. here is where we can raise our aspiration and think about these complex problems are panel has eloquently addressed. outlined a form we use in our business to talk about a couple of different parameters at the same time. y axis, you will see spending and on the x axis, population. what is interesting is to get

the relationship between those two. what we have been focusing on, this most complex care we have chosen to rank ourselves on is the top right box labeled in red. it's the most complicated patients, we spent a fair amount of money on them. to lookaspiration is beyond the little box on the top right to bigger groups. that is where our health care spending is and it's not hard to imagine however buddy in this center box is trying to do costs that you can get a problem and get a focus on deployment and a challenge and even some confusion in thinking whether it's about teamwork, patient engagement or prioritization. we have all of the healthy

people we don't spend much on per person. in the remaining two slides, i would like to talk about how we might spotlight areas to expand our focus. what might we think about and we try toome ways as move our country from focusing just on the most complex diseases and a few things to the many and where the big spending slidehave offered one each on five ideas. each of these has some real potential to move the needle as we say in business and make an impact. let me go through them. i spent my lunch remarks talking about the value of early and accurate diagnosis. i would like to reemphasize that briefly. no matter howhown you analyze this, diagnosis is

an underrecognized and important problem. you can pick it up every week in the new england journal, whether it is the articles just on diagnosis or whatever. diagnosisze the drives everything. the first 13 minutes with a patient sets all kind of spending in motion. when we study medical errors, we see as a category, diagnostic errors are the most expensive, most common, and the most deadly. if we can get it right and build incentives to get early and accurate diagnosis across the country, a lot of things would get at her across our system. specialist,as a patient came with a wrong diagnosis. getting the diagnosis right is hard and there is ever been a financial incentive to get it right. there have been plenty of ethical incentives.

all physicians want to do the right thing and are intrigued by the intellectual challenge of getting the right tightness is, but it's time for our system to incentivize in all the ways we know how to get an early and accurate tightness is. spend very little on diagnosis for some of the big impact with lab diagnostic errors based on autopsy studies and other data show errors are very common and have huge impact with lots of lives lost. i was very grateful to learn just a few weeks ago that the iom has agreed to focus on diagnostic errors and try to improve diagnosis. it's fascinating to me that a minority of this is the physician intelligence or the handoffs about of information from one part of the caregiving path to another part.

recordkeeping and the duplication of results. that is a real opportunity. another thing that's going to be important if we are going to attack the big box is thinking quality care high not just for complex illnesses i've put inthings. the box the top 10 health conditions. you can see it's about half the patients that have 10 chronic conditions. could manage those well, we would solve half our problems. a lot of what i am learning in business is trying the 8020 rule. getting as much as you can with a focused effort as possible. here's an area we could focus. what's interesting and you heard it on this panel is dealing with these diseases is different than

dealing with the complex diseases u.s. news has ranked us so highly for doing. when you are trying to get a liver transplant, you don't care about parking. when you need your diabetes managed week in, week out, or your levels checked, things like parking and engagement, how hard it is to reach your doctor, those things start to matter a lot and friction becomes very important. that is not something our system is focused on. patient engagement, how much they care about their disease, whether it's trying to convince them or help them learn how to spell the names of their illness and open bottle caps, it's a completely different realm that focusing on complex illnesses has allowed us to bypass. but if we are going to move the needle, we have to start taking about it. i have put some ideas here, making the whole friction of the system a lot easier to deal

with. focusing on the pave your modifications, that they'd different kind of health care hairyion, but it is feasible and just as we have tackled many of these challenging problems with biology, if we focus on this as a nation, we can improve these things as well. care. integrating i am gratified to hear the panel talk about this so much. we do need to work as teams and how to figure out how to coordinate care amongst team members and use all of the skills of all the members of the team. see we areto building teams to facilitate this but it will be a mind shift and a cultural change. we all know at there's a definite hierarchy and those

hierarchies get in the way. it is a commonplace, but i will meeat it grade people ask where i live and i say seat 11 c. i've never gotten on a plane and thought to myself i wonder if i have one of the top 10 pilots in the country. whereas i frequently have people ask me who is a top doctor for this or that. the reason for that is he more. people have learned you can build a system that delivers consistent high quality if you can build teams. we can learn a lot in the medical profession. last two ideas are about variation. we have heard how we as a country have failed when in termsto our peers of overall achievement compared to the amount of money we spend him but it is not uniform. if you happen to live in fairfax , younia or in california have as high a life expectancy as anyone in the world. you are doing great.

if you are unfortunate enough to live in mississippi or west virginia, you are worse off than if you were in algeria or bangladesh. why is that lester mark why do we tolerate that? we've got to figure that out. it has been a problem for decades. but we have the eta and and with a national approach to quality care, we have some mechanisms to start to address this. be good anding to understandings, we have to look at those things. that's why i applaud u.s. news for thinking about not just the top small fraction of the most complex cases, but the broad summer routine care we get day in and day out and geographically distributed. finally, let's talk about price and cost. cost and value are all tied together. after all, value is outcome divided by cost.

going to see this variability and outcome and prices, it is pretty straightforward to see how we could have huge variations and we need to figure out why that is happening and tried to reproduce it. the costcinated to see spent across different countries and across the u.s.. interestingly, the 25th percentile is not that much more than other advanced countries. is the 95th percentile that kills us. what is going on? transparencyt some ? reward the right outcomes? right, procedures on the the means are not what kill us, but they get the headlines. it is really these outliers. there may be good reasons for the outliers, but it is hard to areeve those outliers therefore only good reasons all the time. if we scrutinize this and bring

some transparency, something that is striking way absent in modern medicine, we will be able to attack this as well. chance to think through those, we will have the chance to move the needle on a majority of our system. with that, i look forward to chatting with you at the break. i would just say it's time for us to find our ambition. what is it we want to do? not just the best care for the most difficult patients, that find a way to reward high performers in the community. i like to say in my management meetings, let's catch people doing things right. that's one of the great things the u.s. news reporting team does, is it finds people doing things right and highlights them. note, in my new job, i have had a chance to visit not only many hospitals

around the country but because siemens is in the 190 plus countries, lots of places around the world, there's no place like america when it comes to health care. our lowest and hospitals are better equipped than some of the best hospitals anywhere else in the world. it is not a matter of equipment alone. it's not a matter of training, it's a matter of mindset and what we choose to prioritize. i'm grateful to have the opportunity to be here and move things to the next level. thank you for your attention. [applause] >> health and human services secretary for kathleen sebelius is back on capitol hill testifying before the senate finance committee, answering questions about the health care launch oft and the the healthcare.gov website. we will have live coverage at 10:00 eastern on c-span. more live coverage coming up in under an hour.

the senate foreign relations committee is holding a hearing on disability rights and international law. tom ridge will testify along with former attorney general richard thurrock borough and tammy duckworth. that set two: 30 eastern. it is election day in a number of states. live coverage of the governor races in virginia and new jersey gets underway at 9 p.m. eastern. back on capitol hill, house is out this week in recess. he said it is gaveling in and 35 minutes or so to continue work on the employee nondiscrimination bill which would ban works -- workplace discount nation. we've got more from a capitol hill reporter. covering the date -- the debate on the employee nonischemic neck, tell us about what is in this hill and some of the background. it has been before congress before. >> it has been.

the last time the senate took up a version of this legislation, it was back in 1996 and it failed to pass i one vote. house took up a similar version in 2007, but that's the last time this version which would ban workplace discrimination on the basis of sexual orientation or gender identity. 2007 was the last time it came up in either chamber and that's why the legislation moving forward last night is a good yield even if it does face pretty dim prospects in the house. >> your headline in politico, the gay-rights measure advances -- you write about some of the dynamics of that vote on and off the floor. itl us about that. >> yes. was always going to be a question as to which republican senators were going to come forward and help advance the bill. the legislature has two havelican cosponsors who

been very vocal advocates for were twolation. there other republicans who voted for it in the committee and were expected to help push the bill along. but throughout the day, there were a lot of questions on some of the republicans. in particular, rob for men from ohio as well as kelly ayotte from the hampshire. vote last night, there was a fascinating behind- the-scenes effort on the senate floor as reporters were up in the gallery watching the votes and three key republicans were huddling in the cloak room with susan collins and jeff markley, who is the chief sponsor of the legislation. at one point, chuck schumer goes over there and they are working behind the scenes to secure the votes so they could at least move forward. >> in working to secure those votes, did senator to me or the other senators get any sort of commitment for amendment votes?

>> they did. kelly ayotte and rob portman secured a vote on their amendment that heals more with anti-retaliation issues. a way of at it as strengthening protection for religious organizations. senator to me is going to have another religious related amendment that's going to broaden the number of groups that qualify under that religious exemption. senator merkley, who is the bellwether for this, since he is the chief sponsor, said last night he supports the proposal, not so sure about to me. the state of that legislation, that measure is still unclear, but they will get votes on both of them. >> will the senate vote on this bill before thanksgiving? >> at is the plan. harry reid said we are going to get this done.

says he does not believe senators need to use all the time left on the clock for debate on this bill. after you vote on these amendment votes, it is set to pass in the coming days. we don't know exactly when, but the senate has lots of other agenda items to do as well. the way to get that on and move to something else. >> you heard about the bleak prospect in the house and then tweeted yesterday about senator harkin saying he wants the house democrats to circulate a discharge position -- discharge edition in-house. >> if you get 218 signatures on that, it forces the bill to the house floor. the house republican leadership controls the bills that come on the floor, but not if the discharge petition successfully get 218 votes. house democrat are not for sure going to do that option, but a

spokesman for nancy pelosi said all options are on the table. version has 190 three cosponsors, including five republicans. it's a matter of finding the additional signatures to get to the discharge petition if democrats choose to go that way. discharge petitions are difficult for republicans to sign one, bucking their party leadership on the bill. >> you can follow the reporting of my guest on twitter. tanks for the update. >> thanks for having me. >> the senate is back in 30 minutes for more debate on the bill. defense secretary chuck hagel warned today against the dangers of automatic budget cuts in a speech at the center for strategic and international studies. he said nearly a trillion dollars will be cut from the department's budget over the decade unless congress reaches a

budget deal. this is about 30 minutes. >> if you have ever seen the organizational chart of the department of defense, you might have noticed it's a little different from most corporate or business arrangements. the structures tend to put people in boxes. what you will notice about the pentagon is that the box at the people, not two one, but two people in the same box. the secretary of defense and deputy secretary of defense. john amory and i each have the pleasure of working inside that box, not as the secretary but as the deputy. we can both tell you there are downsides to this arrangement. since the secretary chooses who gets what assignments, you can guess who gets to visit with foreign leaders and who gets to having watchedo. firsthand from the closest possible position inside the box

with the secretary of defense, i can tell you secretary hagel has one of the toughest jobs in the world. the job entails an extraordinary range of responsibilities and demands a unique combination of her small qualities. when you consider his experience and achievements, his resume reads like he has prepared for the job his entire life. his patriotism is unquestioned. even though he could have gone off to college, he instead listed in the army and served two tours of duty as a squad leader in vietnam, earning two purple for being wounded in combat. secretary hagel is a highly successful businessman who understands the financial and organizational complexities of the job. he is a former senator, quit to deal with political realities. involved in television, so he is ready for the public

challenge. as a former deputy at the veterans administration, he has demonstrated the compassion by fighting to elevate awareness of agent orange and the damage it did to some of our troops. office,a short time in he has demonstrated all of these qualities and more, proving he is the right man for the job. ladies and gentlemen, it is my distinct honor to present you a true american patriot, the 24th secretary of defense, secretary chuck hagel. [applause] >> bill, thank you. to my friend john amory, thank you. thank you each for what you have done for our country, for what you continue to do, and on thislations

spectacular new building. not only is it a remarkable achievement, but it is a testament to this institution and what it has meant for so many years to this country as it has contributed to the shaping and molding and the outcomes of our policies in the world. you continue to do that. two you are and to your leaders, everyone associated with cs i ask, i congratulate and thank you for what you do and what you continue to do. i want to especially recognize sam nunn for his leadership. he was not exactly a bystander in this effort and continues to be rather engaged. he is one of those unique

leaders are country produces at the right time. years beenmany, many one of the real anchors of our national security policy and one of the real leaders of our country. i know what he has meant to cs i asked, and i particularly appreciated his risking his reputation in helping introduce me at my confirmation hearing. notice he quickly escaped after that. after john warner made the second introduction. he said you are on your own, chuck. [laughter] genteel.ore he just left. [laughter] but i am honored to be here and i'm honored to be here to help welcome your participants and

also kick off and always a very important event. again, congratulations. conference will discuss and continue to help shape america's continued national security priorities. it continues a tradition going when great thinkers and leaders were brought to get and like edward teller henry kissinger and others like those three men for the center's inaugural security conference. their goal was to look 10 years in the future and define political, military, and economic strategies that would help america ultimately prevail in the cold war. determine, as david abshire once wrote, how to use power in all its forms to influence the

actions of adversaries or would the aggressors as well as friends and allies. strategy.e essence of this kind of long-term perspective is always needed and will always be required. but it is especially relevant today as we try to manage the complexities of a volatile, dangerous and rapidly changing world. particularly when geopolitical and gridlock and budget uncertainty here at home continue to undermine the strategies necessary to protect america's interests and enhance its future. i would like to take this opportunity to join you and looking across looking across the strategic landscape and share with you a few per spec is on our shifting long-term

,ational security challenges the u.s. military's role in addressing these challenges, and what this means for the department of defense going forward. america'sknow, challenges are far more different and complex today than the single defining threat we faced in 1962. they are also far different than they were in 2002. when our nation was reeling from the most devastating terrorist attack in our history or even a few years ago, when 100 thousand u.s. troops were on the ground in iraq and tens of thousands of troops were on their way to afghanistan. with the end of the iraq war and the winding down of the combat mission in afghanistan, president obama has been moving the nation of faith perpetual war footing, one in which our priorities and relationships around the world word dominated by the response to 9/11.

as the united states makes this transition to what comes after onlyost 9/11 era, we are beginning to see the dramatic shifts underway that will define our future and shape our interactions in the world. and require our national security institutions to adjust and adapt. this is the story of history of mankind, adaptation and adjustment. centuryong these 21st trends are shifting geopolitical centers of gravity, reflecting the astounding confusion of economic power and the graphic change. india, brazil and indonesia are all helping to reshape the global economy. regional powers like turkey are maturing and asserting greater independence from traditional allies and patriots. the asia-pacific region has taken on a greater prominence in global politics, commerce and security.

and as latin america and africa develop and strengthen, they will be important leaders in helping to build a secure and bosporus 21st century world. cyber activists, terrorists and criminal networks and nonstate actors are also playing a role in defining the international system. governance andof power are emerging as the world's population becomes more andnized, mobile technologically advanced, bringing new standards and expectations as they develop. technology and 21st-century tools of communication are bringing people closer together than at any time in history of man, helping to link aspirations and their grievances. , one of the political thinkers has called this phenomenon a global political awakening.

nowhere is this more evident than in the historic turmoil embroiling the middle east. not since the decade after world war ii has mankind witnessed such a realignment of interests and challenges. history shows these changes and inflection points are not easy to perceive. the former secretary account of his own experience during another defining time in history when he said only slowly did it dawn upon us that the whole world cost structure and order we had inherited from the 19th century was gone and the struggle to replace it would be directed from two bitterly opposed and ideologically opposed our centers. even as we begin to see dramatic shifts, we know the rapid pace of change will only accelerate as the world undergoes and storage generational shift. more

than 40% of the world's 7 billion people today are under 25 and 90% of them live outside the united states and europe. regionsarly turbulent emma like the middle east and sub-saharan africa will continue to experience these challenges as their populations increase and reach far ahead of the educational and employment opportunities that must match them. they will present more uncertainty and risk to global peace, prosperity and stability as we confront an array of new 21st-century challenges. the challenge of terrorism has evolved as it has metastasized since nine/11. this will continue to demand unprecedented collaboration with partners and allies on counterterrorism efforts. many share a common threat regardless of state differences or political ideologies. destructive technologies and weapons that were once the

province of advanced militaries are being sought by nonstate actors and other nations. this will require our continued spacement in cutting edge and cyber technologies and capabilities like missile defense as well as offense of technologies and capabilities to deter aggressors and respond if we must. sophisticated cyber attacks have the potential of inflicting debilitated damages on critical infrastructure. our adversaries will try to use them to frustrate our military advantages and power, striking at the underpinning strength of a nation, our nation and economy. this will require we continue to place the highest rarity on cyber defense and capabilities. meanwhile, natural disasters, pandemic diseases, and the proliferation of weapons of mass distraction present further destabilizing realities to

regions in the world. regional tensions in the middle east and elsewhere continue to have the potential to erupt into larger scale conflicts, drawing some of the most complex threats remain from the nontransparent and heavily armed nationstates like iran and north korea. we continue to adapt to present and emerging threats from nonstate groups, terrorists, and criminal networks, and from w ithin weak states. statehood can be a fiction that hides dangers lurking beneath. all of these challenges will be with us for the foreseeable future. there is not a short-term vision to these are a first century threats. we must manage through these realities as