on nominations. they have been in session since wednesday afternoon. senators confirm block -- barack obama's picked for secretary of the air force. 11ocrats are pushing through , mostly noncontroversial, nominations. if republicans keep their lot of debate time, the senate could be in the session -- in session into saturday. the house wrapped up work yesterday and they have gone home. before leaving, they sent a two- year budget agreement. not efense the budget -- here on c-span will be a -- we will be live with a discussion on health care costs. the discussion will center on the options for handling the rising cost of health care. c-span 3 is live with the

daylong discussion of the federal reserve. it is taking place at george washington university. after a lunch break, they will return at 1:30 with a discussion on whether the federal reserve can be independent and accountable to congress. washington conversations live. >> let me be very clear. this is a diplomatic moment. address oneance to of the most pressing national security concerns the world faces today. implications of the potential of conflict. we are at a crossroads. we are at one of those endpoints -- hinge-points in history. there are concerns about a rant's nuclear program. the other past could lead to continued conflict. these are high-stakes.

kerry oneekend, john why house members should not impose additional sanctions on iran. watch on saturday morning. 2, but tv, is dick cheney. saturday night at 11:00. on c-span 3, a look at the free african-american men and former slaves who fought for the union. that is sunday at 11:00 a.m. eastern. james dobbins says a delay in signing the bilateral security agreement between the u.s. and afghanistan is imposing unnecessary costs to afghan people. he believes the agreement will

be resolved. he made these comments at a house foreign affairs community -- committee hearing. area -- that two hour hearing now on c-span. >> i have been focused on afghanistan since before 9/11. today, the committee recognizes the tremendous sacrifices made by our troops, by their families , so that america is safe from the type of attack that osama bin laden launched from afghanistan. next year, the administration plans to transition from combat operations to and advise and assist role.

we need a workable and realistic transition plan in place. delegation led by adam kissinger and joined by scott perry and juan vargas, traveled to afghanistan and pakistan and they collected information useful to this committee. i thank them for their oversight work. i also want to recognize the committee's military advisor, colonel andrea thompson. she has served towards in afghanistan and organize the trip. i am concerned administration has not defined a mission in afghanistan. u.s. troop strength will drop 34,000 in two months in pending a bilateral security agreement, these numbers will drop lower. will have ag troops

limited role as they should. our objective? what constitutes success? planning for this transition could put american lives at risk. it is questionable whether our diplomatic facilities are , physically and staffing wise, to protect u.s. personnel. this danger will increase as troops withdrawal and transition planners better best figure out how to protect our personnel during this transition. unfortunately, corruption in afghanistan places our aid ofgrams at constant risk waste, fraud, abuse, and despite years of rule of law training, the afghan government has few workable safeguards in place to prevent the misuse of u.s. aid

money. threatens corruption the presidential and the provincial elections that are set for next april. free and fair elections are essential to establishing a stable government. repeat of the widespread election fraud that we saw in afghan'sd undermine faith in their government, setting back the country. corruption hinders afghanistan's economy. the mining sector could tap the posits of industrial metals by attracting foreign investment, but that will not happen with the corruption in afghanistan. on the security front, pakistan 's military and security sought

-- service continue to complicate matters i supporting the taliban on. . they are a double dealer. our primaryne objective of bringing afghanistan under the troll of a democraticly elected government. iran continues to support the and using the banking system to circumvent sanctions. announcedrday, it was president karzai had agreed to a long-term friendship and cooperation pact with iran. we need to counter this because our troops continue to be targeted. they will determine their

future, not us. we can help them develop a stable and democratic government, one respectful of recognized human rights. that is what most afghans want, it is in our interest, and is what our sacrifices demand we strive for. ted deutch for any opening statement he might want to make. >> thank you for the panel for being with us today. theent to afghanistan with goal of rooting out al qaeda and with the work and service of our nation's finest and bravest , itzens, together with bears noting, the service and commitment of 48 of our allies and their greatest citizens, we have made tremendous gains. there have been gains in women's rights, education, and maternal

and child health. 12 years later, we still have 47,000 troops in afghanistan with the potential for thousands more to remain for many years. i am concerned that president overi is blustering whether he will sign the bilateral security agreement, risk of destabilizing afghanistan by destabilizing the security situation even further. it was the safety of u.s. personnel and afghans in jeopardy. i hope he understands he is risking afghanistan's future by playing this game on the bilateral security agreement. a he is committed to partnership, he should cut that the actors. that includes the move to negotiate a security pact with iran. he should sign the agreement. the patience of the congress and american people is wearing thin. it is possible afghanistan will become a safe haven for al qaeda.

i know continuing to achieve strategic gains is not going to be easy, but i fear that the potential of undoing these gains is far greater for u.s. and regional security. discussingard to with our witnesses today. chairman, ileana ros- lehtinen. >> thank you very much. we held two hearings this year that examine this issue. the transition in afghanistan ,nd the way forward for u.s. afghanistan, and pakistan. i lead a delegation to cobble this weekend with mr. kennedy and dr. barra.

we had the honor to meet with our men and women that serve our country in afghanistan. do a tremendous job day in and day out. had the afghanistan, we opportunity to speak with mr. it seemed like he was pre-optimistic about the final security agreement. he was looking forward to its completion, now, however, he is balking at signing the agreement. it is grand council endorsed. as thistly at this -- last weekend, he has lashed out at the u.s. and accused us of threatening here -- him. with iran isting dangerous to our security interest. we are complex and concerned.

pleased to be joined by representatives of the u.s. department of state, the agency for international development, and the department of defense. dobson serveses as the representative for afghanistan and pakistan. he has filled a number of senior positions at the state department and white house. we also have michael dumont. he is the deputy assistant secretary for the secretary of defense. prior to joining the office of the secretary of defense, he served as the federal prosecutor in the criminal division of the u.s. department of justice and managed the justice department programs in iraq. currentlyler, he serves as the assistant to the administrator. -- he has previously worked at the u.s. department of state.

welcome. objection, your statements will be made part of the record. we're going to ask you each to summarize in five minutes your statements. members here are going to have five days to submit statements and questions for the record that you might be asked to respond to. ambassador dobbins, we will begin with you. >> thank you mr. chairman. let me concentrate on what i think is the most topical and immediately important aspect of our situation in afghanistan which is the fate of the bilateral of greed meant and the prospects for longer term american commitment. know, president karzai called grand council to discuss the draft bilateral

security agreement which we and he had concluded. this involved 2500 of that guinness can's influential citizens from throughout the country. debate, it days of was endorsed as written and urged karzai to sign it before the end of the year. this decision underscores the clear and strong desire of the afghan people to continue their partnership with the united states and the international community. with thes agrees afghan people. signing the bsa will send an important signal to the people of afghanistan to the taliban and, to our allies and partners into the region. for the afghan people, it will reduce anxiety and uncertainty about the future. to concentrate on the upcoming elections and to invest with confidence in their own economy. the taliban on may think that the end of 2014 may mean the end

of international support and that their only path to pieces by ending violence and accepting the constitution. bsa will ensure the region that the united states will remain in gauged and will not abandon afghanistan as we once did in 1989 after the soviet withdrawal. other nato allies and international partners, a sign bsa will open the door for nato to begin negotiations of its own status of forces agreement. for all of these reasons, the administration is committed to -- peer delay would add another element of uncertainty as afghanistan prepares for the april 2014 presidential elections. and ourunited states nato allies, delay means a lack of clarity needed to plan for the post-2014 military presence. that would jeopardize fulfillment of the pledges of assistance that nato and other countries and made in chicago and tokyo in 2012.

as ambassador rice made clear during her recent visit to cobble, although it is not our preference, without a prompt signature, we will not have a choice but to initiate planning for 2014 in which there would be no u.s. or nato troops. lans are not decisions. we are not about to decide to abandon all we and the afghan people have achieved over the past 12 years. --ed on the results of the expressions throughout the country and discussions during kabul, i don't believe there can be doubt that the afghan people want american and nato forces to stay and recognize that the bilateral security agreement is a necessary prerequisite. the agreement is also the keystone of a much wider international commitment involving over seven countries ready to provide economic and security assistance to

ighanistan and beyond 2015 putin ofd president russia and others have urged president karzai to conclude the bilateral security agreement. several of these leaders are no fans of the military presence in central asia, but all of them seem to recognize that without a continued international military and economic support, afghanistan risks falling back into civil war. the rise in extremist groups, outflow of refugees and instructions in commerce that would threaten the region as a whole. i see littleinion, chance that the agreement will not eventually be concluded. arrival of the next afghan president to do so, will impose large and unnecessary

people. the app and already the exide because by president karzai's refusal to heed the vice -- the advice is having that effect. i learned from the world bank and other sources that the afghan currency is slipping in value. inflation is increasing. capital is fleeing. property values are dropping. perhaps for the first time since 2001 the outflow of population exceeds the return of refugees. the longer this uncertainty about the future international commitment to afghanistan continues, the more anxiety among the population will increase. potentially dominating the upcoming presidential elections, threatening to turn these into a polarizing rather than a unifying experience for the country. prolonged uncertainty over the -- bilateral security agreement will erode international support for afghanistan. in 2012,and chicago the international community

pledged billions of dollars to support the afghan security forces and the afghan economy the -- beyond 2014. fulfillment of these pledges is dependent on public support and parliamentarian approval. delay can only diminish the prospect that these pledges will be fully met. some, mr. chairman, i that theto believe security agreement will be concluded, but i am seriously dismayed at the cost to the afghan people, that delay, that significant further delay will cause. thank you. >> thank you, ambassador. we'll go to mr. dumont next. >> chairman royce, members of the committee, thank you for the

opportunity to appear before you today to discuss the upcoming year of transition in afghanistan. --ore turning our attention >> move the mic a little closer. attentionturning our to the upcoming year, i would like to review the status of the security transition. afghans reached a decisive milestone unassumingly responsibility for security countrywide. milestone signaled the shift in the international security assistance force as primary mission from combat to training, advising and assisting the afghan security forces. are now successfully providing security for the people of afghanistan. fighting season was the first time that both clans and executed with the afghans wholly in the lead. capable anded to be resilient, conducting all combat operations across afghanistan while taking the majority of the casualties. they successfully

held the security gains in recent years and the insurgency failed to achieve its stated -- achieve his stated objective. an creasing lay maintain the gains made by a coalition of 49 nations. that is a significant accomplishment. the dod will focus on the key areas of support for a successful transition in afghanistan, continuation of the train, advise and assist mission, to develop the nsf into a sustainable force, and the drawdown and realignment of u.s. forces for a post-2014 train and assist mission. the mission will continue to emphasize developing nsf capabilities to conduct high level planning and execution operations. assistance will continue to be focused on organizing, training

and sustaining the nsf. this will include acquisition contracting, strategy and policy development, human resources, management, and financial and human resource management. he nsf can be a guerin tour for afghanistan, but not without progress toward developing a professional force. we will focus on improving accountability and increasing funding of the nsf. coalition forces are working with the afghans to finish up implementing automated systems that will increase accountability in the areas of pay, logistics, human resources and financial management. also focused on developing expertise necessary in the afghan security ministries to plan and budget

transactions to sustain the nsf. although the combat leadership shift demonstrates a first and foremost the capability and resolve of the afghan security forces to secure their nation, and enables the united states and other partners to reduce our forces. president obama announced in february 2013, the u.s. will reduce its force level to 34,000. they will do that by february 12, 2014. this will be maintained through the election. -- election period. this progression will enable effective assistance of coalition forces drawdown and allow for a smooth transition of the nsf to opt rate without reduced -- with reduced

coalition support. the nsf will exercise greater economy and leadership of security operations while having access to support as required and as available. while the process is underway, nato will bring the isaf mission to a close. the mission for u.s. forces in afghanistan is shifting to a continued counterterrorism mission against al qaeda and its affiliates. as the president has made clear, the united states must secure an agreement that protects u.s. troops and must have an invitation to fulfill the promise of the post-2014 partnership discussed at the 2012 chicago nato summit. we are prepared to sign in remote. concluding the bsa promptly would be an important signal to

the people of afghanistan, the taliban and and our allies. ofer more than decade dedication, our coalition partners and the afghan people, we have seen remarkable turnaround in afghanistan. greater economic opportunity, access to health care, education, and freedoms it and individual rights. thank you for continuing to -- int the mission in act afghanistan. i look forward to answering your questions. >> thank you. forhairman royce, thank you allowing me the opportunity to testify before you today. i have been working on and in afghanistan in both civilian and military role since 2002. in addition to having worked emergency -- n i have served as chief of staff in afghanistan. after the fall of the taliban, i saw firsthand and afghanistan

that have been devastated by decades of conflict. afghanistan improved its score in the index by more than 60%, more than any country. changes of this magnitude are not made overnight. especially in such a deeply traditional society. are significant, but fragile. in 2002, there were only 900,000 afghan children in school. virtually none of them were girls. today, there are nearly 8 million children in school and more than one third of them are girls. increasedtancy has from 42 years to over 62 years.

child mortality has decreased by almost 50%. of2002, only six percent afghans had access to electricity. today, the number is 18%. in 2000 two, there were very few fixed telephone lines and making a telephone call out of afghanistan required a satellite telephone. today, the combined phone networks in afghanistan cover 90% of the population and 85% of women in afghanistan have access to a cell phone. 3000 women-are over owned businesses and associations. 20% of afghans enrolled in higher education are now women. women are participants in the afghan political process. as we enter the transition period, the strategies are threefold. maintain and make durable the gains in health, education and the empowerment of women. second, mitigate the economic impact of the military drawdown and finally to foster improved stability by supporting legitimate and effective afghan

governments to include the 2014 elections. there's a high priority and ensuring taxpayer funds are used wisely. while many issues are unique to that country, monitoring projects in challenging environments is nothing that our agency does well around the world. in designing the monitoring strategy, we are incorporating lessons learned in places like colombia, pakistan, and south sudan. i will know that these programs have been reviewed in six separate inspector general reports as well as through reports by the government accountability office. audits provide oversight and discipline for our work and reinforce our efforts to ensure tax dollars are used effectively. there are over 100 audits going of usaid programs afghanistan. the bottom line is that usaid

will terminate programs if they see we are not producing development results. with regards to the elections, a transparent inclusive electoral process is essential for the government transition strategy and critical to afghan stability and democratic development. supportingocused on inclusive and democratic process by supporting afghan electoral authorities in building the capacity of stakeholders in afghanistan to present his -- to participate in a robust and informed way. we support domestic observers, symbols 90, media, local parties, helping them engage in the democratic process. we are supporting the participation of women in all asked x of the electoral process. we are promoting the hiring and training of female staff.

the ability ofg women candidates to campaign effectively. in conclusion, i have worked in afghanistan is a member of the department of defense, usaid, and the department of state. i have attended ramp ceremonies for the fallen heroes of all organizations. of thersonally aware enormous sacrifices made by americans to build a secure and stable afghanistan. we understand the need for constant vigilance, particularly during this transition. . we're looking for things that have the greatest potential for long-term success. -- navigates to the 2014 transition. period, we are looking to make sure the progress is made and maintained.

i look forward to your questions. >> thank you for your good work gentlemen on all of this. out, about the steps being taken concerning the , the reality is in 2000 nine, president karzai had in plaguedd in the fraud- election, and the concern many had is what is being done to certain we don't have a repeat. we already hear some of his commentary about possibly postponing an election. what steps are being taken to make certain that the international immunity -- has in place something that can stand up to his efforts

to try to manipulate the ?lection process for mar state and a idr working on this. who009, there was no doubt the winner was. even if you does allow -- disallow for all of the fraud, karzai was still 20 points ahead. memo the fact that he was willing to commit the fraud is what is concerning because when this is over, afghans have to have some level of confidence and they know what he tried to do last time. was preferred to say this time because the elections are more likely to be closer and is margin of the erie smaller than the marginal fraud. we are reasonably satisfied that the election preparations data is better than i was in 2009 or

2004. on -- taken into accordance with the legislation. it has been fully followed with reasonable adherence to its provisions. the electoral commission seems to have a strong leadership. they have made decisions which are broadly accepted by most of the candidates as fair. inner -- the international community, the united states in particular will follow this closely. i think larry can expand on that. not said karzai has anything today which would indicate a desire to postpone the look guest election. said isng that he has consistent with his desire to conclude this election on time. suspicion lot of based on earlier experiences. democracies, that kind

of suspicion, at the moment we have not seen any evidence -- about theto ask election monitors. that is one area we are playing a pretty important role. we want to make sure that all women have the ability to vote in the situation. that all afghans and young people have the ability to queue up and have their ballot cast. give us an update on that front. the u.s. is committing about $100 million to the election. about $55 million of that is

going into a basket fund to support the election. that provides technical assistance that will help conduct the elections in a way that is free and fair and independent as fraud. -- of fraud. the rest is going to be invested by laterally where we see need. and pollingors station monitors is one of those areas. another is civil society engagement, particularly with respect to women's interest groups. we are investing in technology that we do not have access or sophistication to have asked us to in the last election. smsoke yesterday about technology that women are using to collaborate and coordinate their approach to their candidates to make sure they are getting their issues on the platform to all the candidates. there are technological and technical assistance ways that we are investing our resources and supporting the elections. areas, there continue

to be areas that concern us. one of them is the axis of women to polling places. -- the access of women to polling places. of the problem and they're working to fix it. i cannot promise their solution having beenst, but engaged in there for 12 years, i am pleased to see they have an approach to how they are identifying these problems and pushing and addressing them. they're putting money where the problems are, their training women and their training women in polling laces. we will see a dramatic improvement in that regard. time is expired. i am going to go to ted deutch in florida. in a recent foreign affairs counterinsurgency strategies fail afghanistan. would you agree with the

assertion? if so, why didn't it work? >> i would not agree with that. is we looki say that at the gains that have been made to date in afghanistan since we arrived there. with the support of 48: should nations, as well as -- 48 tolition nations, it is early for anyone to claim the counterinsurgency effort has failed. they have adopted the training and tactics that have been provided to them and taught them. upy're police are stepping to the plate more and more each day. , they have-- frankly gotten confidence and skill that they have not had in the past. exceeding our

expectations and i believe that will continue for the future. failure, i it is a think it is wrong. constituents want us and the expresses clearly, one is to bring home every last u.s. soldier. everyone. when the department of defense residual force going forward, what factored you consider and what will the mission of those forces that might remain in afghanistan after 2014 b and finally to the extent you wish to comment, how would you respond to so many americans who just simply position -- think that it is time to bring everyone home? position ofand the the american people and i served in combat myself on three occasions, including a year in afghanistan. i understand the concerns.

our top priority is to prevent the return of al qaeda and any affiliate terrorist group second launch attacks from afghanistan. that is our first and foremost priority. i can assure you the american military understands that. as far as what the mission well andfter 2014, given a bsa invitation to remain in afghanistan by the afghan people is a train, advise and assist mission to assist in further developing and advancing their skills and their capabilities into the future so they can assist with providing their own security and ensure regional stability. country, aerging merging military force or police force, they will require training assistance and support

generally as we provide with many other nations. ar mission after 2014 will be train, advise and assist mission, along with coalition partners who will and have offered to remain there. ambassador dobbins said, bsa will be critical to that and the afghans are fully aware of that. >> thank you. dobbins, esther sampler, if there were to be a negotiated settlement with the taliban on, do you think the taliban would accept the revisions of the constitution and if so, would that be sufficient? >> we have laid down three conditions for successful negotiation with the taliban and. afghancept the constitution, lay down their arms, and break ties from al qaeda. we would require all three of those. i don't see early breakthroughs in the negotiations. i am not sure that will even be negotiating in the next few months. we have made efforts in the

past. we were consistent in support of a reconciliation process but it takes two to tango. frankly, it is the afghans who have to negotiate peace. predict early advances in this sphere. i would hope that there will be at least some procedural steps, but i cannot promise that. over the longer term, we believe reconciliation is the only way the war is going to and. the quicker you star, the faster you will get there, even if it will be a multiyear process. >> thank you. i yield back. .> we go to ileana ros-lehtinen >> as i mentioned when we met , and ourident karzai delegation, we raise the concerns about his neighbor, the and the threat

that it poses to our interest in the reason -- region. he dismissed the threat that iran poses no problem at all. but pakistan, that is the real threat to stability for afghanistan. surprisen't come as a that this past weekend, karzai rouhani,eader of iran, announced an agreement of a long-term strategic pact that ranges from political cooperation to economic and security partnerships, once again undermining and jeopardizing the u.s.- afghanistan relationship. what is karzai's calculus here? is he trying to hedge his bets by cozying up to a ran --iran. afghanistan and during our hearing, i expressed my concerns about the status of the counter narcotics operations in

the post-drawdown afghanistan and we have been talking about that this morning. we were told that due to lack of --sonnel, these counter not narcotics operations would be limited. the latest numbers indicate that this was a record year for poppy cultivation in afghanistan. this issue is not getting the attention it deserves considering that terrorist activities are typically funded through narcotics. if we can conduct the kind of operations needed to reduce the we don'tduction and if have enough manpower now to fight the issue, what are we going to do next year and post 2014 to stop the illicit drug trade that generates over $100 million a year for terrorist groups question mark i been concerned that we are allowing the post-2014 residual force size to be decided politically and that is purely numbers

driven rather than focused on the task and what is needed, what is the mission that still needs to be accomplished in afghanistan. you testified that a significant, cement is the afghans have been increasingly able to maintain the gains made by our u.s. and coalition forces. although that may be true now, what about in the post- withdrawal afghanistan when they will not have a robust international force in support, or possibly with no u.s. presence at all if the president goes with the zero option when the extremist no longer css -- see us as an impediment to their goals and come to -- against the afghanistan forces in full force. will they be able to sustain those gains? what will happen? do you predict the white house in coordination with the state department, when do you think that we will get that troop level number from the white

house and the state department? i will leave it open to all of you. thank you. , they have provided arms and money to the taliban. it has provided a great deal more money to the afghan government. most programs are quite benign. has, in general, a bad relationship with the taliban and. it almost went to war with them before we did. it is hedging its bets. it is hedging it largely as part of the competition with united states rather than because it has an inherent positive interest in the taliban and. iran once orsited twice a year since he became president. i don't attach a special importance to this particular visit.

they haven't negotiated an agreement. they have simply announced and attention -- and attention. >> thank you, sir. >> i would say, first and foremost, we do continue working with afghan counter narcotics police. they have made significant strides in enhancing case management and prosecutions, including the ability to develop trials,, rests, conduct and imprison those convicted. determinationte a to uphold the rule of law and are increasingly resistant to the influence of corruption. reasons for this, besides the training and assistance they get, they know the eyes of the contributing nations are on them and they understand that it is important upon them an incumbent upon them to make changes. are making achievements in

that regard. we work with them, also on developing good practices for sharing intelligence policies -- intelligence with the police forces so they can get at their narcotics trade and make strides. it is a work in progress and it will require them to assume some of the responsibility and ownership themselves, based on some of the good practices and training that they have received from us and other coalition nations. as far as the nsf continuing to uphold the security gains that have been made in the future, the groundwork is therefore the gains that they have made. >> thank you. >> both as an institution and as a force. >> thank you so much. sorry. out of time. >> we go now to mr. joseph kennedy from massachusetts. >> thank you, mr. chairman. thank you for your service. i was fortunate to visit afghanistan several months ago

and had and then -- had an extraordinary visit. thank you for all that you do for our country. i wanted to speak first to special representative dobbins. bit of oned focus a program that has come up in a number of meetings that i've had and some constituents were concerned about -- contractors and translators. those who have performed an extra ordinary service to our military and civilian courts in and are nowhanistan subject to death threats for their work with us. these are programs that have run into fairly severe challenges. 2008 and eaa, congress created visas for iraqis that work for the government for at least a year.

created underere the afghan allies protection act of 2009. you can give me an -- can you give me an outline to the best that you can, how many afghans are eligible for that program, how many have been processed to date, what that timeline is and , thethe backlog might the causes of the backlog and what we can do to try to help? i believe that we were slow in getting this process into gear. and for the first several years, the number of applicants who successfully completed the process was fairly low. over the last year, however, this has significantly accelerated. in fact, the last year we had 10 times more successful completions than any previous year. in fact, we are now approaching me legislative limit in the

numbers available and we are looking forward to working with congress to extend our authority to bring in additional people. now and how many more -- >> i think about 1600 have been approved over the last year if i remember the figures record. >> how many more of these would you be asking for help for congress? >> i'm not sure. i don't have the figures. addition to the total number, i believe there is an annual number and i believe that runs out in march or april and we will need to work with congress to get that extended because there will be additional people in the pipeline who would qualify. >> thank you very much. i wanted to build a little bit off of the chairman's comments. in afghanistan, the poppy cultivation was a point made over and over

again. i wanted to see if you could outline any details given to enforcement strategy or mechanism to try to get that trade under control. an interagency task force and coordination center that provides intelligence support, training, and assistance to the counter narcotics police. enable the afghans to narcotics traffickers and connections with insurgent groups. they go after the movements, communications, and financing involved in groups involved in the drug trade. to provideso working support for investigations and for military operations that identify people who are involved in the drug trade, getting at their financing, getting at their cultivation, getting at their mold -- movements, eating

at the delivery of those illicit drugs. >> thank you sir. sorry to cut you off. if i could, there is a piece of this which is an economic issue for the cultivation of the poppy for farmers that are choosing to cultivate poppy. falls under the usaid auspices. can you give a brief outline of the strategy and how you see it going? -- iaq -- appreciate you appreciate you recognize that. usaid and the international donors are working to create value change for value crops that are as operable or more profitable than poppy. poppy is a very resilient crop. it does well in afghanistan. furthermore, traffickers do the heavy lifter for the growers. valuewe can get the

changed for saffron, fruits, nuts, this is going to be difficult and challenging environment for us. >> thank you, mr. kennedy. we want to recognize and thank trip of theirra's in terms of the oversight of this committee and also the troops in afghanistan. we also want to recognize joe wilson for his trip there and his son's service in afghanistan. mr. wilson, it is your time. >> thank you, mr. chairman, for your interest in the security of afghanistan, american security, even prior to 9/11. people need to understand and i want to thank each of you for the difference you are making. it originated out of caves in afghanistan. we should never forget that. that is why am grateful for our military service. seene had the opportunity,

the progress that has occurred. i have been there 12 times. my national guard unit, former unit, they served their and led by general houston. deployment ofgest troops from south carolina since 1600. they developed a great affinity for their afghan brothers. i appreciate the chairman referencing my youngest son. last thursday from his service this year in afghanistan. so as i talk about military service, it is quite personal. we are proud of the one 22nd engineer battalion army national guard for their service. i was glad to see representative kennedy raise the issue of the special immigrant visas. iraq.ad two son served in theirorked on bringing interpreters back to the united

states for opportunity, for security. i am grateful i have had a nephew in the air force, he served twice in a rock. raq.n i i understand how important the interpreters are. i want to work with you and specifically hope we will find an extension agreement or proposal as soon as possible. i am also concerned about irania n weapons in afghanistan. in august 2010, the treasury department sanctioned two iranian officers for supplying funds and material to afghan terrorist. that was one example of iran playing an active role in fueling the conflict in afghanistan. what is the role that -- that iran is playing, supporting the afghan terrorist?

supportups does iran and why? >> as i said a little earlier, ron supports both the government and the taliban and. -- it's dominant support is to the government and largely benign aid programs, roads, and other things. and armsovided money to the telethon. the arms and money flow across the pakistani border are much more important than across the iranian border. they're playing both sides of the house. not that of a love for the taliban and, they are doing it as part of competition with united states. it is an effort to demonstrate they can play tough if we got into a military conflict with them. and are hedging their bets it is quite unhelpful but not be approach toiran's afghanistan.

beenthis exception, it has coincidence with our own. they were helpful in 2001, and as i have said, they have had a largely a nine aid program for afghanistan. memo you give real meaning to diplomacy. trying to keep an even balance on these issues, i want to thank you for your service. i am concerned about iran's sanction violations that in january was determined by the special inspector general for afghan read -- afghanistan reconstruction that there had been purchase of fuel for afghan forces in violation of the sanctions here it has that been stopped? what can be done to make sure that the sanctions stay in place >> i'm notrk familiar with the case. i assume this is a dod purchasing issue. i cannot give you a quick answer.

>> i'm sorry, mr. wilson. i don't have that information either. i would have to take that back and get your response. >> that is very important. we have seen success of the sanctions bringing pressure on the irani and regime. particular, that in the sanctions have the potential of encouraging a green revolution. the young people overran -- of iran deserve to have a better life than what they have now. the sanctions have multiple purposes. one is to truly assist a positive change in iran. thank you. anglego now to mr. eliot of new york. -- engle of new york. you, mr. chairman. let me thank our witnesses. for being here.

the three of you have what i consider to be some of the most complex and thankless jobs in the u.s. government and all of us appreciate your service. i share the frustration of my colleagues about the games that president karzai has been playing. he ought to sign the bsa and stop the nonsense. i just wanted to say that. ask ambassador dobbins, much of the resource planning is happening in the field, but i howd like to know what washington is doing similar planning. what is the timeline in which the afghanistan and pakistan offices are going to return to centralau of south and asian affairs and asian bureau and how our state and a id planning to address the new resource environment that will occur with these transitions?

>> i would not say at this point we have a firm plan. there is an intention to look at the current bureaucratic arrangement and the state department in light of the transition at the end of 2014. i think even then, afghanistan is likely to remain a difficult enough and important enough to the united states that you're going to want more than just a desk officer handling it. there could probably be a closer association with the bureau south and central asian affairs. we would probably move to some such arrangement. i think the actual transition is not very complex to make. it is simply changing lines on an organization chart. it is not as if people are going to have to be fired or rooted.

-- were recruited. the fact that we have made a haven't made the decision does not mean we will not be able to make a timely decision. >> the only thing i would add, i think the bureaucratic changes will be driven by the effects we want to achieve any agency. my two missions are the largest omissions that the agency has in the world. even if we were folded back into the bureau, it would have to receive particular and you ask what we do here in washington to help their field team work on the resource allegation -- allocation. the single biggest thing we add an awful lot of valuable input and refining of ideas by engaging washington and in the field in that regard. but thank you.

a key element of the economic transition in afghanistan is regional trade, and a key barrier to getting afghan goods to market is the barrier that exists between pakistan and india. that india provided pakistan with most-favored- nation trading status in 1996. could you provide an update on where the pakistani announcement of giving india trade status as a morestands and general vision of the role that the region can have in stabilizing afghanistan? >> we have races with the government of pakistan on several occasions, and indeed, the governor -- government of india. it came up while prime minister sharif was here in washington during a visit month ago. the pakistanis have indicated india.ntent is to grant

they didn't say so but i think they may be waiting until a new indian government takes office. they probably want to do this in the part of a context of other improvements in the relationship. the pakistanis government under the new prime minister has reached out and tried to improve that relationship. the indians for good historical reasons are approaching this very cautiously. they take the prime minister's they believe that the prime minister is acting in good faith, but they are skeptical he can deliver on some of the things that they need if the relationship is going to progress. m.f.n. for india would be a positive step. and indeed a general opening of the border more commerce would also be very helpful to afghanistan as you indicated. for all those reasons we continue to support it. >> thank you. we go now to mr. jeff duncan of south carolina. >> thank you. i would like to take a few

minutes to point out some of the taxpayer dollars that have been sent to afghanistan and spent almost wastefully. i would like to put an article from bloomberg news in the record about planes park in the weeds after $486 million were spent. these are g-22 aircraft some of which are sitting in the weeds not being used. those are taxpayer dollars spent to purchase those. we also spent somewhere between $25 million and $36 million on a 64,000 square foot unoccupied building in camp leatherneck, which may of 2010 the commanding general, general mills, recommended cancellation of the construction. that was overridden by his superiors. then in may of 2013, the building is still sitting not used. the army regulation 15-6 investigation said we ought to convert that building to a gym

and spend more money converting it to a movie theater. that was overridden. the building is still sitting unoccupied. thank goodness we didn't spend more money. $230 million in spare parts in an inventory warehouse. there was no good inventory or accountability for those spare parts. these are vehicle parts. an additional $138 million in spare parts were ordered just in october of 2013. i want to commend the work of congressman jason chaffetz of the oversight committee who's been working with the special investigator of afghan reconstruction. he's identified dual usage and -- fuel usage and waste and theft in afghanistan. he talked about the expenses of the hospital in kabul where u.s. tax dollars have been wastefully spent. we could go into the bank of kabul fiasco and allocation of dollars there, but infrastructure projects that are all over afghanistan, and there is no oversight. these are around areas that are inaccessible to civilian employees. i would like to point out, i know the panelists are aware of

this, but this is the afghan oversight access in 2009. the shaded areas are areas that civilian contractors or u.s. employees have access to in 2009. to do oversight. on u.s. taxpayer dollars being spent. if i flip over to the projected 2014 oversight areas, you'll notice a stark contrast. i know it's difficult to see but these gentlemen are aware of this, there are just little dots there. these are areas that u.s. inspectors do not have access to for oversight. these are u.s. taxpayer dollars. how much money are we going to continue to spend in afghanistan without proper oversight? that's what it's about. i don't have any questions. i could go through a lot of other examples. i think the american taxpayers that are watching understand their tax dollars are being spent without a lot of oversight

on the part of their government. i'd like to shift gears to ambassador dobbins, i'm interested in the special immigrant visa program and the delays going on there, because congress has recognized the unique dangers faced by iraqi and afghan civilians who work on behalf of the u.s. government by creating programs for these individuals become permanent residents here in the u.s. i have had an example of a gentleman i met in the kandahar the -- yes, the kandahar region of afghanistan about two years ago. he was embedded with the military there and acted as a translator. had taken up weapons to help defend the colleagues of the unit he was working with. and he was definitely threatened by the taliban. his uncle was killed. other family members were threatened. and went through a two-year process where officers from the unit he was embedded with, other

folks that knew this gentleman vouched for his service to america there in afghanistan, but yet it took over two years. he was actually issued a visa by the state department, and then it was revoked right before he left. and had to go through months of trying to understand why it was revoked. then it was reissued. i think it was reissued only after congress got involved questioning why. i ask why have there been so many delays in the after began s.i.v.'s. s.i.v.'s?ghan >> i think we were slow in the early years to implement this program. over the last year, however, it's accelerated significantly. i think there were 10 times more visas issued this year than a year ago. and in fact we are approaching the limit of the program. we'll run out of numbers shortly and will want to work with congress for an extension of the program since there will be additional people who will qualify if we have additional numbers.

on specific cases, i mean we have determined that they did work for the u.s. military. we have to determine that they are under threat. that depends in part where they live. and there are other security related concerns. i can't explain any particular case. i know the case that you're referring to, and within i think two or three weeks, maybe even less, of the visa denial it was then reissued as you indicated. >> i appreciate the assistance on that and got the gentleman here. mr. chairman, i did want to put this in the record. >> without objection. we go to mr. berra of california. >> thank you, mr. chairman. thank you to the witnesses. as has been mentioned previously, i had the opportunity over memorial day to visit afghanistan with congresswoman ros-lehtinen, as well as my colleague, mr. kennedy. when we were there we met some of the most remarkable young men and women in our troops. i do want to praise our troops for meeting every mission and for the wonderful job that they

have done. we also have the opportunity to meet with mr. karzai. in that meeting, this is back in may, he unequivocally express add desire to get a p.s.a. done fairly quickly, and at the same time unequivocally said, he has no desire to stand for election again and wanted to see the elections coming up in 2014 take place without any interference. given that many, and now mr. karzai is backtracking, i would make the observation that this is -- he happens to be who we have to negotiate with, but he's not someone i would call an honest broker. an easy one to negotiate with. i also had the opportunity to visit india and chat with our allies in india who have made significant investments in afghanistan. over $2 billion investments in infrastructure and others also

have had the opportunity to meet with business groups like c.i.i. and major indian multinationals that are interested in making investments and helping fill the void that will occur regardless of whether there is a p.s.a. or not as we start to draw down our own investments ever their major -- our own investments. their major concern is the security situation there. in addition, as i met with the indian government, indian dignitaries, there's also a very dignitaries, there's also a very real concerned that hardened trained jihadi fighters will start shifting over to the indian-pakistan border which we are already seeing flare ups and increasing instance. given that, maybe this is a question for ambassador dobbins what, can we do, working with

india, to, one, continue to maintain an economic structure in afghanistan? again i do worry about as we draw down significant economic resources, as well as working with india on the indian- pakistan border as some these fighters shift over. i'm not sure pakistan has control over these fighters, either. ambassador, your perspective? >> well, we do work closely with india on afghan issues. i met with the indian foreign secretary yesterday on this, for instance. president karzai is visiting india later this week. and for a state visit, in fact. india has a significant aid program and significant investments, to the extent probably the greatest contribution india could make, and pakistan can make in afghanistan, is improving their bilateral relationship. improved relationships between india and pakistan will have two effects on afghanistan.

one effect is it will greatly increase the access of afghan trade to india via pakistan. but secondly and equally important, it will reduce the competition between the two countries for influence in afghanistan in a way that's often proved highly destabilizing. we have been encouraging both afghanistan -- sorry, both pakistan and india to overcome their differences in kashmir, their differences over afghanistan. and i think there is some hope with the new pakistani government. of course the indians have elections shortly. but it's an area that we are continuing to press. i don't think that there's any near-term danger of foreign fighters shifting from afghanistan to the border with india, among other things, because unfortunately the war in afghanistan isn't over.

but the indian concerns are legitimate. and it's something that we do need to be careful about. >> do you sense in your conversation was the pakistani government -- sense the indian government certainly does want to see improved relationships with pakistan as a mechanism of stabilizing south asia as well. do you sense that same desire from the pakistani side? >> i do, and i think the indians do in regards to the new prime minister and his civilian leadership. in pakistan, traditionally the security sphere has been left largely to the military and they have been largely free of civilian oversight or control. the last time that type of control was exercised he was overthrown. he has to be careful how quickly he moves to assert the civilian control of the military and stronger civilian role in designing and implementing

pakistan's national security policy. i think the indians -- he has expressed himself very clearly that pakistan can't be secure unless afghanistan is at peace and relations with india are improved. he's tried to move in both directions. i think the indian government takes him at face value and believes he's sincere. they are a little skeptical that he will prevail in exercising enough influence over the pakistani military. and we'll just have to wait and see. but we give him a fair chance of being able to do so. among other things because the pakistani military now realized that their biggest threat is internal and they realize that they need the political leadership to take responsibility for the kinds of sometimes harsh measures that will be needed to deal with that internal threat. >> thank you. >> we now go to adam kinzinger.

of illinois, who served as an air force pilot in afghanistan and also served in special operations. >> thank you for being here and appreciate your service. as the chairman mentioned in his opening remarks, i just came back from afghanistan. afghanistan and pakistan. pakistan is quite a complicated relationship and one that i expect will probably continue to be complicated. ambassador, as you alluded to i believe and i hope that the pakistanis are starting to understand the taliban is their problem, too. and it's no longer a tool they can use to posture against india or whatever went into that whole calculus there. the point i want to make from this, the people of afghanistan, there is message that has not gotten out to the united states. the people of afghanistan are good people. the people of afghanistan want to live in freedom. the taliban's approval rating in afghanistan is something like

10%. slightly higher than congress, but it's still about 10%. which means the taliban are not popular in afghanistan. this is a message i don't think has gotten out. karzai, and in karzai's posturing to do whatever it is he calculates he wants to do, we met with him as well, and i got a very different view coming out of the meeting one on one with karzai and what i see in the media. i see a man who says we want the united states to be here. we want a long-term relationship for whatever domestic consumption he thinks he's doing, he's doing more harm than i think he realizes. but they are good folks. i'm hoping we learned our lessons from the complete withdrawal from iraq, which was a terrible mistake, and i think is being shown all over the world as a terrible mistake. i hope we continue to press ahead with getting this b.s.a. done and having a long-term commitment. couple quick points i want to make. as i mentioned the americans don't seat success in -- don't see the success in

afghanistan. i think americans still think there's 150,000 troops marching up and down the hill, engaging in the taliban, and we are taking the brunt of the casualties. the afghan military is losing about 100 soldiers a week. they are taking the fight to the taliban when they find themselves engaged. they don't have the air support that american military has, but they are fighting very bravely. it's a completely different situation than what we saw even two years ago. secondly, so that's what americans think. my concern, i want to put this on the record, i can't think the last time i saw the president of the united states tell the american people why we are in afghanistan. i can't do that. i believe we are in afghanistan for a good reason. i believe us remaining engaged in afghanistan post-2014 is important. i can't remember the last time i heard the president say that. the president recently, fairly recently, went to afghanistan and did not meet with president karzai. i thought that was an oversight. so there's things along that line. let me get to my questions. we are looking the a residual force, 9,000 to 10,000 american troops and a few more nato

troops in that process. what was general allen's recommendation in terms of a residual force? mr. dumont, maybe you can answer that, whoever. >> i'm sorry, congressman. i don't have that number off the top of my head. >> do any of you know what general allen recommended? i believe it was somewhere around 15,000 to 20,000 american troops post-2014? i say that to say i'm concerned that we are going to undershoot the amount of troops we have available in afghanistan to do both counterterrorism and support. both in building the afghan establishment and government, and also in supporting their troops engaged in the field. i think it would be very unfortunate for 20 years from now for us to read the history books and say that america was 5,000 troops short of being successful in afghanistan we -- in afghanistan. we visited the prison in afghanistan, and we visited -- i think right now 59 t.c.n.s in prison.

mr. ambassador, do you have any idea what, are we going to do with these t.c.n.s? the afghans don't want them. i wouldn't, either. now we have to figure out what are we going to do with them as we reach the post-2014. are any of you familiar with that situation and have any ideas for what we do? >> in general we are going to have to do something with them by the end of 2014. some of them will be turned over to the afghan. some will be returned to the country of origin when those countries undertake to deal with them appropriately. >> let me ask one more question because my time is running out. now we are into this kind of reduction posture. i think the vast majority of american forces are now focused on withdraw instead of taking the fight the enemy. that's unfortunate. how do you think the offensive went against hakani? do you believe it was completed or do you believe we are leaving too quickly to finish that fight? mr. sampler, start with you?

>> i thank you. i really don't have an opinion on the network. i have worked in afghanistan since 2002. they have been there decades before that. i don't have any opinion on -- >> they were gone, though, -- it would be nice if they were gone, though, wouldn't it? >> it would. >> mr. dumont? do you have any thoughts? >> it is something, obviously, we take seriously and we follow closely and fight against each day. it is something we remain focused on because it is serious to us. the afghans understand that as well. >> thank you for being here, mr. chairman. i yield back. >> thank you. we go now to ms. gabbard of hawaii. who served as an army officer in a rack. >> thank you for being here and -- in iraq.

>> thank you for being here and thanks for your hard work and service, each of you. as we have seen different opinions and different perspectives here today through the committee on the issues in afghanistan. i think these conversations reflect the conversations that we hear when we go back to our districts, we hear in the public about why there is an overwhelming public sentiment to bring all of our troops home is that there seems to be a lack of a clear definition on what our mission is. what is the end state that our troops are trying to accomplish or that we are trying to accomplish there? who is the enemy that threatens the united states in afghanistan? that our troops are fighting against. and when we say we need to accomplish the mission, what does that even mean? what does that look like? when we look back to why we went there in the first place, osama bin laden is no longer a threat. al qaeda has largely been decimated in afghanistan. we see now, of course, pockets and threats coming from other countries and other regions. from these terrorist networks. and we have also seen that because al qaeda has no allegiance to a specific flag or country, our best and most

efficient way to deal with this threat is through. -- is through some of the quick strike force that is we have successfully used in the past with some of these areas. when we look at stability, people talk often about stability in afghanistan as being an end state. we have given many tools, training, infrastructure to the afghan people. the afghan forces. in order to attain this end state, but we also talk about the corruption. the other challenges that exist within the country, the tribal influences which really lead us to understanding that this stability at the end can only be achieved by the afghan people. i've got three questions that follow kind of this structure. first is, with the bilateral security agreement, what are the next steps at this point given what karzai has said and his posturing in not looking at this until after the afghan elections? and how long do we wait for him to make up his mind on what he

wants to do? if eventually the bilateral security agreement is completed and agreed to, the remaining forces that are being projected to stay in afghanistan are -- i have two missions or two purposes from what i have seen and that is to train and assist, and also counterterrorism element. i'm wondering what percentage of that projected -- how those troops are broken up between those two missions? and lastly, with that contingent that is left in afghanistan, i think the d.s.a. has kind after 10-year timeline. has a 10 the b.s.a. year timeline. what is the timeline for our u.s. presence there in afghanistan? is it a timeline? if it's not a timeline is it an end state we are trying to achieve and say once this is achieved then there will be no presence?

ambassador dobbins, if you could start on the b.s.a. and mr. dumont talk a little bit about our forces there. >> well, we are there to prevent afghanistan from again becoming a country with a government that supports al qaeda and allows it free reign within that country. something the taliban did and which they would do again if they came back to power. we believe that concluding the b.s.a. as soon as possible is necessary to sustain the large broad 70-nation coalition that supports afghanistan. we believe it will begin to fragment. we believe the afghan people will become increasingly anxious the longer this goes on. but we haven't at this point set a date beyond which we are no longer prepared to wait. we simply believe there is a big cost in waiting, and it's a cost going to be paid for by the afghan people. i'll let mr. dumont comment on the relationship between the

train and assist and c.t. elements. in terms of the timeline the assumption is this is going to be a declining presence over time. whatever decision is made for 2015 will be again reviewed in the course of 2015 with the hope that the number can be reduced in 2016, etc. the objective over time is an afghanistan that's capable of securing its territory and population without more than the normal level of external assistance that countries at that level of development receive around the world. >> thank you. mr. dumont, quickly. >> as you know the train advise and assist nato mission is to assist the afghans to become capable force, reliable c.t. partners so we don't have to do the c.t. that will take place over time. it will be a combined effort for some time i imagine. the percentage of who will do what i don't believe has been worked out yet. it will remain to be seen how quickly the afghans can assume more control for the c.t. fight in their own country and how

much assistance support they'll require from donor nations. >> thank you, mr. chairman. >> thank you. we go now to mr. -- we go now to the gentleman from florida. >> i want to build on some of the statements made identify by -- made by my colleague from hawaii and mr. duncan in regards of the money being spent, how much money we spend. were you talking about $100 million for election, and another $45 million for equipment for elections. with what gabbard was saying. what is the end game? they'll have a stable government? one that's not wrought with fraud, waste, and abuse? and that will run a country we can be good allies with and trading partners? mr. sampler, if you would. define the end game. what are we looking to gain for success? what would you say that is? >> there's two questions.

the larger end game i'll yield to ambassador dobbins for, that's a policy question. with respect to $100 million on elections, of which 45 is a bilateral part. what we are hoping for is an election the afghans are happy with. i get asked the question often what, we doing in afghanistan in -- what are we doing in afghanistan? and the answer i use is nigh own. it's not government policy, but it's a secure, stable, and democratic afghanistan that governs its population justly and secures its geographic space. >> how much effective is that ansf right now? are they more effective? are they standing up? do they own the security and the -- it's like they are fighting they know it's their responsibility? >> yes, sir, they do. we have transitioned security to them. they are in the lead. they are taking the majority of the casualties. and i venture to say close to 90% of the operations the military is conducting are

afghan-led, afghan-conducted, afghan-planned. some other unilateral c.t. missions we do is also in conjunction with them. they do have a press he on it. -- a presence on it. they are involved in the planning. they are doing the majority of the fighting and taking the majority of the casualties. >> how much of that is based on us being there and our presence there? >> to get them to the point that they are at it's been a long- term effort, obviously. now we are providing -- depending on the level of the unit, for instance, there are counterterrorism forces, we provide little assistance. we have a presence there but they are skilled, they are capable, and they are take the fight to the insurgent threat. the conventional forces are making strides every day and making great progress. we do have an advising mission with them, but they are in the lead. >> ok. are we looking at some point of being able to pull out of afghanistan? is this going to be another permanent u.s. military base around the world that we have?

>> i don't envision a permanent presence as you speak about. i think what will depend on is how well progress is made. how well stability in afghanistan is in effect over time and how well regional stability is in effect also. i think it will be a long-term focused effort that will take review over a period of time to assess how well things are progressing and what the enduring threat is to the united states, if any. >> going back to you, mr. sampler, you're saying the infrastructure is built up and a lot more women are voting, a lot more women are in colleges and school. that's a good thing. is that going to be sustainable without our presence there? is that something they believe in philosophically? or is that just an ideological feeling, an ideal of ours that we are instilling upon them in a muslim country? that they won't maintain after we leave?

>> congressman, that's a great question. it's not an issue of islam. it's more an issue of afghan society. it is something that they are adapting as their own. that's the only way we'll be resilient is if they make it their own philosophy. >> without our presence. >> without our presence. the afghans appreciate what we have done for them. but the afghans themselves want to reach a point where they are self-sufficient and self- sustaining. not all afghans see it this way yet. that's the progress we are making. >> we have talked about the poppy fields. how we need to change the farmers and the whole production mechanism so there is a more profitable crop and get away from $100 million in poppies. yet we are giving $100 million for elections. we have talked about that for 25, 30 years. it goes back to 1992, even before that. that's just a way of life. is that realistic that we can change that without just changing the whole dynamics over there as far as the government and structure and all that? and western ideologies?

>> congressman, i hate to speak in generalities, most afghan farmers don't choose because they want to. they would rather grow food it's just not profitable or sustainable. our job at usaid is to make possible for them to make laving -- to make a living off noncriminal activities. >> thank you. >> we now go to lois frankel of florida, representative frankel's son served in afghanistan and iraq. >> thank you, mr. chairman. i did have the privilege of visiting our troops in afghanistan. our folks from usaid with mr. wilson. i'm glad his son has returned home safely. as has mine. my son also served in usaid. he went back after the marines, he went back to afghanistan. so i thank you-all for your service. i'm grateful for his service and everybody's service. i still have to say that i remain skeptical of the money we are spending there and the waste and the fraud and all that.

but with that said i do have a number of questions. first of all you talk about education and it's heartening to hear about the advancement in education. but specifically i'd like to -- there is a saying -- i don't know who i'm quoting. a great teacher under a tree is better than an ignorant one in a new american built school. my first question is, what are the metrics we are using in terms to assess whether there is success? is it -- are there test scores? is it secular courses? is there any anti-west propaganda being taught? what's the metric used? if the agreement is reached and we do stay there, do you feel that you have a good understanding among all the

agencies which groups are significant threats to the united states and which have goals that are only local? and in terms of the various programs, are we going to see the state department lead on diplomacy, usaid on development, i.c.m. intelligence, or will the military continue to drive those lanes? those are my basic questions. if you have time i'd like to hear also the answer, again, from some of the others i think ambassador dobbins did answer why we should stay. i'd like to hear the other gentlemen's response to that. >> on the education we can measure outputs or outcomes. i'm a proponent of measuring desirable outcomes one of the most positive things in afghanistan in recent years is the figure i cited in my

testimony of afghans entering higher education 20% are women. that would be unthinkable a decade ago. because there were no women who had primary or secondary. they won't be rolled back to burkas or back corner of a compound. in temples outcomes, that's one -- in terms of outcomes, that's of the metrics. one >> what are they learning? do you know when they get through the system what they have learned? >> afghanistan has entrance examines for their universities. i'm not familiar with what they are. i am told by others that they are comparable to other universities in the region. i can get more information. >> let me add one point, twice as many afghans can read and write today as could 10 years ago. that number will go up to three times as many 10 years from now if the kids in school now stay in school. at a basic level literacy is the outcome. >> your other question in terms of western -- anti-western bias in their education. usaid did a $27 million contract

with the ministry of education to purchase textbooks. we did have the right to fuse it. they were afghan textbooks, they designed the curriculum. we didn't interfere with that. we were satisfied it was not prejudicial to the united states or the west. >> want to say something about why we're there? >> i appreciate the question of why we are there. i think this is something all of the foreign service officers have to deal with. why am i leaving my family and going to do this? aim struck given my military time we can do this right or do it again. our hope is that we will be able to create and support a secure, stable, and democratic afghanistan that governs its population justly and secures its geographical space. i use that quite often with the foreign service officers out and -- going out and it captures most of the reasons i think we are there. >> ma'am, with respect to the groups we know are a threat to the u.s. and one that is are local, while we have those identified, there is no

guarantee that the ones who are focused on local activities will not merge and compile resources and personnel to attack ourselves or other coalition nations. that is of concern because some of these groups affiliate they have far-reaching effect than ever intended. >> what about driving the various programs? can somebody answer that? >> i think to be fair i think that there is a division of labor between defense, state, a.i.d., and the intelligence community at the moment that's pretty clear. the collaboration, i have been in every administration since lyndon johnson's. i think the collaboration among agencies is pretty straightforward and amicable. as good as any administration i have seen. i don't see d.o.d. rolling over the other agencies. i think they are on the diplomatic side, there is quite a differential to the state

-- they are quite deferential to the state department and we are to them on the military operations side. >> thank you, mr. chair. >> thank you. we go now to mr. dana rohrabacher of california. >> thank you, mr. chairman. don't know where to begin here. how much are we spending annually in afghanistan now? how much is it costing the american taxpayer? anybody know? >> each of us have somewhat different budgets. >> nobody knows the total budget what we are spending in afghanistan? it's a hearing on afghanistan. can i have an estimate? >> i'm sorry, congressman. >> i'll just have to say it's disheartening to have a briefing from our government people who are involved in a project and

they can't tell me what -- how much we are spending annually. how many killed and wounded have we suffered in the last 12 months? mr. dumont, would you know that? >> sir, do i not. i'll have to get back to you. >> we don't know what the cost is and we don't even know how many killed and wounded there are and we are supposed to believe that you fellows have a plan that's going to end up in a positive way in afghanistan? holy cow. >> we do know that the number of afghan soldiers and police killed is 30 times -- >> i have to tell you something. i'm only interested in knowing how many americans have been killed because the afghans have been killing themselves for centuries. and my father fought in korea, and i remember when he told me, he said, dana, all of our -- these young men who are with me fighting in korea, they would never have believed that we would be there after 50 years. not one of those guys who went to korea to stop the communist

takeover would have believed that this meant that we would have been committed for 50 years. we don't know how many are killed and wounded. we don't know what the cost s -- what the cost is. what will be the cost, you're presenting a plan now, what will be the cost to the united states per year annually after your plan is applied to afghanistan if they accept it? >> we haven't defined force levels there. i think the rough figure is probably about $1 million per soldier. >> how many soldiers are we asking them, pleading with them to let us send our boys into harm's way? how much -- how many soldiers is the plan to continue with our presence? >> the president hasn't made that decision yet. >> is there a proposal to karzai on that? >> no. >> i heard the number 14,000.

is that out of the ballpark? >> if you were talking about a u.s.nato everybody together figure, that would still probably be somewhat high. karzai in fact has expressed no interest in the size of the residual presence. >> yesterday the secretary of state was here and he was telling me everything's -- what we can't do to make the mullahs mad. he wasn't putting it that way. i suggested there was a groveling going on. i think we are groveling again. maybe this is the grovel administration. we are groveling to karzai. i know karzai. i have known him for 20 years. and to suggest -- his family, we all know what his family's done. they have become filthy rich. and we are dealing with a group there now centered around the

karzai clique. drug dealing, skimming of usaid, cronyism at its worst. and we are dealing with pakistan in order to make sure we have a presence there, meaning in afghanistan, and the pakistanis are doing what? we know the pakistanis are behind the i.s.i., who they are financing. we know that they spent money that we end up getting from us to kill american soldiers. this is insanity. then we have people who want to stay longer? it's time for us to get our butts out of that country. maybe not for their sake, for our sake. we don't even care enough to know how much it's costing or how many killed and wounded we suffered. that should be right on the tip of your tongue because that's a cost to everybody's kid. everybody has got a son there or has to know that our number one priority is that person who we

sent over there we care about him enough. but we have some other agenda in afghanistan. i don't see what we are going to accomplish. we are asking what the goals are. if you believe that's accomplishable in afghanistan? i got a bridge to sell you in california. thank you. >> mr. connolly of virginia. >> thank you, mr. chairman. let me just say i do think, i say to the panel, mr. rohrabacher's right. how you can come to a congressional oversight hearing on this subject with your titles and not know how much we are spending every year and not know how many casualties we incur every year, or this last year, i will say to the chairman of this committee it's actually stunning, stunning development. i have been involved in foreign policy hearings and oversight

for a long time. like that wouldn't be a question on the tip of one's tongue? put that aside, mr. sampler, what's going to happen to the oversight of a.i.d.'s projects in afghanistan post-2014? are you going to have -- is a.i.d. going to have to pull back from whole geographic chunks of afghanistan for want of security? >> congressman, thank you for the question. we hope not, but hope is not a plan. in most countries that we work in around the world we rely on host national security forces to provide areas secure enough for us to work. but there is range from what i would call regular aid missions where that's the case to afghanistan. and in between we have cases like pakistan, colombia, south sudan, yemen where we have to come up with creative measures to balance normal operations against conflict operations.

in afghanistan post-2014, we have programs around the country. some will continue to operate. some may have to be adjusted. it will depend on the security situation in the specific microarea as opposed to the countrywide -- >> are there parts of afghanistan where you are operating now that absent something happening you have to plan for a withdrawal or significant curtailment because of want of security? that clearly the taliban is going to reassert itself in certain sectors of afghanistan? >> congressman, i can't name a specific area, but categorically there must be. there will be someplace in afghanistan we are working today where a year from now the situation will have changed and we will no longer be able to work. we'll have to readjust and pull back. >> one of the concerns i have when i went to afghanistan in 2009 was the emergence of a

a parallel, unregulated, no oversight stream of development assistance, economic assistance entirely controlled by local commanders, our military commanders on the ground. i think it started out with great intentions but it ballooned. it became fairly substantial. and it always worried me that it didn't get the attention, say, bilateral aid programs do. it's kind of ad hoc project- ized. it doesn't get the careful scrutiny and evaluation we would normally expect for any normal aid project. what is the status of that funding and the concerns i had in 2009, do you think they have been resolved or addressed in the interim?

and i ask that of any one of the three of you, sure. >> your concerns in 2009 were not unfounded. commanders emergency response program money was to serve as a stabilization goal. i have been in the military and usaid. i can appreciate the value what they were attempting to do. one of the ways we with our d.o.d. colleagues remedied this is put senior development advisors at each of the regional combative command and embedding usaid officers all the way down. all the way down to the prt and the district support team level. from 2007, 2008, 2009, to most recent times i think we have addressed this. we no longer see programs that don't have a development eye cast upon them. that doesn't always mean that the programs are what i would consider good long-term development programs. that's not their goal. their goal is to satisfy something that that tactical commander needs at that moment. we tolerate that. we work with them to make sure it integrates even if at the moment it may not be a development with a sound

-- developmentally sound project. it does serve a military goal. >> obviously it's dramatically reduced -- >> i'm sorry, mr. ambassador. i cannot hear you. >> obviously it's reduced as a result of reduction in u.s. forces, and i would guess as we move to a training advise and assist role, we'll be reduced to zero. whatever the problem was i think it will be resolved in that sense. i do agree with mr. sampler that over time a.i.d. and defense created a joint mechanism for managing the program that brought developmental considerations to bear on those expenditures. i might just mention in response to your earlier questions about total levels of spending, and casualties, that state and a.i.d. between them spend about $2 billion a year in afghanistan at the moment. it was about double that two years ago.

casualties, about 2,100, 2,200 killed in action since the beginning of the conflict and about 20,000 injured. as to the cost of the troops, as i said it's about $1 million a day per troop. we currently have 50,000 troops there, if that was a custom -- a constant through the year, it would be $50 billion. it will be less than that because we are bringing those troop numbers way down over the next year. >> thank you. i know my time is up. thank you, mr. chairman. >> thank you. we go to mr. schneider of illinois. >> thank you, mr. chairman. i thank the witnesses for your time here. also critically for the service you give to our country. i want to we pete what some of -- i want to repeat some of the sentiment that's already been shared. the supreme disappointment in president karzai's approval to -- refusal to sign the bilateral security agreement and game playing with it at a time as

ambassador dobbins you said, time is of the essence here. it has an ongoing impact. being the last, one of the last to ask questions, ambassador dobbins you mentioned the war in afghanistan is not yet over. mr. sampler you said it most eloquently, we either do it right this time or we do it all over again. and the goal, the reason we have invested so much in blood and treasure, is to eliminate a threat, but also long-term to make sure we have a stable government that is working for the prosperity of its people and justly and regional security. that's critical. what struck me listening to that testimony today is that a common thread that you-all touched on. mr. sampler, you said, continued u.s. engagement is critical to afghanistan's stability and protecting the vital interests of our own country. mr. dumont, i think you put it a little differently but it can be

a guarantor for securing a democratic afghanistan. but not without continued progress towards developing a sustainable, full, and professional force. i think that requires ongoing support. finally, ambassador, all recognize that without continued international military and economic support, afghanistan risks falling back into civil war. it becomes in some respect a self-fulfilling prophecy. as we sit here in december looking to a new year, we look forward to next summer and the summer fighting season again. i guess my first question after a long introduction, mr. dumont, maybe you are the one to look to for this what, do you you see as the critical success factors if the ansf is going to stand up and successfully make it through next sum earn continue down a path we are hoping to see?

>> there are several things. one is providing for a safe and secure election. they are quite adept at environmentsecure for voter registration to take place. there are no significant security interest during that time and i think that is a good indicator. but their ability to secure the elections will be critical and that will enhance their confidence going forward. i also think as we draw down and they realize that there is less coalition presence, how well they continue to take the fight to the insurgents will be key. they have been quite adept at doing it during this fighting season, so it has enhanced their confidence tremendously. what will be next for the nsf -- to equip andl be train their troops themselves, and the ability to sustain themselves on the resources they get both from donor nations and

their own resources. those will be the key indicators in the months and years ahead. >> mr. sampler, outside the context of the military, and anticipated military challenges next summer, spring with the election, from your standpoint what is -- what are the greatest threats to your ongoing effectiveness in the next 12-24 months? discussedomething we in the hearing yesterday. i have not heard it today widely. it is the hedging and current time of instability. if afghans have a sense there is a way forward and elections go well, hedging behavior will diminish. but at the afghans feel the international community will walk away from them and leave them to the devices, then hedging behavior will be things like, returning to futile warlords and ethnic war -- fu edal warlords and ethnic warlords. part of the job will be to encourage them that usaid's engagement in afghanistan is not a short term thing.

we engage in countries for decades if there is a need and support from the u.s. congress. our goal will be to convince them that we are here to stay so we can minimize the hedging behavior on behalf of the afghans. but does that hedging behavior -- i am trying to -- >> does the hedging behavior, i'm trying to put it in context. does it lead to a more fractious , pulling away from a more secure, just, and increasingly prosperous afghanistan? is that the challenge e >> basically, hedging behavior is where clan leaders and family members decide to protect their own. they do not make investments. they do not reach out to other ethnic groups. political decisions will be very clan centric. if we can convince them that there is some stability and an opportunity to move forward, they will be more outgoing and more entrepreneurial. >> i hoped to give you the final word, but i ran -- ran out of

time. i apologize. i yield back. >> thank you. >> thank you. mr. schneider, thank you very much for yielding back. we thank our members. we thank also the witnesses for being before us today. as we saw in afghanistan early this morning, another car braum exploded, this 1 -- another car bomb exploded, this one outside the gate of the international airport at kabul, and the taliban claimed responsibility. those carrying out the tie -- the attack had ties to the have connie -- to the hakani network. in terms of the amount spent in afghanistan, it is about 6.7 billion per month by the united states and this committee has oversight over this issue. i want to thank the witnesses for their testimony today. there were a number of questions

asked by committee members. if you can get back to those members with written answers to anything not asked today -- and there will be additional questions forthcoming from numbers of the committee. thank you again for your testimony and we stand adjourned. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> let me be very clear. this is a very delicate, and diplomatic moment. addressa chance to easily one of the most pressing national security concerns that withorld faces today gigantic implications of the potential of conflict.

we are at a crossroads. we are at one of those hinge point in history. one path could lead to an enduring resolution over international community concerns about iran's and clear program. the other path could lead to continued hostility and potentially to conflict. i don't have to tell you that these are high stakes. >> this weekend on c-span, secretary of state john kerry on white house members should not impose additional thanks and against iran. as talks continue on freezing parts of iran's nuclear program. watch saturday morning at 10:00 eastern. span2's book tv, and a talk about the former vice president struggle with heart disease. , a on american history tv look at the free african american men and former slaves who fought for the union.

sunday at 11 a.m. eastern. >> the senate has agreed to end the around-the-clock sessions that have been going on since wednesday afternoon. the majority leader reid has been keeping the senate in session to force votes on 11 mostly noncontroversial nominations. senators will vote shortly on a deputy secretary of state nomination. and later today, they will take a break for the weekend. on monday, the senate voted on president obama's choice to have the homeland security department, jeh johnson. week, thein the federal budget agreement, defense programs, including military pay increases, and the farm bill later this month. live coverage of the senate is on c-span2. minutes, with a live discussion on health care costs hosted by the alliance for health reform. discussion-- the will center on the rising cost of health care. while we wait, the conversation with the chairman of the house

ways and means health subcommittee. >> revisited of kevin brady, how did you vote last night yucca >> i supported the agreement. the best we've got right now is the new affordable care act. i thought it was important not to distract the country from a very important bill. and the sequester, i wanted to reserve it, and also redesign it. to provide relief from the military, which i think is really important. anytime you get a chance to reduce the deficit $23 billion, my vote card is yes. a lot of the conservative groups that have been allied with republicans are very critical of the agreement. freedom works, for one. heritage action for another. they are saying the spending is up front, but the savings is on the

guest: when i first saw the grimmett i thought i would not like this. and then i realized these were real cuts on the mandatory side. they may not be big but they are real. on the discretionary side, spending comes first. mandatory takes a while to build up those savings. beyond the 10-year budget, they are more real. host: what did you think of speaker boehner's criticism? guest: i had the same impression to begin with. as you dug into it it was a real agreement. for conservatives, we are not funding the government the way we were four years ago, which is what we were today is what we do today.

it gives the divided government a chance to focus on principles and the appropriations. i thought it was important. host: unemployment benefits is the first thing he is going to bring up in january. guest: we have yet to hear the white house talk about the need for this. the president has been giving speeches, telling us the economy is improving. these emergency benefits are designed for when unemployment is high and going up. that is not the case and states. it certainly has not been a priority for the president. i think the senate and harry reid ought to pick up one of the 150 jobs bills we have sent to them.

host: our guest is a republican from texas chairman of the ways and mean's committee. unemployment benefits -- if unemployment benefits have been included, how would you have voted? guest: under law, they have gone beyond what their purpose is. the focus is how we get these folks back to work. almost every report shows that the longer you are out of work, the less chance you get back to work. two years ago, when we reached an agreement to extend unemployment, the white house is agreed to extend unemployment programs, match local workers

with jobs, every state has been pushed off. i don't think there's the trust level they are serious about, doing what needs to be done to get folks back into jobs. host: kevin brady, $12.6 billion in security fees for new airline passengers. is that a new tax? caller: i believe this was included in the house conservatives budget. users ought to pay the share of the securities that go with it. i do not like to pay higher passenger fees. i know they are there because i am there. my mom cannot travel anymore.

host: chris in west virginia, you are on with representative kevin brady from texas. are you with us? caller: i'm here. representative brady, there is going to be no extension of unemployment? the job market went south on us. host: actually there is. workers who are unemployed can receive 26 weeks from unemployment in the state. if it is rising, they qualify for another 20 weeks of unemployment. for coal miners, unfortunately, washington, especially the white house, has played a role in losing the jobs because of their focus on removing coal as an

affordable source of energy. i think our focus ought to be helping people who are out of work. that is the best help we can provide. host: kevin brady, does this budget deal throw in the towel for republicans on the affordable care act? in the sense that it funds it and it is not a defunding mechanism. a lot of groups argue to vote against it so that it would be a defunding mechanism. guest: i think the house has successfully defunded about $55 billion. i think this is the long -- the wrong solution for health care. what we have learned is that we can bring the american people along with us.

the more they see the impact of this law and on local businesses, the better opportunity we have to make the changes we would like to see. the budget agreement made sure we do not have a destructive fight that the american public actually seeing this new health care law. host: did the shutdown hurt the republican brand? guest: it did. it took the american public that agreed with us and into an a half weeks increased approval ratings. for conservatives, obamacare continues. you give 100% of and troll of the government over to the president. for us, that is not much leverage. host: next call is chuck from st. augustine, florida.

caller: i'd like to comment on the successful program in congress that really has worked in the last five years, and that is socialized banking. we give them their bonuses, we give them their tax cuts. socialized banking stares us right in the face. yeah, i would like your comments on that. guest: i agree with you. i think the bailout was necessary to stop the financial that was reaching across the world. i did not want the mistakes of wall street and washington -- certainly the legislation that

was passed and the dodd-frank bill gives a wrong solution via i think it institutionalized our government. big banks have gotten bigger. community banks have been in place a hundred years. well-run community leaders are struggling. i don't know of these banks will survive. i think the dodd-frank legislation, i think it has been very damaging to our community banks. host: we are hearing from our conservative twitterers, who may or may not be tea party followers. sam says --

are you hearing this sentiment from your constituents? limitedhe principle of government, more responsibility for individuals, i agree with. the most part we are not hearing that. their frustration is they would like washington and i would like washington to tackle the biggest budget issues, not just the health care law, but social security and medicare are in deep trouble and everybody knows it. we know what we need to do to solve it for the long term. their frustration is get a backbone, congress. i am ready to. our republican conference in the house of all stripes are ready to tackle how we pay social security and medicare. we need the president to sit down with us to figure out how

to do that. host: the next call comes from chuck, an independent from florida. caller: i was just on the air. host: i am sorry. i should pay more attention. alan, south carolina. go ahead. caller: good morning, gentlemen. i would like to say thank you to representative brady for attempting to show he has a conservative viewpoint on the banking issue. my concern is congress has for a number of years tampered with trying to figure out which of the economic symptoms are the most important and has never yet addressed what the disease is, and the disease is they continue to borrow hundreds of billions of dollars every year from privately owned central banks.

that has to stop. if you do not stop that, the disease is going to kill us, and it looks like the disease is getting rampant. i will take my answer off of the air. guest: i appreciate that. one of the key points about this budget agreement, very modest, no question about it, both the white house, democrats, republicans are not tackling the biggest issues we have got. rather than the discretionary, or the big autopilot spending programs we have, we have avoided the tough issues facing the country, and as a result we continue to far more than we can afford. right now, interest rates are extremely low. when those go back to normal, the government will feel the pain of the borrowing and over-

spending we are doing. we need to act now because the future does not look right in that area. host: where is your district? guest: it is north of houston, nine counties. a changed in redistricting. it is a mixture of suburban, technology, health care. host: what is the unemployment situation? guest: thankfully, texas is doing well. we are overall around 6%, but we are in one of the boom areas of the country with energy and trade doing very well. health care is stagnant because of the changes in the law, but we are very fortunate. host: chester in dayton, ohio. democrat. guest: good morning. representative brady, i would

like this question also posed to representative moore -- i would like to see a constitutional amendment separating out social safety nets out. guest: for what purpose? caller: i want to see the safety nets handled by people who want to participate in them, as it would allow people to raise funds. people who do not want to participate, get out of the way, really. you can raise funds. in times like this, the unemployed, we could be putting them to work, and have the money for people that want to participate in the programs. guest: that is the first time that i have heard that idea, but i agree that we need not just government help, but community

help in matching local workers with local jobs. we have a lot of emphasis here in washington on compassion as how long you extend benefits, rather than how soon you get people back into a job and back on their feet. we should do the same thing with minimum wage. the goal should not be to raise the minimum wage, but to get people off of it. oftentimes in washington we miss the real goal of what these programs should be. host: boringfileclerk on twitter do we need a budget at all what we have done well living off of cr's? guest: we have not done well. just the opposite. the cr's essentially say let's fund the government the way it was. we have done that for nearly four years. do you fund your family the way

it looked four years ago, your business? the answer is absolutely not, it is crazy. we do that at the federal government level. it has allowed lawmakers to sure responsibilities. in that area, what paul ryan and senator murray achieved was forcing congress to get back and do their job. host: let's say the senate passes this budget next week. it goes to the president and he he signs it, what is next up? these are top-level numbers. guest: it is important to have the top-level numbers that we have not had in a long time. i am not an appropriator, but i assume they will go to work over the holidays, taking the bills that have been passed in the house, debated in the senate, and put together a coordinated spending bill before january, and then begin the work after

that to fund the government the correct way the next year, moving the appropriations bills forward. it will not be as smooth as i just described, but it is night and day better than what we had. host: if the senate passes this bill next week, what happens to the january 15 c.r. running out? guest: they will have to write bills for that topline number. they will not have the holiday that i am having. they have got a lot of work to do. it will be refreshing to see that. host: there is no threat of a government shutdown on january 15? guest: no. host: mike, radcliffe, kentucky. caller: i am doing just fine. can you hear me ok? host: we are listening. caller: i'm a retiree, military.

all my neighbors that form the combat brigade -- when you're doing 1% cola reduction on combat troops, and you understand only one in eight of those guys that sign up at age 18 or 20 actually make it to retirement, and if they retire at 42, and this 1% cola kicks in until age 62, for most of them, that is over $100,000. you spread that over 20 years, and that is $5,000 a year, and i have no idea if you have any idea how much an nco makes, but it is not much. retirement pay is 40% of base pay, none of that other stuff added on. most of the wives and a few husbands who have wives in

afghanistan are telling their husbands to get out. the last comment i have for this is they really thought that congress had their back because they are out there dying for you. they are now in their 13th year of combat. world war ii lasted three years. host: all right, mike, we will get a response from congressman brady. caller: hang on -- guest: let me start with this. my brother is active duty. i do know how much they make in -- welcomeld like to everybody to today prosper. i would like to thank our partners, the commonwealth sons, who have done a lot of work in this area. the growth of health care spending has moderated over the

last few years. the timeay this is not to declare victory. u.s. spending on health care still exceeds spending in other countries, both in terms of percentage of gdp and also per capita spending. it is also worth noting that of thee consumed 15% federal budget in 2012, and in 2011, the first of the baby boomers hit the medicare program. the care spending is projected to double by 2022. while we talk about differences in this town, today we will talk about areas of consensus, and in particular health care cost consensus. company number of major proposals in the area of health care costs -- there have been a number of major proposals in the area of health care costs, and there has been work finding common ground. we are pleased to have

commonwealth as our partner today and also pleased to have moderatorsome as today. she is vice president for federal and state health holiday. rachel will set the stage for us by framing areas of consensus identified by commonwealth on cost containment proposals. rachel? marilyn,you so much, and thanks to the alliance for health reform. thanks to you who are brave enough to join us on friday the 13th to talk about health care costs. hopefully this is not too painful. as marilyn said, we understand the paradigm that states and alice he states and policy have done. health care costs are three dollars trillion in 2012 in terms of national health expenditures and are expected to rise. just for some context, roughly

20% of our gdp is spent on health care, and the rate of health care costs goes the way expenditures,alth but it is still unclear whether that will continue, and what is potentially driving those reductions. regardless, controlling the cost has been a front and center policy issue for policymakers at the federal and state levels where, especially the state levels, and in addition it is families, employers, and individuals. given the policy focus on controlling health care cost growth as well as the belief that 2013 really offered an unprecedented opportunity to arrive at some policy resolution, a number of stakeholder groups released a set of comprehensive proposals

to control costs while improving the value we receive for our health care investment. several of these groups included , and whileers different approaches among the proposals, there was an incredible amount of agreement among them. it would be wise not to underestimate the importance of the fact that all of these stakeholders and all these groups were coming forward with proposals at the same time. that alone sends an important message that stakeholders across the political continue wilma agree -- continue him agree that much can be done to control costs and to reform the health care system. the hope of the fun to shine a light on areas of commonality, hope to distinguish differences in approaches. there is a piece in your folder that gives you a link to the online tool that was developed out of this partnership. universitywashington

department of health policy that look at reports. these are organizations that released overheads of proposals, not just medicare proposals or coverage proposals, a comprehensive proposal focusing on controlling health care costs to health system transformation. after analysis, the examination revealed substantial agreement on areas of action. as i mentioned before, even when the reports differ on specific recommendations, there were enough commonality to suggest momentum in four key areas. you see those here on this side. paying for value, moving to a system that pays for value over volume, oki at quality improvement in patient engagement, improving market competition, and the setting of spending targets, something that has been country personal, and i

think many of us are pretty surprised to see that in almost all of the proposals. agreements when we looked at that pay for value, not for volume. there are similarities to what bicameral proposals right now as well. the really was part of goal, to see if some of the consensus could make its way into the policymaking system. just some of the common elements of the proposals. more information in your folder. all of them recommend moving away from current sgr formulas. all of them proposing to build upon or expand all turn it up delivery models and payment medical homes are accountable care organizations. a lot of agreement on the importance of using the health insurance marketplaces to encourage interest practices

that support -- insurance practices that supports good purchasing. the quality improvement side, some of the areas that have the most consensus was the idea around the deed for poor measures and metrics. and alignment between public and private programs and the measures that they use in order to make things more consistent and seamless for providers. again, lots of differences on how the proposals suggest we get to those goals, but much agreement on the need for core measures of and there are efforts underway with others to move in that direction. on the improving arctic competition, i think the area we solve the most strongest areas of consensus were on the ideas of price transparency. a lot of discussion over that in the last year. differences in the way that reports approach it, but and

issue we are hearing on both sides of the aisle, in terms of the importance of shining some light on the cost of care, and the prices paid. targets.on spending all of the proposals argument spending targets, some of the program levels, some at the local levels, and all the proposals emphasize and encourage on the state level innovation. glance atyou a quick the online tools that we have available. to theine tools link individual proposals. we encourage you to look at this to do some comparing and contrasting him and then to read war about the individual proposals. with that, i just want to again acknowledge our partners at gw, katie and her team, and thank her for her work on this, and also the for the work that katie's teamwork with. they did an extensive amount of

analysis with those groups to make sure that we were those proposals accurately. thanks to all the organizations that participated. marilyn? >> thank you, rachel. let me go through logistical points. you will notice on the screen behind me, if you are interested ng,tweaking while -- tweeti you can follow the hash tag #costconsense. #costconsensus. we will pick that up. he will pose the question our speakers when it time comes. you can also send us a direct message on twitter at @allhealthreform, and we will pick up your message that way. if you are in the room, you can

ask a question when the time comes in one of two ways. we have microphones in the room, green can also use the card intertech it to write a question and we will get the question to our speakers. -- green card in your packet to write a question and we will get the question to our speakers. your packet has a lot of great materials or you. it has the full speaker biography. it also has the powerpoint presentations for those bakers who have power points today. haveso -- we also additional background material available for you at our website, www.allhealth.org. is live this briefing on c-span today. we also -- there will be a video on our website by monday, and that will be followed shortly after that by a transcript. packet --oint in the

you also have an evaluation for before you leave today. if you would be so good to fill that out, we would be grateful. let's move on to the rest of our program, and we are going to start -- we will hear first from who is at the center of -- paul is a health care economist who is made his business to make sure he knows the trends of health care delivery. we have asked him to discuss areas of consensus. the likelihood of moving forward, given the political atmosphere, and also to look at just how concrete these proposals >> thank you. were a lotaid, there of activities in developing comprehensive strategies for

crop containment. many of them were motivated by expectations that there would be substantial budget legislation. now there are opportunities to put these ideas forward. most of these entities are really seeking consensus. some of them had different stakeholders involved. conservative and liberal policy experts. some have republicans and democrats. one was from the perspective of states. i want to mention that we served as advisers to the bipartisan policy center. i was released in april. the foundation asked me to sympathize a lot of these reports. they had funded seven of the initiatives. i also added three others. one was a commonwealth fund report. this is really about my synthesis.

in vision across the reports was really striking. i would use to reports from rachel. they are consistent. diminishing the role of service. other payment approaches managementcare and and clinical integration. they were seeking improved patient outcomes, as well as cost reduction. achieve most of this transition by the end of this decade. pretty aggressive plans. what were the strategies? the reports had medicare payment policies as a key lever in pushing the system forward. there was one report that i mentioned called the state health care costs commission. it clearly focused on medicaid policy. that was the key lever.

it is definitely a movement away from traditional policies of cutting payment rates. these reports mentioned the limits of cost shifting. services wherefy they saw prices were too high. and they called especially for bidding prophecies to set lower prices. they recognize savings for medicare is achievable only through delivery system improvement that affects all of medical care. squeezing medicare rates and getting a lot of savings, according to these reports, we need to move past that. most of these reports have systemwide policies as well. they include liability reform and the role of nurse practitioners. treatment of health insurance and wellness. the state initiative talks about state reforms guided by spending

targets for each state. the reports address quarters of the affordable care act. at in thesed change payments and the cadillac tax that are not part of the core. none of them proposed premium supports. these efforts are considered to politically toxic to take on. they would talk about provider payment reforms. do not offereforms concrete steps to achieve goals for reduced roles to secret service. many said that we want to have 75% of payments by the end of the decade. those you get there? reports are silent. i was unfortunate. for those reports that did

specify how to get there, the levers tended to be provided payments. some talked about a permanent fix. that includes incentives for physicians to get into integrated coordinated delivery systems. some of the incentives for other providers or more controversial. there were proposals for second- generation aco's in medicare. a lot of concerns were expressed that the current or initial models had shortcomings. -- particularly in their advancements. they sketched out second- generation aco's and something that would expedite the movement away from secret service. they talked about a redesign in medicare benefits. all of them talked about a unified benefits proctor.

unifying part a and part the, at least from the perspective of the beneficiary. the benefit of the structure includes catastrophic -- copayments. but being politically reasonable, these exist with distinct financing for part a and part b alone. they basically asked the actuaries to be creative. attribute spending to the different trust funds. reports hader of particular proposals to discourage comprehensive supplemental coverage. they basically preclude coverage from one -- wiping out all of the responsibilities. the simpson-bowles initiative addressed the medicare age of vegetable -- eligibility.

there were a number of discussions with a focus on revamping the process. it would give greater authorities to state to innovate , using performance incentives on spending a quality to go along with the greater 40. thent to talk about treatment of health insurance. a lot of people do not think a lot about it and do not realize that the cadillac tax, which began in 2018, is actually now our baseline. the policies for tax treatment needed to talk about changes on that baseline. -- focus on asort potential shift from the cadillac tax. they would move to the more long-standing approach of having of theon the exclusion contributions for health

benefits from employees compensation. some of what we saw on these reports were that this could be designed for greater productivity. advantage is capping the tax benefits rather than tack -- premiums. they may have ended certainly done this. let me talk about some opportunities and obstacles for moving forward. the source of opportunity is the consistent of vision. providers, payers, and policymakers. also, the affordable care act coverage, which really starts to hit later in the decade. they are seen as pushing providers forward and making the more interesting in reform of provider payments.

also, i think that the new thinking about federalism has gridlocked grants for a long time. now, there seems to be thinking on both sides that we can use a shared savings approach. -- thethe key obstacles rudimentary state. innovative payment approaches. this is very early in the game. there are concerns that i mentioned before about second- generation. we need it soon. there is also a lack of readiness and many providers to succeed under reform payment approaches. another obstacle is the importance of consistency in payment approaches by payers. payments, there has to be some degree of coordination between what medicare and medicaid are doing and what the private payers are doing. there is a fascinating article

ago, aboutm a month succeeding. subject to incentives. i think that the traditional hostility in the policy world demands this approach as an obstacle. the demand-side approaches have an important role in augmenting supply-side approaches. finally, the polarization in congress. the absence of resolution on broad issues causes entitlement cuts. that is holding up action on health care cost containment. now with thistic initiative where they are all working together to fix things. the fact that they are fixing sgr in isolation, as opposed to as a broad reform, as a broad

restructuring, congress will find that it is much harder to do it that way. the -- it they get to will be much harder to look narrowly than as a broad practice. the key thing is holding it up. there is a lot of agreement and consensus in concrete health care steps. aboute big picture deal entitlements out of the way. thank you. >> great, thank you. we will turn next to lend. policyhe leader of the on ethics at george mason university. he was to rector of the health policy program at the new america foundation. no adviser on health policy at the office of management and budget. he is going to discuss the challenges and barriers to moving forward. we have also asked him to talk

about lessons that policymakers can take from the private sector there. would say that the proposals that rachel and paul described do tend to have a vision of where they want to go. where we would all like to go. there are alternative payment models in general. they tend not to have a concrete roadmap of how to get us there. this rough roadmap is being worked out. demosn public and private and in some places programs as we speak. it is this roadmap or blueprint that we need to construct in ways that work for providers. private plans in the health care system. there are four groups of from writers in the u.s. health-care system today. those that are already there, using global caps.

they are the remaining pioneering ceos. those that are trying to make the serviceon from and are mired in the messiness of doing it with conflicting incentives in different reporting requirements -- not all of whom are moving at the same speed. those that are willing to make the transition, but do not have a cooperative payer plan partner where they are. they are frustrated and they are worried and they're moving too fast. and to slow. they are worried about being left behind. they are worried about getting ahead of the payments, so they are sacrificing revenue without having new payment to make up the difference. finally, there are those that are opposed and will fight to hang on until they retire. job is to make

-- help the good guys. frankly, it is not clear to me the new policy is required now. n re may be more noble -- imble authority and maybe a manhattan project. i am serious about this. charge, which there is no danger of happening, i would assemble a team of advisers to work out a map to give away as a public good. if you think about the medicare fee schedule, it is essentially a public good for every plan in this country. they all use it. we need a new way of playing -- pay. why not devote resources to that roadmap for us all? i love the are that so many -- there

state employees that have a big chunk of buying power. states, all payer claims databases and some nimble antitrusts could be key tools. medicare must be. it is the biggest buyer. it can only lead if the private sector will go where it wants to take it. there is a public and private ownership. shared savings with states are simpler. they are good ideas. it is heartening to see so much support for that across the spectrum. event, rewarding states for symbol metrics, like improving quality performance, is a good idea. the fix, as paul said, is a good idea and the challenge. in town see everyone agree, it is stupid to continue this policy.

paying for it would have been a lot easier if we had been able to lease it in a bigger deal. one want a condition to fix a payment model. that will ultimately make service was attractive overtired. if you think about it for five more seconds, that is not much different from what we're doing now. the trick is not the formula, but the willingness of congress to enforce the attractiveness over time. to make the transition to these alternative payment models, we must know what and how we want to pay the good guys. think hard about who are the good guys. are they the people who just adopt the alternative payment model and do not control cost or are they people who control cost i pointh the service? out that the vast majority of our patients are using this

service. shared savings as key complements the payment. bundling, as much as i like it -- it cannot be done on much is spent at the moment. nor is it likely to be done anytime soon. the point is, it will be with us for while. that is why we have to get the code relative to procedure codes right. we all know which stretch and then needs to move. i ask you this question. is the medical profession ready to do this? that policy,ld say if anything, has deferred too long to the ama dominated committee. we should blow that up and give the other group. giving medicare enrollees is a , they use networks

should have been part of the original rollout. it is coming. that is financial incentives for a tighter network. look at these exchange products and how many are limited. it is definitely a portent of things to come. so many proposals mentioned doing something about medsup. it is interesting to me that all thehose proposals restrict kind of policies that can be sold. rather than taxing the product. as an economist, i will tell you that you can structure taxes to drive people where you want them to go. without denying the right mutually desirable products. that is, by definition, being sold today. denying the right to sell my opinion is risky.

in today's climate of hypersensitivity to freedom being taken away. the absence of the premium support and proposal is not shocking. it is too bad. that is clearly on the table and congress. represents is a major strategic choice. we rely on health plans to enforce spending limits. the government separators are key. or depending on providers to respond to public and private payment reforms. in other words, do you want health plans to run our system or do you want providers? in my opinion, our country is large and diverse. each will lead in different parts of it. the question is, who will set and enforce the discipline of the target global cap rates over time? matters to me that no what, we need government and private affairs to incentivize providers to hit socially

desirable growth rates with high risk payment mechanisms. i have always been confused by those who hate ipab and hate medicare vouchers. take a deep breath and step back. they are after the same thing. holding health spending per capita to something close to gdp growth per capita. there is a dispute over the growth of level of benefits. there is a difference in who bears the risk of failure. beneficiaries -- but there are way more and comment than the antagonist have admitted. our debates would be more honest and more productive if we analysts could help them to see the essential similarities in the indications of their proposals. the cadillac tax simply taxes the exclusion. there are examples of where they

were nonstarters before anyone had heard of the security act, much less the aca. i agree with paul. i spoke with self-insured firms last june. their ceo clients already directed them. make sure that we do not pay the cadillac tax. six years before they come into being. that is a hugely perp -- and packed full provision. provision.ull judgedance can be fairly against objective standards. until then, we rest the same kind of -- it seems to me that the biggest political barrier is sustaining the lower cost growth. what will the savings be spent on? deficit reduction or coverage expansion? the aca answers the question in one way.

they were not coupled with a long run fiscal balance agreement. a long-run fiscal balance agreement was resolved on its own, because we did not yet have an aca. now we do have an aca. it seems to me that the aca supporters ought to give firmly behind some credible version of a long-term disco balance agreement. maybe this little, but important agreement that congressman ryan and senator murray have worked out is the first step toward that. is final point i would make that i was very intrigued by how many proposals talked about these taxes. what are these taxes? maybe this would relieve the split. conserver's hates sin. but they hate taxes. it has always been a good reason to do this.

social economic status of smokers says it is a tax on the lower income. unless you give them access to effective ways to end addiction. it is that kind of trade-off. thank you very much. >> thank you, len. before we turn tour last figure, i want to remind all of our viewers that you can submit questions that we will pose to our speakers through twitter. you can do that by sending us a .irect message on twitter also, if you are in the audience, you can use the microphone. if you want to get your questions ready now, you're welcome to write them on the green cards and our staff will pick them up. to the faculty of the harvard kennedy school of law -- government. she has a long list of

credentials that you can find in your packet. she spent most of her time in washington working as chief for bob dole. she also worked on the staff of the senate finance committee and spent time as secretary of the senate. she is going to talk to us about the accessibility of the major compliments of various proposals. sheila? >> thank you. really, my congratulations to the commonwealth unto others, who did a spectacular job of bringing folks together. paul essentially did an array of what it is that was out there in terms of per postal. he gave us an opportunity and a way to find where there are areas of consensus. there is an opportunity for us to build upon the work that was done in the past. kudos to commonwealth and others to purchase abated in that process.

suggested, i am being asked to give you a sense of what i think the political realities are of what has been put before us. i would also note that the cbo has recently put out their ongoing health-related options for deficit reductions. that is always an opportunity to look at how the look at these issues and think about the savings that would be accrued. there is certainly a host of proposals out there. i would like to step back, if i can, and reflect on the part that rachel mentioned and what paul has described as the building block for what i think we might see going forward. there might well be an opportunity for consensus. having been a staff member of the senate finance committee for a long. of time, and on the senate staff, i have to think of what occurred yesterday.

very positive a way, not as a negative that they failed to do the paid -- i think what it showed, and what was le,,ioned by senator do who commented that it was nice to see bipartisanship. what we saw in the finance committee, what we saw on the ways and means committee is the beginning of a conversation that began a number of years ago. we're coming back to it. that is refocusing on the programs. we're refocusing on the elements, which both sides of the aisle have the opportunity to look at and discuss. we have already found a number of common grounds. i think this will carry over into next year. what occurred in the ways and means committee is the number of -- beginning of that conversation. it will take us into the new year. we will be able to look in

greater detail at what occurred to what has not been identified. the absence of that at this early work does suggest that there is a willingness to take on some of the hard challenges. i think that there is a very positive movement forward in real looking at this program and the changes that could be made. i think that rachel, and some of her summary, and much of the work that paul did, did identify common themes. there are payment changes and moving away from the provider cuts. we have seen though so recently. there are broader questions too. issues around value. value versus volume. it is really a broader conversation about what we do with payment incentives and programs. a clear focus on quality. a clear focus on metrics and performance.

again, something that has been coming for some. period of time. some are more ready than others to engage in that. somenk that engaging is reflection of that. putting clinicians increasingly in charge, to one of lens points, there has been a long- term sense that much of what is occurring is up to the taxpayers. we drove it as public payers or private payers. there's a clear interest in figuring out how to incentivize physicians to become more actively engaged in the broader management of what is occurring in the systems. not simply in the silos that we have seen in the past. i think that timing is always an issue.

the changesagine that we have seen in the aca that play out over a long. period of time. readiness that was pointed out is very variable. the opportunity to analyze data and use it to drive change in behavior to try to drive a certain kind of behavior on the part of the clinician. the access to that information. how it is utilized and by whom. that clearly is an issue that varies across the country in terms of how organized systems are. some are more readily able to access that information. they utilize it in organizing their systems. there are those who are trying to make that transition. they want to access that kind of information. but it carries. certainly, bundling. it is limited to a limited number of circumstances.

the concepts behind that is really about how we break out of the silos and begin to look at the full continuum of care. the opportunity to look at what happens pre-admission, during an admission, and post-admission. theink that traditionally, payment systems have encouraged those silos to exist. now, through bundling and other efforts, what we're looking at is an interest in looking across the entire system. that obviously creates some real challenges. some of those relationships do not historically exist. whether in the postacute environment in nursing homes or other facilities, and home and community-based care -- but there is now a growing desire and need to understand how to help that patient manage. how do we create a payment system to do so? certainly, the movement, whether through acos or other organized systems of care, the problem is

that there is not a single answer. we heard in yesterday's discussion that some of the unique problems that exist in rural communities -- you essentially do not have the number of providers available. as we look at what has been ingested in the proposals before at, we have to look provider differences and has to be recognizing it it will not be one solution. there is an importance in the federal and state bishop, bipartisan,at is and that is the understanding of the value of the role of the state, how the state can incentivize behaviors. the state can have authority, orther in insurance regulatory environments. the adequacy of networks is something we need to look at, certainly with respect to

workforce. the demand on primary care, the increasing number of people coming into the system will put pressure on it, so as we look at incentives to create more opportunities or more providers in those environments, near and dear to my heart is there a role of nurse tactician errs and whether they can practice to the nursextent of their -- practitioners and whether they can practice to the full extent of their education. also team-based care. how do we incentivize those kinds of things. there were a lot of allowance proposals we looked at and in the work that takes place that provide an opportunity to move forward, but there are take differences, and it would be foolish to ignore them. the budget and the concern about the deficit -- how we focus that on the health care programs, knowing they will be caught up in a broad conversation about taxes and the entitlement programs. the lack of readiness on the provider level. the, clearly wide,

and i think both parties will approach that differently, depending on what they are hearing from constituencies. the opposition to demand side proposals, as paul noted. no question, resistance to increased exposure for beneficiaries, but on the other side concern about how you get skin in the game, how you begin to have people pay more close attention. the issue around medigap coverage is one of the issues, how do you encourage to discourage the purchase that covers the first dollar, do you otherwise try to incentivize their behavior in terms of decisions and choices. the politics of these discussions inextricably inked to the tax discussion. in the did not see finance committee, we did not know anything about tax extenders, which will come out in the course of next year plus discussion on a broader tax debate which made back the

broader entitlement debate. varying demands from payers and payer systems. the lack of consistency among payers and the way that providers have to respond. essentially require certain kinds of behaviors or do you leave the open market system as has been suggested? how do we incentivize the states? one of the issues we have confronted in the medicaid, medicare discussions is how do you encourage states in the concepts of who is a little when the savings accrue at the federal government cause of the acute-care sign the program? how do you get states flexibility and ownership of those decisions, but essentially achieve a broader set of goals? the roadmap, as suggested, i think len is correct, there are those who are ready who have the are trying,ose that those that are willing to try, and then there are those who are , hell, no, not until i retire.

the politics of the provider community, internal to the house and the senate and the discussions around the aca which have come located that will make some of these issues difficult, but i believe i have to say a glass half full because what happened yesterday gives us the basis on which we can move forward and refocus on the programs and their future. i would say closing, the other thing we have not touched on to date, but i think we must touch on is the federal government is a purchaser in a variety of ways. medicare, and kate are not the only ways. whether the tri-care program, all the other systems, we have to move forward in a comprehensive and consistent way in terms of the way we organize finance and incentivize the haters on the parts of all our systems, and those systems which have their own politics have to be brought to the table as well. >> great, thank you, sheila.

while folks are getting their questions ready, i will ask the first question. this has to do with the concrete nature of some of the proposals that are on the table right now. panel asike to ask the specifically about spending caps and targets. the way the proposals are set up, would they really come into play? sense of the proposals is unlike an sgr, where the spending caps drives things, the approach that these proposals took the spending caps that they were a act up, and they were therefore cbo. what is different is they were laying out concrete policies, which, if they work out, should keep spending below the cap, and the cap is a act up. even as a backup, the notion would eat that if it is triggered, the response is not a

mechanical reduction in payment rates, but a ramping up of some of the policies that were designed to lower spending. >> i think paul is exactly right. i think experience with the sgr has caused people to be concerned about the role of cats, however they are constructed, how mechanical they are. we have seen in fact since the continuedof the sgr, pushback would occur. in designing any kind of a program like that, the question is how credible is it, what is the result of it, and in fact, it is a act up or mechanism that automatically comes into play, and how that decision is made? people has resulted in being cautious about how those are constructed. >> let's start here. please identify yourself. >> hi. the differentsed,

proposals that have been presented today. i am interested in comments on which ones are most elliptically feasible and also would give us the biggest bang for the buck, if people could comment on two or three that you think would meet that kind of criteria. i will take a first stab at that. i think -- and i would like to hear the comments from the other panelists, from the commonwealth fund's perspective, our take of looking at all these comprehensive proposals was to identify the areas where there was the most agreement and more common focus and similarities in approaches. i look at those as possible areas for a path forward. havethink, you know, we

talked about many of those areas that we think and to be pretty promising. the movement from a way from paying for falling to paying for value, this widespread agreement, has the need for more consolidated and aligned quality measures. i think the directional movement on price transparency from all those -- many of the areas change. that was really the goal of. the project is to identify the main areas of consensus so we could go a little bit deeper and that groups could work a little bit more closer to the ground. but other folks might want to talk specifically about individual proposals. not as a sympathizer of reports, but as an analyst of health care, i believe proprietor payment reform has some of the greatest potential to really move the dial. i think that is worthy of a lot

of energy on the part of the congress. is thathe key things you have to have a link between andficiaries or enrollees the organizations such as the o. that is trying to deliver more efficient care. without this link, that limits it. were part of the bipartisan policy center, and the formmended enrollment model beneficiaries, where they get incentives to enroll, and we did not call them aco's, we call the medicare networks, which i think paved the way for more success, prods,o used the the incentives of favoring the providers in that network. >> i would add that i would say none of them are going to pass

as they are written. nothing ever does. what i would look to and is precisely the point of the exercise, look through what is common across them and there you see the things with traction. i would totally agree that payment reform or basic incentive realignment with market-based tools like transparency and quality measurement and so forth, that has the most legs and i think the most potential for a bipartisan agreement going forward. >> i would agree with all my colleagues. i would add one element, and that is the question of workforce. i think there is not that growing understanding of the need for team-based care and a more collaborative environment rather than it being driven by in this case decisions, in most cases. but an investment in primary care, an investment in a essentially incentives that

create these teams so that essentially when we approach a patient we look at them across a broad array of services. we increase access to services. i also think the emphasis on moving people out of an acute care setting into a home-based or community-based setting, the investments in essentially developing those assets and people that can care for folks in those environments and making it again to a payment system that rewards essentially that kind of coordination. i think there is a fundamental agreement and understanding of that, and how that plays out state-by-state will be somewhat different, but i think there is commitment isng certainly do those things and that will change. >> if i could say one more thing price-- ritual brought up transparency. the point i want to make is -- ortransparency can be transparency in general, really, can be a very useful tool as an adjunct to something else. it is really as an adjunct to

different types of benefit designs where there are are incentives concerning which provider you choose. be an adjunct to the front network type approaches. if you want the beneficiary of nrolle, to get a sense of what network they feel most comfortable in. transparency on its own as a risk of snakes in its wheels, disappointing people unless is hitched up to the perhaps harder policy to pursue where it plays a supportive role. why don't we move over here, and if you could please give your name and affiliation, please. >> i'm a primary care physician. rathera brief comment than a question. you have presented here what the consensus is among a wide swath of the policy community, but it is not among everyone. the focus in these proposals is

utilization, that the beneficiaries need to have to mature skin in the game. commonwealth just produced a report saying americans have more skin in the game than anybody else in any other developed country. there is also great concern in the physician community, the american of the american college of physicians, for example, does not represent its leadership but not necessarily represent its membership. whoe are health economists think the problem is not utilization, but the problem is prices him and it is not physician prices, it is at least under medicare it is prices of images, drugs, tests, the three we haveaccelerators in washington. none of these proposals do anything about that.

by the time your proposals again, the accelerators are here and who is going to pay for them? that will be loved into what ever fees are charged, bundled, or otherwise. bundled intobe whatever fees are charged or otherwise. >> that is an important point that we looked at a specified set of comprehensive proposals that certainly do not represent the totality of all of the ideas out there right now. i do want to clarify, though, and say i do not think that the proposals were limited to looking at limiting utilization, and i think in fact, that is a criteria for selection of the proposals that we looked at. we did not talk about all the provisions, but i think another key element that was in many of the proposals was a focus on beneficiary engagement. that is different than having gettingthe game,

beneficiaries really engaged and giving them more choice. in fact, there is a significant agreement among even some pretty abstantial proposals in to different medicare-type benefit package. i want to clarify it is not just all about limiting utilization among the proposals that we selected. ok, the other side. >> hi, national coalition on think thee and i commonwealth fund and the alliance for doing this. i wanted to return to a point that i think both paul and len made and sheila different a little bit about the notion wouldn't it be great if the sgr reform was part of a broader agreement, closer to a grand bargain, brought entitlement reform -- brought entitlement reform? i wanted to attack that a little

bit. would it be possible, given where we are at now, we come to march, and for lack of that if folks kind of back away from attempting to do sgr now and pay for it in smart ways, wouldn't we undermine that kind of confidence-building effect that that would have? i would like to tease that point out a little bit, from the folks. you do not want to have misunderstand. i mean, it would have been great had a grand bargain been available and if agreement had been reached on a whole variety of things rather than a relatively limited package that has moved to the house and is about to move through the senate and a separate sort of sgr conversations that will continue into next year. no question, a great many of us

on both sides of the aisle had hoped that we would have a much larger conversation, certainly reflected in simpson-bowles, perfected in the work that paul and i were involved in at the bpc and other places, the presumption that the best scenario is the one that looks at this in a much broader context. my reaction was simply that -- i guess too many years on the senate staff said that incremental is not always a bad thing. sometimes the opportunity to begin the conversation and make itself to as lends broader conversation. i think what it did was allowed people to come back together and work together in a bipartisan not seen that. i do not recall the last time the finance committee at a markup, but it has been quite some time. in talking to some of the staff and saying onto looking forward to it and a say i have never been to remarkable for, it was an interesting six prints.

three or four years. if it does nothing more than get people get back to the table, get the sass working together, what i understood was a collaboration, both on the senate and the house sides, i think there is an opportunity there. yes, would it have been great to get a grand bargain? want toly, but i do not suggest that what was done was not in fact important and in fact lends itself to a broader conversation. >> if i could say one thing. what i was referring to is really doing and sgr fix on its own, it seems the pay force have ors have tothe pay-f come for medicare. whereas if you do it more a fix., there is fors are easier if you

have a context. i would second the point that learning to do bipartisan, even at a birthday party, is a really good idea. will turn to this question here, and then we will go to a question that came in on twitter. i want to remind our c-span viewers that they can submit questions to us via twitter at ostconsensus or a twitter healthreform. >> one of the things we have talked about is a shift of paying from autumn to quality and value. one of the levers is quality measurement. i am a big fan of this. it is admittedly a science in its infancy, and some of the implementation has been a little less than ideal, and there has been a big pushback from from

positions in prayer the writers. i'm concerned, are we creating a generation of physicians who are alienated from these sorts of repurchase the quality measurements and performance? >> i can answer part of that question. what i have seen over the last couple of years is a tension between measuring quality or value at the level of a provider organization versus the level of an individual clinician. i heard a lot of these approaches are in never going to work. at the level of individual clinician. i am concerned with the attempt to try to do that. for me, i think the focus should be to encourage the development of organizations that can take on these responsibilities because we are never going to be able to build a direct incentives into the medicare program for individual clinicians that makes sense to them. >> i would just add that i agree

with the individual physician versus group point that paul made, but i would add that there is a difference between ensuring quality for a clinician to continuously improve their organization's performance in measuring quality for the purpose of computing value as we are talking about in these contexts. the dream, of course, is for you all to inform the idiots making the payment am right, and that is why you had a process. i think what all our proposals call for i think, at least one that mentioned it, was more standardization, alignment, i believe is a nice phrase rachel used, but a standardization of the quality metrics being required. i know an integrated system in virginia that is producing something like 249 quality measures or different -- i do not know what the right number is. it is not to 49. i think you got to have this process, but you got to start. we cannot feed paralyzed by the

absence of perfection, and you know this, and so we will go from there. >> one final addition. the other thing that has changed is that more people now talking about not just the measure of quality, yes or no, but having a more informed conversation about how is the data going to be used, and it is very different to get providers on board, and there are some things that people are comfortable using, quality out forms to make palin decisions, and there are some things you know as you make care decisions with the patient. so i think there is a more sophisticated conversation going on right now about quality measurements, aligning those, but also before you are just collecting measures to collect measures, what are they going to be used for from and this understanding that not everything needs to be tied >> >> to benefit decision-making. i want to underscore the point and i agree with

richer. there is a more collocated question today and a more nuanced one. in all the proposals commensurately the work that we did at bpc, there is a sensitivity to the indicators that people breathe asked to track. the cost and the word in on individual providers as well as on the systems, the desire to essentially simplify the process am a make it rich, but make it appropriate and morse and the guy said we can't agree on the uniformity or at least some kind of consistency that providers systemsrunning multiple and the burden of that. there is absolutely. nqf isho is now running invested in understanding cap and developing criteria can be best allies. there is a conversation taking place that touches on a very important issue you have raised. >> ok, from twitter --

one provider payment reform that could be instituted that would demonstrate a shift away from the for service? i would ask the panel to give us a sense of the level of consensus on this one provider reform, payment reform. , i can't -- one thing i want to bring up is in the bpc report, there is a simple thing that providers that are part of and the medicare network or have episode bundling contracts yet higher payment rates. a big difference. >> that was great. >> that was i was going to say as well. there are commonalities among the proposals about -- we've been talking about the sgr's. exempting providers from a threshold per my -- threshold

amount, 25%, of their asian practice, and these new provider arraignments, primary medical homes, exempting them from the sgr freezes or scheduled physician payment rates that happened under sgr repeal. that is one element that sticks out. all the proposals address that in some way. they did not all agree on the level or for how many years, but they addressed how you deal with medicare providers. >> i think it is interesting that both of my very learned colleagues immediately talked about increasing fee for service for the good guys. it shows you how hard this is to move the ball really fall really fast. i will go out little farther on the limb and say some kind -- i do not know exactly what kind -- but some kind of pmpm to

providers who are willing to demonstrate they can do coordination for all the good offf, and there is a start that in a kind of a cumbersome way in the enc on a bipartisan basis, and the senate has a version where they can play pmpm 's for being certified. thaton the board of organization, but i think the idea of rewarding our merry care entities for taking on responsibility -- what i would like to do is link that to some kind of risk down the road, some kind of performance base. maybe the thing grows over time if you bear morris. the key thing is eating the clinicians to be aware of the total cost of care. that is really hard to do, believe it or not, in the current system for most american

are. airs. what most pmph's is show that docs the data, and docs are usually shocked. i did not know that. hitting the data in the doc's ha ays, getting the pathw to the solution and rewarding them for the infrastructure they're going to have to build, that seems something worth voting. i will say the evidence on pcm ih is not thrilling. costd evidence pretty -- evidence pretty mixed right. we have not designed the perfect a bee. that is what i would say medicare could do with a little more oomph. >> thank you. we have a question. a couple questions, actually, addressed to paul, if you would not mind kicking us off on this, and then sheila and len, if you could respond.

this is a much broader cover station than -- cover station then we have time to get into today. what do you think is going on with this health care spending growth slowdown? is it real, is it going to continue, and how much of it can we attribute to potentially systematic changes coming out of butbly not thea aca, the systematic changes at that level? >> that was a very tough question. for everything i have read and from panels i have into, i have been to, clearly the recession and its aftermath was a very large factor in this, and hopefully that will go away over time.

i say hopefully because hopefully the economy will come back. there doesn't to be some evidence of some structural changes -- there does seem to be evidence of some structural changes that need to be made. not the aco's. what people look that when looking at aco's, they are not saving a ton of money. there is evidence about how technological change has slowed down, and as it has slowed down because it is running and has things to do, or because of the recession, because the market is not there? i think some things we are going economy isonce the restored, is we are still going to have a much more payment of the point of service by paid patients, we will have incentives to use provider some more than others, there is a lot that is going to be continuing in a stronger

economy, and i think that will have an effect. ofi am optimistic that some the slowdown in spending will be -- butned and probably probably will not be as extreme as it has been in recent years. >> i think it is fascinating to observe that the slowdown actually began a couple of years in 2007, for the recession really hit. contributedecession to it, no question, but it already started. so what is the deal here, and what has continued? we're speculating here, so i would just say in my opinion it has to do with the fact that a critical mass of health care decision-makers had figured out we got to do something about our health care system's costs. i start with employers sending the signal, sending the signal that we got to find cheaper ways

to do this. hospital leaders -- i have never seen hospital leaders unanimous in being aligned around this point. we got to reduce cost. before the aca. what the aca did was kick in and turbocharge it and really down a marker. we are not going back. let me tell you a secret ash real.pdate reduction is it takes learning out of hospitals forever, basically, at an increasing rate over time. that ain't changing. the penalty on readmissions, which gets worse over time, these things have focused the minds like never before. there has been a system-wide ok, they are serious this time, and some of that is going on. i think everything paul said is right. i think the technology think maybe as important in the short run as anything else. >> i think it is both, a, nation of all things that have then touched on.

there will be elements, that will be sustained. we are also looking in terms of the aggregate at this bubble of baby boomers that are coming to the system that will certainly put enormous pressure on the system. many of the elements that were contained in early work in the sensitivity -- and the sensitivity on the part of players of employers and others about that is not going to go away come and many of those kinds of changes will be sustained. >> the good of this microphone. ok, let's go to this crime. ma media. what we know about increased costs for emergency care, also for delayed treatment of known and medical concerns and conditions? can we make comparisons with the solar health care costs and other nations? ownnt to mention in my personal medical experts this year, i got a referral in august from my general practitioner. i was not able to get an

appointment with a specialist until the end of november. then when i needed to be treated in september, they told me to go to the emergency room. that had to be more expensive, i think. i made to a more jazzy room visits in september as -- i made two emergency room visits is ever as a result of that. >> i do not know if we know anything more in terms of what you're asking than we have known for quite a long time. ishink what is fascinating part of your store is when you look at -- and maybe i am --if you look at what physician groups have to do to qualify for the private- cmh's, whichned p are by far the largest number, the first thing they have to do is figure out a way to give 24/seven access, and it could be that they have to have a nurse on call and call them whatever, but they have to find a way to address the question of a human theg who needs care outside

nine to five situation. that is a precondition for been the payment bump up whatever you get to join the program. weis unambiguously true that have learnt because payers are 7illing to pay for it that 24/ access has a cost-reducing effect. it also has a beneficiary having this effect because you're not just off if you do not have to wait and all that stuff. those things are holding consumers in their. we know going to the er, when need, isot k ridiculous. all that has been known for quite some time. i do not think anything new is there to learn. >> you asked about international comparisons. we know we are paying more than any other industrialized country for health care in total and per have, and americans are more likely to go to the emergency room room because they do not

have access to the usual source of care that anywhere else in the country. have good emergency room metrics. >> one thing that i thought that might be a factor is the distortion in our fee schedule. the fact that we pay so much. more generously for procedures than four visits. that may have something to do with you having to wait months for a visit with a specialist. will take exception to that as a specialist, if i may. >> go ahead. >> i do not want respond to that question, but i will. three or four months is ridiculous, i will agree with him, but i do not think the difference in pay has anything to do because specialists are overrun just like anybody else trying to do clicks. there is much a shortage of specialists as our primary care. one of the other things before we jump on the primary care bandwagon, look at the training

of the primary care docs now compared to them 20 years ago. len as an antidote, and knows this, before i left washington i looked at who was coming into our clinic, and over a five-year. period, we had a 300% growth in patients with functional disease that should have been cared for by the primary care. why did we have to see that 200% increase which ends up delaying the patient with real disease coming in? before we get into this, remember we have to get down and look at a few other things, and i will segue into my question -- a few other things is training. you got to look at training, of how they are being trained. second, it took us an hour and a half into this program before rachel tensioned data that len mentioned four more times, paul

alluded to transparency, but without the data, why do we do it? comment about doing a manhattan project is great. being tovided in this, get schizophrenic -- being too schizophrenic. equality aceson of what i did in 2013 and paid in 2015 is like what we are taught not to tell the mothers, say, johnny, you are bad, wait till dad gets home to spank you. you got to put it into the context of when you are doing it. how are we going to have a manhattan project? infrastructuree to get timely data to the physicians so they can make the improvement? i will tell you right now a lot of the associations that are

doing the quality measures are starting to say, what is in it? where is our association? are stepping back from that. they do not make money for four or five years. i ring that up that l -- i bring whenup that len said that physicians see the data, they will change. when you get physicians comparing what they do against their peers, locally, regionally, nationally, giving them tools to change, whether you do for any payment model or incentives. own wanted to add from my experience of a specialist told me later when i saw them a few weeks ago that if i was already in the system, they probably would have seen me. that was like a first-time referral. that was the reason they told me to go to the emergency room. that is what they explained to me.

>> this is not meant as a political comment, but the likelihood of cms getting a lot of money anytime soon is unlikely. but i think there is a great deal of sensitivity to the timeliness of data. one of the issues that paul and i contend with in the work we age doing with bpc is the of the data. this has been a longtime problem with respect to medicare. len is exactly right that one of the credibility issues with respect to the indicators in quality has in fact been the time lag between essentially the acquisition of the data and the analysis of the data and the practice. there's no question that we have to find a way to make things more relevant, more current month and a more credible as a result, so that people can essentially believe that what they have been given is the basis on which they can make change. in the near-term i do not see a

commitment for a manhattan project, the but the point is a good one. >> so i got to say, there are many things i do not understand in life, and i would start with the american league and the chinese language, and how come it is that the private plans can g, andu data with a 1/4 la let me be clear, the private plans to the processing for medicare, but somehow or medicare cannot do it in two years. i do not understand that. we do not need more money, sheila. you need different people. i cannot figure this out. speak,ou're going to join us at the microphone. understanding in medicare you have a year to split the bill and they wait until all the bills are in. >> the insurers have the same lag. are doing on a rolling

average for medicare, which waits for averages. >> it turns out all i know what docs,te plans are giving and somehow it is enough to get a good guess here. it seems silly to me. >> ok. >> i'm with the commonwealth. a couple of authorizations -- observations. one is on the distinction between the discussion of skin in the game and the distinction between rewards and punishment. i think one of the encouraging things that i see across all of these proposals that we have been talking about today is there is an emphasis on changing the payment system so you reward good behavior, and we need to think about the health care system like that. it is not about punishing bad behavior. good behavior.

right now we reward bad behavior. it has be a change -- that has to be a change. we think about the trend in health care costs. i remind -- i am reminded about whether people are saying health care costs are slowing or what is causing the slowdown is i get the sense it is a spectator sport, and health spending is not a spectator sport. it is something that is generated by millions of decisions every day and is an ongoing thing. whether or not health care spending has slowed because of a recession or because there were structural changes, we need to make sure whatever happens in the future sustained a level of health spending that we find sustainable, and that means action and not just sitting back and watching and waiting. and i think there is action on that front. they're both public and private initiatives that been shown to be promising.

one of the private ones that we have done a lot of work on is the alternative all of the concert in massachusetts, which boost cross blue shield in massachusetts has done, and what they have done is one of the incursion things they have done is taken data and shared with her fighters to compare -- with providers to compare their behavior not only with other providers in the state, but also perhaps fighters in their own practice -- but also providers in their own practice. blue cross blue shield will tell us how she goes into a doctor and point out that the bought dr. next door was prescribing a different much more expensive drug for the same condition that a doctor that she was talking to. and the doctor she was talking to just did not know. i think getting that kind of transparency, and i agree with paul that transparency that is hitched to some workable legislation rule situation has to be done.

and the last point i will make is one of the things that drives me crazy about people talking about health for form is this notion there is a shrinking pie. people talk about blood running in the streets because providers are fretting about the shrieking i. if you talk about over the next 10 years, there are on the order of 50% or 60% more health spending 10 years from now than there is now. i would posit only in health care would that be called a shrinking pie. [laughter] great. i would go to one on the cards, and then we will come to you for your question. we will shift gears a little bit. len, you have a question about what you believed the role of antitrust should be, back to health care reform efforts, and what you may have meant when you said the need for more nimble antitrust? >> good point.

i would hope that somebody would take that bait. it is mired in the past in that it really is focused on structure and predictions of performance. and basically, i would say there has been a tremendous emphasis on organizations proving clinical integration efficiencies before a merger is approved, but they tend to lose in court. they have gotten frustrated over the years. my point would totally be this -- sometimes antitrust needs to be more in my view accepting of the newosition that indeed vertical integration and new virtual integration agreements may be more worthy of getting a pass than they have in the past, but also we need to be aware -- i mean by more nimble am a

sometimes the antitrust remedy is just too cumbersome for current law. there is very little you can do about local market power if there is one hospital or no matter what you wish already one group of cardiologists orthopedists, whatever, pediatricians, so they can hold everybody hostage. if you're in that situation, antitrust is a very cumbersome tool. you to think about this i hate to say it, but i will -- you need to think about regulation in that context. i think of regulation as the as i-case last door, but am an economist, but in the absence of anything else, what do you do? what you could do, and this is what i mean by allowing more nimble permissions, i think domestic medical tourism is greatly underused. i know a retired surgeon in the months into six

retirement, got more out of his mind like most of us will, called up a mining owner he knew, and he said, let me help you? he looked at his data and picked 15 conditions that were the most in the -- expensive conditions, and with mining companies committed to shoulders, hips. he found the best places to get those procedures done in the midwest, and, by the way, all of them had lower prices than a lot of places they were going and they had way fewer complications , etc. the problem was getting the minor from wyoming to go to denver or other places. they used cost-sharing in the plan from the -- a self-insured employer can do that stuff, but they threatened the local monopolies with i was in my group over here unless you come back. that is a brutal form of reference prices. in my view you have got to let that stop go on and encourage

it. the guy told me the biggest problem he had was getting the guys from wyoming to go to denver, because they were afraid that they would get robbed in the parking lot when they came out. [laughter] >> if i can follow up. antitrust policy can be beefed up. but that is not going to be -- it is very cumbersome. it is not paying any attention to these combinations between hospitals and physician entities, which i think is a real concern to me. but there are a whole range of things that are market oriented was either come as len saying, can be done by purchasers, payers, or they can be facilitated to governments. for example, one approach is a tiered hospital network which is very difficult to get off the ground because prominent hospitals can say put us in the best or only one a contract

with you. massachusetts passed a decisive to ban that. there are real opportunities at the state and federal level to not necessarily take a regulatory approach, but to take action which actually fosters, freeze up market purchase, and another is austrian physician organization -- is fostering physician organizations. aco program, the it has special provisions to encourage he smaller physician led programs into the program. we need more of that. >> i'm with the international association of firefighters. the replicas concert is the cadillac tax rate when dr. ginsburg pension placing the tax, -- mentioned replacing the tax, with the exclusion of employer-provider health care, it was the first time i heard that idea, actually. i'm intrigued by that.

on the theme of encouraging good behavior, discouraging bad behavior, actual effects on employees, insurers, what it means, i am interested in hearing about that. in addition to the political realities of whether that is something that has legs or not. primarily, how it works. >> i would think from the perspective of firefighters, the problem with any of these approaches, the cadillac tax or a cap on the exclusion is that some employee groups due to the nature of their work or the nature of their workforce are going to have higher medical spending. that is a challenge of making these policies sophisticated, sensitive enough to adequately recognize that. and this applies both to the cadillac tax and to an bpc reporte, and the

had that. one of the most concrete things is the difference between the two is the way it works out, the cadillac tax is effectively a de facto cap on premiums. you give them the fact that the insurers cannot do that the would it is that they have to charge so much more for anything above the cap, they will not do it, and that is really much more limiting than the approach which is just dealing with the incentives and saying you can have the policy that the higher premium, it is just that you will do it without tax subsidies for that last part of the premium. >> there's a difference in terms of the impact, and as you pointed out, in terms of the employer and employee. as you might imagine, as paul suggests, depending on the cost of the plan, the industry, the

group that is covered by the plan i'm at the nature of the plan, it does have a differential impact. you might imagine that a large employer plan, historically, large union plans, there have been a fair amount of opposition to these kinds of changes. when you look at the political realities, those are stakeholders who would have some strong views on this question. great. we're down to our final couple of questions. of thishad the majority conversation focused on areas of consensus and have steered pretty clear from the affordable care act. -- let's bring it back to that specific topic. this russian asks whether the -- this question asks whether the addition of millions for under the aca poses an additional hurdle for health care cost control.

i might ask folks to think about if there are additional opportunities embedded in there as well. now that we are enhancing the poll that will be insured under the aca, whether in the private marketplaces or in an expanded medicaid situations, what are we facing additional -- in additional hurdles? >> rachel, i think a major positive of expansion of coverage is that i think there will be fewer concerns on the part of providers that if they do practice more efficiently, if they limit hospital admissions, this is an environment where you can do that and will not suffer as much. whenever providers are very busy, presumably they're much more receptive to ideas about having to practice more efficiently. you maybe see it in hospitals.

if the hospital is worried about empty beds, it is going to be different than if the hospital is worried about i am bursting my capacity and i do not have the capital to expand. >> that is an excellent point. i would also suggest when you get right down to it, what the law does, in my opinion, is not all, butmore, many more players in the system on population health as opposed to taking care of me and mine. toe your car all insurers take all comers, you have a different world. that world has not yet come to be. it will come assuming the website will come up in 2014. that will be a different world, a world in which insurers will have to change their business model, and their results model will move from partially, and maybe in some cases, mostly risk selection, to helping all enro

llees five value in the system. there will be a live in aggregate spending. yes, total spend will go up in a blip. because we are going to face in medicare performance, it will take four or five years for the whole blip to begin. the key variable in all of this discussion is the rate of growth of costs per capita, and in my view if you have more players the kazakh population health, -- more players focused on population of, you have more providers taking the lead because they will not go broke, and you have more plans focused on value, that allows the system to deliver value and you have more people interested in developing incentives for that value be to be sustainable by providers. it is easier to contain cost of the long run with everybody in. >> i think this is one of the areas where it is going to be an

interesting scenario to watch between the state level and federal level and what occurs in ofse different pockets expansion. certainly, with respect medicaid among we have seen in recent years a large majority of plants for their existing population ine chosen to put them managed care arrangements. in the course of the conversations around the new expansions in the states that have chosen to go with a different strategy, and with those that have chosen to expand, again, the states have thought out and are looking for opportunities to essentially organized and paid for services in a different sort of way. you might imagine with the increase, if we looking at 8 million people coming in successfully into medicaid expansion in the coming year, that there will be greater pressure on the states to look for those opportunities. the enrollment to the exchanges and the exchange-based fans lent

itself for insurers to look for insurers to look for methods to finance care any more efficient way. one way might be the way to construct their networks. the point he made earlier that we are only beginning to see what these plans are going to look like, the rates they're going to be, how they are going to organize services, what tools they like to be centrally organize that care and keep certainlys down, and the uncertainty about what that risk. to look like, because of the slope enrollment is going to because of the slow enrollment will complete things. it will be a couple years before we see things play out. the underlying insurance regulatory changes to put pressure on them, to figure out how dimensions -- how to manage this publisher differently. there are opportunities, but friendly some challenges. before i post less friends --

before i post the last russian, there is a blue evaluation shaped -- she. i would ask that you fill it out. the last question has to do with 30% of patients accounting for health care costs. the question is, how do we balance between targeting this high cost group first and benefiting the other 70% of the patient population so that they receive better outcomes in high- quality care? >> those are common themes and common strategies. if one can imagine figuring out how to manage that population that are sure nearly expensive, that that can only work to the benefit of the general population in terms of how we organize and think about

services. there's no question that there is increasing attention on the duals, people who are eligible for medicare and medicaid. they are costly. there our efforts to look at the relationship between the state and federal governments in finding ways to finance those patients. that can only benefit the broader conversation about how we think about the ways we organize and manage people over tinuum of care. >> i would look at what real plans are doing, and the medicare demos are doing. what you see is i would say three kinds of patients they are focused on. there are those that are really sick already and you do the best you can come and that is care management and full speed nurse

manager at the side. then there are those who are in bid position that use a lot of services, but they can be much better managed if they were coordinated. that is where people are throwing the new infrastructure. then there are most of us who are healthy most of the us who are healthy most of the time. we don't need much. it is about consumer service there and then about preventing that 70% from getting the condition or having the condition deteriorate. it is about monitoring. you do not want to ignore them, but they don't need near as much infrastructure as the 30%. but they are finding is that they do better on roi if they focus their infrastructure on those that are in that 30%.