different lanes and how to deal with complex cases. we know that the va has the authority to do pay as you rates. i wonder if you would talk about that. talk about what the problems are why you don't use up more often and is that they probably can address that how you compensate the people who make these decisions based on a full claim decided or parkland decided to address these concerns brought up in the previous panel. being that the previous panel product comments about you didn't get credit for it, so it wasn't worth it. without saying yes that's right, no that's not right, let's take that as a base to talk about what we put in place actively right now, which is exactly what you're describing. received acclaim from permit better with 10 issues. break that down into 10 issues and have one great time for 10 readers with one each. break it down to 10 individual

issues and make decisions on the 10 individual issues and compensate the veteran if they're entitled to it as the rating decisions become -- as they're made aware before to do the other. the problem with madison assistant right now today, that is very difficult to do. there are some barriers in terms of its much less efficient in the amount of time it takes our overall process to rate 10 individual issues at one each. the fixes we put in place will allow that to go significantly faster and been our intent is to do exactly that, which is rate by issue. so we understand within your bill. they testified on that previously that we've agreed without the concept. at this point in time, there were complications due to her system limitations. >> when you anticipate those changes will be made? >> i can't put an exact day. what i can tell you is every 90

days be doing a release. i'm not sure which one of those releases that some of these changes are in. one of the changes that is going in and being piloted right now is the vbms authorization mumble and when they been in place to help these individual issues as they are deciding to go through the system quicker. in other words, when i had the vbms authorization model in place come all process individual issues without impacting the total system time. >> will there be safeguards in place so you don't just pay a better and offer a few things and think it will go away as opposed to really do complete? >> we are looking to break in the stance that comes then as a single claim, but it is posted in our system and we track it as though they are 10 individual claims. this isn't just i'm going to receive a claim in break it up by issues. this is the true issue based quality, everything.

>> i know that some of the cases in the reno office have been farmed out to other offices where they can emit vast and stuff like that. if you start break in the claim done so some things are easy and a more complex and you end up into different lanes, you're not going to end up into different places to have your claim completely considered? >> well, depending on mr. or ms. those question a little bit ago about centers of excellence, we certainly need to consider whether those different issues into different lanes even need to be in the same regional office. why a figure with the concept of centers of excellence in the trade happens to be on issue number one in st. petersburg issue number two. why would we not send that claim quite i can move them around the country with a few keystrokes. we still don't have the final this is exactly how it is going to be, but weeks are the options from how i get it to her system right and fast.

>> we just don't want to make it more difficult for a veteran to track where their claim is or understand what is happening with it and when it is happening without scattering it around or making it more complicated. >> yes. you are seeing one of the information points you are interested in is from the reno office. >> we are waiting for some of those answers. >> just under 700 right now. you've heard what we are doing with the 2-year-old claim and 1-year-old claim and now to the 334 days. if the capacity of the regional offices in place to meet timelines we put into meet these different deliverables on the oldest claims, we ship them off to other regional offices. in other words, we make the oldest claim issue a national problem and not one type to a particular regional office. it just so happens in reno today they have a large number of the older claims. they sent those to other offices that have capacity to give veterans done in a timely

manner. thank you. >> i think the gentlelady. >> thank you, mr. chairman. i want to thank the panel as well for the testimony today. mr. murphy, vba currently adjudicate claims related to camp with june in louisville, kentucky. and claims related to radiation in mobile, alabama. can you explain to the committee why this is? >> those claims actually fall under the title of this hearing. they are complex claims. they are highly complex claims. but we don't want to do is have a veteran because they went to regional office ones get one decision an equivalent case in a different rating decision. in order to do that, in order to concentrate efforts in the way we do claims in a paper world, we concentrated them in single places. we provide special training for the processors and raters to work the claim at the same time

we worked with dha and provided training to the individual cmp examiners that work these conditioners and send a factory single jointly trained rating board so they get a consistent accurate output. >> so those two areas are specialized in this particular -- >> yeah. >> for the oig, ms. mccauley, your inspections on this difficult medical conditions, how often is training and a lack of knowledge regarding policies and procedures a problem? how often is that? >> it certainly has shown itself to be a problem as a result of our inspections. ..

>> ok. in consideration of your response, do you think a veteran 18ld benefit from having muslim people are specially , similar to what we just heard? collects we have not examined the issue of this. additional training could be a health in terms of adjudicating it. >> the more accurate and timeliness they can process over

the particular claims? >> we would expect that. yes. >> just to follow-up on my previous questions about camp lejeune where you specialize in one problem i have seen isr time i have you have over 50%. an employernot be or choice. they are training individuals. ack from iraq and afghanistan with tbi and ptsd and mst, issues i think it's important that the the new system i like the idea when you look at the medical conditions. with the medical conditions you can move that anywhere around the country in the timely fashion so if there's a certain regional office that is specialized, such as camp will

june, in louisville, kentucky to deal with the issues. they can get an accurate decision in a timely manner. as i understand some of the concerns some of the vso have it's not done in a regional office. it's not done anyway when you look at the cases being broke toard other areas. they are not performing adequately. i would like to just, you know, see whether or not you would really consider looking at, you know, centers of excellence for those very complex cases since you can move it electronically once the system is up and completely running fully. >> we would consider the centers of excellence concept. in fact, my staff is going through now pulling numbers in terms of accuracy, rating capacity, et. cetera. on regional offices right now to identify are there some clear outliers that say this should be a ceo for ptsd, this should be

for military sexual trauma. we are going through the process now. we're beginning the process. it's not quick. it's going to take some time to do to make sure we get it right. it there are some centers of excellence tounge it right. there are some lessons. should i make them the center for all over the country. number two, if the answer is no, i should not. what are they doing different to get it right that i need to teach the other regional offices. either way it goes, the analysis we're doing is going yeeltd good things for us. back to the other part of your question the vso having some concern about the not being able to have that interaction and look at the file and review it. in the paper world, that was a problem. in the electronic world with the stakeholder entry we haven't placed and come up releases which allow them to see more of the claim file and the decision that is being made. they'll be able to perform that review from anywhere in the country regardless what regional office is working the file. >> i appreciate that answer. for me, i think the number one

priority should be making that sures are veterans are taken care of. not whether or not the claim is processed in the regional office. particularly that regional office is not performing the way it should be. so thank you very much. thank you, mr. chairman. >> i thank the gentleman. and i have a another question. i know, mr. oh -- your testimony highlights that they approved policy and procedures to ensure more timely and accurate decisions to veterans of complex claims. setting aside the discussion we just had, about strong concerns and how they calculate accuracy, va's work toward better policies and procedure is welcome, but what the committee is hearing from the ig is that the regional office repeatedly failing to comply with the policies in place to directors, auditors, managers, it with be a the receipt call exercise.

but to the veteran who underrated or denied because of regional offices noncompliant. this is a complete failure. as i read the american legion testimony. for those in the quote for those veterans va accuracy might as well be zero. the inspector general consistently reports that the need for policy guidance oversight training and supervisor review and 17 of 20 recently respected officer remain on noncompliant. most of which were found to be repeatedly out of compliance. how are you going enforce compliance or put in to put it another way, what will be the penalty for noncompliance? >> i can't answer directly your question whab the penalty for noncompliance. that falls under the office of field operation and deputy undersecretary. however, i can tell you what we're doing to ensure compliance is happening and the solution is not going out yelling at

regional offices direct, directors and telling them you must follow the process. the solution to put a system in place that takes them down the path. and camp how we're doing that today is number one i talked about how we changed rules around ptsd. we no longer had to make a determination about the stressor and get a buddy statement saying what happened. we changed the rules so saying the veteran came in and feared in my life. and assess for ptsd. that's the way we handle from the rule side. when i look from the sm putting in place to ensure at the grassroot level take us back to the temporary 100% and the example there is in the system we nut place with vbms, you can no longer hit a button and move through a screen. you are forced to stop and put a routine future exam date in place and place if under control before they are allowed to press

the button and move through the screen. i forced the behavior without having to go out and push and discuss and come back and re-examine. i know, that it's happening because i can track it and see it on my system. and i report every two weeks. that every two week report everlast year i was seeing 600 case. now 50 cases. the reason for that is today there's somewhere in the neighborhood of 74 or 75 percent of our cases are electronic through vbms. we are working through the lapse of the paper. as we move to the electronic environment, the compliance rate will go up and then i'll see the number drop over time. so the answer to your question is, is i fix it by putting procedures in place that drive the ro in the right direction and put system i think i think if -- fixes in place that force the behavior to ensure the veteran gets the right decision. >> before i yield, e i remind you and remind everybody how many times secretary sat there and talked about

accountability. you do all the system call stuff you want. if you are not motivating people to do it, i know they are highly motivated people who want to do right by the veteran. there's a lack of accountability there. and across the board, but with that i'll yield to mr. oh -- >> thank i apologize for missing the second half of the hearing. i'll get ab update how you responded to the specific issues raised by ms. price and the veteran service organizations that were here. so just briefly bring up two issues. one, is in el paso at fort bliss we have 1800 cases, 1100 are backlogged at the derail site in

seattle. and so just a plea from cornel and william beau month from us in our office representing those soldiers, you know, whatever you can do provide additional intention and focus on that so we can get the folks through there. we have some associated problems with our wounded warrior transition unit there, and part is having the folks who are in this backlog, the bureaucratic loop. the second one ms. price medicationed she filed a fully developed claim and took us through every part what she went through to do that. we been pushing for fully qopped claims filed online. we think that come out of the committee. we can cut the wait time. in el paso right now for atm veteran is 450 days out waco

regional office down to something like 100 or less. i want to pick on what she said. i want do you address the concern it raised with me and others there may be a problem with fully developed claims and our ability to process them in a timely fashion and do so accurately. >> let me start with aye does. with understanding what you're talking about and fort hood and the department of army. >> fort bliss. >> sorry. >> yeah. we put definitive actions in place you'll see the numbers at that regional office start going in the right direction. first of which is in april all of the employees at the seattle d -- broarking we shut down gives an immediate trained capacity to go and start working in the cases. two, is in a may of tbirt we hired an additional 36 raiders in that regional office.

in may of 2013, army reserve personnel were activated and deployed in seattle to help it in getting these cases through quicker. staff at the regional office has been working mandatory overnight and right after the holidays they will resume mandatory overtime through 2014 provided the funding is available us. one other item we have done is we had capacity in providence to take some of those cases. we're working faster so 250 cases per month are being brokered to providence in order to help take some of the pressure off the derail site in seattle. so i think in the coming months you'll see drastic changes in there. one other comment about the process in general. to look at the process and say it's merely a simple claim is to

call complex merely a complex claim and call a complex claim a simple one. as a result, a timely claim going through the process is measured at 295 days. not the 125 days like we see for the traditional bundle. the second part was about ms. price and the fdc and i guess i'm not sure what it is you're asking me there, congressman. >> i guess the concern was apologize again. i missed almost everything you've had to say in response to the stories we've heard earlier. you may have already answered many of the concerns -- raised. one of those was ms. price, i believe before transitioning out had already prepared and filed a

fully developed claim. and yet he an incredibly arduous, lodge battle to get that claim adjudicated in a satisfactory way. and so it causes concern for me and others when we're trying to direct veterans to file those fully-developed claims online and telling them they can get those claims resolved and in some cases close to 100 days versus the average el paso 4050 days. a story like this gives me pause. i want to know whether it is truly exceptional or whether there's more to that. she seemed to indicate from other veterans that she had met with and assisted she's seeing similar cases to hers. and so just wanted to get your quick feedback on that. again, if you've already answered it or would like to an it in more detail at the followup meeting i would be happy to meet thin. if you could talk about how exceptional a case like that

is. >> i have to say discussing in individual veteran and veterans circumstance. what i can tell you is this based on the time frame that ms. price submitted her claim in 2009, when we were receiving fully developed claims at less than 2% to the today where we're receiving 27% of the claims. they're going through with our highest priority and being tracked and monitored on a national basis and national level. so my point is this, the experience that she saw is by no means typical of the process usually in today when the claims are going through in 115, 120 days through the fully developed claim process. other things that happened in the early stages of it, we had a high rate of those claims that were entered in the to fully developed claim process and various reasons right, wrong, or otherwise were removed from the process and put through the normal channel. we track and monitor that routinely now to make sure a fully developed claim that comes in maintains its path through the fully developed claim process. there are specific rules that

will pull that claim out that have process. but now we put the control measures in place, it's not being used or abused. it's not being used to the rate it was when the fully-developed claim process was new. >> my time is expired. i yield back. >> thank you. members, are there any further questions? on behalf of the subcommittee, thank you all for your testimony. you are now excused. i thank everyone for being here with us today. ensuring our veterans receive timely and appropriate decisions regarding their service connected claim is a top priority for the committee and the department. it is unacceptable for the price that -- to be the accuracy of those decisions. will certainly be a seeking more information in the near future on areas discussed as a va continues to march toward the secretary's 2015 goals. i would like to once again thank our witnesses for being here today. i asked unanimous consent the

members have five legislative days to revise and extend any remarks and include any extraneous material. hearing no objection, so ordered. i thank the members for the attendance today. the he [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] korea freedht north a u.s. veteran. he was accused of this crime six decades ago. earlier thisina morning. he is now on his way to san francisco. the decision was made to release him because he had reportedly admitted his wrongdoing and apologize. he is visiting north korea as a taurus before being detained at the north korean government. take you lie to the forum and washington, d.c. for remarks by john kerry.

this is the 10th year bringing together american and israeli leaders from all such as of government and society. secretary kerry will beginning this year's keynote address. next, remarks from another obama administration official. ericsson seki spoke at an event focusing on better in space when returning from active duty. >> thank you all very much. i'm very honored to be here at the not euro conference here. let me thank general barry mccaffrey for his many years of leadership in uniform and government and today in business. he and i have known each other for a long time, from our days as youngsters at west point.

and so i would tell you without question barry mccaffrey is one of the best combat commanders to have come out of my generation of soldiers. [applause] my thanks as well to wes huddleston, your ceo for inviting me today. let me acknowledge judge robert russell. [applause] i still remember vividly my visit to your courtroom in 2009. and it is good to see you again, judge. other members of the judiciary, drug court professionals, drug mentors who make these courts innovative and successful, distinguished guests, ladies and gentlemen, we all know, you better than i, that we are guiding my new mentor.

monument the way we address crime in this country. and so the veterans who have been brought up on charges, they are releasing back to the streets. you have underwritten treatment as a powerful option for dealing with those who a broken our laws. my thanks to the navcp for this ambitious undertaking. there are perhaps four or five courts in january 2009, as i arrived to assume these responsibilities at the v.a., and that barry mccaffrey's urging i went to visit judge

russell. the power of the veterans court concept right then was clear, undeniable, and compelling, and since that visit v.a. has been your full partner, agreed to bring all its capabilities to bear where ever a judge decided to establish a veterans court, and that offer is still good today. last month v.a.'s justice outreach specialist reported courts and operation throughout the country. an increase of nearly 90% this past year alone, with another dozen or so slated to open for

before the end of the year. and so my thanks and congratulations to all of you for what you have done for veterans. in my opinion, we will never be able to do enough for the men and women who have signed on to safeguard our way of life. veterans comprise just over 7% of the entire population of this great country. 22 .2 million of them live amongst us. less than 1% of our country's people wear its uniforms. we ended the draft years ago, and these men and women are the folks who picked that load up for all of us. these are the folks who guarantee our vibrant democracy. of our 22 million living veterans, less than nine million are enrolled in v.a. health care. i am told incarceration is the number one predictor of homelessness. and i am also told there is a nexus of factors to describe both veterans' homelessness. so if we're going to break the

cycle between perforation and homelessness, we will have to raise our level of collaboration, and leverage all of our assets to address these factors which seems so pervasive when dealing with troubled veterans. again, depression, insomnia, substance abuse, pain, failed relationships. this requires the collaboration with a host of agencies. i would start with the departments of housing him urban development, labor, justice, defense, health and human services, education committee, irs, some of the social security and small business administrations, as well as a number of other federal, state, and local agencies and organizations.

veterans are counting on us to solve these challenges. for its part, v.a. operates a large health care -- integrated health care system, maybe one of the larger ones in the country, 151 medical centers, 871 clinics, 300 vet centers, and i know there are 70 mobile outreach clinics that reach out into the most rural areas defined veterans who live remotely. over 1700 remote access points nationwide. beyond health care, v.a. provides $10 billion in education assistance annually, second only to the department of education. v.a. guarantees nearly 1.8 million home loans, the only zero-down in the nation, and our foreclosure rate is lowest among all categories of mortgage loans.

v.a. as the ninth largest life insurance, with 6.7 million clients and 95% customer satisfaction rating. to the support of the congress and the leadership of the president and the advice and assistance of our various service organizations, as well as our partnership with a host of federal, state, and nonprofit organizations, progress since 2009 includes a 50% growth in v.a.'s budget request, from $99.8 billion to more for this year.

enrollment of over 2 million veterans in v.a. health care. 62 new outpatient clinics opened, including our first major v.a. hospital in 17 years. all the backlogs, we have been working on, but a drop of about 36% in those claims in the last 250 days has been the deliberate plan we have put together involving people, processes, and technologies that has come together powerfully. a 24% of decrease in the estimated number of homeless veterans, a remarkable trend during that time of an economic challenge. usually, in these times homelessness goes up. v.a.'s mental health funding has increased. our budget includes $7 billion to increase access to mental health services. a year ago the president looked forward to the hiring of 1600 additional mental health professionals. v.a. has exceeded that goal and hired peer support specialists to augment the professional staff. one of our most successful mental health initiatives has been our veterans crisis line.

many of you know about it. dod knows it, as the military crisis line, same number, same treating mental health professionals answering the phone, 24 hours a day, seven days a week, an example of our partnering to delivering care to those made. since startup, the crisis line has answered over 890,000 phone

calls from veterans in need, and most importantly, 30,000 of those callers were rescued from suicide in progress. [applause] three years ago v.a. asked itself whether we might be overmedicated our patients, especially those under mental health treatment. v.a. worked with dod, and we developed and v.a. is implementing the guidelines that discourage overuse of opiates in favor of other medications and therapies. [applause] some of our 21 health care networks have taken steps to reduce the use of opiates. since 2012, one metric has used its use of high-dose opiates by 20% and decreasing oxycontin use by 99%. [applause] for veterans entering the justice system who are dealing with substance abuse, we have established something all the

justice outreach, vjo. it is an office of 172 full-time specialists working directly with the justice officials to see that veterans who are either before the court or already in jail get the care they need and that courts are supported in their consideration of best possible alternatives to incarceration on this. we are supportive of you on this. we are working to connect our specialists with american indian tribal justice systems to do the same thing. in their first year, 2010, vjo specialist served 5800 veterans. this year that number is up to nearly 36,000 veterans, and we plan to hire another 75 specialists next year. very few of the veterans who are served by vjo are first-time

offenders. over 93% who have spent time in jail or prison, 20% have spent a year or more behind bars. 40% of these veterans have been homeless at least once. these are the challenging segments of our veteran population, but the number is also telling us we are making positive differences for them when we work with the courts to provide them v.a. care and services. 2/3 of veterans before the courts successfully complete their treatment regimens. when they receive v.a. services, the experience and 80% reduction in arrests to year after treatment court admission. they benefit from a 30% increase in stable housing in the year after. v.a., the courts, and our volunteer mentors have been able to attack the cycle between

homelessness and incarceration, giving these veterans a much better chance for success. prevention does not always work, and some veterans do still go to jail or prison, so we have increased our presence there as well. our health care for reentry veterans program -- hcrvp -- has 44 full-time specialists working in a thousand prisons -- and that is about 80% of all prisons in the united states -- and our goal is to release veterans with health care with training to help reentry veterans become productive.

we assist 9000 reentering veterans each year, but we also know by an estimate that that is probably one in six of all veterans being released. last year we added a new online capability called vrss, to enable corrections official to quickly and easily identify any veteran in their institutions. the past three months, the number of jail or prison systems using vrss has more than doubled, with 30 more in the process of accessing the service. i have written to each governor, encouraging collaboration with us through vrss, and with greater participation we will be better able to help veterans. we intend to make vrss available

to the courts as well. veterans who may be dealing with ptsd, depression, insomnia, substance use disorder, and pain need and deserve our help. we have an opportunity to help them with health care, safe housing, education, and jobs, a chance to rebuild lives that somehow lost their way. in closing, in the spring of 2012, navy veteran donald martin parked his pickup truck at a virginia rest area. it had broken down. and federal park rangers found him with an opened container of alcohol, charged him with dui. martin, 57, had been living in his sister's basement,

essentially homeless, after losing his job, unemployed, and going through a divorce, failed relationship. he had also been battling alcohol dependence for decades, and had already had two dui's on his record. substance use disorder. a third dui would mean automatic incarceration, and a downward spiral. his attorney recommended participating in a veterans treatment court. without knowing much about it, martin consented. a u.s. attorney agreed to take the dui charge off the docket, allowing him to appear before a veterans treatment court, heard by that treatment court team, judge robert --who may be here today -- the u.s. attorney, martin's defense attorney, his probation officer, and a v.a. justice outreach specialist from the salem v.a. center, he began a program at the salem v.a. it included group treatment sessions.

he also met with a vocational rehab counselor to address his need for employment. two months into his participation in veterans treatment court, martin was hired as a sprinkler system installer. he said this was a boost his self-esteem and his sobriety. veterans treatment court lasted six months, during which he completed his substance abuse treatment and maintained his sobriety and employment. in the six months, the judge presented him with a challenge coin, symbolizing his graduation from his court. today martin remains employed, has maintained a sobriety, and

has had no further run-ins with the law. he has been promoted three times and received the performance bonus from his employer, and he has reconnected with his ex- wife. martin says of his arrest and its aftermath, a treatment court changed my life. the court was not against me. they were actually in my corner. they wanted me to do well, to get my life straightened out. you would not believe the turn of events in my life. so no of us can imagine a better ending to donald martin's story, but it is all because a judge and his treatment court team dared to care. i'm sure each of you in this room has a similar story to

tell, and so to all of you, my heartfelt thanks for giving these veterans a chance to demonstrate that they were the folks who carried the safety of our country on their shoulders. i am honored to be here this morning, and honored again to see my old friend barry mccaffrey. thank you all very much. >> today is the anniversary of the attack on pearl harbor. indoor this will always as american ideals. today we honor those who lost and thanked all who serve. says he homagell though that served in the years that followed. leonard lance said we honor and remember those who fought and those who lost their lives that pearl harbor, a date which infamy.s to live in both the house and senate will be in monday. john boehner says this the the

last week of legislative business until the new year. he talked about what to expect both the week. gibson is a congressional reporter. thanks for coming on. busy days as i'll are getting ready to wind up the year. the house is suspected to gavel out. what is on the list of items they're hoping to finish up? >> a possible deal on the budget. tiny marie and paul ryan seem to be approaching some kind of agreement dealing with the sequester as well as some other revenue increased others -- s.creaser' we can move forward on spending bills.

loc is insisting unemployment benefits need to be part of the discussion. why is that? might that be an item that is a hurdle for them? >> it expires the week after christmas. several democrats want to see that extended another year. that is not being included in the budget deal. speaker boehner has left the door then. he said he would be open to having another extension. he has not figured out how they're going to get done or if it will get done. >> what happens if they cannot reach a budget agreement? there is no real repercussions immediately. the government stays open. they have about another month to find some other way to get it

beyond the deadline. >> we know they have been working on the farm bill. can we expect to see both? >> it would be unlikely. they're trying to come back together. it is like a race between the farm bill and the conference committee trying to get something done. bringing a lote of people together to frying dust to find those. whether they vote on it is still unclear. >> the senate was working on the defense authorization bill. how are those negotiations going? >> there were going to vote on this in the senate. they did not. they announced they would address the status of the legislation. it willnot seem like finish before christmas rate.

>> what judicial nominations could we expect to see before the holiday break? >> there are three nominations. disputes.with this harry reid has said he would ring this down to the filibuster rules. they do not require 60 votes. gibson is a congressional reporter for political. thanks again for joining us. >> thanks for having me. >> c-span, putting in the room at congressional hearings, conferences in offering complete gavel-to-gavel coverage.

all as a public service of private industry. funded by your local satellite provider. night to watch this in hd. >> does mcdonnell and tom daschle talk about the health e law. [applause] >> well, it is nice to see all of you this morning on a wonderful morning to talk about a very important subject about this country. as a cherokee chief indian once said, the success of a rain dance depends a lot on timing. if timing is everything, the timing to talk about this subject is right now. the implementation of the affordable care act, opportunities and challenges.

we have an excellent program today. we have two terrific speakers. we have denis mcdonough and tom daschle. we also have a panel that will be moderated with a number of distinguished people on the panel. that will be the day. we will have an opportunity for some questions and answers along the road. let me introduce the chief of staff of the white house, denis mcdonough, stillwater, minnesota. it was once said -- and i assume the northern great plains spirit of denis mcdonough exists -- it is perfect for any chief of staff of the white house at any time. he said we were raised by people who taught us that life is an enormous struggle. if at some moment you feel very happy, be patient. it will pass. [laughter] stillwater, minnesota, masters

from georgetown university, chief foreign advisor for the majority leader of the senate, and then the deputy national adviser in the white house and now chief of staff to the president of the united states. please welcome denis mcdonough. [applause] >> good morning, everyone. thank you to georgetown university for holding this discussion on affordable care act. thank you to the two senators from the northern plains. senator daschle has been an important mentor to me. senator bennett, it's good to see you again as well.

i appreciate the opportunity to talk about the affordable care act and what it has done and what it is going to do. i will update you on the progress we have made on fixing the website, healthcare.gov. before i talk about the law and its benefits, let me tell you about a visit i made to the emergency room on a friday night recently with one of my boys after he broke his left arm. the care was excellent. so much of our emergency trauma and specialized care is. what was remarkable to me is not the care that my son got as grateful as i am, but rather the crying of two babies i heard in their emergency room being treated for asthma. dramatic asthma attacks. i cannot know for sure whether those babies were insured or not. if they did have coverage and the access to primary care that comes with such coverage, chances are it would have been far less likely to be getting

emergency care for something like asthma on a friday night in the emergency room. my heart broke for those parents. they seek care for their suffering child in the emergency room. we are talking about asthma, something increasingly and sadly common, but also fundamentally treatable. "the new york times" reminded us it's the single most expensive place to get treatment. there seems to be a strange outbreak of nostalgia for the affordable care act health care system that covers too few and a maddeningly inefficient and a very expensive way.

the personal impact is clear. think about the couple and their young baby on a friday night. there are also huge costs and economic implications of that system. it had been the norm until three years ago. we spent far more as an economy with the growth and per capita terms for a system that delivered last effective outcomes for a smaller percentage of the population. in short, quoting someone i know well, we were spending more each year and getting less. economies suffered and all of it was unnecessary. fighting to deliver quality affordable care and the security that comes with it to every american is paramount. making sure everyone gets a fair shake and as we continue to rebuild our economy and a better middle class and that is what the affordable care act does by

using touchtone american values of transparency and competition to improve health care protections and affordability for those americans who already have insurance and to provide new affordable care act and sort consumers who don't have the -- for consumers who don't have it or want to switch their insurance. we finally put in place real solutions that will continue for decades to come. reforming the system is not an easy task. i have worked on many complicated issues. peace in the middle east, iran, but it deals. -- and budget deals.

reforming the health care system is the single most complicated issue i've faced and does the president often says there is a reason why folks try. is it worth getting a grip on health care holding back our entire economy? you bet. fixing the broken healthcare system has been a labor of love. it is personal for him, as it is for many of you. he knows for each and every

american, getting it right, it's about making people's lives better. while i'm here, let me spend time describing how the law does these two key things, providing security and improving our economy. i will talk about how we're doing all we can to implement the law the right way fairly and flexibly. that includes learning from our experiences with healthcare.gov. the affordable care act fixes n/a the most harmful in wasteful -- many of the most harmful in wasteful aspects of the system here to for. people who already have healthcare coverage before, let me give you a few statistics. thanks to the affordable care act, 105 million americans including women are paying less for preventative care. we are investing in keeping

people healthy rather than treating them when they are sick. 105 million americans are no longer subjected to lifetime limits on their coverage. up to 129 million americans including 17 million kids, 17 million kids who have a pre- existing condition for which they could have been denied coverage are charged more and they are now protected because charging more or denying coverage will be prohibited as of january 1. 7.3 million seniors and people with disabilities who reached the doughnut hole of medicare prescription drug coverage have saved $8.9 billion on prescription drugs. this year, those helping $8.5 billion get money back in their pockets by making sure the premium dollars go to healthcare not overhead or profits. 3.9 billion in premium savings were returned to americans as accountability and transparency policy came through. new major marketplaces and the choice and competition will give a majority of uninsured americans the chance to buy health care coverage for less than $100 a month. think of that for one minute. here uninsured people are now going to do their personal responsibility to get covered so it is their coverage that covers them and not the rest of us when they are forced to get treated in the emergency room. thanks to the affordable care act, states can change their medicare to cover even more uninsured americans and many of

them don't have enough to allow them pay. they have said yes to covering more people including states with conservative governors like ohio, michigan, arizona. if every governor followed suit we could cover another 5 million americans. we're going to keep urging those leaders to do the right thing and to expand coverage at no cost to themselves for the next year. a new report out today shows that in october alone, not counting states like texas, one point 4 million people gained eligibility and medicaid and the children health insurance program. we could cover another 5 million

americans last year. we're going to keep encouraging them to do the right thing and at no cost toe themselves for the next year. in octobert shows ,ot counting states like texas one point 4 million people gained eligibility and medicaid in the children health insurance program. that is up 15% from previous months. those are a few highlights. the impact on our economy will prove dust be profound. we are seeing a rise in health- care costs and the lowest of price inflation and 50 years. employer incentives to hire new workers. in the long run, what we save shows up as higher paychecks for

workers and lower deficits for the government. indeed, the cbo estimates in the second decade, once the aca is in effect it will shave 0.5% gdp off the deficit every year. how do we implement all these benefits to make sure they translate into better care for all americans. he have to keep spreading the word so that americans know that these options are available to them.

the is where much of attention has been since october 1. the new health insurance marketplace will help insure millions of hard-working americans. in states where they are working to make this law work for more of their federal citizens, people are signing up in droves. 50,000 people have signed up in new york. 80,000 in california. 9000 in kentucky. other states are utilizing the federal marketplace. let me talk a little bit about that marketplace. as you know, the website did not work the way it should have on october 1. that's on us. that's on me. as soon as we realize there were problems, we put a team of experts to work and as promised it is working better than now and will work better tomorrow and by the weekend, even better. we will continually improve. the team has doubled the website's capacity to handle

50,000 users at once or over 800,000 users per day comfortably. the average response time has gone from eight seconds to under one second. response time being the measure of time to collect from one page to another on the site. the number of people successfully enrolling is climbing while the error rate has gone from 6% to under 1%. inching closer to industry standard for such websites. we are getting back on track and we will keep improving to make sure that it is what is best for users. we're making the site more user- friendly. the new waiting room instituted pretty well. they requested that they be e- mailed at a time to be invited back. all of them were invited back the same day.

half of them accepted the invitation to go back and they viewed on average 24 pages during their return to the site. while we are welcoming new users and we saw over one million of them yesterday, over one million new visits -- we will also make it a special priority to reach out to those users who have already submitted applications but have yet to actually enroll in a plan. we will make sure that those customers who have selected a planned everything they need to do to make sure they're covered on january 1. we want to make sure everyone is taking the steps necessary, that they have the affordable coverage come january 1. ultimately, we believe that it will be the easiest way for americans to compare and buy quality, affordable healthcare insurance having brought transparency and competition to a market that had been closed and opaque.

as you heard the president say, the affordable care act is much more than a website. we have learned from our experience the past few months and the overwhelming interest we've seen from consumers in the first two months reminds us just how strong the demand is for quality affordable insurance options and that strengthens our resolve to make sure that this law works for every american. no matter what have a we will see this through. we are going to make this law work and as problems arise and we will fix them, just like we are fixing the website. as president obama has said from the very beginning, he's working -- he's willing to work with anyone to make this law work better. it's in the united states of america and the affordable care should never be the privilege of a lucky few but rather a right for every american.

the affordable care act gives us an option to make that realistic and we intend to see this through. thank you very much for the opportunity to be with you. [applause] >> denis, thank you. he needs to get back to the white house but let me just mention to you the effort it took for dennis to be here. originally, we had chris jennings scheduled to come and this weekend, he determined he was not able to be here for other reasons and the chief of staff said he would come and provide a speech and that was very generous of him as well. he needed to get back to the white house but thanks to denis mcdonough, a friend and somebody that i think serves this country very well. next, i have the opportunity to

introduce my friend tom daschle from aberdeen, south dakota. there is a theme here. stillwater, aberdeen, north dakota. i will not tell any south dakota jokes because tom has heard them all. but i will tell you that we have been personal friends for almost four decades now. as i said, he grew up in south dakota and he is a military veteran. he got involved in politics and became the geordie leader of the -- majority leader of the united states senate. i think he's the only person who has ever served in leadership in the senate he was majority leader twice and minority leader twice over one of the longest- serving majority leaders in this country. he is a healthcare expert and has written two books on this and he lectures across the country on the subject of healthcare.

he is a senior advisor and he has agreed to join us today. he will give a presentation and take some questions. welcome, tom daschle. [applause] >> byron, thank you for that generous introduction and thank you all for your warm reception this morning. i really appreciate the opportunity to be with you and to talk, as dennis has, about something we all care deeply about. i think it's appropriate that i'm the third in this line of midwestern speakers -- minnesota, north dakota, the gateway to south dakota and it's only appropriate that i come third. [laughter] dennis, byron, and i grew up in states where, in most of the communities, you put entering and leaving on the same post. most kids are about seven years old when they realize the name of their town is not "resume speed."

we have a lot in common. you can understand why i'm as proud of dennis's work and commitment as i am this morning. i've known him for close to now 20 years and i had the good fortune to work very closely with him even after i left the senate. and i have the opportunity to work together. it's a real honor to have heard him this morning and to see him again doing such good work. let me also thank aaron fox and gw for hosting this important program. did i say gw? i'm sorry. georgetown. of course, judy is here. i appreciate the opportunity to be here with you and thank you for the leadership you have shown in making this possible. i was going to begin my comments by talking about a little bit what we should think about as we

contemplate our certain circumstances and health but i think dennis has done such a good job laying out many of the things that i was going to address that in the interest of time, i will simply restate what is obvious to most people and that is that we have made enormous progress over the course of the last three years, enormous progress in changing the paradigm in health, reducing cost, improving access, and even committing to improve quality. as we consider that progress, there are many things for which i think there is a lot more bipartisan agreement than we often read about in the news media and i want to talk a little bit about where i think the areas of agreement really are and get into some of the details about our future as we look to the enormous work that still remains with regards to health.

obviously, this is a very transformational time. i would suggest and assert that it is the most transformational we have seen in all of our countries history. the magnitude of change that we've experienced and will experience over the course of the next decade is just the beginning of an appreciation of what a transformational opportunity and challenge there is. therein lies both opportunity as well as payroll. those who would somehow resist this change and argue against making this new health paradigm a much more conducive environment. ultimately, i think they stand to lose a great deal as we go forward. as i considered the achievements and this transformational moment , the one thing i would say is that there are a couple characteristics of the american health sector that are going to

remain somewhat unique to america. the first, i would argue, is that unlike every other industrialized country, the united states has never really had what i would call a system. we refer to it as a healthcare system but if you define a system as having a central administrative and decision- making authority, we have never had that. what we have is a collage of subsystems, public and private. medicare and medicaid subsystems being some of the more public but we also have entitlement character the veterans administration and uncompensated care that we all pay for in very inefficient ways in the emergency room and in other ways as people are unable to pay for their own health care. all of those subsystems, that collage, represents one of our greatest strengths in that it

has brought enormous innovation but it is also extraordinarily inefficient and the fragmented nature of those subsystems continue to plague endocrine problems that we are attempting to address and that dennis can a good job this morning outlining. the second characteristic of our healthcare sector is the nature of our healthcare pyramid. i've always advocated that all health in any society looks like a pyramid where at the base you have a wellness and good primary care and you become more and more sophisticated, more and more technologically inclined with the applications at the top of the pyramid being the most sophisticated we have today, heart transplants, mris, very technical applications. that pyramid, it works about the same way and almost every

society where they start at the base and work their way up until the money runs out. in the united states, we started at the top and work our way down until the money runs out. the money runs out so we don't have the kind of emphasis on good primary care and a good wellness program that most other pyramid mid models offering these industrialized countries today. these are ones that will continue to be grappled with. we will not have a system as we define it and we will not have a bottom to top pyramid. can we cover the entire pyramid from top to bottom with better allocation of resources, greater efficiency? that is essentially what we are trying to do as we go forward. there are a number of areas for which the really find really little disagreement.

i cannot find a conservative or someone on the left or the right who would argue that we don't have in the scheme of things a real cost problem today. dennis addressed it. certainly, we have made enormous progress in the last couple of years and we are now at the lowest cost growth we've seen in all of history but if you look at what happened on cost in the united states, just think about the fact that we spend more on health than the next 10 countries in the world combined. we spend more on health than the entire gdp of india, russia, or brazil. when i was born, health was four percent of the gdp. when my children were born, 8 are sent. when my grandchildren were born, 17% and now we are told if i'm lucky enough to have great- grandchildren and historic trends continue, 32% of gdp.

there is not a conservative or liberal in the world who would argue that it is not a problem going forward. as i said, we're making progress but if we were not making progress, the inevitability of that trend is something that we simply cannot sustain. we also have no disagreement really with regard to the fact that there are a lot more people uninsured and not getting the access to care they should in a country as rich and powerful, as good, as ours. i'm lucky to serve on an advisory board at harvard and they recently released a report that really struck me. my town, aberdeen, south dakota, a town of about 25,000 people in the reason this report struck me was because it noted that now on average, every year, about 25,000 people die simply because

they have no health insurance. my town of aberdeen, south dakota, the equivalent, dies every year simply because they don't have access. i think that number is conservative. i would tell you that's unacceptable in this day and age in this united states of america. we also have a quality program -- problem and there was little difference of opinion. something's wrong but over and over again we fall far short even though we spend more than anyone else in the world. we recognize that on cost, access, and quality, it's not even an ideological issue.

i will end my piece of bipartisan analysis on this, what we state what our goal is going forward no one disagrees with the assertion that we should have a high-performance, high-value healthcare marketplace with better access, better quality, better costs. i don't know how you disagree with that and i've never been in a venue where we spend a lot of time together talking about health where we all agree that's really what we're trying to do, build a high-performance healthcare with better quality and lower costs. what i find is that even though there is all of this agreement on the problems, if we had more

time, i would get into the causes of those problems and there are a significant degree of agreement on that but i would just cite one, the lack of transparency. healthcare is the only sector and our economy where we don't know what it's going to cost or who's going to pay. we have more information on every sports figure than we do on every provider in this country. transparency is a real problem because you cannot fix what you cannot see. we cannot see what we have as problems on a regular systematic basis when it comes to health. there is no disagreement about that. the fundamental disagreement among republicans, democrats, liberals, conservatives today is really what is the proper role of government as we address those problems? as we address those causes? as we reach that goal? that is really where the divide is today. our challenge is to overcome

that realization, the issue about the role of government and tried to find ways with which to address a meaningful health reform recognizing the deep division that exists with regard to that central factor, what is the role of government today? in 1900, a government comprised about 15% of all health, 15% government related. in 2011, for the first time in history, government equal than slightly surpassed the private sector with regards to the insurance subsystem i described the moment ago. for the first time in 2011. we are at about a 50-50 approach with regards to health. as the affordable care act was being contemplated, i would just take a minute to talk little bit about history because i think

it's important that this be put on the table. i don't think the president gets nearly enough credit for it. i had many conversations with him and others over those early stages and i will never forget as he was contemplating what model to use, there was a lot of pressure in his party going back to this question of government, to say that what we ought to have in this country is a single-payer system, medicare for all. it's what we need. medicare for all, a single-payer system like a lot of other industrialized countries especially in europe. you know what his answer was? i don't think we will ever get bipartisan support if we tried a single-payer system going forward. i'm going to take the heritage foundation proposal that they came up with in 1993 and we will use that as the model, the basis for the legislation because i want to see if we can find

bipartisan support. >> ok, we will accept that, although we think a single-payer system would work better but at the very least, when you offer these exchanges, there ought to be a public option. you ought to be able to go to every state and pick medicare for all if that's your choice. he says he wants to keep it bipartisan and we will never get republican support if we have a public option. they said, we strongly disagree but at the very least, you want to let government negotiate drug prices and allow importation, something byron really advocated for. having the ability to negotiate prices is what they do at the veterans administration and the president wants again said he wanted to try to keep it i partisan so he vetoed that as well. unfortunately, we were not able

to get very far in creating the bipartisan consensus that he really attempted to produce but we are where we are, the two pivotal moments that occurred in 2012 that bring us to the current circumstances, this two pivotal moments where the supreme court decision that the law was constitutional and the election where we chose one later who advocated one approach over a later advocated another. as we look going forward to the next five years in particular, i would say that there are going to be five very specific levels within which all of this is going to unfold and for which we will see enormous transformational change. the first and most imminent factor perhaps will be congress itself. congress is unlikely to change

the affordable care act finding the necessary votes in both the house and senate and getting the necessary presidential signature so i don't expect any immediate changes with regards to the law itself but we do have an enormous opportunity to change the public programs, medicare and medicaid recognizing that it is a significant budget and cost driver and realizing that by simply changing these two major programs, they can be an engine for change in the entire healthcare marketplace. there, congress has a choice between cutting programs and just shifting the cost on to somebody else, which we have done all too often or redesigning and improving those programs in a way that can bring meaningful change, greater efficiency, and far more opportunity for improvement in access, cost, and quality today. i'm very hopeful that over time congress will choose the latter

and look at the ways with which many organizations have already offered suggestions for redesign and improvement. i have the good fortune to work on two of them myself. one of the bipartisan center around one at brookings where we released reports giving a significant analysis of rogue rams and ways with which they could be redesigned and improved quality. that's the first level. a very important level, as i said, that will be necessary going forward. the second level is the courts. there are a few stories in the paper today about or challenges on mandates, court mandates on contraception, independent payment advisory board thomas and a number of other very critical issues that are yet to be resolved legally. those issues are still pending in various levels through the cord and will have a very consequential impact on what

happens with the new paradigm in health as we go forward. the third is the administrative and regulatory efforts underway now in the executive branch that dennis talked a lot about. there are three components in the administrative and regulatory framework that are very critical. the first is the one we've heard the most about and that is insurance reform. new protections and the fact that we no longer will have to do with pre-existing conditions, lifetime limits, annual limits, something byron spent a lot of time working on when he was in the senate and bob in it as well. he was an extraordinary effective leader on the republican side on many of these reforms of both republicans and democrats were seeking answers to. insurance reform, most evidenced by the creation of these 50 exchanges and with new protections, new products, new

services, all offered on the exchange marketplace and that will be the first component that will have a profound effect as we go forward on virtually every american whether they are in the individual marketplace or not. the second component is not getting as much attention as it will when we go forward and that is meaningful payment reform. one of the biggest cost drivers is the fee-for-service program. producers and providers of our healthcare marketplace today in large measure are rewarded for greater volume and we need to change that. we will change that by changing the payment paradigm away from fee-for-service. that is going to have a huge and very consequential effect on the way that healthcare is provided as we look to the next 10 years. but there it is delivery reform, recognizing the importance of good quality and the importance of best actresses, recognizing ways in which we can do things

better. we have seen an enormous amount of change with the way that care is delivered with electronic devices. as we look to all of it, there is little doubt that health i.t. will likely be the backbone, the nerve center of this new health paradigm going forward and i'm very excited about what prospect there are for doing that. that is the executive and legislative and legal layers. the fourth is happening in the states themselves. they are really becoming incubators of change. every state whether they are participating in a state exchanges becoming a real incubator of this transformation and it's exciting to see what's happening in virtually every state today. innovation has exploded.

i just attended an innovation summit in ohio and it was just remarkable to see all of the new and exciting things going on in the states and that leads me to the final level and that is the private sector. that is where the greatest degree of innovation is really taking place, in norma's changes at all levels, payment, delivery, reform, new products, new opportunities, far more transparency, far more personal capacity for patients and individuals to be involved in their own health with a greater and greater emphasis on wellness rather than no mess. those are the five areas in which i think you are going to see enormous change over the course of the next 10 years, change that i think is exciting and brings us closer to the high-performance, high-value healthcare marketplace that i think republicans and democrats, liberals and conservatives all

aspire to. in closing, i would simply say that i think there are four important test of leadership that will ultimately determine whether or not we are successful . the first test of leadership is resiliency. in any transformational moment, we know there are going to be set ask. we know there will be lost yardage, fumbles, a great deal of frustration. we know that there will be losses and gains but the real question is this each time we are knocked down, each time we are struck with a loss, how resilient will we be? how able are we to pick ourselves up, learn from the experience and move on? i think americans are very resilient people. we have shown that now for more than 200 years. i'm reading a fascinating book about the man who united the states and it's an extraordinary book about the resiliency that

our country has shown ever since it was founded. i believe we will show that resiliency again in this even more transformational moment for health in america. the second is innovation. we need it now. if necessity is the mother of invention, innovation is really the key. i believe that we have already begun to see the capacity for innovation all across this country and public sectors. we're going to find innovative and new ways to push to address our challenges in some context of we have not even thought of today as we begin to look at the exciting possibilities and clearly innovation is a key. the third is collaboration. we have to recognize that in this fragmented series of subsystems, we truly need to

work even more closely together and that is why they need to be saluted for the work they're doing in bringing us together today. the collaboration like this, a collaboration among providers, collaboration between government and private entities, a recognition when he to integrate to become more cohesive, it is clearly a very key test that we will all face as we look at the future. the final issue is engagement. those who believe they can sit on the sidelines and not be engaged in public holocene fail to recognize the important interrelationship that exist today between public and private sectors in health at all levels. we have to be willing and prepared to be as engaged as if our lives depended on it. because they do. i would simply restate the need for resiliency, the need for

collaboration, the need for innovation, the need for engagement to determine whether or not we are as successful as i know we can be in this transformational moment. henry ford once said, coming together is a beginning. staying together is progress. working together is success. let you would can work together as a country facing this tolerant dutch -- facing this challenge. building a new transformational health care marketplace for all. thank you. [applause]

>> we have microphones if you want to raise your hands. we will bring a microphone to you. >> thanks for your remarks. you said that the ultimate objective on a bipartisan basis is a high-performance high quality marketplace. stopping with that word, do you think that where we are ultimately headed is a marketplace where health insurance plans, an exchange system that includes a larger share of the population so that the risk pool is larger, the risk can be spread more uniformly and there is more competition among plans to give us more incentive for quality and cost control.

if that is true, noting that the affordable care act only takes us so far in that direction, where is the next step? >> that is a great question. could you hear the question in the back? good. ok. again, in the interest of time, i haven't collaborated on my football field metaphor but i -- this gives me an opportunity to talk about it. what the affordable care act does is allow us to be on the football field for the first time in a meaningful way at about the 30 yard line. i think we have got 70 yards to go to reach our goal. in all of the categories that i glided over to quickly. we have a lot of work to do. we aren't anywhere near the quality, the access -- we may or may not be near the cost- containment aspirations we have permanently.

this is going to take a lot more work. it is going to take even more legislation. we don't have the capacity simply through the aca to get to the goal line in and of itself. what we have done is put the framework in place, creating a new paradigm that will allow us to make new improvements. i can take my fumble metaphor to this football field metaphor because there have been a lot of fumbles. i hope we can show the resiliency to keep going, to get down the field, closer to that goal line. i am confident we will. it will take everything i said as tests of leadership to make that happen. >> thank you. thank you very much for your wonderful talk and all that you have done in this area. i would like to ask a question about what you described.

it seems to me that the reforms one of the reasons we have the wrong incentives around the top of the pyramid is because that is where profits are. the private sector invests huge amounts of money there. are there additional policy changes that are needed that are not currently in aca that could help flip that incentive structure? and get the private sector to create a wellness industry? >> i appreciate the question a great deal. the answer is, we have put in place a number of new policy components that will begin to allow us to cover the entire pyramid. i don't think we will ever find a time when the american health sector diminishes in terms of importance, its reliance on technology.

we are technologically driven in this country. that is a great asset in many respects that it is a liability as well. it is an asset in that we have allowed the most technological means to be used in some cases that have really made a difference. some people confuse our technology with our system, our marketplace. they say, we have the best in the world but we don't have the best sector in the world. if you look at any performance criteria, i think we have the best technology in the world. a lot of people around the world want to access that technology. come to the united states to be able to do that. what this law does and what i think a growing consensus even in the private sector outside the law acknowledges is that if we are really going to make a difference in the new health paradigm, we have got to come to

the bottom of the pyramid and recognize that is where the efficiencies are. putting greater emphasis on wellness and less on illness at the top of the pyramid not only produces better results, but costs less money. it isn't that it has to be either or. our goal is to cover the entire pyramid. putting the balance where it really needs to be with a far greater emphasis and reliance on bottom of the pyramid care than we ever had in history. this law begins to do that but it is going to take a lot of additional effort. the eerie medical school is here and we were talking before about the emphasis on internal medicine and the need for more primary care. i was just delighted to hear that they are one of the top schools in the country now in offering good primary care education and internal medicine opportunities. i believe it is coming. it is a crass expression, but i

think it is true, you have to follow the money. you have to follow the money with regard to reimbursement, with regard to educational opportunities and where the money is for assistance for students, follow the money all the way through the process. i also think scope of practice is very critical. we have got to find that her balance with the way care is provided today. let's give nurses more authority than they have today. we can do a lot better in designating proper roles as we look at good prevention and wellness as well. >> hi, senator. i am with the national academy for state health policy. one of the areas you mentioned was the role of states. i was wondering if you could talk a little bit about some of the long-term consequences for

the different experiences you will be having from state to state. i am thinking a state like new york where they have done their own marketplace and they are expanding medicaid, consumers there are having a much different experience than maybe mississippi. >> i always thought that having models for state exchanges is really a good thing. we have the state models and we are already seeing in states like california and kentucky, a number of states, washington, connecticut, obviously massachusetts -- they have done extremely well and their performance ought to be highlighted and studied as to what it is they are doing that other states failed to do so far. the second model is the hybrid model where you have got partial federal involvement and partial state involvement. i think there is a lot to be said for that model as well.

maybe the federal government is in a better position to do somethings that the states can't do. especially in rural states like mine in particular, we may not have an adequate risk pool in small states to be able to handle the actuarial challenges that we will be facing going forward. it could be that that hybrid is the perfect solution for things like that. then, you have the federal exchange. those who believe we ought to try to nationalize our health care sector even more will see whether we can make it work. the early running would argue that states do a better job than the federal government at setting up the exchange, but it is early. it is too early to make any determination in that regard. i also think the states, right now, are doing such exciting things with regard to pilots and the studies that are underway across the board. patron reform, delivery reform, new health paradigms, you have a

lot of new organizational tests that are being examined, studied. i think we will learn a lot from that as well. then, i haven't mentioned medicaid. you have already got, what is it, 26 states that have signed up so far for the medicaid expansion. i think ultimately all 50 states will do it because this is something that from an economic as well as a health point of view is just too good to ignore. you are going to see tremendous innovation, a lot of innovation engagement, some real spectacular examples of health leadership. we will glean a lot of information that i think will be applicable as we look to the future of health nationally. >> thank you very much. >> thank you all very much. [captions copyright national cable satellite corp. 2013]

[captioning performed by national captioning institute] >> we will have morning health care a lot tomorrow with holsinger. he will talk about reintroducing the health care law and maker actions in the implementation. and we will talk about the employment numbers that were released friday. david lands end with johns hopkins school of international studies and information about the vice president's trip to asia and more on u.s. china relations. there calls and tweets on the day's headlines. >> in this after war, things escalate so quickly. a moment that seemed so loving can just turn and slip and be so out of control. thatis one of those days ended with adam packing to leave

and sasha going through this things and seeing a hidden handgun and saying what is the deal? on top of all the other pressures, they had no money. and she just held the gun and he went in the room and came out with a shotgun and really tried that theyat her so would get her goat so much that she would pull the trigger and kill him. >> "the return home" is only half the story. knowing the man of the u.s. second battalion 16th infantry sunday night at 8:00 on c-span's "q&a." >> as you walk in, there are tables out in front with lots of pamphlets. prior to entering the gun show. and the pamphlets are like how the government is trying to take away your rights. those are the guys i wanted to

talk to. they were the guys at the leaflets, the ideas. they said who are you. academic and i'm doing research on these organizations, these ideas and trying to understand the guys of that. and studying man -- studying man who believe the stuff. i just said, look, i don't get it. but here's my job. i want to understand how you guys see the world. i want to understand your worldview. you will not convince me and i will not convince you. that is off the table. what is on the table is i want to understand why you think the way you do. >> downward mobility, racial and gender equality, michael kimmel on the fears, anxieties and rage of angry white men sunday night at 9:00 on afterwards. part of the tv this weekend on

c-span 2. >> and online for december's book tv book club, we want to know what your favorite books were in 2013. >> the house recently held a hearing on the impact of the health care law on smith -- on small businesses. spoke specifically on the employer mandate, requiring employers to provide health insurance for small companies that have 50 or more workers. this is 55 minutes. >> good afternoon.

i called this meeting to order. aware, thell well health care law requires businesses that employ 50 or more full-time or full-time equivalent employees to offer health insurance or pay in employer mandate penalty or tax. a critical issue is the definition of employee. but equally important is the issue of which and how many employees are contributed to the business. the answer may be simple for one business with a single owner. however, when an individual shares ownership of multiple entities or when a business has multiple owners, the answer is less clear. today, we will examine the aspect of determining whether businesses are considered single or multiple entities under the health care law, which requires businesses to abrogate employees and could be subjective to the

obamacare employer mandate. according to the national federation of independent as is, 39% of small businesses were -- with 20 or more employees will at least 10% of one or more of their businesses. to determine the threshold of 50 or more employees has been met in the situations, the health care law utilizes the internal revenue service code controlled, group, business, abrogation rules, which are complex and confusing even to most experts. some experts have suggested that most small business owners could not interpret these rules without the guiding and -- without the guidance and related specialist.ax despite the administration's promises at the health care law would help small businesses, each week seems to bring entrepreneurs more bad news, more costly regulations, more and certainty and less incentive to grow their business and create jobs. a recent u.s. chamber of

commerce international franchise association survey found that 53% of small-business owners believed the law will have a negative impact on their business. economy, manyging small business owners are simply not hiring or are reducing worker hours to avoid the employer mandate. thank you to this outstanding panel of witnesses who have taken time in their busy schedules to be here today. we look forward to your testimony. i now yield to ranking member .lass small businesses are the back on of our economy. past, high health-care costs and declining coverage have hindered small-business owners and their employees. our practice has tempered nation. hasu.s. chamber of commerce conducted a survey about small

businesses, asking them what is the main issue that they are concerned about? they talk about the costs of health insurance, to be able to provide. in fact, 62% of small businesses in this country provide no health insurance to their employees, their families are themselves. will anything, this law enable small businesses to participate in the exchanges. if we have a larger pool, in the process, we will bring premium costs down because that will provide the kind of leverage that will enable them to things.e good the affordable care act has changed the landscape. the has covered options, increase purchasing power, and

consumers control over their own health care. yes, as with any love this magnitude, some fixes will need to be made along the way. it happens every day. that is what the legislative process is all about. we pass a law, implement them, and we will in any way that we make it to be fixed. mechanism ofthe legislation is all about. that means listening to those most affected and working together to ensure small firms secure quality affordable health care. today, we will do just that by hearing from witnesses about a complicated issue. employees --re law includes a health care mandate

50 businesses with more than full-time employees. the goal is to discourage employers from dropping coverage and leaving employees on their own to find insurance. the enforcement of these rules has been delayed until 2015. many small employers must begin adapting now. this will focus on a particular area of the law that many small firms may not be familiar with. the business everyday should rules. traditionally, these rules have been used to treat separate as this is as a single employer for purposes of retirement plans. this is not new. we have used them. when it comes to benefit plans. incorporated was the the purpose of avoiding

flu mandate. every main concerned about how this very complex role will impact small firms. what kind of average, what kind of resources will be there to assist small businesses, for them to understand the rules and to abide by them. it came as little surprise to many tax experts that these rules are being employed to determine business sizes. unfortunately, for many family- owned as this is an franchise- owned, these rules are not commonplace. for this reason, we must consider how the business thegation rules intact small business model. though some smaller players have party been applying this rule to , all havest to comply

a stiff learning curve ahead of them. i hope that are hearing today provides more information on just how many small employers currently navigate through it and have many more will be affected. i hope our guests will help walk us through this complicated standards and how best to educate owners of their new [indiscernible] with proper planning and outreach, many employers could avoid the pitfalls. i thank all the witnesses for being here and i look forward to your [indiscernible] >> thank you very much, mr. chairman. >> debra walker is a certified public accountant and a national director of compensation and .enefits for jerry beckert she advises small and large

businesses on compensation, benefits and employment facts matters. you have five minutes. , chairmanternoon calls, ranking member about alaska's, and members of the committee. thank you for hosting this important hearing on the effect of the sith -- of the business segregation rules on small business in applying the health care provisions. i am debra walker, a cpa with over 35 years in the employee benefits area. to determine if the employer subject to this shared responsibility rule in the affordable care act, this -- the business needs to determine who the employer is. that decision is made by looking at related entities related by and also byship services that the entities provide to each other. to make the determination, one needs to understand detail of ownership and these services that are provided to each other. i written submission describes these rules in excruciating detail and i can assure you that

no one would apply the rules in a complex situation without looking at the regulations. mentioned, used by the affordable care act, are whether determining benefits are applied on a nondiscriminatory basis. those rules for retirement plans are voluntary, not mandatory. in addition, because we are right line tests, they offer the opportunity as evidenced by the qualified plan rules of ways to plan around them. in other words, for people to avoid the rules in addition, it often happens that the application doesn't make as much sense as it otherwise may. in the health care context, where we are looking whether we have 15 employees or not, it is a complicated test for the few

taxpayers that are nearing the 50-employee limit. one can expect that those 50-oyers nearing the would look at the impact of higher health care costs. many small employers, as mentioned, offer a retirement land, hey 401 k safe harbor plan. they don't even need to apply these rules because they are not subject to the discrimination test due to the safe harbor. small businesses could not do this without advice and many of the advisers for small business are not familiar with the rules. therefore, i offer an alternative suggestion and it is a suggestion that would be a fact and circumstances test. it would look at whose individual that hires, that fires, that makes purchasing decisions, that sets prices. who operates a business on a day-to-day business?

in that case, we don't have to worry about half the investor and ever get those entities. by focusing on day-to-day operations, employer would be defined by the industry in which that employer or individual operates and it would not affect the competitive position of the system. the unwanted effect of a bright line test wouldn't exist. this fact and circumstance idea is not new. it in tax law for years, 30 or 40 years, in determining whether somebody is an employee or an independent contractor. 1980s toied in the have certainty whether determining if somebody is an employee or an independent contractor. there were too many varied situations between service writers and recipients. draw hard andd to

fast by the rule and bright line rules would be circumvented. so what we have is the 20-factor where there is not specific way to any factor. the weight of the factors change depending on the industry. irsany advisor and the refused the particular situation to make the judgment call. circumstancesnd test subject to everybody. there is another place that talks about separate lines. this is also in the qualified retirement plan. a second line of business is a portion of and i don't -- of an employer identified by property and services provided to the customer. the revelations define what is a separate line of business and it has to be organized individually, there has to be a distinct cost center

and there can be no more than .oderate of course, as i mentioned, the determination is always subject to audit by the irs. the rules could require a notice requirement-- to the irs. a procedureuld have as they do with the separate line of business as well as an independent line of contractors, where in fact the two businesses could apply for the irs to make a determination. summarize, the mechanical test used for qualified planned rules are overly complex and understood only by a limited number of tax professionals. a small business can not apply to them without professional help. it is a small set of professionals that deal with these rules and these rules are only going to apply to businesses for a few years.