americans live lives much better than their parents. and we are rightfully troubled because many of our people are still caught in what seems to be a pervasive and unending financial struggle. it bothers us because we are united by the belief that every american deserves the equal opportunity to achieve success.

washington journal continues. we want to welcome to our table congresswoman barbara lee. thank you for being here. we talked about the 50th ofiversary of johnson's that president lyndon johnson's war on poverty. -- 50th anniversary of president lyndon johnson's war on poverty. the supplemental poverty

rate in 1967 was 20%. if you look at why it has to do ,ith a lot of the tax credits the food stamp program, medicaid, medicare, all of those great societies that provide us opportunities for people. we are a long way to go because we squeeze all of these initiatives and policies. primarily the tea party republican congress creating the job opportunities of people who are living or want ,o be lifted from the poverty they had those opportunities to get job training and jobs. what are the democrats solution? need to immediately extend unemployment, taxation. when you look at the fact that 11 million people have been

killed -- have been kept from the ranks of the poor just by the emergency unemployment policy and programs, this is extremely important not only for those people to not fall into the ranks of the poor, but also for our economy and the economic benefits for people to receive unemployment compensation until they are able to sign for the job. we also need to raise the fromum wage from 7000 -- seven dollars and $.10. wageing range -- a living would be $25 per hour. we need universal preschool, childcare. make sure these assaults on the poor and the .orking poor stop the house passed a $40 billion cut in food stamps. what is that going to do? i have legislation to cut poverty in half in 10 years.

we need republicans to still inmit or even reduce poverty half. we have a strong legislative agenda. host: the senate cleared a hurdle to consider the legislation. they are saying it has to be paid for. when has emergency employment conversation been paid for? those people are living on the edge, looking for a job. why are they being used as a political plot line now? three-month extension so we can work this out. i don't believe we can consider cutting benefits to pay for unemployment compensation.

this is morally wrong and economically stupid. he said he was open to offsetting the cuts if congress agreed to a larger extension. oil subsidies, farm subsidies, corporate tax loopholes, you have areas that the republicans would not touch. cutting subsidies for people who are trying to survive, who are looking for a job, i don't believe that is a good strategy. i am confident the president would not want to cut benefits to pay for emergency unemployment compensation. i was at the white house yesterday when the president gave a magnificent speech. passion and his understanding. he was raised by a mother. myself.at

i was on food stamps and public systems. this is a bridge over troubled water. people need that lifeline. we need that lifeline until we can figure out how this economy and economic growth can benefit everyone. how much we talking about the people receive for these benefits monthly? about: we are talking $500, to $800 -- $500 to $800 per month. look at what has happened, you have to add on top of that that a family of four is losing that he five dollars to $45 -- that a family of four is to $45.5 people on the bottom of the economic spectrum are being hit very drastically. host: and the impact on the

economy? guest: huge. when you look at snap benefits, for every one dollar of food stamp benefits the economy gets back about one dollar 75 -- about $1.75. talking about 300, 400,000 jobs. there are economic impacts for not extending unemployment compensation. host: from "the wall street journal closed -- from "the washington post close quote -- post" -- shington they disagree on stimulating the economy. economists disagree

with what "the washington post" says. to lose hundreds of thousands of jobs. that is a fact. whether they are conservative or liberal, most economists believe in the fact that air is a huge economic benefit. people have to pay their bills, buy food. people in the upper income level do not spend as low income people spend to get by. carol is up first, a democratic caller. you are on the air with congresswoman barbara lee. caller: i'm from georgia. we had a situation in my hometown, we lost 40,000 jobs.

her switch from as we had our senator switch from democrat to republican. me tell you something, the gop is bought and owned. the blacks are not getting out of vote. withstanding everything that has 2013,ed between 2010 and we don't want to talk about the real issue, which is that we need to be telling young people they need to get out and vote. -- we areout and vote looking for ways. we seek everything that is going on. you all have a hard job being a democrat. you are telling me you have people on medicaid talking but

you don't want that talking about they don't want you to have medicaid. i don't understand. we have arisen as to its tone people in georgia not to vote. told me i need to get better insurance -- and -- i answereds as with my nieces and nephews. host: we will let the congresswoman response. guest: you are right. there are efforts taking place. the votinge rollback rights act. i hope people throughout the country, especially the african- american community, understands what is going on in terms of voter suppression. helps people become more educated and aware as to the power of the vote and why we cannot allow this retrenchment to occur.

we conductt that voter registration drives and stay politically engaged in between the election. thank you for your concern. one vote can make it difference. we saw a huge turnout in the past presidential election. we must continue with that momentum and enthusiasm and understand this is our country and we have the right and duty to vote. wants somehner concession from democrats if the government was to take over government extension. the tweets and -- -- dee tweets in -- would ask the speaker

why in the world we are seeking concessions on emergency unemployment compensation bills. i would say that is just wrong, it is mean-spirited, and we should not do that. people are vulnerable and living on the edge. we should not talk about concessions only talk about people who work for these unemployment compensation. 99% of these people are looking for jobs. they need to be able to get a job. $1.4 million has been lost already. blaming the political causes the wrong thing to do. kentuckyepublican from was on the floor to advance the legislation.

that aret is democrats playing political games with this idea of income inequality. [video clip] ofwe have seen a number stories about how democrats are planning to spend the year by making an issue of economic hardships. instead of working on reforms that would actually help people s plan to exploit those for political gain. that is a political speech, downright wrong. you can't tell me that extending unemployment situations is a political gain. we have low wage workers who are on food stamps. we have low wage workers who

we are talking about providing a quality of life and the american dream for each and every american who deserves it. they all deserve it. people are working hard. that is a political speech. i hope the public understands democrats are up here fighting to increase minimum wage and extend emergency unemployment compensation. support ton get engage in debate for real policies, which create more jobs. >> let's go to david in oklahoma . independent caller. in the marine corps a long time ago. i can tell you how they can pay for all the unemployment and older people and all that. they need to cut the military budget and quit messing around and trying to kill people all

the time. that would solve a lot. that is all i've got to say. thank you. thanks, david. began under crisis the bush administration with two worst. -- wars. our mennot to mention and women who fought so bravely, we lost trillions of dollars. this is where the economic crisis began and we cannot forget it. we can cut the pentagon budget. programs are in we have identified areas that could be cut in the budget. get out of afghanistan now. our troops fought reedley and it

is time to end that. to restructure our security policy where our country is where we can remain global leaders, but also at -- also have a pentagon budget that is sane and rational. there are many members of congress who are looking at this budget and understanding there is a lot taking place. trillions of dollars in suitcases. that is a fact. we need to do better. were an outspoken critic of the iraq war. -- veterans are very upset they their buddies, their

fellow people on the battlefield. what do you say to them and people who lost their loved ones? guest: our thoughts and prayers go out to these families. sacrifices made by these troops, i am in daughter of a veteran of two wars. the tragedies and losses can never be regained. i was personally against afghanistan. it was a blank check to use go backrever until we to repeal that. many members, 133 members, voted against the war in iraq. there were no weapons of mass destruction and no reason to insert ourselves. we see what is taking place now. it is traffic -- tragic. they have to step up. they have been trained. job they werethe

asked to do in iraq. , wee who have come home need to help them with benefits and economic security and move forward and get these delays in their benefits corrected and make sure they have a semblance of economic security that they so deserve. that is what we have to do in congress. >> we are talking about income disparity. in alabama, republican caller. caller: yes, ma'am. you were talking about unemployment. where are the jobs? this have more jobs in country, we would not need all of this unemployment. the point. is economic growth and the creation of jobs have got to be the primary strategy.

for creating opportunities for people to get off of unemployment compensation. the unemployment rate has and reduced. in some parts of the country, it is higher than other parts. this administration has tackled the economic issue as best as they could with the tea party republican congress putting obstacles in the way. we have to do better. there are many people in minority communities and rural communities especially, 99 weeks along this part of a long-term unemployed third we need to provide workforce training. we do not need to do that as a condition of unemployment. we need to invest through our department of labor and workforce training so people can have the requisite skills for the new jobs that exist. in no way should that be a condition. we have to create economic growth and job creation and address income inequality. senator mcconnell does not quite

understand the gap between the very wealthy and low income is growing and minutes -- middle income. the middle-class is feeling vulnerable because they are on shaky ground. >> this article tweeted out saying -- guest: i have to just disagree. look at what the president has put forward. let's start with universal preschool and early child education. we have to start there. also, i am on the appropriations committee and i see each and every day the fact that the republicans do not want to in early childhood education, in head start. we see headstart start as the result of the sequester having been cut, we have seen all kinds of public education initiatives

being eroded as a result of the lack of investment in our public education and the budget that require us to really support young people. workforce training, skills early childhood education, investment in our public schools, targeted arestments in schools that failing for a variety of reasons, that is what we must do. president and democrats in congress have been very forceful with our education agenda. >> ohio, democratic caller. good morning. i wanted to ask the representative about this sequester and the budget bill that passed. democrats helped pass those two bills. itt i'm wondering is, why is democrats -- i am a black

registered democrat. i just wondered why democrats are voting for the bills and then get on tv and say how horrible and terrible they are and how bad the republicans are? we all know how bad the republicans are. we need a democratic congress and senate and also president. you are a member of the congressional black congress and i believe the progressive caucus. aren't you guys fighting harder for regular people? i do not. caret i do not just listen to regular media. what young to find out guys are for. you are not for working-class people right now. i do not hear it. you keep voting for budgets like the murray ryan budget and the sequester. they are killing us. let me thank you. i am sorry you're not hearing it. the chairman of the congressional black caucus is a

phenomenal chair and she is leading the congressional black caucus on a variety of fronts in terms of our priorities. one of which is addressing economic growth and in -- income inequality. thendly, with regard to ive caucus, we have been around the country raising the level of awareness with regard , havingum wage workers to rely on food stamps and medicaid. raise the needed to minimum wage and make sure there are low-wage workers that benefit from the economic growth beginning to take place. i am sorry you are not hearing it. we have a republican run house of representatives. in working engage .ith the majority hopefully next november, that will change.

leader closely was a phenomenal speaker. we passed many built and many of the recovery -- recovery act would save millions of dollars -- millions of jobs. as democrats, we are fighting to take action the house. defend thei have to progressive caucus and the congressional asian pacific american caucus, the hispanic caucus, and our democratic caucus, fighting agent every day for the average american family. every man, woman, and child, to provide these ladders of opportunity so that those who are middle class do not fall into the ranks of the poor and as the result of some republican policies, that is beginning to happen. budgetdid the two-year deal you voted for -- >> i did not vote for it. that deal did not include the extensions of emergency

unemployment compensation. some members did not vote for that. of his voted for it because we did not want and other government shutdown. we have a responsibility to work with the tea party and the republicans to try to create a budget where we can minimize and get back to the regular order so we can have appropriations bills. >> clarify for the viewer you did not vote. jonathan says, does he quality mean my income should equal yours? should a janitor make as much as a doctor? we are talking about disparities and gaps. a janitor should make a living wage. a low-wage worker should make enough money to take care of their family. regional statistics as it relates to how much a living

wage should be. in california, it is upwards from 15-20 dollars an hour. we are talking about people having enough income to take care of their families and do what they want to do. we have to provide those opportunities for increased job training and education and those who want to move up the economic ladder. those opportunities should be there but we are talking about huge gaps where the top one percent, the billionaires, the thisrate ceos, are making huge compensation. ceo compensation. when you look at low-wage to wide the gap is much for the majority of low-wage workers. host: carol next, independent caller. lady ini agree with the

ohio. i think the democrats need to get more back on. from issues. do not turn away from the affordable care act. losingor the people these union jobs. nobody supports unions anymore. fouris the next scary letter word even though it has five. what about the union jobs? what about these corporations that take those jobs overseas? the democrats never voted for that budget. that budget was a scam. guest: the democrats are fighting to make sure the affordable care act works. 45 attempts to repeal it. majority of democrats support the affordable care act and want to make sure it works. over 20 republican governors refused to accept the medicaid

provisions of that. a middle-class life here in america, the primary pathway has been through our labor union movement. you can look at the record of all the legislation's put forward who tried to erode road or undermine unions in the labor movement. democrats are standing firm and fighting hard.

we are doing everything we need to do to make sure we are not undermining the middle unit and the middle class in our country. next up, republican caller . her, how wanted to ask can people trust the president after he lied about the obamacare situation? that is terrible. why did she think the democrats do nothing wrong? they do everything wrong. we are fed and enjoying dollars in debt and a do not know what they will do about it area -- it. we do notm not saying do anything wrong. we are fighting to do everything right. we are fighting to make sure there is economic growth and the jobs are created for people in

our country so everyone can be part of the american dream. the president has come forward and talked about him is takes we made with the affordable care act. it is beginning to work. a lot of chemical problems. if you have any new initiatives, he was the only investor in the world who do not have the universal health care system for all americans and all of our citizens. we candoing everything to make sure the affordable care act worked, and the president has come forward and talked about it, and we have to see this as a way, one bullet in the overall process. but it is working. are beingof people covered and will be covered. >> the house voting this week on legislation to make health

air.gov more sick era. this is a republican effort. we have to really look. seen the details. the efforts to undo and repeal the affordable care act. step toward repeal, i will not. class 10 minutes left with the congresswoman. we are talking about income disparity in this country. as democrat approach to it we mark the 50th anniversary today of lbj's war on poverty he on january 8, 1964. the front page of "the washington times" this morning --

guest: i just have to say, when you look at the fact the republican through the house wanted to cut food stamps by $40 million, the president did not support that. he put forward many economic growth initiatives that have tracks.pped dead in its let me read you -- i am glad you mentioned the 50 year anniversary. we have linda johnson come to capitol hill to greet her and talk to her about her family's history and where we go from here. i want to read some of the initiatives begun under president johnson. a civil rights act. the food stamp act. older americans act. social security amendment of 1965. housing and urban development

was established then. the public works and economic development. immigration and nationality act. of 1966.rition act child protection act of 1966. the national school lunch act. we had medicare and medicaid and other policies established 50 years ago as a result of president johnson's vision, who begins to address poverty and income inequality way back then. many of these initiatives have been under attack and part of what has been taking place is democrats have been working just andreserve this safety net the government support system, cane policies, until we achieve full employment. that is what this country should get. >> democrats will be helping to highlight these? guest: every day, we will have 50 speeches. beginning today.

what they havend accomplished, but also, what could take days if these continue to be eroded, and where we need to go from here. that is starting with extended the emergency unemployment compensation of raising the minimum wage. >> making the speeches during the morning our? -- hour? >> they will be at noon. lyndon will be in the gallery. she is a phenomenal woman doing on early childhood education. we want to say thank you to her and honor her dad and mother and to talk about where we are now in 2013 and how we move forward with the same values. that is what this is about. these are the american values president johnson 50 years ago set forth in his speech and those values remain.

>> we will be covering that on our website. we cover the house gavel-to- house on c-span. you can go to c-span.org for coverage of all of the events. you mentioned lady bird johnson. she was part of our "first ladies" series. if you are interested in her , go to ourshe played website to find out more. let's go to camp in missouri, democratic caller. missouri, democratic caller. caller: since there is so much scientific evidence living that building seven was brought down with plea -- pre-planted explosives in 9/11, and 2000 building experts demanding a new investigation of its destruction, in the interest of transparency, why should we not have a new investigation into

the cause of why the third tower ell? it when no plane hit it? we have to think once again of the people lost in that tragic event and recognize many investigations have occurred as a result of that. some conclusive and some inconclusive. evidence is still coming out, but i'm not certain a new investigation will lead anywhere. there are those really pushing for that. in a democracy, we have to continue to put our points of views out and continue to ask if what you believe is right. there have been many investigations of many people failing or accurate and provided the most in-depth conclusions. a tweet -- guest: these are really not jobs

bills. we are talking about bills that would provide for more tax loopholes,orporate trickle-down theory type of policies. those that would create jobs. these bills do not create jobs. i hope you look at those bills very carefully and recognize the majority of them would continue to allow for income inequality to increase. we do not see any of those bills that would address low-wage workers, that would address raising people out of poverty, that would protect the middle class and create good paying jobs. the bills just did not do that and i hope you would look at them and see exactly what they would provide for. >> we are getting an announcement this morning, breaking news private sector employment picked up in december as employers added 238,000 jobs. clearly, the economy is

moving in the right direction. under this administration, it is always been very difficult. we had an increase in job creation in the private sector, where we have seen you wrote in has been in the public sector with huge bug -- budget cuts. public-sector employees have either been laid off, the jobs have been cut, and salaries have been frozen. this administration, when you look at the unemployment rate, when up -- when the barack obama demonstration came in as a result of the economic crisis, that the bush administration created through their economic this administration has done a phenomenal job. we have a long way to go. and unemployment rate in the african-american community, communities of color, over 12 it -- 12%, that is unacceptable. he looked at different regions of the country, rural community unemployment rate, we have to intotargeted resources economically distressed

communities where we can create more jobs and opportunity. it is clearly moving in the right direction in economic growth, that is key to winning this new war on poverty. host: republican caller in modesto, texas. caller: yes. where thehere unemployment is the lowest in the country. i am self-employed. 25 years. the problem with unemployment is you do not have a job there, you have to move on. your solution, if you don't have a job, you have to move on? caller: yes. you have to go out and find new jobs were there is work.

people, trained hands, they have got their hands out. guest: i am glad you are working. i am glad there are parts of the country where jobs are more plentiful and economic growth is taking place. also, there are other factors involved. i know people often times who are unemployed, for example long-term unemployment, employers will not hire them for a variety of reasons. they may not have the skill set as the result of long-term unemployment. we need to invest in workforce training. , and rick is fortunate to be able to move around, some people are not that mobile and do not have the resources to move to different parts of the country. we need a regional approach to really create economic growth throughout the country, especially where the unemployment rate is the highest. >> democratic caller.

, forwant to thank you bringing out certain things. i want people to remember the republicans said they wanted to president a one-time and it did not work, so they are doing everything else to try to make him look bad. i hope people really look at that. my other thing is, how many --es -- why don't somebody that is not the word i wanted to say. there,ne putting it out when you say cut government spending, that is not just washington. that is all the way down to your city government. you are correct. city and state government. when you talk about government spending, you're talking about public-sector jobs being cut.

secondly, you're talking about services. ,e saw this with the shutdown one that unfortunately occurred. services were not provided. when you talk about government spending, we have to have a government that is functional, but we cannot talk about a .overnment that does not exist many members, especially the tea party, have come to congress not only to create a smaller government but to dismantle government. that is very dangerous. it is a government of the people by the people and for the people. inhere is an e-mail wisconsin. how much poverty in our country is caused by personal choices, such as -- guest: you are talking about a lot of social issues we need to address for providing strategies to help people.

single mothers, i was a single mother. unfortunately, i ended up on public assistance and food stamps and medicaid. turning that time, we had some of these initiatives in place where i could get through college and take care of my kids and get a job. i ended up starting a business and working as a legislative administrative assistant on capitol hill. here i am today. it would not have happened had it not been for that. wes is very competent and are not making excuses for people. we have to have strategies in place and policies in place that help people overcome many of these issues and personal responsibility is a factor in this, but not the only factor. we have to recognize it has got to be a comprehensive approach to address all the major social and economic issues and inequality inequities we see in our society. i say little more about your personal story, how long were you on government assistance in the various forms?

>> three years. >> in that time, that helped you go from where you were to where you are now yucca >> there is no way i could've survived during that time had it not been for that. it was a really hard time. often times, looking for someplace to live. fortunately, i had a great family who helped me out with my kids. i ended up going back to college. that is what i wanted to do. go to school. not necessarily run for public office, but so i could take care of my two little boys. i had been through traumas and difficult days. i do not know what would've happened to me had i not been able to go to the welfare office and say, i need help to get through this. the american people were there for me. >> what made you think you would go there? or was it a person that influence you? was, how i get to the next day and try to do

research to figure out how to survive during that time. i wanted to take care of my kids. that was the biggest thing. what do i need to do? i knew i needed to get a college education. and be able to have the skills and the knowledge base to have the quality of life to take care of them. primarily, my kids. >> how old were your boys? guest: they were little boys. and family menrs now. i have five grandchildren and they are all doing great. i am so proud of my sons. me intwo kids who helped trying to figure out how to help them achieve a quality of life. i do not know what i would've done. that the american people and president johnson had these programs in place to help me through. a bridge over troubled water. people do not want to be on food stamps. they do not want to be and

medicaid. they do not want to be on public assistance. they want to work and get a job and take care of their famili oe

costs. it's hosted by the university of virginia's miller center. >> it may interview with c-span

and other broadcasts made of this press conference. i would like to welcome you here for the release of the miller center state health care costs containment commission and its report entitled cracking the code on health care costs. health care access, quality and cost have been at the center of the nation's public policy challenges for much of the past two years. and it is likely that that will remain the case for the foreseeable future. while the rate of increase and cost of health care has slowed over the last few years, it has still hit the tipping point and it is having a huge impact on consumer budgets. it is forcing major cuts in state and federal funding for education and infrastructure, which are critical to the growth of the u.s. economy. there are also questions about the extent to which the high

cost of health care makes u.s. companies less competitive in world markets. the work of the commission is consistent with the mission of the miller center which has been to serve as a central gathering point for nonpartisan policy discussions since our founding almost 40 years ago. other recent public policy issues addressed by the miller center include presidential war powers, federal transportation policy, immigration reform, and the challenges facing america's middle class. unlike some policy issues where we know what to do but lack the political will, health care costs containment is in its infancy and so we must go through a period of accelerated state experimentation to determine what really works. a supreme court justice indicated in 1932 that states are the laboratories of

democracy. the commission's report provides states with a blueprint to follow during this period of experimentation. much like states have led in clean air, welfare and education reform, they are likely the level of government to lead the transformation of health care delivery system. not only are states nimble in making adjustments to programs that work but in health care most of the policy leaders belong to states. it is also true that health care solutions need to be attaileredo health care markets and the cultures of individual states. the commission met three times in the miller center's washington, d.c. office and has had numerous conference calls in developing a strong consensus on the report and its recommendations. while we hope that the federal government's health care leadership listens in, this

report was written specifically for governors, state legislative leaders and other health care leaders at the state level. the federal role as we see it in the area of cost containment is to support the state role by providing additional information to states and perhaps financial incentives to encourage states in taking a more active role. states, however, have to take the leadership role in cost containment. let me introduce the members of the commission at this point. those who are here. first, the two co-chairs. mike leavitt, former governor of utah and former secretary of health and human services and bill ritter, the former governor of colorado. the private sector representatives who are here, george hallersversohalverson, a

drivous and glen steel. then we have bob, a medicare trustee and former director of the congressional budget office and the urban institute. rob with community catalyst. several other members who were not able to be with us today include a representative from united health, jay cohen, mike davis with general mills, the former executive of colorado department of health care policy and financing and lloyd dean with dignity health. finally, i would like to say a special thanks to our two major funders. first, kaiser permanente, a special appreciation to george halverson and second to the robert wood johnson foundation which is represented by andy hyman. now i would like to turn the

program over to governor bill ritter who will outline the role of states in health care cost control and the huge number of policy levers available to states to both enhance quality and reduce the cost of rate increases over time in the health care field. governor ritter. >> thank you. good afternoon. prior to talking about the state's role and many policy levers to moderate health care cost increases, i want to make a minute and make a few general points. first, there are chapters in our report on the health care problem, the affordable care act, and on what the federal government can do to help states control costs. this press conference is going to focus on two bottom line issues. the state policy levers and our specific recommendations. second, although the title of

the commission and the report itself talk about costs, increasing quality is of equal importance to the commissioners. the commission members believe that we can do both, enhance quality and reduce the rate of cost increases over time. third, although there are no silver bullets with respect to restraining health care costs, the most important goal is to transform the delivery system that is one that is fee for service to one that is comprehensive and integrated using payment models that hold organizations accountable for the cost and the quality of care. fourth, this report is written for governors, state legislative leaders, and other health care leaders in the state. this is because the transformation must be led by states. health care markets and cultures differ from state to state so

solutions must be tailored to individual states. it is true that we are in a period of experimentation attempting to determine what really works, but if you look in retrospect what states have already done, they have a pretty good track record for experimenting and for being very good laboratories at being able to say what works and what doesn't. as a former governor, i'll admit that i have a bias when it comes to public policy in favor of states. but i think the commission members would agree with me that we're all surprised and really heartened as we begin to dig into this issue and look at what states have at their disposal in terms of policy tools to control health care costs. i'm going to talk about five different buckets of policy tools. first, the purchasing power of

state health care programs including medicaid, those for states and to some extent local employees and individuals in state exchanges. so medicaid, state and in some states local employees, and individuals who are enrolling in the state exchanges. that's one bucket. second, state laws and authorities that governor insurance scope of practice, provider rates and medical malpractice. the third bucket, state laws affecting market competition, consumer choice, antitrust, and price and quality transparency. fourth, the authority to invest in initiatives that improve population health specifically programs that help lifestyle choices and personal responsibilities. fifth, the power of governors to engage. under the first category of

health care spending, programs administered by state governments, the number of individuals eligible for health care coverage through state administered programs is going to approach 80 million over the next several years. that's far larger than the 53 million enrolled in medicare. this includes medicaid patients, which will likely have 70 million enrolled in the next few years, but it also includes 3 million state employees. it's a potential of 11 million local employees in addition to that who could be part of state programs. it includes another 6 million who will be purchasing health care through state exchanges. so if you add up all those totals, it's a huge purchasing power at the state level which can be used to transform the delivery system from fee for service to one that provides high quality low-cost care. under the second category i mentioned, state laws and regulations that affect

insurance. all states regulate health insurance including a review of solvency, review of rate increases, contractual rules between plans and providers. while a few states make rigorous review of rate increases and at times deny increases, most do not have the resources to perform a serious analysis. that said under state laws, they have vast authority to do it. also, all scope of practice laws regarding what nurse practitioners and physician assistants and other nonphysicians can do and how they're paid come from state laws. many states are redefining these responsibilities so that nonphysicians can practice to the extent of their own capabilities. medical malpractice laws are state laws. many states have rate setting authority. maryland is the only state right now that sets hospital rates. there's a whole ability on the part of states where rates are

concerned, where regulations are concerned, to control health care costs increase. under the third category, the one that talks about laws that affect competition and transparency, all states antitrust laws on their books although they are seldom used. increasingly states require providers and plans to make costs and quality information available to consumers on a timely basis. as governor of colorado passed a law that talked about report cards for hospitals to increase transparency around quality of care. fourth category, the public initiatives to promote population health. increasingly around the country these are being developed by states. some may be school based such as exercise requirements or food and nutritional guidelines. others are community based such as grants for walking and bike paths but states are very much paying attention to their own ability to look at wellness as one index of controlling cost

increases. the final and fifth category is perhaps the most powerful. it's the ability of governors to engage stakeholders to create a stakeholder process that looks at change. it can take a while for a new governor to comprehend this power. it's not written in the constitution. typically not written in any law but correctly utilized it is a powerful vehicle for change. that's just a summary of the different policy levers, some of the biggest policy levers that states have. you can see that there are many such opportunities for states. if you look at all of the ones put together, it became clear to members of the commission, to governor leavitt and myself, many things can happen that allow states to have important

control over health care costs. i'm honored to be on the commission with governor leavitt. he's steep in the subject matter. it's an important policy issue for this country that we're fortunate to have a man of mike leavitt's credentials to be part of this commission and part of the larger dialogue. governor leavitt, thank you. i invite you to the podium. >> thank you, governor ritter. may i just extend some appreciation of my own to the miller center for initiating this project. also the kaiser foundation and as mentioned earlier robert woods johnson and their role and to all of you for coming to hear the report and for c-span for allowing those who are not able to be here to hear about it. this is an important report.

could i suggest that three things i would like to make before we get into the recommendations. the first is that this report was done primarily with the context that we believe market forces when utilized can reshape the health care system. you'll see integrated into a lot of this a thinking that market forces properly constrained by the roles of government can in fact be the most effective way in which this is done which plays very much into the subtext of this report, which is states can have a tremendous impact on this process. states in a way do reflect a marketplace because there are laboratories of democracy. the second is that these recommendations have been based on conditions as they exist with

the affordable care act. if in fact the act begins to migrate or change over time, it won't necessarily change the opportunity for states but it could in fact change some of the things that were inherently placed in this report and lastly could i suggest that this is a long-term process. this a five to ten-year horizon we're talking about and not something that will happen quickly. governor ritter talked about the policy levers. within the context of those policy levers could i just briefly outline the seven main recommendations that the report makes. the first is that states should create an alliance task force or a work group to transform the care system in their state. this is a classic collaborative problem. it requires collaborative leadership and the collaborative

leadership needs to be formalized. governor ritter spoke about the role of the governor and i would like to underscore that point. the governor in the state needs to lead. the governor in a state is in a unique position not just to use the levers of government but also to call upon the community. it's a unique role granted a governor. but in addition to the governor, there are other state government officials who play a critical role. the medicaid director who typically would have responsibility for 15, sometimes as many as 25% of the lives in a state being paid for through that mechanism. that's a key player and a function of state government. typically the insurance

commissioner who regulates the vast majority of the market that remains outside of medicare and medicaid. very important player in the health reform. again, a state official. and another example would be the hr person or the benefits person in a state. typically the state government is the largest employer in a state and hence a significant part of the health marketplace falls under that person's responsibility. but it shouldn't simply be in this collaborative process. it shouldn't be just state officials. it needs to be those that are patients. it needs to be care providers. it needs to be insurers. the governor has the capacity to bring all of that together as a convener with sufficient stature to begin to focus the state on this problem. recommendation number two,

define and collect data to collect a profile of health care in that state. could i suggest that there is no national health care system. there is no national health care market. there are 316 hospital referral regions and 50 states and so states have the capacity to take the marketplace within their state and begin to concentrate on it in its unique characteristics. so being able to gather that data, to give the governor and the community a clear picture of what the system looks like in their state is a very important first step. recommendation number three, establishing baselines and goals for health care spending for equality and other measures that

are appropriate. states need a goal. they need to know what the status quo is producing and there needs to be a public commitment made to reducing costs within that marketplace. again, if you begin to look at the levers available to governors and states, they're considerable. it's not only control of the marketplace but it's also control of the regulatory environment. that really gets to the heart of our recommendation number four. and i think perhaps the most important. governor ritter mentioned it already. that's using the powerful leverage that the state has with existing health care programs such as medicaid, such as the employer -- state as an employer, state employees.

they can promote regular. we can reform health care regulations to promote a system effectively. malpractice is often brought up. that's typically handled at the state. the scope of practice for nurse practitioners and physician assistants and other nonphysicians typically done at the state level. often that's the place where not only the scope of their practice is determined but the limit to which they can practice is determined. another recommendation, encouraging consumer selection based on information. have transparent information of cost and quality. states have the capacity to harness that data.

in nearly 30 states, we have all payer data bases where the state has accumulated information from all of the plans. those can be used to drive that kind of information. and lastly, the final recommendation, help promote population health and personal responsibility follow health. this recognizes that health is very much an ecosystem. it involves the health of people, which can be everything from trails and having walkable communities, to clean air and clean water. all of those things are part of what allows states to have an impact. so in summary, the governor should chair and convene a process within states to attack the health care costs in their state. they should have data that gives them a baseline from which to operate. they need to have goals. goals that will in fact generally a parade of five to

ten years to actually see the cost curve in their state overall taking in not just the public sector but the public and private sector. they need to use state programs as the basis of that. they need to encourage consumers to shop for value. they need to use the regulatory levers that they have and then look at this as a state ecosystem. subtext, states can have more impact than you think. now, with that i would like to encourage the members of the commission who are present to join us on this podium because we're going to now take some questions and i would like to first of all have questions come from those from the media and others who are here, present for this report and then we'll go to some questions from the miller center social media channels. who may i call on first for a question? julie. >> a number of states are doing things.

one of them is massachusetts. i wonder if you could chat about whether you think the way they're approaching cost control in massachusetts is an example of what you would like to see in other states. >> very good. you have firsthand knowledge of that as the head of blue cross blue shield of massachusetts. >> thank you, governor. and it is a good question. i would first say i'm always a bit cautious about recommending massachusetts solutions. one of the statements in the report is that each state is different and each market is different. having said that, many of the recommendations mirror some of the actions that our state has taken in massachusetts. our state cost containment law was only recently passed. it's already created a climate in massachusetts that mirror a lot of the recommendations in this report. more collaboration among government and the private sect sector. a sense of shared commitment in the state that we need to lower cost while we improve quality.

and as a consequence, we are seeing costs come down or i should say growth in costs come down. another key recommendation in the report that has been adopted in massachusetts has been widespread acceptance of changing the way we pay for care. so the fee for service system, which i think the report and other experts identify as being fundamentally inflationary, is being changed in massachusetts and physicians and hospitals are voluntarily adopting and agreeing with health plans like ours at blue cross blue shield and others to accept what we call global payments, payments that include incentives for quality and incentives for control costs and studies independent studies by experts have demonstrated that we are starting to get to that holy grail in health care which is better care and lower costs. i think the massachusetts experience is instructive.

while i have the podium, one or two other comments i would like to make. i do believe that if individual states adopted the vast majority of these recommendations, health care costs would come down and there's some passing reference to the affordable care act, but my view is evolution of the affordable care act actually makes the recommendations of this report more relevant because as the affordable care act has evolved, we've watched as states have made individual decisions to perhaps take a different path, whether they've adopted to expand medicaid or not or run their own exchanges are not. some of the national standardization that was anticipated in the affordable care act has not come to pass at the same level which has put a much greater focus on states as locust of accountability of health care which is the premise of this report. does that get to the question you asked?

>> it does. can i do a follow-up? >> sure. >> wait for the mike. >> sorry. so many of these recommendations sound like addressing maybe additional regulation, additional control by the states. how is that going to fly in some of the states that think there's perhaps already too much regulation of the health care sector? >> i think as both governors acknowledged we need to achieve balance between government regulation and oversight and market innovation. although massachusetts is often viewed as a state where government oversight is widely accepted and in fact some of the most important steps we've taken to control costs have actually come from the market, have come from innovation together from plans and from hospitals and i think there are some very -- states with republican governors that innovated in this area very successfully. i think each state has to kind of settle where they are comfortable with that balance

between regulation and innovation in the market but as a basic premise as you just heard from our presenters, governments have a lot of -- state governments have a lot of authority and even in states which have less of a regulatory climate or history, they are overseeing insurance regulation, public health departments, employee benefits, so those are all opportunities to kind of focus on health care affordability. >> i would like to make a comment on that. i'm from the state of utah. utah would likely be considered a different regulatory environment than massachusetts. but what's interesting to me is that both massachusetts and utah have achieved a fairly high level of integration in their health care systems by comparison to most other states. massachusetts background is well known in reform.